Every finding on record at Lifeceare Roseau Manor

Based on observation, interview and document review the facility failed to ensure utilization of appropriate sling sizes assessed for use with mechanical lift/stand devices for 3 of 4 residents (R1, R3, R4) reviewed for safe transfers with mechanical lift/stand devices.Findings Include:R1R1's Transfer/Discharge Report indicated she admitted to the facility 6/30/21. R1's diagnoses included Multiple Sclerosis, dementia, weakness and dysphagia.R1's quarterly Minimum data set (MDS) dated [DATE], Identified moderate cognitive impairment and indicated she was dependent on staff for transfers.R1's Balance and Transfer assessment dated [DATE], indicated all transfers were completed with a total body lift and two staff. R1 was unable to safely or consistently bear weight. R1 weighed 152.2 pounds (lbs.) and directed the use of a yellow (medium) bordered slingR1's care plan dated 2/5/26, identified a self care deficit related to disease process and directed staff to perform transfers with a full body lift and two staff.During observation on 3/25/26 at 8:16 a.m., R1 was seated in a wheelchair in the dining room. Underneath R1 was a black sling with green edges, which indicated a large sling.During observation on 3/25/26 at 10:18 a.m., R1 had two slings in her room, one on her wheelchair and one in her recliner. Both slings were a size large (green).During observation and interview on 3/25/26 at 10:33 a.m., NA-A verified the sling on R1's chair had been used to transfer her to bed and verified the sling was a size large. NA-A stated the care guide indicated a yellow (medium) sling.R3R3's Transfer/Discharge Report indicated she admitted to the facility 8/8/24. R3's diagnoses included arthritis, reduced mobility and weakness.R3's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she was dependent on staff for all transfers.R3's Balance and Transfer assessment dated [DATE], indicated she did not ambulate and transferred with the use of a mechanical lift and two staff. R3 weighed 122.8 lbs. and directed the use of a red (small) sling.R3's care plan dated 2/5/26, identified a self care deficit related to shortness of breath and self-limits and directed the use of a mechanical lift for transfers.During observation on 3/25/26 at 8:32 a.m., R3 was seated in a wheelchair in the dining room. R3 had a black sling with [NAME] edges (large) underneath her.During observation and interview on 3/25/26 at 9:18 a.m., R3 was in bed. R3 had a green (large) sling on her wheelchair. NA-A and NA-B confirmed they had transferred R3 using the large sling. NA-A reviewed the care guide and said staff should have used a red (small) sling to transfer R3. NA-A and NA-B stated they usually just used the sling that was in the room. NA-A and NA-B acknowledged they had not reviewed the care guide prior to the transfer.R4R4's Transfer/Discharge Report indicated she admitted to the facility 4/27/23. R4's diagnoses included dementia, weakness and unsteadiness on feet.R4's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated R4 was dependent on staff for transfers.R4's Transfer and Balance assessment dated [DATE], indicated she was non-ambulatory and transferred using a mechanical stand and two staff. R4 weighed 118 lbs. and directed the use of a mechanical stand with a red (small) harness.R4's care plan dated 3/18/26, identified a self care deficit related to dementia and anxiety and directed the use of a standing lift and two staff for transfers.During observation on 3/25/26 at 8:54 a.m., NA-C and NA-B transferred R4 from the toilet to bed using the mechanical stand and a yellow (medium) harness.During interview on 3/25/26 at 9:26 a.m., NA-C stated the sling size was listed on the care guide and said R4 should have had a medium harness for transfers. NA-C reviewed the care guide and verified a red (small) sling was care planned for R4. NA-C said she used what was already in the room.During observation and interview on 3/25/26, an mechanical stand was observed on the secured unit with a yellow (medium) sling draped over it. NA-D said the sling size was based on height and weight. NA-D stated staff used the sling that was on the unit.During interview on 3/25/26 at 12:45 p.m., the assistant administrator stated prior to performing a transfer with a mechanical device, staff were expected to ensure the sling was placed properly, ensure lift was in good condition and ensure the sling/harness size was appropriate for the resident.Facility Policy Safe Patient Handling and Movement Policy undated, indicated it is the duty of employees to use mechanical lift devices in accordance with instructions and training.

Based on interview and document review, the facility failed to complete a comprehensive assessment following resident to resident incidents to maintain safety of the residents for 1 of 5 residents (R2) reviewed for dementia care.Findings include:R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and diagnoses included dementia, anxiety, and depression. R2 exhibited physical behaviors directed towards others (for example: hitting, kicking, pushing, grabbing) 4-6 days, verbal behavioral symptoms directed towards others 4-6 days, other behavioral symptoms not directed towards others such as hitting/scratching self 1-3 days, rejection of care 4-6 days, and wandering 4-6 days. R2 required setting up or clean up assistance with eating, substantial/maximal assistance for toileting and was dependent on staff for all other care areas. R2 used antipsychotic, antianxiety, antidepressant, diuretic, and medications.R2's Delirium Care Area Assessment (CAA) dated 11/18/25, identified inattention, disorganized thinking, and altered level of consciousness had been R2's baseline since her initial admission more than nine months ago which led to her requiring 24-hour supervision and activities of daily living (ADL) assistance. This was not new or worsening. This had been R2's baseline for more than a year per R2's family. R2's Behavioral Symptoms CAA dated 11/18/25, identified R2's goal was to continue to attempt to express self and avoid complication such as social isolation and avoidance behaviors. Staff were to provide simple step by step instructions, allow time to process and respond, don't offer too many choices, repeat and rephrase as needed, provide verbal and nonverbal prompts and cues, approach in a calm and unhurried manner, offer smiles, list potential needs one at a time and observe for indication/acknowledgement that was what she wants/needs, provide reassurance, leave alone in safe situation and return later when unable to console or deescalate agitation, administer medications as ordered for anxiety, depression, agitation and observe for adverse effects and notify R2's physician of concerns, document target behaviors for physician to review with ongoing visits/consults. R2 was at risk for miscommunication, frustration, agitation, worsening symptoms of anxiety and depression, falls with injury, adverse effects of medications, social isolation, escalating adverse behaviors, unmanaged pain, and unmet needs. Medications were monitored per policy with behavioral health consultations.R2's Cognitive Loss/Dementia CAA dated 11/18/25, identified R2's goal was to continue to make her needs known, minimize risks, and avoid complications. Staff were to assist with communication with verbal and nonverbal prompts and cues, allow time to process and respond, offer reassurance, and allow to vent frustrations. R2 was at risk for miscommunication, frustration, anxiety, depression, adverse behaviors, and unmet needs.R2's Psychotropic Drug Use CAA dated 11/18/25, identified R2's goal was to continue to attempt to express self and avoid complications such as social isolation and avoidance behaviors. Staff were to provide simple step by step instructions, allow time to process and respond, don't offer too many choices, repeat and rephrase as needed, provide verbal and nonverbal prompts and cues, approach in a calm and unhurried manner, offer smiles, list potential needs one at a time and observe for indication/acknowledgement that is what she wants/needs, provide reassurance, leave alone in safe situation and return later when unable to console or deescalate agitation, administer medications as ordered for anxiety, depression, agitation and observe for adverse effects and notify R2's physician of concerns, document target behaviors for R2's physician to review with ongoing visits/consults. R2 was at risk for miscommunication, frustration, agitation, worsening symptoms of anxiety and depression, falls with injury, adverse effects of medications, social isolation, escalating adverse behaviors, unmanaged pain, and unmet needs. Medications are monitored per policy with behavioral health consultations.R2's care plan revised 2/10/26, identified R2's target behaviors included wandering, poor safety awareness, verbal aggression, physical aggression, crying out that was disruptive to others, unable to understand boundaries, elopement risk, and grabs on to other walkers/items. The care plan identified nonpharmacological interventions to try, such as calm, hurried approach; approach with 1 or 2 staff; leave alone and return later when safe to do so; and distract with snacks. R2's Physical Aggression Initiated dated 12/3/25 at 3:30 p.m., identified R2 was attempting to enter another resident's room. When the other resident said, go to your own room, R2 stated shut up you bitch and then swung her hand toward the other resident's face. The other resident raised her arm and stopped the blow with her forearm. Staff stepped between the residents and R2 swung a second time. R2's hand connected with the other resident's forehead before staff was able to completely stop R2. Staff reported the hit as weak. Immediate action taken was the residents were separated and redirected. However, the document failed to identify potential triggers for R2's behavior or potential interventions to prevent further incidents.R2's Physical Aggression Initiated dated 12/5/25 at 12:15 p.m., identified staff reported R2 hit another resident on the right shoulder four times as staff was attempting to get R2 to let go of the other resident's walker. Staff stated it was possible R2 was attempting to hit staff and not the other resident. R2 was unable to provide a description of the incident. The immediate action taken was staff intervened and redirected R2 with another activity. However, the document failed to identify potential triggers for R2's behavior or potential interventions to prevent further incidents. R2's nursing progress note dated 12/9/25 at 11:30 a.m., identified R2 had a behavioral health video appointment regarding management of psychotropic medications related to dementia with aggressive behaviors and anxiety. R2's provider was informed R2 had an increase in verbal and physical aggression toward staff and other residents. The incidents appeared to be triggered by R2 not getting her way (for example, being told she could not have something another resident already had) or when ADLs were being attempted. The noted further identified a review of R2's psychotropic medications were completed, but no nonpharmacological interventions were discussed. R2's Physical Aggression Initiated dated 12/18/25 at 6:00 p.m., R2 was attempted to squeeze between the wall and another resident's wheelchair in the dining room. Staff tried to tell R2 to stop because there was not enough room to safely pass. R2 became aggressive swinging out and hitting staff several times, pulling hair, pinching skin. The other resident also told her to stop, and R2 hit him once on the back of the neck. The other resident was not injured. A few minutes later R2 tried taking silverware from another resident. This resident asked her to stop, and R2 swung out at him, but he raised his arm and blocked R2's punch. The immediate action taken was R2 was redirected, staff took R2 for a walk down the hall and R2 eventually sat down in a chair. However, the document failed to identify potential triggers for R2's behavior or potential interventions to prevent further incidents. R2's nursing progress note dated 1/6/26 at 8:39 a.m., identified R2 had a behavioral health video appointment regarding management of psychotropic medications related to dementia with aggressive behaviors and anxiety. A review of staff notes was completed to evaluate whether the last medication change was effective. Based on documentation, R2 had been sleepier, has not been aggressive toward other residents but has been physically and verbally aggressive with staff at times when cares are attempted. The note further identified that a review of R2's psychotropic medications was completed, but no nonpharmacological interventions were discussed. During a telephone interview on 2/17/26 at 5:45 p.m., family member (FM)-A stated she and FM-B had visited R2 on 2/12/26. R2 had been up all night and hadn't had cares and eaten. FM-A stated the staff let R2 lie in bed all day and then R2 was up all night. FM-A stated they had discussed R2's behaviors with the facility many times and they were told the facility would provide more training to the staff on how to care for a resident with dementia.During an interview on 2/18/26 at 4:50 p.m., nursing assistant (NA)-A stated R2 had a lot of behaviors and could get combative with staff and other residents. You don't see it coming. NA-A stated she didn't trust R2 around the other residents and immediately stepped between them whether R2 was agitated or not because R2 could hit hard.During an interview on 2/18/26 at 5:00 p.m., FM-B stated there were times when family visited R2 didn't have her glasses, dinner will just sit there, and staff did not offer to assist R2. A lot of the time, R2 just remained in her bed or room in the dark with alarms blaring. FM-B stated it wasn't fair to R2, she's just existing. During an interview on 2/19/26 at 7:52 a.m., NA-B stated R2 was difficult resident and had a lot of behaviors. R2 was unpredictable and, in the previous weeks, R2's behavior had gotten a lot worse. R2 was very clingy and would hang on you. Staff tried their best to keep R2 away from other residents. For example, if a resident was sitting in a chair and R2 wanted to sit there or was trying to move the chair and staff tried to redirect R2, R2 would become angry and start hitting the staff and R2 could hit the other resident too. That's why staff tried to keep R2 away. R2 would cling to one person so staff would have to ask for help and the help had to do whatever was needed because R2 wouldn't let the staff go. Also, if the staff did get away from R2, that would make R2's behaviors worse. Staff just had to do their best to keep R2 away from the other residents. Some days, R2 would sleep all day. Some days, R2 was up all day. Staff never knew. Staff were just told that if R2 was sleeping to not ask if R2 wanted to get up. Staff were to be encouraging to R2 to get up for the day.During an interview on 2/19/26 at 8:09 a.m., trained medication aide (TMA)-A stated R2 was very combative. Any time staff had to touch R2 it made R2 more combative. R2 was unable to understand every small, direct communication and nothing calmed R2 except R2's family. R2 could be vulgar too. TMA-A stated she had never witnessed or been told R2 was combative with other residents.During an interview on 2/19/26 at 8:36 a.m., registered nurse (RN)-A stated staff were expected to report all resident-to-resident incidents immediately. First, staff were directed to ensure all residents were safe, separated and without injury. Then, the charge nurse would report the incident to the administrator and social worker. Then, an investigation of the incident would occur, and family was notified. All incidents were then discussed during the interdisciplinary team (IDT) meeting. For R2's resident-to-resident incidents, staff were just to monitor. The facility used the communication page of the electronic medical record system, however, RN-A stated she could not determine if a communication had been entered regarding R2's behaviors and/or possible interventions to prevent resident-to-resident incidents.R2's medical record lacked evidence a comprehensive assessment was completed following each incident to identify potential new interventions to keep R2 and others safe.During an interview with the director of nursing (DON) and licensed social worker (SS)-A on 2/19/26 at 9:52 a.m., the DON stated staff had been working with R2's behavioral health provider to adjust R2's medications but R2's family was hesitant to follow recommendations. R2 was difficult because there wasn't really any sign of aggression. R2 could be happy or R2 could be tired and could be fine. There wasn't any way to determine the trigger of R2's behaviors. However, the DON stated a lot of behaviors did occur when R2 was told no or during cares. During the facility's psychotropic meeting, staff review the behavior charting and see if there was anything the nursing assistants were seeing/charting but not reporting up. Then the care plan was reviewed and updated if needed. This was done quarterly. The DON stated she did not know what could have been care planned to help prevent R2's resident-to-resident incidents.During an interview on 2/19/26 at 1:45 p.m., the administrator stated staff were expected to recognize potential signs of aggressive behaviors, identify root causes, to create potential interventions to prevent incidents and to care according to what had been decided on as a team. Also, staff were expected to reassess and change the care plan as needed.The facility Care Planning policy revised 6/09, identified a care plan would be developed and maintained on each resident according to the RAI guidelines to provide mandated and essential information in an organized manner to develop and maintain a plan of care for each resident.A facility policy regarding dementia care was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure a schedule 2 narcotic (a medication with a high potential for abuse) was stored in a manner to prevent diversion for 1 of 3 units (Maple Unit); and failed to monitor temperature on a medication refrigerator temperatures of 1 of 2 medication fridges (Maple Unit) reviewed for medication storage. Findings include:During observation on 2/19/26 at 8:25 a.m., the director of nursing (DON) did a tour of the medication room on the Maple unit (memory care unit). Upon entering the locked medication room on the unit, it was observed there were keys in a lock on one of the cupboards. The DON reached up and pulled the cupboard door open as it was not locked. In the cupboard there was a 30-milliliter (ml) unopened bottle of liquid morphine (a scheduled 2 narcotic). The medication refrigerator did not have a thermometer inside of it nor was there evidence the temperatures were monitored. The refrigerator contained two vials of injectable lorazepam 2 milligrams (mg)/ml. for R22. The refrigerator had cool air coming out upon opening and the freezer had some frost buildup. During an interview on 2/19/26 at 8:40 a.m., the DON stated the liquid morphine needed to be double locked and it wasn't. When staff were done in the medication room, they should have locked all locks and taken the keys with them to ensure resident safety. The refrigerator temperature should be monitored daily and there should be a thermometer in the refrigerator to ensure the efficacy of the residents' medications were maintained. There was no evidence there was missing morphine, or the fridge temperature was out of range. During an interview on 2/23/26 at 9:35 a.m., the consulting pharmacist (CP) returned a call from 2/18/26. The CP stated that schedule 2 narcotics are to be double locked for safety and refrigerator needed the temperature to be monitored to ensure medication stability. The facility's Labeling and Storing of Medication policy dated May 2009, identified schedule 2 medications were to be locked with double locks. The policy did not address the monitoring of medication refrigerators.

