Every finding on record at Meadows on Fairview

Based on observation, interview and record review the facility failed to ensure tracking and surveillance was initiated and transmission-based precautions (TBP) implemented for 1 of 1 residents (R70) who was tested for clostridioides difficile, a highly contagious infection (C. Diff). The facility also failed to ensure proper hand hygiene was performed for 1 of 1 residents (R70) who was assisted with personal cares. Findings include: R70's admission Minimum Data Set (MDS) dated [DATE], indicated R70 was cognitively intact and had diagnoses of a femur fracture and heart failure. Furthermore, R70 required assistance of staff for toileting and was frequently incontinent of bowel and bladder. R70's provider order dated 4/14/25 at 7:00 a.m., instructed staff to send a stool sample for C. Diff. R70's bowel movement task sheet dated 4/2025, indicated R70 had diarrhea and watery stools mixed with soft stools. From 4/13/25- 4/14/25, R70 had only diarrhea. R70's care plan dated 3/29/25, indicated R70 required enhanced barrier precautions until incisions are fully closed and healed and instructed staff to gown and gloves during high contact care activity. Furthermore, R70's care plan indicated R70 required extensive assist with one staff for toilet transfers. R70's electronic medical record lacked indication R70 required TBP during the time R70 was tested for C. Diff. A facility document titled Infection Surveillance Monthly Report, dated 2/2025- 4/2025, lacked indication R70 was included for their loose stools and C. Diff testing. An observation on 4/14/25 at 12:05p.m., R70's door was open and R70 was laying in bed. Outside the door was a sign that stated Enhanced barrier precautions and directed staff to wear a gown and gloves with high contact cares. When interviewed on 4/14/25 at 12:05 p.m., R70 stated they were not feeling the best and their stomach was a little uneasy. R70 further stated the diarrhea had come back. R70 stated it was pretty bad when they first admitted , then seemed a little better, but now was back. An observation on 4/14/25 at 5:09 p.m., nursing assistant (NA)-A entered R70's room without donning a gown or gloves to deliver R70's dinner tray. NA-A then exited R70's room with a pink water cup and brought to a dirty dish area. An observation on 4/14/25 at 7:20 p.m., without donning gown or gloves, NA-A entered R70's room with a vital sign machine. NA-A did not don a gown or gloves. NA-A obtained R70's vital signs and then took their order for breakfast and lunch for the following day. NA-A then brought the vital machine out of the room and proceed back into R70's room. NA-A assisted R70 to their wheelchair. NA-A obtained gown and gloves before assisting R70 into the bathroom. NA-A told R70 the container in the toilet was for a stool sample and R70 can just go as she normally did. At 7:37 p.m., NA-A performed hand hygiene donned a gown and gloves before entering R70's bathroom. NA-A removed R70's pants and placed them in a laundry basket. NA-A then placed a clean brief around R70's feet and assisted R70 to change into a gown for bed. R70 stood up with assistance and NA-A used several wipes to clean R70's bottom as R70 had a bowel movement. Without glove change or hand hygiene, NA-A pulled R70's brief up and assisted R70 back into the wheelchair. NA-A then removed gloves and without hand hygiene donned new gloves. NA-A then assisted R70 back to bed and removed 70's compression socks. The call light was placed near R70 before NA-A rinsed out the compression socks in the sink and hung on the grab bar in the bathroom to dry. NA-A removed gown and gloves and performed hand hygiene with hand sanitizer before exiting the room. When interviewed on 4/14/25 at 8:03 p.m., NA-A stated R70 was having loose bowel movements, and they were odorous. A sample would be sent to test for C. Diff. NA-A verified R70 was on EBP because of their surgical incision. Furthermore, NA-A verified they did not perform hand hygiene or exchange gloves after assisting with wiping and before donning new gloves. An observation on 4/15/25 at 7:27 a.m., R70's door had a sign that stated Enhanced Barrier Precautions and instructed staff to don a gown and gloves for high contact