Every finding on record at Lakeside Generations Health Care Center

Based on interview and document review the facility failed to maintain a medical record containing appropriate resident assessments and complete progress notes following an incident for 1 of 3 (R1) resident records reviewed for record completion. Based on interview and document review the facility failed to maintain a medical record containing appropriate resident assessments and complete progress notes following an incident for 1 of 3 (R1) resident records reviewed for record completion. Findings include: R1's care plan, dated 5/15/26, indicated he had PTSD and directed staff to approach him in a calm and slow manner to avoid startling him. It also indicated his coping strategies were to talk with someone when he feels frustrated or overwhelmed. R1's admission Minimum Data Set (MDS), dated [DATE], indicated he had diagnoses of vascular dementia with mood disturbance, coronary artery disease, diabetes, anxiety, depression, post-traumatic stress disorder (PTSD) and was cognitively intact. R1's chart lacked documentation following an incident which occurred on 7/20/26, when another resident physically grabbed him and wouldn't let go, resulting in a 1.5 cm skin tear to his left hand. It lacked information regarding the incident and assessment following the incident. R1's skin assessment, dated 7/20/26 indicated he had a 1.5 centimeter (cm) skin tear on the top of his left hand. It lacked further detail regarding the cause of the injury. During an interview on 8/11/26, at 2:49 p.m., registered nurse (RN)-A stated she was working when R1 was grabbed and scratched by another resident on 7/20/26. The residents were separated and R1 stated he was scared when it happened. He planned to stay away from the other resident. She stated she did not complete an incident report or progress note. She stated her focus was on the resident who was the aggressor in the incident. During an interview on 8/11/26, at 3:03 p.m., nurse manager (NM)-A stated there should be a progress note and for both residents involved in a resident-to-resident altercation and an incident report should have been completed. During an interview on 8/11/26, at 3:35 p.m., the director of nursing (DON) stated an incident report, assessment and documentation should have been completed after the resident-to-resident physical alteration for both residents involved. She stated R1's chart lacked any documentation of the incident that occurred on 7/20/26. During an interview on 8/11/26, at 3:40 p.m., the regional nurse stated, looking back the nurse should have completed a near miss incident report, regarding the resident-to-resident physical incident on 7/20/26. During an interview on 8/11/26, at 3:44 p.m., the administrator stated physical incidents that occur between residents should be documented on an incident form. Their progress notes should include details of the incident and follow-up assessments made. He stated the incident reports are reviewed and analyzed to determine root cause of the incident, determine if training is needed, implement interventions to prevent further occurrence. The facility incident log dated 5/11/26 through 8/11/26 lacked any resident-to-resident incidents. The facility Incident Reports-Events policy, dated 5/6/25, directed all persons providing services in a nursing home to report any accident or injury to a resident. The nursing home must complete a detailed report of the accident and the action taken after learning of it. Additionally, if a facility has a near miss situation that could have resulted in an incident, this should be reported along with prevention strategies. Document in the resident's electronic medical record the date, time, and name of the person notified. All incidents require an immediate follow-up assessment regarding contributing factors to the incident, current and previous interventions, and plan of action taken after learning of the incident. All event/incident reports will be reviewed for patterns or trends, and statistical data will be reported to the Quality Assessment Performance Improvement (QAPI) committee.

Based on interview and document review the facility failed to provide notification of changes to a resident's representative when an incident occurred and when they were sent to the hospital for 1 of 3 (R2) residents reviewed for notifications.Findings include: R2's care plan, dated 9/24/25, indicated she hallucinated and experienced delusional thoughts. It was updated on 6/9/26 to include that she was short-tempered and easily annoyed by others, including verbal symptoms toward others, hitting staff, and grabbing another resident's arm. It directed staff to assess behavior that endangers R2 and/or other residents and intervene if necessary. R2's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had diagnoses of schizophrenia, heart failure, hypertension (high blood pressure), diabetes, and severe cognitive impairment. A progress note, dated 7/20/26 at 9:16 p.m., indicated R2 went after another resident in the hallway. With both hands extended she grabbed the hand and arm of the other resident and would not let go, resulting in a 1.5 centimeter (CM) skin tear to his left hand. A progress note, dated 7/20/26 at 11:30 p.m., indicated provider was contacted and telehealth assessment was conducted regarding R2's severe agitation and physical behaviors. Provider's orders included an intramuscular (IM) injection, but staff were unable to administer it and her behaviors were unmanageable. Provider was contacted again and a transfer to the emergency department (ED) was recommended. A progress note, dated 7/21/26 at 12:01 a.m., indicated R2 was sent to the ED for further evaluation. A progress note, dated 7/21/26 at 3:00 a.m., indicated R2 returned to the facility. R2's chart lacked notification to her representative/family member of her escalation of behaviors, the physical incident with the other resident and lacked notification of her transfer to the hospital all on 7/20/26. During an interview on 8/11/26, at 2:49 p.m., registered nurse (RN)-A stated she was working when R2 was physically aggressive with another resident on 7/20/26. She stated she did not notify R2's daughter of the incident because she wasn't the victim. R2 was being supervised at the time. During an interview on 8/11/26, at 3:03 p.m., nurse manager (NM)-A stated R2's FM should have been called after the physical incident with another resident and when she was sent to the ED. During an interview on 8/11/26, at 3:35 p.m., the director of nursing (DON) stated R2's FM should have been called following the physical incident with the other resident and when she was sent to the ED. During an interview on 8/11/26, at 3:40 p.m., the regional nurse stated the FM should have been notified of the incident that occurred between R2 and another resident. FM should have also been called when R2 was sent to the ED. During an interview on 8/11/26, at 3:44 p.m., the administrator stated the facility should have notified R2's FM after the physical incident with another resident and when she was sent to the ED. During an interview on 8/11/26, at 4:02 p.m., FM-A stated she was unaware R2 had a physical incident with another resident on 7/20/26 and was unaware R2 was sent to the ED that night. She stated she would like to be notified of incidents and if R2 goes to the ED. The facility Change in Condition policy, dated 5/4/22, directed a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status and when it is necessary to transfer the resident to a hospital/treatment center. The facility Incident Reports-Events policy, dated 5/6/25, directed all persons providing services in a nursing home to report any accident or injury to a resident. The nursing home must complete a detailed report of the accident and the action taken after learning of it. Additionally, if a facility has a near miss situation that could have resulted in an incident, this should be reported along with prevention strategies. All incidents are to be reported to the resident's representative. Document in the resident's electronic medical record the date, time, and name of the person notified.

Based on interview and record review the facility failed to transcribe and administer a diuretic medication for 1 of 3 residents (R1) who had a diagnosis of heart failure that required medication management to prevent fluid related complications. The facility's failures resulted in actual harm for R1 when R1 was not administered 13 doses of Furosemide (diuretic) which contributed rapid weight gain, worsening respiratory status, and hospitalization for acute chronic congestive heart failure and hypoxia. The facility implemented corrective action prior to the survey by 2/4/26, therefore citation is issued at past non-compliance (PNC) Findings include: R1's hospital Discharge summary dated [DATE], identified R1's primary diagnoses included chronic hyponatremia, acute on chronic diastolic congestive heart failure and chronic respiratory failure with hypoxia. The discharge summary included an order to administer: Furosemide 20 mg tablet for acute chronic diastolic congestive heart failure. Instruction: Wait to take this until January 17, 2026. Take two tablets (40 mg) by mouth once daily in the morning. R1's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R1 had no cognitive impairment, was receiving a diuretic medication, and required moderate assistance with toileting and transfers. R1's activity of daily living (ADLs) care plan dated 1/14/26, indicated R1 required medications to be administered as ordered. Additionally, it directed staff to monitor R1's fluid restriction and record weights according to the facility policy. R1's facility physician orders that were transcribed into the electronic health record (EHR) did not include the order for Furosemide 20 mg tablets as per the hospital Discharge summary dated [DATE]. The facility admission Checklist and Observation Schedule for admissions procedures dated 2/7/24, required staff to obtain signed hospital discharge orders and initiate applicable order sets, including CHF. In review of R1's record, it was not evident the CHF order set was initiated. R1's progress note dated 1/23/26 at 8:14 a.m., indicated R1 had not been placed on daily weights since admission on [DATE]. The note indicated that staff initiated R1's daily weight on 1/23/26. Review of R1's weight record identified on 1/15/26, R1's weight was 118.4 pounds (Ibs.) and on 1/23/26 R1's weight was 124.7 Ibs, an increase of 6.3 Ibs. Despite the increase in weight there was no indication of a comprehensive assessment/analysis that identified possible etiology of the weight gain. Review of the January 2026 Medication Administration Record (MAR) showed R1 did not receive any doses of furosemide 40 mg from 1/17/26 through 1/29/26 (13 doses) in accordance with the hospital discharge order. R1's medication incident report dated 1/30/26 at 2:35 p.m., indicated R1's medication incident began on 1/17/26 and was identified on 1/30/26. The report identified R1 had gained unexpected weight but did not specify what the weight gain was. The report also indicated R1's vascular provider was notified of the weight gain as well as the medication error and ordered Furosemide to be restarted as prescribed. The report did not identify if the rounding physician and/or medical director of the facility was notified. R1's weight record identified the following weights between 1/15/26 through 2/1/26: On 1/15/26, weight (wt.) 118.4 lbs. On 1/16/26, wt. 118.6 lbs. On 1/17/26, no wt. recorded On 1/18/26, wt. 125.6 lbs. (gain of 7.2 lbs. in 3 days) On 1/19/26, no wt. recorded On 1/20/26, wt. 125.0 lbs. On 1/21/26 and 1/22/26, no weights were recorded On 1/23/26, wt. 124.7 lbs. On 1/24/26, wt. 123.7 lbs. On 1/25/26, wt. 124.0 lbs. On 1/26/26, no wt. was recorded On 1/27/26, wt. was 124.0 lbs. On 1/28/26, wt. was 135.8 lbs. (representing an 11.8 gain in one day and a 17.4 lb. gain in 15 days). On 1/29/26, wt. was 136.4 lbs. On 1/30/26 and 1/31/26 no weights were recorded. On 2/1/26, wt. was 136.1 (gain of 17.7 lbs. in 19 days.) R1's progress note dated 2/2/26 at 12:00 a.m., indicated staff transferred R1 to the hospital due to hypoxic episode with low oxygen saturation and temperature of 101F (Fahrenheit) on 2/1/26 at 9:30 p.m. R1's progress note dated 2/2/26 at 8:24 a.m., indicated R1 was admitted at the hospital with hypoxia, and she had gained 18 pounds since the previous hospitalization on 1/14/26. R1's hospital admission note dated 2/2/26 at 8:04 a.m., identified R1 was admitted at the hospital with worsening weakness, worsening hypoxia, hypertensive and saturating in low to mid 80s on room air with coarse breath sound at bilateral lung bases and x-ray wheeze upper lung fields. The note further identified R1's B-type natriuretic peptide (BNP), a test to measure a hormone produced by the heart to detect or monitor heart failure was markedly elevated at 11,015 consistent with known heart failure and likely volume overload contributing to R1's respiratory distress. The facility Medication Error Summary dated 2/2/26 identified staff failed to transcribe the furosemide order and failed to identify R1's CHF diagnosis or initiate the CHF monitoring order set (daily weights, edema checks, respiratory assessment). R1's hospital Discharge summary dated [DATE], identified R1's was hospitalized for an acute on chronic hypoxic respiratory failure secondary to influenza A infection with contributing factors including underlying heart failure with pleural effusions. R1's new physician orders dated 2/3/26 included: Auscultate lung sounds, make progress note if abnormal lung sounds are present. Check for edema and respiratory effort. Notify provider if indicated. During an interview on 2/11/26 at 3:09 p.m., R1 stated she felt miserable on 2/1/26 due to fever and shortness of breath, so she started screaming to get the nurse who came when she called 911 to go the hospital. R1 reported being diagnosed with heat failure and taking Furosemide to prevent fluid buildup around her heart. During an interview on 2/12/26 at 12:37 p.m., a licensed practical nurse (LPN)-A indicated when R1 was admitted on [DATE], she was the one who transcribed medication orders into R1's record. LPN-A reported there were distractions during order transcription which contributed to missing the Furosemide order and missing CHF diagnosis in order to initiate the CHF order set. LPN-A explained they found out about the medication incident because R1 had weight gain. LPN-A stated it was a system failure because RN-A double checked the orders, did not identify CHF diagnosis with furosemide order, and nurses on the cart did not raise any concerns regarding R1's CHF diagnosis either. LPN-A indicated she did not know R1 had CHF otherwise she would have made sure daily weight, edema, and lungs sounds were monitored. During an interview on 2/11/26 at 1:50 p.m., a registered nurse (RN)-A stated she was the second nurse who verified R1's admission orders but failed to identify the Furosemide order and CHF diagnosis to initiate the order set. RN-A explained she did not have any excuses for this failure and had since received re-education on CHF admissions, what to look for like weight gain, lungs sounds, edema, and fluid overload. During an interview on 2/12/26 at 11:38 a.m., RN-B indicated on 1/30/26, R1's vascular clinic had called the facility for R1's medication administrations and his weights for routine follow-up monitoring post hospitalization; it was the vascular clinic who identified R1 had not received the Furosemide per physician orders. RN-B then reviewed the hospital Discharge summary dated [DATE], in which she confirmed the furosemide order, nor the CHF order set was not represented in the facility's physician orders for administration and treatment. RN-B stated she assessed R1, restarted furosemide 40 mg daily, initiate daily weights, and monitor R1's symptoms. RN-B indicated she had not notified the facility physician of R1's medication error or the weight gain. RN-B explained R1 not receiving furosemide 40 mg per physician order could result in heart failure exacerbation, weight gain, edema and shortness of breath. During an interview on 2/12/26 at 2:43 p.m., a physician assistant (PA)-A asserted she did not have any record about the facility notification regarding any missing or unavailable medication. PA-A stated she was not aware of R1 not receiving her furosemide 40 mg daily from 1/17/26 through 1/29/26. PA-A explained the potential complication for R1 with CHF diagnosis not receiving her furosemide 40 mg for 13 days could result with fluid overload, weight gain, edema, respiratory and heart failures. PA-A reported staff called on 2/1/26 requesting to send R1 to the hospital due to low oxygen saturation. PA-A stated she expected nursing staff to notify the medical team when there is a medication error for further instructions. During an interview on 2/11/26 at 2:55 p.m., a pharmacist (PH)-A explained that a resident who missed furosemide 40 mg daily should be monitored for fluid overload, weight increased, edema, and respiratory failure. PH-A emphasized the importance of furosemide for residents with CHF. During an interview on 2/12/26 at 3:50 p.m., RN-C, the regional clinical director stated she became aware of the medication error on Monday 2/2/26. RN-C confirmed staff failed to identify the CHF diagnosis, did not initiate the CHF order set, and did not transcribe the furosemide order. RN-C explained when R1 was not administered physician prescribed furosemide 40 mg, this could lead to heart failure exacerbation, rapid weight gain, fluid overload, and respiratory distress. During an interview on 2/12/26 at 3:02 p.m., the medical director (MD)-A stated the incident was self-reported and he provided CHF care education to the nursing staff after the incident. MD-A reported he was not aware R1 had CHF as primary diagnosis at the admission. MD-A explained R1 not having furosemide 40 mg as prescribed could lead to CHF exacerbation, shortness of breath, rapid weight gain, edema, and respiratory distress. The facility Medication management Policy dated 7/18/18 and reviewed 9/30/25, required medications to be administered to residents as prescribed by the primary MD/NP/PA and to be transcribed as received per policy. The facility put the following corrective measures in place and was verified as completed by 2/4/26: -LPN-A was suspended pending investigation and re-education was provided on 2/2/26. -The facility reviewed and revised site admission checklist. Once completed, start education and auditing use of admission checklist on 2/3/26. -The facility audited charts of all residents with CHF diagnosis to ensure order set is in place. Order set added if not currently scheduled on 2/3/26. Education for direct care staff regarding CHF Management by Medical Director (Teach the teacher to continue education for all new hires and on routine basis by facility staff) on 2/4/26. On 2/11/26 through 2/12/26, staff were interviewed and were able to articulate the ordering and the admission procedures for CHF residents. This deficient practice is being cited at past Non-compliance.

