Every finding on record at Lake Ridge Care Center of Buffalo, Inc.

Based on observation, interview and document review, facility failed to ensure appropriate personal protective equipment (PPE) was properly utilized for 2 of 2 residents (R7 and R14) on enhanced barrier precautions (EBP), 1 of 1 resident (R58) on enhanced respiratory precautions (ERP). This had to potential to affect all residents the trained medication aide (TMA)-A came into contact with during her shift. In addition, facility failed to ensure infection control practices were followed when staff left used linens, towels and resident personal clothing on the floor for 2 of 2 residents (R7 and R14). The facility failed to ensure an attending clinical provider consistently wore a face mask while in patient areas during a period when the facility was in outbreak status, and masking interventions were being implemented facility wide. This had the potential to affect all 51 residents, as well as other staff and visitors who were in general areas. Further more, the facility failed to ensure continuous positive airway pressure supplies (CPAP) supplies were dried in a sanitary manner for 1 of 1 residents (R1) reviewed for CPAP use. Findings include: R7 R7's admission Minimum Data Set (MDS) dated [DATE], indicated R7 required substantial assistance from another person for toileting hygiene and lower body dressing. Required partial/moderate assistance for upper body dressing and supervision or touching assistance for oral hygiene and personal hygiene. R7 was dependent on assistance for bed mobility including rolling left to right, sitting to lying and lying to sitting on side of bed. R7 was dependent on assistance to-sit-to-stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer. R7 utilized an indwelling urinary catheter and was occasionally incontinent bowel. R7's diagnoses included cancer, anemia, hypertension, benign prostatic hypertrophy and obstructive uropathy. R7's care plan last revised 1/5/26, indicated R7 required EBP related to an indwelling catheter. Approach included: Follow enhanced barrier precautions per policy. During observation and interview on 1/5/2026 at 9:47 a.m., TMA-A was in R7's room. TMA-A was not wearing a gown or gloves. A large pile of linens and towels was observed on the floor outside the bathroom. Licensed practical nurse (LPN)-C exited R7's room and explained R7 just finished his shower, this was the reason the linens and towels were on the floor, in case you were wondering. TMA-A exited R7's bathroom while stating, she was cleaning the mess up and placed the towels and linens in a plastic bag. R14 R14's admission MDS dated [DATE], indicated R14 required partial/moderate assistance with upper body dressing, substantial/maximal assistance for toileting hygiene, shower/bathe, and lower body dressing. R14 required supervision or touching assistance for personal hygiene. For rolling left and right in bed, sit to lying and lying to sitting on side of the bed, R14 required supervision or touching assistance. Sit to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer R14 required supervision or touching assistance. R14 was always continent bowel, and occasionally incontinent bladder. R14 diagnoses included anemia, atrial fibrillation, heart failure, diabetes mellitus and cellulitis of both left and right lower limbs.R14 had three venous and/or arterial ulcers which required application of nonsurgical dressings and application of ointments/medications. R14's care plan last reviewed 1/7/26, indicated R14 required EBP related to wounds on toes. Approach included: Follow enhanced barrier precautions per policy. During interview on 1/5/2026 at 10:04 a.m., LPN-C stated R7 required EBP due to having an indwelling urinary catheter and R14 required EBP due to have a wound. During observation on 1/5/26 at 10:15 a.m., a sign posted on R7 and R14's room door notified of Enhanced Barrier Precautions and gave direction to wear gown and gloves. A pile of dark personal clothing was noted on the floor on R14's side of the room. Clothing was not bagged. LPN-C, wearing gown and gloves, entered the room. TMA-A asked LPN-C, Why are you all gowned up and stuff? TMA-A was not wearing a gown or gloves. R58 R58's face sheet, undated, indicated diagnoses included acute heart failure, chronic obstructive pulmonary disease and anemia. During observation on 1/5/26 at 9:57 a.m., a sign posted on R58's door notified of Enhanced Respiratory Precautions and gave direction to wear gown, gloves, eye protection and respirator (N95) in room. A plastic cart with pull out drawers was outside R58's room. Contents in the drawers included disposable gowns, disposable gloves, face shields and individually packaged N95 masks. TMA-A performed hand hygiene (HH), donned a N95 mask, gloves and gown before entering R58's room. TMA-A shut the door behind her. During interview on 1/5/26 at 10:27 a.m., TMA-A stated the signs on the doors (R7, R14 and R58) give direction regarding the type of PPE is to be used when in the room. For R7 and R14, gown and gloves were needed with cares (according to the sign) and for R58 gown, gloves, and an N95 were needed. TMA-A stated she did not don a gown or gloves before entering R7 and R14's room this morning because she did not see the sign on the door and was not aware either required EBP. TMA-A assisted R7 was personal cares, including a shower, dressing, catheter care and transfer assistance. TMA-A assisted R14 with personal cares including personal hygiene, dressing and transfer assistance. TMA-A stated she did not need to don a face shield before entering R58's room because she wore eye glasses so the face shield was not required. TMA-A stated placing used/soiled linens, towels and resident personal clothing on the floor was not appropriate, but I had no where else to put them. During interview on 1/6/26 at 11:43 a.m., director of nursing (DON) stated he was aware of the observations made on 1/5/2026 regarding TMA-A not donning appropriate PPE but was not aware of linens and resident personal clothing being placed on the floor. DON expected EBP was followed with any high contact care activity in a resident's room. A list of the specific care activity requiring EBP and the appropriate PPE to wear in that room was included on the sign posted on the resident's door. This was important to protect residents from the spread of multidrug-resistant organisms (MDROs). This was especially important for residents who are at higher risk for contracting MDROs, such as those with indwelling medical devices and those with wounds. DON stated R58 was on ERP due testing positive for COVID-19 after admission. DON expected PPE use in any room with [NAME] include either goggles or a face shield, standard eye glasses were not considered eye protection. Regarding linens and resident personal clothing left on the floor, DON stated those items should not be thrown directly on the floor, they should be bagged first. Especially in a shared room as it is a shared environment and could lead to infection prevention and control concerns. Facility policy, Personal Protective equipment with last review date 7/2/2025, directed staff personal protective equipment appropriate to specific task requirements is available at all times. Certain PPE may be required when working in the facility, such as facemasks or eye protection during a respiratory virus pandemic. Facility policy, Transmission-based precautions, enhanced barrier precautions and empiric precautions with last review date 9/29/2025, included the following: Section titled Best practice recommendations for enhanced barrier precautions: Use enhanced barrier precautions sign. Direction to staff included: If contact precautions do not otherwise apply, enhanced barrier precautions are recommended for residents with any of the below criteria: Bullet 2: A resident with a chronic wound regardless of MDRO status .Bullet 3. Residents with an indwelling medial device, even if the resident is not known to be infected or colonized with an MDRO. Examples of indwelling medical devices include but are not limited to: Central vascular lines, PICC or Mid-line catheters, indwelling urinary catheter, nephrostomy tube, feeding tube, tracheostomy tubes . Section titled Enhanced respiratory precautions: Use for residents with COVID-19. Residents in enhanced respiratory precautions require: Keep door closed if able; Gown; N95 mask; Eye protection; Gloves. Mask Use On 1/5/26 at 9:00 a.m., upon entrance to the facility, the survey team was informed by the receptionist of the current status of respiratory precautions in place at the facility, and instructed survey team mask use was required. During survey observation, on 1/5/25 at 10:10 a.m., clinical provider (CP)-A was observed to be rounding with unidentified nursing staff member. CP-A was observed to be unmasked initially, however, placed mask on once surveyor was noticed. On 1/5/25 at 10:28 a.m., CP-A was observed in a resident room and was not wearing a face mask. CP-A was standing approximately 12 to 18 inches away from both rounding nurse and resident. Upon exiting room, CP-A was observed to place mask after surveyor was noticed in the hallway. On 1/5/25 at 2:01 p.m., CP-A was observed multiple times going between the provider office and the front desk of the nurse's station, providing documents and obtaining/providing information to/from staff. The office was directly across the hall from the nurse's station; however, residents, staff and visitors were observed passing through this area. On 1/5/25 at 2:15 p.m., an interview was held with CP-A regarding the use of face mask throughout the nursing home visit. CP-A stated upon entering the facility, he did observe that mask use was in place and had talked with staff regarding this. CP-A stated he generally used masks while completing patient care, however, acknowledged he did not consistently use when outside of patient care areas. When asked about observation of visit with resident made with out mask in place, CP-A acknowledged he should have worn the mask during the visit. CP-A stated masks were really indicated for people who were symptomatic to prevent spread to others, and otherwise mask use was not necessarily indicated. When asked about the perception of others when observed by both staff and residents, CP-A acknowledged he should set the example with the use of mask when implemented in the facility as a precaution. On 1/8/26 at 5:35 p.m., an interview was held with licensed practical nurse (LPN)-A, Long Term Care Unit Coordinator (UC)-A and registered nurse (RN)-A, Transitional Care Clinical Coordinator (CC)-A. CC-A stated the expectation would be for the provider to wear a mask while in common areas and around others. CC-A stated he had asked the provider to wear masks as per facility policy during outbreak. UC-A stated the facility encouraged masks for everyone. UC-A stated facility staff were required to wear masks, and staff would not be allowed to not wear a mask while precautions were in place. CC-A stated the provider was one of the facility vendors and the expectation was for him to wear a mask. CC-A stated if staff were uncomfortable approaching the provider, they should have sought either CM-A, CC-A, or director of nursing (DON) to follow through with this. On 1/08/26 at 6:08 p.m., an interview was held with DON. DON stated he had made similar observations and had directed CP-A regarding the need for mask use. DON stated it was the expectation masks were to be worn by providers while in the facility. DON stated when observed, it was the expectation of the facility that the staff was to request the provider to wear face mask as required by facility policy. The facility policy, titled Respiratory Illness-Covid 19, Influenza, RSV, original date 11/13/25, identified: Source control is recommended more broadly in certain circumstances as described in CDC'sPreventing transmission of viral respiratory pathogens in healthcare settings that can be found on the CDC website. Source control requirements for new admissions should follow facility policy. People who are recommended to wear source control should not go places where they are unable to wear a mask. The policy identified the facility was to provide appropriate masks and/or respirators to residents, staff, and visitors. R1 R1's annual MDS dated [DATE], indicated R1 had moderate cognitive impairment and required assistance with activities of daily living. R1's diagnoses included sleep apnea, congestive heart failure, chronic kidney disease, acute respiratory failure with hypoxia (lungs cannot get enough oxygen into the blood), pulmonary nodule, and chronic pain. R1's care plan last reviewed/revised 11/25/25, did not address BiPAP (noninvasive ventilation that helps you breath) use. R1's physician order report printed 1/8/26, directed staff to clean BiPAP tubing, mask, nasal pillow daily by placing in mild soap and water and soaking for five minutes. Rinse with warm water and allow to air dry between uses. On 1/5/26 at 1:59 p.m., observed R1's BiPAP mask, nasal pillows and hose were hung on the towel bar that was attached to the inside surface of the shared bathroom door. The mask, nasal pillows and hose were observed to be hung on the towel bar again on 1/6/26 at 11:35am, and again on 1/7/26 at 9:29 a.m. When interviewed on 1/8/26 at 2:55 p.m., licensed practical nurse (LPN)-A stated the masks, nasal pillows and hoses were not normally hung in the bathroom. LPN-A stated, that's gross, not a normal place to hang medical equipment to dry. When interviewed on 1/8/26 at 3:15 p.m., LPN-B stated the mask/nasal pillows and tubing should be rinsed out and hung to dry in the bathroom or place on the nightstand to dry. LPN-B then stated, maybe for infection control reasons the supplies should not be hung in the bathroom due to spray that occurred when the toilet is flushed. When interviewed on 1/8/26 at 4:10 p.m., director of nursing (DON) stated the expectation was for masks/nasal pillows, tubing and water chambers to be rinsed every morning then hung to dry in the resident's room. DON stated the supplies should never be hung the bathroom for infection control. Facility policy CPAP/BiPAP last reviewed 3/10/25, indicated cleaning of masks, nasal pillow and tubing were to be cleaned BiPAP tubing, mask, nasal pillow daily by placing in mild soap and water and soaking for five minutes. Rinse with warm water and allow to air dry between uses.

Based on observation, interview, and document review, the facility failed to provide appropriate table height in the dining room for 1 of 2 residents (R33), reviewed for accommodation of needs. Findings include:R33's quarterly minimum data set (MDS) dated [DATE], indicated R33 was cognitively intact, required assistance of one with activities of daily living (ADLs), was independent with eating after staff sets up meal. Diagnoses included hemiparesis (weakness on one side of the body) hemiplegia (loss of movement on one side), dysphagia (difficulty swallowing), weakness and chronic pain syndrome, severe kyphosis (excessive forward rounding/hunching of upper back).R33's care plan, last review date 10/21/25, indicated R33 required set up and supervision for eating due to hemiparesis with intervention of staff to provide set up and supervision assistance with meals. On 1/6/26, at 12:08 p.m. R33 was observed in the main dining room, sat in wheelchair, R33 was leaned forward and to the right, tabletop was chin height to R33. R33 was eating from the plate she had placed on her lap. On 1/7/26, at 12:18 p.m. observed kitchen staff place R33's plate on the table which was chin height to R33. R33 moved the plate from the table to her lap, proceeded to eat. R33 was leaned forward and to her right. When interviewed on 1/8/26, at 2:45 p.m. nursing assistant (NA)-A stated R33 was independent with eating, had weakness on her right side, may lose food when she ate, but had not noticed R33 placed the plate on her lap to eat. When interviewed on 1/8/26, at 3:15 p.m. licensed practical nurse (LPN)-A stated R33 had not mentioned having problems or difficulty when eating but had noticed R33 placed the plate on her lap during lunch today. LPN-A did not recall if R33 requested the table to be adjusted. During interview on 1/8/26, at 5:46 p.m. R33 stated when the plate was on the table she felt like my nose is in my food. R33 stated she had asked staff to lower the table but had been told it could not be lowered any further that it already had been. R33 state she preferred to eat in the dining room and was willing to try alternatives to putting meal on her lap, R33 stated it was very difficult to eat soup from her lap. During interview on 1/8/26, at 5:57 p.m. director of nursing (DON) stated if there was something that could be done to make mealtime better for someone it should have been done. DON stated the table did not have the ability to be lowered further that it had been, at attachment to the table was requiredFacility policy Dining Room Service dated 1/1/19, indicated the dining experience would enhance the individual's quality of life and be supportive of the individuals' needs during dining. Further, the policy indicated tables would be adjusted to accommodate wheelchairs, etcetera, positioning at mealtime must be appropriate for individual's needs.