cares. Without gowning and gloving, NA-B entered R70's room and assisted to the bathroom. When in the bathroom, NA-B donned gloves and then assisted pulling R70's soiled brief down before R70 sat on the toilet. NA-B removed their gloves, gave privacy and closed the bathroom door. Without hand hygiene, R70 began to straighten out the pad, sheets and blanket of R70's bed. NA-B went into check on R70 in the bathroom. NA-B then knelt down near R70's feet and without gloves or gown, removed R70's soiled brief and placed in the garbage. Without hand hygiene, NA-B donned gloves and assisted with putting a clean brief and pants around R70's ankles and placed clean socks. R70 requested more time. NA-A removed gloves, performed hand hygiene with hand sanitizer and told R70 to put their light on before leaving the room. At 7:50 a.m., NA-B performed hand hygiene, donned a gown and gloves and entered R70's room. NA-B assisted R70 to stand and used a wet washcloth to clean R70's bottom. The washcloth was then placed on the counter next to R70's sink and a towel was obtained to dry. Without hand hygiene or glove exchange, NA-B pulled up R70's clean brief and pants before assisting to the wheelchair. NA-B moved R70 up to the sink to wash up. R70 initially grabbed the soiled washcloth and towel used to clean their bottom, however NA-B interjected and gave R70 a clean washcloth to use. NA-B finished up with morning cares and performed hand hygiene with hand sanitizer before exiting R70's room. When interviewed on 4/15/25 at 8:05 a.m., NA-B verified gloves and gown were not worn during all cares provided for R70. NA-B further verified no gloves were worn when removing the soiled brief and hand hygiene should have been completed after removing gloves and when moving from soiled to clean area. When interviewed on 4/15/25 at 1:17 p.m., registered nurse (RN)-A stated R70 had issues with diarrhea and had been given a supplement to try and bulk them up. After having the supplement for a few days, R70 continued to have loose stools on Sunday. RN-A left a message for the provider who ordered a stool sample to be checked for C. Diff on Monday. RN-A stated it was collected yesterday, but there had been no results yet. RN-A further stated R70 did not require any additional precautions right now because the test was not back yet. If R70's C. Diff test came back positive, R70 would need contact precautions which meant a gown and gloves were to be always worn when in the room and hand washing was needed instead of hand sanitizer. When interviewed on 4/15/25 at 3:37 p.m., the infection preventionist (IP) who was also the Director of Nursing Information was gathered from resident admission information, progress reports and other reports in the EMR. The IP further explained any resident who was started on an antibiotic had a case or line opened for them. This included their name, kind of infection, the antibiotic they were on, any symptoms, labs, and if TBP needed. IP stated only infections that were on antibiotics were included in the tracking system. Any potential infections were monitored by the nurses who would update the providers as needed. The IP expected TBP to be implemented when any resident had a pending test for a communicable disease such as C. Diff. IP verified there was a communication breakdown and had not been aware R70 had continued diarrhea and had been tested for C. Diff until the negative results came through today. IP further stated R70 should have been placed on contact precautions and staff should have used soap and water for hand hygiene once the C. Diff test was ordered. Furthermore, the IP expected staff to perform hand hygiene between each glove exchange and when moving from clean to dirty areas during resident cares. A facility policy titled Hand hygiene revised 4/2024, directed staff to utilize soap and water after known or suspected exposure to C. Diff. The policy further directed staff to change gloves during patient care when moving from a contaminated body site to a clean body site and to performed hand hygiene between any glove changes. A facility policy titled Transmission/Isolation Precautions revised 1/22/25, directed staff to review needs for precautions/isolation with IP or supervisor.