Based on observation, interview, and document review, the facility failed to date frozen items when the original packaging was opened. Additionally, the facility failed to maintain food in the original packaging to assure the packaging date remained on food items. This deficient practice had the potential to affect all 43 residents who ate food prepared from the kitchen. Findings include: During the initial kitchen tour on 12/02/24, at 1:15 p.m. , a tour was completed, accompanied by the Certified Dietary Manager (CDM)-A, and the Director of Food and Nutrition Services (DFN)-A. The following was noted: -One bag of precooked chicken, which measured approximately 12 inches by 14 inches, was not in the original packaging and lacked a date on the bag to indicate packaging date. -One bag of ravioli, measuring approximately 9 inches by 13 inches, was not in the original packaging and lacked the packaging date. -Two partial bags of chicken patties, both observed to have been opened and contained approximately 1/2 package of patties, however, lacked identification as to when they were opened. -To partial bags of opened cheese curds, which were both approximately 1/2 open, however, also lacked indication as to which date it was opened. An unidentified staff member, was observed working in the freezer, and stated she was prepping the freezer for delivery tomorrow, and had removed the items from the boxes to save space. On 12/05/24 at 10:28 a.m., a follow up tour of the freezer was completed with DFN-A. At this time, the following was observed: -One open bag of onions, with approximately 1/3 of bag remaining, which lacked labeling to indicate the date opened. -One bag of mixed vegetables, with approximately 1/4 left, which lacked indication as to when they were opened. DFN-A stated the vegetables were not there yesterday, and indicated they would have to work further with education of staff as to the importance of of dating opened packages. A facility policy, Refrigerator and Freezer Storage, last review 1/12/24, identified all food in the freezer are wrapped tightly, labeled, and dated if not in the original container. Additionally, the policy also identified that leftover food items are stored in approved containers, labeled and dated.

Based on observation, interview and documentation, the facility failed to consistently implement hand hygiene during provision of personal cares for 1 of 1 resident, R99, observed for wound care. Findings include: R99's Admission Face Sheet dated 12/5/24, identified R99's primary diagnosis as acute respiratory disease. R99's Face Sheet indicated additional diagnosis included retention of urine, which required an indwelling foley catheter (a tube inserted into the bladder to allow urine to empty from the bladder into a closed urinary catheter bag). On 12/4/24 at 7:15 a.m., personal care observation was initiated for R99. R99's entrance door had a personal protective equipment door supply hanger in place. This was identified as being in place related to enhanced barrier precautions for R99. As noted on the CDC website (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html), dated 6/20/24, enhanced barrier precautions include use of a gown and gloves during high-contact resident care with residents who are either infected or colonized with an MDRO (multi drug resistant organism-an infection resistant to many antibiotics and difficult to treat), as well as for residents with an indwelling medical device or wound regardless of MDRO colonization status. During high contact care, pathogens can transfer to staff hands and clothing. Using gowns and gloves will decrease that risk and the risk the staff will transmit the pathogen to other residents. On 12/4/24 at 7:15 a.m., nursing assistant (NA)-A and NA-B performed hand hygiene outside of R99's room, placed gowns, and gloves prior to entering the room. R99 was in bed, and resting with covers in place. Upon removal of the covers, it was noted R99 had been incontinent of stool, which had saturated the undergarment, and soiled resident down to the knees. Staff proceeded with preparation of supplies, gathering multiple towels and washcloths, undergarments, and a basin of warm, soapy water from the sink in the main portion of the room. Incontinence care for bowels was initiated first due to the level of incontinence. NA-B provided assist to reposition and support R99 in position while NA-A performed personal cleansing. While performing personal cares, it was noted R99's leg band to secure the catheter tubing was soiled and needed to be replaced. R99's dressing on buttocks was also noted to be soiled and needed replacement. Following cleansing, NA-A removed soiled gloves. Upon going to replace gloves, noted there were no gloves in the room, and opened door and obtained fresh gloves with the PPE supply on the outside of the door. NA-A placed fresh gloves on, however, failed to perform hand hygiene with either hand sanitizer outside of door, or soap and water in room. After assisting R99 to a back lying position, and having adjusted the pillow, NA-A proceeded to complete incontinence care and catheter care. It was observed during performance of cares fresh washcloths were used when others became soiled, and soiled linen was placed into laundry bin in room. NA-A used walkie talkie at bedside to request additional washcloths and a leg strap. Following use of walkie talkie twice, NA-A removed gloves and discarded them, and again obtained additional gloves from the PPE supply on outer side of the door. NA-A failed to perform hand hygiene prior to placing fresh gloves. Following placement of fresh gloves, NA-A used walkie again to request nurse to perform wound/skin care. At 7:32 a.m., after incontinence, catheter and wound care were completed by nurse NA-A and NA-B removed soiled gloves and obtained fresh gloves from the PPE caddy outside of the room, and placed fresh gloves without performing hand hygiene (either with hand sanitizer or soap and water). NA-A and NA-B continued with morning cares, placing compression hose, and putting catheter bag cover in place. NA-A prepared supplies for nurse, including prescription powder in the drawer, as well as protective cream. NA-A then proceeded to remove soiled gloves, and obtain new gloves from the PPE caddy from the door. Hand hygiene was not performed. New gloves were place. At 7:39 a.m. RN-B arrived gowned and gloved to complete wound/skin care. Following cares, RN-B removed her gown and gloves, and exited room carrying dressing and powder without performing hand hygiene in the room, however, surveyor did not exit room with RN-B. NA-A and NA-B proceeded to assist R99 with dressing and morning cares after wound/skin care was completed. NA-A and NA-B removed soiled gloves, and replaced gloves from the PPE caddy, however, failed to perform hand hygiene. NA-B proceeded with cleansing of the meatus and wiping down of the catheter with alcohol wipes to the junction with tubing. Following this, personal cares were completed and resident was transferred into his wheelchair with the standing lift. Upon completion of cares, gowns and gloves were removed by NA-B, and linens were bagged without gowns or gloves worn. Hand hygiene was not completed following removal of gowns and gloves, either with hand sanitizer or soap and water. R99 was assisted from room to go to the dining room. NA-A and NA-B removed gowns and gloves prior to leaving the room. On 12/4/24, at 7:56 a.m., NA-A was interviewed regarding glove changes and hand hygiene, and as to how the process was performed. NA-A stated there should have been gloves in the room for use by staff with cares. NA-A stated hand hygiene was to be performed in the process of every glove change, however, did not have pocket sanitizer on her this morning. NA-A was then observed to take walkie from bedside table and place on hip. NA-A stated she was going to clean it off with a disinfectant wipe, and acknowledged walkie talkies should not be handled with soiled gloves. NA-A proceeded to wipe walkie talkie with wipe, dispose of wipe, and then washed hands. NA-A stated she was careful to open door with elbow, and not hand when obtaining gloves. NA-A stated hand sanitizer was to be used at the start of care, between dirty and clean glove changes, and at the finish of care. On 12/4/24 at 1:30 p.m., NA-B held out a bottle of hand sanitizer to surveyor and stated she did not have this in her pocket this morning, however, stated she was aware of the need to perform hand hygiene between removal of soiled gloves, before placing clean gloves. On 12/4/24 at 2:49 p.m., wound care observation was completed with RN-A. Prior to entering the room, hand hygiene was performed with hand sanitizer, followed by placement of gown and gloves for enhanced barrier precautions. RN-A received assistance of RN-D to assist with turning and reposition. Resident was positioned onto left side for provision of cares. During observation, it was noted although RN-A did change her gloves when going from a soiled task to clean (i.e. removal/disposal of dressing, and cleansing of wound) she did not complete hand hygiene, either with alcohol hand cleanser or soap and water. RN-A completed wound care measurement without gloves. RN-A was not actually touching wound with measurements, but holding measuring tape up to it. Dressing placed by RN-A after measurements without gloves. Upon completion of cares, RN-A removed gown prior to exiting the room and performed hand hygiene prior to going on from cares. On 12/4/24 at 3:07 p.m., RN-A stated she was aware she should have sanitized between glove changes. RN-A went on to state You always wash your hands after changing gloves. It is assumed if you have gloves on you could have bodily fluids (on your hands). On 12/4/24 at 3:44 p.m., concerns were reviewed with the director of nursing (DON). DON stated it was her expectation hand hygiene was completed prior to initiating cares, between glove changes, and upon the completion of cares. DON stated hand hygiene can be completed with hand sanitizers or with soap and water. DON stated this was important to prevent potential spread of infections. The facility policy, Infection Control, last reviewed 7/17/24, directed staff that gloves were to be worn whenever there may be direct contact between the caregiver's hands and blood, body fluids, mucous membranes, feces, or contaminated items. The procedure directs to wash hands prior to placing the gloves, going on to direct staff if gloves became torn or heavily contaminated, gloves are to be changed before completing the task. The policy directs staff to remove soiled/torn glove, and directed them to wash hands after. The facility policy, Hand Washing/Hand Hygiene, reviewed 7/17/24 indicated hand washing with sanitizer and hand washing with soap and water may be used interchangeably, unless hands are visibly soiled, or if working with a client that has C. Diff or Norovirus (illnesses which cause nausea and diarrhea which can be spread with contact, and are not effectively killed with alcohol based hand sanitizers). The policy identified hand washing was the single most effective way of controlling the spread of infection. 44645

