Every finding on record at Living Meadows at Luther - Madelia

Based on interview and record review, the facility failed to revise a person-centered care plan following significant changes in condition related to hydration status to reflect hospital discharge instructions for hydration management, fluid intake, and monitoring for 1 of 3 residents (R1) reviewed for hydration .R1's face sheet identified diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, nutritional deficiency, moderate protein-calorie malnutrition, and hemiplegia and hemiparesis affecting left non-dominant side.R1's Nutrition Assessment Worksheet dated 4/14/26 identified R1's estimated nutritional needs of 1,560 kcal/day (30 kcal/kg) and 52-62 grams of protein/day. The section labeled Fluid Needs contained an arrow pointing to the adjacent box; however, the box was blank and no daily fluid requirement was documented. The assessment identified R1's weight as 114.2 pounds and R1 required nectar-thick liquids.R1's care plan dated 1/17/25, identified potential for fluid volume deficit related to inadequate fluid intake, and dependent for fluid intake manifested by concentrated urine, confusion, constipation, and weight loss. Interventions included observe, document, and report to provider any signs/symptoms of dehydration including: decreased urine output, poor skin turgor, dry mucous membranes, confusion, hypotension, tachycardia, fever, sudden weight loss, headache, or dizziness; encourage, assist with fluid intake, and report changes in ability.R1's nutrition care plan dated 1/17/25, identified potential for hydration problems. Interventions updated on 5/20/26, included to offer extra fluids between meals for hydration in activities, in common areas, and in room. observe for signs/symptoms of dehydration.R1's ED note dated 5/6/26, identified R1 came to ED for critical lactate level drawn. R1 did not want IV antibiotics. Facility stated he had been eating and drinking well. R1 was drinking well in the ED and had already had 100 milliliters (mL) of water with no difficulty. Fluids need to be pushed a little bit more as he was somewhat dehydrated. Plan for discharge included but not limited ensure fluids are being offered every hour while awake. Monitor strict intake and output (I & O) for 48 hours.R1's ED note dated 5/7/26, identified R1 had returned to ED after he was reportedly to have refused water all night and has an intake of 450 mL output of 700 mL at facility. R1 had asked for water three times in the ED since arrival, which was less than an hour. admitted to hospital for IV hydration and antibiotic. R1's hospital discharge note dated 5/10/26, identified R1 had treatment for diagnoses that included dehydration. Comfort focused care with treatments to include every two-hour repositioning, offer water with every reposition, monitor I & O, may irrigate catheter with sterile normal saline as needed.In review of R1's record from 5/4/26 through 5/10/26, there was no indication R1's care plan was revised following two emergency department visits and a hospitalization to reflect hospital discharge instructions, including to encourage increased fluid intake, offer fluids every hour while awake, offer water with every two-hour repositioning, monitor strict intake and output, and monitor changes in output.R1's significant change MDS dated [DATE], identified R1 had moderate cognitive impairment. R1 had a mechanically altered diet. Dehydration/fluid maintenance were triggered during the assessment.R1's care area assessment (CAA) dated 5/29/26, identified dehydration/fluid maintenance were triggered based on clinical manifestations of dehydration which included altered lab values. R1 was at risk for dehydration due to poor intakes and need for nectar fluids, will develop care plan, continue current plan.Although R1's CAA identified the care plan would be developed, the care plan had not been updated following the clinical manifestation of dehydration.During an interview on 7/17/26 at 10:26 a.m., licensed practical nurse (LPN)-A and LPN-B were present. LPN-A and LPN-B reviewed R1's care plan. LPN-A stated there were no interventions in the care plan for fluid intakes after R1 returned from the hospital on 5/10/26. LPN-B could not find any interventions after hospitalization but stated there should be.During an interview on 7/17/26 at 11:15 a.m., director of nursing (DON) stated R1 had returned from the hospital on 5/10/26 and was on comfort cares. DON explained comfort cares involved residents still getting normal basic care needs that staff would provide to everyone. R1 should have had his care plan revised with interventions after hospitalization and when R1 returned to baseline.The facility care plan policy requested on 7/17/26, at 12:23 p.m. via email but not received

Based on observation, interview, and document review, the facility failed to assess, monitor, and implement interventions to maintain adequate hydration for 1 of 3 residents (R1) reviewed for hydration.Findings include Findings includeR1's face sheet identified diagnoses of nutritional deficiency, moderate protein-calorie malnutrition, and hemiplegia and hemiparesis affecting left non-dominant side.R1's care plan dated 10/18/24, identified potential for urinary tract infection (UTI) related to history of frequent UTI, indwelling urinary catheter. Interventions included to offer cranberry juice, identify and provide preferred fluids, and offer fluids. On 1/20/25, urinary incontinence with potential for altered urine pattern. Interventions dated 7/19/24, directed staff to encourage fluid intake, R1 had frequent UTI's and low/dark urine output, encourage fluids (if appropriate) as R1 preferred/allowed.R1's care plan dated 1/17/25, informed staff R1 also had a potential for fluid volume deficit related to inadequate fluid intake, and dependent for fluid intake manifested by concentrated urine, confusion, constipation, and weight loss. Interventions directed staff to observe, document, and report to provider any signs/symptoms of dehydration including: decreased urine output, poor skin turgor, dry mucous membranes, confusion, hypotension, tachycardia, fever, sudden weight loss, headache, or dizziness; encourage, assist with fluid intake, and report changes in ability. The nutritional care plan dated 1/17/25 identified R1 had a potential for hydration problems with Interventions that directed staff to offer extra fluids between meals for hydration in activities, in common areas, and in room. observe for signs/symptoms of dehydration.R1's care plan dated 3/5/25, informed staff R1 had potential for alteration in bowel elimination related to decreased intake of fluid with the goal to be/remain free of discomfort or complications related to constipation. Interventions directed staff to keep fluids within reach, offer sips of fluid with cares.R1's care plan dated 4/29/25, informed staff R1 had a potential for altered renal function related to acute renal failure (2/20/25) manifested by urinary retention and decreased urinary output. Interventions included: assess, record, and report to physician as needed: changes in blood pressure, changes in mentation, new or worsening fatigue, new or worsening edema, nausea or vomiting, or muscle spasms or cramping; report any changes to nurse.R1's Nutrition Assessment Worksheet dated 4/14/26 identified R1's estimated nutritional needs of 1,560 kcal/day (30 kcal/kg) and 52-62 grams of protein/day. The section labeled Fluid Needs contained an arrow pointing to the adjacent box; however, the box was blank and no daily fluid requirement was documented. The assessment identified R1's weight as 114.2 pounds and R1 required nectar-thick liquids.During a phone interview on 7/17/26, at 10:06 a.m., registered dietician (RD)-A stated she completed R1's dietary assessment on 4/14/26. R1's fluid intake should be 1,560 mL which would be 30 per kilogram (kg). RD-A stated she would review progress notes, recent labs, DM-A's review on food and fluid intake from care conferences, and if the resident had intake and output (I&O) records while completing her assessments.R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, difficulty communicating some words or finishing thoughts, sometimes missed part/intent of message but comprehended most conversation. No behaviors. Partial/moderate assistance with upper body dressing; partial/moderate assistance with eating and had a mechanically altered diet.In review of R1's record from 4/29/26 through 5/4/26, although R1's care plan identified a potential for fluid volume deficit related to inadequate fluid intake and directed staff to observe, document, and report signs and symptoms of dehydration, encourage and offer additional fluids, and report changes in ability, the record did not identify documentation of R1's daily fluid intake, nursing assessments evaluating whether R1 was receiving adequate hydration, or monitoring of signs and symptoms of dehydration. During this same period, nursing documented catheter urine output each shift; however, the record did not consistently document urine characteristics, such as color or concentration, or include any assessment identifying whether the amount of urine output was adequate in relation to R1's fluid intake.R1's catheter output on 4/29/26 was 100 milliliters (mL)R1's catheter output on 4/30/26 was 460 mL.R1's catheter output on 5/1/26 was 475 mL.R1's catheter output on 5/2/26 was 950 mL.R1's catheter output on 5/3/26 was 700 mL.R1's catheter output on 5/4/26 was 425 mL.R1's progress note dated 5/4/26 at 1:55 p.m., identified R1's foley catheter was removed and a new one was inserted. Procedure effective, dark urine. At 11:49 p.m., Acetaminophen 650 mg was given for pain/discomfort and fever.R1's progress note dated 5/5/26, at 2:46 a.m., identified R1 had bloody urine. At 3:02 a.m., R1 had been transferred to ED at 11:00 p.m. for evaluation due to a change of condition following a catheter change earlier in the morning with noted blood in urine. At approximately 9:15 p.m. R1 was warm to the touch. Vital signs: Temperature 101.6 F (normal 97.8-99.1), pulse 115 (normal 60-100), respirations 18/minute (normal 12-18), 02 saturations 95% on room air (normal 98-100), blood pressure 115/71 (normal 90/60- 120/80). At 6:51 a.m., R1 was in ED all night.R1's emergency department (ED) note dated 5/4/26-5/5/26 identified R1 presented with blood in the catheter bag after a Foley catheter change. The facility reported R1 had a temperature of 100.0 F and was slightly tachycardic. Upon arrival to the ED, vital signs were within normal limits. A bladder scan showed very little urine in the bladder with no significant clots. Hematuria was present in the catheter bag with good catheter flow. Laboratory studies included CBC (complete blood count), CMP (complete metabolic panel), CRP (c-reactive protein) lactic acid, blood cultures, and urinalysis. Results included a creatinine of 1.4 mg/dL (normal 0.9-1.5 mg/dL), a white blood cell count of 26,000 with a left shift (normal 5,000-10,000 cells), a CRP of 12.2 (normal below 5), and a lactic acid level of 2.5 (normal 0.5-2.2 mmol/L). R1 received one liter of intravenous fluids and one gram of intravenous Rocephin. Following treatment, the lactic acid level decreased to 1.7. The ED discharged R1 back to the facility with oral antibiotics and instructions to repeat laboratory testing, monitor the urinary catheter for additional bleeding or changes in output, return to the ED if symptoms worsened, and encourage more water today. Diagnoses included UTI, sepsis, chronic indwelling Foley catheter, and acute kidney injury.R1's progress note dated 5/5/26, identified R1 returned from ED at 8:45 a.m.R1's catheter output on 5/5/26 was 500 mL.Although the ED included order to encourage more water and return if symptoms worsen. , R1's record from 5/5/26-5/6/26, did not identify if R1 consumed more fluid and no indication if symptoms worsened.R1's laboratory results dated [DATE], identified lactic acid 2.9 (normal 0.4-2.0) this was a critical level.R1's progress note dated 5/6/26, at 10:35 a.m., identified facility nurse spoke with nurse at clinic regarding critical lab result of acid lactate 2.9. Updated on R1's condition of continued hematuria (blood in urine). Facility nurse spoke with MD-A who stated R1's overall condition was not improving. Send to ED for evaluation and/or observation. R1 transferred to ED at 12:20 p.m. following critical lab results.R1's ED note dated 5/6/26, identified R1 came to ED for critical lactate level drawn. R1 had a severe UTI and sepsis that could be life threatening. R1 did not want IV antibiotics. Facility stated he had been eating and drinking well. R1 was drinking well in the ED and had already had 100 milliliters (mL) of water with no difficulty. Fluids need to be pushed a little bit more as he was somewhat dehydrated. Plan for discharge was to stop Keflex (antibiotic) and start Levaquin (antibiotic); order at discharge included ensure fluids are being offered every hour while awake. Monitor strict intake and output (I & O) for 48 hours.R1's progress note dated 5/6/26, identified R1 returned from ED. Discharge orders included antibiotic for 10 days, monitor strict input and output for 48 hours. Follow-up appointment with provider on 5/8/26 at 10:15 a.m. R1's output upon return from ED was 400 mL.R1's Intake and Output record dated 5/6/26 following R1's ED visit on the evening shift documented 450 mL of fluid intake and 150 mL output on the evening shift since return from ED. The Intake and Output record did not identify overnight shift intake or output.R1's progress note dated 5/7/26, at 12:53 a.m., documented R1 complained of upper back pain. R1 was repositioned in bed and had an upper back massage. The note did not identify if fluids were offered or consumed. At 7:42 a.m., the note identified at 5:30 a.m., R1's brief was saturated in dark blood with bleeding around catheter tubing, in the catheter tubing, and bag. Output was 225 mL. R1 moaned and had facial grimaces, stated he had back pain. R1 was transported to ED.R1's catheter output on 5/7/26 during the night shift was 225 mL. There was no record of amount of fluid consumed on the shift.R1's progress note dated 5/7/26 at 1:53 p.m., identified R1 was admitted to the hospital with diagnoses at admission per MD were acute kidney injury, sepsis, and dehydration.R1's ED note dated 5/7/26, identified R1 had returned to ED after he was reportedly to have refused water all night and has an intake of 450 mL output of 700 mL at facility. Facility reported R1 complained of back, abdominal pain, and had blood in urine. R1 had asked for water three times in the ED since arrival, which was less than an hour. Assessment/Plan included Lactated Ringers 1,000 mL for sepsis, acute kidney injury and dehydration from low water intake overnight. admitted to hospital for IV hydration and antibiotic.R1's hospital discharge note dated 5/10/26, identified R1 had treatment for sepsis, UTI, acute kidney injury, dehydration, and pneumonia. comfort focused care with treatments to include every two-hour repositioning, offer water with every reposition, monitor I & O, may irrigate catheter with sterile normal saline as needed.R1's intake and output (I&O) record dated 5/10/26 identified a day shift intake of 230 mL with 625 mL output, and an evening shift intake of 180 mL with 350 mL output. No intake or output was recorded for the night shift. On 5/11/26, the record identified 595 mL intake with 600 mL output for the day shift. No intake or output was recorded for the evening shift. The night shift record identified 30 mL intake and 400 mL output.R1's MDS nurse note dated 5/11/26 at 1:15 p.m., identified R1 required intravenous fluids in the past seven days specifically to address the need for additional fluid intake and hydration needs. The need for fluids was determined by physical exam and/or diagnostic testing. Rehydration was reasonable and necessary.R1's physician order dated 5/12/26, identified to discontinue by mouth intake monitoring. comfort cares no need to monitor intake.In review of R1's record there was no other direction and/or monitoring developed to determine hydration status for maintaining comfort and/or prevent complications.R1's significant change MDS dated [DATE], identified dehydration/fluid maintenance were triggered during the assessment. R1 had moderate cognitive impairment. R1 had a mechanically altered diet.R1's handwritten Nutrition Assessment Worksheet dated 5/15/26 documented R1 received three times a day supplements prior to hospitalization. Intakes/Fluid section included Poor-overall decline during [illegible word] IVF during hosp- . The assessment did not include the amount R1 required to maintain adequate hydration.R1's care area assessment (CAA) dated 5/29/26, identified dehydration/fluid maintenance triggered based on clinical manifestations of dehydration which included altered lab values. R1 was at risk for dehydration due to poor intakes and need for nectar fluids, will develop care plan, continue current plan.Food and fluid intake records were requested for the period of 5/6/26 through 7/16/26; however, the facility only provided records from 6/1/26 through 6/8/26. Although the CAA identified R1's continued risk for dehydration and indicated the care plan would be developed, the record did not identify revisions to the care plan or documented interventions addressing the identified hydration risk. Review of the available dietary food and fluid intake records identified documented meal fluid intake and corresponding urine output; however, the documented amounts were not totaled, compared, or otherwise assessed to determine whether R1 was receiving adequate hydration.6/1/26: Breakfast 8 ounces (oz) (237 mL), lunch 8 oz, and dinner 4 oz (118 mL), for a documented total of 591 mL. Fluid output was 550 mL.6/2/26: Breakfast 8 oz, lunch 8 oz, and dinner 4 oz, for a documented total of 591 mL. Fluid output was 325 mL. 6/3/26: Breakfast 4 oz, lunch 4 oz, and dinner 4 oz, for a documented total of 355 mL. Fluid output was 750 mL.R1's clinic note dated 6/9/26, identified R1 had completed course of antibiotic from hospitalization which had periods of lethargy, restlessness, and intermittent pain, along with poor oral intake and weight loss. Over subsequent weeks, symptoms stabilized and kidney function improved. Foley catheter remains in place with adequate output and no recent complications.R1's nursing assistant (NA) care sheet directed staff to offer sips of fluid with cares, encourage and assist with fluid intake and report changes.During an observation and interview on 7/16/26, at 9:09 a.m., dietary aide (DA)-A was passing water pitchers to resident rooms. DA-A stated water was passed twice a day; once on the morning shift and another time between 3:30 p.m.-7:00 p.m. DA-A stated dietary did not record fluid intake for water pitchers.During an interview on 7/16/26, at 11:52 a.m., NA-C stated R1 returned from the hospital really sick, which was why he was on comfort cares and had fluids offered every two hours. R1 did not like to drink but enjoyed thickened Coca-Cola and hot chocolate. Nursing assistants were supposed to offer small sips when they were in his room but did not have to report or document how much R1 drank. NA-C reviewed R1's Comfort Care Sheet that she explained needed to be completed every two hours. The top of the sheet had every two hours circled, and the day shift section listed handwritten times of 8:00 a.m., 10:00 a.m., 12:00 p.m., and 2:00 p.m., with no corresponding 1-4 entries documented. NA-C stated NA-B had not yet completed the sheet. NA-C stated all residents' care plans instructed staff to encourage fluids and that staff encouraged fluids while assisting residents with toileting.During an observation on 7/16/26, at 12:15 p.m., NA-C entered R1's room and asked if he wanted to get up for lunch, took him to the restroom, but NA-C did not offer R1 fluids while she was in R1's room.During an observation on 7/16/26 at 12:30 p.m., R1 was seated in a wheelchair at the dining room table with a glass of water in front of him, however, R1's wheelchair was positioned far enough from the table that he could not independently reach the glass. R1 took a sip of water from the mug that NA-C gave him. At 12:41 p.m., NA-C came back to the dining room and pushed R1 closer to the table and offered him a drink. At 12:46 p.m., licensed practical nurse (LPN)-B went to R1's table and handed R1 his mug.During an observation on 7/17/26, at 7:33 a.m., R1 was sitting in his recliner. R1's water pitcher was on the far side of the overbed table, and R1 attempted but was unable to reach it independently. At 7:42 a.m., unidentified NA offered R1 water, assisted him into his wheelchair, and transported him to the dining room for breakfast. At 7:46 a.m., R1 was seated at the dining room table without any beverages present. After R1 reached toward the table as if looking for a drink, staff provided water and hot chocolate. R1 immediately drank several sips of both beverages. At 7:52 a.m., R1 requested another glass of water. By 7:55 a.m., R1 had not yet received the requested water and continued signaling staff. Licensed practical nurse (LPN)-A subsequently provided another glass of water, which R1 immediately drank approximately half of, along with his nutritional supplement during medication pass. Staff later encouraged R1 to continue drinking, and by the end of the meal R1 had finished both glasses of water and consumed approximately one-quarter of his second cup of hot chocolate.During an interview on 7/16/26, at 10:00 a.m., NA-A stated she thought residents received new water pitchers every two hours. If a resident needed water, they would put on their call light then NAs would call for dietary to replace. NA-A explained dietary staff recorded how much fluid residents drank when they replaced the pitchers and would record meal intakes. Overnight NAs collected urine and documented the output at the end of their shift. On day shift overnight urine collection bags would be changed to leg bags; any urine output would be documented and included in the total output at the end of the shift. NA-A indicated evening shift would be the opposite of day shift- staff removed the leg bag and applied the overnight bag recording any output for end of shift totals.During an interview on 7/16/26, at 10:19 a.m., NA-B stated R1 was able to drink on his own but occasionally needed encouragement. R1 was not always a good drinker, and staff were encouraged to offer fluids every two hours; otherwise, R1 would not drink. NA-B attempted to offer R1 fluids each time she entered his room. Sometimes R1 would take only a small sip, and NA-B would encourage him to drink more. NA-B stated R1 never refused fluids. R1 had more urine output after staff encouraged fluids following his return from the hospital. NA-B was unaware of the specific amount of fluid R1 was expected to receive each day. NA-B explained water pitchers were passed by dietary on the day and evening shifts. NA-B thought fluid intake was documented by either dietary staff or nurses but stated nursing assistants did not document fluid intake in the medical record. NA-B stated catheter output was documented in the morning and at the end of the shift. NA-B reviewed the paper rounding sheet used for R1 and stated it contained a numbered system (1-4) identifying care tasks, with 4 representing drinks. NA-B stated staff marked 4 when fluids were offered but could not explain how staff would determine or document the amount of fluid R1 consumed.During an interview on 7/17/26, at 9:03 a.m., NA-D stated R1 would be able to drink by himself from his water pitcher if it wasn't full. NA-D thought a smaller pitcher would help R1 be able to drink independently.During an interview on 7/16/26, at 1:35 p.m., LPN-A stated R1 did not always accept fluids when offered and preferred hot chocolate, Coca-Cola, and chocolate nutritional supplements. LPN-A stated R1's fluid intake declined after an order dated 12/16/25 changed R1 to nectar-thick liquids, and R1 required increased encouragement to drink thereafter. Before hospitalizations nursing assistants had reported R1's urine had been dark for a long time but did not exhibit signs of a urinary tract infection, so staff generally attributed dark urine to poor fluid intake and encouraged additional fluids. After staff encouraged fluids, R1's urine output increased and appeared less concentrated. LPN-A stated R1 frequently had a dry mouth and sunken eyes. LPN-A stated that in early May 2026 R1 began experiencing problems with his Foley catheter and required multiple emergency department evaluations before ultimately being admitted to the hospital with sepsis, dehydration, and acute kidney injury. Following his hospitalization, R1 returned to the facility on comfort care but was not enrolled in hospice. R1 was asking for water more frequently than usual after returning from the hospital, which was unusual for him. Although R1 eventually returned to his baseline, he continued to require frequent encouragement to drink fluids. LPN-A stated dietary normally documented residents' fluid intake unless a resident was on strict intake and output (I&O), in which case nursing documented intake and output. R1's fluid intake was not routinely monitored by nursing because he was not on I&O except when ordered. LPN-A was unable to locate R1's registered dietitian assessment in the electronic medical record and did not know whether dietary food and fluid intake records were scanned into the record. LPN-A stated each nursing shift documented urine output for that shift; however, no one calculated or monitored R1's total urine output over a 24-hour period. If the facility was strictly monitoring I&O, staff should total both intake and output, but LPN-A had never seen a form documenting 24-hour totals for R1. After reviewing R1's urine outputs from May 1 through May 7, 2026, LPN-A stated R1 normally produced approximately 250 to 300 mL of urine per shift, and outputs of 100 to 150 mL would prompt nursing to consider reasons for the decreased output, including catheter obstruction or inadequate fluid intake. LPN-A stated catheter flushing was performed as needed based on nursing judgment, and nursing assistants were expected to report changes such as bloody urine or decreased output to nursing staff.During an interview on 7/16/26, dietary aide (DA)-B had a three-ring binder and was going table to table recording residents' food and fluid intake. DA-B was documenting fluid intake and considered one mug to equal 8 ounces (oz). If a resident drank half the mug, he recorded 4 oz. If a resident consumed two 8 oz glasses during the meal, he documented the intake as 8,8. The record documented the amount of fluid consumed but did not identify the type of fluid. DA-B stated Dietary Manager (DM)-A collected the records after meals and kept them in a large folder in her office. DA-B further stated water pitchers were not included in the recorded fluid intake when they were picked up.During an interview on 7/16/26, at 12:59 p.m., DM-A had paper that she stated were resident food/fluid intake records. DM-A collected the record and then would place the records in a file cabinet. DM-A did not normally review the amounts of food/fluid residents had each meal but would review the food/fluid intake record a week or so before the resident care conference and complete a dietary assessment. R1 was considered at-risk so fluids were encouraged but not monitored. DM-A did not have the dietician recommendation for how much fluid R1 should have in a day and was unaware how much he should have but stated she could email the registered dietician (RD)-A and get a copy. Usually, R1 just got the standard amount of beverages for meals, so he would have three 8 oz glasses at meals.During a phone interview on 7/17/26, at 10:06 a.m., RD-A stated nursing and dietary were to encourage and offer as much fluid as they could when R1 returned from the hospital. RD-A stated she did not specify in the assessment how much fluid to offer because they were thinking about hospice. RD-A stated she completed dietary assessments quarterly and with MDS's. When RD-A noticed an issue with a resident's assessment, she would notify the team (nurse, anyone who might be involved in the resident's care). RD-A stated the facility did not have a good process in place and there was a lot of work that needed to be done with coordination of dietary assessments and nursing. RD-A could not articulate why the facility did not have access to the dietary assessments she completed. RD-A was not aware of how nursing monitored fluids on R1.During an interview on 7/17/26, at 8:30 a.m., LPN-B stated she did not have access to registered dietician assessments.During a follow-up interview on 7/17/26, at 10:26 a.m., LPN-A and LPN-B were present. LPN-A and LPN-B stated they did not complete intakes on R1 so would not be able to verify if he received 1,560 mL of fluid each day. LPN-B stated the nurse would not look at intakes unless it was ordered. R1 had an order when he returned from the hospital, but that was discontinued on 5/12/26, because R1 was on comfort cares, so no need to monitor. Comfort care meant the staff were to keep the residents comfortable and included being pain free, repositioning, not having skin breakdown. Staff would still do cares and treatments on residents, including providing fluids and medications. Nurses would notify families if residents were not doing good so they could decide if they wanted hospitalization or to remain at facility. R1 slowly improved and returned to baseline a few weeks after being back at the facility.During an interview on 7/17/26, at 11:15 a.m., director of nursing (DON) stated she expected staff to offer fluids to R1 when he was awake. However, she would not expect staff to wake him up during the night unless there was an order that specifically said to wake R1 up and offer fluids. DON thought if it was a critical situation the ED would have hospitalized R1 to give IV fluids. DON stated R1 did have lower urinary outputs in the beginning of May as she reviewed them but recently they were 900-1,000 mL/day. Currently, no one monitored the 24-hour outputs, but DON stated it would make sense to monitor them. DM-A monitored fluid intakes, and if she noticed an issue, she would bring to interdisciplinary (IDT) meeting. Currently, the monitoring is all done on paper by the dietary department and not available on the computer. DON could not articulate how the fluid intake was monitored on the weekends or when DM-A was out of the office. R1 had the best fluid intake in the morning and by supper it was like a rock and a hard place, some days better than others. DON stated R1 should have had strict I & O started after he returned to his baseline to monitor dehydration.During a phone interview on 7/17/26, at 1:09 p.m., medical doctor (MD)-A stated dehydration could cause acute kidney injury and harm. Those two diagnoses indicate that fluids were not offered enough and R1 got dry. MD-A would expect the facility to monitor the 24-hour urine output, and if they did not, nurses should at least review the previous 2-3 shifts nurse's notes and put a nursing order in to increase fluids and notify the provider. MD-A hoped that an experienced nurse would look at a foley bag, notice the contents were dark, and pass on the information to monitor. The facility Encouraging and Restricting Fluids policy dated 10/2010, identified the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Document any evidence of dehydration such as weight loss, confusion, drowsiness, dry skin etc.The facility Output Measuring policy dated 10/2010, identified the purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period.The facility Intake, Measuring, and Recording policy dated 10/2010, identified the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period. A Table identified Resident served 8 oz glass of water + 240 mL, leftover fluid 3 oz = 90 mL, total liquid consumed 5 oz = 150 mL.The facility Resident Hydration and Prevention of Dehydration policy dated 10/2017, identified the facility would strive to provide adequate hydration and to prevent and treat dehydration.The dietitian will assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need.Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current standards of practice.Physician orders to limit fluids will take priority over calculated fluid needs. The dietitian may refer calculated needs to the physician if restrictions potentially increase risk for dehydration.The dietitian and nursing staff will educate the resident and family regarding hydration and preventing dehydration.Nurses will assess for signs and symptoms of dehydration during daily care.Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care.Intake will be documented in the medical records.Dietary will report intake of less than 1200ml/day to nursing staff.If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan.ADL status, diagnosis, individual preferences, habits, and cognitive and medical status will be considered in all interventions.The physician will be notified.Orders may be written for extra fluids to be encouraged between meals and/or with medication passes.A specific minimum amount should be included in the order (e.g. 240ml fluids BID with medication pass). Force fluids is not an appropriate order. Encourage fluids is not an adequate order.The dietitian, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. Orders for medications that may exacerbate dehydration (e.g., diuretics) will be reviewed and held if medically appropriate.Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration.If laboratory results are consistent with actual dehydration, the physician may initiate IV hydration. Hospitalization will be recommended, as necessary.Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. The interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved.