Based on interview and record review, the facility failed to ensure a non-pressure wound was comprehensively assessed for 1 of 2 (R12) residents reviewed for non-pressure skin concerns. Findings include: R12's admission Minimum Data Set (MDS) dated [DATE], indicated R12 had cognitive impairment and diagnoses of diabetes. Furthermore, R12 had a diabetic foot ulcer. R12's provider and nursing orders dated 3/10/25, directed staff to change R70's wound vac (device that provides negative pressure to wound to promote healing) on Mondays and Thursdays. R12's care plan dated 3/18/25, indicated R12 was at risk for pressure injuries due to presence of wound vac, neuropathy and diabetes with diabetic foot ulcer. Interventions included for staff to assess/record/monitor wound healing with wound vac dressing changes, obtain measurements, document status of wound perimeter, wound bed healing progress and report declines to the provider. R12's skin and wound evaluation assessment dated [DATE], was in progress and included wound measurements. However, the remainder of the assessment was blank. R12's skin and wound evaluation assessment dated [DATE], was in progress and included wound measurements and identified R12's wound to be a pressure wound present on admission. R12's electronic medical record lacked indication R12's wound had been assessed or measured other than 3/6/25 and 4/3/25. An interview on 4/15/25 at 1:06 p.m., registered nurse (RN)-A stated R12 had bone infection on the left foot and has had the wound vac in place since admission. RN-A stated the wound vac was changed on Monday and Thursdays and may need to get a wound picture updated. RN-A further stated there was no weekly documentation or measurements needed and had not been told that was needed. RN-A further stated documentation of it occurred in progress notes. When interviewed on 4/15/25 at 4:11 p.m., the Director of Nursing (DON) stated R12 had a diabetic ulcer and there had been some confusion with it being a pressure ulcer. DON further stated the facility did the wound cares and the podiatrist followed the wound. DON verified R12 did not have wound assessments or measurements completed weekly and would expect nurses to do that even with podiatry following. A facility assessment titled Management of Skin Alterations revised 9/11/24, directed residents with wounds will have weekly monitoring for appropriateness of treatment, signs of infection, pain or discomfort, and signs of healing.

Based on document review and interview the facility failed to ensure a written notification of transfer was sent to the office of the Ombudsman for long term care for 2 of 2 residents (R1, R13) with the potential to affect all residents transferred to the hospital. Findings include: R1's face sheet dated 7/24/24 listed the following diagnoses: chronic respiratory failure with hypoxia (long term breathing issues with low blood oxygen), chronic obstructive pulmonary disease (long term narrowing of the breathing passages), diabetes, obesity, congestive heart failure (the heart was unable to pump efficiently), dysphagia (difficulty swallowing), atrial fibrillation (top two chamber of the heart beat erratically), coronary artery disease (narrowing of the veins/arteries in the heart), dependence on supplemental oxygen, obstructive sleep apnea (stops breathing for spells of time while sleeping), and peripheral vascular disease (the body struggles to return blood from its extremities). Progress notes indicated R1 was hospitalized twice on the following dates: 4/10/24 through 4/12/24 5/14/24 through 5/28/24 and went to the emergency department of 6/5/24, and R1's medical record lacked evidence a written notification of transfer was sent to the Ombudsman for long term care. R13's face sheet dated 7/24/2024, listed the following diagnoses: hypertension (high blood pressure), unspecified dislocation of right hip (right hip our of hip socket), restless leg syndrome (restless legs), presence of right artificial joint (surgical joint replacement) and major depressive disorder (Feeling sad). Progress notes indicated R13 went to an emergency department on 4/29/24 and was hospitalized on [DATE]. R13's medical record lacked evidence a written notification of transfer was sent to the ombudsman for long term care. Facility provided document, referred to as, Hospital Transfer List, indicated list of resident transfers over the last six months, and included R1 and R13. During an interview on 7/23/24 at 1:06 p.m., director of nursing (DON) stated the facility transfer list document included the residents R1 and R13. DON stated she did not believe the ombudsman had been notified of R1 and R13's transfer to the hospital and she was reviewing the facility policy. During an interview on 7/23/24 at 2:04 p.m., DON stated the notice of transfer to ombudsman for R1 and R13 had not been done but should have During an interview on 7/23/24 at 2:25 p.m., licenses social worker (LSW) stated she had not notified the ombudsman for the transfer and hospitalization of R1 and R13. LSW stated the transfers should have been sent to the ombudsman upon review of the facility policy. Facility provided document, titled, Transfer and Discharge from the facility indicated, copies of notices for emergency transfer must also be sent to the ombudsman, and can be done monthly. 49657