Based on observation, interview and document review, the facility failed to ensure past recertification survey results were available for review. This had the potential to affect all 51 residents residing in the facility, as well as family, visitors and staff.Findings include: On 1/8/26 at 12:00 p.m., a review of the survey binder was completed. It was noted that all required recertification surveys, as well as complaint investigation surveys were present, with the exception of the most recent recertification survey of 1/15/25. On 1/8/26 at 12:05 p.m., an interview was completed with the administrator. Administrator acknowledged the most recent recertification results of 1/15/25 were missing from the survey binder. Administrator stated, the results of all surveys and complaint investigations were to be present in the survey binder, in addition to the plan of correction, and results were to be placed in a spot easy for residents, family members/responsible parties, visitors, staff, and others who may be interested were able to review. The facility policy, Posting of Survey Results, last reviewed 11/20/25, identified the facility was to have the survey results and plans of corrections available to all residents. This was noted to be the responsibility of the administrator. The policy went on to identify the following was to be in place with the posting of survey results:

Based on interview and document review, the facility failed to promptly obtain diuretic medication and failed to notify the physician to prevent the continued increase of carbon dioxide for 1 of 2 residents (R24) reviewed for medication errors. This practice resulted in a significant medication error and actual harm when R24 did not receive medication for 4 consecutive days resulting in R24 being sent to the emergency room to receive care for acute onset chronic respiratory failure with hypoxia (condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) and hypercapnia (condition where there is too much carbon dioxide (CO2) in the blood). Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R24's diagnoses included acute on chronic diastolic heart failure, hypertension, hyponatremia, schizophrenia, chronic obstructive pulmonary disease, respiratory failure, acute and chronic respiratory failure with hypoxia, paroxysmal atrial fibrillation, acute kidney failure, dysphagia, and emphysema. R24's physician's order dated 10/25/2024, identified R24 was prescribed 250 milligrams (MG) of oral Diamox (diuretic medication) twice daily for increased CO2 and hypercapnia. Review of R24's laboratory results for labs drawn on 10/25/24, indicated R24's CO2 levels were greater than 45 mmol/L (millimoles per liter). The range for normal CO2 levels are between 20 to 29 mmol/L. Review of R24's medication administration record (MAR) from 10/21/24 to 11/3/24, identified Diamox was ordered on 10/25/24 but was not administered to R24 for a total of eight doses. Seven of the eight doses (10/25/24 through 10/28/24) indicated Not Administered: Drug/Item Unavailable. Dose on 10/29/24 indicated Not Administered: Drug/Item Unavailable - Comment: called A&E for supply. R24's progress notes from 10/25/24 to 10/29/24 gave no indication R24's Diamox prescription was never received from pharmacy or R24's provider was contacted. Progress notes failed to identify any attempt to receive or follow up on R24's Diamox medication. R24's progress note dated 10/29/24 at 11:04 a.m., indicated resident was sent to the emergency department (ER) due to difficulty breathing, severe low oxygen saturations (69%), high respirations (32 breaths per minute) and skin was gray in color. R24's hospital discharge summary dated 11/1/24, identified principal diagnoses of acute on chronic respiratory failure with hypoxia and hypercapnia. The following criteria for acute respiratory failure were met; increase of at least 2L (liters) from chronic home O2 (oxygen), PCO2 (partial pressure of arterial carbon dioxide) greater than 50, O2 sats less than 89% more than once, and respiratory rate greater than 20 breaths per minute. Summary indicated shortness of breath, at baseline resident on 3L oxygen and needed up to 15L of oxygen and now back down to 3L, although no wheezing patient had significantly diminished air entry to the bases, was retaining CO2 and likely leading to increased work of breathing and addition of oral prednisone (steroid) for 5 days. R24 was discharged from hospital and returned to facility on 11/1/24 at 1:30 p.m. During interview on 12/4/24 at 10:42 a.m., pharmacist stated Diamox was a lot like Lasix as it helped to rid body of excess fluid and worked by inhibiting the enzymes as it disrupted the balance between acid base ratios. Potential side effects of not receiving the medication would be shortness of breath. Pharmacist stated R24 not receiving eight doses of medication contributed to resident being sent to the ER for increased CO2 and hypercapnia. She would considered this a significant medication error as it would affect her breathing. Pharmacist stated medication was filled on 10/29/24 from the original prescription that was prescribed in April 2024 for once daily. She was not able to find an order, that was prescribed in October, for Diamox twice daily in the system. Pharmacist stated facility may not have sent the updated prescription to the pharmacy. During interview on 12/5/24 at 8:05 a.m., trained medication aide (TMA)-B stated if a medication was not available, she would notify the nurse. TMA-B stated the nurse does the communication/ordering of medications. TMA-B stated she would write down medications that are needed and give them to the nurse as it is sometimes difficult to get things. TMA-B stated if it had been a couple of days and medication was still not available, she notified the nurse again to remind to call pharmacy to see where medication was. During interview on 12/5/24 at 9:01 a.m., nurse practitioner (NP) stated medication was prescribed on 10/25/24 on the direction of Dr. [NAME] for increasing CO2 and hypercapnia based on labs that were obtained on 10/25/24. NP stated she was not aware of facility notifying her of resident not receiving medication. NP stated R24 was sent to the ER due to her history of COPD (chronic obstructive pulmonary disease) and CO2 retention. During interview on 12/5/24 at 10:20 a.m., TMA-C stated if medication was not available, she would first check the Omnicell to see if medication was available and if not, she would report it to the nurse by writing it on her report sheet. TMA-C stated the nurse was the only one that does the communication with pharmacy. TMA-C stated director of nursing (DON) talked to her on 12/3/24 regarding her process if medication was not available. During interview on 12/5/24 at 10:46 a.m., health unit coordinator (HUC)-A and HUC-B stated when a new order was received, they enter the order in the electronic health record (EHR), place the order in file folder for nurse to review and scans the order to their email to send to pharmacy. HUC-A and HUC-B stated they did not have any confirmation page/email that order was sent to pharmacy. During interview on 12/5/24 at 10:58 a.m., licensed practical nurse (LPN)-B stated if a TMA was unable to find a medication, they should go and look in the Omnicell for medication. If medication was not available in the Omnicell, TMA should tell nurse who would call the pharmacy and document the communication in the progress notes. LPN-B stated new orders are entered in the EHR and sent to pharmacy by the HUC and then the nurse would go and verify the order. LPN-B stated she did not remember this medication or if she contacted pharmacy. LPN-B stated if she had contacted pharmacy, she would have documented it in a progress note. LPN-B stated she does not recall being updated by any TMA's that medication was not available. During interview on 12/5/24 at 11:39 a.m., TMA-D stated if medication was not available, she would check the Omnicell and would then notify the nurse. TMA-D stated the nurse was the one that follows up with pharmacy regarding medications. During interview on 12/5/24 at 12:29 p.m., LPN-C stated if medication was not available, Omnicell should be checked for availability. Pharmacy would then be called to check on the status and would also check the medication receipt book from pharmacy to see if medication had been delivered. LPN-C stated a progress note would be documented regarding communication with the pharmacy. During interview on 12/5/24 at 12:39 p.m., DON stated she expected the nurse to contact pharmacy to get clarification on what was happening with delivery of any medication not received. She expected the TMAs to communicate to the nurse on duty when a medication was not available. Some nurses documented pharmacy communication in progress notes, and some documented it on the medication administration record (MAR). DON stated it was best practice to document all communication with providers. New orders were transcribed by the HUC and then placed in the unit folder for the nurse to verify order. DON stated the HUC sent orders to the pharmacy upon transcription of order. DON stated she was on medical leave at the time of medication error and that a preliminary investigation was completed by a LPN-A but was not thoroughly completed. From a clinical standpoint, there was a critical lab value, and we did not give the medication that was prescribed to mitigate the risk. If medication was administered as prescribed, they may not have needed to send R27 to the hospital. During interview on 12/6/24 at 9:19 a.m., LPN care coordinator-A stated if a medication was not available, the TMA would check the Omnicell to see if medication was available and if medication was not in Omnicell, TMA would notify the nurse. LPN-A stated the nurse would call the pharmacy to check on the status of the medication. LPN-A stated she would expect the nurse to document any communication with pharmacy or providers. LPN-A stated she was notified on 10/29/24 that R24 had not received any Diamox that was prescribed on 10/25/24. She followed up with pharmacy, was informed the medication would be out for delivery on the night of 10/29/24. LPN-A stated she started the incident event in the EHR and mentioned the incident to a couple of people but did not do any other investigation and/or interviews regarding incident. During interview on 12/6/24 at 10:00 a.m., DON stated that she was in the middle of investigating the incident when she talked to surveyor on 12/5/24. DON identified if it wasn't charted, it wasn't done and confirmed no documentation was found regarding incident. DON stated education and new procedures were implemented in the past 12 hours to prevent reoccurrence. Changes to procedure consisted of proper communication chains, reminders of what to do when a medication was not available, changed the option in the EMR where TMAs are not able to use the drug unused/unavailable feature and education of placing a progress note on all communications that have transpired. During interview on 12/6/24 at 10:26 a.m., medical director stated the facility had not made him aware of this medication error and found it during his monthly review of incidents and pharmacy review. Medical director stated communication was not timely. The facility Medication Administration policy, dated 10/8/24, indicated medications will be administered by licensed nurses or trained medication aides under the supervision of a licensed nurse. The facility Ordering Medication policy, dated 10/8/24, indicated if medication was not found, staff to look on the printed sheet to verify that it was filled and look for the medication before calling the pharmacy. If, after searching, staff cannot find the medication and it is not in the printout as being sent, call the pharmacy. The facility Trained Medication Aide job description, dated 12/8/2023, indicated TMAs are to report medication refused or not given to the overseeing nurse. The facility Licensed Practical Nurse job description, undated, indicated LPNs coordinated medications, supplies and equipment including ordering, receiving, storing, and disposing of all items in accordance with facility policies and procedures.

Based on interview and document review, the facility failed to ensure a level II preadmission screening and resident review (PASARR) was completed for 1 of 1 residents (R35) residents reviewed with a diagnosis of Mild intellectual Disability. Findings include: R35's Annual Minimum Data Set (MDS), dated [DATE]; indicated R35 had diagnosis of anxiety disorder. In review of R35's History and Physical, dated [DATE], diagnoses also included obsessive compulsive disorder (OCD) and Adjustment disorder with anxious mood. R35's admitted was [DATE]. In review of R35' level I PASARR was completed on [DATE] prior to admission and indicated a PASARR level II was required before R35 admitted to a nursing facility. Form also indicated the presence of a developmental disability. In review of R35's Level II PASARR (dated [DATE]) indicated the diagnosis of Mild Intellectual Disability. The anticipated length of stay: ,d+[DATE] days. In further review of R35's level II PASARR, under Final Determination of Length of Stay, The screener completing this form marked the following: The person has developmental disabilities or related conditions and meets one of the following conditions (if yes, pick one of next four options): > As determined by the physician, this person requires recuperative care for physical illness or surgery for the hospitalization was required within the past two weeks. This person does require nursing facility (NF) services and will be admitted to the NF for a time limited stay of 150 days or less. > This person has a terminal illness and/or requires hospice services. Based on signed statements from the physician, this person's life expectancy is six months or less. This person does require NF services and will be admitted to the NF for long-term care. > This person requires a NF stay of fewer than 30 days and the person is expected to return to the community following the brief NF stay. This person requires NF services and will be admitted to the NF. > This person had ongoing medical and health needs and requires NF services. This person will be admitted to the NF for a stay of 151 days or more. Of the four options given none of them were marked as the reason for admission. The Level II PASARR indicated Anticipated discharge date of [DATE]. In further review of R35's medical record, a second Level I PASARR had been completed on [DATE]. Both Level 1 PASARRs were accompanied by a Level II. Both Level IIs were dark and illegible, being unable to determine if R35 rquired any services, the nursing home could not provide. An attached email documented R35 had Department of Human Services (DHS) approval R35's continued long term care stay only through [DATE]. In interview on [DATE] at 10:16 a.m., R35 stated he had been living in a group home in Otsego before coming here. He was unaware of why he was in this facility, only that this was where he was to now live. During multiple survey observations, from [DATE] - [DATE], R35 was observed independently attending facility activities and meals with verbal cueing, laying on his bed watching TV, and walking around the central dayroom / entrance area people watching. On [DATE] at 3:25 p.m., attempt was made to contact by phone the [NAME] County social worker (COLSW) who had completed all of R35's PASARRs. A voice message was left with a call back number. No call back had been received during the duration of the survey. During a telephone interview on [DATE] at 7:43 a.m., R35's family member (FAM)-A stated R35 had been in multiple group homes since his mother died . During the last group home stay, the facility was not monitoring R35's blood pressures and edema (fluid retention in his feet and legs), and had not been updating the primary physician when blood pressures were elevate and edema was present. Family requested nursing home stay due to their concerns the group home setting was not meeting R35's health care needs. FAM-A stated the biggest issue they group homes were having with R35, was resident digging in / playing with his bowel movements. The group home he was in was not monitoring his behavior, and R35 was storing stool soiled clothing throughout his room. Family had ask for oversight, but it was not being done by the facility. During interview on [DATE] at 3:11 p.m., licensed social workers (LSW)-A and LSW-B stated they were unaware R35's Level II PASARR had not been completed by the COLSW. Both LSWs stated they assumed the Level II PASARR was complete and accurate. LSW-B stated R35's family were concerned resident's health needs were not being met in the group home setting. Both LSWs state they are not the ones who determine R35's length of stay, but rather the COLSW and DHS. LSW-B stated the County has historically been behind in assessments. A review of the facility's policy, entitled Pre-admission Screening and Resident Review (PASRR)-MN, last revised [DATE], the policy indicted the following: Developmental Disability 1. Potential residents who are determined to have a developmental disability or related condition must be approved for admission by the state Developmental Disability Authority (DDA) and approval must include an approved length of stay prior to admission into the nursing facility.

Based on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed, accurate, and revised to assure assessed care needs were implemented for 1 of 2 residents (R35) reviewed for care planning. Findings include: R35's Annual Minimum Data Set (MDS), 11/05/2024; indicated R35 had diagnoses including anxiety disorder. In review of R35's History and Physical, dated 10/27/23, additional diagnoses included obsessive compulsive disorder (OCD) and Adjustment disorder with anxious mood. In review of R35' level I PASARR was completed on 10/30/23 prior to admission and indicated a PASARR level II was required before R35 admitted to a nursing facility, indicated the presence of a developmental disability. In review of R35's Level II PASARR (dated 11/09/23) indicated the diagnosis of Mild Intellectual Disability. In review of R35's care plan (last revised 11/13/24), R35 had a documented problem of: Problem Start Date: 11/22/2023 Category: Psychosocial Well-Being Resident has [PASARR] Level II for Persons with Mental Illness and or Intellectual Disability or a related condition due to DX of Obsessive-compulsive disorder, unspecified and Adjustment disorder with anxiety . Resident needs specialized services and the [PASARR] screening team has determined that resident meets the criteria for NF care. [NAME] County will provide or arrange for the following specialized mental health services. Goal: Resident will exhibit fewer mood symptoms of isolating self in the next 90 days and accept redirection and reassurance from staff and family. [Resident] will maintain active daily schedule per interests. Approaches: > Referral will be made to Senior Linkage Line for change of condition in accordance with MDS guidelines. > Referral will be made to Senior Linkage Line if resident has an inpatient psychiatric stay or equally intensive treatment. > Resident will see their psychologist and psychiatrist on regular basis. In an interview on 12/6/24 at 8:40 a.m., LTC (long term care) clinical coordinator (LPN)-A stated the psycho-social care planning is completed by the social service department. LPN-A was unaware of any sessions with a psychologist or psychiatrist on regular basis. During an interview on 12/6/24 ay 8:49 a.m., the facility licensed social workers (LSW)-A and LSW-B stated the facility has arrangements with Associated Clinic or Psychology (ACP), however, R35 had never received services while in the facility. LSW-B stated in conversations with R35's family, they did not feel these services were necessary. LSW-B stated R35's Care plan should have been updated. In review of the facility's policy, entitled: Care Plan and Baseline Care Plan (last revised 10/14/22) indicted the following: 3. The interdisciplinary team, in conjunction with the resident, resident's family, significant other or resident representative, shall develop a comprehensive person-centered care plan for each resident. This comprehensive care plan will be in the [electronic health record] by day 21 of the stay or 7 days after completion of the comprehensive initial MDS, whichever comes first. 4. The resident care plan is constantly changing. It should be updated routinely in the electronic record to reflect resident's current condition. The resident care plan is reviewed for accuracy, updated with quarterly MDS review, and all other scheduled MDS assessments.