Based on observation, interview and record review the facility failed to complete hand hygiene for 1 of 1 resident (R1) who was observed for quality of care.Findings include:R1's face sheet identified diagnoses of hemiplegia and hemiparesis (mild to moderate weakness) affecting left non-dominant side. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had a urinary indwelling catheter, was frequently incontinent of bowels and required substantial/maximum assistance from staff for toileting hygiene. During an observation on 7/16/26 at 12:04 p.m., R1 was in his room sitting in his recliner. At 12:15 p.m., nursing assistant (NA)-C entered the room to prepare R1 for lunch. NA-C transferred R1 to his wheelchair, wheeled him into the bathroom, and donned gloves without first performing hand hygiene. NA-C lowered R1's pants and brief, removed the soiled brief, and placed it in the trash receptacle. Without removing her gloves or performing hand hygiene, NA-C handled and applied a clean brief to R1 while R1 remained seated on the toilet. R1 then stood, and NA-C wiped R1's buttocks. When the wipe was removed from R1's rectal area, brown-colored stool was observed on the wipe. NA-C discarded the wipe in the trash receptacle; however, without removing her contaminated gloves or performing hand hygiene, NA-C pulled up R1's clean brief and pants, tied R1's pants, touched the arm of the wheelchair, placed a gloved hand on R1's gait belt, released the wheelchair brakes, propelled R1 out of the bathroom, and removed the gait belt. NA-C then removed her gloves, removed the garbage bag from the trash receptacle, placed a new liner in the receptacle, took the garbage bag down the hall to a garbage bin, discarded it, and performed hand hygieneA phone call was placed to NA-C on 7/17/26, at 1:55 p.m. with no return call. During an interview on 7/17/26, at 1:33 p.m., NA-E stated she would usually perform hand hygiene between glove changes. NA-E would put on gloves prior to taking a resident to the bathroom, remove her gloves after touching soiled products, perform hand hygiene, and then put on clean gloves. During an interview on 7/17/26, at 1:41 p.m., infection preventionist (IP)-A stated staff had recently completed education on perineal care and hand hygiene. IP-A stated staff were expected to remove soiled gloves, perform hand hygiene, and don clean gloves when providing resident care in accordance with the facility's infection control policies and procedures. The facility Handwashing/Hand Hygiene policy, revised 9/28/23, included, but was not limited to, the following directions for staff:Hand hygiene is the primary means to prevent the spread of infections.Personnel shall follow handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.Perform hand hygiene before moving from a contaminated body site to a clean body site during resident care.Perform hand hygiene after contact with blood or body fluids.Perform hand hygiene after contact with objects in the immediate vicinity of the resident.Perform hand hygiene after removing gloves.The use of gloves does not replace handwashing/hand hygiene

Based on observation, interview, and record review, the facility failed to monitor and assess a fluid intake to ensure a physician-ordered fluid restriction was implemented as prescribed for 1 of 1 residents (R2) reviewed for hydrationFindings include:R2's face sheet identified diagnoses of hypokalemia, hypo-osmolality and hyponatremia.R2's annual MDS dated [DATE], identified R2 had mild cognitive impairment. R2 had no difficulties with hearing, vision, or speech. R2 had a mechanically altered diet. R2 had impairment on one side of upper extremity and both sides of lower extremities. R2 used a walker and wheelchair for mobility. R2 was independent eating.R2's dehydration/fluid care plan dated 1/8/25, identified R2 had a potential for fluid volume deficit. Interventions included to observe/document/report signs/symptoms of dehydration including: decreased urine output, poor skin turgor, dry mucous membranes, confusion, hypotension, tachycardia, fever, sudden weight loss, headache, or dizziness. Updated on 3/16/26, Monitor fluid restriction per doctor order and report any concerns as needed. Encourage fluid intake, fluid restriction per order, and report changes in ability.R2's nutrition care plan dated 3/16/26, identified interventions updated on 7/6/26, to include 1,200 mL (milliliters) /24-hour fluid offer extra fluids between meals for hydration at activities, in common areas and in room. offer supplement in the form of 6 oz twice daily.R2's dehydration risk dated 7/5/26, identified a score of 10 indicating R2 was at risk for dehydration.R2's physician visit note dated 7/14/26, identified R2 was on a prescribed fluid restriction. Assessment/Plan included to continue monitoring hydration status, fluid restriction 1,200 mL/day.R2's paper Daily Fluid Intake Tracker records dated 5/1/26 through 7/6/26 identified a target fluid intake of 1,200 mL. Both the dietary and nursing Daily Fluid Intake Tracker forms included handwritten instructions of 240 mLs per meal, 180 mLs supplement twice daily, and 120 mLs total water pitcher (60 mLs twice daily). The nursing form also included the handwritten instruction, Do Not Chart Fluids Given by Dietary. The dietary form directed staff to Give to [name] Dietary Manager upon completion. Both forms included a preprinted fluid conversion reference (30 cubic centimeters [cc] = 1 ounce [oz], large glass = 8 oz, small glass = 4 oz, coffee cup = 6 oz). Neither form identified a calculated daily fluid total or documented the total amount of fluid R2 consumed each day from both nursing and dietary. There was no indication R1's fluid intake was evaluated or assessed to ensure the prescribed fluid goal of 1200 ml was met. Examples from the record included5/1/26: The nursing Daily Fluid Intake Tracker documented fluids provided during medication passes, supplements, and snack/coffee. The daily total was left blank. The documented nursing intake totaled 780 mL. A separate dietary Daily Fluid Intake Tracker documented beverages including milk, orange juice, coffee, and water. The daily total was left blank. The documented dietary intake totaled 36 ounces (oz) (1,064 mL). The documented combined nursing and dietary intake totaled 1,844 mL, which exceeded R2's prescribed 1,200 mL daily fluid restriction by 644 mL.6/13/26: The nursing Daily Fluid Intake Tracker documented fluids provided during medication passes, supplements, and free water provided at R2's request. The daily total was left blank. The documented nursing intake totaled 540 mL. A separate dietary Daily Fluid Intake Tracker documented beverages including orange juice, milk, coffee, and water. The daily total was left blank. The documented dietary intake totaled 1,320 mL. The documented combined nursing and dietary intake totaled 1,860 mL, which exceeded R2's prescribed 1,200 mL daily fluid restriction by 660 mL.6/27/26: The nursing Daily Fluid Intake Tracker documented fluids provided during medication passes, supplements, and water. The daily total was left blank. The documented nursing intake totaled 390 mL. A separate dietary Daily Fluid Intake Tracker documented beverages including orange juice, milk, coffee, and water. The daily total was left blank. The documented dietary intake totaled 1,200 mL. The documented combined nursing and dietary intake totaled 1,590 mL, which exceeded R2's prescribed 1,200 mL daily fluid restriction by 390 mL.7/6/26: The nursing Daily Fluid Intake Tracker documented fluids provided during medication passes, supplements, and water. The daily total was left blank. The documented nursing intake totaled 600 mL. A separate dietary Daily Fluid Intake Tracker documented beverages including orange juice, milk, coffee, and water. The daily total was left blank. The documented dietary intake totaled 1,200 mL. The documented combined nursing and dietary intake totaled 1,800 mL, which exceeded R2's prescribed 1,200 mL daily fluid restriction by 600 mL.Review of R2's laboratory results during June 2026 identified laboratory values relevant to monitoring R2's hydration status, including:R2's routine chemistry labs dated 6/3/26, identified blood urea nitrogen (BUN) 37 (normal 7-18), glomular filtration rate non-African American (GFR non-AA) 55 (normal 60-9999), sodium 138 (normal 136-145), B-type natriuretic peptide (BNP) 2,329 (normal 5-450). BNP was considered a critical lab result.R2's routine chemistry labs dated 6/17/26, identified BUN 31, GFR non-AA 55, sodium 135, chloride 95 (normal 98-107).R2's routine chemistry lab dated 6/24/26, identified BUN 32, GFR non-AA 53, C02 33 (normal 21-32), chloride 95, sodium 135, GFR QST 34 (normal range for > or = 90 years not established).During an observation and interview on 7/16/26, at 3:49 p.m., R2 was not in her room. R2 had a 16 oz gray water pitcher in her room and a stack of 5 oz cups on her table. Licensed practical nurse (LPN)-A came to room and observed the lid of the water pitcher to have masking tape with 4 oz written on it. LPN-A opened the water pitcher and stated it seems like more than 120 mL in the water pitcher, which would be the daily allotment. LPN-A left R2's room and called the dietary department. LPN-A stated dietary told her they used a measuring cup to fill R2's water pitcher with 60 mL both day and evening and used the big gray pitcher. LPN-A stated she could not be certain whether R2 obtained additional water from the water fountain or refilled her water pitcher from the faucet in her room.During an observation and interview on 7/17/26 at 7:34 a.m., R2 was in her room watching tv with her feet up on a chair. R2 stated she liked water and it was ridiculous not being able to have it. R2 stated the facility never gave her much water at all I take what I get. R2 stated if she asked for extra water, staff would say they were going to get her some and would not return so she would wait until they replaced it.During an observation on 7/17/26 at 8:03 a.m., R2 had wheeled to her designated spot in the dining room and drank all her fluids before her meal was brought out to her.During an observation and interview on 7/17/26, at 9:00 a.m., dietary assistant (DA)-A was passing freshwater pitchers to residents. DA-A picked up the pitcher for R2 and opened it. There was ice in it and a small amount of water. DA-A stated yesterday's water pitcher could have been full because of the ice.During an interview on 7/16/26, at 10:00 a.m., nursing assistant (NA)-A stated R2 was on fluid restrictions and only could have a certain amount each day. NA-A did not mention what R2's fluid restriction was.During an interview on 7/16/26, at 10:19 a.m., NA-B stated R2 was on a fluid restriction, but she did not know why. NAs did not have anything to do with R2's fluids, the nurses and dietary would provide R2 with all fluids; NA's would ask nursing before giving fluids to R2. R2 had a form at the desk for filling out fluid intake but NA-B thought the nurses filled it out. R2 had small 5 ounce (oz) cups in her room that she used to rinse her mouth after brushing her teeth and dietary would provide a large water pitcher twice a day. R2 had a bathroom in her room with a sink so she could fill the water pitcher or 5 oz cups, if she wanted. NA-B was unsure if R2 took the 5 oz cups herself from the water fountain dispenser or if staff gave them to her but R2 was aware she was on fluid restriction.During an interview on 7/16/26, at 1:35 p.m., licensed practical nurse (LPN)-A stated dietary documented fluid intake unless a resident was on a fluid restriction. For residents on a fluid restriction, nursing completed a daily fluid restriction form. R2 was on a 1,200 milliliter (mL)/24-hour fluid restriction for her sodium level. Nursing documented fluids provided with medication passes and supplements. LPN-A stated she attempted to use fluids provided with meals or from R2's water pitcher to administer noon and bedtime medications; however, if those fluids were unavailable, nursing would provide additional fluid and document the amount on the fluid restriction form. If R2 requested additional fluids, such as during activities, staff would provide a half cup and document the additional amount. LPN-A stated R2 usually drank her meal beverages immediately and frequently requested replacement drinks because she preferred them cold. LPN-A stated R2 appeared to be always thirsty and her family did not want staff to refuse fluids. LPN-A stated she had observed R2 obtain cups from the water fountain but had not personally observed R2 drinking from the water fountain or obtaining water from the bathroom faucet. LPN-A stated staff did not always have R2 in view and could not be certain whether R2 obtained additional fluids from those sources. Completed fluid restriction forms were given to the dietary manager (DM)-A each day; however, LPN-A was not aware of anyone reviewing the nursing and dietary records together to determine R2's total daily fluid intake or whether R2 met, exceeded, or remained below the prescribed 1,200 mL fluid restriction. LPN-A could not locate R2's registered dietitian assessment or the completed 24-hour nursing and dietary fluid intake records in the medical record.During an interview on 7/17/26 at 10:26 a.m., LPN-A and LPN-B were present at the nurse's station. LPN-B stated dietary decided what water pitcher would go in each resident's rooms. LPN-A stated there were some smaller blue mugs that dietary would pass at water pass but was not sure how it was decided which resident got which sized pitcher. LPN-A thought the large water pitchers were too big for a lot of the residents. LPN-A stated ice was considered a liquid and once melted would be considered 10 mL/2 ice cubes. LPN-B stated she would inquire with dietary about getting a smaller pitcher for R2.During an interview on 7/16/26, at 9:09 a.m., DA-A stated water pitchers were passed to residents twice a day. Dietary staff were aware of which residents were on thickened liquids and fluid restrictions. Water fountains were also available to residents to drink from when they were thirsty.During an interview on 7/16/26, at 12:54 p.m., DA-B stated they did not record the amount of fluid consumed from water pitchers except for R2, since she had a fluid restriction. The water pitchers were 16 oz.During an interview on 7/16/26, at 12:59 p.m., dietary manager (DM)-A stated R2 was on a fluid restriction due to her sodium level and was allowed 1,200 milliliters (mL) of water each day. Director of nursing (DON) and DM-A had divided up the total amount of fluids R2 could get from each department. R2 had fluids with breakfast, lunch, dinner, and water pass from dietary. Nursing had an amount they provided with medication pass which they recorded on a paper sheet and turned into DM-A each day. DM-A kept the daily totals in a soft file for R2. R2 did not ever seem to have a problem with hitting her goal intake amount. DM-A would not report R2's total fluid intake for the day to anyone or calculate the 24-hour total to identify overages or shortages. DM-A was unaware that R2 had 5 oz cups from the water fountain in her room and could not articulate if R2 drank from those during the day or from the water fountain to get extra fluid.During an interview on 7/17/26, at 11:15 a.m., DON stated dietary department decided what size water pitchers each resident had. DON was aware dietary had different sizes of water pitchers for residents. Dietary would get the totals for the fluid restriction and tally it up. It was all completed on paper. If DM-A had any concerns with fluid intake, she would bring them to the interdisciplinary (IDT) meeting. Currently no one at the facility would monitor fluid intake when DM-A was not working.The facility Encouraging and Restricting Fluids policy dated 10/2010, identified the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Document any evidence of dehydration such as weight loss, confusion, drowsiness, dry skin etc.The facility's Resident Hydration and Prevention of Dehydration policy dated 10/2017 identified the facility would strive to provide adequate hydration and prevent dehydration. The policy directed:The dietitian will assess all residents for hydration as part of the comprehensive assessment, at least quarterly and more often as necessary.Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments using current standards of practice.Physician orders restricting fluids will take priority over calculated fluid needs.Nurses will assess residents for signs and symptoms of dehydration during daily care.Fluid intake will be documented in the medical record.Dietary will report fluid intake of less than 1,200 milliliters (mL) per day to nursing.If inadequate fluid intake or signs and symptoms of dehydration are identified, intake and output monitoring will be initiated, the physician will be notified, and monitoring will be incorporated into the care plan.The dietitian, nursing staff, and physician will assess factors contributing to inadequate fluid intake.Laboratory tests may be ordered to assess hydration status when indicated.Nursing will monitor and document fluid intake, the dietitian will be kept informed of the resident's status, and the interdisciplinary team will update the care plan and document the resident's response to interventions until fluid intake and related factors are resolved.