Based on interview and document review the facility failed to ensure a safe discharge transfer to a home care agency for 1 of 3 residents reviewed for discharge. The facility did not communicate with the home health agency leaving the resident with a safety risk. The following day after the resident had been transferred home, a family member needed to assist resident with her catheter cares. The family called the home care agency that was on the discharge orders, and they were informed the home care agency had declined the resident. The resident was left without services. The resident was readmitted that same day back to the transitional care unit. Findings Include: Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 15 indicating R1 was cognitively intact. R1 required limited assistance with activities of daily living, bed mobility, walking in room and on unit, dressing toileting use and personal hygiene. R1 had an indwelling catheter. During an interview on 9/14/21, at 9:10 a.m. R1 reported going home on the 9/4/21 of a Labor Day weekend and had to return to the facility on [DATE]. R1 stated the day after returning home, she felt something was wrong with her catheter, so she called her granddaughter, who was a nurse to come over. R1 knew she was going to have home care start after the weekend, but uncertain as to when. R1 stated she left the transitional care unit with a urinalysis pending and found out after returning home it was urinary tract infection ([CONDITION(S)]). Antibiotics were started on 9/5/21. R1 stated I did not feel safe, I have a past history of [CONDITION(S)]'s and I have fallen and become disoriented with them, I am glad I wasn't hurt, and I don't really know how to take care of this catheter. During an interview on 9/14/21, at 9:33 a.m. Family (F)-A reported the facility let R1 discharge with pending a [CONDITION(S)], a catheter she is not used to and no nursing services on a holiday weekend. F-A reported finding out the granddaughter went over to R1's house due to catheter concerns, so R1 called the home health agency to see when a nurse would be admitting R1. The facility had told the family that home care services would start within 48 hours of discharge. The home health agency told F-A that they had declined R1 due to being at a capacity of clients and to reach out to the facility for further instructions. The F-A called the facility and spoke with Registered Nurse (RN-1) who stated that all the discharge paperwork showed the Fairview Home Care referral had been placed. FA told RN-1 that Fairview told her that R1 had been declined and to reach out to the facility. RN-1 searched medical records and could not find it documented that Fairview Home Care had declined the referral. RN-1 reached out to the administrator, director of nursing (DON) and the social worker (SW) per F-A request. The administrator was reached and looked for the referral in Epic (the electronic medical record system) and found where home health agency had declined R1. The administrator told the family to return R1 back to the facility immediately. The family returned R1 to the facility on [DATE]. The family spoke with the SW on 9/5/21, who stated the facility does not check the status of the referrals and FCC vendor out referrals when they decline. The home health agency did not send the referral to another vendor. No home care agency had been set-up when F-A visited facility on 9/7.21, the TCU was working on it. During an interview on 9/14/21, at 10:18 a.m. the SW stated the referral order was placed into a home health agency via Epic for the home care referral on Friday 9/3/21. Home care begins within 48 hours of discharge. The home health agency will sometimes vendor out the referral to another agency if they decline the referral. The home health agency documents in Epic if a referral is accepted or decline along with any other information if the referral is sent to another agency. The Meadows TCU does not follow-up if the referral goes through or not, we have never had an issue. During an interview on 9/14/21, at 12:33 p.m. the director or nursing reported the F-A was quite upset when they realized R1 had gone home without home care services in place. The facility acted promptly on the day R1 was having difficulty at home and realized an error had occurred. The administrator had R1 return to the TCU. R1 needed home care in the home for physical therapy, occupational therapy, speech language therapy, home health aide and skilled nursing for catheter oversight and education. It is not my expectation for the facility to follow-up and make sure home care referral have been accepted. During an interview on 9/14/21, at 12:48 p.m. RN-1 reported receiving the call from F-A on 9/5/21 and had no information regarding the discharge. RN-1 searched R1's medical for record for information and the only information to be found was discharged to home on 9/4/21 with Fairview Home Care. The family was upset saying they declined her, what now? RN-1 reached out to the SW, DON, and the administrator. During an interview on 9/14/21, at 1:12 p.m. the administrator stated that on 9/5/21 the facility reached out to him stating the R1's family was upset calling the facility and calling the home health agency wanting clarification about home care services being declined and what the next step was. The administrator investigated the situation and noticed that the home health agency had documented a denial in the electronic medical record and had not assigned another agency. The administrator had R1 return to the facility immediately for safety concerns until the situation could be resolved. Review of facility's Transfer and Discharge from the facility policy dated 7/20, indicated: The resident and resident representative will be involved in the discharge planning process. Ebenezer provides assistance and support to ensure a safe and appropriate discharge for the resident. When a resident's health has improved and the resident no longer needs the services provided by the facility, the care team assists the resident and representative with the arrangements needed to discharge to the appropriate setting. The resident's health information necessary for continuity of care is provided to necessary parties.