Based on interview and document review, the facility failed to follow through on a grievance regarding medication found in recliner for 1 of 1 resident (R2) reviewed for grievances.Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and diagnoses included dementia, anxiety, and depression. R2's care plan revised 2/10/26, identified R2 preferred medications crushed in vanilla pudding.An e-mail dated 2/12/26 at 5:31 p.m., identified family member (FM)-B reported to registered nurse (RN)-B that FM-B reported to the charge nurse two whole pills were found on R2's chair (one with an imprint C) and R2's Wanderguard (device to monitor exiting) was found on R2's bed footboard. FM-B identified R2's medications were crushed, and the family was unsure if the pills found were missing doses or dropped pills. The e-mail included three photos. The first photo was a broken pill with an imprinted c and light orange in color. The second photo was a pill broken in half, orange in color and partially dissolved. The third photo was a Wanderguard wrapped around the footboard.During a telephone interview on 2/17/26 at 5:45 p.m., FM-A stated on 2/12/26 FM-A and FM-B were at the facility to visit R2. FM-A and FM-B found a pill in R2's chair in R2's room, then found another on the floor even though R2 took her medications crushed. When FM-A and FM-B brought the pill to nursing, they were told the facility could not determine what the medication was nor where it came from. FM-A stated it made her feel awful that R2 was cared for this way. FM-A brought other concerns to the director of nursing (DON), however, FM-A stated she was just told it shouldn't be that way, but the facility didn't really do anything about it.During an interview on 2/18/26 at 5:00 p.m., FM-B stated it was crazy. On 1/12/26, after visiting R2, FM-B and FM-A found a pill in R2's chair. FM-B took a photo of the pill and brought the pill to the charge nurse. R2's wandguard was also at the foot of R2's bed. The following day, FM-B sent an e-mail to the care coordinator. FM-B stated it was half a pill that had been scored with another small portion next to it. FM-B stated she was told it was weird because R2's medications were crushed before administration. FM-B stated she was told the care coordinator spoke with staff who didn't know what the pill was. During an interview on 2/19/26 at 8:36 a.m., registered nurse (RN)-A stated she was the care coordinator for R2. When a family member reports a concern, RN-A makes a note of it. RN-A or the social worker would interview the resident. If the resident cannot be interviewed, RN-A would figure out what she could and would report back to the family what was found. This should be documented in the resident's chart in a family communication note. However, RN-A stated there was no way to run a report for these concerns in order for the facility to track the different concerns to determine if there was a pattern. RN-A sated she was aware of FM-B's concern regarding an unknown medication found in R2's room. However, RN-A stated no formal grievance was documented and no formal grievance was completed. RN-A stated FM-B's email didn't provide how long the medication was there, where the chair came from because the chairs were not static to resident rooms, and there wasn't enough information for RN-A to investigate further. RN-A did not call and speak with FM-A to obtain clarifying information. RN-A took the photo from the e-mail and looked at R2's medication cassettes from the medication car and didn't find a match. RN-A did not review other resident medication cassettes to determine if there was a possible match. RN-A then e-mailed FM-A to let her know she couldn't determine what the medication was nor where it came from. No further investigation was completed. During an interview with the director of nursing (DON) and licensed social worker (SS)-A on 2/19/26 at 9:52 a.m., SS-A stated most complaints come to her. Then, SS-A would talk to the DON and together they would determine a solution. The DON stated there was a formal grievance process, however, if they were able solve the problem the formal process wasn't followed.During an interview on 2/19/26 at 1:45 p.m., the administrator stated staff were expected to report complaints to the charge nurse who reported concerns to the administration. Staff were able to use e-mail or phone after hours and administration would follow up. An investigation and resolution should be documented.The Patient Complaint of Grievance Policy revised 10/11/24, identified the facility informed patients of their rights, including the right to resolution of grievance. Complaints and grievances related to patient care and services at the facility were addressed according to the following guidelines. Patients and/or their representatives voicing a complaint or making a grievance would not jeopardize the quality of care or access to future health care services.Procedure:A. Grievances submitted to facility personnel in writing, verbally, via e-mail, or over the telephone are forwarded to the Director of Quality & Risk Management or the Director of Clinic Operations, who are considered the patient advocate/patient representatives. In the event the Director of Quality & Risk Management or the Director of Clinic Operations is not available, this role will be assumed by the Chief Nursing Officer or other administrative personnel.B. The facility's staff in receipt of a grievance will communicate with the patient or their representative regarding the plan to investigate and follow-up the grievance.C. The investigation of the grievance shall be conducted by the Director of Quality & Risk Management or Director of Clinic Operations, who will collaborate with the areas involved. The medical staff peer review process will be used to investigate a grievance concerning the quality of medical care as needed.D. All grievances will have a prompt written or verbal response, within 7 days if possible depending upon the nature of the grievance. For more complicated grievances requiring extensive investigation and analysis, the Director of Quality & Risk Management will contact the patient or their representative stating that the hospital is still working on the response, which they should expect within 30 days if possible. Exception: Grievances regarding situations that endanger the patient shall be addressed immediately.E. All grievances are followed-up in writing. The final written response shall include the name of the facility, a contact person at the facility, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. All grievance response letters will be mailed to the patient's home address unless the patient or representative has asked otherwise.F. Tracking of complaints/grievances and identifying trends is an important part of the quality improvement process. Grievance information is aggregated, tracked, trended and communicated by the Director of Quality and Risk Management or designee to leadership on an as-needed basis.

Based on observation, interview, and document review, the facility failed to ensure urinary catheter care was provided in a manner to prevent contamination and potential urinary tract infection (UTI) for 1 of 1 residents (R30) reviewed for catheter cares. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had severe cognitive impairment and required an indwelling urinary catheter. Diagnoses included an enlarged prostate and obstructive uropathy (a condition where a blockage hinders the flow of urine). R30's care plan dated 3/28/24, identified R30 had indwelling urinary catheter related to obstructive uropathy and an enlarged prostate. The following interventions were implemented: - Position catheter bag and tubing below the level of the bladder and away from entrance room door. - Monitor and document intake and output as per facility policy. - Monitor/document for pain/discomfort due to catheter. CNA - Monitor/record/report to MD for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The care plan also identified R30 was on Enhanced Barrier Precautions related to indwelling foley catheter use. Staff were to wear personnel protective equipment (PPE) as identified in EBP policy (gloves and gown, face protection if performing activity with high risk of splash), during high-contact resident care activities: Transferring, Providing Hygiene, Changing briefs or assisting with toileting and Device care or use. R30's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 4/3/24, identified the goal for R30 was to continue to transfer and ambulate safely independently and avoid complications. Staff were to assist with activities of daily living (ADLs) as needed and observe for increased dependence with ADLs and notify R30's physician (MF) of decline, encourage to participate in functional maintenance program to maintain abilities, encourage to attend group exercise, observe condition of skin daily with cares and weekly on bath day and notify MD of areas of concern, observe for symptoms of pain and offer prn pain medication and nonpharmacological interventions for pain and observe for effectiveness and notify MD if ineffective, assist with urinary catheter management and observe for complications and notify MD of concerns, observe for new or worsening symptoms of depression and side effects of Zoloft and notify MD of concerns, observe for social isolation, invite and encourage to attend meals and activities in the dining room, allow to vent frustrations, offer one to one visits. R30 was at risk for increased ADL dependence, falls with injury, skin breakdown, infections, worsening symptoms of depression, adverse behaviors, social isolation, frustration, anxiety, unmanaged pain, and unmet needs. During an observation on 4/8/25 at 3:53 nursing assistant (NA)-C assisted R30 back to his room from a group activity. NA-C offered toileting to R30, but R30 declined, and NA-C stated he would assist R30 to lie down in bed. - At 3:55 p.m., NA-C began to position R30's wheelchair next to R30's bed, but then stated NA-C needed to check R30's catheter leg to bag. NA-C put on gloves and raised R30's left pants leg to expose R30's catheter leg bag. The bag was approximately half full of amber colored urine. NA-C stated wait right here. I'll gown up. NA-C exited the room and put on a disposable gown, put on a pair of gloves then applied another pair of gloves on top. No hand sanitizer was used. - At 4:02 p.m., NA-C obtained R30's plastic graduate from R30's bathroom and placed it directly on the floor in front of R30. NA-C open R30's catheter leg bag port, drained the urine, then cleaned the port with an alcohol wipe. NA-C poured the urine in the toilet and rinsed the graduate. NA-C then removed the top layer of gloves but did not perform handwashing or used hand sanitizer. - At 4:04 p.m., NA-C placed a gait belt around R30 and assisted R30 into bed. -At 4:07 p.m., NA-C removed the gown and gloves and used hand sanitizer. NA-C stated he did not need to wash his hands or used hand sanitizer when he removed the top layer of gloves because he was wearing double gloves. I always do that. NA-C stated he had done the double glove thing a long time and had just seen it around. NA-C stated the double gloving probably shouldn't be done and only one pair of gloves should be worn at a time with hand sanitizer between. Additionally, NA-C stated he normally placed a disposable washcloth under the graduate when draining urine but did not do that. NA-C stated staff were instructed to do both to help prevent the spread of infection. During an interview on 4/9/25 at 10:02 a.m., registered nurse (RN)-B stated she was the facility infection prevention nurse. Staff were expected to use hand sanitizer or wash their hands every time they removed their gloves. Additionally, staff should put a barrier between the floor and the graduate every time they drain a catheter bag to prevent splashing on the floor. During an interview on 4/9/25 at 10:18 a.m., licensed practical nurse (LPN)-A stated staff were expected to wash their hands every time they took off their gloves and to put a barrier between the graduate and the floor, like a paper towel, in case of splashing. During an interview on 4/9/25 at 10:23 a.m., LPN-B stated staff were expected to wash their hands after taking off their gloves and to put something underneath the graduate. The facility had disposable underpads to lay down on the floor then put the graduate on top of that. During an interview on 4/9/25 at 10:24 a.m., RN-C stated staff were expected to either use hand sanitizer or wash their hand when they removed their gloves. When doing catheter care staff should lay down something like a disposable underpad, something that will soak up urine and not allow the urine to soil the floor. During an interview on 4/9/25 at 1:02 p.m., the director of nursing (DON) stated staff should put down a disposable underpad as a barrier on the floor when emptying a catheter. Staff were also expected to follow enhanced barrier precautions. Double gloving was unacceptable. Staff were expected to put on a single pair of gloves, wash their hands or use hand sanitizer after removing and then put on a new pair of gloves to prevent potential infection. During an interview on 4/9/25 at 1:09 p.m., the assistant administrator stated staff were expected to follow policy and procedure to ensure the safety of the residents and staff. The facility policy Hand Hygiene/Handwashing undated, identified all staff should practice proper hand hygiene to prevent the spread of infection. Staff were directed to perform hand hygiene in the following situations: - Before direct resident contact. - After contact with residents' intact skin. - After contact with body fluids or excretions, mucous membranes or non-intact skin, and wound dressings if hands were not visibly soiled. - After removing gloves. The facility policy Indwelling Urinary Catheter: Use, Insertion Care and Maintenance dated 3/20/24, identified staff were directed to use Enhanced Barrier Precautions (EBP)-don gloves and gown, during any manipulation of the catheter or drainage system. The facility policy Enhanced Barrier Precautions - EBP undated, identified Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator - Wound care: any skin opening requiring a dressing