Based on observation, interview and document review, the facility failed to review potential options and interventions for 1 of 2 residents (R10) reviewed for pressure ulcer/injury. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 was alert and oriented. R10 was identified as having no functional limitation in range of motion (ROM) in her upper or lower extremeties, and ambulated independently with the use of a walker. R10 was identified as being independent with personal hygiene, able to complete upper and lower body dressing, with the exception of putting on and taking off shoes. The MDS indicated R10 was independent with ambulation, transfers, and bed mobility. The MDS indicated R10 was able to walk 150 feet and did not require the use of a wheelchair. R10's medical diagnoses included medically complex conditions, anemia, hypertension (high blood pressure), peripheral vascular disease/peripheral arterial disease(PVD/PAD-a disease that caused problems with the blood vessels or arteries outside your heart or brain), diabetes (a group of diseases that affect how the body uses blood sugar (glucose), osteoarthritis, and age related osteoporosis. R10's admission care plan dated 6/26/18, identified R10 had impaired mobility related to age, weakness. Additionally, R10 had a trochanter fracture of the left hip (fractures of the proximal femur (thigh bone) at the area where the bone attaches to the hip, most commonly seen following ground-level falls in the elderly. The care plan identified R10 was at risk for falls related to history of syncope (fainting episodes) and other contributing factors. R10's admission diagnoses included a periprosthetic fracture (fracture that occurs around an orthopedic implant) around internal prosthetic right hip joint. R10's care plan was reviewed upon return from the hospital on 11/21/24, related to ADL's. The problem statement was initiated on 6/26/18 and indicated R10 was status post trochanter fracture of left hip, however, lacked updated diagnosis of right femur fracture. The care plan interventions were updated to reflect the use of EZ stand with weight bearing as tolerated on 11/20/24. The interventions identified resident received assist of 2 with bed mobility, however, that was initiated on 6/26/18, with no current updates. On 12/2/24, identified R10 was at risk for further skin alterations related to Braden score and multiple other factors, however, the problem statement lacked indication of recent right humerus fracture, or the fact that resident no longer rests in her bed to decrease pressure points. The interventions remain unchanged with the exception of addition of Treatment as ordered. The interventions included the use of pressure redistribution mattress, implemented 11/16/20, however, no interventions were in place to identify R10 was not resting in bed, and lacked indication of interventions to accommodate return to bed for sleep/rest/off loading. On 12/2/24, at 6:51 p.m. R10 was seated in her recliner in her room. R10 had bruising surrounding her right, and significant bruising to her left arm. R10 stated she had fallen and fractured her right hip, below her replacement, when walking to the bathroom with her walker. R10 stated she had not tripped on anything, although, stated she had been light headed intermittently, but not severely. R10 stated she had a spot on her buttocks, on which staff put a patch and salve. R10 stated the staff were unsure what was causing this spot but stated it was felt to be related to sitting in a chair. R10 stated she had added pillows to the seat of recliner and this was helpful. R10 stated she had used special cushions in the past but was not satisfied with this, and no longer used them. R10 stated she had slept in her recliner since her return from the hospital on 11/20/24, and had not slept in her bed since her return as it was too painful. On 12/4/24, at 11:08 a.m., nursing assistant (NA)-C was observed with the transfer process from the recliner with the use of the EZ stand. Once upright in the EZ stand, R10 was assisted via the EZ stand into the bathroom. R10 refused observation of skin condition while in the bathroom. On 12/4/24, at 1:55 p.m. registered nurse (RN)-C stated R10 used a standard pillow in her recliner for pressure reduction. RN-C stated R10 had a foam cushion in her wheelchair for comfort. RN-C stated she would discuss the use of cushions with nursing and therapy to determine what was best to use as resident was chairbound/wheelchair bound. A review of narrative notes was completed and identified the following: On 11/20/24, at 4:59 p.m. , the Hospital Return Nurse Assessment was completed and identified the risk areas for skin in the following areas: decline in her ability to completed her activities of daily living (ADLs), decline in ADLs, fracture of right hip periprosthetic fracture, fragile skin, pain, PVD, and sepsis. The assessment also identified R10 was bedfast/wheelchair bound, with a functional limitation in range of motion. A Braden Scale (an assessment used for prediction of pressure injury risk), was included within the assessment, and R10 was scored at 15-18, which identified R10 was at risk for skin breakdown. The document identified risk factors of mobility risk factors, and identified R10 was at risk for pressure injury. The assessment identified R10's ability to sleep over the past 5 days was rarely, or not at all impacted by injury. On 11/18/24, at 10:28 a.m., R10 had been found on the floor in front of her roommate's bed. R10 stated she was going to the bathroom, became dizzy, and fell . R10 was sent to the emergency department for assessment. A subsequent note of 11/18/24, at 1:58 p.m., indicated the facility received a call from family who stated R10 had broken her right femur (thigh bone) and was unsure as to when she would return to the facility. On 11/20/24, R10 returned to the facility. Upon return, R10 required increased assitance with care and transferred with the use of an EZ stand lift (a mechanical lift which uses a sling behind back), to provide support for transfers. A review was completed to determine if R10's being either wheelchair bound or in her recliner was identified. The notes were also reviewed for identification R10 did not lay down in bed to decrease pressure related to pain. A review was completed for education regarding potential risks and benefits of not using pressure relieving interventions, such as laying down in bed, use of pressure reduction cushions, etc. The following was noted: On 11/23/24, at 10:02 p.m., the note indicated R10 was in recliner for the entire shift, however, lacked interventions in place for offloading, or change in position. The documentation lacked indication as to discussion of potential risks related to limited movement and impact on health. On 11/24/24 at 5:12 p.m., the note indicated R10 had been in her recliner most of the afternoon. The documentation lacked discussion of the risks and benefits. Pain interventions were offered. On 11/26/24 at 10:33 a.m., indicated R10 required increased with cares related to increase in pain, and impaired mobility. On 11/27/24 at 10:50 a.m., narrative note identified R10 required increased assistance with ADLs, including dressing, toileting, and bed mobility. On 11/30/24, at 10:07 p.m., the narrative note identified increased pain with transfers, but R10 denied pain when seated in chair (recliner). On 12/4/24 at 3:44 p.m., an interview was held with the director of nursing (DON) to discuss skin status on R10, and the potential for further skin breakdown related to lack of interventions. DON stated they had tried alternate cushions and R10 had refused. DON stated staff had explained risks and benefits. A request was made for documentation to review the interventions in place, assess provision of risks versus benefits with current interventions, and review with therapy for potential interventions. Additionally, the DON was informed although R10 had a pressure redistribution mattress in her bed, R10 did not rest in bed due to the pain caused with laying down. Narrative notes up to the date of 12/5/24 at 11:47 a.m., written by the director of nursing, reviewed R10's current skin condition, and the potential risks and benefits of not using a pressure reduction cushion in the recliner as had been previously recommended. The narrative notes lacked indication R10 remained in recliner when not up in the EZ stand or in wheelchair, had been sleeping in her recliner, and had not slept in her bed with the pressure redistribution mattress in place since her return from the hospital on 11/20/24 The facility policy, Care plan and baseline care plan, reviewed 2/28/24, identified the policy, bullet #4, the care plan is constantly changing and is to be updated routinely in the electronic record to reflect the resident's current condition. The policy reflects under the Procedure, #3 the care plan is to be updated as needed to assure that they are an accurate reflection of the resident and their care needs.