Based on observation, interview and document review the facility failed to develop and implement a process to prevent the spread of infection related to laundering of personal items. This had the potential to affect all 14 residents residing in the facility. Findings include: During interview and observation on 4/25/19, at 11:02 a.m. nursing assistant (NA)-A stated the personal laundry for the residents in the facility was done in the assisted living building. An observation of the second floor laundry room in the assisted living building identified the use of standard washing machines. NA-A stated staff used regular laundry detergent in the machines and had disintegrating bags for potentially hazardous clothing items. During interview on 4/25/19, at 11:02 p.m. registered nurse (RN)-A stated the facility did not have any high temperature or chemical washing machines. RN-A stated if a resident had a contagious infection the staff put the clothing in bags, but still brought the laundry to the assisted living to be washed. RN-A stated the facility used Purex laundry detergent. On 4/25/19, at 12:05 p.m. the administrator stated the washing machines used for the resident laundry did not heat up over 115 degrees. A facility policy titled Linen Handling to Prevent Infection Transmission dated 11/18, indicated it is important that all potentially contaminated linen be handled with appropriate measure to prevent cross-contamination. The policy indicated contaminated laundry must be disinfected with a detergent plus disinfectant (typically bleach) product, washed in a high water temperature and a high temperature dry cycle. The policy further indicated to destroy microorganisms in laundry items is through hot water washing temperatures above 160 degrees Fahrenheit for 25 minutes.

Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene and glove use during glucometer checks for 1 of 1 resident (R3) reviewed for glucometer checks, and 1 of 1 residents (R1) reviewed for wound care. Findings include: R3's Admission Record printed 5/31/18, indicated R3's [DIAGNOSES REDACTED]. R3's Order Summary Report dated 5/31/18, directed nursing to monitor R3's blood glucose before meals and at bedtime. On 5/29/18, at 3:48 p.m. licensed practical nurse (LPN)-A was observed in the process of doing a glucometer check (to monitor blood glucose levels) for R3. LPN-A was not wearing gloves while poking R3's finger with the lancet and obtaining the blood sample in the sample strip in the glucometer. LPN-A returned to the medication cart, disposed of the lancet in the sharps container, sanitized her hands, opened the medication cart, wrapped the glucometer in a Sani-cloth, and sanitized her hands. At that time, LPN-A stated she usually wears gloves, but hadn't that time. On 5/31/18, at 2:34 p.m. registered nurse (RN)-A verified staff should be wearing gloves when doing a glucometer check, and should sanitize hands after glove removal, and before touching clean items. R1's Admission Record printed 5/31/18, indicated R1's [DIAGNOSES REDACTED]. R1's care plan initiated 5/17/18, indicated R1 had a [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) bacterium causing an infection in the left foot. R1's care plan directed staff to use contact precautions, wear gowns and masks during changing of contaminated linens, and use standard or universal precautions (avoiding contact with bodily fluids, by means of the wearing of nonporous articles such as medical gloves, goggles, and face shields). The care plan also directed staff observe for signs and symptoms of infection, and wash hands immediately after activities of daily living, care tasks and activities. R1's Order Summary Report dated 5/31/18, included orders for left foot wound, treatment for [REDACTED]. R1's progress notes for antibiotic treatment dated 5/31/18, indicated R1's left foot wound dressing was changed every other day, no drainage noted through the dressing, R1 was without a fever, and was seen by infectious disease. R1's antibiotic therapy had been continued for another 30 days due to suspected osteo[DIAGNOSES REDACTED] (infection of the bone) beneath the