Based on observation, interview and document review, the facility failed to ensure dish machine chemical sanitization solution was monitored to ensure dishes were properly sanitized. In addition, the facility failed to ensure temperatures were monitored in 1 of 2 kitchen freezers and 1 of 3 refrigerators (coolers). This had the potential to affect all 36 residents who resided in the facility. Findings include: Initial kitchen tour was conducted on 3/24/25 at 10:38 a.m., with cook (C-A) and dietary manager (DM)-A. Informed during the tour that the dish machine used chemicals for disinfection (low temperature dish machine). No chemical monitoring logs were visible in or around the dish machine area. Dietary aide (DA)-A was asked to provide the logs. The logs were in a binder on the other side of the kitchen. The paper logs indicated chemical monitoring was done very infrequently. A document titled Dish Machine Temperature & Sanitization Record indicated water temperature and sanitation solution was to be monitored daily with each of the three meals. Results were as follows: -- March 2025: chemical disinfectant had been tested 6 out of 69 opportunities. -- February 2025: 25 out of 84 opportunities -- January 2025: 26 out of 93 opportunities -- December 2024: 11 out of 93 opportunities -- November 2024: 1 out of 90 opportunities -- October 2024: 7 out of 90 opportunities -- September 2024: no documentation -- August 2024: no documentation -- July 2024: no documentation -- June 2024: 1 out of 90 opportunities -- May 2024: 6 out of 93 opportunities DA-A stated he was aware the disinfectant solution and temperature should be monitored and documented with each meal service, but did not have an explanation for why it had not been done. DM-A, who was new to the role, was unaware it had not been monitored. During an interview on 3/24/25 at 12:55 p.m., C-B was operating the dish machine. Using a chemical test strip, C-B tested the disinfectant solution in the dish machine, which registered at an acceptable level of 50 parts per million (PPM) and the gauge on the dish machine indicated an acceptable temperature of 128 degrees Fahrenheit (F). C-B admitted he knew the temperature and sanitizing solution should be monitored, but did not have a reason why it had not been documented. C-B acknowledged monitoring the chemical solution and temperature was important to kill bacteria on dishware. FREEZER & REFRIGERATOR TEMPERATURES During the initial kitchen tour on 3/24/25 at 10:41 a.m., C-A opened the silver 2-door freezer and couldn't find a thermometer. C-A immediately obtained a thermometer and added it to the freezer. The foods in the freezer were frozen solid to the touch. Temperature logs for the 2-door silver refrigerator and 2-door silver freezer were reviewed. The temperature log was titled [NAME] Temperature Sheet and on the bottom was a section titled Freezer and Cooler Temperatures. The last time any temperature was recorded was on 1/20/25. Temperatures at that time were in acceptable temperature ranges: Silver cooler: 36 degrees F Silver freezer: 2 degrees F During an interview on 3/25/25 at 11:11 a.m., C-A stated the morning and evening cooks were supposed to document temperatures of each refrigerator and freezer and record it. C-A stated, We just weren't doing it. C-A acknowledged food needed to be maintained at correct temperatures to prevent spoiling and foodborne illness. During an interview on 3/25/25 at 11:30 a.m., DM-A acknowledged she had just started her role and had not been aware of the lack of monitoring and would correct it right away. On 3/26/25 at 12:15 p.m., the administrator was informed of kitchen findings. Facility Cleaning Dishes/Dish Machine policy dated 2021, indicated all dishware would be cleaned, rinsed and sanitized after each use. The dish machine would be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The policy indicated for low temperature dishwasher, wash temperature should be 120 degrees F., and 50 PPM hypochlorite (bleach). Facility Dish Machine Temperature Log policy dated 2021, indicated dishwashing staff would monitor and record dish machine temperatures to assure proper sanitizing of dishes. The director of food and nutrition services would post a log near the dish machine for the staff to document temperatures. Staff would record dish machine temperatures for the wash and rinse cycles at each meal. The director of food and nutrition would spot check the log to assure temperatures were appropriate and staff were correctly monitoring dish machine temperatures. Facility Food Storage policy dated 2021, indicated food would be stored at appropriate temperatures. Temperatures for refrigerators should be between 35 to 39 degrees F. Thermometers should be checked at least two times a day. Every refrigerator must be equipped with an internal thermometer. Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times daily.

Based on observation, interview and document review the facility failed to provide timely repositioning for 1 of 1 resident (R13) who was dependent upon staff for repositioning and high risk for pressure ulcers. Findings include: R13's facesheet received 3/26/25, included diagnoses of Alzheimer's disease with early onset, osteoarthritis and spasticity (a condition with increased muscle tone, stiffness and involuntary muscle contractions). R13's quarterly (MDS) assessment dated [DATE], indicated R13 had severely impaired cognition, and no behaviors. Activities of daily living (ADL's) included R13 uses a wheelchair and is dependent on staff for transfers, bed mobility, locomotion and for eating. R13 has no current skin issues but is at high risk for development of pressure ulcer. R13 has had no recent weight loss or gain and is incontinent of bowel and bladder. R13's Braden Scale for Predicting Pressure Sore Risk dated 12/24/24, had a score of 12 indicating R13 is at risk for skin breakdown. R13's care plan dated 4/10/24, indicated R13 has a potential for impaired skin integrity and is high risk for skin breakdown with interventions including: apply ointments/medications as ordered, use pressure reducing devices (mattress on her bed and cushion in her chair), assist with hygiene and general skin care. Avoid using hot water for cleaning. Reposition every two hours while in bed and offer fluids with position changes. Monitor skin daily with cares and report changes to charge nurse. Use moisturizer with cares and keep skin clean and dry. Use mechanical lift for transfers. Use incontinence pads and barrier cream to peri area as needed. Keep linen clean, dry and wrinkle free. Reposition every hour when up in chair. Increase protein in diet as appropriate and dietary consult as needed. A provider progress note dated 3/20/24, indicated R13 had a stage 2 pressure injury (open wound that affects both the top and bottom layers of the skin) of sacral region (large triangular bone at the base of the spine). The open area on left sacrum was 1.8 centimeter (cm) x 1 cm x 0.2 cm. Adjacent to this wound is a pinpoint open area. Drainage is minimal and green. Edges are well defined and slightly macerated (skin is soft, wet or soggy to the touch and can delay wound healing). Right sacrum 1.2 cm x 0.2 cm x 0.1 cm think slit. No drainage and no odor. Will change treatment to cleansing with acetic acid 0.25%, skin prep to the intact periwound skin, applying calcium alginate AG (wound dressing that can absorb large amounts of exudate and has antimicrobial properties) to the wound bed and cover with a gentle adhesive foam dressing changing every other day or sooner if needed. Patient does rely on nursing staff for her repositioning and toileting needs. She does not have an air mattress on her bed at this time as she has a lip mattress. Staff are looking at options to apply an air overlay. Review of Skin Problems notes: 3/13/25: Right buttock skin is intact and within normal limits. Left buttock abrasion, scant drainage present, wound bed is 100% red, granulating tissue measuring 1.2 cm x 0.8 cm by 0.2 cm. Macerated tissue measuring 0.2 cm by 0.2 cm. Provider notified. 3/14/25: Abrasion to the left buttock continues to be open with a small 0.3 cm by 0.5 cm abrasion right below the current abrasion. 3/15/25: Abrasions x 2 to left buttock area. Area cleansed and dressing applied as ordered. Right buttock skin starting to slough, at this time is not open and cream was applied. 3/19/25: Dressing change to abraised [sic] tissue to left inner buttock completed. Small abraised [sic] tissue noted on 3/14/25 below current abraised [sic] site remains apparent. Also has abraised [sic] tissue to right inner buttock measuring approximately 0.2 cm x 0.2 cm. Physician notified of changes. 3/20/25: See provider note (above). 3/22/25: Left and right inner buttock/sacrum; previous dressing soiled and removed to be changed. Moderate purulent drainage present on dressing. Wound appears light red, granulating tissue present. On observation 3/24/25 at 12:10 p.m., R13 was seated in her Broda (positioning chair) chair in the dining room. R13 was being assisted by staff with meal. On observation 3/25/25 at 8:44 a.m., R13 was seated in her Broda chair and was assisted from the dining room back to her room after breakfast by nursing assistant (NA)-A. At 8:45 a.m., R13 with assist from NA-A, and NA-B and a mechanical lift, was placed in her bed and positioned on her right side. NA-A and NA-B stated R13 is repositioned every two hours. NA-A and NA-B did not check R13's pad at this time. R13's bed did not have an air mattress or overlay present. Continuous observation including interviews, was started 3/25/25 at 8:45 a.m.: 9:15 a.m. R13 remains on her right side asleep. No staff into room. 9:43 a.m. R13 remains on her right side. No staff into room. 10:20 a.m. R13 remains in the same position with no staff entering the room. 10:46 a.m. R13 continues on her right side. No staff entered the room. 11:09 a.m. no change in position. Laundry staff entered room to put laundry away and activities staff changed the calendar in the room. 11:30 a.m. R13 continues on her right side. No staff into room. At 11:32 a.m. activities assistant (AA)-A looked into R13's room and stated R13 usually comes to sensory class at 11:00 a.m. but didn't come this morning. 11:38 a.m., license practical nurse (LPN)-A stated R13 was given a suppository this morning around 9:45 a.m. so they didn't get her up for sensory class. 11:54 a.m. no change in R13's position and no staff into the room. On observation and interview 3/25/25 at 12:00 p.m., NA-A and LPN-A entered the room. NA-A stated she was unsure if R13 had been repositioned since she assisted with putting her to bed as she isn't working R13's hallway. NA-A and LPN-A checked R13's pad. Stool was present and was smeared onto sacral dressing that was present on left sacral area. LPN-A after cleaning up stool, removed sacral dressing and stool was present under the dressing along with serosanguinous (bodily fluid with mixture of serum and blood) drainage. LPN-A cleansed wound with acetic acid 0.25% (antimicrobial properties) placed on a sterile 4x4 guaze pad, Xerofoam (sterile petrolatum-based gauze dressing used as a non-adherent dressing and promotes a moist wound environment) placed onto wound and covered with adhesive dressing. LPN-A measured wound on left sacral area which was 1.5 cm by 1.0 cm with a white spot present in the middle of the wound. LPN-A stated she was unsure what that was but the wound was improved from the last time she changed dressing. Right sacral area had no open area or abrasions present. LPN-A indicated the redness on both buttocks was from previous pressure sores that come and go. R13 with assist of mechanical lift and LPN-A and NA-A was placed in her chair and taken to dining room for lunch. R13's medication administration record (MAR) indicated (Dulcolax) Bisacodyl 10 mg suppository dose rectal daily as needed for constipation was given 3/25/25 at 7:52 a.m. On interview 3/25/25 at 1:10 p.m., LPN-A indicated the suppository was given earlier than she had initially thought and R13 should been respositioned every 2 hours. On interview 3/25/25 at 1:59 p.m., NA-C stated she had not laid R13 down in her bed so was not sure when she needed to be repositioned. NA-C confirmed she had not repositioned R13 at all this morning and stated she was alerted to R13 not being repositioned and staff are now using a reposition sheet. On interview 3/26/25 at 10:48 a.m., the director of nursing (DON) stated she would expect staff to reposition R13 every 2 hours as indicated by the care plan. The DON indicated she has initiated a paper form for reminders for staff to reposition R13 as she had been made aware of R13 not getting repositioned yesterday. Facility Repositioning policy dated 11/19/24, included: - Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation and providing pressure relief. -Evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals -Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. -Positioning the resident on an existing pressure ulcer should be avoided in most situations since it put additional pressure on tissue that is already compromised and may impeded healing. - A turning/repositioning scheduled includes a continuous consistent schedule for changing the residents position and realigning the body. -Residents who are in bed should be on at least an every 2 hour repositioning schedule or as determined by assessment.

Based on observation, interview and document review, the facility failed to ensure range of motion (ROM) services were provided according to the assessed need for 1 of 1 resident (R24) reviewed for positioning and mobility. Findings include: R24's facesheet printed 3/26/26, included diagnoses of heart failure, peripheral neuropathy (nerves located outside the brain and spinal cord are damaged causing weakness, numbness and pain), Parkinson's disease (progressive neurological disorder that affects movement, balance and coordination), and osteoarthritis (degenerative disease with pain and stiffness) of multiple joints. R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R24 was cognitively intact, had no behaviors including refusal of care and required assist of 1-2 staff for dressing and bed mobility and assist of 2 staff for toileting and transfers. The MDS included R24 has frequent pain which interferes with activities of daily living and rated pain at a level of 3 on scale of 1-10. R24's medications included opioid use, antidepressant, diuretic, hypoglycemic and antiplatet agent. R24's care plan last revised 2/26/25, indicated R24 had a self care deficit related to pain, decreased mobility, muscle weakness, and fatigue. Interventions included assist of 1-2 for dressing, and grooming. Toileting and transfer require assist of 2. Special directions included encourage/assist resident to complete AAROM (active assistive range of motion) with bilateral upper extremities twice a day with morning and evening cares (as tolerated/allowed by resident). May be completed when seated in wheelchair or when lying in bed. Report concerns/refusals to nurse. See therapy communication for additional information. On observation and interview 3/24/25 at 1:19 p.m., R24 stated staff don't do exercises with me at all. On the wall in R24's room, ROM exercises for elbows and shoulders was posted. R24 indicated she was in therapy and they ordered these exercises but no one ever helps her do them. R24 stated she does go to restorative nursing services one to two times per week and they help her do other exercises. R24 added she isn't able to do the exercises by herself as it is too painful to move her arms very far without some assistance from staff. R24's Rehab Communication form dated 1/6/25, by OT-C for nursing staff included Please complete AAROM to bilateral upper extremities with AM and PM cares as patient tolerates either seated in wheelchair or lying in bed. Exercises to complete are attached. R24's Occupational Therapy Discharge Summary for dates of service 12/10/24 - 1/6/25, signed by occupational therapist (OT)-C included discharge to current skilled nurse facility with bilateral upper body AAROM twice a day by nursing to shoulder flexion/extension, shoulder abduction/adduction, shoulder horizontal abduction/adduction for 10 reps per motion. Prognosis is good with consistent staff follow-through. R24's treatment records for 1/8/25 thru 3/26/25, for encourage/assist resident to complete AAROM (active assistive range of motion) with bilateral upper extremities twice a day with morning and evening cares included 3 missed out of 77 opportunities with the initials by the nurse on duty that day completing the documentation. On interview 3/25/25 at 4:47 p.m., OT-C indicated R24 was in therapy until 1/6/25. OT-C stated R24 is compromised in her shoulders and elbows and needs ROM one to two times a day to maintain her motion. OT-C indicated AAROM is short for active assistance range of motion meaning staff should be assisting her. On interview 3/25/25 at 4:52 p.m., R24 indicated no one did ROM with her today but she did attend restorative therapy. On interview 3/26/25 at 9:52 a.m., nursing assistant (NA)-D indicated NA's are responsible for doing ROM and R24 does her ROM exercises on her own. NA-D indicated they do not document if ROM is done or if resident refuses. On interview 3/26/25 at 9:54 a.m., NA-B indicated R24 does her ROM exercises on her own. NA-B added we will assist if she asks for help. NA-B indicated they don't document if ROM is completed or if resident refuses. On interview 3/26/25 at 9:58 a.m., registered nurse (RN)-A stated NA's are responsible to complete ROM but R24 can do her ROM exercises on her own. When asked if staff are completing the AAROM, RN-A indicated I think she is completing them or I assume it is getting done when I document it is completed. On observation and interview 3/26/25 at 10:13 a.m., R24 was dressed and seated in her wheelchair in her room. R24 stated she needs staff to help her with her exercises and she is unable to do them without assistance. R24 demonstrated she could lift her arms approximately 2 inches without assistance and discomfort. R24 added they have done ROM on her once since January when it was ordered. R24 indicates staff never offer, never do the exercises with her when assisting her to get dressed and thinks staff just don't care. On interview 3/26/25 at 10:44 a.m., the director of nursing (DON) stated if it is on the treatment record I would expect the nurse prior to documenting completion to check with the NA's to ensure it was offered and completed or check with the resident to ensure staff are completing it. The DON indicated she would expect the NA's to be completing this with the resident per therapy recommendations. Facility Range of Motion Exercises policy dated 12/10/24, included: -Review the resident's care plan to assess for any special needs of the resident. -Be gentle with the resident and do not rush the procedure. -If the resident becomes weak, or complains of pain, cease the exercise and summon the staff/charge nurse. -Support the extremity at the joint as it is being exercised. -Move each joint through its range of motion three times unless otherwise instructed. -Move each joint gently, smoothly and slowly through it range of motion -Remember to stop an exercise before the point of pain. -Documentation should include the date and time performed, name and title of the individual who performed the procedure, the type of ROM exercise given, whether the exercise was active or passive, how long the exercise was conducted, if and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure, any problems or complaints made by the resident related to the procedure, if the resident refused the treatment, the reason why and the intervention taken. The signature and title of the person who is record this data.