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were consistently implemented in accordance with Centers for Disease Control (CDC) recommendations to reduce the risk of infection for 1 of 4 residents (R31); and failed to ensure appropriate hand hygiene was completed during provision of personal care for 1 of 4 residents (R8) whose cares were observed. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 was cognitively intact and required assistance with activities of daily living. R31's care plan, printed 4/9/25, identified all R31's actual or potential problems along with interventions to help R31 meet established goals of care. The care plan outlined R31 was on enhanced barrier precautions (EBP) due to positive for vancomycin-resistant enterococci (VRE) infection in urine. Staff were directed to wear PPE of gloves, gown and face protection if performing activity with a high risk of splash and during high contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. On 4/7/25, at 4:00 p.m. R31's room was observed from the hallway which had an orange colored sign posted on the middle of the door which read [STOP SIGN] Enhanced Barrier Precautions [STOP SIGN] . Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities . Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assistance with toileting . Across the hall was a hard plastic cart with gowns and other PPE supplies inside. On 4/7/25, at 5:08 p.m. R31 was observed in a half way seated position on the edge of her bed. The room call light was on and R31 stated she wanted assistance to get into her wheelchair. Registered nurse (RN)-A and nursing assistant (NA)-A entered the room and approached the bed to assist R31 into her wheelchair. Neither of the staff had a gown on as directed by the signage. RN-A positioned a gait belt around R31's waist and both staff assisted R31 to a semi stand position and slowly seated her in her wheelchair. R31 then requested assistance to use the toilet. Another nursing assistant (NA)-B entered R31's room to assist with R31's care and RN-A removed her gloves, applied alcohol-based hand rub (ABHR) to her hands and exited the room. NA-B was not wearing a gown as directed by the signage on R31's door. NA-B stated R31 was care planned to have two staff present with care at all times. NA-A wheeled R31 into her bathroom and assisted her onto the toilet after lowering R31's pants and brief. When R31 was finished, NA-A donned gloves and assisted R31 back into her wheelchair. NA-A's uniform was observed brushing against R31 body several times as she was assisting her with toileting and transfer. NA-B stated she was not sure why R31 was on EBP and would have to check with the nurse. During interview on 4/7/25, at 5:15 p.m. NA-A stated staff were notified which residents required EBP during shift report, however, she had not attended the full shift report because she had to assist floor staff with a resident's care. NA-A stated she had forgotten to put on PPE when she had assisted R31 with transfer and toileting. When interviewed on 4/7/25, at 5:15 p.m. RN-A stated R31 had bacterial colonization in her urine and they all should have been wearing PPE gowns when they had helped R31 to transfer and toilet. During interview on 4/8/25, at 3:46 p.m. RN-B verified she was also the facility's infection control preventionist and stated any residents with a draining wound, invasive device like a foley catheter or a history of MDRO would be placed on EBP. Staff knew which residents required EBP because of the signage on the resident's door. R31 had been on EBP since her admission. Staff should have stopped when R31 requested assistance with toileting and donned gown and gloves prior to assisting her, even with the initial transfer from her bed to her wheelchair. When interviewed on 4/9/25, at 9:40 a.m. the director of nursing (DON) stated staff should wear PPE of gown and gloves when assisting R31 to transfer or with cares such as toileting. R31 had resistive bacteria in her urine and the PPE was required with any transfers or assistance with cares to reduce the risk of spread of infection. It was required for staff to don a gown for transfers and personal cares, including toileting and staff had been educated on the facility's policy for EBP. The facility's undated policy Enhanced Barrier Precautions-EBP identified EBP was an infection control intervention designed to reduce transmission of multidrug-resistant (MDROs) in nursing homes. Nursing home residents with wounds that required a dressing, an indwelling medical device, and/or residents with MDRO infection or colonization would require EBP. Gown and gloves were required during high contact resident care activities. Examples of high contact resident care activities which required gown and glove use of EBP included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device or wound care. A CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) manual, dated 7/2022, identified MDRO transmission within a nursing home was common and contributed to substantial resident morbidity and mortality. The feature outlined EBP were defined as, . expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The feature identified several examples of high-contact resident care activities including dressing, bathing, providing hygiene, transferring, changing linens or briefs, and wound care. 40943 R8's quarterly MDS dated [DATE], identified a severe cognitive impairment and diagnoses that included dementia, muscle weakness, and type 2 diabetes. R8 was non-ambulatory and was dependent on staff for all care areas. R8's care plan dated 3/28/20, identified R8 had an ADL self-care performance deficit related to impaired balance, unsteady gait, limited range of motion, musculoskeletal impairment, right lower leg/foot fracture and non-weight bearing status. Staff were directed to provide: BED MOBILITY: R8 used (1/2 rails on bed) to maximize independence with turning and repositioning in bed; DRESSING: R8 required (extensive assistance) by (1) staff to dress to pull on/off socks, lace up right foot brace and pants; PERSONAL HYGIENE: R8 required (extensive assistance) by (1) staff with personal hygiene and oral care to clean full upper denture and comb back of hair; TOILET USE: Transfer on/off toilet or commode with total body mechanical lift with 2 staff. Due to inability to consistently bear weight for transfers; and TRANSFER: Total body mechanical lift with 2 staff for all transfers. Needs to wear shoes during transfers. During an observation on 4/9/25 at 7:24 a.m., nursing assistant (NA)-D entered R8's room to provide morning cares. - At 7:29 a.m., NA-D put on gloves and explained to R8 she needed to check R8's incontinence brief. NA-D checked R8's brief and stated a new would need to be put on because the brief was soiled with urine. NA-D did remove her gloves and washed R8's face with a disposable washcloth. NA-D removed R8's incontinence brief and used a disposable washcloth to clean urine and feces from R8's skin. - At 7:34 a.m., NA-E entered the room and obtained a clean brief for NA-D. NA-D removed her gloves but did not wash her hands or use hand sanitizer before putting on new gloves. NA-D assisted R8 to put on the clean brief. - At 7:39 a.m., NA-D and NA-E assisted R8 to wash her upper body, put on deodorant and dress. R8 was then assisted into her wheelchair with a full body mechanical lift. - At 7:56 a.m., NA-D removed her soiled gloves and assisted R8 to breakfast. NA-D did not wash her hands or use hand sanitizer. During an interview on 4/9/25 at 7:58 a.m., NA-D stated you should use hand sanitizer whenever removing gloves, especially after cleaning feces. It's feces and you don't want to spread that anywhere else. During an interview on 4/9/25 at 10:02 a.m., registered nurse (RN)-B stated she was the facility infection prevention nurse. Staff were expected to use hand sanitizer or wash their hands every time they removed their gloves. During an interview on 4/9/25 at 10:18 a.m., licensed practical nurse (LPN)-A stated staff were expected to wash their hands every time they took off their gloves. During an interview on 4/9/25 at 10:23 a.m., LPN-B stated staff were expected to wash their hands after taking off their gloves. During an interview on 4/9/25 at 10:24 a.m., RN-C stated staff were expected to either use hand sanitizer or wash their hand when they removed their gloves. During an interview on 4/9/25 at 1:02 p.m., DON stated staff were expected to put on a single pair of gloves, wash their hands or use hand sanitizer after removing and then put on a new pair of gloves to prevent potential infection. During an interview on 4/9/25 at 1:09 p.m., the assistant administrator stated staff were expected to follow policy and procedure to ensure the safety of the residents and staff. The facility policy Hand Hygiene/Handwashing undated, identified all staff should practice proper hand hygiene to prevent the spread of infection. Staff were directed to perform hand hygiene in the following situations: - Before direct resident contact. - After contact with residents' intact skin. - After contact with body fluids or excretions, mucous membranes or non-intact skin, and wound dressings if hands were not visibly soiled. - After removing gloves.

Based on interview and document review the facility failed to adequately supervise and respond to an alarm sounding exit door for 1 of 3 residents (R1) reviewed for elopement risks. R1 exited the facility without staff knowledge and was found by a visitor on the ground with WC next to them outside the facility door. R1 had abrasions and bent glasses. The immediate jeopardy began on 3/13/25, at approximately 12:45 p.m., when R1 was found outside the facility on the ground next to his wheelchair. The IJ was identified on 3/21/25, and the administrator was notified of the IJ on 3/21/25, at 12:50 p.m. The immediate jeopardy was removed on 3/17/25, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: On 3/21/25 at 8:53 a.m. video footage of the R1's elopement on 3/13/25 was reviewed. The video showed R1 at a set of closed double doors approximately six feet from the nurses' station and dining room entrance at 12:34 p.m. At 12:35 p.m., R1 was seen on the video opening the double doors and going through toward the front entry a few feet away. R1 was able to push on the door and go outside at 12:36 p.m. At 12:37 p.m., housekeeper (HK)-A approached the door and turned off the alarm that was sounding then left the area. R1's Admission Record indicated he admitted to the facility 9/21/23. Diagnosis included Alzheimer's and dementia. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated use of a wander alarm. The MDS indicated R1 had hallucinations, displayed physical and verbal behaviors and no wandering behaviors during the assessment period. The MDS indicated R1 was independent with transfers and wheelchair mobility. R1's Elopement Risk Screening dated 2/20/25, indicated R1 was alert and oriented, voiced a desire to leave and had previous elopement attempts. R1's care plan dated 12/30/24, identified target behaviors that included argumentative, resistant to assistance with activities of daily living, verbal aggression and identified him as an elopement risk. The care plan directed staff to allow him to vent his frustration, distract with activities such as a marble game and call family if needed to assist with redirection. The care plan indicated R1 was independent with transfers and ambulation in his room and indicated he could self-propel his manual wheelchair. Facility incident reports identified the following: 11/28/24 at 1:23 p.m., visitor alerted nursing there was a man (R1) in a wheelchair outside the building. Visitor reported the man pushed on the front door as it was beeping until it opened, then went out the door. The visitor cleared the door alarm and alerted staff. R1 stated he was going to the store to get chewing tobacco. Nursing staff found him self-propelling his wheelchair behind the handicap parking area. There were cars driving around the area at the time. R1 was brought back into the building safely. Staff were notified and told to monitor R1's location. The incident report indicated R1 may have been disoriented/confused due to many residents and family members being in and out of the building for a holiday meal. 1/25/25, Staff was alerted to door alarm sounding and observed R1 outside attempting to get back in the building. A plow truck driver stopped and said he saw resident outside before staff arrived. He had been plowing snow at the time R1 eloped. R1 was wearing a heavy flannel shirt and shoes but no jacket. Will continue to monitor and ensure hourly checks for safety are completed. Double doors between nursing station and front door to be shut. 3/13/25 at 12:45 p.m., exit door alarm sounded when a visitor left the facility. Staff went to shut off the alarm and saw R1 sitting on the cement next to his wheelchair with a visitor attempting to assist him to sit up. R1 was seated on the curb straight out from the front door. R1 had abrasions to the right side of his forehead, his glasses were bent up against his face and he had a laceration to his nose, abrasions to thumb, both knees, elbow, and wrist. When asked what happened, R1 said I was going around and down. When asked where he was going R1 said, well, home. Immediate action taken included: hourly checks to monitor whereabouts, education provided to staff who had shut off the initial alarm and education initiated for all other staff. During interview on 3/21/25 at 7:26 a.m., the director of nursing stated she had been in the building on 3/13/25, when R1 eloped. The DON said she had viewed the camera footage and said the double doors had been closed since R1's last elopement but he had been able to open them. The DON said R1 had also attempted to go through the family dining room to get to the front door in the past. The DON said after the incident on 3/13/25, she sent education related to alarms to all facility staff and to all staff at the attached hospital. The DON said they had collaborated with the fire Marshall and set up the door so it would not open if a wander alert was in the vicinity. The DON said the door had been wander alert activated but said if someone went through the door and a resident followed them out, the door would not alarm. The DON said now the door alarmed if a wander alert was nearby. The DON said the door had also been changed to alarm if open for 10 seconds compared to the previous 30 seconds. During interview on 3/21/25 at 7:36 a.m., HK-A stated on 3/13/25, she heard the alarm sounding at the entrance to the facility. HK-A stated the set of double doors between the nurses station and the entrance had been closed so she went through them, did a quick glance, and turned off the alarm and went back to what she had been doing. HK-A stated she had not gone outside to see if a resdient had left the building. During interview on 3/21/25 at 8:53 a.m. The quality specialist said part of the video footage was no longer available. She said when she viewed the footage the previous week it showed R1 got to the edge of the sidewalk and flip forward out of his wheelchair on the curb. During interview on 3/21/25 at 9:25 a.m. licensed practical nurse (LPN)-A stated R1 was confused and wanted to go home. LPN-A stated R1 would often sit by the front door and watch people come and go. LPN-A said on 3/13/25, she had been passing medications. She said her medication cart was right outside the dining room and the last time she had seen R1 he had been eating. LPN-A said the double doors leading to the entrance were shut and said she saw a visitor leave and heard the alarm. LPN-A stated she looked outside and saw R1 sitting on the curb outside the door. She said R1 had several abrasions, a laceration to his nose and said his glasses were smooshed. During interview on 3/21/25 at 11:14 p.m., the director of nursing (DON) identified the root cause of the elopement being the staff member shut off the alarm without looking to see if a resident had exited the building. The DON said R1 could have been more seriously injured. She stated if the weather had been colder, he could have suffered from hypothermia or death. An elopement policy was requested but not received. The past noncompliance immediate jeopardy began on 3/13/25. The immediate jeopardy was removed 3/17/25, and the deficient practice corrected after the facility implemented a systemic plan that included the following actions: - 3/13/25, Immediate education provided to the staff member that shut off the alarm. - 3/13/25 through 3/21/25,Education to all staff about alarms and process of checking outside for residents prior to shutting off an alarm and notification to nursing staff. - 3/17/25, Maintenance evaluated the door alarm and collaborated with the Fire Marshall to decrease the amount of time door opened if pushed. Maintenance also changed the wander alert alarm so it would activate when resident was near the door.