wound. R1's progress notes for antibiotic treatment dated 5/29/18, indicated R1's left foot wound had a small amount of brown and purulent drainage (containing pus; a sign of infection). On 5/30/18, at 3:09 p.m. LPN-B was observed to prepare to do a dressing change on R1's left foot wound. LPN-B sanitized her hands and put on a gown, mask and gloves. LPN-B entered R1's room, and took out a bin of supplies. LPN-B removed R1's left stocking and [MEDICATION NAME] (elastic tubular support), and stated there was no dressing was in place. R1's wound had yellow slough (dead tissue) on approximately 90% of the wound base, and 10% pink granulation (new tissue growth). LPN-B sprayed the wound cleanser and cleansed R1's foot wound with wound cleanser and gauze, opened dressings, opened a tube of Iodosorb gel (cleans wound by absorbing fluids, removing exudate, slough and debris and forming a gel over the wound surface) and squeezed it into the inside of the gauze pad wrapping. LPN-B opened the gauze packing, removed her soiled gloves, and put on clean gloves without performing hand hygiene. LPN-B put the Iodosorb on the wound base with a cotton-tip applicator, put the Nugauze packing (fine dressing that absorbs fluids) over the wound base after moistening it with sterile water, and opened a packet of skin prep and applied it to the skin around the wound. LPN-B then put an [MEDICATION NAME] dressing ([MEDICATION NAME] adhesive dressing consisting of a breathable non-woven top layer and a low-adherent absorbent pad) over the wound, removed her soiled gloves, and put on clean gloves without performing hand hygiene. LPN-B threw away the old [MEDICATION NAME] that was previously over the wound, then looked at R1's healed wounds on his arms and put [MEDICATION NAME] (skin protectant ointment that moisturizes, nourishes and protect the skin to aid in healing) on R1's left lower extremity. LPN-B then removed her soiled gloves, and put clean gloves on without performing hand hygiene. LPN-B cut a clean piece of [MEDICATION NAME], put it on over R1's left foot, dressing and up the leg, and put R1's stocking and shoe on. LPN-B removed the protective pad from under R1's leg, threw it in the garbage, removed her soiled gloves, applied clean gloves, and did not perform hand hygiene. LPN-B closed up the top of the garbage bag, tied it, and put it in the biohazard bag. LPN-B removed her soiled gloves, and without performing hand hygiene, wiped the scissor blade with an alcohol swab, put away the treatment supplies in the bin, and took a garbage bag out of the cabinet in R1's room. LPN-B removed her gown, gloves, and mask and disposed of them in the biohazard bag. LPN-B then washed her hands. On 5/30/18, at 3:39 p.m. LPN-B verified she should have sanitized or washed her hands between glove changes, especially from dirty to clean. LPN-B stated she tried to be very careful not to touch dirty things and contaminate her gloves, but acknowledged she could have contaminated R1's supplies if her gloves were soiled. LPN-B stated R1's wound did not have yellow slough yesterday, but she cleaned it all out of the wound today, when she cleansed it. On 5/31/18, at 2:34 p.m. registered nurse (RN)-A verified staff should wash or sanitize hands when entering a room, doing wound care, before leaving the room, and after removal of gloves following removal of a soiled dressing. Staff should then don new gloves, do clean tasks, and then wash or sanitize after removing gloves. RN-A verified staff should not touch wound care supplies after removing a dressing or when gloves were soiled, and verified there could be cross contamination of organisms. The facility policy and procedure for Blood Glucose Disinfection revised 3/17, directed staff to disinfect the glucometer after using it, while wearing gloves. The facility policy and procedure for Hand Hygiene revised 9/17, directed staff to wash hands after removing gloves, and to change gloves before touching a residents non-intact skin or open wound, and change gloves if moving from a contaminated body site to a clean body site, and remove gloves after contact with a resident and medical equipment.