Based on document review, interview, and observation the facility failed to provide care in accordance with professional standards of practice when the facility failed to complete an assessment for use and placement of an hourglass sling used during Hoyer transfers for 3 of 3 residents (R5, R20, and R21) reviewed for accidents. Findings include: R5's annual minimum data set (MDS) dated [DATE] indicated, R5's was cognitively intact, dependent for transfers, and had the following diagnoses: cerebral vascular accident (CVA)(stroke), coronary artery disease (CAD)(thickening of the cardiac arteries), hypertension (HTN) (high blood pressure), diabetes (DM), hemiplegia or hemiparesis (inability to move one side of the body), and below the knee amputee. R5's care plan dated 11/15/24, indicated R5 required the assistance of two staff and a mechanical lift with a large sling for transfers. R5's medical record lacked evidence any assessment for the appropriate size, usage, application of the full body lift sling, or cognition level of the residents or appropriateness to use the sling, was completed. R20 quarterly MDS dated [DATE] indicated, R20 was cognitively intact, substantial-maximum assistance or dependent for transfers, and had the following diagnoses: HTN, DM, anxiety, and depression. R20's care plan last revised 12/4/24 indicated R20 required the assist of one staff and the ez-stand for transfers to the commode, and the assist of two staff using a large sling and the Hoyer for transfers from the wheelchair to the bed. R20's medical record lacked evidence any assessment for the appropriate size, usage, application of the full body lift sling, or cognition level of the residents or appropriateness to use the sling, was completed. R21's annual MDS dated [DATE] indicated R21 was severely cognitively impaired, dependent for transfers, and had the following diagnoses: non-traumatic brain dysfunction, HTN, renal insufficiency (kidneys don't filter the blood as they should), DM, and Alzheimer's. R21's medical record lacked evidence any assessment for the appropriate size, usage, application of the full body lift sling, or cognition level of the residents or appropriateness to use the sling, was completed. On 11/22/24 at 10:52 p.m., the facility reported R21 had slipped forward and fallen from a Hoyer sling during a transfer from the wheelchair to the bed. R21's historical care plan dated 11/2/24 through 11/25/24, in place at the time of the fall indicated, R21 would use a small sling with assist of two staff and the hoyer lift. R21's current care plan last revised 11/26/24 indicated, R21 transferred with the assist of two using the Hoyer lift, with the loops of the sling to be placed at green on green. The Ez way Inc. Operators instructions dated 10/24/24, indicated the use of the deluxe sling, which crosses between the legs, with no mention of the full body sling or its usage and placement on the body. The Hourglass sling document date accessed 12/2/24, was provided, however it described the sling characteristics but did not discuss placement and usage in reference to the body. On 12/2/24 at 2:36 p.m., nursing assistant (NA)-E stated they had assisted in a transfer of R21 from the wheelchair to the bed on 11/22/24. NA-E stated R21 had been using an hour glass full body sling and Hoyer lift. NA-E stated the correct placement of the sling was to place the thicker top section at the shoulder or base of the neck and the lower thicker section just between the middle of the lower thigh to just above the knee joint. NA-E also stated R21 was not very verbal and had a tendency to curl up in the fetal position when transferring. During the transfer NA-E stated R21 had started to slide down and through the middle open area of the sling. NA-E stated they had attempted to hold R21's knees to guide the body and prevent the fall, however R21 slide forward and fell from the sling approximately 2-3 feet and had a small laceration to the right side of their head just above the ear, behind the hairline. NA-E confirmed at the time of R21's fall, the lower thick section was placed at the base of the buttock not at the lower thigh/upper knee joint, and R21 had slid out of the sling due to it's improper placement. On 12/2/24 at 3:44 p.m., nursing assistant (NA)-D stated they had assisted in a transfer of R21 from the wheelchair to the bed on 11/22/24. NA-D stated R21 had been using an hour glass full body sling. NA-D stated the correct placement of the sling was to place the thicker top section at the shoulder or base of the neck and the lower thicker section just between the middle of the lower thigh to just above the knee joint. NA-D confirmed at the time of R21's fall, the lower thick section was placed at the base of the buttock not at the lower thigh/upper knee joint, and R21 had slid out of the sling due to it's improper placement. On 12/4/24 at 12:50 p.m., the registered nurse manager (RN)-A stated nurses were responsible, during the admission process to use the sling color coding system form to choose appropriate sling and size for the resident. The sling color coding system form only references a deluxe sling, a sling that is shaped like a U and the bottom two straps cross between the legs. The document lacked mention or measurements for use of a full body hour glass sling, which was the type of sling used during transfer/fall incident. RN-A stated they would then document the sling they had chosen in the care plan, and confirmed no formal assessment/tool was used, nor were measurements taken or documented in the chart. RN-A was unsure if another form was utilized when sizing for the hourglass sling, and stated they used the sizing chart for both slings. Furthermore, RN-A stated if a resident was confused or agitated during the assessment, staff would re-approach but there was no assessment that addressed this concern. On 12/2/24 at 4:35 p.m., the representative for EZ way Inc.(O)-E stated hour glass slings can be used for residents with contractions, amputations, or who cant open their legs to use the U-shaped sling, however they would not recommend using them on someone who was confused or combative. O-E stated the appropriate placement of the sling was the top thicker area at the top of the shoulders, and the narrow section on the hips, and the lower thicker part on the thigh just above the knee. O-E stated using the improper size sling or improper placement can lead to a resident falling out of the sling. During follow-up conversation on 12/3/24 at 10:03 a.m., O-E stated they had provided the facility with training materials and in person trainings about patient safety, placement, and proper sling usage, but was unsure if they had provided them with the full-body assessment tool. On 12/2/24 at 3:37 p.m., the director of nursing (DON) stated upon admission the nurses were expected to use the manufacturer guidelines to appropriately size the slings for residents based on height and weight. The DON stated the nurse can choose which sling was used based on resident preference, or if they were confused, they choose the full body hour glass sling to prevent skin breakdown. Once chosen, the sling and size were placed in the care plan, however confirmed there was no formal assessment in place. On 12/2/24 at 6:22 p.m., DON stated their expectation for sling placement was halfway between the knee and butt. The DON stated staff had been trained via walk through demonstration of appropriate and safe placement, measurements, and they have an orientation checklist they go through with staff at the time of hire. The facility EZ Way Smart lift (Hoyer) competency checklist undated, discussed the safe and proper use of the EZ Way Smart Lift. However, it did not discuss proper placement on the body with the exception of making sure the resident is positioned in the center of the sling. On 12/5/24 at 11:38 a.m., DON stated the overall purpose of nursing assessments was to identify a change in condition, getting a history, and preventing undesirable outcomes. The DON expected assessments to be documented in the observation tab or in a progress note within point click care, to enable the facility to identify possible concerns and could go back and conduct another assessment if necessary. Lastly, the DON stated it was importance to complete assessments. If they were not documented it was not completed, and were necessary to improve the residents quality of life and prevent undesirable outcomes. The facility policy Floor-based, Full body Sling Lift use last reviewed 3/28/24, indicated residents who require the use of a mechanical lift will be assessed for the appropriate sling size on admission before beginning use of a mechanical lift and with significant weight change.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Payroll Based Journal (PBJ) [NAME] Report 1705D for FY (Fiscal Year) Quarter 4 2023 (July 1-September 30) identified the Metric of Excessively Low Weekend Staffing triggered. Daily staff schedules for weekend hours staffed during the reporting period were reviewed and compared to the facility simple PB&J spreadsheet. Comparative findings are listed below: On 7/1/23, the document titled Simple PB&J spreadsheet, provided by the facility, had a cumulative total of actual hours worked as 132.50 hours worked when tallied. A review of the automated total at the top of the spreadsheet indicated hours worked as 126.25 hours. On 7/2/23, the document titled Simple PB&J spreadsheet, provided by the facility, had a cumulative total of actual hours worked as 130.50 hours worked when tallied. A review of the automated total at the top of the spreadsheet indicated hours worked as 125.50 hours. On 7/8/23, the document titled Simple PB&J spreadsheet, provided by the facility, had a cumulative total of actual hours worked as 122.5 hours worked when tallied. A review of the automated total at the top of the spreadsheet indicated hours worked as 167.0 hours. On 7/9/23, the document titled Simple PB&J spreadsheet, provided by the facility, had a cumulative total of actual hours worked as 117.5 hours worked when tallied. A review of the automated total at the top of the spreadsheet indicated hours worked as 122.5 hours. The spreadsheet with actual hours worked had #'s through the dates from the period of 7/9/23-8/1/23. On 8/5/23, the document titled Simple PB&J spreadsheet, provided by the facility, had a cumulative total of actual hours worked as 115.5 hours worked when tallied. A review of the automated total at the top of the spreadsheet indicated hours worked as 123.5 hours. On 8/6/23, the document titled Simple PB&J spreadsheet, provided by the facility, had a cumulative total of actual hours worked as 124.50 hours worked when tallied. A review of the automated total at the top of the spreadsheet indicated hours worked as 124.50 hours. The spreadsheet with actual hours worked had #'s through the dates from the period of 8/10/23-8/31/23. On 9/2/23, the document titled Simple PB&J spreadsheet, provided by the facility, had a cumulative total of actual hours worked as 133.0 hours worked when tallied. A review of the automated total at the top of the spreadsheet indicated hours worked as 123.75 hours. On 9/3/23, the document titled Simple PB&J spreadsheet, provided by the facility, had a cumulative total of actual hours worked as 132.75 hours worked when tallied. A review of the automated total at the top of the spreadsheet indicated hours worked as 126.0 hours. On 9/9/23, the document titled Simple PB&J spreadsheet, provided by the facility, had a cumulative total of actual hours worked as 123.75 hours worked when tallied. A review of the automated total at the top of the spreadsheet indicated hours worked as 122.75 hours. The spreadsheet with actual hours worked had #'s through the dates from the period of 9/10/23-9/31/23. During interview on 2/28/24, at 12:19 p.m. the director of nursing stated the the completion and submission for the PB&J was completed at the corporate level. The facility provided schedules for the dates outlined as being triggered in the report, and information was reviewed. After exit from facility on 2/29/24, at 1:17 p.m. the director of clinical reimbursement provided the information requested on a spreadsheet titled Simple PB&J spreadsheet. The director stated she was unaware of any excessively low staff levels triggered by this reporting process. Upon request for related policy and procedures, the director stated they follow the guidelines established by CMS and do not have a separate policy for completion of this.

Based on document review and interview, the facility failed to identify diagnosis for use of medications for 4 of 6 residents (R4, R6, R16, and R34) reviewed for unnecessary medications and antibiotics. Findings include: R6's face sheet identified diagnoses of hemiplegia and hemiparesis following a cerebral infarction (weakness and loss of movement following a stroke) on the left side, myocardial infarction (heart attack), diabetes mellitus type 2, hypertension (high blood pressure), hyperlipidemia (high fats in the blood), chronic pain, constipation, and muscle weakness. Review of the physician's order report dated 1/30/24 identified R6 received lisinopril 10 mg oral (PO) daily, rosuvastatin 10 mg PO daily, aspirin 81 mg daily, metoprolol succinate 25 mg PO daily and diclofenac sodium gel 1% topically as needed (PRN) three times a day, however these medications lacked diagnosis for use. 35992 R4's face sheet identified diagnoses of chronic diastolic (congestive) heart failure (a disease where the heart is unable to pump the blood through the body efficiently), a displaced fracture of upper end of left humerus (the long bone of the upper arm), pain in left arm, rheumatoid arthritis (chronic inflammatory disorder which can affect more than joints) of multiple sites with involvement of other organs and systems, heartburn, and dysphagia (difficulty in swallowing food or liquid). A review of the physician's orders report dated 2/14/24, included orders for acetaminophen 500 mg tablet, 1,000 mg orally once a day early morning between 2:00 a.m. to 3:00 a.m. The order, initiated on 2/1/24, lacked diagnosis for use. R4's orders also included the use of calazime paste; 0.44-20.6% one application twice daily to the left shoulder as needed. A faxed communication with the provider, dated 1/8/24, requested directions and indications for use. The response directed staff to apply to left shoulder, however, lacked indication or diagnosis for use. R16's face sheet identified diagnoses of acute on chronic systolic (congestive) heart failure, type 2 diabetes mellitus (an illness which can cause high blood sugar) with diabetic polyneuropathy (a disease which can cause pain and tingling in legs related to damage from diabetes), acute pulmonary edema (fluid accumulation on the lungs), shortness of breath, other forms of shortness of breath, and essential hypertension (high blood pressure). A review of the physician's orders report, dated 2/14/24, identified an order from 11/13/23 for Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation one puff with inhalation once a day which lacked a diagnosis for use. An order for furosemide 20 mg twice a day, initiated on 2/5/24, also lacked diagnosis for use. R36's face sheet listed diagnoses included the following diagnoses: indwelling urethral catheter (a tube inserted into the bladder to drain urine), toxic encephalopathy (a disorder of the brain caused by exposure to toxic substances), benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland) with lower urinary tract symptoms, retention of urine, elevated white blood cell count and unspecified-leukocytosis (condition where your blood has too many white blood cells, which fight infections and diseases), a history of urinary (tract) infections, and history of Covid (a viral illness which can display with a variety of symptoms). R36's February Medication Administration Record (MAR) indicated the following medications were ordered by the provider, however, lacked diagnoses or indication for use: amlodipine 5 mg one tablet daily, initiated 5/5/23; Bactrim DS (sulfamethoxazole-trimethoprim) tablet; 800-160 mg orally once a day, initiated 10/17/23, placed on hold 1/29/24, with resumption on 2/9/24, levothyroxine tablet 88 mcg one tablet daily, effective 2/9/24; metformin tablet 500 mg one tablet orally twice a day, initiated 1/23/23; cefdinir capsule 300 mg orally twice a day, initiated 1/29/24 through 2/8/24; and Macrobid (nitrofurantoin monohyd/m-cryst) 100 mg capsule orally twice a day, initiated 1/29/24 through 2/8/24. On 2/27/24 at 2:45 p.m., registered nurse (RN)-B stated when transcribing physician orders into the electronic medical administration record (eMAR) indication, dose, directions, route, resident name, and parameters should have been included. On 2/28/24 at 10:01 a.m., the director of nursing (DON) stated her expectation was to have indication (diagnosis) for use included in the order, and each order to be double checked by another nurse. DON stated it was important to include indications for medications, because the staff need to know why they were giving the medications to the residents. During a return call on 2/29/24 at 9:03 a.m., A&E Consultant Pharmacist stated he expected the following to be included in medication orders; medication name, dose, frequency administered and the duration. In addition, the provider information, patient information, and the diagnosis were to be included. Facility policy Transcription of orders revised 2/12/24, indicated medication orders must include name of medication, dosage, route, and frequency. Each medication must also include a diagnosis for usage.