Based on interview and document review, the facility failed to offer pneumococcal vaccine booster as directed by the Centers for Disease Control (CDC) for 3 of 5 residents (R13, R14, R24) reviewed for immunizations. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses including diabetes mellitus and heart disease. R13's undated Minnesota Immunization Information Connection (MIIC) report identified R13 had received the pneumococcal polysaccharide vaccine (PPSV23) on 3/10/09, and the pneumococcal conjugate vaccine 13 variant (PCV13) on 10/31/17. R13's medical record lacked evidence the pneumococcal conjugate vaccine 20 (PCV20) booster was offered and/or education was provided in conjunction with the provider to R13/R13's representative. R14's admission MDS dated [DATE], identified diagnoses including diabetes mellitus, heart disease and kidney disease. R14's MIIC report identified R14 had received the PPSV23 on 9/14/99 and 11/3/16, and the PCV13 on 11/3/16. R14's medical record lacked evidence the PCV20 booster was offered and/or education was provided in conjunction with the provider to R14/R14's representative. R24's quarterly MDS dated [DATE], identified diagnoses including cerebral infarction, atrial fibrillation, metabolic encephalopathy, and heart disease. R24's MIIC report identified R24 had received the PPSV23 on 2/2/05 and 10/1/08, and the PCV13 on 7/30/18. R24's medical record lacked evidence the PCV20 booster was offered and/or education was provided in conjunction with the provider to R24/R24's representative. During interview on 2/14/24, at 9:10 a.m. registered nurse (RN)-A stated she had not been offering the PCV20 to residents. When she used the CDC application for vaccination review for the new CDC guidance it indicated vaccinations were complete but residents were eligible for the PCV20. RN-A was not aware the residents should still be offered the PCV20 vaccine if they were eligible and five years had past since the last PCV vaccine. When interviewed on 2/14/24, at 9:30 a.m. the director of nursing stated she was aware of the need to offer the PCV20 vaccine to residents who were eligible. DON was unaware RN-A had not fully understood the PCV20 should be discussed with eligible patients. The facility policy Pneumococcal Immunizations dated 3/29/23, identified all residents would be offered pneumococcal vaccinations. The CDC guidelines for pneumococcal polysaccharide vaccine (PPSV23), pneumococcal conjugate vaccine (PCV13, PCV15, and PCV20) would be followed.

Based on interview and document review, the facility failed to immediately report allegations of staff to resident abuse to the facility administrator and/or the State Agency (SA) for 2 of 2 residents (R1 and R4) reviewed who had allegations of staff to resident abuse. Findings include: The facility report submitted to the SA on 3/16/22, at 11:09 a.m. identified the event occurred on 3/14/22 at 6:00 a.m. Nursing assistant (NA)-A went into R1's room while R1 was attempting to get out of bed and use a walker to go to bathroom with NA-B. After entering the room. NA-A stated R1 needed to use the wheelchair to go to bathroom. NA-B reported NA-A scooped R1 up and popped her in the wheelchair kind of hard. NA-A wheeled R1 into the bathroom and kept shoving R1's right arm onto grab bar trying to get R1 to hold on. When R1 was unable to hold onto grab bar, NA-A pulled the wheelchair back and NA-B assisted transferring R1 onto toilet. NA-B reported NA-A yelled in R1's face to go pee. NA-A reported NA-a then popped R1 into her wheelchair pretty hard, using super excessive force and continued to yell at R1 in her face. NA-B reported she had not observed this kind of behavior by NA-A in past; however, NA-B observed NA-A being very short with other residents at times. During interview on 3/30/22, at 11:22 a.m. NA-B stated she did not immediately report the allegation of abuse because she had to finish working her shift with NA-A; and was never alone with the nurse to do so. After considering the incident she reported it to the director of nursing (DON) on 3/16/22, after speaking with NA-C who stated she observed a similar incident with NA-A and R4. NA-B further stated she should have reported the incident immediately During interview on 3/30/22, at 11:32 a.m. NA-C stated the DON called and spoke with her because she was investigating the report made by NA-B. NA-C stated she then told the DON about the incident between NA-A and R4. NA-C stated she knew she should have reported the incident immediately, oh I knew. A report to the SA for an allegation of abuse for R4 by NA-A was requested for review; however, the facility failed to provide a report submitted to the SA. During interview on 3/30/22, at 2:13 p.m. the DON stated she provided verbal education to NA-B and NA-C that reporting all incidents must occur immediately because allegations of abuse must be reported within two hours. However, the DON did not file a report to the SA regarding the allegation with NA-A and R4 because it was the same alleged perpetrator, but I should have. The facility policy Vulnerable Adult - Resident Abuse, Neglect, Mistreatment, and Misappropriation of Property dated 9/26/17, identified all staff were responsible for identifying signs and symptoms of possible abuse. The facility administrator was to be notified immediately of any incident of resident abuse. Suspected abuse would be reported to the State Agency (SA) no later than two hours after being notified of potential abuse. Physical abuse was defined as hitting, slapping, pinching, and kicking. It also included controlling behavior through corporal punishment. Mental abuse was defined as, and was not limited to, humiliation, harassment, threats of punishment or deprivation. Sexual abuse was defined as non-consensual contact of any type with a resident.

Based on observation, interview and document review the facility failed to ensure each fall was comprehensively assessed and appropriate interventions were assessed for and/or implemented in an effort to reduce falls for 1 of 4 residents (R9) reviewed for falls. Findings include: R9's care area assessment (CAA) dated 8/18/20, identified a risk for falls, history of falls, decreased mobility and altered mental status. The CAA indicated R9 had a bed alarm, routine toileting and chair alarm to help prevent falls. R9's falls most often occurred related to toileting needs, urgency/frequency, or confusion with bladder infections. R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had severe cognitive impairment and required extensive assistance from two staff for bed mobility, transfers and toileting. R9 had lower extremity impairment on both sides, was continent of bowel and frequently incontinent of bladder. Further, R9 had sustained two or more falls without injury and two or more falls with injury since the previous assessment. R9's care plan dated 5/10/21, identified a risk for falls and a history of repeated falls. Care planned interventions included: bed alarm, routine toileting and chair alarm to help prevent falls as well as pain medication, anti-anxiety medication and non pharmacological interventions for behaviors, pain and risk for falls. The care plan directed staff to check R9 on rounds every two hours and encourage bathroom on a routine basis. The interventions updated on 4/26/21, indicated R9 had demonstrated to staff how she put herself on the floor mat intentionally. When R9 was found on the mat, staff were to ask if she intentionally put herself there and if R9 said yes, staff did not need to count the incident as a fall. R9's incident reports identified the following falls: - 3/23/21, at 8:45 p.m. R9 was found kneeling on the floor mat with her arms on the bed, bed alarm sounding. R9 stated she did not want to be in bed anymore and wanted to get up. A Falls Worksheet dated 3/24/21, indicated interventions included: mats on both sides of bed, call light was within reach, bed alarm was sounding. R9 awakened easily to noise in hallway so sometimes the door was closed. There was no evidence a comprehensive fall assessment was completed including evidence new interventions were assessed for and/or why new interventions were not necessary. - 3/26/21, at 11:20 p.m. R9's alarm was sounding and staff heard her calling for help. R9 was found on hands and knees resting against the bed on the floor mat. She was yelling for help. Reported she had company coming and was trying to get up. There was no evidence a comprehensive fall assessment was completed including evidence new interventions were assessed for and/or why new interventions were not necessary. - 3/28/21, at 4:00 p.m. staff heard R9 yelling from her room. Staff responded to find R9 lying on her left side on the floor mat next to the bed. R9 was sitting and stated she needed to get out of there and was having delusions. No mat was in place and alarm did not sound. R9 reported mild hip pain. Staff were reminded the importance of having the mat in place. The alarm was found to have a broken cord and was replaced. A Falls Worksheet dated 3/28/21, indicated mats were not in place at time of the fall. Mats need to be placed as care planned and staff were reminded. The bed alarm was in place but was not working. The call light was in reach and R9 was reminded the importance of pushing her call light, even though R9 had severe cognitive impairment. There was no evidence a comprehensive fall assessment was completed including evidence new interventions were assessed for and/or why new interventions were not necessary. - 4/3/21, at 9:10 p.m. R9 was found kneeling over her bed, unsure what she wanted to do. A Falls Worksheet dated 4/3/21, indicated R9 did not know what she was doing at the time of the fall. There was no evidence a comprehensive fall assessment was completed including evidence new interventions were assessed for and/or why new interventions were not necessary. - 4/19/21, at 8:45 p.m. R9 found sitting on her butt on the floor mat next to her bed. R9 was talking about her children and wondering if they were awake. A Fall Worksheet dated 4/19/21, indicated alarm had been sounding and R9 was assisted to the recliner. There was no evidence a comprehensive fall assessment was completed including evidence new interventions were assessed for and/or why new interventions were not necessary. - 4/25/21, at 2:35 a.m. R9 was found with her knees on the mat and her upper body on the bed. R9 stated she was trying to get to the bathroom. A Falls Worksheet dated 4/25/21, included a section for recommendations/interventions. The section was left blank. There was no evidence a comprehensive fall assessment was completed including evidence new interventions were assessed for and/or why new interventions were not necessary. - 4/25/21, at 9:13 a.m. R9 was found sitting on the floor mat next to her bed. R9 stated she tried to get up and check on the kids. A Falls Worksheet dated 4/26/21, indicated R9 was trying to get up and check on the kids. Intervention identified as R9 was brought to the common area. The Falls Worksheet further identified R9 had five falls in the last 30 days and 12 falls in the last 31-180 days. - 5/8/21, at 10:35 p.m. R9 was found on her knees on the mat with her upper body on the bed, holding on to the side rail. R9 stated she fell out of bed. A Falls Worksheet dated 5/8/21, indicated R9 stated she fell out of bed and thought she was cold and that's why she fell . Intervention indicated she was put back to bed and covered up; however, did not identify interventions to prevent further falls or an assessment to identify why new interventions were not warranted. - 5/30/21, at 5:00 a.m. R9's alarm sounded. Staff entered the room and found R9 on the floor next to her bed. The report indicated the interdisciplinary team (IDT) reviewed the fall, R9 had been incontinent at the time of the fall likely putting her at increased risk for fall. R9 had been checked on continence rounds one hour before and as a result, no change to care plan was recommended. The intervention included Will have pharmacist look at medications. R9's nursing Progress Notes identified the following: 6/12/21, at 6:40 a.m. staff responded to R9's alarm and found her kneeling on her floor mat. R9 stated she was getting up for the day. 7/16/21, at 11:45 P.M. R9 was found seated on the floor mat next to her bed. R9 stated she was going to get up and said I sat here. 7/17/21, at 12:57 a.m. R9 was found rolling out of bed with her knees on the floor mat. R9 was incontinent of urine. 7/17/21 at 1:29 p.m. R9 found sitting on the floor mat at the edge of the bed. R9 stated she was getting up. 7/18/21, at 4:28 a.m. R9 found on the floor mat next to the bed. R1 was experiencing hallucinations. 7/21/21, at 11:09 a.m. R9 was found lying on the floor next to her bed. R9 stated she needed a cup of coffee and had rolled too fast. A Falls Worksheet dated 7/21/21, indicated R9 reported she wanted coffee and rolled too fast. A request for medication changes was identified as an intervention. During observation on 7/21/21, at 5:26 a.m. R9 was lying in bed asleep. At 5:54 a.m. nursing assistant (NA)-B entered R9's room, woke her up and asked her if she wanted to get up. R9 stated she wanted to stay in bed. At 5:56 a.m. NA-D and NA-F entered R9's room, turned on the lights, raised the bed and got R9 up and dressed for the day. While NA-D and NA-F were putting R9's pants on, R9's legs were observed to be contracted and R9 complained of pain when her legs were straightened. R9 was assisted out of bed and into her recliner with a mechanical lift. At 6:06 a.m. licensed practical nurse (LPN)-A gave R9 pain medication and asked her if her knees hurt. R9 replied yes. During interview on 7/21/21, at 6:12 a.m. NA-D stated R9 would crawl out of bed because she was unable to stand. NA-D stated usually it was because R9 had a mess in her pants. NA-D said R9's fall interventions included fall mats, bed alarms and gripper socks but stated R9 didn't walk. NA-D said there was nothing they could do to prevent R9 from falling and said R9 had never had a horrible fall. On 7/22/21, at 9:00 a.m. NA-C stated R9 had fallen the previous day and had checked on her around 9:45 a.m. , after she returned from her break the other staff had found R9 on the floor. NA-C stated R9 was not reliable to use her call light and often woke up after having bad dreams. If R9 rolled over she would fall. NA-C stated some nights R9 was up all night and would sleep in her chair or bed all day and sometimes she was awake all day. At 10:15 a.m. registered nurse (RN)-A stated R9's care plan indicated she had demonstrated she had been attempting to get out of bed intentionally and was not having falls. RN-A said R9 was able to slide herself to the edge of the bed, put her feet down and roll out of bed intentionally. RN-A stated R9 was not able to stand and needed assistance from staff. RN-A stated the bed alarm was used to alert staff if R9 was moving around in bed or wheel chair and said R9 did not remember to use her call light. RN-A said a falls assessment was conducted quarterly with the MDS and R9 was a high risk for falls. RN-A stated no patterns had been identified. At 11:52 a.m. the director of nursing (DON) stated after a fall the interdisciplinary team looked at data prior to the fall such as what was happening at the time of the fall to try to determine the cause. The DON stated the team would then try to come up with ideas to prevent further falls. The DON stated R9 had a lot of behaviors and R9 had demonstrated how she crawled out of bed but said if R9 did not say she crawled out of bed they counted it as a fall. The DON stated R9 often got restless in the early morning and a lot of times the night shift got her up. The DON stated a comprehensive assessment of R9's falls had not been completed. A facility policy Fall Risk Assessment/Re-assessment dated ,d+[DATE], indicated the facility was to identify residents at risk for falls and develop fall precautions with an overall goal to reduce the incidence of falls. The policy directed the IDT to review falls on business days or within 72 hours and monitor interventions and modify as needed. The policy indicated falls would be reviewed quarterly and at quality assurance meetings.