Based on interview, and document review, the facility failed to ensure hydromorphone (opioid medication used to treat moderate to severe pain) was administered as prescribed for 1 of 1 resident (R7) reviewed for medication error. This deficient practice resulted in an immediate jeopardy (IJ) for R7 who received a hydromorphone (narcotic opioid) dose ten times greater than what was prescribed and required Narcan (used for the emergency treatment of known or suspected opioid overdose) administration. The IJ began on 4/16/24, at approximately 9:00 a.m. when R7 was administered hydromorphone which was ten times greater than what was prescribed. R7 had to very little to no responsiveness, eyes glossy, respiratory rate 10 breaths per minute (normal 12-20 per minute), oxygen saturations varied and dropped to 87% (normal 95% or greater) on room air. The administrator, director of nursing (DON), and registered nurse (RN)-A, consultant, were notified of IJ on 4/25/24 at 9:35 a.m. The facility had implemented corrective actions on 4/17/24, therefore the deficient practice was issued as past noncompliance. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact, required moderate staff assistance for activities of daily living. Diagnoses included heart failure, renal failure (kidney failure), polymyalgia rheumatica (inflammatory disease which results in muscle ache and stiffness in different parts of the body), and palliative care, on a scheduled pain medication regimen, received PRN (as needed) pain medications, frequent pain, moderate pain intensity, had a condition or chronic disease that may result in a life expectancy of less than 6 months, taking an opioid medication, and hospice care. A facility reported incident to the state agency (SA) dated submitted on 4/16/24 at 1:03 p.m., indicated on 4/16/24 at 9:00 a.m., R7 was given PRN Dilaudid (hydromorphone) for pain/discomfort by licensed practical nurse (LPN)-A. Nurse (LPN-A) reported she gave 2.5 ml's (milliliters) instead of the prescribed 0.25 ml's (2.5 mg) (milligrams). R7 was given Narcan to reverse the noted adverse effect. The report further indicated R7's RR (respiratory rate) decreased to 11, became glossy eyed, staring off and unresponsive after receiving incorrect dose of Dilaudid. The report indicated nurse (LPN-A) will have a medication pass audit completed today 4/16/24, to ensure she is competent in med pass including medication rights. R7's medication administration record (MAR) dated 4/1/24-4/30/24, indicated R7 on 4/16/24 had hydromorphone 10 MG/ML liquid dose ordered: (0.25 ml) by mouth every 2 hours as needed for: pain or dyspnea. R7's Individual Narcotic Record dated 4/16/24 at 9:00 a.m., indicated LPN-A documented 0.25 ml of hydromorphone 10 mg/ml was removed. The Individual Narcotic Record dated 4/16/24 at 6:00 a.m., indicated 22.25 ml of hydromorphone remained and the next dose of hydromorphone was removed on 4/16/24 at 9:00 a.m., and 19.75 ml remained. The Individual Narcotic Record indicated 2.5 ml's of the hydromorphone was removed at 9:00 a.m. and had not received the 0.25 ml as the order identified, but instead received 2. 5ml (10 times more than prescribed). Medication Incident Report dated 4/16/24, indicated R7 received 2.5 mg of hydromorphone rather than 0.25 mg. LPN-A written documentation indicated Dilaudid order was 0.25 ml (2.5 mg) by mouth four times a day, drew up in 3 ml syringe, that was in med drawer, went to room administered oral meds first than liquid medications, FM-A and FM-B were in room. Hospice RN-B entered the room as finishing giving medication. RN-A came and wanted to know of any refills for hospice residents, and when checking at about 9:35 a.m. they discovered wrong dose given. RN-B informed both family member (FM)-A, FM-B vitals were obtained eyes fixed, very little to no responsiveness, eyes glossy. RN-B notified NP-C of the incident and NP-C ordered Narcan. The report further indicated Narcan was administered at 10:13 left nostril and 10:16 right nostril. R7 then started responding, talking to staff, eyes no longer glossy, taking sips of water, and talking with family member (FM)-A, FM-B, and RN-B. The incident report further indicated this error could have been prevented for the future: triple check completed and also only 1 ml syringes in cart most of all double check dose/med with another nurse. Adverse outcomes, glossy fixed eyes unresponsive, decreased respirations. N (skilled nursing) daily visit note dated 4/16/24, hospice RN-B indicated findings/plan of care changes R7 was in bed with FM-A at bedside and FM-B joined visit shortly after writer arrived. R7 was very soft spoken and responses delayed. R7 appeared more withdrawn during visit, confusion noted with conversation. R7 had more of a glossy stare today as well, pain 0/10. Med error found at approximately 9:50 a.m., when writer and LPN-A reviewed medication use and needed refills, it was found that 25 mg of hydromorphone was administered instead of the orders dose of 2.5 mg. At 9:53 a.m., telephone call to nurse practitioner (NP)-C to report medication error, and writer spoke to FM-A and FM-B regarding use of Narcan and family agreed with use. NP-C ordered Narcan, and Narcan was used from the facility E-Kit (emergency kit) medication box. Prior to the administration of Narcan, R7 was obtunded, not responding to writer, lips were cyanotic (bluish discoloration of the skin), and respiratory rate was 10/min (breaths per minute), oxygen saturations varied and dropped to 87% on room air, and placed supplemental oxygen at 2L/min. First Narcan administered and 10:13 a.m., and second dose administered into right nostril at 10:16 a.m., R7 remained lethargic and respirations 10/min after the first administration of Narcan. After second dose [Narcan], R7 was alert and very talkative. Writer also called the poison control hotline to report incident and to receive further guidance for symptoms to monitor due to the ingestion of high medication volume, and was indicated to monitor for respiratory depression. 12:50 p.m.-2:22 p.m., RN-B was with R7 to monitor symptoms and towards the end of visit R7's eyes were fluttering and she appeared tired, respirations were regular and even at 18 breaths per minute. NP-C ordered Narcan for use if respiratory repression were to redevelop and increased lorazepam to 0.5 mg every two hours. Writer reviewed with LPN on the evening shift to monitor R7 closely for respiratory depression, educated on use of the PRN Narcan if needed. On 4/23/24 at 8:15 a.m., FM-A stated herself and FM-B were in R7's room when LPN-A was observed to administer R7 her regular pain medications via a syringe in her mouth. FM-A stated R7 became really out of it after the medication administration. FM-A stated the hospice RN-B was at the facility to assess R7. FM-A stated after RN-B assessed R7, LPN-A entered the room and confirmed she gave the wrong dose of R7's pain med and gave 2.5 ml instead of 0.25 ml. FM-A stated RN-B educated family about that administration of Narcan would reverse of the effects of the high dose of the pain mediation R7 was experiencing. FM-A confirmed R7 was less alert and had decreased breathing. FM-A stated two doses of Narcan was administered nasally to R7. FM-A stated after the first dose of Narcan there was no change in R7, and then after the second dose of Narcan R7 was more alert. On 4/23/24 at 3:18 p.m. LPN-A stated prior to 4/16/24, she had not administered R7's 10 mg/1 ml of Dilaudid. LPN-A stated on 4/16/24 at approximately 9:00 a.m., she reviewed R7's Dilaudid order on the computer and label on the bottle. LPN-A stated she used the 3 ml syringe that was in the bag in the medication cart with R7's name. LPN-A confirmed she drew up 2.5 ml of hydromorphone and R7's other oral meds were crushed and mixed with pudding. LPN-B stated she entered R7's room and FM-A and FM-B were present in R7's room, and she administered R7's crushed oral pills in pudding first with water, and then administered the Dilaudid via syringe in R7's mouth. LPN-A stated the hospice RN-B entered the room during the medication administration. LPN-A confirmed she had given R7 one dose hydromorphone of 2.5 ml (25 mg), and she was unaware she made an error until 9:35 a.m., (35 minutes later) when when hospice registered nurse and LPN-A reviewed R7's medication supply and refills. LPN-A stated both her an RN-B assessed R7 and noticed eyes fixed, very little to no responsiveness, eyes glossy, respiratory rate 10 breaths per minute, oxygen saturations varied and dropped to 87% on room air. LPN-A stated RN-B contacted the hospice provider for direction and NP-C ordered Narcan. LPN-A stated she administered Narcan to R7 into each nostril three minutes apart. LPN-A stated R7 remained lethargic with respirations 10/minute after the first dose of Narcan. LPN-A stated after the second dose R7 became more alert and awake. LPN-A confirmed she read the label on the Dilaudid medication bottle incorrectly and mixed, milliliters versus milligrams and confirmed she was to have administered 0.25 ml versus the 2.5 mg. LPN -A stated after the incident the 3 ml syringes were removed from the medication cart and she will double check controlled substance medications with another nurse prior to administration of resident's medications. LPN-A confirmed she received extensive education from the DON about medication administration and the DON observed and audited her during an administration of mediations. On 4/23/24 at 3:45 p.m., the DON stated on 4/16/24 she arrived at the facility at approximately 11:00 a.m., and LPN-A informed her of the medication error with R7. The DON sated LPN-A confirmed she gave R7 2.5 ml of Dilaudid instead 0.25 ml's. The DON stated Narcan had been given to R7 to reverse the medication error and confirmed the medication error was a serious mistake. The DON stated following the medication error an investigation was immediately started, LPN-A was provided education, additional medication training and competency training. The DON stated education was completed for all nurses and trained medication aides (TMA's) on 4/17/24, on the ten rights of medication administration (right medication, dose, time, route, patient, education, documentation, right to refuse, assessment, and evaluation), education of administering mediation, adverse consequences, medication errors, and controlled substances policies. The DON confirmed a significant medication error occurred and she expected nurses and TMA's to follow give medications as ordered and ensure the label was read and the correct dose was administered to prevent any adverse effects. The DON stated the 3 ml syringe was not expected in the medication cart or used for medication administration. The DON stated the 3 ml syringes were removed and replaced with 1 ml syringes. On 4/24/24 at 4:50 p.m., during a telephone interview the facility consultant pharmacist stated R7's dose of 2.5 mg of hydromorphone was ten times the ordered dose, and could cause adverse effects such as, unresponsiveness, slowed breathing and possible death. The consultant pharmacist stated Narcan would reverse the effects of an overdose of the medication, and stated a smaller caliber syringe for medication administration would be expected when administering a concentrated dose of hydromorphone. The facility consultant pharmacist stated the nurse was expected to read the label and prepare the medication correctly. The facility consultant pharmacist stated the facility to follow physician orders and confirmed a significant medication error had occurred when R7 received 10 times the dose of hydromorphone. On 4/24/24 at 5:44 p.m., during a telephone interview NP-C stated on 4/16/24 at approximate 9:50 a.m., hospice RN-B notified her via telephone R7 had received the wrong dose of hydromorphone. RN-B described that R7 was more sleepy, glossy eyes, was still breathing, and due to observations described NP-C stated she ordered Narcan after talking to the family. NP-C stated any dose of the hydromorphone could cause decreased respirations, and stated the 2.5 ml that was administered was not the correct dose ordered. NP-C stated she was told R7 was more alert after the Narcan administration. NP-C. stated she doesn't know what would have happened if Narcan was not given, and can not speculate the outcome. On 4/25/24 at 9:47 a.m., during a telephone interview RN-B stated on 4/16/24 at approximately 9:00 a.m., she entered R7's room and LPN-A was administering R7's medications and FM-A was at bedside and FM-B entered shortly after. RN-B stated LPN-A and herself reviewed the bound narcotic log book and discussed med refills. RN-B stated when the the log book was reviewed LPN-A knew she administered too much hydromorphone. She assessed R7 who was obtunded, not responding, respirations 10/min and oxygen was at 87%. RN-B explained she then spoke to hospice NP-C and reported the med error, possible use of Narcan, and NP-C gave a verbal order to administer the Narcan. At 9:26 am., R7's respirations were 15 breaths per minutes, and between 9:53 a.m.-10:13 a.m., their respirations were 10 breaths per minute, less arousal and less awake. LPN-A administered the first dose of Narcan and R7 had continued decreased respirations and unresponsiveness, then waited 3 minutes and administered second dose of the Narcan and R7 became more alert and talkative. RN-B stated she contacted poison control and was advised to watch for respiratory depression and continue to monitor the resident. RN-B stated the label on the hydromorphone bottle was correct with 10 mg/ml and to give 0.25 ml. R7's initial hydromorphone was supplied from the local pharmacy and the concentration was 1 mg/1 ml. RN-B stated the hydromorphone R7 received after was supplied by hospice and at a higher concentration. RN-B stated she gave education to staff when a higher concentration was supplied, and a sticker was attached to the bottle and indicated higher concentration. RN-B stated at a previous visit to the facility RN-C confirmed R7 was not using 1 mg/1 ml and she educated RN-C on the 10 mg/ml with the 0.25 ml dosing. RN-B stated she would expect staff to use the 1 ml syringe that comes with the medication. RN-B confirmed the facility took action right away and removed the 3 ml syringe from the medication cart and replaced with 1 ml syringe. The facility Administering Medications policy dated 4/19, indicated: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; e. any complaints or symptoms for which the drug was administered; 29. New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. The facility Adverse Consequences and Medication Errors policy dated 2/23, indicated: 1. An adverse consequence refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. An adverse consequence may include: adverse drug/medication reaction; side effect 2. The staff and practitioner strive to minimize adverse consequences by: following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; 3. Residents receiving medication are monitored for adverse consequences. 4. Adverse consequences are promptly identified and reported. Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications errors include: wrong dose, requiring treatment with a prescription medication. resulting in cognitive deterioration or impairment, life threatening, resulting in death. 4. Medication errors are managed according to facility policy. Procedures 1. Review the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. 2. When a resident receives a new medication order, review the following: The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. 3. Evaluate the resident for possible medication-related adverse consequences when the resident has clinically significant change in condition/status, including: 4. Monitor the resident for medication-related adverse consequences w 5. In the event of a significant medication-related error or adverse consequence, take action, as necessary, to protect the resident's safety and welfare. 6. Promptly notify the provider of any significant error or adverse consequence. 7. Implemented the provider orders and monitor the resident for 24 to 72 hours, or as directed. 8. Communicate the event to the oncoming shift as needed to alert staff of the need for continued monitoring. 9. Document the following information in an incident report and in the resident's clinical record: 11. Data regarding medication adverse consequences and errors The past noncompliance IJ which began on 4/16/24, was removed as of 4/17/24, when the facility implemented corrective action which was verified through observation, interview, and document review. The plan included: -All nurses/TMA's on 4/17/24, educated on and given copy of Administering Medication, adverse consequences and medication errors, and controlled substance policies as well as educated and given a copy of the Rights of Medication Administration. -Removal of the 3 ml syringe from all medication carts and replaced with 1 ml syringe, staff education on use of the 1 ml syringe only in the medication carts -LPN-A education and medication pass audit on 4/16/24. During observation on 4/22/24, 4/23/24, and 4/24/24, six licensed nurses were observed to prepare and administer 30 medications to different residents which included narcotic suspensions, topical, eye drops, insulin, and oral medications. No errors were observed. Interviews: On 4/23/24 1:46 p.m., RN-Confirmed he received education on the ten rights of medication administration and education of 1 ml syringe use for medication administration. On 4/23/24 at 2:11 p.m., LPN-B confirmed she received education on the ten rights of medication administration and education of 1 ml syringe use for medication administration. On 4/23/24 at 3:18 p.m., LPN-A stated she received training on the ten rights of medication administration, double check of medication label, education on mg vs ml, and use of 1 ml syringe for mediation administering, and observation of mediation pass. On 4/24/24 at 6:34 p.m., LPN-E confirmed she received education on the ten rights of medication administration and education of 1 ml syringe use for medication administration. On 4/24/24 at 6:37 p.m., RN-D confirmed she received education on the ten rights of medication administration and education of 1 ml syringe use for medication administration. On 4/24/24 at 8:06 a.m., LPN-D confirmed she received education on the ten rights of medication administration and education of 1 ml syringe use for medication administration. On 4/25/ 24 at 8:15 a.m., LPN-C confirmed she received education on the ten rights of medication administration and education of 1 ml syringe use for medication administration.

Based on observation, interview and document review, the facility failed to ensure hand hygiene was maintained during cares for 1 of 1 resident (R1) observed during personal cares. Findings include: During on observation on 9/25/23, at 9:50 a.m. hospice registered nurse (HRN) was in R1's room with R1 and had brought in a full body lift. HRN stated she was waiting for a staff member to assist her. During an observation at 9:54 a.m. HRN and nursing assistant (NA)-A assisted R1 to his bed with a full body sling. HRN and NA-A put on gloves and opened R1's brief. HRN and NA-A while wearing gloves cleaned and removed bowel movement (BM) and the soiled brief from R1's bottom. HRN removed her soiled gloves and sanitized her hands and doned new gloves. NA-A removed the soiled brief from her side of the bed and cleaned R1 from her side putting the soiled brief in the waste basket. Without removing gloves and performing hand hygiene, NA-A then assisted HRN put a clean brief on and pull up R1's pants. NA-A then removed soiled gloves and held them in her hand, while pushing the button on the bottom of R1's bed to lower the bed. NA-A then dropped the dirty gloves in the waste basket. Without providing hand hygiene NA-A grabbed pillows off R1's chair, handing one pillow to the HRN and assisted with positioning R1 by lifting and positioning his legs with his pillows. NA-A then went into the bathroom and put on new gloves without sanitizing or washing hands, pushed the button to turn off call light, grabbed the garbage out of the waste basket, replaced with a new bag, and then picked up the bag of soiled linens. NA-A then left the room with her gloves on while holding the soiled bags. She dropped the bags along with her soiled gloves in a container that in the hallway. NA-A then went around the corner to a sink and washed her hands. During an interview on 9/25/23, at 10:08 a.m. NA-A stated she should have washed her hands after handling the dirty brief and knew that when you remove your gloves you should wash your hands. During an interview on 9/25/23, at 4:45 p.m. DON stated it would be an expectation that all staff are trained on and should follow the hand hygiene policy. Facility policy, Handwashing/ Hand Hygiene, revised 10/2018, identified the facility considers hand hygiene the primary means to prevent the spread of infections. Policy implementation included washing/Alcohol-Based Sanitizer; immediately before and after touching a resident, before performing any non-invasive procedures, before moving from a contaminated site to a clean body site during resident care, after contact with residents' skin, after contact with blood or bodily fluids, after contact with objects (e.g., medical equipment in the immediate vicinity of the resident; after removing gloves. The use of gloves does not replace hand washing/hand hygiene.