Based on observation, interview, and document review, the facility failed to ensure state agency survey results were posted and, in a location, easily visible and accessible to all residents, staff and visitors. This had the potential to affect all 42 residents living in the facility as well as any visitors or staff who wished to review this information. Findings include: On 02/28/24 at 0930 a.m., the area identified to house the past survey results binder was located across from the nursing station in a small cubby with one shelf about three feet off of the floor. The binder for past survey results was not located on the shelf. On 02/28/24 at 09:58 a.m., a resident council meeting was held with R6, R8, R19, R24, and R26 in attendance. The council members indicated they did not know where to find previous survey results. On 02/28/24 at 02:11 p.m., administrator stated survey results were kept in a plastic binder on a shelf across from nursing station. The binder was not visible when walking into the facility or while standing at the nursing desk. An obvious posting of the survey results availability was not observed. The administrator pointed to the shelf where the binder should have been and stated the binder should be there, however, the binder was not in the indicated location. Facility policy dated 5/21/18, with review date of 10/22/23, indicated survey results will be available in a readable form such as a binder or large print; facility will post these results in a place(s) that is/are readily accessible to residents, family members and the facility will post notice of availability of these reports in areas of the facility that are prominent and accessible to the public.

Based on observation, interview and document review the facility failed to check the temperature of hot holding foods prior to serving to residents, provide for proper storage for opened food items, ensure foods were not expired, and ensure proper personal protective equipment was worn by kitchen staff. This had the potential to affect 44 of 46 residents. Further, the facility failed to have a system in place to monitor and record refrigerator/freezer temperatures for resident personal food items. This had the potential to affect 2 of 2 residents. Findings include: During an observation and interview on [DATE], at 4:47 p.m. dietary aide (DA)-A failed to check the temperature of the food prior to serving it from the steam table. DA-A confirmed food had been in the steam table since 4:10 p.m. DA-A stated she forgot to check the temperature of the food and did not routinely document food temperatures. DA-A stated food should be at least 180 degrees. During interview on [DATE], at 4:50 p.m. certified dietary manager (CDM) and dietary manager confirmed temperature monitoring and logging was not a part of their practice. During observation and interview on [DATE], at 9:51 a.m. the dry storage unit contained; eight cans of sliced pickled beets with a best by date of [DATE], an opened bag of potato chips lacked opended on date, a bag of cool ranch Doritos lacked opened on date and had expiration date of ,d+[DATE]. There were 2 bags of cool ranch Doritos chips with expiration dates of ,d+[DATE] and ,d+[DATE], an opened package of Krusteaz pancake mix lacked an opened on date, an opened package of Stove Top stuffing lacked an opened on dated. Dietary manager stated open items were taped to sealed and discarded within one week after opened on date. During observation and interview on [DATE], at 10:25 a.m. cook-A was observed to have a beard without a beard net. He stated he did not think it was necessary. During an interview on [DATE], at 10:55 a.m. CDM stated her expectation was the cook to wear a beard net. During observation and interview on [DATE], at 9:30 a.m. dietary manager stated residents were able to keep food in the coffee shop. The resident refrigerator contained unlabeled and expired pineapple. Further, the freezer contained properly labeled food. However, the thermometer showed 24 degrees which was outside the safe range. A cabinet contained an unlabeled smuckers chololate topping with expiration date of [DATE] and lacked an opened on date. Dietary manager stated monitoring and logging of temperatures were not a part of their practice. Further, there was no process to review for expired foods in the coffee shop. Facility policy indicated foods were to be prepared and served in a manner that complies with safe food handling practices. Opened foods were to be label with resident name and opened on date prior to being put in storage and beard restraints must be worn.

Based on interview and document review, the facility failed to ensure all alleged violations of abuse were reported to the state agency (SA) for 1 of 2 residents (R8) who were reviewed for alleged abuse. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], identified cognitively intact with diagnoses including Post-traumatic Stress Disorder (PTSD), major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, and a history of cerebral infarction. R8's care plan dated 10/11/21, listed cognitive loss/dementia with a BIMS (brief interview for mental status) score indicating cognitively intact, having poor judgement and safety awareness, lacking insight into his needs and deficits with a history of previous financial exploitation by family. When interviewed on 1/12/23, at 10:54 a.m. R8's psychologist stated she had completed a Saint Louis University Mental Status (SLUMS) test with R8 in December of 2022 in which he had scored 23/30 indicating mild cognitive impairment. R8's Psychologist stated he had deficits in his short- term memory, executive brain function and decision making. R8's progress notes dated 12/10/22, indicated resident was overheard by staff on his personal computer talking with a female from California through Facebook messenger. Staff reported this to the charge LPN. R8 reported to charge LPN that he was going to marry the female and he had given her the number of a $100.00 gift card he had asked his brother to get for him to buy Christmas gifts. Staff attempted to educate resident on his vulnerability and the potential for fraud. The charge LPN notified the facility social worker by phone. The charge LPN called R8's brother who is also his financial power of attorney to inform him as well. When interviewed on 1/10/23, at 4:31 p.m. the Social Services Director (SW) stated this incident was brought to her attention on Saturday 12/10/22 shortly after the occurrence and it wasn't reported to a state agency at that time as there was no confirmation that the female the resident had been communicating with had used the gift card. SW stated the gift card was purchased by R8's brother per resident request to purchase Christmas gifts for family. SW stated that she was made aware on Sunday morning 12/11/22, that the $100.00 gift card had been used and the decision was made to inform [NAME] County law enforcement. SW stated she was informed by law enforcement they had filed a MAARC report and did not think another report needed to be made by the facility. When interviewed on 1/11/23, at 2:02 p.m. the administrator stated that they had not reported the incident because law enforcement had reported it and acknowledged after review of their facility vulnerable adult policy, a report by the facility should have been made within the time frames indicated by their policy. When interviewed on 1/12/23, at 8:45 a.m. nursing assistant (NA)-A stated with any suspected abuse facility protocol was to immediately notify the charge nurse, the director of nursing, the social worker or the administrator. When interviewed on 1/12/23, at 8:55 a.m. licensed practical nurse (LPN)-A stated the protocol for suspected abuse was to immediately report suspected abuse to the on-call registered nurse, administrator, director of nursing or the social worker. When interviewed on 1/12/23, at 9:00 a.m. registered nurse (RN)-A stated that in this incident law enforcement had been called and per facility abuse policy a vulnerable adult report should have been filed by the facility. The facility policy Vulnerable Adult-MN dated 10/14/22, identified Each employee is responsible to report without fear of reprisal immediately, any knowledge of suspected/alleged abuse, neglect, exploitation of residents including misappropriation of resident property and to Report all suspected/alleged violations immediately, or no later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury to the state agency and to all other agencies as required. The facility policy Vulnerable Adult-MN dated 10/14/22, identified Skilled Nursing Facilities (SNF's) report to MAARC instead of OHFC in very limited instances where the perpetrator is not employed by, or connected to the facility. An example of this would be financial exploitation where the perpetrator is a family member, significant other, or other non-facility and non-contracted staff.

Based on interview, observation, and document review the facility failed to ensure a system was in place for reconciliation of controlled substance medication in 1 of 1 medication storage rooms to prevent potential loss or diversion. This had the potential to affect all 45 residents residing in the facility. Findings include: A tour of the locked medication storage room was conducted with the director of nursing (DON) on 11/5/19, at 1:50 p.m. revealed the Certificate of the Inventory and Destruction of Controlled Substances Form: Long Term Care Facilities, 17 different residents with 29 discontinued controlled substances in a locked safe in a cabinet dated from 8/30/19 through 11/4/19 which included the following prescription numbers: 4-[MEDICATION NAME] 100 milligram (mg)/5 milliliters (ml) 30 ml remained, 8/30/19 8-[MEDICATION NAME] 100 mg/5 ml 8.25 ml remained, 8/30/19 6-[MEDICATION NAME] 100 mg/5 ml 21.25 ml remained, 9/13/19 7-[MEDICATION NAME] 5 mg/325 mg 51 tablets remained, 9/13/19 1-[MEDICATION NAME] 50 mg 3 tablets remained, 9/13/19 8-[MEDICATION NAME] 50 mg tablets 30 remained, 9/13/19 7-[MEDICATION NAME] 0.5 mg 18 tablets remained, 9/13/19 2-[MEDICATION NAME] 5 mg/325 mg 1 tablet remained, 9/20/19 4-[MEDICATION NAME] 5 mg/325 mg 9 tablets remained. 9/20/19 0-[MEDICATION NAME] 5 mg/325 mg 18 tablets remained, 9/20/19 4-[MEDICATION NAME] 2.5 mg 18 tablets remained, 10/9/19 8-[MEDICATION NAME] 2 mg/ml 27 ml remained, 10/9/19 2-[MEDICATION NAME] 2 mg/ml 25.75 ml remained, 10/9/19 4-[MEDICATION NAME] sulfate ER 125mg 38 tablets remained, 10/13/19 8-Tylenol #3 300 mg/30 mg 23 tablets remained, 10/15/19 5-Tylenol #3 300 mg/30 mg 50 tablets remained. 10/15/19 0-[MEDICATION NAME]/[MEDICATION NAME] 5 mg/325 mg 22 tablets remained, 10/17/19 8-[MEDICATION NAME]/[MEDICATION NAME] 5 mg/325 mg 4 tablets remained, 10/18/19 1-[MEDICATION NAME]/[MEDICATION NAME] 10mg/325 mg 51 tablets remained, 10/18/19 6-[MEDICATION NAME]/[MEDICATION NAME] 5 mg/325 mg 68 tablets remained, 10/23/19 4-[MEDICATION NAME] 100 mg/5 ml 8.75 ml remained, 10/27/19 7-[MEDICATION NAME] 100 mg/5 ml 30 ml remained, 10/27/19 2-[MEDICATION NAME]/[MEDICATION NAME] 10mg/325 mg 60 tablets remained, 10/27/19 4-[MEDICATION NAME] 50 mg 21 tablets remained, 11/4/19 5-[MEDICATION NAME] 100 mg/5 ml 27.5 ml remained, 11/4/19 0-[MEDICATION NAME] 10mg/ml 60 ml remained, 11/4/19 1-[MEDICATION NAME] 10mg/ml 10 ml remained, 11/4/19 3-[MEDICATION NAME] 10mg/ml 120 ml remained, 11/4/19 4-[MEDICATION NAME] 5 mg 15 tablets remained, 11/4/19 During an interview on 11/5/19, at 1:50 p.m. the DON stated 3 case managers and myself have access to the locked safe in the cabinet. The DON stated the controlled substances should be destroyed monthly. At 2:03 p.m. the DON stated when the controlled substances were not destroyed for two months and the opportunity for diversion is there for sure. The DON stated they count the controlled substances when they were put into the locked safe and when we destroy them, there is no counting of the discontinued controlled substances in the locked safe in between times that does open the door to diversion. At 3:00 p.m. the DON stated I typically like to have the controlled substances destroyed monthly, but our policy does not state it needs to be on a monthly basis. The facility policy Medication Management dated 8/26/19, revealed the following: 1. When a scheduled II-V medication is discontinued, upon resident death, or upon discharge of a resident when schedule II-V medications are not sent with resident upon discharge these medications must be destroyed by DON (or designee) and a second nurse. 2. Medications are to remain in the locked narcotic box on the medication cart and will be counted per narcotic count policy until they are removed for destruction. 3. As soon as practical after discontinuance, death or discharge the following should occur: a) Complete medication disposition form indicating the prescription number and quantity of each medication and indicating whether it was sent home with resident or is being sent to DON for destruction. b) Complete information in the bound narcotic ledger indicating that the medication has been removed for destruction. This documentation is to be cosigned by DON (or designee) upon removal of the medication from the med cart. c) Complete the information in the index at the front of the bound narcotic ledger that the medication has been removed and yellow out that line in the index. d) DON (or designee) will complete the certificate and inventory destruction form. This form will be double checked against medications being destroyed by second nurse during the destruction process.