Based on observation, interview and document review the facility failed to ensure hand hygiene, to prevent cross contamination, was performed after incontinence cares for 2 of 5 residents (R3, R6) who were observed during toileting assistance. Findings include: R3's quarterly MDS dated [DATE] indicated R3 had little to no cognitive impairment or behavior issues. R3's MDS indicated she was independent with Activities of Daily Living (ADLs). R3's MDS indicated she was continent of bowel and bladder. R3's daily care sheet dated 7/19/21 indicated R3 required assistance with toileting and transferring. During observations on 7/21/21, at 7:27 a.m. nursing assistant (NA)-A entered R3's room and sanitized their hands and put on clean gloves. NA-A assisted R3 into her wheelchair and brought R3 to the bathroom. NA-A assisted R3 to stand, pulled down R3's pants with gloved hands and removed a urine soiled brief. With contaminated gloves NA-A opened R3's lip balm, used a contaminated gloved finger to place lip balm on R3's lips. With the contaminated gloves NA-A then put on clean pants and a clean brief on R3's legs. While wearing the contaminated gloves NA-A washed R3's face and upper body, and assisted R3 to dry off. NA-A assisted R3 to stand and using the contaminated gloves NA-A cleaned and dried R3's bottom; pulled up R3's brief and pants; transferred R3 to her wheelchair; and brought her to the over bed table. NA-A removed the contaminated gloves and sanitized his hands as NA-A left the room. During interview on 7/21/21, at 7:43 a.m. NA-A stated the same gloves were wore throughout assisting R3 with her cares. NA-A usually wore the same gloves from start to finish with morning cares, unless a resident had a brief soiled with fecal mater. Further, the staff should change their gloves and wash their hands when ever going from dirty to clean, like after removing a brief. R6's quarterly MDS dated [DATE], indicated R6 had mild cognitive impairment and weakness. The MDS also indicated R6 required supervision with activities of daily living (ADL's) including toileting, transferring and personal hygiene. R6's Bowel and Bladder assessment dated [DATE], indicated R6 was incontinent of stool 1-3 days per week. During observation on 7/21/21, at 6:17 a.m. NA-D was in the bathroom next to R6 while R6 was standing near the toilet and holding onto the grab bar on the wall. NA-D was wearing gloves and wiping stool from R6's buttocks. With the same dirty gloves, NA-D proceeded to dress R6 with a clean brief and pajama bottoms. NA-D failed to doff dirty gloves or complete hand hygiene after performing perineal care and prior to touching R6's clean clothing. During interview on 7/21/21, at 6:30 a.m. NA-D stated when providing cares for a resident she would change her gloves when they were soiled or dirty with stool. NA-D did not remove the dirty gloves or use hand sanitizer after performing perineal cares and prior to dressing R6. During interview on 7/22/21 at 1:27 p.m. the director of nursing (DON) stated staff should change gloves and perform hand hygiene whenever they go from dirty to clean. After incontinent cares were completed, staff should remove and throw away the dirty gloves, perform hand hygiene, and put on new gloves prior to touching anything else. Staff should not continue to wear dirty gloves when performing clean duties including putting on a clean brief and/or clean clothing. The facility's Infection Control Practices policy revised date 2/10 directed staff to wash their hands after direct resident contact, including toileting, to prevent infections of any nature. The facility's undated Hand Hygiene/Handwashing policy directed staff to practice proper hand hygiene to prevent the spread of infection by using soap and water or alcohol-based hand rub. The policy further directed staff to perform hand hygiene after completing activities including contact with body fluids or excretions and removing gloves.

Based on interview and document review, the facility failed to implement infection control precautions for 2 of 2 residents (R3, R4) who displayed symptoms of possible COVID-19 infections in an effort to prevent the spread of COVID-19. This had the potential to affect all residents residing at the facility. Findings include: R3's quarterly Minimum Data Set ((MDS) dated [DATE], indicated he received assitance from one staff with all activities of daily living (ADL)s, and was occasionally incontinent of bowel and bladder. R3's MDS indicated had not used supplemental oxygen (O2) during the assessment period. R3's care plan dated 10/19/20, indicated R3 was able to transfer independently in his room, and was able to use the toilet independently when cued by staff. The care plan further identified R3 had a [DIAGNOSES REDACTED]. On 10/5/20, R3's progress note indicated staff received a call from the [MEDICAL TREATMENT] nurse requesting a health status update on R3 from the previous night. Upon arriving to [MEDICAL TREATMENT], R3 reported he had not been feeling well, and had a temperature of 100.2 degrees Fahrenheit (F). The facility staff told the [MEDICAL TREATMENT] nurse R3 had complained of his stomach vibrating the previous overnight, and he had two bowel movements. R3's temperature had been taken and was 97.0 F at 6:45 a.m. The [MEDICAL TREATMENT] nurse inquired about COVID-19 testing, and was told R3 had a negative test the previous Monday, and the facility was awaiting the most recent result. On 10/5/20, through 10/10/20, R3's Vitals Summary indicated the following: oxygen (O2) saturation levels were 90-96 percent (%) on room air. On 10/10/20, a progress note indicated R3 complained of nausea and shortness of breath (SOB). Vitals were within normal limits, but blood pressure was lower than R3's baseline. R3 received supplemental O2. On 10/11/20, at 1:18 a.m. R3's Vitals Summary O2 saturation level was 79%. The report lacked indication if supplemental O2 had been used. On 10/11/20, at 10:32 a.m. a progress note indicated R3's O2 level was 76% on room air. Staff updated R3's significant other on R3's condition, and he was being sent to the emergency room . On 10/11/20, a progress note indicated R3 was sent to the emergency room . R3's temperature was 99.7 and his O2 saturation level was 74-79 % without O2, and 84% on 2 liters (L) O2 via nasal cannula. The note indicated R3 had been experiencing emesis over the the last few days, as well and weakness, requiring one to two staff to transfer when he was independent at baseline. R3 had also complained of nausea and SOB on and off the last few days. On 10/11/20, a progress note indicated R3 returned from emergency room with orders for [MEDICATION NAME] nebulizer treatments (breathing treatments) and O2 continuous. On 10/11/20, a progress note indicated R3 appeared SOB but refused O2. R3's O2 saturation levels were 76% on room air. R3 did accept the O2, and his levels increased to 96% on 2 L. R3 was still using accessory muscles to breathe. On 10/11/20, a progress note indicated R3 was assessed after the noon meal, was using O2, and he tolerated it well. R3 had a temperature of 99.3 F, and was fully dressed with a jacket on. On 10/14/20, a progress note indicated when staff entered R3's room, he appeared pale. R3's O2 saturation was 76% on room air. R3 was placed on supplemental O2, and his saturation levels increased to 86%, and his O2 was increased to 3 L. R3 appeared weak, and was assisted to go to bed. R4's annual MDS dated [DATE], indicated she required extensive to total assitance for all ADLs. The MDS indicated R4 was frequently incontinent of bladder, and always incontinent of bowel. R4's care plan dated 10/22/20, identified R4 had impaired balance and musculoskeletal impairment. The care plan directed staff to provide extensive assistance for bed mobility, transfers, and toileting. On 10/7/20, a progress note indicated R4 was hollering out, I'm hot. R4 was pale, and her O2 saturation was 82% on supplemental oxygen set to 2 L. R4 had inspiratory and expiratory wheezing. 10/9/20, a progress note indicated R4's physician ordered scheduled nebulizer treatments three times per day, and a chest x-ray. The physician ordered a COVID-19 test to be completed, which will be done on 10/12/20. On 10/13/20, a progress note indicated R4's O2 saturation level was 63% on 4 L, her facial color was a dusky purple, and she showed labored breathing. After administering a nebulizer, R4's saturation increased to 93%. After breakfast, R4's O2 levels decreased to 83%. Staff was called to R4's room by a nursing assistant (NA) who was assisting R4 to eat. R4's face was cool, diaphoretic (sweaty), and dusky. R4 was audibly wheezing. R4's O2 was increased to 5 L., and her O2 level was 88% on supplemental O2. On 10/14/20, a progress note indicated R4 had difficulty maintaining her O2 saturation, with readings of 66-75% on 5 L. R4's pulse was 110, and she was cyanotic (bluish). On 10/22/20, at 9:29 NA-A was interviewed and stated she had worked with R4, who had been having a hard time breathing. NA-A stated while taking care of R4, she had tried to put R4 in her wheel chair and R4 had been purple and blue. NA-A stated R4 used O2 at her baseline, but her O2 continued to drop. NA-A stated the decrease in R4's oxygen levels was new for R4. In regard to R3, NA-A stated he had been sent to the emergency room because of weakness and low O2 levels. NA-A stated neither R3 nor R4 were placed on any increased precautions while they were showing possible signs of COVID-19. NA-A stated they were treated like all of the other residents in the facility, and stated staff wore masks and eye protection, but no isolation gowns were used when providing care to either resident. At 9:29 a.m. licensed practical nurse (LPN)-A was interviewed and stated R4 had displayed a decrease in her O2 saturation levels. LPN-A stated while R4 used O2 at her baseline, her saturation levels began decreasing even after her O2 was increased, and she had been displaying SOB. LPN-A stated if there was a new onset of symptoms, staff should have initiated a gown and an isolation cart, but stated this had not occurred while R3 and R4 were symptomatic. LPN-A stated even though R3 ha been sent to the emergency room , no precautions had been initiated. At 10:01 a.m. the director of nursing (DON) stated R4 was not placed on any increased precautions even though she displayed a decrease in O2 saturation levels and SOB. The DON stated, I honestly don't know why. The DON stated R3 had been sent to the emergency room for SOB and low O2 saturation and he was sent back to the facility. The DON stated R3 had not been placed on any increased precautions. The DON stated when a resident was showing symptoms of COVID-19, they should have been placed in isolation, had a COVID-19 watch sign placed on their door along with an isolation cart, and communication to staff. The DON said this had not been done when R3 or R4 were showing symptoms of COVID-19. At 10:49 a.m. the infection preventionist (IP)-A stated the quarantine procedure for admission depended on where they came from. IP-A stated if a resident admitted from an outside facility they were placed on a 14 day quarantine and a COVID-19 watch. IP-A stated a COVID-19 watch included: residents were isolated to their rooms but if they had to come out would wear a mask, staff were to use goggles, face masks, and gowns if providing care. IP-A stated if a resident admitted or returned to the facility from their hospital, she knew the flow of their hospital system and counted the number of days they had been hospitalized and reduced the isolation days in the facility by that number. IP-A described symptoms of COVID-19 as fever, cough, SOB, decreased O2 saturation levels, nausea and diarrhea. IP-A stated if a resident displayed any of these symptoms she would have expected staff to increase the infection control precautions. The facility policy Standard Precautions and Transmission Based Isolation Guidelines dated 6/02 directed the purpose of the policy was to prevent the spread of infection among heath care workers and patients. The policy directed droplet precautions were used when a patient was known or suspected to be infected with microorganisms transmitted by droplets generated by coughing, sneezing, talking or aerosolized during procedures. Precautions included: Placement in a private room or cohorting with a patient with same microorganism and no other infection, Masks to be worn when working within a three foot distance and patient mask if possible if transport was necessary. The policy indicated a gown was to be worn when entering a room if substantial contact with environmental surfaces or items in the room, if patient was incontinent or had diarrhea or wound drainage.

Based on interview and document review, the facility failed to ensure incidents of potential abuse had been thoroughly investigated for 3 of 4 residents (R1, R2, R3) reviewed for allegations of potential abuse. Findings include: An incident report submitted to the State Agency (SA) by registered nurse (RN)-A on 8/16/20, at 7:00 p.m. indicated on 8/15/20, at 10:30 p.m. an unidentified nursing assistant (NA) reported that R1 had been verbally abused by NA-A during an incontinent episode while in the common bathroom. R1's pants had not been replaced leaving her in a public area with a nightgown that went above the knees. R1 stated she was not okay with wearing pajama pants in public area. The report also indicated the staff member degraded R1 in front of other employees. The report identified NA-B and NA-C as witnesses to the incident. The 5-Day Investigation Summary submitted to the SA on 8/20/20, at 4:03 p.m. indicated NA-B and NA-C were interviewed and verified verbal and emotional abuse to R1 by NA-A and that she was demeaning to and about R1 to other staff. NA-A was terminated from employment on 8/18/20. However, review of the incident investigation documentation revealed that other than R1, no other residents had been interviewed regarding potential abuse. An incident report submitted to the SA dated 5/13/20, indicated R2 reported to staff that she had been forced to sit out front (in the common area) as a form of punishment and when she would attempt to return to her room, a staff member would wait until she got near her room and would pull her backwards to the front sitting area again. The next night, upon entering R2's room, it was noted by oncoming day shift rehab aide that R2 had pillows stuffed around her legs and torso, her legs were elevated, and the call light was on the floor. The 5-day Investigation Summary submitted to the SA on 5/18/20, indicated rehab aid (RA) reported the morning of 5/13/20, she heard R2 tapping on her bedside table. Upon entering, R2 was found with a pillow to left shoulder and right hip and call light was on the floor. R2 reported to RA she had been asking to get up and was told she couldn't. R2 was frustrated about night staff not allowing her to get up. When DON (director of nursing) and LSW (social worker) interviewed R2, she explained the night shift would not let her stay in her room and told her she had to go downstairs. R2 said she was pulled backwards in her wheelchair to the front sitting area five times. Review of video footage of the corridors and staff that R2 alleged abuse, were gently found pulling her backwards in her wheelchair several times on the night of 5/10/20-5/11/20. They pulled her backwards as she placed her feet flat on the floor (refusing to move forward). Review of the incident investigation notes revealed the investigation included interviews with R2 and only one additional resident were performed. No other resident interviews were conducted regarding potential abuse. On 8/27/20, at 10:13 a.m. the director of nursing (DON) reviewed the aforementioned incidents and investigative interviews conducted and stated further investigation into the incident involved R1 was not needed as they were planning to terminate the staff member involved. In addition, the DON also verified only one additional resident had been interviewed related to the incident involving R2. On 8/27/20, at 1:17 p.m. during a telephone interview, the administrator verified thorough investigations had not not been completed for the aforementioned incidents. On 8/27/20, at 1:53 p.m. in a follow up interview, the DON verified thorough investigations had not been completed for the aforementioned incidents in order to determine the potential scope of potential abuse, and should have been. An incident report submitted to the SA dated 2/12/20, indicated R3 reported to staff that she had been treated rough and that the staff member was uncaring, in a hurry and caused resident pain. The 5-day Investigation Summary submitted to the SA on 2/14/20, indicated R3 reported to NA-H that she did not want NA-G in her room anymore because NA-G was too rough, causing R3 to be almost in tears and was upset over the way she was being treated. When RN-B interviewed R3, she explained that NA-G was rough with her on 2/11/20, and described NA-G as uncaring and in a hurry. R3 stated NA-G grabbed and pulled on skin, was told to stop and did not. R3's progress note dated 2/12/20, at 7:52 a.m. indicated R3 reported NA-G was rough during incontinent cares and described caregiver as uncaring, in a hurry and caused resident pain. R3 reported NA-G grabbed and pulled on my skin and did not stop when asked too. The facility investigation documentation revealed other than R3, no other residents had been interviewed regarding potential abuse. On 8/27/20, at 10:26 a.m. RN-B stated an incident investigation included resident and staff interviews, family notification, MD notification and, if applicable, filing a VA report with the SA. -At 12:40 p.m. the director of nursing (DON) verified the investigation regarding NA-G's concern did not include interviews with other residents and stated it should have in order to identify if they had also experienced rough treatment. The Vulnerable Adult - Resident Abuse, Neglect, Mistreatment and Misappropriation of Property policy and procedure reviewed 8/6/20, indicated the investigation was the process used to try to determine what happened. The nurse would begin the investigation immediately upon knowledge. A root cause investigation and analysis would be completed and the information gathered was given to administration. The investigation would include: allegations, who was involved, residents' statements, involved staff and if applicable, witness statement of events, a description of the resident's behavior and environment at the time of the incident, injuries present, if any, observation of resident and staff behaviors during the investigation and environmental considerations.