Living meadows F609 Based on observation, interview and document review, the facility failed to immediately report allegations of verbal abuse to the State agency (SA) for 1 of 1 resident (R1) who reported allegations of physical abuse while in the facility. Findings include: Facility Reported Incident (FRI), submitted to the stated agency (SA) on 9/7/23 at 5:32 p.m. identified the allegation type as physical abuse. R1 was sent to emergency department (ED) for evaluation of sudden onset of right-sided pain, shortness of breath, and blood in urine. R1 had reported to his family member in ED that he had was thrown on the toilet last night by a black male. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment. R1 was dependent on staff to assist with bed mobility, transfers, dressing, toilet use and personal hygiene. MDS also indicated R1 was able to make self-understood, was able to understand others, had no behaviors, did not have delusions or hallucinations, and had no rejections of cares. During an interview on 9/25/23, at 1:09 p.m. R1 stated he didn't want to forget what happened to him. R1 did not verbalize what had happened or when it had happened. During an interview on 9/25/23, at 2:35 p.m. NA-B stated she had taken care of R1 on 9/7/23. NA-B stated R1 had told her after breakfast a black man had broken his ribs. NA-B informed licensed practical nurse (LPN)-A and registered nurse (RN)-A of the statement immediately around 9:00 a.m. NA-B stated RN-A had provided pain medicine to R1 after he had been informed of R1's pain and stated he would check on how R1 was doing later. NA-B stated she was concerned with the allegations and between 11:00 and 11:30 a.m. had R1 repeat the allegation with RN-A in the room with her so he could hear it directly from R1. During an interview on 9/25/23, at 12:06 p.m. RN-A stated NA-B had informed him R1 stated the black male nurse on overnight had hit him or broken his ribs. RN-A said he believed NA-B had reported to him around 11:00 a.m. on the day he had sent R1 into the hospital but was unable to recall exact date. RN-A stated he had instructed NA-B to notify CM-A of the allegation. During an interview on 9/25/23, at 11:23 a.m. clinical manager (CM)-A stated RN-A came to her on the morning of 9/7/23 around 11:30 a.m. and reported R1 was in pain, having trouble breathing and was being sent to ED by ambulance. CM-A indicated NA-A had reported R1 made the statement the black nurse broke my ribs around 12:45 p.m. after reporting the allegation to RN-B and licensed practical nurse (LPN)-A. CM-A stated she did not report the allegations to SA until after she had spoken to R1's family member (FM)-A who reported R1 had alleged a male black nurse had thrown R1 on the toilet that resulted in injuries of broken ribs and a pneumothorax (air around or outside the lung from chest trauma, excess pressure on the lungs or a lung disease). CM-A stated she believed she reported the allegations R1 made to SA around 4:15 p.m. on 9/7/23. CM-A stated she was aware of the facility policy that directed to report allegations of abuse immediately (within 2 hours). During an interview on 9/25/23, at 12:43 p.m. RN-B stated CM-A had informed her of R1's allegations. RN-B stated she did not hear anything more until around 4:00 p.m. when R1's family member called and reported the same allegations and R1's injuries. RN-B stated after the phone call she had assisted CM-A with the investigation and the report to SA around 4:15 p.m. RN-B stated her, and CM-A initially didn't think it was abuse because the statement seemed so vague. During an interview on 9/25/23, at 2:01 p.m. FM-A stated when R1 was asked in the ER what had happened he had stated the person taking care of him the night before had thrown him on the toilet. FM-A stated the doctors informed her that the injuries R1 had could not have been from a previous fall and would have had to recently have happened. Facility policy, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator or DON/supervisor who will then report to administrator and to other officials according to state law. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observation, interview and document review, the facility failed to ensure dishwashing sanitization for 1 of 1 dishwashing machine and 1 of 1 three-compartment sink was appropriately monitored. Findings include: During an interview and observation on 6/26/23 at 11:30 a.m., dietary manager (DM)-A stated the kitchen had been without hot water for two days (since Saturday 6/24/23) and the plumber had been there to fix the problem. DM-A stated in the meantime the kitchen was using disposable dishes, tableware and cups for residents, and staff were cleaning and disinfecting cookware in the three-compartment sink. Dietary supervisor (DS)-B was observed standing at the three-compartment sink washing a large pot in the first sink. DS-B stated they were using Dawn brand dish soap because the automatic detergent dispenser had not been working. DS-B did not know what the temperature of the water in the first sink should be, but DM-A stated they had been boiling water to put in the sink. DM-A did not know the required temperature of the water in the second sink. In addition to not knowing the required temperatures, DM-A stated they did not have a way to measure the temperature of the water in the three-compartment sink. No guidelines were observed near the three-compartment sink for staff to refer to for guidance. Furthermore, DM-A admitted staff had not been testing the concentration of the disinfectant in the third sink. The facility policy on the three-compartment sink was requested. Policy provided by DM-A: --Cleaning Dishes - Manual Dishwashing (three-compartment sink) dated 2013, indicated dishes and cookware were to be washed after each meal to ensure dishes were clean and sanitary. SINK 1: Wash. Wash dishes in detergent and warm water to remove soil. Water should be about 120 to 125 degrees Fahrenheit (F). SINK 2: Rinse. Rinse dishes in clean, warm water. Prepare the sink with hot water 120-140 degrees F. SINK 3: Sanitize: Measure the appropriate amount of sanitizing chemical into the appropriate amount of water (following manufacturers guidelines). Test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure appropriate level. When quaternary ammonium was used, the sanitizing solution when tested was to be 150 to 200 PPM (parts per million). During an interview and observation on 6/28/23 at 11:15 a.m., vendor representative (VR)-C, stated he was present to perform monthly preventative maintenance on the dish washing machine. VR-C stated he also maintained the three-compartment sink and had noticed the foot valve for sink #1's detergent had not been putting out soap and therefore repaired it. During an interview and observation on 6/28/23 at 11:22 a.m., dietary aide (DA)-A stated dishes in the dish washing machine were sanitized with a chemical sanitizer. DA-A stated the hot water problem had been fixed and the dish washing machine had hot water again. DA-A ran a load of dishes through the dish washing machine and tested the sanitizer water solution with a test strip. The strip read at the appropriate concentration according to manufacturer's instruction. DA-A then recorded the concentration on a paper log titled Dish Machine Temperature and Sanitizer Record. Many blank spaces were observed on the log indicating monitoring had not been done consistently. A copy of the June 2023 Dishmachine Temperature and Sanitizer Record was provided by DM-A. The log indicated temperature and sanitizer solution was to be checked at breakfast, dinner, and supper. Documentation of monitoring the water temperature and concentration of sanitizer solution showed lack of monitoring on the following dates and mealtimes: 6/1/23 - supper 6/2/23 - supper 6/3/23 - 6/5/23 - breakfast, dinner, supper 6/6/23 - supper 6/7/23 - supper 6/9/23 - breakfast and dinner 6/10/23 - breakfast, dinner, supper 6/12/23 - supper 6/14/23 - supper 6/16/23 - supper 6/17/23 - supper 6/18/23 - breakfast, dinner, supper 6/19/23 - supper 6/21/23 - supper 6/23/23 - breakfast, dinner, supper 6/24/23 - breakfast, dinner, supper During an interview on 6/28/23 at 11:11 a.m., findings related to the use of the three-compartment sink and the monitoring of the dishmachine had been reviewed with DM-A. DM-A acknowledged the findings were accurate. DM-A stated the three-compartment sink had rarely been used and therefore staff did not know how to use it when they had to switch over to the three-compartment sink. DM-A admitted there were no reference materials readily available to guide staff through the process of using the three-compartment sink. Furthermore, DM-A was aware staff did not consistently monitor the water temperature and the concentration of the sanitizing solution of the dishmachine. DM-A acknowledged she was responsible for ensuring staff were trained and adhered to policy. DM-A stated she would utilize VR-C to provide education and re-training. On 6/28/23 at 12:03 p.m. the administrator was informed of the findings and stated he would ensure DM-A received the assistance and resources necessary to ensure regulatory compliance. Facility policy titled Cleaning Dishes - Manual Dishwashing (three-compartment sink) dated 2013, indicated dishes and cookware were to be washed after each meal to ensure dishes were clean and sanitary. SINK 1: Wash. Wash dishes in detergent and warm water to remove soil. Water should be about 120 to 125 degrees Fahrenheit (F). SINK 2: Rinse. Rinse dishes in clean, warm water. Prepare the sink with hot water 120-140 degrees F. SINK 3: Sanitize: Measure the appropriate amount of sanitizing chemical into the appropriate amount of water (following manufacturers guidelines). Test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure appropriate level. When quaternary ammonium was used, the sanitizing solution when tested was to be 150 to 200 PPM (parts per million) Facility policy titled Sanitization of Dishes/Dish Machine dated 2013 indicated water temperature and chemical parameters. The policy did not indicate the frequency of monitoring temperature and concentration of sanitizing chemical for the dishmachine.

Based on interview and document review, the facility failed to implement a bowel movement (BM) protocol for 3 of 3 residents (R13, R21, R23) reviewed for constipation. Findings include: R13's facesheet printed 6/28/23 included diagnoses of congestive heart failure, osteoarthritis, and hypertension. R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R13 had severe cognitive impairment, clear speech, was able to understand and be understood, and required extensive assistance of one staff for toileting. R13's care plan did not include constipation. R13's physician orders included: --4/13/23: Senna-S (a stimulant laxative) one tablet twice a day for constipation. --6/24/23: Docusate sodium (stool softener) one capsule twice a day as needed for constipation R13 had standing orders (written protocols nurses can complete without first obtaining a physician order) for the following medications related to constipation: --Milk of Magnesia (laxative) 30 ml (millimeters) by mouth daily as needed for constipation --Dulcolax 10 mg (milligram) suppository rectally daily as needed for constipation --Fleets enema (laxative) rectally daily as needed for constipation --MiraLAX (laxative) 17 gm daily as needed A nursing order dated 11/22/22 instructed nursing staff to ask R13 and nursing assistants (NA) about BM's, and to assure BM's were charted in the electronic medical record (EMR) every shift. If a resident had gone more than three days without a BM, staff were to follow the facility BM protocol and notify provider of concerns. A document titled Bowel Management Monitoring and Protocol Procedure dated 7/19/22 outlined the process a nurse would utilize to monitor a residents BM's and action to take when a resident had not had a BM for two and/or three days. During record review, it was noted R13 had gone periods of more than three days without documentation of a BM: 4/8/23 to 4/12/23 - four days 4/12/23 to 4/16/23 - four days 5/8/23 to 5/12/23 - four days 5/23/23 to 5/27/23 - four days 6/5/23 to 6/9/23 - four days During an interview on 6/28/23 at 8:58 a.m., licensed practical nurse (LPN)-A confirmed R13 had more than three days between bowel movements. LPN-A could not explain why nurses had not been aware and stated nurses had not been monitoring the frequency of R13's BM's. Together reviewed R13's standing orders which included a variety of medication options for constipation. LPN-A stated awarenss of the facility BM protocol but had not able to locate it. R21's facesheet printed 6/28/23, included a diagnosis of constipation. R21's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R21 was cognitively intact and required extensive assistance of one staff for toileting. R21's care plan dated 3/13/23, indicated the potential for constipation due to decreased fluid intake; a goal was for no constipation, and approach was to encourage and assist with fluid intake. R21's physician orders included: --5/16/23: Senna-S one tablet twice a day for constipation. --6/24/23: Docusate sodium one capsule twice a day as needed for constipation R21 had standing orders for the following medications related to constipation: --Milk of Magnesia 30 ml by mouth daily as needed for constipation --Dulcolax 10 mg suppository rectally daily as needed for constipation --Fleets enema rectally daily as needed for constipation --MiraLAX 17 gm daily as needed A nursing order dated 1/1/23 instructed nursing staff to ask R21 and NA's about BM's, and to assure BM's were charted in the EMR every shift. If a resident had gone more than three days without a BM, staff were to follow the facility BM protocol and notify provider of concerns. During record review, it was noted that R21 had gone for periods of more than three days without documentation of a BM: 4/7/23 to 4/14/23 - seven days 4/16/23 to 4/21/23 - five days 5/23/23 to 5/27/23 - four days 5/28/23 to 6/4/23 - seven days 6/4/23 to 6/11/23 - seven days 6/18/23 to 6/24/23 - six days During an interview on 6/27/23 at 8:54 a.m., nursing assistants (NA)-A and (NA)-B both stated NA's were responsible for documenting BM's in the EMR. NA-A looked in the EMR and stated NA's were not able to see a resident's last recorded BM and therefore did not know the length of time between BM's. During an interview on 6/27/23 at 2:55 p.m., R21 stated she had gone long periods without a BM, Oh yes, I'm on chemotherapy and it's one of the side effects. R21 could not say how many days she had gone without at BM, adding, We're working on it today. During an interview on 6/28/23 at 8:58 a.m., LPN-A confirmed R21 had gone long periods of time between some BM's. LPN-A stated R21 had often been out of facility for appointments and with family and may have had a BM off site. LPN-A stated staff were not in the habit of asking R21 when she returned if she had a BM. LPN-A acknowledged that regular BM's were important for resident well-being and comfort. The director of nursing (DON) who joined the conversation, acknowledged the BM protocol should have been readily available to nursing staff for reference and it had not. When eventually the BM protocol had been found, it had been reviewed with LPN-A who acknowledged the protocol gave clear guidance to nursing staff when a resident did not have a BM in two and/or three days. During an interview on 6/28/23 at 9:35 a.m., the DON stated it was her expectation that nurses monitor resident BM's via a BM report in the EMR. The DON stated the report displayed names of residents who had not had a BM for two and/or three days. The DON acknowledged it was possible not all nurses knew how to run the report. The DON stated it was also her expectation that nurses adhere to the BM protocol and standing orders. During an interview in 6/28/23 at 11:03 a.m., R13's and R21's nursing order instructing nurses to ask residents and NA's about BM's, and to assure BM's were charted in the EMR every shift was reviewed with registered nurse (RN)-C. RN-C stated this order was more of an FYI (for your information) and did not require documentation by a nurse, hence could be overlooked. Facility policy titled Bowel Management Monitoring and Protocol Procedure, dated 7/19/22, indicated the following: 1. Evening nurse would review the bowel movement log every evening shift. 2. Any resident who had not had a BM in two days would be placed on a list to receive a laxative, given by evening shift nurse or trained medication aide. 3. Any resident who had not had a BM in three days would be placed on a list and provided to the night shift nurse to administer a rectal suppository. If the resident had not had a BM by the end of the day shift, the day/evening nurse would repeat a rectal suppository. If the resident did not have a BM within four hours of second suppository, nurse would perform assessment of resident and notify the doctor for further intervention. 44630 R23's significant change in status Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment, required two-person physical assist with bed mobility, transfer, dressing, one-person physical assist with toilet use and personal hygiene, utilized a wheelchair, no rejected care behaviors, frequently incontinent of bowel. Diagnoses included: heart failure, hypertension, diabetes, anxiety, and depression. R23's care plan dated 6/27/23, indicated potential for alteration in bowel elimination and constipation; goal indicated: will remain free of discomfort related to constipation; approach indicated: nurse administer medications as ordered and assess for effectiveness and adverse effects per routing, if no bowel movement in 3 days follow facility protocol, nurse aide document bowel movements every shift per facility policy. Report changes in bowel pattern or consistency to nurse. Review of R23's bowel movement report indicated the following dates where more then 3 days occurred without a BM: 4/9/23 at 10:34 p.m., x1 large 4/13/23 at 1:56 p.m. continent x1 small soft (4 days later) 4/20/23 at 10:53 a.m., incontinent x1 medium loose 4/28/23 at 9:09 p.m., continent x1 medium soft (8 days later) 6/7/23 at 3:31 p.m., continent x1 medium hard 6/13/23 at 9:46 p.m., continent x1 large soft (6 days later) Review of R23's medical record did not include evidence of attempted interventions related to R23's bowel movements. On 6/26/23 at 12:57 p.m., R23 was seated in a wheelchair and indicated problems with constipation and will not have a bowel movement for over three days. On 6/28/23 at 9:30 a.m., registered nurse (RN)-A confirmed NA's and nursing charted when a resident had a bowel movement, and it was nursing's responsibility to monitor. Further, when a resident went three days without a bowel movement, staff were expected to follow the bowel protocol and initiate the bowel programs standing orders. On 6/28/23 at 9:32 am., RN-B, the nurse consultant, stated nursing was expected to monitor resident's bowels daily and follow the bowel management standing orders. RN-B confirmed resident's bowels were not monitored as expected. On 6/28/23 at 9:35 a.m., during an interview the director of nursing (DON) stated nursing was expected to monitor resident's bowel movements every shift and access the bowel report on the electronic medication record (EMR). The DON stated the bowel report on the EMR would indicate residents who have not had a bowel movement for three days. The DON stated staff were expected to follow the bowel monitoring management protocol and procedure. The DON confirmed R23 had not had a bowel movement in three days.

Based on interview and document review the facility failed to report an allegation of misappropriation of property timely (narcotic drug diversion) to the State Agency for 2 of 3 resident (R2 and R3) whose medications were diverted. Findings include: A Facility Reported Incident (FRI) submitted to the State Agency (SA) on 6/7/23 at 5:25 p.m., alleged R3's narcotic (medications used for pain control but a high risk for overdose and addiction) medications were tampered with and replaced with non-narcotic medications. Another FRI submitted to the SA on 6/7/23 at 5:40 p.m., alleged R2's narcotic medications were replaced with non-narcotic medications. Staff interviews on 6/21/23, revealed the alleged drug diversion were first identified on 6/6/23 at approximately 10:30 p.m. but not reported to the SA until 6/7/23 at 5:25 p.m. (approximately 19 hours later). During an interview on 6/21/23 at 10:55 a.m, licensed practical nurse (LPN)-A stated she worked the night shift (10:15 pm-6:45 a.m.) on 6/6/23. LPN-A explained during the shift to shift narcotic count with registered nurse (RN)-A, she noted that R2's medication package containing Oxycodone (highly addictive narcotic) had two pills that were different from the rest of the tablets in the package. The backing of the medication card in those spots had been punctured and taped over. The nurses also noted R3's medication package containing Oxycodone 5 mg had one pill that didn't look like the rest of the tablets and the backing had also been punctured and taped. LPN-A stated she reported the discrepancies to RN-B and LPN-B when they arrived for the day shift (6 a.m. to 2:30 p.m.) on 6/7/23. LPN-A indicated she had not director of nursing (DON). During an interview on 6/21/23 at 11:45 a.m., RN-B stated she worked the day shift on 6/7/23 and LPN-A reported the narcotic discrepancy and package tampering during the morning shift to shift narcotic count. RN-B stated she got busy and didn't think about it again until the evening shift to shift count with the oncoming evening nurse at approximately 2:30 p.m RN-B stated she alerted DON to the narcotic discrepancies at approximately 3:00 p.m RN-B further stated LPN-A and RN-A should have notified the DON immediately on 6/6/23, when they noticed the pills were different and the package tampered with. During an interview on 6/21/23 at 1:35 p.m., the DON stated she was notified of the alleged narcotic tampering and replacement of non-narcotic medications on 6/7/23 at 3:00 p.m. DON stated she should have been notified immediately which was 6/6/23 at approximately 10:30 p.m. to assure timely reporting to the SA and to initiate an investigation sooner. The facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating last revised 9/22, indicates . if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknowns source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or resulting in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observation, interview and document review, the facility failed to date opened containers of food stored in two kitchen refrigerators and in walk-in freezer, failed to ensure expired food and damaged containers of food were identified and removed, failed to ensure proper maintenance for structural defects of an ice maker machine. This had the potential to affect all 35 residents who were served food and beverages from the facility kitchen. Findings include: During interview and observation of kitchen on [DATE], at 12:27 p.m. with cook (C)-A, observed food items in the stand-up refrigerator, walk in refrigerator /freezer that were not dated or marked and/or were expired. C-A indicated all kitchen staff were responsible for checking food for opened dates and expiration dates, all refrigerators and freezers should be gone through daily, on weekends staff should be completing a significant walk-through of all areas. C-A indicated if any food or drink is not dated when opened, it should be removed immediately. C-A indicated all left-over prepared food and beverages when marked are good for 3 days from date opened; food prepared, dated, then frozen was good for 3 months. The follow items were observed during tour: Stand-up refrigerator: 1. Honey thickened orange juice; container approximately ,d+[DATE] full; opened date [DATE]. 2. Prunes in facility plastic container with lid on; approximately ½ full; opened, not labeled or dated. 3. Apple juice concentrate; approximately ½ full; opened, not labeled or dated. 4. Prune juice; container approximately ¾ full; opened date [DATE]. 5. Grape juice in facility plastic pitcher; not labeled or dated. Walk-in refrigerator: 1. Yoplait mountain berry, single serve; broken with yogurt leaking out of bottom onto packaging case. 2. Mandarin orange slices in clear juice in facility plastic container; approximately ½ full; not labeled or dated; sitting on top of pushcart. 3. Eggs; in plastic facility container covered with lid; approximately eight in count; had an expiration date of [DATE]; sitting on top of pushcart. 4. Tator tots in original plastic bag; approximately half full; sitting on bottom ledge of pushcart; not labeled or dated. 5. Kikkoman soy sauce (2 bottles); bottles each approximately ¾ full; open dated on [DATE] and [DATE]; sitting on top of pushcart. Walk-in freezer: 1.Pub burger patties; approximately 6 patties; noted to have ice particles on patties and bottom of Ziploc bag; expiration date [DATE]. 2. Frozen ham in plastic container and covered with plastic lid, approximately ¾ full, sitting on stain-less steel rack, noted to have ice particles covering ham and bottom of container; expiration date [DATE]. 3. Bean and ham soup, in plastic container and covered with plastic lid, approximately ½ full, sitting on stain-less steel rack, expiration date [DATE]. The following was observed in kitchen on [DATE] at approximately 11:50 a.m Walk-in refrigerator: 1. Shredded cheese in facility plastic container with lid; approximately ½ full; not labeled; expiration date on lid [DATE]; sitting on top of pushcart. 2. Swiss cheese slices in facility plastic container with lid; approximately ¼ full; not labeled; expiration date [DATE]; sitting on top of pushcart. 3. Mrs. Gerry's creamy coleslaw in original plastic container; approximately ½ full; opened date of [DATE]; sitting on top of pushcart. 4. Chicken gravy in facility plastic container with lid; approximately ½ full; sitting on stainless steel rack; expiration date [DATE]. Ice machine: Left side of lid to resident ice machine appeared to have structural defect; opening at outer side, opening above lid; flaky white debris observed above lid. As cook-A was opening lid, flaky white debris observed to fall between opening at left side of lid and onto ice in machine. During an interview, on [DATE] at 12:53 p.m., C-A indicated in discussion of improperly labeled and dated food items, as well as beverages; staff should have gone through all refrigerators and freezers to check for expired items daily, on weekends staff should have completed significant walk through of all areas to remove anything missed during daily checks during the week. When interviewed, on [DATE] at 9:50 a.m., C-A indicated since initial inspection on [DATE], kitchen staff removed all expired food and beverage items. C-A indicated when food and beverage items are delivered to facility, staff placed a date on food items to know which items are newer vs. older, as older food items are to be used up first. C-A indicated when food items were opened, staff would write open and the date, to indicate when staff needed to discard items. During an interview, on [DATE] at 9:57 a.m., C-A indicated there was a structural defect with ice machine lid that maintenance had repaired 1 week ago. C-A indicated seeing flaky white debris on top of ice machine lid, stated she would expect all staff to clean area prior to opening lid and using ice out of machine. C-A indicated believing flaky white debris being from hard water, as they had issues with hard water build-up that was fixed approximately 1 week ago; could not verify for sure that flaky white debris was indeed from hard water build-up. When interviewed, on [DATE] at 10:03 a.m., maintenance supervisor (MS)-A indicated flaky white debris on top of ice machine lid is due to hard water build-up to ice machine. MS-A indicated when shown the structural defect, opening to left side of ice machine lid, he had repaired this 1 week ago. MS-A verified left side of lid to ice machine is still in need of repair, indicated he will run plastic along ice machine edging to prevent any debris from getting into resident ice. Facility policy titled Food Storage, dated 2013, does not indicate when beverages should be discarded after opening. According to CMS guidelines, all opened containers are dated or used within 7 days in the refrigerator or according to facility policy. Facility policy title Food Storage, dated 2013, indicated leftover food should be clearly labeled and dated before being refrigerated. Leftover food should be used within 3 days or discarded. Facility policy titled, Dry Storage Area, dated 2013, indicated leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods. Facility policy titled Food Storage, dated 2013, indicated for refrigerated food storage, all foods should be checked to assure that foods (including leftovers), would be consumed by their safe use, by dates; or frozen (where applicable), or discarded. According to the United States Department of Agriculture (USDA), when refrigerated after opening, should discarded after 30 days. Facility policy titled, General Food Preparation and Handling, dated 2013, included keeping food items free of injurious organisms and substances. Section identified Equipment, located in General Food Preparation and Handling 2013 policy; all food service equipment should be cleaned, sanitized, dried, and reassembled after each use.