Based on observation, interview, and document review, the facility failed to comprehensively assess and implement interventions to ensure proper wheelchair positioning and prevent potential complications for 2 of 2 residents (R6 and R19) reviewed for wheelchair usage. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 had severe cognitive impairment. R6's care plan identified R6 had a self-care deficit and required assistance with transfers and occasionally with locomotion and utilized a wheelchair. During observation on 12/3/24 at 4:07 p.m., R6 was being pushed down hallway in her wheelchair with no foot pedal on. R6's left foot was dragging and bouncing on floor. Staff did not provide reminders to R6 to hold her foot up. During observation on 12/4/24 at 12:47 p.m., R6 was being pushed down hallway in her wheelchair with no foot pedal on. R6's left foot was dragging and bouncing on floor. Staff did not provide reminders to R6 to hold her foot up. During observation on 12/4/24 at 4:32 p.m., R6 was being pushed down hallway in her wheelchair with no foot pedal on. R6's left foot was dragging and bouncing on floor. Staff did not provide reminders to R6 to hold her foot up. During observation on 12/6/24 at 9:10 a.m., R6 was being pushed down hallway in her wheelchair with no foot pedal on. R6's left foot was dragging and bouncing on floor. Staff did not provide reminders to R6 to hold her foot up. R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 had cognitive impairment. Further, R19's care plan identified R19 had a self-care deficit and required assistance with transfers and locomotion in a wheelchair to reach desired destinations and utilized a wheelchair. During observation on 12/2/24 at 11:36 a.m. R19 was being pushed down hallway in his wheelchair with no foot pedals on. R19's feet were dragging and bouncing on floor. Staff did not provide reminders to R19 to hold his feet up. During observation on 12/3/24 at 11:49 a.m. R19 was being pushed down hallway in his wheelchair with no foot pedals on. R19's feet were dragging and bouncing on floor. Staff did not provide reminders to R19 to hold his feet up. During observation on 12/3/24 at 4:52 p.m. R19 was being pushed down hallway in his wheelchair with no foot pedals on. R19's feet were dragging and bouncing on floor. Staff did not provide reminders to R19 to hold his feet up. During observation on 12/4/24 at 4:39 p.m., foot pedal was observed laying on top of R19's walker along the wall in his room. During observation on 12/6/24 at 9:08 a.m. R19 was being pushed down hallway in his wheelchair with no foot pedals on. R19's feet were dragging and bouncing on floor. Staff did not provide reminders to R19 to hold his feet up. During interview on 12/4/24 at 3:25 p.m., nursing assistant (NA)-A stated foot pedals are used as needed. NA-A stated R6 has one foot pedal that should be used if staff are assisting her with propelling wheelchair. NA-A stated R19 has foot pedals that staff use as needed. During interview on 12/6/24 at 9:01 a.m., trained medication aide (TMA)-A stated foot pedals should be used for any resident who had them and needed staff assistance transporting to and from any destination. TMA-A stated R6 does not have or use foot pedals. TMA-A stated R19 does not use foot pedals often. During interview on 12/6/24 at 9:19 a.m., licensed practical nurse (LPN)-A stated foot pedals are used when the resident is not about to pick up their feet or needed assistant with keeping their feet off the floor. LPN-A stated foot pedals should be used for residents who are not able to keep their feet up when staff pushed the wheelchair to and from destinations. R6 did not use foot pedals. Foot pedals should be used for R19 if he was not picking his feet up. LPN-A stated she expected staff to utilize foot pedals in all observations noted above. LPN-A stated it was important for foot pedals to be used for safety when escorting residents in a wheelchair to and from destinations and to prevent injuries. During interview on 12/6/24 at 9:48 a.m., director of nursing (DON) stated that foot pedals are assessed upon admission and would be accessible when needed. DON stated foot pedals are not always on the wheelchair but are stored in resident's room to be used as needed. When a resident was exhibiting signs of not being able to keep feet held off floor when being transported to and from destinations, DON expected foot pedals be placed on wheelchair and used. She expected staff to use foot pedals in all observations noted above. DON stated it was important to use foot pedals on wheelchair during transport to prevent injury and that it was best practice. A wheelchair positioning policy was requested but was not provided.

Based on interview and document review, the facility failed to follow a care planned intervention to prevent or reduce the risk of aspiration for 1 of 2 residents (R7) reviewed for nutrition and needing supervision at meals. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition and required assistance with all activities of daily living (ADL)'s. R7's diagnoses included traumatic brain dysfunction, unspecified intracranial injury with loss of consciousness of unspecified duration, hypertension, peripheral vascular disease, hemiplegia, traumatic brain injury, depression, polyneuropathy, dysphagia - oropharyngeal phase, dysarthria and anarthria, osteoarthritis, chronic kidney disease and bicipital tendinitis. MDS indicated R7 needed supervision or touching assistance with eating. R7's Nutrition Care Area Assessment (CAA) dated 7/23/24, identified R7 was at risk for swallowing problems due to dysphagia, need for special diet or altered consistency which might not appeal to resident and the inability to perform self-care or mobility without significant physical assistance. CAA indicated R7 was currently on a pureed diet with mildly (nectar) thick liquids, facility to continue to provide diet per order and observe weights and intakes for changes. No referrals at this time, will proceed to care plan with goal to tolerate food and fluids served. R7's care plan, print date of 12/4/24, identified R7 required a pureed diet (in smooth applesauce consistency) with mildly thick liquids (nectar) related to dysphagia with instructions to thicken liquids more if coughing. R7 utilized adaptive equipment to increase independence at meals (lipped plate and Kennedy cup). Staff was to provide close supervision at his table to control pacing and remind him to stop and swallow when he started coughing, resident's preference was to sit at a table by himself, resident used bedside table to eat in dining room. Care plan also identified R7 had an alteration in activities of daily living (ADLs) related to history of traumatic brain injury with subsequent hemiplegia/hemiparesis affecting right dominant side, weakness, osteoarthritis, polyneuropathy, and pain, at risk for decline in ADLs. An intervention directed staff to provide close supervision with all meals for pacing assist and to remind resident to place silverware down between bites and monitor bite size. R7's physician orders, print date of 12/4/24, included orders to assist resident with feeding to control bite size and diet of puree food in smooth/applesauce consistency with mildly/nectar thick liquids (if coughing, thicken more). Diet order included special instructions of close supervision to control pacing and remind him to stop and swallow when he started coughing. R7's quarterly nutrition review progress note, dated 10/14/24, indicated staff was to thicken liquids more if R7 was coughing and that R7 required close supervision when eating. Progress note also indicated R7 was to receive assistance at meal to control bite size/pacing and remind him to stop and swallow when starts coughing. During observation on 12/3/24 at 12:04 p.m., R7 was seated at table in dining room drinking chocolate milk out of Kennedy cup. At 12:08 p.m., R7 received a lipped plate and was using his left hand to eat with regular silverware. R7's food was pureed and fluids were appropriately thickened. R7 was struggling to get food to his mouth due to not being able to flex left arm at the elbow. R7 took large spoonfuls of food and would take one spoonful after another without pacing between bites. At 12:26 p.m., R7 began coughing and had a non-productive cough that lasted several seconds. Staff did not intervene when R7 was coughing. No staff were present at his table and did not provide reminders to R7 throughout meal. Staff seated two tables away assisting another resident with eating. During observation on 12/3/24 at 5:08 p.m., R7 was seated at table in dining room and dietary staff delivered plate. R7's food was pureed and fluids were appropriately thickened. R7 was again struggling to get food to his mouth and had food dripping down face. Resident took large spoonfuls of food and would take one spoonful after another without pacing between bites. At 5:20 p.m., R7 continued sitting at table alone. At 5:36 p.m., R7 was assisted out of dining room by staff. No staff were present and did not provide reminders to R7 throughout meal. During observation on 12/4/24 at 12:08 p.m., R7 was sitting at table in dining room. R7's food was pureed and fluids were appropriately thickened. R7 was again struggling to get food to his mouth. At 12:16 p.m., R7 had food dripping down his face. At 12:17 p.m., R7 began coughing and had a non-productive cough. At 12:23 p.m., dietary staff went to R7's table, gathered dirty clothing protector and left table. At 12:24 p.m., staff asked R7 if he was finished, R7 nodded his head yes. At 12:28 p.m., staff assisted R7 out of dining room. No staff were present and did not provide reminders to R7 throughout meal. During interview on 12/4/24 at 3:27 p.m., nursing assistant (NA)-A stated R7 received pureed thickened foods due to difficulty swallowing. NA-A stated she was not aware of any other assistance R7 needed at mealtimes. During interview on 12/6/24 at 9:01 a.m., trained medication assistant (TMA)-A stated R7 was able to feed himself but needed close supervision which consisted of watching for coughing and monitoring bite size. TMA-A stated if R7 was taking too big of bites, staff were to provide reminders to R7 to slow down and watch bite size and staff may need to help with feeding as needed. During interview on 12/6/24 at 9:19 a.m., licensed practical nurse (LPN)-A stated R7 was independent with eating but needed supervision with ensuring he is not eating too much and providing reminders to take smaller bites and to slow down. LPN-A stated R7 did not need any assistance with eating but if staff heard any coughing they would go and check on his. LPN-A confirmed R7 had an order for close monitoring when eating. LPN-A stated it was important to ensure close supervision was occurring during mealtimes to ensure that R7 did not choke or aspirate on food. LPN-A stated staff should be providing reminders regarding bite size and to slow down when eating. During interview on 12/6/24 at 9:55 a.m., director of nursing (DON) stated R7 needed close supervision with meals as ordered and staff should be in close proximity to R7, so they are able to offer reminders as warranted. DON stated it was important to follow these orders/instructions as it was ordered for R7's safety and to work on R7 controlling his pace and reducing the risk for aspiration. The facility Feeding of residents by staff policy, dated 3/27/24, indicated residents unable to feed themselves will be provided with assistance per their care plan. Staff sit at eye level with resident and offer small bite-sized portions on the fork or spoon at a regular rate.

Based on observation, interview, and document review, the facility failed to ensure 3 of 3 residents (R36, R19, R39) were comprehensively assessed for safety and ability to self-administer medications who were reviewed for medication administration. Findings include: R36 R36's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact and had diagnoses which included lung disease, heart failure and high blood pressure. Identified R36 required set-up and supervision assistance with eating and oral cares and received hospice services. R36's care plan dated 8/12/23, indicated R36 had a potential alteration in respiratory status related to lung disease, and directed staff to administer medications as ordered. Identified staff were to monitor for changes in respiratory status including signs of distress and shortness of breath. The care plan lacked indication R36 was able to self-administer medications. R36's Self-Administration of Medication (SAM) observation dated 7/14/23, indicated R36 did not self-administer medications, nor did R36 want to self-administer medications. R36's Physician Order Report dated 10/1/23 to 10/31/23, printed 10/18/23, included ipratropium-albuterol solution (to prevent wheezing and shortness of breath) for nebulization (where the liquid medication is placed into a machine which turns it into a mist so it can be inhaled into the lungs); 0.5 milligrams (mg)-3 mg (2.5 mg base)/3 milliliters (mL). The orders lacked an order for R36 to self-administer her medications. During an observation on 10/16/23 at 7:12 p.m., licensed practical nurse (LPN)-A added R36's ipratropium-albuterol solution to the nebulizer cup, attached it to the nebulizer mask and placed the mask on R36's face affixing it with an elastic band around R36's head. LPN-A turned on the machine, informed R36 they would be back in a little bit, left the room, returned to the medication cart and dispensed and administered medications to another resident down the hallway. At 7:26 p.m. LPN-A returned to R36, turned the machine off and removed R36's mask. During an interview on 10/16/23 at 7:26 p.m., LPN-A stated staff set up the treatment for R36 and confirmed the staff left the room and allowed R36 to complete the nebulizer treatment without staff supervision. LPN-A stated staff knew the residents well and identified when a resident could self-administer medications by observing them or by reviewing the care plan. LPN-A indicated she was not aware if there was a SAM completed for R36. R19 R19's quarterly MDS dated [DATE], indicated he was cognitively intact and required extensive assistance of one staff for dressing, toileting, and personal hygiene. Identified R19 received pain medication as needed. R19's ICD-10 Diagnosis Report - Clinical dated 10/18/23, included R19 had cellulitis of both the left and right legs, diabetes, and morbid obesity. R19's care plan dated 9/26/23, indicated R19 wished to self-administer oral medications after staff set-up as appropriate per evaluation and included R19 was safe to keep TUMS at bedside however did not address any topical creams. R19's SAM dated 9/26/23, indicated he wanted to self-administer some medications, and was safe to keep TUMS at bedside. The assessment did not address topical creams. R19's Physician Order Report dated 10/1/23 to 10/31/23, printed 10/18/23, included 1% diclofenac sodium gel (a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild to moderate pain), four grams, apply topically once per day at bedtime and twice per day as needed to left hip and left knee. The orders lacked an order for R19 to self-administer his ointments. During an observation and interview on 10/16/23 at 4:12 p.m., R19 sat in his wheelchair in his room with both legs wrapped in ace bandages and a Band-Aid on the side of his left knee. R19 stated he was having a lot of hip and knee pain and just returned from the doctor where he received injections to reduce the pain. A nearly empty tube of diclofenac sodium gel sat in a basin on the nightstand in front of him within reach. R19 stated he applied it himself, usually before he got out of bed and indicated it was effective for a couple of hours. R39 R39's significant change Minimum Data Set (MDS) dated [DATE], indicated he was moderately cognitively impaired and had diagnoses which included stroke and aphasia (difficulty communicating). Identified R39 required limited assistance of one staff for personal hygiene and toileting. R39's care plan dated 7/17/23, indicated he had potential alteration in skin integrity, included treat per provider orders and lotion as needed to moisturize skin. R39's SAM dated 8/14/23, indicated R39 did not self-administer medications nor did R39 wish to self-administer medications. R39's Physician Order Report dated 10/1/23 to 10/31/23, printed 10/18/23, included menthol-zinc oxide ointment (skin protectant), 0.44-20.6%, apply topically to skin soiling/saturation every shift and as needed, and miconazole nitrate powder (an anti-fungal), 2% (percent), apply topically to the skin and skin folds every shift and as needed. R39's orders did not include topical menthol ointment (Vicks VapoRub). In addition, the orders lacked an order for R39 to self-administer medications. During an observation and interview on 10/16/23 at 2:23 p.m., R39 was lying in bed and had dry, flaky patches of skin on his nose. R39 stated staff did not apply any treatment to the flaky patches, pointed to his side table which contained a tube of general barrier skin protectant cream and a tube of menthol-zinc oxide ointment. In addition, a container of anti-fungal powder was located on top of his night stand next to the table, within reach. During an observation on 10/16/23 at 5:50 p.m., R39 self-propelled in his wheelchair from his room into the hallway and had a thick white opaque product covering his face. LPN-B walked by him, noted the cream, and asked R39 why his face was white. R39 stated he applied some cream to his dry skin on his face. LPN-B accompanied R39 back to his room to remove the cream. During an interview on 10/17/23 at 5:16 p.m., LPN-B stated she walked by R39 the previous day and noticed his face appeared powdered and white. LPN-B asked R39 what was on his face and he stated he applied moisturizing lotion to it. LPN-B was not aware of what cream he had applied and stated the product was caked on so she washed it off and gave him a bottle of moisturizing lotion. LPN-B reviewed R39's medical record and confirmed he had a cream and a powder ordered for his bottom however had nothing prescribed for his face. In addition, LPN-B confirmed there were no orders for R39 for self-administration of medications. During an observation on 10/18/23 at 7:43 a.m., one jar of topical menthol ointment was located on top of R39's bedside table. During an observation and interview on 10/18/23 at 10:14 a.m., R39 was lying in bed watching television with his bedside table next to him. A jar of topical menthol ointment approximately 75% (percent) full remained on the table within reach. R39 stated he used the ointment daily and put it on his lips, nose, and sometimes in his mouth. During an interview on 10/17/23 at 5:16 p.m., LPN-B stated SAM's were completed upon admission and reviewed at care conferences to ensure appropriateness, however there were no residents on the unit who could self-administer medications at that time. LPN-B indicated when a resident received nebulizer treatments and was assessed as safe, staff could set up the treatment, leave the resident while the treatment proceeded, and come back to check on them later however staff needed to stay close by. In addition, LPN-B stated medicated creams should not be self-administered without a SAM which identified the resident was safe to self-administer. LPN-B indicated it was important to assess residents to allow them to be as independent as possible and to identify any potential safety risks. Upon review of R19's medical record, LPN-B confirmed he had a prescription for a topical pain cream for his left hip and left knee, however his SAM did not identify he was able to keep it at bedside and apply it himself. Further, LPN-B stated R19 was unable to reach his own hip to apply it. Upon review of R36's medical record, LPN-B confirmed the record lacked a SAM which identified R36 could administer her own nebulizer treatments without supervision. During an interview on 10/18/23 at 10:32 a.m., registered nurse (RN)-A stated residents were asked if they wanted to self-administer medications upon admission, and if so, a SAM was completed and re-evaluated quarterly to assure they were safe to self-administer. RN-A indicated when appropriate, the provider wrote an order, and it was added to the care plan. RN-A stated she expected staff to remove any unapproved medications found in a resident room, place it in the treatment cart and notify her so she could complete a SAM. RN-A confirmed SAM's had not been completed on R39, R19 and R36. During an interview on 10/18/23 at 11:26 a.m., director of nursing (DON) stated SAM's were expected to be completed upon admission to determine if residents wanted, and/or were able to safely self-administer their own medications. DON indicated when the results of the SAM determined a resident was safe to self-administer medications, staff informed the provider who approved it via orders. The facility policy titled Self Administration of Medication policy dated 2/20/23, indicated when a resident wished to self-administer medication, the nurse would complete the applicable assessment in the electronic health record. If determined appropriate, staff would obtain an order from the provider, and it would be added to the care plan. When a nebulizer treatment was set up for the resident and the resident was left unattended with the treatment running, that was considered a self-administration of medications.