Based on interview and document review, the facility failed to ensure allegations of potential abuse were immediately reported, no later than 2 hours, to the State Agency (SA) and administrator for 1 of 4 residents (R1) reviewed for potential allegations of abuse not reported to the SA and administrator timely. Findings include: A nursing home incident report, submitted to the SA on 8/16/20, at 7:00 p.m. indicated an unidentified nursing assistant (NA) reported that R1 had been verbally abused by NA-A during an incontinent episode while in the bathroom. The report indicated the incident had occurred on 8/15/20, at 10:30 p.m. however, the SA was not notified until 8/16/20. On 8/26/30, at 2:55 p.m. NA-B verified he and NA-C had witnessed the incident involving NA-A and R1 and stated he had immediately reported it to registered nurse (RN)-A. On 8/26/20 at 3:08 p.m. RN-A verified NA-B had reported a concern regarding an incident which occurred on 8/15/20, involving R1 and NA-A. RN-A stated she had gone to the bathroom where the reported incident had occurred and listened outside the closed door. RN-A stated NA-A and R1 had pretty much finished up with cares and at that time, she had not heard anything of concern therefore she had returned to the charting room. RN-A stated NA-C approached her in the charting room and reported that NA-A had been yelling at R1 while she was in the bathroom. RN-A indicated she had instructed NA-B and NA-C to document their observations and she would address the issue the following day. RN-A confirmed at the time of the report, she had not informed any of the management staff, nor had she interviewed R1 or NA-A regarding the allegation. RN-A indicated she had filed reports to the SA before, but wanted to get NA-B and NA-C's statement prior to filing the report. RN-A stated she spoke with the director of nursing (DON) the following day who informed her a vulnerable adult report would need to be filed with the SA. RN-A stated she thought they had 24 hours to submit a report to the SA. On 8/27/20, at 11:47 p.m. the DON verified she was notified the next day of the aforementioned incident at which time she had directed RN-A to report the incident to the SA. On 8/27/20, at 1:17 p.m. the administrator stated the aforementioned incident had not been reported within two hours because she thought that allegations of abuse were to be reported within two hours only if there was serious bodily injury had occurred. The Vulnerable Adult-Resident Abuse, Neglect, Mistreatment and Misappropriation of Property policy reviewed 8/6/20, indicated an incident or suspected incident of mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of property must be immediately, upon knowledge, reported to the administrator. The administrator would be notified in person or by phone. The administrator or designee would make an initial report of the incident or suspected incident, to the SA immediately upon knowledge,in accordance with the law.

Based on observation, interview and document review the facility failed to evaluate, and analyze behaviors and justify the continued use of [MEDICAL CONDITION] medications in 1 of 5 (R13) residents reviewed for unnecessary medications. Findings include: R13's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R13 had [DIAGNOSES REDACTED]. The MDS indicated R13 had moderate cognitive impairment and exhibited no inappropriate behavior symptoms or wandering. The MDS also indicated R13 received daily antipsychotic, antianxiety and antidepressant medications daily. R13's Cognition Care Area Assessment (CAA), dated 8/16/19, indicated R13 was at risk for verbal or physical abuse by staff or others, unmet needs, safety concern, frustration, depression and anxiety. R13's [MEDICAL CONDITION] CAA dated 8/16/19, indicated R13 had a long history of anxiety and use of antianxiety medications. The goal was for anxiety symptoms to be managed with current regimen and redirection and to maintain functional ability. The CAA indicated R13 was at risk for side effects of medication, worsening anxiety, depression, falls with injury and unmet needs. Physician orders [REDACTED]. Additional medications were added as follows: -On 10/5/18 [MEDICATION NAME] 15 mg one time a day. -On 10/23/18 [MEDICATION NAME] 2 mg intramuscular (IM) one time as needed and [MEDICATION NAME] (antipsychotic medication) 50 mg at bedtime for one week then increase to 75 mg at bedtime. -On 10/30/18 [MEDICATION NAME] increase to 75 mg at bedtime. -On 6/3/19 [MEDICATION NAME] increase to 75 mg two times a day. Review of R13's quarterly [MEDICAL CONDITION] medication review revealed the following: -Review dated 8/29/18, listed anxiety disorder with targeted behaviors of bowel obsession, repetitive questions, demanding, short tempered, personal history of abuse, history of fearful of bath and disrobing, wandering, verbally aggressive toward other residents, territorial regarding dining room seating, striking out at staff, paranoid delusions regarding, distrustful of certain male staff. The review indicated R13 received [MEDICATION NAME] (an antianxiety medication). The review of target behavior monitoring indicated behaviors occur sporadically throughout the day. Review dated 10/24/18, revealed R13 received [MEDICATION NAME] (an antipsychotic medication), [MEDICATION NAME], and [MEDICATION NAME] (an antidepressant medication). The review of target behavior monitoring indicated behaviors occur sporadically and tend to escalate in the afternoon and evening. Review of R13's [MEDICAL CONDITION] medication review dated 1/29/19, revealed R13 received [MEDICATION NAME] and [MEDICATION NAME]. The review of target behavior monitoring indicated behaviors occur sporadically and tend to escalate in the afternoon and evening. Review of R13's [MEDICAL CONDITION] medication review dated 4/18/19, revealed R13 received [MEDICATION NAME] and [MEDICATION NAME]. The review of target behavior monitoring indicated behaviors occur sporadically and tend to escalate in the afternoon and evening. Review of R13's behavior tracking log revealed the following: -October (YEAR) listed sixteen different incidents of various behaviors. -November (YEAR) listed one incident of demanding behavior. -December (YEAR) listed two incidents of obsession with bowels, and demanding, short tempered behavior. -January (YEAR) listed one demanding behavior, two incidents of going to bed in afternoon, and one incident confused evening as morning. -February 2019 listed one incident of confusion, trying to go to bed at 4:00 pm. -March 2019 had no behaviors recorded -April 2019 had no behaviors recorded -May 2019 had no behaviors recorded -June 2019 did not have a behavior tracking log document -July 2019 had no behaviors recorded. Review of R13's MD/Nursing communications records revealed the following: -10/2/18 R13 consistently up during the night that required staff intervention. Request for [MEDICATION NAME] for [MEDICAL CONDITION]. -10/14/18 R13's daughter reported resident is acting strange. R13 is very paranoid and reported to daughter she is being followed. Threatened to call police on a male resident and told daughter they would need to hurry and go out the window. -10/22/18 R13 attempted to exit facility two times. Continues to have anxiety over neighboring resident who wanders frequently. R13 has not been sleeping well due to this anxiety and reports feeling afraid to sleep. Showing paranoia regarding her medications and refused bedtime medications. Threatened staff member with scissors and physically striking out. -11/1/18 R13 had become frightened and was screaming for help when neighboring male resident wandered into her room. Later, R13 exited male resident's room after hitting him in the face with a belt. -11/2/18 R13's daughter reports her mother is agitated and very afraid of the wandering male resident. Daughter requested different room for her mother away from this resident but no other room was available. Daughter took R13 to her home on leave of absence for the weekend to promote safety and comfort of both residents involved. -11/5/18 R13's paranoia and anxiety related to history of abuse and recent conflict with another resident puts R13 at risk for emotional distress and poor coping. R13 has been restless, anxious, wandering and not sleeping. R13 repeatedly voices not feeling safe and expresses's anger toward a specific male resident who wanders. R13 perceives this resident as stalking her. -11/5/18 Referral to a geriatric behavioral unit. -11/6/18 Physican indicated resident should not be sent for an acute psychiatric stay but to treat R13 at the facility and to proceed with out patient evaluation. -11/21/18 Care conference note indicated improved adverse and target behaviors since transfer of another male resident. -6/3/19 Resident has been having increase sun downing in the early afternoon which resulted in a fall on 5/31/19. R13 noted to have increase confusion and restless in early afternoon. Request increase in [MEDICATION NAME]. Review of R13's medical record lacked an analysis of R13's behaviors in relationship to the prescribed medications. On 7/16/19 at 11:24 a.m. Certified nursing assistant (CNA)-E stated R13 is usually pretty good. Stated she had not seen real aggressive behaviors in the past five or six months. -At 11:38 a.m. Trained medicine aide (TMA)-A stated R13 would get nervous around wandering males. Stated R13 was frightened of a male resident that used to reside at facility and R13 would frequently hide in activities. Stated she thought R13 felt safe at facility now. -At 11:47 a.m. Registered nurse (RN)-B verified she could not find any behavior monitoring specific to paranoia or elopement. RN-B verified there was no qualitative or quantitative data regarding how often behavior is occurring. RN-B confirmed R13's behaviors were improved. RN-B further confirmed there was no documentation in recent nurses progress notes regarding sundowning behaviors noted in 6/3/19 notation. RN-B confirmed R13 had not exhibited several behaviors in past months and should be changed to history of. On 7/17/19 at 9:20 a.m. RN-A confirmed a dose reduction on [MEDICATION NAME] should be attempted and the recent increase in this medication is inappropriate. RN-A verified qualitative and quantitative review of behavior monitoring was not being done. -At 10:51 a.m. Pharmacist-B confirmed the medication [MEDICATION NAME] should be re-evaluated if behavioral incidents were improved. -At 12:25 p.m. Director of nursing (DON)-A confirmed [MEDICATION NAME] should be monitored and re-evaluated when behaviors improve. DON-A verified quantitative and qualitative review of behaviors were not being done. -At 1:53 p.m. DON-A verified R13's [MEDICATION NAME] was increased on 6/3/19, however, the progress notes lacked any documentation to support the increase in medication. DON-A was unable to find any behavior incident documentation to support the increase in the medication [MEDICATION NAME] on 6/3/19. DON-A verified there was no recent documentation in R13's record regarding an increase in behaviors. Review of [MEDICAL CONDITION] Medication Monitoring policy and procedure dated 4/2010, indicated that the attending physician will review use of [MEDICAL CONDITION] medication when resident seen by physician on monthly nursing home rounds and as needed. Mood/behavior and [MEDICAL CONDITION] medication will be reviewed quarterly in coordination with minimal data set (MDS) and care conferences, and at monthly behavior/[MEDICAL CONDITION] meetings. GDR's will be reviewed and/or attempted in two different quarters with at least one month between attempts in the first year and then reviewed and/or attempted yearly after the first year. GDR may be declined due to clinical contraindications documented by the physician or resident's target symptoms returned or worsened after most recent attempt at GDR.