Based on observation, interview and document review, the facility failed to provide services to maintain range of motion (ROM) of upper extremities for 1 of 3 resident (R23) reviewed for ROM. Findings include: R23's current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R23 usually understands, has severe cognitive impairment and required extensive assistance of staff with bed mobility, locomotion, dressing, grooming and eating. R23's care plan, last revised 3/5/21, identified decreased activities of daily living (ADL's) participation. R23 required extensive assist to dependent with one to two staff with all dressing, grooming, bathing tasks, and total assist with bed mobility. R23 at times requires total assist with eating to able to eat per self, very slowly, using a plate guard, mechanical soft diet with nectar liquids. The care plan also included special directions of ROM needing to be completed to maintain strength and mobility to bilateral upper extremity weakness. ROM exercise list and instructions are in the chart. The plan of care did not include a hand splint. R38's current certified nursing assistant (CNA) card printed 3/28/22, included range of motion needs to be completed to maintain strength and mobility related to bilateral upper extremity weakness and ROM exercises are in chart. Review of the occupational therapy (OT) plan of care starting date of 9/23/21, included a treatment diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Initial assessment included partial to moderate assistance with eating with helper doing less than half the effort. Goal is for R23 to effectively reach and grasp regular sized cup, utilize bendable utensils to manage food on utensils and increase right hand grasp strength in order to manipulate small objects. Long term goal included R23 to perform self-feeding with decreased bilateral upper extremity ROM and strength for improved eating time and accuracy. Review of OT progress and discharge summary note dated 12/29/21, included R23 met several goals related to his upper extremities by increasing ROM and strength for functional use of his arms, and hands during self feeding. R23 tolerated resting hand orthotic (hand splint) during afternoon naps to prevent contracture of left hand, fingers and wrist. Using adaptive silverware and plate, R23 increased his self feeding skills to 90% independent. See recommendations for nursing restoration plan. Review of R23's medical record included pictures and explanation of exercises dated 12/28/21, by occupational therapist (OT)-F, and included elbow flexion and extension, shoulder internal and external rotation and wrist supination pronation, wrist flexion and extension and finger abduction to closed fist to be repeated 10 times, one time a day and to complete before and after left arm orthotic. A picture of ComfySplints included a picture and instructions on how to apply to left hand. A separate caregiver education sheet dated 12/28/21, signed by OT-F included passive (ROM) of shoulder abduction, shoulder external and internal rotation, shoulder flexion to be completed three times before meals. R23's medical record also included Self-Feeding Procedure dated 12/29/21, by OT-F titled discharge plans and instructions that are different than what is written on care plan, and included passive ROM to bilateral upper extremeties and to see attached instructions. Use plate with dycem (nonslip pad), plate guard, large grip left bent utensils and nosey cups placed to right side. A picture of how to set R23 plate, cups and eating utensils was included. During observation and interview on 3/28/22, at 2:29 p.m., R23 was lying in bed with his fingers folded over to his palm on both hands. R23 stated both his hands are numb and upon request was able to move fingers approximately 1/4 of an inch. R23 stated no one completes ROM on his hands, or arms and he does not wear a splint on his left hand and arm. No splint seen in room. During observation and interview on 3/29/22, at 10:01 a.m., R23 is sitting in his wheelchair with both hands on his lap, fingers curved to the palm of his hand and no splint present. R23 indicated he does not remember having a splint for his left arm and does not believe he has had any ROM done in a long time but was unable to identify time frame. R23 does not believe he has had any therapy for a long time. During observation on 3/29/22, at 12:03 p.m., R23 was sitting in his room and was assisted to the dining room by nursing assistant (NA)-B. No ROM exercises were completed prior to transfer. During observation on 3/29/22, at 12:39 p.m., R23 was seated in his wheelchair in the dining room with staff member seated with him encouraging him to eat. R23 had dycem under plate with plate having a stand up rounded plate on back, large handled utensils and cups with adaptive curve. R23 was slowly feeding himself and was able to hold utensils and grasp his glass of liquid. During interview on 3/29/22, at 2:10 p.m., NA-B indicated R23 doesn't wear a splint on either of his hands or arms. NA-B indicated she believes OT completes range of motion for R23, and that he does move his hands minimally enough to grasp his cup at meals and his adaptive silverware. NA-B indicated ROM isn't on the schedule to be completed for R23, and staff will only complete it if they have time. NA-B indicated she has never done ROM or placed or removed an arm or hand splint on R23. NA-B indicated they don't document when they do complete ROM exercises. During interview on 3/29/22, at 2:20 p.m., NA-C indicated she used to work as a restorative aide and completed ROM on R23, adding she has been pulled from restorative to work on the floor and is scheduled about 1 day per month since around June 2021 to complete restorative care. NA-C indicated R23 would not be able to do exercises without assistance, and has never seen NA's complete ROM. During interview on 3/29/22, at 3:08 p.m., RN-C indicated R23 used to have a splint, but was refusing it and doesn't remember seeing one in his room lately. RN-C indicated R23 is also supposed to get ROM to his arms and upper extremity before his meals and reminded NA-A to complete this before supper. RN-C further added R23 requires assistance with feeding frequently and is unsure if NA's are completing ROM. During interview on 3/29/22, at 3:18 p.m., NA-A indicated she does her best to complete R23's ROM but it doesn't always get done. During interview on 3/30/22, at 9:25 a.m., R23 indicated no one has done exercises on his hands or arms for a very long time. R23 added he used to wear a splint but is unsure where that is. R23 indicated he hasn't been able to feed himself much lately and would rather feed himself. R23 stated he thinks he is weaker since they don't do the exercises with him. During interview on 3/30/22, at 9:43 a.m., NA-A indicated she did not get R23's ROM completed last evening prior to the meal. During interview on 3/30/22, at 9:46 a.m., NA-B indicated she was told by trained medication aide (TMA)-A that nursing staff do not complete ROM exercises at this time. During interview on 3/30/22, at 10:09 a.m., TMA-A indicated the restorative aide is responsible for completing ROM exercises and did instruct NA-B that NA's are not responsible for completing ROM exercises. TMA-A added she has never seen a splint in R23's room. During interview on 3/30/22, at 9:54 AM registered nurse (RN)-A indicated the facility has a restorative aide who works Tuesday and Thursday's. RN-A further indicated the NA's are not responsible at this time to complete ROM exercises. RN-A did add the restorative aide does get pulled to the floor for direct patient care quite often. During interview on 3/30/22, at 10:03 a.m., OT-G indicated R23's referral was completed in December 2021 due to a decline in able to feed self and there was a different OT here at that time. OT-G did indicate R23, despite not receiving ROM or wearing his splint, is still able to feed himself the majority of the time. OT-G watched him the previous day and she did not see any decline in R23's abilities. The ROM is helpful prior to meals but three times a day is likely unrealistic. OT-G indicated once a day should be adequate. OT-G indicated she wasn't aware the ROM wasn't getting completed and R23 wasn't wearing a splint on his left hand and arm. During interview on 3/30/22, at 10:50 a.m., the director of nursing (DON) indicated they recently completed a skills fair that included a discussion on staff completing ROM as she had identified restorative services have not been getting completed as the restorative aide is now working most of the time with direct patient care. The DON added this hasn't been completely implemented yet. The DON confirmed if ROM and splint is ordered, they should both be completed. Requested ROM/Restorative policy and procedure and none was received.

Based on interview and document review, the facility failed to develop and implement a comprehensive antibiotic stewardship program with established monitoring to help reduce unnecessary antibiotic use and reduce potential drug resistance. The lack of a program had potential to affect all 47 residents residing in the facility. Findings include: During interview on 11/6/19, at 1:08 p.m., the interim director of nursing (DON) was identified as infection preventionist. The infection and antibiotic tracking logs were requested with (MONTH) and first week in (MONTH) 2019 received. The DON indicated the previous DON who was responsible for tracking antibiotic use, was not completing the tracking logs. No other evidence of monitoring for unnecessary antibiotic use was provided. The DON indicated they began using the Loeb's criteria within the last few months. The DON further indicated a flow sheet titled Antibiotic Stewardship was developed with use beginning (MONTH) 1st 2019, which includes resident name, symptoms, interventions, lab ordered, diagnostic tests ordered, antibiotic ordered, antibiotic time outs and results of time out. The DON indicated the timeouts are completed 48-72 hours on all antibiotics started on residents and includes symptoms monitoring reporting to the providers who then determine if the resident should continue on the antibiotic. The DON indicated not all providers are receptive to the antibiotic time outs but the facility plans to continue them. A policy titled Antibiotic Stewardship Program dated 11/2017 with review date of 10/2019 included: - It is the policy of Living[NAME]at[NAME]Madelia to implement and maintain an Antibiotic Stewardship Program (ASP), which will promote appropriate use of antibiotics while optimizing the treatment of [REDACTED]. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety and reducing treatment-related costs. - The Core Elements of stewardship for nursing homes are outlined by the Center for Disease Control. Living[NAME]ASP activities will, at a minimum, include those basic elements: leadership, accountability, drug expertise, and action to implement recommended policies or practices, tracking measures, reporting data, education for clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improvement.

Based on interview and document review, the facility failed to ensure consistent and comprehensive monthly surveillance data was tracked to identify trends and patterns to reduce the spread of illness and infection. This had the potential to affect all 47 residents residing in the facility, staff and visitors. Findings include: During an interview on 11/06/19, at 1:08 p.m., the interim director of nursing (DON), who was identified as infection preventionist, shared the infection tracking log, which included onset date, infection site, pathogens, risk factors, precautions/treatment and notes. The logs were completed for (MONTH) and the first week in (MONTH) only. Upon request for the previous months logs, the DON indicated the previous DON said she was using the Infection Control and Response form to document infection monitoring but was not. The DON indicated there was no evidence located the infection logs were completed prior to (MONTH) 2019. The DON confirmed most of the infection program started within the last two months including assessment and evaluation of infections, signs and symptom monitoring, and use of Loeb's criteria for infection treatment. An Infection Control Policy dated 11/2017, with review date of 10/2019, included: - The DON will act as the Infection Prevention and Control Program Coordinator (IPCPC). All communicable diseases known to residents and staff should be reported to the IPCPC for surveillance and tracking. When trends or outbreaks are noted it will be at the discretion of the IPCPC to implement further measures to prevent continued spread of said communicable disease or infection. All attempts will be made to monitor any person entering this facility for infectious diseases and prevent further spread. - Surveillance and reporting: IPCPC or designee will monitor residents and all other persons in the facility (as able), physician visit notes, nursing notes, report boards, etc for evidence of signs/symptoms of infections. Further monitoring for infection or communicable disease will be done through vital signs, system assessments, lab studies, x-ray studies, or other tests as determined per the situation. Department managers will report employees presenting with signs and symptoms of infections, employee call ins for illness/infection, or other infection control concerns to the IPCPC or designee for further instruction. IPCPC or designee will report all reportable diseases to the Minnesota Department of Health per guidelines.

Based on observation, interview and document review, the facility failed to comprehensively assess and develop interventions to promote safety with smoking for 1 of 1 residents (R44) who was smoking outside the facility. Findings include: R44's BIMS (Brief Interview Mental Status) dated 10/17/19, identified R44 had intact cognition with no mental status changes from her baseline. R44's diagnosis, signed by her physician on 10/29/19 indicated: History of disease of digestive system, nicotine dependence, and major [MEDICAL CONDITION]. On 11/5/19, at 12:46 p.m. R44 was interviewed outside the front door of the facility approximately 25 feet from the door. She was observed sitting alone, and her wheelchair was 1 foot away from a cigarette ash receptacle. R44 had a coat draped across the front of her and was facing away from the front of the building. R44 was observed to dispose of ash on the ground from her lit cigarette. Dry leaves covered the ground around the cigarette ash receptacle. While visiting with R44, ash was observed to drop off the end of the cigarette and roll across the surface of the [NAME]et laying across her. R44 stated the [NAME]et covering her belonged to her husband and stated he'd gone inside the building because he was too cold. R44's husband was observed to be sitting inside the door of the building on a bench, R44's chair was turned away from the door in a position she could not be observed while smoking. R44's care plan updated 10/17/19 did not include a plan of care to address smoking and safety. On 11/5/19 at 1:45 p.m., during an interview with the interim director of nursing (DON) she confirmed the care plan did not address R44 smoking. Further she stated, R44 does not smoke with us, we do not participate in her smoking at all, she does not have cigarettes on the property with us. Sometimes her husband comes in for a meal and he will share a cigarette with her outside. R44's minimum data set (MDS) assessment dated [DATE], indicated R44 required extensive assist of 2 for activities of daily living, and limited assistance with eating her meal. Tobacco use was not identified on the MDS. R44's medical record was reviewed and lacked any evidence R44 had been comprehensively assessed for safety with smoking despite still going outside to smoke with family; and smoking a cigarette without supervision. During an interview on 11/5/19, at 3:02 p.m. with the social service director (SSD), she indicated it was her responsibility to complete the smoking assessment for residents at the facility. She stated she was aware that R44 was smoking. The SSD stated it was her expectation that if a resident is smoking she be informed and confirmed she had not been informed. The SSD stated she would have completed the assessment for smoking, added it to the care plan, and educated the family and the resident regarding the facility's smoking policy. During an interview on 11/6/19, at 11:05 a.m. with the registered nurse (RN)-C was asked if she was aware that R44 was a smoker, and RN-C indicated she found out 2 weeks ago. I guess when her husband comes in and has lunch with her he will take her outside for a smoke. Two weeks ago she told me she was having a nicotine fit. RN-C indicated she was not aware R44 smoked until then. The facility Smoking policy dated 3/29/19 included: 2, An assessment is completed by the social services director to determine if any limitations to smoking privileges are required as it relates to safety and health precautions. 3. Any smoking related privileges, restrictions, and concerns (e.g. need for close monitoring) will be noted on the care plan and personnel caring for the resident will be informed of these issues. 5. Any resident with restricted smoking privileges requiring monitoring will have direct supervision of a staff member, family member, visitor, or volunteer at all times while smoking.

Based on interview and document review, the facility failed to ensure a transfer notice was given to 2 of 2 residents (R33, R46) upon transfer to the hospital. In addition, the facility failed to have a system in place to ensure residents were given written notices upon transfer. This deficient practice had the potential to affect all 47 residents residing in the facility. Findings include: Record review revealed R33 had been transferred to the hospital 7/13/19 via ambulance. On 7/13/19, a phone call confirmed the resident was admitted to the hospital with [REDACTED]. A form titled Notice of Voluntary Resident/Patient Transfer or Discharge was received from social services (SS)-A upon request. The form indicated the date of anticipated discharge as 7/1319, with date notice was provided as 7/13/19. Record review revealed R46 had been transferred to the hospital on [DATE]. A progress note indicated a call was received 9/19/19, indicating R46 was seen in the emergency department and admitted to the hospital on [DATE] [MEDICAL CONDITION]. No bed hold was present in the medical record. Upon request, a form titled Notice of Voluntary Resident/Patient Transfer or Discharge was received from SS-[NAME] The form indicated the date of anticipated discharge as 9/19/19, with date notice provided as 9/20/19. During interview on 11/6/19, at 09:10 a.m., the interim director of nursing (DON) indicated nursing staff notify the family member regarding the transfer to the hospital but confirmed no notice of transfer or discharge is given in writing to the resident or family member. The DON further indicated the social services director (SS)-A is responsible to notify the Ombudsman of the transfer or discharge. During an interview on 11/07/19, at 10:42 a.m., SS-A indicated only the bed hold is given to the resident. The Notice of Voluntary Resident/Patient Transfer or Discharge form goes to the Ombudsman. SS-A confirmed no notice of transfer or discharge is given in writing to the resident or family member. A policy titled Transfers and Discharges From Facility, dated 10/1/18, included: - Residents will not be arbitrarily transferred or discharged from the facility or to another room without notification. - Residents will be notified in writing of the proposed discharge and its reason no later than 30-days before the discharge. The notice will include the discharge location. - The notice will provide information on how to contest the discharge action with the address and telephone number of the area Ombudsman. - The notice period may be shortened in situations outside the facility's control such as .a change in the resident's medical/treatment program. A Bed Hold Notice will be completed when transferring a resident to a hospital or for therapeutic leave.