Based on observation, interview and document review the facility failed to develop interventions to provide adequate supervision and safety with smoking for 1 of 1 residents (R38), who continued to smoke unsupervised and was identified as safe to smoke only when supervised. Findings included: R38's significant change Minimum Data Set ((MDS) dated [DATE], identified R38 had intact cognition and needed extensive assistance with activities of daily living (ADLs) including bed mobility and transfers. R38's current [DIAGNOSES REDACTED]. R38's most recent Smoking Risk observation dated 10/23/19, indicated R38 had a BIMS (cognitive test) of 15/15, does not use oxygen, was able to verbalize safety precautions to staff, did not show evidence of burn marks on clothing or other belongings, hands were steady to hold cigarettes, no vision problems that would hamper smoking, and had ability to call for assistance. However, this assessment also indicated R38 was not able to dispose of ashes/cigarettes safely, had been seen smoking in non-smoking areas, displays poor decision making due to addiction, and resident is safe to smoke only when supervised. R38's care plan, last revised 10/8/19, indicated R38 required supervision for outdoor activities due to aftercare following surgical amputation of both legs. During an observation on 11/04/19, at 6:49 p.m. R38 was observed smoking, off facility property with son. R38 stated her family holds her cigarettes and lighter and only smokes when family or friends take her out. No burn holes were observed on her clothing or blanket that was wrapped around her lower part of body. Progress note dated 10/20/19, nursing documented: Staff found a kitchen coffee mug in residents room with cigarette ashes in it. The cup was removed from the resident's room. Progress note dated 10/20/19, nursing documented: Res rang door bell at 11: 20 pm to be let in building. She smelled of cigarette smoke and did confront res that she is not to go out the front door unattended. she immediately said 'yes I can, yes I can, I would not lie to you I promise!' Stated to res once again that there is very specific instructions on where res can be going outside without supervision and that is only the patio. The only way she is to be going out the front door is with her father. Res wheeled away and ignored writer. Progress note dated 10/21/19, social services documented: Writer was approached by two CNA's that they may have seen resident take a pack of cigarettes and put it under her shirt. Writer went to go visit with resident while she was in her room getting ready to leave for an appt. Writer asked if resident had cigarettes on her. Resident stated no. Writer asked if it was okay to check in her coat pockets, resident stated that was fine. Writer found a lighter. res stated the lighter is for when she goes out to smoke with her dad that he does not carry one for her. Writer then stated that an aide thought they saw her put a pack of cigarettes up her shirt, and asked if writer could check. She then stated, I do have pack of cigarettes on me. writer asked where they are, and she pulled them out from under her shirt. At first, she stated she did not know she couldn't have a lighter or cigarettes in her possession in the facility. Writer stated that this was reviewed on the risk vs benefits form and that she signed off on this. she stated, ya, I know. R38's Resident Smoking Agreement dated 10/24/19, indicated smoking was not allowed on the premises and all smoking materials would be at the nursing station. Progress note dated 10/28/19, nursing documented: This evening around 9 p.m. resident went outside. Staff notified me that she was smoking right outside the front door on the patio. By the time I was walking out, she was coming in. She smelled of smoke as I walked by her. Two CNA's came out of the East soiled utility room complaining of the smokey smell in there. Progress note dated 11/06/19, social services documented: It was reported to writer by TMA that a CNA returning from break saw resident smoking a cigarette on the property in the front of the building. When TMA went to go see if resident was still smoking, she was already returning from outside. Writer saw resident and asked to talk with her, she said yes, writer and resident went to her room. Writer asked if she was just outside smoking on the premise and she stated she just came back in from smoking on the curb of the road off the premise. Writer asked how she got down there and she stated a friend of hers. Writer asked where she got the cigarette and lighter from to smoke and she stated that her dad came to visit earlier and gave her an extra cigarette and lighter to hold on to as he didn't think he would be coming back later today to bring her off the property to smoke. She states she acknowledges the smoking policy about not keeping cigarettes or lighter in her possession in the facility and that family member is suppose to hold on to the materials. She states it won't happen again. During an interview on 11/06/19, at 1:31 p.m. director of nursing (DON) stated, We don't allow smoking in our facility or on our property. If they smoke, they have to sign out and go off premise. The DON also indicated they did not hold the tobacco products or lighter. Further, the DON stated risk versus benefits conversations were had with R38 several times. Stated R38 would agree to suggestions and then become non-compliant. During an interview on 11/07/19, at 8:47 a.m. the administrator stated I feel we did everything possible. She smokes. We are a non-smoking campus. We are not responsible for what happens off campus. The administrator indicated various attempts for compliance including risk versus benefit conversations, nicotine patch, nicotine gum, involvement with the ombudsman, and issuing a Notice Of Intent to Discharge. All interventions have been ineffective. Further, the administrator stated She went out again last night without telling staff. She is non-compliant. A facility smoking policy for non-smoking facilities, revised 6/14/19, identified protocols to follow when admitting residents who smoke, however, it lacked direction for supervision when resident was assessed safe to smoke only when supervised but continued to smoke unsupervised.

Based on observation, interview and record review, the facility failed to report to the state agency (SA) allegation of resident to resident abuse for 1 of 4 residents (R7, R10) who reported physical abuse from another resident. Findings include: R7's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R7 was cognitively intact. R10's quarterly MDS dated [DATE], indicated R10 was cognitively intact. During initial screening interview on 11/4/19, at 6:05 p.m. R10 stated that R7 had hit her in the hallway. Record review indicated R10 had hit R7. R7 and R10 were involved in an altercation on 10/27/2019. R10 was self-propelling backwards in a wheelchair while R7 was using a walker going towards R10. R7 stated to R10 to watch out as R10 could not see R7. R10 then struck R7 on the arm. During interview on 11/4/2019, at 6:05 p.m. R10 stated R7 accused R10 of bumping R7 with R10's wheelchair (WC). R10 further stated that the allegation was not true. During interview on 11/6/19 at 10:22 a.m. R7 stated that there was only one incident when R10 hit her on her arm and said I'm sure it hurt. R7 further stated that R7 stays away from R10 and stated I avoid her with a 10 foot pole. R7 additionally stated she feels safe in the facility. During interview on 11/6/2019, at 11:16 a.m. the administrator stated licensed practical nurse (LPN)-A called the administrator to report the altercation between R10 and R7. The adminstrator further stated she spoke over the phone with LPN-A and certified nursing assistant (CNA)-A and discussed the allegation. The administrator stated she believes R10 was wilful and intentional when R10 hit R7 on the arm. The administrator further stated CNA-A witnessed the incident and immediately reported it to LPN-A and called the administrator immediately. Additionally the adminstrator stated based on the interviews with LPN-A and CNA-A she felt there was no injury and the adminstrator did not have any concerns regarding the allegation. The administrator then shared a document titled Federal Long Term Reportability for Abuse Under F225 Resident- To Resident Altercations dated 7/2014. The administrator stated based on following the decision tree there was no negative impact for either R7 or R10 the administrator did not file a vulnerable adult (VA) report with the S[NAME] The administrator also stated since R7 was on a anti coagulant (a medication that prevents blood from clotting) the facility staff were monitoring R7 for bruising. The adminstrator further stated there is no documentation of the conversations between LPN-A and CNA-[NAME] During an interview on 11/6/2019, at 1:03 p.m. R7 stated it bothered her when she had to avoid R10 and that R7 tries to put R10 out of her mind R7 stated she just stays clear of R10. During an interview with the director of nursing (DON) on 11/7/2019, at 10:26 a.m. the DON stated if there was a resident to resident altercation that was wilful and deliberate the DON would file a VA with the S[NAME] The DON further stated the process for investigation was to make sure the residents were safe, interview the residents involved, interview staff member, other residents, and the residents family members. The DON further stated there would be a written investigation using an internal form. The DON additionally stated a summary of the investigation would be documented. During an interview on 11/07/19, at 1:59 p.m. CNA-A stated he witnessed the incident between R7 and R10. R10 was self propelling backwards in R10's WC and R7 was using R7's walker walking toward R10. CNA-A stated R7 told R10 to watch out, I'm right behind you and R10 stated you better watch out. CNA-A further stated both R7 and R10's voices were beginning to escalate so CNA-A moved immediately towards R7 and R10. CNA-A stated R10 raised R10's arm to swing at R7 and R10 made contact with R7's arm. CNA-A stated R10's actions were intentional and R10 knew what she was doing. CNA-A stated R7 went to her room and CNA-A escorted R10 back to her room. CNA-A then immediately reported the incident to LPN-A and called the administrator to report the incident. CNA-A further stated CNA-A told the administrator R10's actions were intentional and that R10 knew what she was doing. Additionally, CNA-A stated the administrator asked LPN-A to go to the administrators office to retrieve some information and LPN-A called the administrator right back. CNA-A stated he was not part of the conversation with the administrator to determine if a VA needed to be reported to the S[NAME] During interview on 11/7/2019, at 3:12 p.m. LPN-A stated the administrator was called immediately and discussed the incident, went to the administrators office to retrieve the document titled Federal Long Term Reportability for Abuse Under F225 Resident-To-Resident Altercations and called the adminstrator back. LPN-A stated LPN-A and the administrator reviewed the document. LPN-A stated the adminstrator stated there were no injuries and a VA did not need to be filed with the S[NAME] A policy titled Vulnerable Adult-MN dated 10/31/2019, indicates Cassia prohibits the abuse, neglect, exploitation of residents, and mistreatment of [REDACTED]. All residents of the facility are considered vulnerable adults due to physical or mental disability or dependence on institutional services. Report all alleged violations and substantiated incidents immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result serious injury, or no later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury to the state agency and all other agencies as required. Definition of abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. It also includes deprivation by an individual, including caretaker of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, or pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse facilitated or enabled through the use of technology. Willful: (as used in the definition of abuse) means the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. A copy of the investigation and interviews with the administrator, CNA-A, LPN-A regarding the allegation of resident to resident abuse for R7 and R10 were requested and not provided.