Based on observation, interview and document review, the facility failed to monitor and report changes to the physician for 1 of 2 residents (R26) reviewed for increased [MEDICAL CONDITION] (fluid retention) in feet/ankles. Findings include: R26's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R26 cognition was intact and was independent or required supervision only for activities of daily living (ADL's). R26 did not have any listed skin conditions and was not prescribed a diuretic (medication to reduce fluid). Review of R26's Order Summary Report dated 7/17/19, did not include any orders for diuretics, compression stocking, monitoring for [MEDICAL CONDITION] or weights. R26's Care Plan dated 3/30/19, indicated that R23 was able to dress self, transfer and toilet self independently. The care plan indicated R23 had arthritis and staff were directed to monitor, document and report to medical doctor (MD) and signs or symptoms or complications of arthritis such as joint pain, joint stiffness, swelling, decline in mobility or self care ability. On 7/14/19, at 5:36 p.m. R26 was observed seated in wheelchair with legs dependent, not wearing socks only slippers on feet. Bilateral ankles/feet appeared swollen. R26 stated her feet and legs were painful. On 7/15/19, at 2:38 p.m. R26 was talking with unidentified staff stating I did not sleep very good, my legs were burning. Observed bilateral [MEDICAL CONDITION] to ankles/feet. R23 was seated in wheelchair without socks only slippers with feet dependent. Resident stated she has told staff about her swollen feet and there have not been any changes. R23 stated they sometimes are so painful I have to lie down. On 7/16/19, at 7:45 a.m. R26 was observed seated in wheelchair with legs dependent, in the dining room, not wearing socks only slippers. Feet/ankles bilaterally appeared swollen. - At 1:28 p.m. observed registered nurse (RN)-B in hallway with R26 and an unidentified family member examining R26's feet/ankles. - At 1:32 p.m. RN-B stated she was not aware of [MEDICAL CONDITION] in R26's ankles/feet until it was brought to her attention by R26 and family member. RN-B stated the [MEDICAL CONDITION] was 3+ bilateral [MEDICAL CONDITION] (swelling that is significant enough to cause an indentation in the skin when depressed with a finger. RN-B indicated a message would be sent to the physician. - At 2:04 p.m. nursing assistant (NA)-A stated this is the first time she noted [MEDICAL CONDITION] in R26's feet and ankles and she reported it to the RN. On 7/17/19, at 8:41 a.m. observed R26 seated in wheelchair with legs dependent, not wearing socks only slippers. Feet/ankles bilaterally appeared swollen. R26 stated she did not sleep very well last night due to the pain in her feet. R26 stated she had reported increased swelling to staff (cannot recall which staff) before yesterday. Right foot appeared more swollen than left. - At 9:02 a.m. RN-B stated R26 had re-occurring [MEDICAL CONDITION] in feet/ankles. RN-B examined feet/ankles and stated it was not as bad as yesterday reporting 1.5+ [MEDICAL CONDITION]. RN-B stated she would expect the NA's to report any changes to nurse on duty. Review of weekly Skin Observation Tools identified the following: - On 7/15/19, no [MEDICAL CONDITION] noted - On 7/8/19, no [MEDICAL CONDITION] noted - On 6/24/19, no [MEDICAL CONDITION] noted - On 5/27/19, both lower legs have discoloration and both ankles are swollen. - On 5/20/19, both lower legs have discoloration and both ankles are swollen(non-[MEDICAL CONDITION]). - On 5/13/19, both lower legs have discoloration and both ankles are swollen(non-[MEDICAL CONDITION]) - On 4/15/19, both lower legs have discoloration and both ankles are swollen. - On 3/18/19, both lower legs have discoloration and both ankles are swollen. - On 3/11/19, both lower legs have discoloration and both ankles are swollen. - On 3/4/19, both lower legs have discoloration and both ankles are swollen. - On 2/25/19, both lower legs have discoloration and both ankles are swollen. On 7/17/19, at 12:25 p.m. RN-B indicated the only documentation regarding [MEDICAL CONDITION] in lower extremities that she could locate was on the weekly skin assessments. RN-B could not locate any progress notes or indication that physician had been notified of [MEDICAL CONDITION]. RN-B indicated that no daily assessments for increased [MEDICAL CONDITION] or weight gain or interventions for [MEDICAL CONDITION] were implemented for R26. - At 12:39 p.m. director of nursing stated she would expect when [MEDICAL CONDITION] is present that there would be daily monitoring, documentation of findings, elevation of extremities and notification of physician. Policy/procedure for [MEDICAL CONDITION] monitoring was requested but not provided.

Based on observation, interview, and document review, the facility failed to assess need for assistive devices to prevent falls for 1 of 4 residents (R4) reviewed for accidents. R4's quarterly minimum data set ((MDS) dated [DATE], indicated R4 was moderately cognitively impaired and required extensive assistance from two staff for transferring and toileting. R4's activities of daily living (ADL) care area assessment (CAA) dated 2/5/19, indicated R4 needed assist with transfers, mobility and did not walk. R4 was at risk for injury to self and falls with injury. R4's falls CAA dated 2/5/19, indicated R4 was at risk for falls related to ADL dependence, cognitive impairment, vision loss, [MEDICAL CONDITION] and medications for anxiety/depression. Staff were to assist with ADL's and anticipate needs. R4's care plan indicated R4 required extensive to total assist of staff with toileting. Resident may be assisted with two person physical assist or when weak using Maxi-Move hoyer lift and two staff on and off commode/toilet. Staff manages clothing, completes toileting hygiene and changes incontinent brief. R4's care plan was updated during survey to include use of Maxi-Move hoyer lift with toileting and transfers. Care Guide for R4 indicated two staff assist for transfers and Maxi move as needed for toileting. On 7/15/19, at 1:20 PM R4 was being assisted to toilet by nursing assistant (NA)-B and NA-E. A gait belt was applied and staff asked R4 to place her hands on his shoulders while NA-B grabbed onto gait belt and lifted R4 up from wheelchair and pivoted to toilet. R4 had knees bent at 90 degree angle during transfer - At 1:23 p.m. R4 was assisted to stand from the toilet, with hands on shoulders of NA-B and NA-B lifting by using gait belt. R4's knees were only at 90 degrees angle. - At 1:26 p.m. NA-B and NA-E transferred R4 into bed by having R4 place hands on NA-B's shoulders and NA-B lifting R4 by gait belt. R4's knees were noted at 90 degree angle during transfer. - At 3:31 PM during interview NA-B stated that R4 does not participate well with transfers. NA-B stated he places R4's knees at his knees, he lifts R4 and pivots to either wheelchair or bed. NA-B stated he knows he is lifting more with R4 and that some staff may have difficulty with that. -At 3:36 PM observed certified occupational therapy assistance (COTA) having R4 give me a big hug with R4's hands on COTA's shoulders. COTA grabbed onto gait belt to lift R4 from sitting on edge of bed and transfer to wheelchair. NA-C assisted with transfer by grabbing onto R4's pants, mid back, and pivoting R4 into wheelchair. - At 3:40 p.m. NA-C stated rarely use a lift with R4. Most of her transfers are like what we just did where R4 rarely participates and we do most of the lifting. On 7/16/19, at 8:49 a.m. NA-D and NA-A observed assisting R4 to toilet. R4 did not stand, knees at 90 degree angle, during two person transfer with gait belt. NA-D held onto gait belt while NA-A grabbed the back of R4's pants to stand and pivot to toilet. NA-A stated R4 does not like the maxi-move lift so we do not use it. - At 8:59 a.m. 2 NA's assisted R4 to stand from toilet while a third NA cleansed R4 and applied incontinent pad and pulled up pants. During this time R4 did not extend knees past a 90 degree angle. - At 1:12 p.m. registered nurse (RN)-A stated therapy evaluated R4 several weeks ago and did not feel the hoyer lift was appropriate. RN-A stated she had not seen R4 transfer for awhile and audits with transfers were not completed. The NA's can make the decision to use a standing transfer with a gait belt or the Maxi-move. -At 1:20 PM NA-D, NA-F, and NA-A entered room to transfer R4 to the bathroom. RN-A came to observe transfer. RN-A confirmed that R4's knees were at 90 degree angle and pivot was not safe. RN-A confirmed that transfer was not safe and that staff should use the Maxi-move with R4 for all transfers. RN-A stated we probably do more manual lifting here than we should. On 7/17/19, at 10:05 a.m. NA-H stated she has informed nurses on multiple occasions that transferring R4 with 2 staff was not safe for R4 or us. - At 10:56 a.m. RN-A stated that staff have reported concerns with unsafe transfers with R4 in the past. - At 12:45 p.m director of nursing stated she would expect staff to report if a resident is declining in their ability to transfer safely and that the team would change the type of transfer for the resident to be safe and then make referrals to physical/occupational as necessary. Review of Safe Patient Handling and Movement Policy, undated, indicated that Lifecare Medical Center wants to ensure that its residents are cared for safely, while maintaining a safe work environment for employees. Direct care staff should assess high-risk patient handling tasks in advance to determine the safest way to accomplish them. Additionally, mechanical lifting equipment and/or other approved patient handling aids should be used to prevent manual lifting and handling of patients. Review of Maxi Move policy/procedure, undated, indicated the Maxi Move is intended to be used where the patient: - sits in a wheelchair - has no capacity to support themselves - cannot stand unsupported and is not able to bear weight; not even partially

Based on observation, interview, and document review, the facility failed to ensure appropriate hand hygiene was provided following perineal care for bladder incontinence for 1 of 1 resident (R17) who was observed during morning cares. In addition, the facility failed to analyze monthly surveillance data for trends and patterns to reduce the spread of illness and infections and implement corrective action for identified infection issues in the facility. This had the potential to affect all 47 residents who resided in the facility. Findings include: R17's Face Sheet dated 8/2/18, indicated R17's [DIAGNOSES REDACTED]. R17's quarterly Minimum Data Set ((MDS) dated [DATE], identified R17 had severe cognitive impairment, required extensive assistance of one person for personal hygiene, during toilet use (cleansing self after elimination, changing pad, and adjusting clothing), and had occasional bladder incontinence. Review of R17's care plan dated 2/26/18, indicated R17 required extensive assistance of two staff for toileting and changing incontinent pad. Staff adjusted clothing and managed hygiene. The care plan directed staff to encourage R17 to wash her hands and face with step by step direction from staff. R17 was observed during morning cares on 8/1/18, at 7:26 a.m. when nursing assistant (NA)-C assisted R17 to the bathroom toilet. It was noted that R17 had been incontinent of bladder as the incontinent pad was saturated with urine, R17 also voided while on the toilet. NA-C assisted R17 to put on pants and a shirt and proceeded to assist R17 to stand using a transfer belt. With gloves on, NA-C cleansed R17's backside and bottom. Without removing her gloves or washing her hands, NA-C placed a incontinent pad on R17, pulled up R17's pants, took a hold of the transfer belt and assisted R17 back into to the wheelchair. NA-C touched the door knob, and arm rest of R17's wheelchair before removing her soiled gloves and performing hand hygiene. Following washing her hands, NA-C donned gloves and assisted R17 to brush her teeth. With the same gloved hands, NA-C proceeded to turn on the water in R17's sink, cleansed the tooth basin, turned the water off, touched R17's door, opened R17's bedside stand, lowered R17's side rail, made the bed, gathered the garbage, pushed R17 down the hall until reaching the soiled utility room where NA-C opened the door, disposed of the garbage and removed the gloves. NA-C proceeded to push R17 into the dinning room and positioned her at a table then used alcohol hand sanitizer to complete hand hygiene. NA-C was interviewed on 8/01/18, at 2:36 p.m. and confirmed she had not removed her gloves or performed hand hygiene after providing R17 partial peri-care, or immediately following oral care. The director of nursing (DON) was interviewed on 8/1/18, at 2:52 p.m. and stated she expected glove removal and hand hygiene performed immediately following peri-care and oral hygiene according to the facility policy. Review of the facility policy and procedure for Hand Hygiene/Handwashing (undated) directed all employees to practice proper hand hygiene to prevent the spread of infection before and after direct patient contact, and after removing gloves. The facility Infection Control Tracking and Trending logs from (MONTH) (YEAR), to (MONTH) (YEAR), were reviewed. The logs included a spreadsheet which identified columns for the following: date, room number, resident name and medical record number, illness-symptom, lab/X-ray, medication/treatments, INR (international normalized ratio - a test evaluating coagulation) 72-96 hours after start of antibiotic if on [MEDICATION NAME] (a blood thinner), and resolved. The logs also included a map of the facility with a colored coded legend handwritten on the left side. The legend indicated the following category color codes: urinary-yellow, wound-green, GI (gastrointestinal)-pink, respiratory-orange, otic-blue, ophthalmology-purple, other-red. A dot corresponding to the infection category was placed on the map with the corresponding resident room number. Review of the logs revealed the following infections: January: urinary-2 (both on Cherry Lane hallway), respiratory-4, GI-1 February: urinary-3 (1 on Cherry Lane, 1 on Maple Grove and 1 on Oak), respiratory-1, otic-1, GI-1 March: urinary-2 (1 on Maple Grove and 1 on Pine), GI-1, respiratory-1, ophthalmology-1 other-1 April: urinary-2 (both on Cherry Lane), wound-2, respiratory-3 May: urinary-3 (2 on Cherry Lane and 1 on Pine), respiratory-2, ophthalmology-2, June: urinary-5 (1 on Cherry Lane, 2 on Maple Grove, 1 on Pine and 1 on Oak), wound-2, respiratory-2 July: urinary-4 (3 on Cherry Lane and 1 on Oak), respiratory-9, GI-2 On 8/2/18, at 10:24 a.m. the Infection Control Tracking and Trending logs were reviewed with the DON and the infection preventionist (IP). The DON indicated the previous IP had retired 7/13/18, and the current IP was scheduled to transfer from the hospital to the nursing home on 8/6/18. The DON stated the goal was for the IP to look at each issue/potential infection as needed, however, currently IP reviewed the infection logs weekly. The DON stated each weekday she met with the interdisciplinary team (IDT) to discuss any ongoing or acute illness/infections and indicated any new issue was entered on the infection tracking log, as well as logged onto the facility map, color coded by type: urinary, wound ,GI, respiratory, otic, ophthalmology and other. The DON indicated issues were documented on the map as they occurred and monitored for patterns/trends. DON stated if a trend was noticed they would implement interventions to prevent outbreak such as keep residents to their room, educate staff, or make a change in cleaning techniques, etc. depending on the issue. The DON indicated she may also do audits for hand hygiene, medication administration techniques, etc. The DON further stated the information was compiled quarterly and reported to the QA (quality assurance} committee. The information reported included: incidents, rates, patterns, trends, and actions taken. The DON also stated the facility had an infection/prevention and control meeting every other month in conjunction with the hospital. When queried about the incidences of urinary tract infections from (MONTH) through July, the IP confirmed a potential trend on the Cherry Lane hallway. The DON confirmed this had not been identified and indicated they had some residents with catheters and residents who were resistive to cares on that hallway. The DON also verified it could have potentially been a trend. The DON also confirmed they had not identified a trend with respiratory illness and had not implemented any particular interventions to address the respiratory illness outbreak in July. The Infection Control Practices policy dated 2/2010, indicated the purpose was to carry out all procedures using infection control policies to lower incidences of infection and to provide surveillance and interventions to prevent or control infections of any nature. The policy indicated all infections were recorded with date occurring and treatment prescribed and are reviewed at least monthly by IP and the DON for trends, patterns and incidence rate.