Based on interview and document review, the facility failed to allegations of abuse were reported to the State Agency (SA) immediately (within two hours) for 2 of 3 residents (R2 and R3) reviewed for allegations of abuse. Findings include: R2's quarterly minimum data set (MDS) dated [DATE], indicated R2 had dementia and depression and was moderately cognitively impaired with no behaviors. R3's significant change MDS dated [DATE], indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Facility Reported Incident by the administrator dated 1/29/22, indicated co-workers reported comments that an employee had made while getting some residents up this morning that involved name calling and potential rough handling. The report further indicated an alleged perpetrator (AP) as nursing assistant (NA)-A. The report further indicated NA-A was immediately suspended pending investigation and ultimately terminated due to finding of abuse. Review of the facility five day report submitted 2/03/22, to the (SA) indicated NA-A had not kept vulnerable adults safe from physical or verbal abuse, but other staff were the ones that reported her actions in accordance to with the policy. The five day report further indicated the administrator was immediately notified regarding the report from the staff at the facility and immediately went to the facility regarding the report and escorted NA-A out of the building and staff were asked to write up statements regarding what they had witnessed. During interview 2/24/22, at 9:38 a.m. the director of nursing (DON) stated she was out of town and received a text message from NA-B the morning of 1/29/22, at 9:00 a.m. which included a picture of a note indicating all of NA-B's concerns of NA-A's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she was immediately put on suspension pending investigation and stated this was out of the ordinary for NA-A to act in the way to the residents and they were not short staffed but she was working with staff she normally did not work with. The DON provided the text message she received the morning of 1/29/22, at 9:00 a.m. to surveyor which indicated NA-B provided in the text message concerns with NA-A and the DON sent immediately to the administrator indicated: -Tone of Voice Stand up! Get Going Help -name calling fat ass, tuba -rough with residents -vocalized [room number ] (R2) don't be so rough -calls them names when they can hear such as dumb ass, dope she mumbles it under her breath around residents that have no hearing impairment -when [room number] was standing in EZ stand (mechanical lift) she said slap him in the ass and he heard it. -[R3] said I'm going to kill you to [NA-A] because of how rough she was. Even though the text message indicated additonal residents R2 and R3 on 1/29/22, the facility failed to immediately report those incidents of abuse. During interview 2/24/22, at 3:30 p.m. the facility administrator stated at the time of the incident the information was only based on a text message from an employee reporting another employee. The administrator stated he had no residents reporting abuse, just staff alleging employee to resident abuse. Adding, the specific problem was an alleged perpetrator (AP) who we immediately suspended and they felt this was an employee issue and that they should just report the initial resident on the report then the remainder of of the residents on the 5 day report. The administrator did state the all of their staff were immediately retrained on the abuse policy after the incident occurred and NA-A was terminated after their investigation. Facility Vulnerable Adult-MN Policy reviewed 7/20/21, indicated Cassia prohibits abuse, neglect of residents and processes ensure that the resident is free from abuse. The policy further indicated Each employee is responsible to report suspected/alleged violations of mistreatment, neglect exploitation of residents, and abuse of residents and/or misappropriation of resident property immediately, but no later than 2 hours after the allegation is made.

Based on interview and document review, the facility failed to ensure an annual performance review was conducted for 2 of 2 nursing assistants (NA-A, NA-B) whole files were reviewed. This had potential to affect all 42 residents residing in the facility during the abbreviated survey. Findings include: During the abbreviated survey, from 9/8/21 through 9/9/21, evidence was requested demonstrating completed performance evaluations for NA-A and NA-B, along with their hire dates. NA-A's provided Employee Review, indicated the review was a 90 day review and was due on 4/24/19, (based on calculation of a 1/24/19 hire date). The review was signed by NA-A on 4/16/19 (over two years prior). NA-A's employee file lacked documentation of annual performance reviews for January 2020 and January 2021. NA-B's provided Employee Review, indicated the review was a 90 day review and was due on 10/1/20 (based on calculation of a 7/1/20 hire date). The review was signed by NA-B on 12/11/20. No other performance reviews were provided during the abbreviated survey period. NA-B's employee file lacked documentation of an annual performance review due July 2020. During interview on 9/9/21, at 1:20 p.m. human resources employee (HR)-A stated she initiated the Employee Review form. She explained she tracked when this form was due and sent it first to the staff development nurse. Once the staff development nurse completed their review responsibilities, the review was forwarded to the employees supervisor. The employees supervisor met with the employee and reviewed the form. The form then went to the administrator for final review. She stated the employees were reviewed for performance generally 30, 60, and 90 days after hire and annual performance reviews were required once a year based on their hire date. She explained at the beginning of each month she reviewed her tracking form for what was due the following month and initiated the Employee Review forms based on that review; however, she denied she followed up on the reviews she sent out to ensure the reviews were completed and returned to her. Further, she denied Employee Review completion audits were conducted. When interviewed on 9/9/21, at 3:05 p.m. the director of nursing (DON) verbalized she performed all nursing staff performance evaluations and followed up with, I am not good at doing them. She acknowledged she was aware NA annual performance reviews were not completed as required. She explained timely completion of the performance evaluations was the biggest weakness in her position as DON. That is an area that comes up on my [performance] review every year. She confirmed all NAs were required to have an annual review, so that you can track to see if there are issues with the employee. Failure to complete annual performance reviews meant employees would potentially, fly under the radar which increased the risk for [resident] abuse. A policy related to NA performance evaluations was requested: one was not provided.

Based on observation, interview, and document review, the facility failed to comprehensively assess residents for the ability to self-administer medications after nurse setup for 1 of 1 residents (R146) observed self-administering medications. Findings include: R146's Nursing Admission Observation Detail List Report dated 6/3/21, indicated R146 admitted to the facility on [DATE] having been alert and orientated to person, place, and time. The admission report identified a heading labeled Self administration of medications which questioned if the admitting resident desired to administer their own medications during their stay at the facility. This section lacked a required No or Yes - (if yes, complete self administration of medication observation) response for R146. R146's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The report lacked evidence of a self-administration of medication order dated prior to 6/8/21. During continued observation and interview on 6/8/21, at 8:57 a.m. registered nurse (RN-A) prepared R146's eight morning medications as directed by the above Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A placed the medication and [MEDICATION(S)] cups on R146's tray table; located directly in front of R146 as she sat in her wheelchair next to her husband. RN-A obtained R146's blood sugar, performed hand hygiene in the bathroom, and exited R146's room before she ensured R146 had taken the medications. At 9:13 a.m. RN-A re-entered R146's room and administered R146's morning insulin. At 9:14 a.m. RN-A exited R146's room in which the cup of [MEDICATION(S)] remained unconsumed on the tray table in front of R146. RN-A failed to inquire if R146 had taken her medications and did not remain in R146's room to ensure she consumed the [MEDICATION(S)]. - Once returned to the medication cart, RN-A was questioned on R146's having a self-administer of medication order. After RN-A reviewed the electronic medical record (EMR), and before she answered the question, she walked to R146's room and asked R146 if she wanted medications left on the table for her and explained she could enter such an order if R146 desired it. R146 acknowledged she wished this. RN-A returned to the cart and started R146's self-administration assessment process in the EMR. RN-A confirmed R146 had not had an order prior to exiting R146's room; however, she stated, .she does now. RN-A explained she was required to do a self-administration observation assessment to determine if a resident was safe to self-administer their medications before medications were left with a resident; however, she denied she would be required to obtain an official physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated, I automatically know who can self-administer their medication; however, continued with, She [R146] is fairly new. In addition, RN-A explained, .with her [R146] being fairly new, I should have checked to make sure that that [self-administration order] is in place. R146's medical record lacked evidence she had been comprehensively assessed to be safe to self-administer her medications, or an order to do so, after nurse set-up prior to R146 being administered her 6/8/21 morning medications by RN-A. On 6/8/21, at 9:40 a.m. RN-A approached the surveyor and explained she had obtained an official physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated, I do need it [official physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 6/8/21, at 9:41 a.m. R146's tray table was observed to be free of the [MEDICATION(S)] cup. R146 stated sometimes staff leave her unsupervised after setting her up with her medications but not all the time. R146 had been unable to provide details on prior dates, times, or involved staff who may have left medications with her; however, she did confirm RN-A had left them with her that morning. In addition, R146 confirmed she was in agreement with her being left unsupervised with her medications after setup with a comment of, .I took them at home and I can take them here by myself. When interviewed on 6/10/21, at 12:13 p.m. long term care nursing manager (RN-B) stated if a resident desired to self-administer their medications a nurse would be required to perform an observation and if the observation deemed the resident could safely self-administer their meds they would them obtain an order from the medical provider. Prior to this process, RN-B explained she expected the nurse would remain within eye sight of the resident to ensure something does not happen. RN-B acknowledged R146 should not have had her medications left with her unattended without an order to do so. A policy Medication Administration, dated 6/2000, directed staff, Do not leave any medication unless the resident has an order to self administer.

Based on observation, interview, and document review, the facility failed to ensure medications were labeled with current and accurate administration instructions to prevent potential medication errors for 1 of 6 residents (R194) observed to receive medication during the survey. Findings include: On 6/7/21, at 5:25 p.m. licensed practical nurse (LPN)-A prepared medications at a mobile cart for R194. LPN-A removed a narcotic bubble medication pack from the cart's locked narcotic storage box which had a visible, white colored label affixed to the front corner. The label identified R194's name along with the medication instructions, [MEDICATION(S)]/APAP [hydrocodone/acetaminophen ([MEDICATION(S)]) (opioid pain medication)]] TAB [tablet] 5-325 mg [milligram] C-II 1 - 2 tablets by mouth every 4 hours as needed (1 tab for pain 4-6; 2 tabs for pain 7-10). The medication bubble pack identified pharmacy attached caution stickers alongside the label; however, the pack lacked evidence of a direction change alert. After preparing the [MEDICATION(S)], LPN-A documented the remaining [MEDICATION(S)] count in the narcotic log book on R194's designated individual narcotic record page. The page identified the same white label as that on the medication bubble pack; however, also lacked any indication of a frequency order change alert. LPN-A did not verbally identify any potential concerns with R194's [MEDICATION(S)] order before or after she administered two tabs of [MEDICATION(S)] to R194 in her room. On 6/9/21, a telephone order (T.O.), dated 5/24/21, identified R194's [MEDICATION(S)] had a direction change which increased the frequency of administration to every three hours as needed. The T.O. identified LPN-A had obtained the order change and that long term care nursing manager (RN)-B had completed the second nurse order processing check. The T.O. lacked evidence the order had been faxed to the pharmacy. R194's June 2021 Medication Administration Record (MAR) directed staff to administer the [MEDICATION(S)] every three hours as needed. The MAR directed order was dated 5/24/21. During interview on 6/9/21, at 9:31 a.m. pharmacist (P)-A stated the pharmacy had on file a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . P-A stated the original [MEDICATION(S)] order date had been 5/23/21 and denied the pharmacy computer system identified the [MEDICATION(S)] order frequency change from 5/24/21. When interviewed on 6/9/21, registered nurse (RN)-C compared R194's [MEDICATION(S)] order and the [MEDICATION(S)] bubble medication pack label. After, RN-C verbalized the MAR directed staff to administer the [MEDICATION(S)] every three hours as needed; however, the medication pack directed every four hours as needed. RN-C acknowledged a direction change sticker should have been placed on the medication pack and on the individual narcotic record page when the frequency order on 5/24/21 had changed. In addition, RN-C examined R194's telephone order's and explained the 5/24/21 T.O. should have had a stamp on it that indicated the order was faxed to pharmacy. RN-C confirmed this stamp had not been on the T.O. as per facility practice. RN-C stated a risk factor of staff not being alerted to a potential medication order change would be the resident may receive the wrong medication, the wrong dose, or the medication would be administered at the wrong time. During interview on 6/10/21, at 12:13 p.m. RN-B stated the facility did not have an official policy to apply a direction change sticker on the medication label if an order had changed; however, the facility did have direction change stickers available for staff to use, or staff would use a marker to write an alert on the label. RN-B explained she expected staff to follow the orders as directed on the MAR; however, if there was a discrepancy between the MAR and the medication label, staff should then review the original physician order(s) in the paper medical record to determine the most current administration direction(s). RN-B confirmed she had not faxed R194's 5/24/21 [MEDICATION(S)] order to the pharmacy when she had double checked the order on 5/24/21, as she explained she had thought LPN-A .was going to fax it. RN-B stated the importance of ensuring medications are given as ordered would be so the resident would be free of complications. A policy Medication Administration, dated 6/2000, indicated a procedure which directed, Do not change labels on the medication bottles. This may only be done by a pharmacist. It is acceptable, under a nurse's instruction, to place a Direction Change Refer to Chart label on a medication where the order has been changed, but current supply is to be used up at the new dose/direction. This is to be done at the time of processing the order change or shortly thereafter.