Based on observation, interview, and document review, the facility failed to ensure three years of survey results were available and accessible for residents or visitors. This had the potential to affect all 45 residents residing in the facility. Findings include: On 11/4/19, at 1:43 p.m. the survey results were observed in a three ring binder on a shelf by the DON's office door. Upon review of the enclosed documents the early 2019 State survey and (YEAR) State survey results were in the three ring binder. The three ring binder lacked (YEAR) State survey results. The area lacked information for residents and visitors to find the third year of State survey results. An interview on 11/6/19, at 10:58 a.m. the administrator stated the State survey results were posted by the administrator and there should be three years of State survey results out there. At 11:05 a.m. the administrator stated the State survey results for (YEAR) were not in the three ring binder with the other State survey results. The facility policy Posting of Survey Results dated 5/23/19, revealed the survey results and approved plan of correction (as applicable) will be available in a readable form such as a binder or large print. The facility will post these results in a place (s) that is/are readily accessible to resident, family members and legal representatives of residents. The facility will also have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the receding 3 years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request.

Based on observation, interview, and document review, the facility failed to ensure opened food items, not in the original containers were dated and failed to implement proper glove use and hand washing during food service, which had the potential to effect 45 of 45 residents eating food from the kitchen. Findings include: During observation on 1/28/19, at 12:23 with cook (C)-B during initial tour of kitchen, 2 covered containers of flour and one covered container of sugar were observed. The flour and sugar were out of their original packaging. The containers lacked labeling indicating the the manufacturer's expiration date. C-B stated she did not know the expiration dates of the flour or sugar. During observation and interview on 1/28/19, at 5:19 p.m. cook (C)-A was wearing gloves while checking temperatures of food on steam table. C-A retrieved and replaced a three ring binder from upper shelf directly behind steam table. C-A did not remove gloves or perform hand hygiene. With the same gloves, C-A began serving food. Further C-A served food from steam table and touched unwrapped bread and crackers with same gloved hands which were served to residents in dining room. During follow up interview on 1/28/19, at 6:02 p.m. with dietary director (DD)-C and C-A, C-A stated she did not remove gloves or perform hand hygiene after removing and returning three ring binder from shelf behind steam table. Further C-A stated she should have changed gloves and performed hand hygiene after touching three ring binder and before serving food with gloved hands. DD-C stated dietary staff should follow facility policy on hand hygiene. The facility's policy Augustana Elim Care Services with a subject of hand hygiene dated 10/2/18, indicated hand washing/sanitizing is necessary before and after eating or handling food and after touching environmental surfaces or equipment near residents. The facility's policy Food Preparation and Handling dated 11/2017 lacked direction on labeling of food removed from original container with manufacturer's use by date.

Based on interview and document review, the facility failed to ensure the pharmacist medication regimen recommendations were evaluated and addressed by a physician for 1 of 5 residents (R39) reviewed for unnecessary medication. Findings include: R39's 11/28/18 quarterly Minimum Data Set (MDS) indicated R39 was severely cognitively impaired. R39 required extensive assistance with personal hygiene and dressing. R39 [DIAGNOSES REDACTED]. R39's physician orders [REDACTED]. A 9/6/18 Consultant Pharmacist Drug Regimen Reviews form, identified R39 had a fall during a transfer. R39 reported weakness. R39's blood pressures (BP's) were lower, with approximately 1/2 of systolic blood pressures less than 100 and diastolic blood pressures less than 60. The review identified R39 was on two anti-hypertensive medications (Losartan and [MEDICATION NAME]) and indicated Could 1 be DC's (discontinued)?' A visit note by R39's primary care physician (MD)-B, dated 9/20/18, indicated R39's blood pressure 112/56. The note lacked documentation that the pharmacist's recommendations were reviewed or actions taken to address the recommendations. A 10/3/18 Consultant Pharmacist Drug Regimen Reviews form, identified the recommendations from the 9/6/18 review were not addressed and repeated the recommendation if one of the blood pressure medications could be discontinued. R39's medical record lacked physician documentation addressing the pharmacist's recommendations. A 11/6/18 Pharmacist Progress Note indicated blood pressures were reviewed. Not going to F/U (follow up) on request to reduce BP meds (medication) at this time d/t (due to) BP's not being low and appearing asymptomatic. During an interview on 1/30/19, at 9:02 a.m., the director of nursing (DON) stated the pharmacist completes monthly reviews on resident's medications. The DON stated the registered nurse care coordinator reviews the recommendations and faxes the recommendation to the primary MD. Depending on the urgency, the MD may be called, a second fax may be sent, or if the MD was scheduled to round soon, the MD could address the recommendation at the next visit. The DON stated there has been some push backs and slow responses from some MD's. The medical director has been involved at times, contacting MD's to promote a response. During an interview on 1/20/19, at 9:42 a.m. registered nurse (RN)-A stated she had faxed the recommendations to MD-B and did not get a response. RN-A stated when MD-B rounded on 9/20/18, MD-B was given a copy of the fax with the pharmacist's recommendations. RN-A stated MD-B did not change any of R39's medications. RN-A reviewed R39's medical record and stated there was no physician documentation addressing the pharmacists recommendations. The facility's policy Medication Regimen Review, dated 8/20/18, indicated Urgent concerns identified by the pharmacist will be reported to the Director of Nursing (or designee) at the time it is identified. The prescriber will be notified of the identified concern using the facility's system of notification of change in condition. The attending physician will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. These non-urgent recommendations should be reviewed and acted upon during the next scheduled physician visit (within 60 days).

Based on observation, interview and document review, the facility failed to assess a new and declining pressure ulcer, and failed to provide care plan interventions including timely repositioning to promote healing and prevent worsening of pressure ulcers for 1 of 3 residents (R37) reviewed for pressure ulcers. R37 suffered actual harm when she developed 2 pressure ulcers on coccyx, one of which advanced to a stage III. Findings include: R37's quarterly Minimum Data Sets (MDS), dated [DATE], indicated R37 was at risk for pressure ulcers (localized injury to the skin and or underlying tissue, usually over a bony prominence), however, did not have any pressure ulcers at the time of the assessment. The MDS indicated use of a pressure reducing mattress on the bed, pressure reducing cushion on her Broda wheel chair (reclining wheel chair with taller back and elevating leg rest) and indicated R37 was on a repositioning program, and had interventions to decrease risk for developing pressure ulcers. R37's MDS, further indicated severe cognitive impairment and required extensive assist of two for bed mobility and transfers. R37's Care Area Assessment (CAA), dated 10/6/17, indicated R37 was confined to a bed or chair most of the time, needed a special mattress or seat cushion to reduce or relieve pressure and required a regular schedule of turning to relieve pressure. R37 resident profile printed 4/26/18, identified Diagnoses: [REDACTED]. R37 care plan, dated 4/10/17, identified R37 was at risk for pressure ulcers. The goals included 1.) skin will remain intact 2). will not develop any new skin concerns 3). will have needs met and remain comfortable. Interventions included, skin check with weekly bath, pressure ulcer assessment, skin assessment with tissue tolerance assessment per nursing home policy, Braden scale, podiatry exams as needed, keep linens clean, dry and wrinkle free, keep skin clean and dry, and minimize skin exposure to moisture. On 3/30/18, new interventions included, pressure relieving cushion in Broda wheel chair, and heel protectors on when in bed. Nursing Aide Care Sheet, undated, indicated R37 should be turned and repositioned every two hours, have a pressure relieving cushion in her Broda wheelchair, heel protectors on at night, and be toileted upon rising, after meals and every two to three hours while awake during the day. Night shift to check and change every two hours. -Progress note, dated 4/6/18, at 3:31 p.m. indicated registered nurse (RN)-A documented an open area to coccyx that measured 0.8 centimeters (cm) x 0.4 cm. Resident stated, It smarts right there. Will start [MEDICATION NAME] cream to be applied once a shift until healed. The progress note indicated presence of a pressure ulcer, however, the record lacked evidence that an assessment was completed to determine factors that caused the newly developed pressure ulcer. -Progress note, dated 4/13/18, at 10:42 a.m. indicated licensed practical nurse (LPN)-A documented R37 has a superficial open area, roughly 1 cm round to her right butt cheek, barrier cream applied. -Progress note, dated 4/17/18, indicated hospice was at facility and has no changes or concerns at this time. Hospice nurse updated on pressure ulcer and no change in plan of care for skin treatment. The note further indicated that the hospice nurse stated she would update MD with any changes. -Progress note, dated 4/20/18, at 1:24 p.m. RN-A documented pressure area on coccyx has declined, was one area of concern, now is two areas on both sides of coccyx. See Wound Management. Will start stoma powder and [MEDICATION NAME] to be completed by nurses. The progress note indicated worsening of the pressure ulcer and development of a second pressure area on coccyx, however, the chart lacked evidence that an assessment or evaluation was completed to determine and address what caused the decline. Wound Management form, dated 4/20/18, RN-A indicated a right side pressure ulcer on coccyx with measurements of length- 1.6 cm by width- 0.5 cm , a stage I pressure ulcer. (intact skin with non-blanchable redness of a localized area over a bony prominence) Wound Management form, dated 4/20/18 by RN-A indicated a pressure ulcer on left of coccyx. Length is 1 cm by width 0.4 cm, a stage I pressure ulcer. Comments indicated on left side coccyx started stoma powder and [MEDICATION NAME]. Treatment Administration History record, dated 4/6/18 through 4/20/18, indicated to check coccyx open area every shift and ensure [MEDICATION NAME] cream barrier is applied to area at least once a shift by nursing assistance. During continuous observation, on 4/25/18, starting at 7:12 a.m. R37 was up in Broda wheelchair sitting at table with one other resident in the lobby/common area. At 7:43 a.m. R37 was wheeled to dining room for breakfast. R37 was served breakfast and was provided some assistance with eating. Following breakfast, a nursing assistant wheeled R37 in Broda chair to common area, up to a table where she had been sitting prior to breakfast. At 9:02 a.m. R37 was wheeled in Broda chair by activity aid (AA)-A to a table in the art room. No attempt was made to reposition or toilet R37 since the start of the continuous observation. R37 sat alone at the table in the art room with head down, and eyes closed. AA-A greeted R37, however, eyes remain closed, with head bent forward, and appeared to be sleeping. R37 did not participate, rather just sat in her chair at the table with eyes closed. At 10:41 a. m. R37 was wheeled to the common room/lobby to a table with other residents. At 10:43 a.m. in common room/lobby, nursing assistant (NA)-A explained R37's routine cares. NA-A further stated R37 has a low bed with a mat next to bed, is limited assist with dressing, denture cares, hair in morning, and washing up and needs help with incontinence, so is washed up and provided a clean brief and is helped with repositioning. NA-A stated she cares for R37 quite a bit as she is on her wing and went on to state that R37 is total care. NA-A stated, I don't know what time R37 was last repositioned, but I can go look. NA-A stated (R37) was repositioned at 6:50 a.m. when she got her up this morning. At 11:02 a. m. that same day, R37 remained in Broda chair, slumped over, eyes closed in common lounge room. R37 had not been repositioned or toileted since 6:50 a.m., over four hours, rather than the every two hours as directed per the Nursing Assistant Care Sheet. During interview, on 4/25/18, at 12:02 p.m. the director of nursing (DON) stated R37 should be toileted upon rising, after breakfast, after lunch, at HS (hours of sleep) and every 2-3 hours while awake. The DON stated R37 care plan indicated reposition every 2 hours or as needed. DON stated her expectation is that the nurses follow the care plan. During observation, on 4/25/18, at 12:19 p.m. the DON entered the dining room, wheeled R37 out of dining room to hallway and stopped to talk to two NAs. The two NAs then wheeled R37 to her room. At 12:22 p.m. NA-B and NA-C assisted R37 to stand and to transfer to the toilet. Due to R37's position in the bathroom, it was difficult to visualize the pressure ulcers at this time. During interview, on 4/25/18, at 12:55 p.m. RN-A stated she looks at wounds weekly, and the other LPNs or RNs look every shift. RN-A stated the NAs should report any changes if ulcers are getting worse, if not, no report is needed. RN-A stated NAs should tell a nurse if there are changes from shift to shift and to see if ulcers remain stable. RN-A stated hospice is here 2 times weekly, and they let the physician know if changes have occurred and if wound is worse. RN-A further stated they at times utilize a consultant wound nurse out of [MEDICAL CONDITION], however, R37 was not referred to the consultant wound nurse. RN-A stated R37 had first developed a pressure ulcer about a month ago on the right side of coccyx. At 1:13 p.m. R37 was laid down in bed on her left side. RN-A stated the ulcer on the left coccyx is larger than it looked on Friday, and the right ulcer is smaller. RN-A stated, I am sure my measurements will be bigger. RN-A measured the wounds and stated finding included: left side is 2.6 cm x 1 cm and into second layer of skin, not really slough (non-viable, yellow, gray, tan or brown tissue in the wound bed) but becoming slough, and getting deeper, and that the yellow was not there on Friday. RN-A further stated R37 needed to lay down, and get off her bottom. RN-A went on to say right side wound is superficial, 0.4 x 0.4., left side is a stage II (partial thickness loss of skin, presenting as a shallow open ulcer, the wound bed is viable pink or red. Granulation, slough and eschar are not present) and right side is stage I, but [MEDICATION NAME] tissue, and very fragile, not granulation, (pink, red moist tissue that fills an open wound) that R37 had treatment powder first and cream next. RN-A then stated she would look into more aggressive treatment, and be changing treatment as wound had changed. RN-A added, I will want the nursing assistants to lay her down more. RN-A cleansed her coccyx and applied barrier cream. R37 agreed to lay on left side as RN-A stated, your bottom is pretty sore. Progress note, dated 4/25/18, at 1:49 p.m. indicated RN-A measured pressure ulcer to coccyx area and areas have declined. Fax sent to update rounding MD. Called hospice and left message updating. Will encourage resident to lay down and turn side to side. Have been updating hospice on skin issue and have no new orders from them. Will change treatment to bottom If MD recommends something else and will change order. During interview on 4/25/18 at 2:02 p.m. RN-A indicated the yellow area on R37's left of coccyx is 40% slough. During interview at 2:18 p.m. RN-A was reviewing the staging tool she reported she used for staging a pressure ulcer. After reviewing the tool, RN-A indicated due to the slough, the pressure ulcer should be staged as a stage III. (full thickness, loss of skin in which subcutaneous fat may be visible. Slough may be visible but does not obscure the depth of the tissue) She also indicated the NAs should be repositioning R37 every 2 hours. Wound Management form, dated 4/25/18 at 1:45 p.m. indicated a pressure ulcer on coccyx, length- 2.6 cm, width- 1 cm, stage II pressure ulcer. Comments indicated, stoma powder and [MEDICATION NAME] cream. On same date, at 2:28 p.m. coccyx pressure ulcer is documented as length 2.6 cm by width 1 cm, a stage III pressure ulcer. Comments indicate, will apply new foam dressing to area. On 4/25/18 Treatment Administration History Record, indicated to check dressing to coccyx every shift, change dressing every three day and as needed. Cleanse ulcer with wound cleanser, apply no sting barrier film to surrounding skin, and cover with sacral foam dressing. Writer placed a phone call to MD, rounding physician for this facility, on 4/26/18, at 8:05 a.m. and message was left regarding the above. No phone call was returned. On 4/26/18, at 12:42 p.m. RN-A documented she had spoken to the hospice nurse regarding air mattress and one has been ordered for R37. Hospice nurse updated on new foam sacral dressing as of 4/25/18 and hospice nurse indicated she will update the MD. Continue to encourage R37 to lay on side in bed at least once a day as R37 likes to be up in her chair. R37's care plan, was updated on 4/26/18, and included a new goal of 1) current pressure ulcer will heal without issues. On this same date, a new intervention included 1. complete treatments 2). follow repositioning plan 3). monitor for changes in condition and update medical doctor and hospice as needed. From 4/6/18 to 4/20/18, 2 new pressure ulcers developed. Interventions included applying cream and powder to bottom, however, the record did not indicate an assessment was completed to determine root cause of the pressure ulcers or that any new pressure ulcer interventions were put into place to prevent worsening or the development of new ulcers until 4/26/18 when R37 developed a stage III pressure ulcer. Lake Side Health Care of Dassel Skin Care Program Policy, indicates A resident who enters an Augustana facility will not develop a pressure injury unless the individuals clinical condition demonstrates, and a physician or NP authenticates, that it was unavoidable. A resident who has a pressure injury will receive the necessary treatment and services to promote healing, prevent infections, and prevent new injury's from developing. Any alteration in skin integrity will be communicated to the resident's physician and family. Treatments will be ordered by physician/NP or by utilizing facility wound care protocols.