Based on observation, interview and document review, the facility failed to ensure a multi-use [MEDICATION NAME] solution vial used in a skin test to help diagnose [MEDICAL CONDITION] (TB) infection in persons at increased risk of developing active disease was dated when opened and destroyed in a timely manner. This had the potential to affect all new admissions and new staff hired after 7/31/18. Findings include: On 7/31/18, at 1:34 p.m. during review of the medication storage refrigerator, an open vial of [MEDICATION NAME] solution was observed undated as to when opened/accessed. Licensed practical nurse (LPN)-A verified the vial had been opened, was approximately half full and the vial nor the box had been dated when opened/accessed. LPN-A stated it was practice to date multi-use vials when opened and dispose after 28 days from being accessed. On 8/2/18, at 9:59 a.m. the director of nursing (DON) confirmed it was her expectation for staff to note the date a multi use vial was opened and then disposed of it 28 days after accessed. The DON confirmed the [MEDICATION NAME] solution should have been disposed of 28 days from having been opened. The DON was unable to locate a policy/procedure related to the dating and proper disposal of multi use vials of [MEDICATION NAME] solution.

Based on observation, interview and document review, the facility failed to accommodate resident preferences for arriving at the dining room up to 1.5 hours prior to meal service for two of 6 residents (R42, R7) who voiced concerns during the Resident Council group meeting. In addition, the facility failed to accommodate 1 of 1 resident's (R7) preference for medication pharmacy services. Findings include: During the initial dining observation on 7/30/18, at 5:01 p.m. 20 residents were observed seated at the dining room tables. The meal distribution service began at 6 p.m. and concluded with the last meal being served at 6:30 p.m. On 8/1/18, at 1:10 p.m. the resident council group was held. R42 & R7 both voiced concerns with being taken to the dining room too early before meal service. R42 stated she did not like being told when she had to be in the dining room, You have to sit there in the wheelchair so long. R42 stated she liked to watch the news before going to supper. R42 stated she voiced her concern at her care conference meeting, and was informed that she did not have to go to the dining room early, but some of the nursing assistants (NA) still tried to push her to go sooner than she liked to. R7 also stated the NAs would bring her to the dining room an hour or more prior to meal services, and she did not like sitting there that long. The other four residents involved in the meeting were independent in ambulation and wheelchair propulsion, therefore, did not require assistance to get the to the dining room. All six residents present at the meeting confirmed residents who required mobility assistance were often brought to the dining room up to 1.5 hours before their meal was served. On 8/1/18, at 2:27 p.m. the registered dietician (RD) stated that if the residents did not want to be brought to the dining room early, they could also be seated in the area by the birds or the television area while they waited for the meal service to being. -At 2:58 p.m. NA-A stated the residents were assisted to the dining room according to when the NA's supper break was. NA-A stated the staff tried to bring half the residents to the dining room before their supper break at 5:00 p.m. However, NA-A stated the residents who required mechanical lifts to transfer were not assisted until after the staff break, so those residents were not up in their chairs too long. On 8/02/18, at 9:39 a.m. the director of nursing (DON) stated the NA's supper breaks were at 4:30 & 5:00 p.m. The DON stated the staff breaks were part of the reason the resident suppertime was switched to 6:00 p.m. so the residents' were not brought to the dining room before 5:30 p.m. The DON confirmed there were about 20 residents in the DR on 7/30/18, at 5:00 p.m. and the last meal was served at 6:30 p.m. R7's admission Minimum Data Set ((MDS) dated [DATE], indicated R7 was cognitively intact, and had [DIAGNOSES REDACTED]. R7's Notice of Admission form, indicated R7 admitted to the facility in April, (YEAR). The form further indicated R7's pharmacy choices as the Veterans Administration (VA) and Mattson's pharmacy. On 7/30/18, at 6:47 p.m. R7 stated the facility had not ordered his medication from the VA, which was his preferred pharmacy. R7 stated if his medications were ordered from the VA, he would get his medications filled, and would not have to pay for them as the VA would automatically send his medications every 90 days. R7 stated he had been receiving his medications from the VA at home prior to his admission to the facility. R7 stated a couple of months ago, he had requested his medications be filled at the VA which had not happened yet. R7 produced a pharmacy bill in which he had a co-payment of $117.00 dollars for June, (YEAR). R7 stated if his medications were filled at the VA, he would not have this bill to pay. On 8/1/18, at 8:19 a.m. registered nurse (RN)-A confirmed R7 had requested his medications be filled through the VA, but stated she had not documented R7's pharmacy request in his clinical record, as she did not have time to document every conversation she had with the residents. RN-A confirmed R7 had been receiving his medications from the VA while at home. RN-A stated R7 needed to have an appointment at the VA however, R7 declined to go to Fargo, and preferred to see his physician at the facility for his physical. RN-A confirmed she had failed to provide further follow up, or act on R7's pharmacy request, and stated there are so many things to take care of here that sometimes things get overlooked. On 8/1/18, at 1:26 p.m. licensed social worker (SW)-A confirmed R7 had selected the VA and Mattson's pharmacy for his pharmacy services, which she assumed had been followed up with by nursing. The SW-A stated she would contact the VA with R7 to find out how to handle this situation. On 8/1/18, at 2:10 p.m. the director of nursing (DON) stated she was unaware of R7's request for his medications to be filled through the VA, and it was her expectation for the staff to follow up on resident requests in a timely manner including R7's pharmacy request. -At 2:45 p.m. SW-A stated the facility need to have better coordination of identifying these types of resident concerns. The facility 'Roseau Manor admission booklet revised 6/17, indicated each resident may choose his own pharmacy.

Based on observation, interview and document review, the facility failed to ensure a right leg rest was applied to the wheelchair as directed by the plan of care to minimize the risk of injury for 1 of 4 residents (R62) who was identified at risk for accidents. R62 sustained harm related to an incident on 9/13/12, which resulted in a fractured right leg. Findings include: R62's [DIAGNOSES REDACTED]. R62 came to the facility to receive rehabilitation services, with a plan to return home after therapy services. The orthopedic physician surgical consult dated 8/2/12, indicated R62 had suffered a right supracondylar (just above the knee joint) femur fracture 4 months ago which healed without surgery. No causal factor was identified related to this fracture. On 9/14/12, according to the x-ray report, R62 sustained a fractured right tibia (a break in the upper part of the shin bone) at the facility. The admission Minimum Data Set ((MDS) dated [DATE], indicated R62 was cognitively intact, required extensive staff assist to transfer and did not ambulate. The Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 8/21/12, indicated R62 had limitations in ADLs related to the recent hip fracture which caused unsteadiness and weakness. The quarterly MDS dated [DATE], indicated R62 was cognitively intact, was totally dependent on staff for transfers, and did not ambulate. The plan of care (POC) dated 8/24/12, indicated R62 required assistance with wheelchair mobility for fine maneuvering daily, but was also able to propel self. The POC directed staff to ensure foot pedals were in use. The physical therapy assistant (PTA)-B progress note dated 9/11/12, indicated R62 was to continue with physical therapy (PT) five times a week. PTA-B indicated R62 attempted to limit weight bearing (WB) on the right when standing. In addition, PTA-B documented R62 was able to sit to stand with moderate assist of one, was able to stand for one minute two times and for three minutes one time with contact guard assist. The occupational therapist (OT)-A progress note dated 9/11/12, indicated R62 continued to need significant assistance to attain an erect posture. The PTA-A progress note dated 9/12/12, indicated R62 was now 50 percent weight bearing. The note further indicated R62 was frustrated that she could not walk yet. The progress notes identified on 9/13/12, at 10:00 a.m. OT-A saw R62 for therapy and at 11:00 a.m. physical therapist (PT)-A saw R62 for therapy. On 9/13/12, at 3:00 p.m. licensed practical nurse (LPN)-C documented in the progress notes that R62 had told her her foot had been caught under the wheelchair when she was being pushed. On 9/13/12, at 3:02 p.m. LPN-B documented in the progress notes that R62 was being wheeled in the wheelchair and her Crocs (rubber shoes) got caught on the floor and her right leg rolled under the wheelchair approximately 6 inches. No injury was noted at that time. The progress note dated 9/13/12, at 4:19 p.m. by PT-A indicated R62 had indicated she got her foot caught under the wheelchair and reported she was having pain. On 9/14/12, at 4:35 a.m. the progress notes by nursing indicated R62 had made several anxious complaints about her right leg. The note also indicated R62 had not been able to do therapy due to her leg hurting and had the start of a large bruise to the lower right leg. The progress note dated 9/14/12, at 10:38 a.m. by LPN-D indicated the physician ordered an x-ray of the right upper and lower leg. The x-ray report dated 9/14/12, revealed a proximal tibia fracture (a break in the upper part of the shin bone). PT-C documented on 9/14/12, that R62's tibia was fractured and R62 was now non-weight bearing. The bone density scan results dated 9/17/12, indicated R62 had osteoporosis with a high risk for fractures. On 12/18/12, at 7:05 a.m. R62 was observed in the wheelchair at the breakfast table with a foam boot on the right leg which was positioned on a leg rest. R62 had a Croc shoe on the left foot. At 8:11 a.m. R62 was observed to self-propel her wheelchair out to the lobby using her left foot and right arm on the wheel. At 11:52 a.m. the social worker verified the tibial fracture from 8/13/12, and stated a staff person had been wheeling R62 and her foot got caught under the chair and then R62 had complained of pain. At 12:06 p.m. the director of nursing (DON) stated she had witnessed the 9/13/12, incident in which R62 was being wheeled in the wheelchair. She added R62's right foot with the Croc shoe got stuck on the floor and went approximately 6 inches under the wheelchair. The DON stated R62 had said "ouch." The DON also stated R62 did not have the right leg rest on the wheelchair. The DON stated, at that time, NA-A had found the footrest and attached it to the wheelchair. The DON stated an investigation was completed after R62 complained of pain, and a vulnerable adult report was filed. The DON stated during the investigation it was determined that therapy staff (PT and OT) had seen R62 prior to the incident. The DON also stated the next day R62 had complained of pain and the physician had ordered an x-ray which revealed the tibial fracture. The DON stated R62 was placed in a half cast until she could see the orthopedic physician. Additionally, the DON indicated R62 had severe osteoporosis with a high risk for fractures and stated R62 had sustained a lot of fractures in a short amount of time. The DON verified R62 had used the right leg rest on the wheelchair since admission to the facility and stated when the 9/13/12, incident occurred R62's POC directed the use of foot rests which was not followed. At 12:43 p.m. RN-A stated according to the POC the right leg rest should have been used during the incident. At 12:49 p.m. R62 indicated her foot had been caught while being wheeled in the wheelchair, stuck to the floor and then twisted causing it to break. At 12:57 p.m. PT-A stated R62 had weak bones with significant osteoporosis. PT-A stated R62 had told her when she was in the wheelchair her leg got pinched back. PT-A stated R62's goal was to go home, and they were progressing her weight bearing. At 2:55 p.m. LPN-B stated R62 had always self propelled her wheelchair. LPN-B indicated on 9/13/12, R62 had asked her to take her to her room. LPN-B stated R62 had Crocs on both feet, and there were no leg rests on the wheelchair. LPN-B also stated she did not know R62 was supposed to have the leg rest on the chair. LPN-B stated R62's foot bounced on the floor and then got stuck under the wheelchair. LPN-B stated she wanted R62's family notified to get the resident different shoes. LPN-B stated the next day she had heard R62 had broke her leg from the incident. LPN-B stated OT had just been in the room with R62 prior to the incident. LPN-B indicated if OT had wanted R62 to have the right leg rest on, then they would have put it on. LPN-B stated she did not think R62 needed the leg rest. At 7:26 p.m. NA-A was interviewed via phone. NA-A stated she had been assigned on R62's hallway along with another staff member on 9/13/12. NA-A stated she had assisted R62 that morning to get up for the day. NA-A stated therapy had been working with R62 in her room. NA-A stated R62 had wheeled out of her room to the bird aviary. NA-A stated R62 had the leg rest on the wheelchair earlier in the day. NA-A stated her assumption was that the therapist would know to apply the leg rest, if it was needed. NA-A indicated she saw LPN-B bringing R62 to her room. NA-A stated LPN-B had told her R62 was having pain. At that time, NA-A stated she had asked LPN-B where R62's leg rest was, and was told by LPN-B that it was a good question. NA-A stated nobody seemed to know who had not placed the leg rest on the chair. NA-A stated R62 had used the right leg rest from the time she was admitted . NA-A stated it was "human error." On 12/19/12, at 7:56 a.m. the DON stated she would have wanted the staff to recognize the leg rest was not on, and she added, they did notice, however, it was after R62 was pushed about one to two feet without it. At 8:03 a.m. OT-A was interviewed via phone. OT-A stated she saw R62 the morning of 9/13/12. OT-A indicated R62 was not good with weight bearing. OT-A indicated she had removed the right leg rest when she went into the room, and then put it back on when she left. OT-A stated R62 would be alert enough to know how to remove the leg rest, however, she felt R62 would not. OT-A stated R62 had always used the right leg rest. At 8:13 a.m. PT-A was interviewed via phone. PT-A stated she would have removed the leg rest when doing therapy with R62, and would have put it back on again. PT-A stated R62 would have been able to hold her right leg up on 9/13/12. At 8:46 a.m. RN-A stated R62 had worn the Croc shoes since admission, and was completely opposed to wearing other footwear. At 9:06 a.m. NA-A stated she remembered on 9/13/12, pointing out to LPN-B that R62's leg rest was not on the wheelchair. NA-A indicated LPN-B had responded by agreeing that the leg rest needed to be placed. At 9:15 a.m. R62 stated she remembered taking her foot out from under the wheelchair. R62 stated she did not know why the leg rest was off the chair, but she had not removed it. R62 could not remember if she had wheeled herself out to the bird aviary, or if staff had assisted her. R62 stated she said "Ow" when it happened. R62 stated the staff asked her what was hurting and she replied her foot. R62 then stated she had bruising on her leg and she went to the doctor for an x-ray and found out it was "broke again." R62 indicated with another fracture it would take longer for her to heal and go home. The investigative report completed by the DON on 9/14/12, indicated the wheelchair leg rest was not used for transporting R62. Education was completed with LPN-B regarding the importance of the use of the leg rest for R62 as directed by the POC. Possible non-use of the leg rest was identified as a potential cause of the fracture, along with a [DIAGNOSES REDACTED].