Based on interview and document review, the facility failed to comprehensively assess and develop a bowel management program for 1 of 1 residents (R39) reviewed who reported being constipated from taking narcotic medications. Findings include: R39's 14-Day Prospective Payment Systems (PPS) Minimum Data Set ((MDS) dated [DATE], identified R39 had intact cognition and was continent of bowel. In addition, R39's care plan dated 3/11/19, identified R39 was continent of bowel; however, was at risk for an alteration in bowel function due to a ruptured hepatic cyst. The care plan had several interventions for R39 including monitoring bowel pattern daily and providing medications as ordered. When interviewed on 3/18/19, at 7:11 p.m. R39 stated she was having issues with ongoing constipation (condition in which there is difficulty emptying the bowels) from taking narcotic medications. The floor nurses were repeatedly providing her milk of magnesia (MOM); however, it was not working very well. R39 explained she was currently on her fourth day without having a bowel movement, and added she wanted to take something to help keep her having more regular bowel movements and help reduce her abdominal discomfort. R39's progress note dated 2/21/19, identified an recorded entry which read, Gave MOM for 'couple days since I had a bowel movement and I just can't go', waiting for results. R39's most recent Nursing Observations - MDS 3.0 - Elim dated 2/22/19, listed a section labeled, Bowel Function Observation, which addressed R39's current bowel status. R39 had no selected, actual bowel problems and was recorded as, Always continent. Further, the assessment listed a question which read, Constipation present? This was answered with a radio-button response of, No. The completed assessment did not identify R39 as having any potential issue with constipation despite having a progress note completed the day prior, on 2/21/19, which indicated R39 as needing MOM to help move the bowels. R39's Vitals Report dated 2/16/19 to 3/19/19, identified R39's recorded bowel movements. The report identified the following: - On 2/21/19 and 2/22/19, R39 was recorded as having large bowel movements. - On 2/23/19, R39 had a medium bowel movement. - On 2/26/19 (three days later), R39 had a medium bowel movement. - On 3/1/19 (three days later), R39 had a large bowel movement. - On 3/4/19 (three days later), R39 had a medium bowel movement. - On 3/8/19 (four days later), R39 had a large bowel movement. - On 3/9/19, R39 had a medium bowel movement. - On 3/11/19, R39 had a large bowel movement. - On 3/13/19, R39 had a large bowel movement. - On 3/15/19, R39 had a medium bowel movement. - On 3/19/19 (four days later), R39 had a large bowel movement recorded as being, Dry/Hard. R39's medical record was reviewed and lacked evidence R39 had been reassessed for constipation despite having voiced concerns about not being able to move her bowels, and going several times with three or more days as not having bowel movements on the Vitals Report. Further, R39's physician order(s) lacked any evidence a scheduled, ongoing bowel management program had been initiated despite R39 consuming narcotic medications and having repeated episodes of three or more days without having bowel movements. During subsequent interview on 3/19/19, at 2:35 p.m. R39 stated she did finally have a bowel movement; however, needed a suppository in order to make it happen. R39 stated she wished the facility would give her [MEDICATION NAME] (a laxative) as she used to take it daily and it helped prevent her constipation issues. On 3/19/19, at 2:38 p.m. nursing assistant (NA)-A was interviewed. NA-A explained R39's bowel movements were tracked using the computer system; however, R39 has not been going much as R39 had a cyst on her liver which causes her pain and subsequently makes her not spend much time out of her bed. Further, NA-A stated R39 had a bowel movement that day; however, it was hard though as she needed a suppository to be able to go. During interview on 3/19/19, at 2:50 p.m. licensed practical nurse (LPN)-A stated R39 had been on her fourth day without having a bowel movement, so she provided R39 with a rectal suppository in the morning hours and she had very large results. LPN-A explained the overnight shift creates a list everyday which lists the residents' who are on several days without having a bowel movement and need interventions such as prune juice or MOM. LPN-A expressed she had seen R39 appear on the list several times before, so just that day (on 3/19/19) she completed a request for the nurse practitioner to address a bowel management program for R39 during the next visit. When interviewed on 3/19/19, at 3:01 p.m. registered nurse (RN)-A stated a residents' bowel status was assessed on admission, quarterly thereafter and with any significant changes. The floor nurses run a report daily which identifies residents needing to use the standing orders for fruit balls, prune juice or MOM; however, if they need more than these items, they should be in contact with the nurse practitioner to address a bowel management program. RN-A reviewed R39's medical record and stated she felt the staff had a really good handle on R39's bowel movements. On 3/20/19, at 12:56 p.m. the director of nursing (DON) was interviewed and explained residents' bowel status was monitored continuously by the staff. DON stated the nurse on 3/19/19, completed a request to the nurse practitioner regarding R39's bowel management; however, it should have been done probably awhile back. Further, the DON stated a resident repeatedly noticed on the bowel list and needing ongoing use of standing orders for laxatives should be relayed to the physician and a plan developed to help promote the comfort of the resident. A provided Bowel Management Program policy dated 7/2016, identified all residents would be free of fecal impaction and any identified at risk for constipation would be monitored appropriately. A procedure was listed which included, For residents identified to have constipation issues which are not adequately resolved with nutritional measures, contact MD for bowel medication as needed.

Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 2 of 3 residents (R27, R24) reviewed whose Medicare A coverage ended and then remained in the facility. Findings include: R27's Centers for Medicare and Medicaid Services (CMS)- signed as received on 10/16/17, identified a last covered day (LCD) of 10/18/17, when R27's Medicare coverage would end. R27's undated Census Records listing identified on 10/19/17, R27's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R27's medical record was reviewed and lacked any evidence a SNFABN had been provided to explain the estimated cost per day or provide rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. R24's CMS- signed as received on 12/27/17, identified a LCD of 12/29/17, when R24's Medicare coverage would end. R24's undated Census Records listing identified on 10/19/17, R24's payer source changed from Medicare Part A to Medicaid, and remained in the facility. R24's medical record was reviewed and lacked any evidence a SNFABN had been provided to explain the estimated cost per day or provide rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. When interviewed on 1/30/18, at 1:10 p.m. registered nurse director of quality (RNQ)-A stated the facility can't locate any documented evidence R27 and R24 had been provided a SNFABN as, the notice wasn't issued. RNQ-A stated the billing department would follow up with R24 and R27 to ensure they were fully aware of their charges. Further, RNQ-A added it was important to ensure coverage notices were provided timely so residents who wished to remain in the facility after their Medicare coverage ended were aware of the estimated cost(s) associated. During interview on 1/30/18, at 1:35 p.m. the director of nursing (DON) stated R24 and R27 admitted to the facility for therapy services under Medicare A coverage. Their Medicare A coverage ended when therapy was discontinued, and the SNFABN notices were not done. DON added, We will correct it right away. A facility provided Medicare/Medicaid Coverage and Liability Notices policy dated 11/2017, identified the facility shall inform Medicare beneficiaries of his or her potential liability for payment. The policy directed when Part A services are used, the facility shall use the (SNFABN).

Based on interview and document review, the facility failed to ensure recommendations for cataract evaluation were acted upon, and glasses were fitted with the correct lenses prescription for 1 of 1 residents (R22) reviewed for vision. Findings include: R22's quarterly Minimum Data Set ((MDS) dated [DATE], identified R22 had intact cognition and was able to communicate needs and wishes without difficulty. R22's medical [DIAGNOSES REDACTED]. R22's care plan revised 1/3/18, indicated R22 to have adequate vision with her eye glasses in place. The care plan directed staff to provide assistance to schedule eye exam(s) as requested or as needed. On 1/29/18, at 2:31 p.m. R22 was in her room working on a puzzle with visible eye glasses in place. R22 stated they were her old glasses, as her other glasses she had previously received caused her to have triple vision so they had been sent back for correction of the prism almost two months ago. She had been seen by the eye doctor at the facility and was informed by the eye doctor she needed to have prism lenses. R22 stated she had been having trouble with headaches and added she may need to pursue an alternate evaluation as there had been no follow up on her glasses which had been previously sent in. R22's On-Site Vision Care Note dated 11/20/17, identified R22 had good vision but with, reduced vision due to [MEDICAL CONDITION]. A note identified a referral was indicated to fit R22's glasses with a prism. Additionally, the document indicated an appointment should be scheduled to have [MEDICAL CONDITION] looked at with report to be sent. There were no additional referral notes to reflect a follow up of prism placement in prescription lens or indication of cataract referral completed. A narrative note, dated 11/20/17, by the health unit coordinator (HUC)-A indicated R22 was seen by On-Site Vision Care on that 11/20/17, and notes were placed in chart. During interview on 1/31/18, at 11:49 a.m. HUC-A stated the facility was waiting for On-Site to come back in follow up and added they were to have completed a visit on 1/29/18, but the visit was canceled and had not yet been rescheduled. HUC-A stated a referral for cataract evaluation would need to be scheduled at West Metro Ophthalmology in Stellis Health Clinic. HUC-A stated she was unaware of glasses being sent back for prisms and spoke to registered nurse (RN)-C in follow up. The HUC-A stated she had been informed by RN-C the glasses were in the medication cart until the resident was seen in follow up by On-Site. HUC-A stated if the resident had requested glasses be sent in for repair, this should have been completed, however, stated she was unaware of this request. HUC-A stated there should have been an appointment made for evaluation by the ophthalmologist. HUC-A stated when a resident was seen by On-Site Vision, a progress note was completed and provided to the health unit coordinator. The notes would then be reviewed by the nurse and the physician before they were filed in the chart, however, HUC-A stated the note did not appear to have been reviewed. During interview on 2/1/18, at 10:25 a.m. RN-D stated she was aware R22's eye glasses were in the med cart as resident was having problems with double vision and RN-D had placed them in the med cart. RN-D stated on 12/28/17, she spoke with HUC-A regarding R22's concerns with new glasses. The documentation reflected HUC-A reported On-Site would be out 1/29/18 and it was noted R22 could be seen on 1/29/2018. RN-D went on to state R22 preferred to wear her old glasses as she experienced problems with double vision when wearing the new glasses. The director of nursing (DON) joined the interview at 10:30 a.m. and stated On-Site Vision Care comes to facility routinely and does a complete visual evaluation, and then fits resident with corrective lenses at the facility. The DON stated the On-Site Vision note was not always reviewed by the physician, however, it should be reviewed by the nurse and follow up scheduled accordingly. The DON stated the referral for consultation on [MEDICAL CONDITION] should have been coordinated, according to payer source, after the referral had been made on 11/20/17. A facility policy, titled Hearing and Vision Services, dated 11/17, identified under procedure once vision or hearing services have been identified the social worker/social worker designee/HUC will assist the resident by making appointments and arranging for transportation.

Based on observation, interview and document review, the facility failed to comprehensively assess for smoking risk factor for 1 of 1 residents (R5) who was currently smoking off campus. Findings include: R5's significant change Minimum Data Set ((MDS) dated [DATE], identified a [DIAGNOSES REDACTED]. R5's cognitive decision making skills were moderately impaired which identified he made poor decisions and required cues and supervision. The MDS identified R5 needed extensive assistance with all activities of daily living (ADL's) and had limited range of motion to one upper extremity. Further, R5 was currently using tobacco products. During the facility entrance conference on 1/29/17, at 1:15 p.m. the administrator and director of nursing (DON) stated the facility had one resident who smoked off campus. They identified R5 by name. R5's Smoking Risk Observation dated 11/1/17, included areas to assess for: smoking material, frequency of use, smoking in unauthorized areas, carelessness with smoking materials, smoking behaviors, general awareness and orientation, mobility, capabilities to follow the smoking policy, smoking risk total, referrals and care plan actions. The assessment did not include an area for abilities to light, ash or dispose of smoking materials safely. R5's smoking assessment had not been fully completed and only indicated a moderate problem with mobility, all other sections of the smoking assessment were blank. The smoking assessment indicated R5 had a smoking risk of two on a scale of 0-9, indicating he was a safe smoker taking only the mobility section into account. R5's care plan revised 11/15/17, identified R5 had a history of [REDACTED]. R5 had friends that will take him off campus to smoke and provide smoking materials. No smoking materials are in the facility. Resident will not have any smoking related injuries Interventions included: Monitor for [MEDICAL CONDITION] injuries from smoking after he returns from smoking; Remind friends that he needs to sign out and smoke off campus; Remind resident of the risk and benefits of smoking. R5's progress note(s) identified the following: - 11/15/17, R5's friends let staff know R5 wanted to go out to smoke. R5's friends were informed of the no smoking policy. R5 shrugged his shoulders and proceeded to propel his wheelchair with his foot to the door with his friends. The unit manager updated. Will set up skin checks after smoking. Risks were explained. R5 is smoking off the property currently. - 11/15/17, R5 returned. Skin check revealed no concerns from smoking. - 11/29/17, Resident had friends visiting and went outside in front of facility, and were observed smoking. Writer re-educated resident and visitors the campus was non smoking and needed to smoke off facility property. Resident and his friends stated they forgot. Resident and visitors then put their cigarettes out and appeared to be disposing of them in a to-go cup with liquid in it. Resident's nurse updated. - 12/10/17, Resident went outside with friends today. Provided risks and benefits prior to him going outside of facility. Skin check and safety evaluation done upon return. No new skin issues upon return and no issues with clothing noted (Burn holes). Resident's clothing smelled like cigarette smoke. Writer asked resident if he had smoked and resident just smiled. - 1/07/18, Friends here and went out to smoke. No redness,[MEDICAL CONDITION] skin or burn holes noted in clothes when came back in. Refused shower, skin assessment showed no skin issues at this time. - 1/11/18- Nursing reviewed with R5's brother R5 goes out with his friends and will smoke while he is out. R5's brother stated he wanted R5 to go out with his friend, but would like the friends to be asked to not provide cigarettes for him. - 1/13/18, Resident's friends came to visit resident and was brought outside to smoke. Risks and benefits explained to resident. Observed resident's skin when resident came back inside, no burn marks or redness noted to skin. Care conference of 1-11-18 On 1/29/18, at 5:40 p.m. R5 was interviewed regarding smoking and R5 could only respond to questions with 'yes or no' responses. R5 indicated he currently smoked off campus with friends. R5 indicated he had not burned himself while smoking. R5 was unable to state how often he smoked or where he kept his smoking materials. R5 patted the pocket to his jacket indicating he kept his smoking materials in his jacket pocket. R5's right hand was flaccid and rested on a half tray of his wheelchair. R5 had full range of motion (ROM) to his left hand. R5 did not have any visible burns, nor did he have and burn holes in his clothing or jacket. During interview on 1/30/18, t 3:06 p.m. nursing assistant (NA)-A was not sure if R5 smoked. NA-A stated he had left the facility with friends in the past, but was unaware of where they went. She had never noticed R5 to have [MEDICAL CONDITION] burn holes in his clothing and would alert the nurse if he did. When interviewed on 1/31/18, at 7:51 a.m. NA-B stated R5 periodically went off facility property with friends to smoke. The nurses checked [MEDICAL CONDITION] burn holes upon his return to the facility as a precaution. To her knowledge, R5 had not ever burned himself. On 1/31/18, at 11:47 a.m. licensed practical nurse (LPN)-A stated R5 left the facility about once a month with friends and they bring him to smoke. Prior to R5 leaving the facility she explained the risks of smoking to R5. The risks given to R5 were related to his health and the greater risk R5 had of having another stroke if he continued to smoke. LPN-A stated upon his return to the facility his skin and clothing were checked for burns. LPN-A stated when the facility was aware a resident smoked a smoking observation was completed to address any potential safety concerns. She was not ware if there were any safety concerns regarding R5's abilities to smoke and would need to ask the unit manager. On 1/31/18, at 11:54 a.m. registered nurse manager (RNM)-A stated she was aware R5 smoked off property with friends and the nurses check [MEDICAL CONDITION] his skin and in his clothing upon return to the facility. RNM-A reviewed R5's Smoking Risk Observation dated 11/1/17, and stated R5 quit smoking in September of 2017. RNM-A stated when R5 admitted to the facility he was not currently smoking. She stated an assessment should have been completed when the facility became aware R5 was smoking again to see if the resident was safe to smoke. RNM-A stated R5 was not able to use his right hand, but could use his left hand without limitations. She stated R5 was not sent out of the facility with smoking apron as a prevention for burns, but he had a big coat and tray table on his wheelchair and felt R5 did not have any history of burning himself. RNM-A indicated R5 did not have any cigarettes on him and none have been found in his room or coat. On 1/31/18, at 1:04 p.m. the DON stated on admission all residents are asked if the smoke. Residents are told prior to admission the facility did not allow smoking on campus. If residents choose to smoke they have to leave facility property and staff cannot accompany them off property to smoke. A smoking assessment should have been completed when the facility became aware R5 was smoking; although she didn't see adding any different interventions for R5. Further, without visualizing R5's smoking it was hard to know if he was safe to smoke. R5 had full range of motion with his left hand so likely he would be able to smoke safely. The facility Smoking and Tobacco Free Facility policy dated 1/13/12, identified Smoking or tobacco use is strictly prohibited within business owned vehicles, buildings, grounds and property. The policy did not identify how to identify residents who smoke, assessments to be completed, or how to ensure residents who smoke are safe.