Based on interview and document review, the facility failed to ensure allegations of resident to resident abuse were reported in a timely manner to the State agency (SA) for 2 of 3 residents (R1, R2) reviewed for potential abuse. Findings include: Review of an initial incident report submitted to the SA on 2/13/19 at 10:06 a.m., indicated on 2/12/19 at 9:00 a.m., R1 was in the hallway by R2. A nursing assistant (NA) saw R1 grabbing at R2's groin area with his hand. The NA pulled R2 away from R1. The NA explained to R1 that his behavior was not appropriate. R1 then attempted to touch the NA's buttock, the NA further expressed to R1 that this was also not appropriate. R1 appeared to not have empathy over the situations as he was laughing and blowing kisses to the NA when explained about his behaviors. Although R1 was observed exhibiting sexually inappropriate behavior towards R2, the SA was not informed until 25 hours later. Review of an initial incident report submitted to the SA on 3/13/19 at 17:50 (5:50 p.m.), indicated staff witnessed R1 propel his wheelchair over to R2 who was also in a wheelchair. R1 had his hands on R2's breast over the shirt so was not touching the resident's skin. When staff attempted to redirect R1 he began laughing and then attempted to touch the TMA's (trained medication aide) breast. R1 was redirected and the residents were separated. Later in the afternoon, staff witnessed that R1 had grabbed R2's bilateral arms and was shaking her. The residents were separated and R1 was redirected away from R2. R2 was noted to be sobbing after the incident; staff were able to redirect her and she calmed. Although R1 was observed to exhibit sexual/physical inappropriate behavior towards R2, the SA was not informed until 29 hours later. When interviewed on 3/14/19, at 3:48 p.m. the social worker (SW) stated incidents of abuse were to be reported within 24 hours. If an incident happened on the weekend the charge nurse was to notify the administrator; they have a login on the VA reporting website to complete the initial incident report. SW further stated at the nurses meeting today they were reminded where the binder was at each nursing station with instructions for logging into the site and completing the incident report. When interviewed on 3/15/19, at 9:00 a.m. licensed practical nurse (LPN)-B stated if there was a resident to resident altercation, be it physical, verbal, or sexual, would first separate the residents and distance them, assess and make sure the residents were ok, then notify the family, physician, and the director of nursing (DON) and/or assistant director of nursing (ADON). LPN-B further stated she was not responsible for reporting incidents to the state agency. When interviewed on 3/15/19, at 9:15 a.m. registered nurse (RN)-B stated if there was an altercation between two residents would first separate the residents and make sure both were ok, assess for injuries, and attempt to interview each of the residents and any staff that may have witnessed the incident or seen the residents prior to the incident happening. RN-B further stated would notify each resident's family, the physician, and also the DON or ADON (if DON not reachable) should the incident happen during the evening or on the weekend. RN-B confirmed resident to resident altercations should be reported to the state agency. RN-B confirmed she had not been responsible for submitting reports of abuse to the state agency and would want the support of the administrator or DON/social services if she were to submit a report. RN-B confirmed the administrative staff, either the administrator or social worker, had been taking responsibility for reporting incidents of abuse to the state agency. RN-B stated yesterday (3/14/19) there had been a staff meeting with in depth discussion related to chain of command and responsibility related to reporting incidents to the SA. When interviewed on 3/15/19, at 9:17 a.m. the administrator confirmed there had been a delay in facility reporting of abuse incidents. Administrator stated she was trying to get to the bottom of WHY the nurses were not following through with reporting even though they had access to the NHIR (Nursing Home Incident Reporting) for a long time. Administrator further stated having a meeting yesterday (3/14/19) with staff which included education on incident reporting. The policy titled Reporting of Maltreatment of [REDACTED]. Procedure 1) Employees of(NAME)Memorial Home are mandated reporters and must report any situations that are defined as abuse, neglect, or injuries of unknown origin to the Nurse-in-Charge. 2) Ensure that any potential for abuse is eliminated. If this is staff to resident abuse, the staff person will be instructed not to provide further care to the resident and may be suspended from his/her duties until the incident can be further investigated. If this is resident to resident abuse, the abused resident will be removed to a safe environment and the perpetrator may need to be removed to his/her room or a safe environment. Short-term separation of the perpetrator from any other residents may be necessary if he/she poses a threat to the safety and welfare of other residents. The Nurse-in-Charge will document the reason for the short-term separation. a. Notify the physician as necessary. b. Notify the Administrator, Director of Nursing, and Social Services Director. c. Fill out a Resident Incident Report, noting that the type of incident is Potential Abuse, Suspected Crime. 3) Incidents that occur while the Designated Reporter (i.e. Social Services Director) is on-site, the Nurse-in-Charge shall notify the Designated reporter. The Designated reporter will: a. Report the incident electronically to the Office of Health Facility Complaints (OHFC) immediately. Print a copy of submission to OHFC. b. Notify the Madelia Police Department in cases of suspected crime (e.g. assault, sexual assault, theft, forgery, robbery, burglary, etc.) c. Notify the family of the incident. 4) Incidents that occur while the Designated Reporter is off-duty, the Nurse-in-Charge will complete the steps described in 3a through 3d.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure relieving interventions for 1 of 1 resident (R22) reviewed who had a current facility acquired stage 3 pressure ulcer. The deficient practice resulted in actual harm for R22 when a stage 2 pressure ulcer worsened to stage 3. Findings include: Review of the current facility face sheet identified R22 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. R22's admission Minimum Data Set ((MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition, extensive assistance of staff with bed mobility and transfers, did not walk and was at risk for pressure ulcers/no pressure ulcers present. The MDS also identified R22 had pressure reducing devices for bed and chair, turning/repositioning program and applications of ointments other than to feet. The Care Area Assessment (CAA) for pressure ulcers dated 9/5/18, identified R22 did not have any pressure ulcers present and was at risk for developing pressure ulcers related to requiring assist with ADL's (activities of daily living) and bed mobility as well as due to incontinence of bowel and being at risk for skin breakdown per assessment. R22 has [DIAGNOSES REDACTED]. R22's Braden (a skin assessment to determine risk for pressure ulcer) scale dated 8/24/18, identified risk factors including decreased sensory perception in fingers/toes, history of past pressure ulcers and can't raise legs in a straight position. The Braden identified a moderate risk for skin breakdown. R22 was identified as having very limited sensory perception with impairment limiting the ability to feel pain or discomfort in 1/2 of body, chairfast, moderate to maximum assistance to move, very limited mobility. The Braden scale completed 9/6/18, indicated R22 had additional risk factors including a sore present over left lateral malleolus and decreased sensory perception in fingers/toes. The Risk score was identified as mild risk for skin breakdown. Sensory perception was identified as slightly limited, can't always communicate pain or need to reposition, chairfast, and moderate to maximum assistance to move. During observation on 10/23/18, at 1:55 p.m. R22 was sitting in dining room in wheelchair (w/c) playing BINGO. R22's was observed with their feet up on a foot board, which was on bottom of her wheelchair. R22's feet were resting directly on her footrests. R22 stated, I have boots to wear when I am in the wheelchair but they don't stay on so I don't wear them. R22's left foot was rolled out and resting on the the left outer edge of the foot board and the bar for her leg rest, this area was in direct contact with the pressure ulcer on her foot. No pillows were under the feet, or protective boots to prevent pressure on the pressure ulcer site. During observation on 10/24/18, at 9:45 a.m. R22 was observed sitting in her w/c in her room. R22 stated she wore the heel boots when in bed. R22 stated she never wore foot boots at home and stated , I didn't have all this stuff at home (foot board on leg rests). They put this on shortly after I got here. R22 stated when she was at home her legs dangled when sitting in her w/c, so there was no pressure on her feet. R22 stated, I can't feel anything in my feet or legs so I don't know what is or where my foot is resting. R22 stated she wore the protective foot boots when in her bed and had feet up on a pillow when lying down. R22 stated she had never had a pressure ulcer on her foot before, and was unable to move her feet due to her diganosis of MS. R22 stated the facility was, working with my w/c company to get something that will keep my legs and feet straighter. R22 She pointed at boots on the floor in room and stated that is the best that they have for me to use here. R22 was not wearing the protective foot boots at this time, and her foot was in direct contact with the footrest. At this time, a licensed practical nurse (LPN)-B performed a treatment to the pressure area. LPN-B asked R22 several times if the treatment to her foot hurt, and R22 responded, I can't feel anything in my legs or feet. LPN-B confirmed R22's foot wound was now a stage 3 pressure ulcer. During the observation, an area was observed to the inner aspect of the right heel, which was very reddened and had a reddened, unopened area in the center. LPN-B stated R22 had this area before and it went away on its own. LPN-B called the director of nursing (DON) to room to observe area. LPN-B wrapped R22's right foot with ace wrap and put sock half way back on foot. No boots were put on R22's feet. At 10:07 p.m., R22 was observed sitting in the dayroom. The left foot (outer aspect where ulcer located) was noted to be resting on the foot board and support bar of her foot pedal. The inner aspect of R22's right foot remainded reddened in color. On 10/25/18, at 9:23 a.m., R22 was seated in her w/c in the activity room. At this time, R22 had protective boots on her feet. Review of the OT (occupational therapy) note dated 8/28/18, idenfied therapist noted R22's bilateral lower extremities (BLE) hanging off of foot rests upon approach and during evaluation. Therapies placed a footboard over leg rests to increase safety and decrease risk of pressure sores in fee and BLE. Review of the PT (physical therapy) note dated 8/28/18, idenfied consider splints for positioning of feet and ankles. OT note from 8/29/18, identified patient had both feet placed on hard surface with pressure on the sides of feet, therapist at that time added labs wool to relieve pressure,and also discussed heel float boots to reduce pressure while in wheelchair and in bed. On 9/4/18, OT note identified therapist placed more cushioned board underneath R22's feet for extra support and education R22 on letting nursing know if it feels like there is too much pressure with new set up and have them remove. On 9/4/18, PT applied lateral thigh pads positioned to reduce abduction at the hips. On 9/5/18, OT contacted R22's wheelchair company to begin process of obtaining needed wheelchair positioning. On 9/6/18, PT documented R22 reported she had a sore on left lateral ankle. PT staff informed nursing. A 9/11/18, PT note identified staff repositioned feet in neutral position on foot plates. A 9/13/18, OT noted identified wheelchair specialist met with therapist and patient to complete seating assessment and make modifications to power wheelchair. R22 was educated on utilizing tilt on wheelchair to assist with pressure relief. It was recommended R22 have angle adjustable foot plates, shoeboxes, calf panel and larger 4x8 thigh pads to maximize overall position and prevent breakdown related to pressure. Review of R22's skin condition notes dated 9/6/18, at 10:39 a.m. identified R22 had received a shower in the a.m. Staff identified a quarter sized open area with little drainage noted to right inner ankle. Area was noted to be red with [MEDICAL CONDITION] noted. A note dated 9/6/18, at 10:51 a.m. identified PT staff notified nursing that R22 had a sore present on left foot. Staff documented because R22 has MS, her feet tend to lay naturally in a relaxed, unnatural position which results in her feet having in rolled outward appearance versus natural anatomic positioning. Staff noted open sore at the location of left lateral malleolus. R22 denied bumping, catching it on something or having something occur resulting in an injury to the area, however R22 has very little feeling in her fee/lower limbs related to MS diagnosis. Area was measured and cleansed with normal saline. Skin prep was applied to the periwound area and wound was covered with protective dressing. R22's Wound care skin integrity evaluation, dated 9/6/18 identified a facility acquired, full thickness, unstageable (obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) to the left lateral malleolus. The pressure ulcer was described as 2.20 cm length by 2.10 cm width. Depth was undetermined, no tunneling or undermining was identified and drainage was serosanguinous. R22's PUSH (pressure ulcer scale for healing) was 11 (PUSH scores range from 1-17 with higher numbers being identified as worse pressure ulcers). Intervention was wound care with daily dressing change. A physician's visit record dated 9/7/18, identified stage 2 pressure ulcer left lateral ankle. Orders included increase [MEDICATION NAME] (diuretic medication) to 60 mg daily, clean wound with safe cleans or similar, apply silver [MEDICATION NAME] over wound and cover with absorbent dressing. Measure wound/change dressing daily. Follow by wound care nurse. A nurse practitioner (NP) note dated 9/12/18, idenfied ulcer to left ankle that had been evaluated, treatment to continue and see a wound nurse if wound doesn't respond to current treatment. A physician visit record dated 9/21/18, for check of left foot wound identified debridment of eschar (a piece of dead tissue that is cast off from the surface of the skin) from wound. Mild to moderate swelling over left ankle, 1.5 cm x 1.5 cm pressure ulcer on left lateral malleolus. Dry with dark colored eschar covering wound. Staff to continue with dressing changes recommended by wound care, consult wound care for re-evaluation. Little to no movement in bilateral lower extremities. Consult nutrition to see if they would recommend [MEDICATION NAME] supplementation to help with wound healing. A follow up skin note dated 9/28/18, identified pressure ulcer as being reddened with dark center and some yellow/white tissue around outer edges of wound, light to moderate drainage and 2.5 cm by 2 cm. A wound skin integrity evaluation by the wound nurse dated 10/3/18, identified stage 3 (involves the full thickness of the skin and may extend into the subcutaneous tissue layer. At this stage, there may be undermining) pressure ulcer, 2.20 cm by 2.10 cm. Prevention provided: introduced turning/positioning schedule, routine skin assessments, use of pressure reduction/relieving devices, protective dressings. Treatment intervention: cleanse site per facility protocol. Pat dry. Apply skin prep to the surrounding skin and allow it to dry. Apply calcium alginate (cut to fit) the wound bed. Cover with absorptive dressing. Apply elastic bandage from the base of the toes to just below the knee. Dressing change daily. Elastic bandage change every 23 days and as needed (PRN) for soilage. PUSH score 11. A follow up skin note dated 10/12/18, identified stage 3 pressure ulcer, 2 by 1.5. Prevention provided: turning/positioning schedule, routine skin assessments (integrity and tissue tolerance), use of pressure reduction/relieving devices, protective dressings. Wound treatment unchanged from 10/3/18. Skin note from 10/19/18, identified stage 3 pressure ulcer. Prevention provided: routine skin assessments (integrity and tissue tolerance), protective dressings. 2 cm by 1.5 cm with 0.4 cm depth. Skin note from 10/24/18, right inner ankle/heel - 3.5 by 4 cm reddened area, with a 2 cm by 2.5 cm slightly raised area inside. Area cleansed, and left open to air. R22's care plan for pressure ulcers dated updated 9/6/18, identified risk for skin breakdown. Sore present on left lateral foot. Interventions included keep heels elevated in bed, assist with positioning when in bed and in chair, avoid pressure on feet/ankles,protect feet/ankles with pillows as needed and dietary consult, provide nutritional supplement to promote wound healing as ordered. Increase protein in diet as appropriate to ensure adequate for wound healing and maximize oral intake. Monitor protein intake to ensure adequate amount for wound healing, maximize oral intake. The dietary care plan dated 9/11/18, identified potential for alteration in nutrition. Interventions included offer peanut butter at breakfast. The current NA (nursing assistant) care plan idenfied transfers with 2 assist, use hoyer lift, bed mobility with 1-2 assist, check for skin irritation around devices, position for comfort, assist with repositioning, use pillows for support, keep heels elevated in bed, avoid pressure on feet/ankles and protect fee/ankles with pillows as needed. During interview with R22 on 10/25/18, at 1:07 p.m. she stated I had those side board things in my chair tucked in the sides. They were trying to keep my legs from falling out. The guy that came for my wheel chair took them back to therapy. I haven't seen them since. He readjusted my chair and then I was lined up right. Since then I have pushed the sides of my chair back so it didn't work anymore. I have towels I could use but I don't because they push these things on my w/c back out. She stated they stay in for a little while but then they bow out again (legs). The towels don't help. The wheelchair guy was here in September. It was after I had the sore I think. He is getting me better stuff to protect my feet he called them shoe boxes. R22 stated she got the sore from the pressure of her foot resting on the board/leg rest. She stated when those side board things were in it made a difference my feet stayed on the board. She stated now my legs bow out again and my feet roll out and rest on the sides. During interview on 10/25/18, at 9:50 a.m. nursing assistant (NA)-G stated they tried those side board things in her chair a while ago but I haven't seen them for a long time. It might have been that she didn't like them. Now we put towels under her legs. They are supposed to keep her feet from rolling out. She doesn't have them in today though she told me she didn't want them. They are in the chair in her room. No towels were found in the chair in her room. During interview on 10/24/18, at 9:58 a.m. the certified dietary manager stated we usually do [MEDICATION NAME] until healed and one week post healing. She stated a dietary consult was not done when R22's pressure area was discovered and stated I will start the [MEDICATION NAME] today. During interview on 10/24/18, at 10:00 a.m the dietician stated, if a wound is a stage 2 or higher we would start the [MEDICATION NAME]. However, she stated no nutritional interventions were put into place. During interview with registered nurse (RN) -D on 10/24/18 at 1:44 p.m. she stated, We sent her to the Dr. the day after we found the pressure ulcer. The doctor said it was a stage 2 and a couple days later the wound nurse came and she called it unstageable. All of our mattresses are pressure reducing and she (R22) wears boots at night. We couldn't figure out what happened or caused it. (R22) is very delicate and can't feel her feet. During interview with the physical therapy (PT) assistant PTA-A on 10/24/18, at 1:19 p.m. she stated, OT (occupational therapy) has worked with her (R22) for positioning. They ordered some equipment that we needed a doctor's signature for. That is our foot board on her chair but I don't know for sure if the leg rests were on there before or not. During interview on 10/25/18, at 9:45 a.m. OT-A stated R22 had been admittd with her legs dangling when in the wheelchair. OT-A stated, She (R22) had foot rests however, her feet did not rest directly on the foot rests, they wer just dangling. We (OT) put everything on her chair that is on their now (footboard). When we were seeing her, we had put lateral supports in the w/c to keep her legs in (to prevent them rolling outward). However, now the supports are not in her chair nor are they in her room. The w/c guy has been here and might have taken them out, I'm not sure. Her positioning was way better when we were seeing her it was not like this (lateral foot resting on side of footboard/leg rest). OT-A further stated R22 never refused anything they suggested for her care, and was always cooperative. During interview on 10/25/18, at 12:59 p.m. RN-D stated PT had provided documented recommendations on a sheet of paper which had been put on the floor for staff. RN-D stated she did not have any recommendations in her files from OT regarding positioning for R22. RN-D stated, They (OT) did not give me anything or I would have it here. Regarding the wound RN-D stated, I would say the ulcer is probably from the pressure of her foot laying on the side of the board. During interview on 10/25/18, at 10:15 a.m. OT-A stated, Sometimes we write a note to nursing to communicate our recommendations. We are not very consistent with that. I don't think I wrote one regarding (R22's) positioning recommendations. When asked if there was no communication note how staff would know what recommendations to follow OT-A stated, Well, they would see the stuff in her room and they are pretty good about using the stuff if it's in the room. During interview on 10/25/18, at 9:30 a.m. the director of nursing (DON) stated, I saw the area the day therapy found it. It was acquired here as our initial assessment shows no open areas. The DON stated, If (R22) was supposed to have lateral supports in her chair and they were not in her room, I would expect nursing to follow up on why they are not being used. Any therapy recommendations should be on the care plan. I would agree she had pressure on her feet from them laying on the foot board and resting on the leg rest. The DON stated therapy should have sent a note to RN- D about their recommendations and what the staff were expected to do.