Based on observation, interview and document review, the facility failed to ensure appropriate administration of insulin for 2 of 3 residents (R90, R92) who was observed to receive insulin from an insulin pen. This had the potential to affect 4 residents who utilized insulin pens in the facility reviewed during a medication observation. Findings include: R90 On 4/4/17, at 8:36 a.m. licensed practical nurse (LPN)-B was observed retrieve a Humalog Kwik [MEDICATION NAME] (used to control blood sugar) for R90 from the top drawer. LPN-B then took the cap off, wiped the rubber [MEDICATION NAME] with an alcohol wipe then twisted the needle onto the [MEDICATION NAME] tip then proceeded to prime the pen with one unit of Humalog. At 8:43 a.m. LPN-B then indicated R90 was going to receive 2 units of Humalog insulin per the sliding scale for blood sugar of 133 in addition to 10 units scheduled at breakfast and lunch making a total of 12 units. At 8:46 a.m. LPN-B was asked about priming the pen prior to dialing the dose, and LPN-B stated she had been instructed to prime the pens with only one unit and that was what the consultant pharmacist wanted the nurses to do. At 9:07 a.m. surveyor requested for the package insert and LPN-B stated the pen did not come with any. At that time LPN-B indicated she had R2 left to administer two different insulin types using [MEDICATION NAME]'s. LPN-B was asked what the facility policy was for priming [MEDICATION NAME]'s however, LPN-B stated she was not sure. At 9:09 a.m. LPN-B and surveyor went into the medication storage room and reviewed the package insert for R2's [MEDICATION NAME] and [MEDICATION NAME]which both directed to prime the pens with 2 units. During review of the Physician order [REDACTED]. R92 On 4/5/17, at 7:55 a.m. LPN-A was observed apply a pair of gloves then was observed retrieve R92's [MEDICATION NAME] from the top drawer of the medication cart. LPN-A then cleaned the rubber [MEDICATION NAME] tip with an alcohol wipe then screwed the needle on the tip then dialed 13 units of [MEDICATION NAME] without priming the pen. At 7:57 a.m. LPN-A and the surveyor walked away from the medication cart and got to R92's room door and as LPN-A was going to knock and enter room, surveyor intervened. When asked if she had primed the pen prior to dialing the 13 units LPN-A acknowledged she had not and stated she was supposed to prime the pen with 2 units before dialing the actual dose. LPN-A returned to the cart dialed the pen back to zero them primed the pen with 2 units wasted it then dialed the scheduled 13 units. At 7:59 a.m. LPN-A returned to R92's room and administered the correct dose of insulin this time. During review of the Physician order [REDACTED]. On 4/5/17, at 12:29 p.m. when asked about her expectation for nurses priming the [MEDICATION NAME], registered nurse (RN)-A stated they are supposed to prime with 2 units. Will have to do some education. On 4/5/17, at 12:40 p.m. the director of nursing stated she would expect the nurses to prime the [MEDICATION NAME] Will do education. DON indicated the facility policy was for nurses to prime the pens with two units and was not sure why the LPN-B thought it was supposed to be primed with one unit. DON further stated the LPN-B did work at another facility and was not sure about the confusion on the amount to prime with. The facility Injection Subcutaneous-Insulin policy revised 10/13, directed Screw the appropriate pen needle onto pen. Dial up 2 units and perform an air shot to prime needle and ensure that you see insulin come out of needle. This step can be repeated until insulin is observed .