Based on observation, interview and document review, the facility failed to ensure repeated requests for dental treatment were acted upon and addressed for 1 of 2 residents (R41) reviewed for dental hygiene and who had broken, missing teeth. Findings include: R41's admission Minimum Data Set ((MDS) dated [DATE], identified R41 had moderate cognitive impairment, required limited assistance with personal hygiene and had, Obvious or likely cavity or broken teeth. Further, R41's undated Census Records listing identified R41's payer source as, Private Pay MA (Medicaid) Pending. R41's Dental Care Care Area Assessment (CAA) dated 12/26/17, identified R41 to have obvious or likely cavity, or broken teeth. R41 was recorded as, she has not seen a dentist for a long time, but would like to see one. Facility will add her to the list to see the dentist. Further, a section labeled, Referrals, directed a referral was warranted to the facility dental services. On 1/29/18, at 3:23 p.m. R41 showed the surveyor her teeth. R41 had no teeth on her upper palate and visibly broken and missing teeth on her lower palate. R41 stated her teeth had been in this condition for several months and she wanted to get them fixed, however, was concerned about her financial ability to do so. R41 had no issues with chewing or swallowing; however, she (had) to be careful about what she ate because of her teeth. R41 stated she would give anything to have her teeth looked at by a dentist as she was worried they were going to start hurting adding, I keep my mouth shut all the time so people can't see it. R41 was unaware if the facility had dentist service(s) available or what options she had to get them looked at. R41's admission care plan dated 12/20/17, identified R41 had her own teeth with some missing and/or broken. There was handwritten dictation adjacent to this which identified, Would like to see a dentist. Further, R41's comprehensive care plan created 1/10/18, identified R41's oral status with only had a couple teeth that are badly decayed. Will have dental follow up. An intervention was listed as, Oral care am & pm. Dental consult (as needed) as resident allows/desires. R41's progress note dated 1/4/18, identified R41 had a care conference. In this conference, staff identified R41 needed several services including dental care. The note described, The facility HUC/medical records (health unit coordinator) has been alerted to this need for scheduling the appointments. R41's medical record was reviewed and lacked any identified follow-up with dental services or plan to address R41's repeated desires to be seen by a dentist for her missing, broken teeth. There was no evidence of resources which had been tried, implemented or exhausted in attempt to meet R41's repeated requests to be seen by the dentist. On 1/30/18, at 2:16 p.m. HUC-A and HUC-B were interviewed. They were aware of R41's request to be seen by the dentist a couple weeks ago, however, they were waiting for her MA to begin before she could be seen by the dentist. HUC-B stated she offered R41 a screening by the dental hygienist, however, R41 declined and stated she wanted to see a dentist, not the hygienist. When questioned about the current status of a dental appointment for R41, HUC-A and HUC-B stated neither of them had consulted with the dental provider to review options for care until the MA became effective, nor had they reached out to the acting social worker (SW) to review other care options until the MA was approved. HUC-A cited some concerns with a lack of transportation for R41 then, as a result of the MA still pending, however, stated she had not even checked with the family to see if they could transport R41 to the dentist adding, that didn't happen. On 1/31/18, at 12:20 p.m. registered nurse manager (RNM)-B and SW were interviewed about R41's dental care. SW verified she had not been consulted by the HUC(s) about exploring options for outside dental care for R41. SW stated she completed R41's admission paperwork with her and she had been interested then about getting dental care but did not know if her insurance would cover it so she wanted to wait until she found out if her MA was approved, however, SW added it could take up to several months before they would know. RNM-B stated the current dental provider, who comes to the facility for visits, was a nightmare to work with so the plan was to just wait for R41's MA to be approved and go from there. R41's dental needs and concerns wasn't emergent, so they were just waiting on the MA. RNM-B stated she felt the facility had acted adequately and did everything we should do for R41's dental care. SW stated there needed to be a conversation with R41 about her dental care needs and wishes, then staff should set up an appointment accordingly. A facility provided Dental Services policy dated 11/2011, identified the facility would provide on-going dental services for residents which were .appropriate to their needs. The policy directed an appointment would be scheduled as needed.

Based on observation, interview and record review, the facility failed to ensure the necessary coordination of services between the facility and hospice agency was completed by reviewing and incorporating the plans for services provided by hospice for 1 of 1 residents (R2) reviewed for hospice. Findings include: R2's admission Minimum Data Set ((MDS) dated [DATE], identified R2 displayed severally impaired cognition and required extensive assistance with activities of daily living (ADL's) including dressing, grooming, bathing, and mobility. Further, R2's medical [DIAGNOSES REDACTED]. R2 was also noted to have experienced pain during the assessment period, receiving both scheduled and unscheduled pain medications, in addition to receiving non-pharmalogical interventions (turning, repositioning, etc .). R2 was also noted to be at risk for skin breakdown. R2's care plan created 11/9/17, identified R2 received hospice skilled nursing and social service visits per schedule and PRN. However, the care plan lacked any evidence or outline as to the frequency of these visits. Further, the care plan lacked any information on additional services being provided by the outside hospice agency including hospice health aide visit(s), spiritual counselor visits, volunteer visits, massage therapy, music therapy, and any bereavement services. During observation on 1/31/18, at 12:06 p.m. R2 was seated in a Broda chair (an adaptive chair to promote position) with back reclined slightly, with bilateral side supports, and feet supported on foot rests. Family member (FM)-A was observed to provide total assist with meal. R2 was observed to sit with eyes closed, mumbling responses, facial expression relaxed. Although eyes were closed, R2 responded to verbal prompts and touch cues to lips to open mouth and eat. During interview on 1/31/18, at 12:06 p.m. family member (FM)-A stated they were familiar with the hospice role as R2 had received services in their home prior to the admission to the facility. FM-A stated she was aware of the support systems' hospice provides to patients, like nursing and spiritual support; however, was unaware of the extent or frequency to which these things were being used for R2. FM-A explained R2 had a history of [REDACTED]. Further, FM-A stated a care conference was planned with the facility for later the same day and she was hoping to get several questions answered regarding R2's current condition, anticipated decline and the end of life process. R2's interdisciplinary team (IDT) progress note following the care conference dated 1/31/18, identified FM-A attended the care conference along with a hospice social worker, registered nurse (RN)-C, Oasis unit coordinator (OUC). facility activities staff and dietary supervisor. The documentation indicated FM-A was provided with end of life educational literature by hospice social worker. During interview on 2/1/18, at 10:05 a.m. RN-C was interviewed regarding R2's current hospice services in place and the plan of care while R2 was enrolled in hospice services. RN-C stated she was unaware of these things, despite attending the care conference on 1/31/18, and referred the surveyor to RN-D for further questions. During interview on 2/1/18, at 10:10 a.m. RN-D stated she was aware the hospice home health aide (HHA) visited weekly to provide assistance with bathing. RN-D also stated R2 received music therapy, nursing visits, and social worker visits, however, she was unaware of the frequency of these visits. RN-D stated the facility had their own care plan in place, and the hospice care plan would be something used by the hospice staff. The facility was to coordinate cares with hospice, although RN-D was unaware of the exact services provided. nor at what frequency they were to be provided. RN-D attempted to locate this information in R2's medical record and hospice certification information, however, was unable to do so, stating it was important to have this information available to ensure coordination of care for R2. On 2/1/18, at 10:20 a.m. a review was completed with the director of nursing (DON) of the electronic record and the resident chart and noted the hospice care plan was absent. The director of nursing (DON) stated she would contact the hospice agency and request a copy of the care plan be faxed to the facility. The DON stated the hospice care plan outlined the services provided by the hospice team and the frequency the services were to occur. Further, DON stated the facility care plan and hospice care plan together would be reflective of care and services provided to R2. A copy of the Initial Hospice Plan of Care/Contingency Plan which was obtained from hospice by the facility and provided to the surveyor on 2/1/18 at approximately 12:30 p.m. which outlined the services provided by hospice and at frequency they would be delivered. A Service Agreement By and Between Guardian Angels + Elim Hospice and Lake Ridge Care Center dated 12/2/2008, identified a Combined Plan of Care as a written care plan established, maintained, reviewed and modified, in collaboration between Hospice and the Nursing Facility that includes (a) an assessment of each patients needs, (b)an identification of the Hospice Services, including management of discomfort and symptom relief needed to meet such patient's needs and the related need of the Hospice Patient's family, and (c) details concerning the scope and frequency of such Hospice Services. (d)(sic)delineation of accountability of services. Additionally, the contract identified under facility responsibilities, design and maintenance of nursing facility plan of care, the nursing facility was to develop a plan of care for the hospice patient. The nursing facility and hospice would then develop a joint/combined plan of care for the residential hospice patient, reviewing periodically and modifying in accordance with regulations.

Based on observation, interview, and document review, the facility failed to develop a comprehensive care plan for 1 of 1 residents (R36) who was identified as a smoker. Findings include: R36's quarterly Minimum Data Set ((MDS) dated [DATE], identified R36 had moderate cognitive impairment, and required extensive assistance with transfers and mobility. During observation on 11/8/16, at 6:06 p.m. R36 was observed in her wheelchair going outside the facility with her husband to the edge of the nursing home parking lot. R36's husband lit a cigarette and handed it to his wife. R36 was able to hold the cigarette, ash safely, and smoke independently. When R36 was done smoking, she handed the cigarette to her husband to extinguish. R36 smoked the entire cigarette with only her husband present. During interview on 11/8/16, at 6:08 p.m. R36 stated she smoked two cigarettes a day, one after lunch and one after supper. Further, R36 stated her husband took her outside to smoke and she only smoked when he was with her outside. R36's Smoking Risk Observation dated 9/21/16, identified R36 was a current smoker who smoked a, Couple times per day. Further, the observation identified R36 was safe to smoke and her care plan developed, Plan of Care Updated. R36's care plan dated 11/2/16, lacked any information on R36's smoking habits, abilities, or interventions for staff to implement to assure she remained safe while smoking with her husband. When interviewed on 11/8/16, at 6:53 p.m. nursing assistant (NA)-D stated she was unaware if R36 was a smoker or not, nor if there were any interventions to ensure she smoked safely. During interview on 11/9/16, at 6:21 a.m. NA-C stated she was not aware R36 was a smoker, nor if there were any interventions to ensure she smoked safely. When interviewed on 11/9/16, at 7:13 a.m. NA-E stated R36 was not a smoker to her knowledge, nor if there were any interventions to ensure she smoked safely. During interview on 11/9/16, at 12:23 p.m. registered nurse (RN)-A stated R36 had been assessed to be safe with smoking, however the care plan had not been updated as indicated by the assessment. Further, RN-A stated R36's daily smoking should have been included on her care plan. When interviewed on 11/10/16, at 10:01 a.m. a director of quality registered nurse (RN)-B stated all resident's should be monitored for safety. Further, RN-B stated all resident assessment and safety needs should always be documented in a resident's care plan. A facility policy on care planning was requested, but was not provided.