Based on interview and document review, facility staff failed to provide emergency care for 1 of 9 residents reviewed, (R1), who requested cardio [MEDICAL CONDITION] resuscitation (CPR) and did not receive CPR when R1's heart stopped and respirations ceased. R1 was a full code status. Harm occurred when R1 passed away. Findings include: R1's quarterly Minimum Data Set (MDS) dated (MONTH) 20, (YEAR), indicated R1 was diagnosed with [REDACTED]. R1's facility admission face sheet dated (MONTH) 15, (YEAR), indicated R1's advance directive was to do CPR. R1's Provider Orders for Life-Sustaining Treatment (POLST) indicated CPR should be performed in the event R1 had no pulse and was not breathing. The POLST was signed by R1's spouse and social worker (SW)-C on (MONTH) 15, (YEAR), and signed by the physician on (MONTH) 25, (YEAR). R1's hospital records dated (MONTH) 5, (YEAR), indicated R1 was admitted to the hospital with [REDACTED]. R1's facility admission face sheet dated (MONTH) 7, (YEAR), indicated R1's advance directive was to do CPR. R1's care plan revised on (MONTH) 8, (YEAR), included a goal for R1 to express acceptance of his family's decision for long-term nursing home placement due to difficulty caring for R1 at home. The approach indicated social services would review the resident's advance directive wishes with the family, however it did not identify what the advance directive wishes were. R1's hospital records dated (MONTH) 3, (YEAR), indicated R1 was a full code when admitted to the hospital for pneumonia and influenza A. R1's physician's progress notes dated (MONTH) 5, (YEAR), indicated the physician discussed R1's code status and the benefits and burdens of a full code status with R1's family. R1's family requested R1 remain a full code. R1 progressed through his hospital stay, and was discharge back to the facility on (MONTH) 9, (YEAR). R1's facility admission face sheet dated (MONTH) 9, (YEAR), indicated R1's advance directive was to do CPR. R1's incident report dated (MONTH) 11, (YEAR), at 7:05 p.m., indicated licensed practical nurse (LPN)-E found R1 sliding down and out of his wheelchair, so with two staff assistance R1 was lowered to the floor, assessed for injuries, and transferred to R1's bed with a hoyer lift. The incident report and nursing notes indicated R1 was monitored and vitals were stable. The physician was notified of the fall at 11:15 p.m., and family would be notified in the morning. R1's nursing progress note dated (MONTH) 12, (YEAR), at 8:46 a.m., indicated nursing assistant (NA)-I and NA-N called for LPN-E to evaluate a situation with R1. NA-I and NA-N stated they heard R1 call out for his mom, so NA-I and NA-N went to R1's room to check on him and do vitals. NA-I could not get any vitals and called for LPN-E. LPN-E told NA-I to put oxygen on R1 while LPN-E called 911, but 911 took too long to answer and LPN-E was called back to R1's room and R1 was dead. R1 had no vitals and no response to tissue touching the eye. LPN-E received a call back from 911, and LPN-E told the ambulance they were no longer needed. NA-I and NA-N cleaned the body and prepared it for family and the funeral home. At 1:04 a.m., LPN-E called R1's wife and two daughters to notify them of R1's death. The physician was notified at 1:10 a.m. of R1's death, and the funeral home removed the body at 2:50 p.m. A second R1's nursing progress note dated (MONTH) 12, (YEAR), indicated LPN-E was on the west side of the building when NA-I and NA-N called for LPN-E to evaluate R1 in his room on the east side. When LPN-E entered R1's room, NA-I informed LPN-E she was unable to get any vitals on R1. LPN-E could not get a pulse or oximeter reading on R1, so LPN-E told NA-I to put oxygen on R1 while LPN-E checked R1's chart and called 911. Before the 911 dispatcher answered the call, LPN-E was called back to the room by NA-N. LPN-E hung up the phone and returned to R1's room and pronounced R1 dead by tissue touching on the eye. As LPN-E was leaving R1's room, the 911 dispatcher was calling to follow up on the hang up call they received from the facility. LPN-E told the 911 dispatcher they were no longer needed. A 911 transcript dated (MONTH) 12, (YEAR), indicated a 911 dispatcher received a call from the facility at 00:49:30, but it was a hang up call with no one on the line. The dispatcher called back to the facility at 00:49:53 but there was no answer. The dispatcher called back a second time at 00:50:09 and after five rings LPN-E answered the phone. The dispatcher asked LPN-E if everything was okay due to the hang up call. LPN-E stated she hung up to go check on R1 and R1 was gone now. LPN-E stated she called for the ambulance, but then staff called LPN-E back into R1's room so LPN-E hung up the phone. The dispatcher asked LPN-E if she needed an ambulance and LPN-E stated, No, not anymore. The dispatcher asked, Not anymore? LPN-E stated, Nope not anymore. The call ended. R1's death certificate dated (MONTH) 15, (YEAR), indicated R1's cause of death was sudden cardiac death. When interviewed on (MONTH) 6, (YEAR), at 3:00 p.m., LPN-F stated she worked the day before R1 died , and LPN-F noted no change in condition or concerns regarding R1's medical condition during her shift. LPN-F stated if a resident was dying it was expected staff would check the resident's code status on the POLST in the residents chart, and if CPR was indicated it should be initiated while someone calls for the ambulance. When interviewed on (MONTH) 7, (YEAR), at 4:00 p.m., NA-J stated you could determine by looking at the color on the outside of a resident's chart if they are to receive CPR. NA-J stated the nurse is notified if a resident has a change of condition, and if the resident is dying in case the resident is to receive CPR. When interviewed on (MONTH) 12, (YEAR), at 3:10 p.m., NA-I stated on the night of (MONTH) 11, (YEAR), NA-I started her rounds at midnight and heard R1 call out mama. NA-I stated R1 was known for calling out mama, when calling out for his wife. NA-I checked on R1 and he was lying in bed and appeared to be sleeping. NA-I continued with her rounds, which included checking the residents' pulses. NA-I estimated it takes about 25 minutes to complete the rounds in her hallway. NA-I stated she needed to get a full set of vitals on R1, due to the incident that occurred on the earlier shift when R1 was sliding out of the wheelchair and was lowered to the floor. NA-I stated when she entered R1's room she knew immediately something was wrong and she needed to stay with R1, so she asked NA-N to get LPN-E. R1 had been breathing fine at midnight, but now R1 had his head turned to the side with one leg hanging off the bed as if he had been trying to move. NA-I stated it was obvious R1 was struggling to breath and gasping for air. R1 was very pale and his arms were heavy. R1's eyes were open but R1 had no reaction when NA-I waved her hand in front of R1's eyes and called R1's name. NA-I was unable to feel a pulse at R1's wrist and neck, and unable to get a reading on the oximeter. As NA-I attempted to put the oxygen on R1 that was in his room following his hospitalization for pneumonia, R1 took his last breath just as LPN-E entered the room. NA-I did not think LPN-E heard R1 take his last breath. LPN-E checked for a pulse and oximeter reading, and then left the room to call 911. While LPN-E was out of the room, NA-N noticed R1's skin color changing from pale to a bruising color under R1's arm. NA-I uncovered R1 and observed the skin on R1's legs changing color. NA-I stated they needed to let LPN-E know in case there was something else they could do for R1, but NA-I knew once the color change occurred there was nothing else they could do for R1. NA-I told NA-N to go tell the nurse R1 had passed away. LPN-E came back into R1's room and assessed R1, and then told NA-I and NA-N they could prepare R1 for family. When interviewed on (MONTH) 13, (YEAR), at 2:35 p.m., SW-C stated as part of the admission process she completes the POLST with the resident and/or family. SW-C provides information and educates the resident and/or family as needed about end of life options, so they can make an informed decision. The SW, resident and/or family, and physician sign the POLST, and it is kept in the front of the resident's chart. The POLST is reviewed at the quarterly care conferences and as needed. SW-C did not inform residents and families about the facility's policy to not perform CPR on a resident determined to be full code if the death was un-witnessed, as SW-C was not aware of the CPR policy. When interviewed on (MONTH) 14, (YEAR), at 9:05 a.m., LPN-E stated on (MONTH) 11, (YEAR), around 7:00 p.m., LPN-E found R1 sliding out of his wheelchair, so she called for help and with the assist of two staff R1 was lowered to the floor. LPN-E assessed R1 and there were no injuries, so the hoyer lift was used to lift R1 off the floor and place him in bed. LPN-E stated R1 did not fall, however when a resident is assisted to the floor it is considered a fall and the fall protocol is followed, including checking vitals every shift. LPN-E stated R1 was monitored after the incident, and R1 had no change of condition that evening. Sometime after midnight, LPN-E stated NA-N informed LPN-E that NA-I was unable to get vitals on R1. LPN-E was on the west side of the building and it took a couple of minutes for her to get to R1's room. Upon entering R1's room, LPN-E checked for a pulse using the oximeter and there was no pulse. LPN-E did not do any other assessments on R1 at that time, but noted his hand was warm when she applied the oximeter and there were no sounds coming from R1. LPN-E left the room to check R1's chart and call 911. R1's chart indicated R1's code status was for CPR to be attempted. LPN-E called 911, but hung up before they answered as NA-N called LPN-E back to R1's room. When LPN-E returned to R1's room, she checked R1's chest for any heart rhythm or breathing, and checked R1's eyes by touching them with a tissue and there were no reactions so LPN-E determined R1 had died . As LPN-E, left R1's room [ROOM NUMBER] called back to the facility to follow up on the hang-up call, and LPN-E told the 911 dispatcher she did not need them anymore since she determined R1 was dead. LPN-E notified the family, physician and funeral home. During the interview, LPN-E could not remember if R1's last breath was before or after she got to R1's room or when she went to call 911, but LPN-E never saw R1 breathing. LPN-E stated if R1 was breathing when NA-I and NA-N were with R1, then R1 probably should have had CPR done. LPN-E stated she thought about going back to R1's room to do CPR when she discovered R1 was a full code, and that was why she attempted to call 911 to send the ambulance; however, when NA-N called LPN-E back to R1's room he was not breathing and LPN-E determined he was dead. LPN-E stated she should have probably stayed and assessed R1 the first time she was called to R1's room, when LPN-E had tried the oximeter and touched R1 knowing he was warm, but she did not assess any further at that time. R1 was not moving and there were no vitals but she did not confirm he was dead at that time. LPN-E stated if a resident is a full code, CPR should be attempted no matter what. LPN-E stated she could not remember what the policies indicated regarding implementing CPR, and she was not aware of any chart code on the edge of the chart that identified a resident's code status. When interviewed on (MONTH) 19, (YEAR), at 11:55 a.m., LPN-G stated a resident's code status is identifiable by a band on the outside of the resident's chart, along with information inside the front of the chart. LPN-G stated R1's code status called for CPR to be done, so LPN-G would expect to do it until the ambulance arrived to take over the resuscitative efforts. When interviewed on (MONTH) 19, (YEAR), at 1:10 p.m., registered nurse (RN)-D stated signed POLSTs are kept in the front of resident's charts, and are identified on the care plans. RN-D stated if a resident were dying she would expect staff to check for the code status, and if CPR was indicated staff should initiate CPR. RN-D stated she would initiate CPR on a resident found not breathing, since you could not be sure how long the resident had not been breathing. RN-D was not sure what the facility CPR policy indicated. RN-D stated on every shift there are staff working that are trained to do CPR. When interviewed on (MONTH) 19, (YEAR), at 1:35 p.m., the director of nursing (DON) stated when she admits a resident she reviews the POLST and the CPR policy with the resident and family, so they are aware of situations where CPR may not be initiated. The DON did not know if R1's family was informed about the CPR policy. The DON stated she would expect staff to do as taught and implement the CPR policy and respond appropriately. If staff saw a resident collapse that was a full code, the DON would expect staff to initiate CPR and call 911 for the ambulance. If staff found a resident not breathing that was a full code, the DON would not expect staff to initiate CPR. The DON stated R1's nursing note indicated NA-I and NA-N told LPN-E they could not get vitals on R1. When LPN-E entered R1's room R1 did not have a pulse, therefore CPR was not started. The DON was not aware of what else happened or why LPN-E tried calling 911. The DON stated she would expect LPN-E to be competent to assess the situation, and the documentation indicated R1 was expired when LPN-E entered the room. The DON stated when staff are hired they are expected to read the facility policies, and the policies are always accessible to all staff. The DON did not know when the policies were last reviewed with staff. The facility Advance Care Planning Policy/Procedure revised (MONTH) 16, 2013, indicated each resident has the right to formulate an advance directive to ensure resident wishes are honored. If a resident's code status is determined to be full code, CPR will not be performed if death is un-witnessed. Criteria for un-witnessed death: absence of apical pulse; absence of respiration; no response to sternal rub; no corneal response. Social Services will place the proper chart code on the edge of the chart. Advance care planning documents will be reviewed quarterly at care conferences and as needed. The facility Unwitnessed Death of a Resident with an Advance Directive of CPR or no Advance Directive Policy/Procedure dated (MONTH) 2003, indicated the purpose is to honor resident/family wishes. If a resident is found expired by staff member, no CPR is initiated. If a resident is found expired and more than five minutes has passed since the resident was last witnessed to be alive, no CPR is initiated. The facility Chart Code Policy/Procedure dated (MONTH) 2006, indicated color coding name tags on the charts identified yellow for a resident who has an advanced directive for DNR/DNI, and blue for a resident who is to be resuscitated.

Based on observation, interview and document review, the facility failed to provide assessment and appropriate interventions to prevent elopement off the facility campus for 1 of 1 resident reviewed (R3) who had a history of [REDACTED]. The IJ began on 5/25/14, when R3 wheeled himself to the Cenex gas station and a community member had to contact the facility, informed them of his location and staff were summoned to bring R3 back to the facility and was identified on 6/25/14. The administrator was informed of the immediate jeopardy (IJ) at 1:00 p.m. on 6/25/14. The immediate jeopardy was removed on 6/26/14, but noncompliance remained at the lower scope and severity level of D-isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R3 had multiple incidents of elopement off the facility campus, which was located on a busy roadway (recent: 5/25/14, 5/28/14 & 6/19/14 and historically: 6/30/13 & 7/4/13). Facility staff were aware of R3's exit attempts; however, the facility failed to assess, monitor and provide interventions to reduce the risk of elopement for R3. R3 had been admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. R3's quarterly Minimum Data Set ((MDS) dated [DATE], identified that R3 required extensive assistance with transfers, dressing, hygiene and toileting. The MDS identified R3 was unable to ambulate but was independent with mobility in the wheelchair. The MDS further identified R3 had modified independence with decision making and had limited communication/speech capabilities due to the CVA. Documentation was lacking in the medical record to indicate that a comprehensive assessment, including assessment of R3's physical and cognitive abilities related to his unsafe practice of leaving the premises without staff supervision, had been conducted. During observation on 6/24/14, at 6:35 p.m. R3 was observed to be seated in his wheelchair in the center of the staff parking lot on the west side of the facility. R3 was observed to be leaning significantly forward with his forehead near his lap. R3 was also observed to have difficulty wheeling his wheelchair due to the forward/right leaning position, and his right sided paralysis of upper and lower extremities. R3 was observed to utilize only his left hand when he propelled the wheelchair. On 6/24/14, at 7:00 p.m. licensed practical nurse (LPN)-A was questioned whether she knew the wherabouts of R3. LPN-A stated that sometimes R3 went outside but she was not currently aware of his location. LPN-A stated, "Staff kind of watch him, they should try to toilet him every two hours. There is not a specific plan to monitor his whereabouts." LPN-A stated she thought nursing assistant (NA)-A had checked on R3 earlier that shift. During another observation on 6/24/14, at 7:05 p.m. R3 was observed to be still seated in the wheelchair, sitting outside the facility near the road, in the staff parking lot drive-way which leads to a busy street. On 6/24/14, at 7:10 p.m. NA-A was interviewed about R3. NA-A stated, "I looked for (R3) after supper but could not find him, then I had to get back and help the other residents so they could get ready for bed." NA-A stated she had not reported to any other staff that she had been unable to locate R3. On 6/24/14, at 7:20 p.m. NA-B and NA-C were interviewed and stated R3 often went outside by himself. NA-A stated that at times they had been unable to locate R3 when they looked for him. The NAs stated that sometimes, due to R3's leaning position in the wheelchair, he could be seated next to the shrubs around the facility and would be unable to be seen because the shrubs there are taller. NA-B and NA-C both stated they were aware that R3 had left the facility campus in the past and had been returned with the help of community members. On 6/24/14, at 7:30 p.m. LPN-B stated R3 frequently went outside of the building but was unaware of any specific plan to monitor R3's whereabouts. At that time, LPN-A stated she thought R3 had an agreement to stay on the facility campus but verified the resident sometimes did not honor the agreement. LPN-B stated R3 was non-compliant and made unsafe decisions at times. During an interview on 6/24/14 at 7:50 p.m., the administrator verified R3 frequently went outside the facility and that he had been found off campus multiple times and had been brought back to the facility by community members. The administrator stated R3 did not listen to directions and did not always make good decisions. The administrator verified she was aware R3 had sustained a fall from his wheelchair while off campus when unsupervised. The administrator stated she was aware R3 had crossed the busy road adjacent to the facility and had also been found lying in the street in the past. The administrator also verified she was aware that R3 had experienced episodes of getting stuck in his wheelchair off of the facility grounds. When informed about the staff not knowing R3's whereabouts, the administrator stated, "If it were another resident identified as missing, the facility would initiate their missing person plan. I am not sure why staff did not do that when (R3) was noted to be missing". The administrator stated staff should know where R3 is located at all times and when his location is unknown, staff should initiate a search. During document review it was noted that R3 had recently left the facility unsupervised on 5/25/14, 5/28/14 and 6/19/14. Further record review revealed the resident had a history of [REDACTED]. The following documentation was noted in the resident's progress notes: (1) An entry dated 6/30/13, at 10:50 p.m. indicated that during the evening shift, R3 had wheeled himself outside after supper. The documentation further indicated at 6:05 p.m. a community member had knocked on the facility door and a NA had answered the door to find six community members standing around R3 who had fallen out of his wheelchair and was laying in the street next to the sidewalk. The documentation indicated R3 had wheeled off the sidewalk and had fallen out of his wheelchair into the street. (The street where R3 had fallen was a busy street on the east side of the facility with moderate traffic and a commercial factory located across the street where semi-trucks frequently load/unload goods). The nurse's notes described the sidewalk curb as uneven and raised at one end, not even, or flat with the road; (2) Progress notes dated 7/4/13, at 9:40 p.m. identified that R3 had been brought back to the facility by a couple of community members who had stated R3 had crossed the street located by the factory on the east side of the facility and that R3 had been found stuck in his wheelchair on the street corner. (To get to the corner R3 had to cross a busy road and maneuver many environmental obstacles (i.e. curbs, vehicles, uneven pavement, and small inclines)); (3) Progress note documentation from 5/25/14, described as during the evening shift, indicated R3 had independently wheeled outside himself out of the facility, and blocks away from the facility. During interview with the social service designee (SSD) on 6/24/14, at 2:00 p.m., the SSD stated R3 had wheeled himself to the Cenex gas station on 5/25/14, and a community member had contacted the facility to inform them of his location. Staff had been summoned to bring R3 back to the facility. (The Cenex store was noted to be approximately one-half mile from the facility on a busy street with a moderate incline from the facility to the store. Due to R3's limited ability to propel the wheelchair, it would have taken a significant amount of time to propel this distance); (4) Another nurses' note, dated 5/28/14, at 9:06 p.m., identified that R3 was again returned to the facility at 7:00 p.m. after having been located a block from the facility. The medical record lacked any further documentation about the incident. An assessment related to the safety of R3 leaving the premises unsupervised was not evident in the record. (5) Progress notes from 6/19/14, at 3:59 p.m. indicated the charge nurse had informed the SSD that R3 had been found in the alley a couple blocks away, near the house of someone who knew R3. According to the documentation, the community member had assisted R3 back to the facility because it was starting to rain. R3 was reportedly stuck in his wheelchair in the community member's yard and needed assistance to free his wheelchair. Documentation indicated the community member had reported R3 was unable to find his way back to the facility. R3's medical record lacked a thorough investigation and assessment of the elopement. R3's record was reviewed. It was noted that although documentation dated 7/9/13, at 4:25 p.m. indicated that social services had discussed with R3 the risk of crossing the street unsupervised, and the importance of informing staff, R3 had found "what this writer was talking about to be funny." The documentation indicated that at that time discussion had also occurred related to R3 using a name card, or use of a button similar to life line, so he could summon help if required. The documentation indicated R3 had indicated he would be okay with either option. Documentation by the SSD dated 6/19/14, indicated that R3 had been spoken with about remaining on the facility campus to ensure his safety, but that R3 had found the conversation amusing and laughed. No additional follow-up, assessment, nor interventions were evident in the medical record. On 6/25/14, at 10:37 a.m. registered nurse (RN)-A was interviewed and stated she was unaware if there had been an assessment to identify whether R3 was capable of safely leaving the facility campus independently. RN-A verified the care plan lacked any guidance to staff related to R3's elopements and/or safety abilities when out of the facility. RN-A stated she would have expected R3's care plan to have had interventions developed which included monitoring his whereabouts. RN-A verified R3 did not always make safe decisions and was at risk for injury, and RN-A stated the SSD should have conducted a safety/elopement assessment due to R3's history of elopements. During an interview on 6/25/14, at 12:50 p.m. the SSD stated R3 had a history of [REDACTED]. The SSD stated she had instructed R3 regarding the need to stay on the facility property, verified R3 had laughed when the situation was addressed. The SSD confirmed she had not conducted any further assessments related to the resident's elopements. The SSD stated she was a new employee so had been unaware of the earlier elopements and falls that R3 had experienced.The SSD also verified the care plan lacked planned interventions related to R3's safety risks. She further stated that R3 had poor judgement related to safety, describing him as carefree. During an interview with R3's primary physician on 6/26/14, at 11:20 a.m., the primary physician stated that R3 would not be safe if given the opportunity to be off the premises unsupervised. The physician confirmed R3 should not leave the premises unsupervised. The physician also stated she had been unaware that R3 had eloped on 5/25/14 and 5/28/14. The immediate jeopardy that began on 5/25/14 was removed on 6/26/14 when the facility initiated an IJ removal plan which included: providing one on one supervision for R3 while awake; documented hourly checks with Code Gray (missing person protocol) initiation if unable to locate R3; aplication of a code alert to the wheelchair frame to alert staff when R3 exited the building; initiation of an elopement assessment related to R3's cognitive status; and when they had provided education to all staff regarding reporting all resident elopements to ensure tracking, assessment, monitoring and interventions were implemented; Direct care staff and licensed nurses were interviewed to determine whether they were aware of their responsibilities to monitor and report resident elopements, and to ensure they were aware of the plan to assure the safety of R3. The administrator was notified the IJ was removed on 6/26/14 at 4:20 p.m., but the noncompliance remained at the lower scope and severity level of a D, no actual harm with a potential for no more than minimal harm, isolated because a comprehensive assessment related to R3's physical safety and cognitive abilities had not been thoroughly completed. The facility policy Elopement, dated 1/2003, identified the following procedures to be implemented for a missing resident: 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as possible 2. Should an employee observe a resident leaving the premises, he/she should: a. Attempt to prevent departure; b. Obtain assistance from other staff members in the immediate vicinity, if necessary; c. Instruct another staff member to notify the charge nurse or director of nursing that the resident has left the premises. 3. Upon return of the resident to the facility ' the director of nursing or charge nurse should: a. Examine the resident for injuries; b. Contact the attending physician and report what happened; c. Contact the legal representative and inform them of the incident d. Complete and file an incident report; and e. Make appropriate notations in the resident ' s medical record. 4. Should an employee discover that a resident is missing from the facility, he/she should: a. Determine if the resident is out on an authorized leave or pass. If not: b. Make a thorough search of the building and premises. If not located: c. Notify the administrator and the director of nursing, social worker first if unable to reach the director of nursing or nurse manager on duty; d. Notify the residents legal representative e. Notify the attending physician; f. Notify law enforcement officials g. If necessary, notify volunteer agencies-law enforcement will make that determination; h. Provide search teams with resident identification information; and i. Make an extensive search of the surrounding area.

Based on observation, interview and record review, the facility failed to ensure that residents would be free of mental abuse for 1 of 1 residents (R1) reviewed for an incident of suspected maltreatment. Findings include: On 12/04/2010 R1 had an episode of stool incontinence; the facility staff person who reported to R1's room to assist with incontinence cares made verbal statements to R1 that caused R1 to feel humiliated. Record review for R1 revealed a hospital discharge report dated 07/29/2010 that contained documentation that R1 was being admitted to the nursing home for anxiety control; this report also indicated R1 was being treated for [REDACTED]. Additional record review also revealed a physician nursing home visit dated 10/20/2010 that showed R1 continued with [MEDICAL CONDITION], significant anxiety and latent panic attacks ("sifnificantly reduced at this present time"). The 10/20/2010 physician visit note also contained documentation that R1 "still wants to go home as usual" and a clinic appointment was scheduled to discuss potential discharge to home. This clinic appointment was held 10/26/2010 and R1 was given "elements" that would need to be addressed prior to discharge, which included household and personal care assistance. R1's quarterly Minimum Data Set (MDS) (a resident assessment and screening tool) dated 11/09/2010 indicated R1 is continent of bowel and bladder. This MDS also showed R1 exhibited feelings of depression/hopelessness nearly every day, feelings of being a failure/letting self or family down for several days and thoughts of being better off dead (but not having intent to cause self harm) for several days. R1's care plan contained documentation of staff interventions to "monitor for change in continency", "establish environment of mutual trust and respect" and "give non-judgemental support." Continued record review for R1 revealed several nursing progress notes from admission to 12/04/2010 that contained documentation of R1 feeling upset about not being able to be discharged home yet and feeling that R1's spouse "wants nothing to do with (R1)." Nursing progress notes dated 11/29/2010 through 12/2/2010 contained documentation of episodes of stool incontinence. Review of the facility incident report for an occurrence on 12/04/2010 (4:50 a.m.), contained documentation of alleged mental abuse towards R1 by Employee G/nursing assistant (NA). The report indicated Employee G was upset with R1 for being incontinent of stool and yelled at R1 "Would your (spouse) like you to do that" and "I understand why the doctor won't release you." Employee G was terminated following a facility internal investigation of this incident. R1 was interviewed on 1/25/2011 at 2:18 p.m. R1 recalled the incident of 12/04/2010 and stated Employee G "was loud and rude." R1 further stated this incident caused emotional upset. R1 became tearful and cried during this interview. R1 stated Employee G "didn't have that right" to say these things and R1 felt "very humiliated" by Employee G's actions towards R1. R1 worried that R1's spouse did not want to be involved with R1 and questioned several times the reason the physician has not allowed a discharge back home. R1's Med Sheet for December 2010 showed R1 exhibited anxiety during the day shift of 12/04/2010. Employee F/NA was interviewed on 3/3/2011 at 3:49 p.m. and stated resident #1 was "very upset" the entire day on 12/04/2010 and verbalized details of this incident to others throughout that day.