Based on observation, interview, and document review, the facility failed to notify the physician timely when an antihypertensive medication was inconsistently held or inappropriately not held when blood pressure (BP) was outside of the ordered parameters, and when the resident routinely refused to take an ordered diuretic, for 1 of 5 residents (R8) reviewed for unnecessary medications. Findings include: R8's Minimum Data Set (MDS), dated [DATE], identified R8 was cognitively intact with active [DIAGNOSES REDACTED]. R8's current physician orders, printed 4/26/18, identified R27 took several medications, including but not limited to, the following medications: [REDACTED] -[MEDICATION NAME] (used to treat too much fluid) 40 milligrams (mg) once daily in the morning, and 20 mg once daily at noon, for heart failure. -[MEDICATION NAME] extended release (antihypertensive medication) 12.5 mg once daily in the morning for heart failure, with special instructions, administer with food. Hold [MEDICATION NAME] if BP (blood pressure) below 120/65. goal for BP should be 130 systolic (maximum pressure during one heart beat) and diastolic (minimum pressure in between two heart beats) <90. R8's Medication Administration Record [REDACTED] -On 4/1/18, R8's BP was 104/62. Although R8's BP was below the parameters ordered, R8's MAR indicated [REDACTED]. -On 4/2/18, R8's BP was 112/64. Although R8's BP was below the parameters ordered, R8's MAR indicated [REDACTED]. -On 4/7/18, R8's BP was 104/58. Although R8's BP was below the parameters ordered, R8's MAR indicated [REDACTED]. -On 4/15/18, R8's BP was 118/64. Although R8's BP was below the parameters ordered, R8's MAR indicated [REDACTED]. -On 4/16/18, R8's BP was 110/50. Although R8's BP was below the parameters ordered, R8's MAR indicated [REDACTED]. -On 4/18/18, R8's BP was 113/72. Although R8's BP was above the parameters ordered for diastolic blood pressure, R8's MAR indicated [REDACTED]. -On 4/19/18, R8's BP was 105/68. Although R8's BP was below the parameters ordered for systolic blood pressure, R8's MAR indicated [REDACTED]. On this same day, [MEDICATION NAME] was not given at noon due to R8's refusal. -On 4/20/18, R8's BP was 112/68. Although R8's BP was above the parameters ordered for diastolic blood pressure, R8's MAR indicated [REDACTED]. -On 4/21/18, at noon, R8 refused his [MEDICATION NAME]. -On 4/22/18, at noon, R8 refused his [MEDICATION NAME]. -On 4/23/18, at noon, R8 refused his [MEDICATION NAME]. -On 4/24/18, at noon, R8 refused his [MEDICATION NAME]. -On 4/26/18, R8's BP was 115/74. Although R8's BP was above the parameters ordered for diastolic blood pressure, R8's MAR indicated [REDACTED]. On this same day, [MEDICATION NAME] was not given at noon due to R8's refusal. R8's record identified he had, on several occasions, received [MEDICATION NAME] outside of the ordered parameters, or it had been held when it should have been given. In addition, R8 had refused his noon dose of [MEDICATION NAME] for 6 of the last 8 days, from 4/19/18 through 4/26/19. Review of R8's progress notes, dated 4/19/18, included, BEHAVIOR: Resident refused [MEDICATION NAME] ([MEDICATION NAME]) today and stated, I would rather die of heart failure than piss the bed. States he had been incontinent and wet his pants X 2 and wasn't happy about it. Continue to monitor. During an observation and interview on 4/26/18, at 10:17 a.m. R8 was seated in a chair in his room. R8 stated he used a wheelchair or a four-wheeled walker for locomotion, and although he had a history of [REDACTED]. R8 had no obvious [MEDICAL CONDITION]. R8 stated he had been telling the staff that he doesn't want to take his [MEDICATION NAME] in the afternoons because he's tired of peeing myself. R8 indicated staff had talked to him about why he should be taking the [MEDICATION NAME] but stated, I don't like that stuff. During an interview on 4/26/18, at 10:49 a.m. registered nurse (RN)-A stated she was not aware that R8's [MEDICATION NAME] had been held several times in the month of 4/18 due to BP being low, either systolic or diastolic, per ordered parameters, and on five occasions, was given [MEDICATION NAME] even though the systolic and diastolic BP were both lower than the ordered parameters and should have been held. RN-A stated she did not have time to check on each resident's medications every day and was not made aware of this. RN-A stated R8's physician had not been notified. RN-A indicated she had learned today in report that R8 had been refusing his [MEDICATION NAME]. RN-A stated R8's physician had not been notified about that either. In a follow up interview on 4/26/18, at 11:21 a.m. RN-A stated she was unclear what the ordered parameters meant, if staff were to hold the [MEDICATION NAME] if the BP was less than 120 systolic, or less than less than 65, or both systolic and diastolic needed to be less than 120/65 to hold it. RN-A stated the parameter order was unclear and verified that staff were inconsistently interpreting whether or not the [MEDICATION NAME] should be given, therefore, there was a potential for error. RN-A stated, That's all on me. I should have notified the physician. RN-A stated she would be notifying R8's physician and would be clarifying the parameters for R8's BP and when the [MEDICATION NAME] should be held. Also, RN-A stated she would be notifying R8's physician that he had been refusing his [MEDICATION NAME]. During an interview on 4/26/18, at 3:13 p.m. director of nursing (DON) stated if refusals of medication were happening more than a couple of times, or if medication was being held, the RN/resident care coordinator should be notified and an update to the physician would be appropriate if there was no resolution. On 4/30/18, at 3:21 p.m. R8's physician's nurse returned phone call. She stated the physician is typically notified after 2-3 days of a resident refusing a medication, or a medication has been held due to being outside the ordered parameters, and the physician would have expected the staff to call if they needed clarification for the BP parameter order. Review of the facility's policy, Pharmaceutical (Medication) Administration Policy, revised 11/17, included, When residents refuse medications this will be documented in the EMAR (electronic medical administration record) as Not Administered with an explanation of why it was not given. If a resident routinely refuses medication(s) the provider will be notified. Review of the facility's policy, Physician and Resident Representative notification, revised 11/16, included, Primary Physicians, Residents, and the Resident representative, consistent with their authority, will be updated with all resident condition changes as soon as possible.