Based on observation, interview, and document review, the facility failed to ensure medically related social services needs were identified and provided for 2 of 4 residents (R29 and R28) reviewed for social services. This resulted in actual, psychosocial harm for R28, who expressed fear, inability to sleep, and demonstrated signs of distress regarding concerns with her roommate (R29). Findings include: R29's quarterly Minimum Data Set ((MDS) dated [DATE], indicated the resident had severe cognitive impairment and had dementia with depression. R28's quarterly MDS dated [DATE], indicated the resident had severe cognitive impairment, and had dementia with depression. The MDS indicated R28 was depressed, had trouble sleeping, had little or no energy, felt bad about herself, and had trouble concentrating. R28's Care Area Assessment (CAA) dated 6/12/15, indicated the resident received Zoloft, an antidepressant, for [DIAGNOSES REDACTED]. R28's care plan dated 9/11/15, indicated she was depressed and was to receive one to one visits to encourage expression of feelings and to, Explore possible reasons for the resident's distress (e.g., environmental/psychosocial stressors, treatable medical conditions, etc); Implement a mood management plan to compliment drug therapy : sertraline (Zoloft). The care plan indicated R28 had the potential for abuse from others related to cognitive loss, and the approach was for staff to discuss behavioral issues with the team members as needed, and evaluate the need for psychological referral and evaluation. R28's progress notes reviewed from 7/09/15, to 10/25/15, indicated the following incidents related to R29, who is R28's roomate: On 7/9/15, Res. (resident) has been crying today. Res. is stating how when she was little her mom used to make her watch the baby and she didn't like it. Res. has also been say that her roommate asks so many questions and needs things and she is getting tired. On 7/15/15, a note documented by activities indicated Resident is having a hard time with her rooming situation. She says she is not getting much sleep because roommate is up a lot at night talking, delusional as to where she is and accusing resident of things. Resident is crying a lot and is in hopes of changing rooms. Writer consoled resident and said she would see what she could do about the situation. On 8/24/15, resident and roommate had a dispute. R28 stated her roommate yelled at her and she became upset, was crying, and stated she was done dealing with her roommate and wanted a new room. On 8/25/15, a progress note from social services indicated, Spoke with res regarding incident with roommate last night, res did remember arguing with her roommate. She didn't say she wanted a different room today, but just said that she didn't want to talk to her roommate about just anything, only the weather. Writer validated her feelings letting resident know she doesn't have to talk to roommate about anything she didn't want to. On 9/1/15, Resident refusing to go into bed as roommate blocking roommate from entering. Resident when in room, 'peeks' into roommates side of room to make sure she is okay. On 9/5/15, resident talked with writer and stated, I'm loosing my mind, my roommate is rubbing off on me; up at 1 am. Talks of wanting a different room, did leave a message for SW (social worker), 1 on 1 with resident, and was effective at this time. On 9/10/15, resident complaints of not sleeping well last night stating the lady in her room kept her up asking who she is and where she is. On 9/10/15, progress note from social services indicated, Writer was walking down the hall and res stopped writer and was upset because she stated 'I just saw on TV that I am being taken to court! I have nothing, this is not fair they stole all my money!' When writer asked who stole her money she was not able to say. Res roommate was then coming out of the room and res said 'oh that little [***] ! She was screwing with him all night!' Writer let res know that was not nice to call some one names. Writer asked who him was and roommate got closer res said 'oh look here she is she just wants to screw' and she shook her fist at roommate. Writer directed ladies in opposite direction but it took some time for residents to go there separate ways. Res kept stating that 'this is my room' and 'she goes in there all the time and screws him, she is such a little [***] , I cant even eat- I don't even want to look at her. On 9/12/15, resident found in roommates bed and she stated she does this to me all the time. On 9/23/15, resident stated she was up all night with the lady in her room yelling all night. Resident stated she was, Going crazy. One to one was given. On 9/23/15, Writer unplugged cord from computer res. stating 'I wish I had one of those' res was asked what? 'That cord for around my neck- I don't sleep cause of that lady in my room.' Res. stated 'I really wont do that but I never get any sleep with her in there.' 1 on 1 was given with relief. SS updated. On 10/6/15, social service note indicated residents daughter called, To talk to writer about concerns that resident called her about a man who was after her and her roommate, who was sleeping with all sorts of men and how resident just wanted to commit suicide. Assured Dtr (daughter) that no men were in the building and that res has talked about seeing the men before and they turn out to be not here and roommate does not have men in her bed at night to which (daughter) stated she figured and was not worried about it. She (daughter) was most worried about the suicide comment. (Daughter) is requesting a call from the MD (medical doctor) when he is here on Thursday and Writer let (daughter) know that she would talk to MD as well about res behaviors. Writer then spoke to res about suicidal behaviors and res has no plans to harm herself and is safe at facility. No further action needs to take place today. On 10/07/15, Res in confrontation with another Res in hallway this evening. Res was talking about going to 'See my lawyer this week to see what the weather is going to be.' She was also talking about how another res 'needs her ass kicked.' Res eventually calmed down and went into her room. Will continue to monitor. A Lake Ridge Care Center Fax Update/Order form dated 10/8/15, indicated the MD attempted to call R28's daughter but had the wrong phone number and he would call the social worker tomorrow. On 10/20/15, Writer informed by NAR (nursing assistant registered) that Res claims roommate said she was going to cut her throat. Res called daughter to inform daughter of situation. Writer asked aides what happened. Aides said roommate didn't want to go in room because Res said she didn't want her there. Then Res made the claim that roommate said she'd cut her throat. Aides said roommate wasn't even around Res to make such a comment. Res and roommate separated at this time. Res on her way back to bed. On 10/22/15, social service note indicated Met with resident and discussed comments she made on 10/20/15. Res stated that she did not feel her roommate was going to slit her throat, res stated she felt safe and was not afraid of her roommate. She stated her roommate just wants the whole room that's all and she just gets that way sometimes. Asked res twice if she felt safe with her roommate during the conversation and both times res waved her hands at writer and said oh yes its fine. On 10/23/15, social service note indicated resident came to writer upset with roommate because of all of her visitors and that she needed to get out of her room because her roommate gets mad at her and shuts the door on her. Because she was so upset writer asked if she felt like hurting herself and res stated, No, I don't think so. On 10/23/15, Resident was up at the front door saying 'I am getting out of here.' Writer told resident, Oh it's raining out. You don't want to go out there. Resident replied, I don't care about the rain. I'm not staying here another night; live with these awful people here, I'm leaving. Resident was resistant at first but then writer got resident to go to the Vineyard. Writer reported this info to social services and nursing. At this time nursing put a Wanderguard on resident. An Associated Clinic of Psychology visit note dated 8/17/15, indicated R28 had depression, and did not have suicidal ideation. The recommendations were to use validation techniques when she appeared to have concerns, or when she voiced concerns. A Geriatric Services Of Minnesota physician visit dated 9/10/15, indicated, The patient (R28) did get a bit weepy today while complaining about conflicts with her roommate. I spoke with various staff and apparently the patient has had problems with at least a couple of other roommates and I think she maybe a candidate for a private room. The plan indicated to facility staff, I will be happy to support a waiver request for a private room. There was no indication the physician recommendation regarding R28 receiving a private room was followed up on by the facility. During interview on 10/26/15, at 1:53 p.m. nursing assistant (NA)-T stated R28 and R29 started to have troubles being roommates a few months ago, because R29 gets, Crazy in the late afternoon and night time. R29 becomes more confused, and is up hollering during the night. NA-T stated they have come to work in the early morning and R28 would be awake and out of bed crying stating she is fearful of her roommate because R29 was, Making her uncomfortable. R28 had expressed she, Doesn't like being in that room, and continued to be unsettled about having to remain in the room with R29. R28 had ongoing episodes several times a week of not sleeping well at night because of R29, and NA-T stated these concerns were reported to social worker (SW)-A, but SW-A stated she had spoken to R28's family and they didn't want the resident to change rooms, but rather just wanted the facility to add some pictures and music to try to enhance the physical space of the room for R28. NA-T stated one of R28's daughters had recently visited from out of town, and she had expressed desire for R28 to change rooms because she could, See how it was, between R28 and R29; however, NA-T stated, Nothing ever got done, about R28 and R29 rooming together. During interview 10/26/15, at 4:08 p.m. NA-A stated R28 and R29, Argue all the time, and (R29) is very forgetful; she cant remember five minutes to the next. She forgets what side of the room she is on and they both dig into each others things and it upsets both of them. (R28) gets upset and will go on a rant that she has no one in her family; she has said she is better off dead but never told me she had a plan. She is not on any suicide checks. We are told there is not enough charting to separate them and the nurses do the charting. It would be nice if they could be separated. During interview 10/26/15, at 4:13 p.m. licensed practical nurse (LPN)-A stated, They (R28 and R29) fight a lot. I have asked for a room change and left messages with the social worker. I'm almost ready to give up; we keep charting and nothing gets done with it and the staff are very frustrated, they don't ask us about room changes and about what would work best, and who would be compatible with who. I suggested for her (R28) to move to room 126 when that was open because I felt her and the other roommate would be a good fit and they never moved her. (R28) tells me she wants to move (R28) says things that she wants to kill herself. LPN-A then stated, I don't think things are charted as often as they occur. LPN-A stated R28 and R29 just, Got into it with each other in the hall. During interview 10/26/15, at 4:23 p.m. R28 stated, I have never been treated like this ever in my life. R28 started to cry, and LPN-A (who was present at the time of interview) gave her a Kleenex. R28 stated, I have asked for a different room, I want a different room, and I have told the gals that work here that! R28 continued to cry wiping her tears with her Kleenex. R28 then began rubbing her head and stated, Oh my god I am so tired of this, I have it in the back of my mind to end my life. I am [AGE] years old, why do I have to put up with this? R28 stated her roommate (R29), Is nastier than nasty. At 4:33 p.m., R28 was still crying. During interview on 10/26/15, at 4:36 p.m. social worker (SW)-A stated everyone at the facility was aware R28 and R29 did not get along. SW-A stated she and the director of nursing (DON) had discussed moving the residents to separate rooms, but felt it would not be a benefit to move either one of them. SW-A stated R28 hallucinates and had made comments about a man being in the room when there hasn't been a man around. SW-A stated she was not aware if R29 was keeping R28 up at night, and stated she had asked R28 about her suicide thoughts and she had never had a plan. SW-A stated she had offered to move R28 to a different room, however, her daughter in law did not want her to move. SW-A stated the facility did not currently have any private rooms available, and the empty rooms all have roommates, and the facility felt they would rather wait for a private room to open before moving R28. SW-A stated she had not filled out a waiver for a private room because she will wait until the resident was actually moved into the room, and there might be a couple opening in the near future. SW-A stated R28 had been seen by the Associated Clinic of Psychology and they were to be seeing R28 on a monthly basis, however, the last time visit was 8/17/15, and there currently was not a follow up appointment scheduled. SW-A stated she would need to call the Psychology clinic being it had been a few months, because the Psychologist was, Not very good about keeping her schedule with the residents here. During interview 10/26/15, at 5:07 p.m. R28's family member (FM)-A stated she was aware of R28's concern with her roommate, and the resident does complain to her about it. FM-A was not aware the physician had recommended a private room for R28, nor had the facility spoken to her about moving R28 to a different or private room. During interview 10/26/15, at 6:03 p.m. DON stated a lot of the staff know there, Is a clash between (R28) and (R29). The DON stated she was not aware where the social worker was at with the situation between the resident, and the SW made the determination regarding resident room assignments, however, the DON stated, I am not sure why they haven't moved one of them. DON stated she heard about suicidal comments from R28, but was not aware R28 made a comment about wanting a cord for around her neck, and stated, If she (R28) said that, she had a plan. A facility policy addressing the responsibilities of social services was requested, but was not provided.

Based on observation, interview and document review, the facility failed to comprehensively assess and develop interventions to reduce pain for 1 of 3 residents (R118) reviewed for pain. R118 voiced complaints of unmanaged pain, and demonstrated distressing pain during a wound dressing change. The facility also failed to provide proper wheelchair positioning for 1 of 1 residents (R57) who was leaning significantly to the right side. Findings include: PAIN: R118's undated Resident Admission Record identified [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], identified R118's cognition was intact and she required limited assistance for most activities of daily living (ADLs). The MDS identified R118 did not receive scheduled pain medication, but received as needed (PRN) pain medication and non-pharmacological interventions for pain management. The MDS identified the pain made it difficult to sleep at night, and limed her day to day activity. A self-reported numerical pain rating scale identified her current pain was a nine out of 10 (a zero (0) to 10, numeric pain rating scale of 0 = no pain, 10 = the most intense pain imaginable). Her pain was identified as frequent, but did not include a verbal description of the pain even though the MDS identified she had one arterial or venous ulcer at the time of the MDS. The Care Area Assessment (CAA) dated 8/24/15, identified R118 needed assistance with all ADLs due to weakness and decreased mobility from [MEDICAL CONDITION], but wanted to do as much for herself as possible. The CAA identified R118 had a stasis ulcer on her right leg that was infected and continued to drain large amounts of fluid. The CAA identified R118, Is complaining of pain due to [MEDICAL CONDITIONS], and stasis ulcer on right lower leg. States that PRN [MEDICATION NAME] ([MEDICATION NAME], an [MEDICATION NAME] medication) relieves pain. Also uses warm towels and repositioning. Staff will continue to monitor for pain and update MD (medical doctor) as needed. Although the MDS identified R118 had pain, which made it difficult to sleep, and limited her day to day activity, the facility had not assessed this area to determine if the pain regime was appropriate for R118. The care plan dated 10/9/15, identified R118 was at risk for uncontrolled pain related to [MEDICAL CONDITION] and stasis ulcer to her right lower extremity. The care plan goal was for R118 to state her pain was decreased with the use of an [MEDICATION NAME], or show non-verbal signs of decreased pain. Interventions included the following: ·Encourage R118 to report pain levels PRN, per a numeric scale as able. ·Administer medications to R118, routine and PRN, as ordered for pain. ·Monitor R118 for changes in comfort PRN, reassessing her pain as needed. ·Offer R118 comfort measures PRN, of repositioning, heat, cold, massage, diversional activities, etc . During observation and interview on 10/21/15, at 11:30 a.m. R118 complained of unmanaged pain related to an open sore to her right, lower leg. She stated a routine dressing change had just been completed to her right leg and reported the pain she experienced during these dressing changes was excessive, stating her pain hits over a 10. R118 stated if the nurses think of giving her pain medication before and after the dressing change they will, along with some ice. The ice packs, and pain medication at times, Will subside almost, and then all of the sudden it is like a grabbing pain that almost sends me through the ceiling. During this conversation, R118 was frequently rubbing her right, lower leg and applying ice packs to the area. R118 stated her current pain level was,down to a five (5) . it is tolerable. R118 reported a pain rating of 5 was an acceptable level of pain for her. On 10/22/15, at 9:28 a.m. R118 was observed in her room, receiving her morning medications from licensed practical nurse (LPN)-F. Both LPN-F and R118 confirmed she had just received a pain medication ([MEDICATION NAME] 300 mg, pain medication to treat nerve pain) and she typically liked to wait for her pain pill to kick in, before her dressing change was completed. R118 asked LPN-F to return in a half hour to complete her dressing change and to bring an ice pack. At 10:01 a.m., R118 stated, (Her pain medication) never quite cuts it . when they start scraping, there's nothing (that could stop the pain). At 10:11 a.m., LPN-F gathered supplies for R118's dressing change. While LPN-F was outside of the room, R118 was asked whether her pain medications were helping. She stated, (It) never does, and rated her pain a seven, out of 0-10 pain scale. At 10:16 a.m. LPN-F returned to R118's resident room, completed her preparations for the dressing change and was about to begin the treatment when R118 asked, Where's my ice pack? LPN-F stated she had forgotten to bring the ice pack, but would bring it immediately upon completion of the dressing change. R118 said loudly and firmly, No. You get that now. LPN-F said, Okay, yes mam. LPN-F retrieved an ice pack and then began the dressing change. At 10:22 a.m., LPN-F removed the Kerlix (gauze bandage rolls) and ABD pad (a highly absorbent dressing used to provide padding and protection for large wounds). LPN-F then used a saline aerosol spray to slowly remove pieces of Silversorb (an absorptive dressing) and slough, by wiping, rolling and picking off the black colored debris from R118's open wound. While LPN-F was removing the dressing and completing debridment of the wound R118 was wincing, jerking and pulling away throughout the procedure. At 10:27 a.m., R118 had tears in her eyes, which she wiped with tissue paper that she held in her hand throughout the dressing change. During the dressing change R118 made LPN-F stop and pause several times, to take a breath and breathe before continuing. When R118 was ready for LPN-F to proceed with the dressing change she would take a deep breath, grimacing her face, and choked with emotional tone to her voice, and said okay. At 10:29 a.m., R118 stated, Okay, it's starting to burn. LPN-F asked R118 if she had not left enough time for her pain medication to begin working. R118 replied, No, I'm just gonna have to get something stronger for the pain. As soon as LPN-F applied the Kerlix, R118 immediately applied the ice pack to her right lower leg and made LPN-F stop before the stockinet and gripper socks were applied, allowing R118 to breathe, and rest after the dressing change was completed. LPN-F used that time to administer another PRN pain medication ([MEDICATION NAME] 5mg 1 tablet, narcotic pain medication) to R118. LPN-F administered the medication, applied R118's stockinet and gripper stocks, and at 10:37 a.m., left the room. R118 rated her pain as a nine, and during the dressing change, stated, It's gotta hit 15, because I'm about ready to pass out from the pain. At 10:43 a.m., R118 was still holding the ice pack, firmly to her leg. At 10:45 a.m., R118 rated her pain as an eight (8) and stated her pain level was starting to decline at this time. LPN-F did not ask R118 to rate her pain before, during or after the dressing change even though LPN-F administered PRN pain medication to R118. During interview on 10/22/15, at 10:51 a.m. LPN-F confirmed the verbal and non-verbal pain indicators she observed, which was a typical reaction during her dressing changes. LPN-F reported R118's doctor and nurse practitioner were aware of these symptoms. LPN-F stated R118's pain management regimen consisted of offering [MEDICATION NAME] first, then [MEDICATION NAME] if the [MEDICATION NAME] was not effective. LPN-F added, she could also have ice at any time and this has been the same pain management regimen for R118 for some time. She was not sure what the rational of the physician was, for not making further changes to the pain medicaiton regimen. LPN-F stated, She trys to give her (R118) time when she removed the dressing, so she (R118) can take a breath and get her bearings and will then continue when she is ready. R118's current physician orders [REDACTED]. ·Wound treatment to stasis ulceration on right lower extremity- cleanse wound, apply Silversorb, cover with ABD pad and Kerlix, change dressing daily and PRN. ·[MEDICATION NAME] 300 milligrams (mg), twice daily for [MEDICAL CONDITION]/ [MEDICAL CONDITION]. ·[MEDICATION NAME] 50 mg, every four hours PRN for pain, for chronic pai[DIAGNOSES REDACTED]. ·[MEDICATION NAME] 5 mg, every four hours PRN for pain not relieved by [MEDICATION NAME], for chronic pai[DIAGNOSES REDACTED]. Review of R118's physician progress notes [REDACTED]. R118's New Patient history and physical examination [REDACTED]. The report did not further address her pain. On 8/24/15, nurse practitioner (NP)-A noted R118 had complaints of pain to her right lower extremity with dressing changes. On 9/10/15, NP-A noted the appearance of R118's right lower leg and reviewed the dressing treatments. NP-A noted, Discussed pain control will add [MEDICATION NAME] for mod (moderate)/severe pain. On 9/23/15, a Wound Care/ Hyperbaric Medicine History and Physical noted, There is a wound on the anteromedial portion of (R118's) right lower leg. This measures 11 x (by) 12.5 x 0.1 cm (centimeters). The wound is about 60% yellow [MEDICATION NAME] and 40% pale red. It is very tender to touch and I am unable to do any sort of debridment on it. It does not appear to be infected . I initially tried to dress the patient's wound with [MEDICATION NAME]; however, the patient developed a lot of discomfort with this. My initial inclination had been to treat it with lodosorb in an attempt to control drainage but the patient was afraid that that would be painful . She did receive a dose of [MEDICATION NAME] here and once her pain got better her wound was then dressed . On 10/8/15, NP-A addressed R118's chronic right lower leg ulcer. NP-A noted, Resident today says, 'I'm ok,' but frowning and awaiting R (right) LE (lower extremity) dressing (change). C/o (Complains of) pain to R LE. Refuses to go back to Monticello Wound Clinic- 'They don't know nothing.' She is very particular about what she will allow to be put on R LE wound . looks unhappy- waiting for dressing (change). The note directed no change to the wound treatment and to continue with antibiotic treatment for [REDACTED]. On 10/19/15, NP-A noted R118's emergency room visit was reviewed. The note did not address R118's stasis ulcer. No further assessment, description, or plan for pain management were included in the physician progress notes [REDACTED]. Review of R118's Electronic Medication Administration Record [REDACTED]. The September 2015 EMAR identified R118 took a total of 103 doses of PRN pain medication. She took 68 doses of [MEDICATION NAME] 50mg, which were effective 42 of 68 opportunities; slightly effective 14 of 68; not effective 2 of 68, and other, which was not identified for 1 of 68 opportunities. R118 had 35 doses of PRN [MEDICATION NAME] 5mg in September 2015, which was effective 14 out of 35 opportunities; slightly effective 3 out of 35; and other which was not identified 3 out of 35, opportunities. The October 2015 EMAR identified R118 was administered 100 doses of pain medication for right, lower extremity leg pain. She took 49 doses of [MEDICATION NAME] 50mg, which was effective 18 out of 49 opportunities; slightly effective 17 out of 49; and not effective 6 out of 49 opportunities. R118 had 51 doses of PRN [MEDICATION NAME] 5mg, in October 2015 which was effective 34 out of 51 opportunities; slightly effective 11 out of 51; not effective 5 out of 51 and other, which was not identified, 1 out of 51 opportunities. Review of the EMAR PRN administration times from September to October 2015, did not correlate with R118's dressing changes, because the dressing changes were not consistently documented. Even though R118 was administered 203 doses of PRN pain medication, taken in 55 days, approximately 3.7 doses of PRN pain medication each day, along with her scheduled [MEDICATION NAME] 300 mg twice a day. R118 continued to experience significant pain with her dressing changes. Review of R118's nursing progress notes from 8/17/15, through 10/26/15, identified complaints of pain for R118: On 8/24/15, at 10:18 p.m. LPN-G noted, Changed dressing on lower right leg . About an hour later Resident had c/o a 'burning pain.' Writer asked if a pain pill would help or if it was too much and it needed to be taken off? Resident asked for it to be taken off. Writer took off dressing . cleaned wound and only applied [MEDICATION NAME] with non-stick dressing then covered with ABD and wrapped with Kerlix. Resident has not have any further c/o pain but is requesting that she receive something else on the wound that won't burn. On 8/27/15, at 1:09 a.m. LPN-D noted, (R118) rates pain 8/10; .per resident alginate dressing 'burns' refused to have on skin; .communication being sent to update PMD (primary medical doctor). On 8/27/15, at 10:23 a.m. LPN-F noted, Leg dressing changed . Area continues to be red, macerated et (and) tender to the touch . Resident claims the wound spray hurts her when use for washing wound. Resident refused it to be used on her D/T (due to) reported pain. On 9/6/15, at 10:48 p.m. LPN-D noted, (R118) c/o pain in RLE . dressing removed per (R118's) request; cool cloth applied with some relief; leg has been elevated; will reassess in one hour when may have prn pain medication. On 9/7/15, at 1:39 p.m. registered nurse (RN)-C noted, (R118) refused to have dressing put on in fear that it would start hurting again . (R118) is leaving it open to air. PRN given. On 9/8/15, 2:28 p.m. LPN-B noted, Writer called the on call MD/NP and left a message regarding resident's wound on her leg. Resident is refusing to let staff place a dressing on her leg per orders. On 9/8/15, 11:10 p.m. LPN-C noted, (R118) c/o pain to RLE. (R118) is unable to have any more prn pain medication for another 2 (two) hours. On call physician . said to use standing order of Tylenol. Will administer Tylenol and continue to monitor. On 9/13/15, at 12:25 p.m. LPN-B noted, . (R118) does c/o pain during a.m. dressing change . PRN pain medication given x (times) 2 at this time. On 9/19/15, at 1:12 a.m. LPN- D noted, (R118) c/o 7/10 pain right lower extremity; somewhat relieved with prn [MEDICATION NAME], ice, and [MEDICATION NAME]; dressing changed by DON (director of nursing). On 9/23/15, 10:39 p.m. LPN-I noted, (R118 was) medicated as directed for leg pain. (R118) states, '[MEDICAL CONDITION] bad when drainage is left on my leg.' On 10/8/15, at 2:09 p.m. LPN-F noted, (R118) continues to c/o pain et request frequent dressing changes et PRN pain meds which were helpful when 2 different PRN pain meds were given closer together. Resident has been seen by NP. Area on leg measures 16 cm x 10 cm draining et macerated with some greenish color at first change when NP was in room. On 10/12/15, 2:27 p.m. LPN-F noted, (R118) continues to c/o pain. PRN pain meds given x 2. Resident makes requests for dressing changes. Leg continues to be painful et macerated during dressing changes. On 10/15/15, at 12:09 p.m. LPN-J noted, Treatment completed to RLE . C/o pain while treatment is being completed, had received pain med prior to tx (treatment) being done. States that it hurts when it is open to air. On 10/17/15, at 11:37 p.m. LPN-D noted, (R118) rates RLE pain 7/10, somewhat relieved with ice pack and PRN pain medication. During interview on 10/26/15, at 10:42 a.m. nursing assistant (NA)-A stated, R118 has pain in her legs and she had seen her pretty upset and crying. NA-A stated has seen R118 in pain and/or has complained of pain to her almost daily. NA-A stated she told the facility nurses when R118 complained of and/or appeared in pain, to see if she could be given any pain medication. NA-A stated the pain medications seemed somewhat effective, (but) never 100% (effective). During interview on 10/26/15, at 2:32 p.m. registered nurse (RN)-H reported R118's pain was mainly in her right lower leg, where she had an open area. RN-H stated the area has been improving, but was taking a long time. Upon review of the EMAR, RN-H reported R118's pain rating was typically around an 8 (0-10 pain scale) prior to receipt of her PRN pain medications. She reported R118's physician was at the facility every Thursday and was responsible for monitoring to ensure her pain management regimen was sufficiently effective. RN-H stated the most recent notation of the physician/ nurse practitioner commenting on her pain was the physician's progress notes, on 10/8/15. RN-H reported R118 had attended a wound clinic, but stopped going after 9/23/15, because she was very upset and did not want to go there anymore. RN-H stated she had spoken to R118 about her pain, as recently as 10/14/15, and she had indicated satisfaction with her pain management regimen. Upon inquiry as to R118's acceptable level of pain, RN-H replied she was unsure. RN-H stated that she was aware R118 had significant pain with dressing changes, but believed the current pain management regimen was effective for her. She stated the nature of R118's wound was going to result in some, inevitable pain during dressing changes. However, when told of the observed dressing change on 10/22/15, RN-H denied knowledge of R118 having reactions to that extreme. RN-H stated, If she (R118) is saying she is having that much pain, she is having that much pain. RN-H denied any reports of pain concerns for R118, from the facility nurses or NAs. RN-H stated, she expected staff would have updated the physician if/when they identified unmanaged pain, as the physician could have looked at getting an increase in R118's pain medication. RN-H stated R118's use of the ice pack was typical, however, If that was what we were seeing, then that would not be a sufficient management of her pain. RN-H confirmed, R118's pain should have been reassessed. RN-H confirmed the facility used section J of the MDS as their sole pain assessment, which was only completed on a quarterly basis. During interview on 10/26/15, at 5:11 p.m. the director of nursing (DON) stated she gas completed R118's dressing changes on a frequent basis. She made sure R118 was medicated about one hour before the dressing change and asked her (R118) frequently throughout the dressing change, how she was doing. The DON stated she soaked the Silversorb in a significant amount of normal saline to keep it from sticking to her leg and made sure she had an ice pack to use for her leg at the time of dressing change. The DON stated she typically looked at R118 and tried to get her to laugh, distracting her during the dressing change. The DON stated she felt these interventions were as effective as they can be. The DON stated, when R118 was first admitted to the facility, the dressing changes were much more painful than they were presently. The DON stated she had never seen R118 cry during a dressing change and upon discussion of the observed dressing change (10/22/2015), she denied having seen that kind of response from R118 any time she had completed or observed her dressing changes. The DON stated she expected some discomfort with this type of dressing change, but if R118 had demonstrated significant signs of pain as identified in the 10/22/15 observation, she expected the nurses to document this in the medical record and see what they could do about getting some different [MEDICATION NAME] medications for her. Although R118, had a stasis ulcer, had frequent progress notes that identified significant pain, and had nurses and nursing assistants who observed R118 in pain, either during her dressing changes or other times during the day. R118 only received [MEDICATION NAME] 300 mg twice a day, for a routine scheduled pain medication, and [MEDICATION NAME] 50 mg PRN for pain and [MEDICATION NAME] 5 mg PRN for moderate to severe pain. R118 only received the [MEDICATION NAME] 300 mg prior to her dressing change in the morning of 10/22/2015, and then received [MEDICATION NAME] 5mg after the dressing change was completed. Even though R118 voiced complaints of unmanaged pain, and demonstrated distressing pain during a wound dressing change. The facility did not comprehensively assess and developed an appropriate pain management interventions to assist in reducing her pain. The facility's Dressing Change, Clean policy dated 6/14, directed nursing to check physician orders [REDACTED]. The policy did not further address pain management during dressing changes. Facility policies regarding pain management with dressing changes were requested, but no additional policies were provided. WHEEL CHAIR POSITIONING: R57's quarterly MDS dated [DATE], identified R57 used a wheelchair for mobility, and required extensive assistance with activities of daily living (ADLs). R57's care area assessment dated [DATE], indicated she had contractures, and limited range of motion. R57's care plan dated 9/23/15, indicated alterations in mobility related to increasing weakness and directed staff to refer to physical and occupational therapy as needed. A Resident Progress Noted dated 9/13/15, indicated pillow given to resident on wheel chair due to resident leaning to right. A Resident Progress Note dated 9/5/15, indicated R57 was up in wheel chair and would drift off, leaning to right. During and observation on 10/19/15, at 8:16 p.m., R57 was sitting in a wheel chair. She appeared to be sleeping with her head resting on her right arm, leaning to her right. On 10/20/15 at 9:58 a.m., R57 was again observed sitting in her wheel chair, leaning to her right side. On 10/21/15, at 8:58 a.m., R57 was leaning to her right side in her wheel chair with her head resting on her tray table. On 10/23/15, at 3:55 p.m., R57 was observed sitting in her wheel chair, leaning to her right side with her head resting on a pillow that was placed on the right arm rest of her wheel chair. Although R57 continued to lean to the right, there were no supports noted in her wheelchair to support her trunk that prevented her from leaning. During and interview on 10/23/15, at 11:32 a.m., NA-B stated R57 refuses to lay down a lot of the time, that's why we put pillow by her head. NA-B further stated R57 has always leaned to the right side, not sure why that is. During an interview on 10/23/15, at 11:48 a.m., occupational therapy assistant (OTA)-J stated R57 was recently given a right lateral support for her wheel chair. OTA-J stated R57 was seen for a referral about a month or so ago, but was not picked up for ongoing therapy. He felt R57's chair size was appropriate but that (R57) was more fatigued. During an interview on 10/26/15, at 1:53 p.m., NA-T stated, R57 is like that all the time, they get her up for breakfast and then she falls asleep in her wheel chair. NA-T further stated, she used to lean a little but her leaning has been going on for the past few weeks. During an interview on 10/26/15, at 2:07 p.m., LPN-H stated, some they they have difficulty getting her (R57) to lay down. Sometimes they will place a pillow under her head to buffer the uncomfortable position but, she always looks like that. LPN-H further stated, she though this was her second chair, and was unsure if (R57) had lateral supports or if they helped or not. R57 was at high risk for falling out of her chair because she is always leaning to her right. LPN-H further stated, R57 had been screened by occupational therapy for positioning, but was unsure if she had been re-evaluated. During an interview on 10/26/15, at 2:32 p.m., occupational therapist (OT)-K and OTA-J stated, they had received a referral in September for R57 because of her leaning and gave her a lateral supports. They also recommended she (R57) lie down if tired and listed the potential for several negative outcomes of a sore back, and neck. At the time of the referral in September 2015, the lateral support was providing R57 with the amount of assistance she needed to sit up right and be able to propel herself in her wheel chair. OT-K and OTA-J further stated, R57 was never leaning that bad when we saw her and that her current positioning was a change and she should have been referred back to therapy for an evaluation. A policy addressing positioning for residents was requested, but was not provided.