Based on observation, interview and document review, the facility failed to ensure medical justification for the use of an indwelling catheter was provided for 1 of 3 residents (R35) who were reviewed for urinary catheters. Findings include: On 4/3/17, at 2:08 p.m. when asked was there use of an indwelling Foley catheter, registered nurse (RN)-A stated Yes. When asked the reason for R35's catheter RN-A stated was related to urine retention. On 4/4/17, at 2:52 p.m. R35 was observed lying in bed on her back, lights out on room. When approached and asked about the catheter and when it had been put in place resident was not able to re-call however, stated the staff always did empty it for her. When asked if she had any pain/discomfort R35 stated no she stated she was able to use the bathroom for her bowel movements. The catheter bag was hanging on the right side of the bed at the time. R35's urinary incontinence and indwelling catheter Care Area Assessment (CAA) dated 11/27/16, indicated resident had a recent fall resulting in a right femur fracture, recent hospitalization and was admitted to the transitional care unit (TCU). The CAA indicated the Foley catheter had been discontinued on 11/28/16. R35's care plan dated 12/28/16, indicated resident was not able to complete activities of daily living (ADLs) independently at the time. The care plan indicated R35 had left a fracture, weakness and limited functional movement. The care plan directed staff to provide TOILETING: 1 assist to help with personal hygiene and clothing management. The care plan did not identify resident had a Foley catheter. R35's Physician order [REDACTED]. R35's [DIAGNOSES REDACTED]. In addition, the MDS indicated R35 had an indwelling catheter, required extensive assist of one for toilet use and personal hygiene and required extensive physical assistance of two staff with transfers and did not ambulate. R35's Physician Notes from 11/22/16 to 3/28/17, were reviewed and lacked documentation of rationale for the ongoing use of the indwelling catheter. In addition, it was revealed through review of the Progress Notes, the provider had documented the family had indicated urine retention had been a problem for R35 following surgeries, with most recent hospital stay 12/24/16 through 12/28/16, after R35 had a fall and had sustained a right [MEDICAL CONDITION]. During further review of the physician and nurse practitioner (NP) notes it was revealed [MEDICATION NAME] (used to improve urination in men with [MEDICAL CONDITION]) had been discontinued on 1/9/17, however no recommendation was done to identify the cause of the retention. On 4/4/17, at 3:17 p.m. RN-A reviewed the interdisciplinary (IDT) notes stated R35 had been retaining urine and had large amount of post void residuals (PVR's) around 1/17/17, and the nurses were straight catheterizing R35 and this was when the catheter was inserted again. RN-A stated from 12/31/16, 1/1/17, 1/2/17, and 1/3/17, were dates the nurses had documented R35 was retaining urine and resident needed staff to straight catheterize her as she had PVR's great than 375 ml after the blood scans. When asked if any attempts had been done to discontinue the catheter RN-A stated honestly I don't believe so. When asked what the [DIAGNOSES REDACTED]. When asked if had been referred to the urologist to rule out the cause of the retention and why R35 was not able to fully empty her bladder, RN-A stated no. RN-A also stated around the time the catheter had been inserted other PVR's had been done and R35 showed large amounts of PVR's however not greater than 375 ml for the nurses to straight catheterize R35. RN-A did review multiple NP and doctor notes which indicated resident had urine retention however did not indicate the cause. RN-A reviewed R35's care plan and verified the care plan did not address R35 had a Foley catheter Am totally embarrassed. RN-A acknowledged it was supposed to be in the care plan I have gone through this care plan several times. RN-A also reviewed medical record and verified when R35 had been admitted to the facility originally the catheter had been discontinued on 11/28/16, and had been successful. RN-A stated Am going to suggest to the NP to attempt a trial. On 4/5/17, at 12:46 p.m. the director of nursing (DON) stated she would have expected a trial to have been done after the catheter was re-inserted to discontinue the catheter. DON also stated she would have expected the doctor or nurse practitioner to have followed up with the catheter use justification for use. When concern was brought up about no documentation in the medical record which addressed any attempt trials done to discontinue catheter or if R35 had been sent to the urologist to identify the cause of the retention, DON stated she would be following up with the NP and doctor to see if there was any documentation for this. The facility Indwelling Catheter policy revised 10/16, directed the following: 1) Each resident is assessed and a [DIAGNOSES REDACTED]. Indwelling catheters will only be used for residents with [MEDICAL CONDITION], or bladder obstruction, to assist in the healing of an open sacral or perineal wound, prolonged, strict immobilization or for comfort at the end of life. Obtain a urology consult. 2) Each resident with a urinary catheter receives a comprehensive assessment and individualized care plan for the treatment or management of their catheter. Attention is given to minimize risk factors for infection. Continued need for the indwelling catheter is assessed periodically. Maintain a closed catheter system. 3) Continually assess resident need for urinary catheter and remove catheter as appropriate .

Based on observation, interview and document review, the facility failed to ensure 1 of 3 residents (R35) who had an indwelling catheter had a care plan developed reviewed for urinary catheter use. In addition, the facility failed to develop a care for 2 of 2 residents (R39, R35) reviewed for pressure ulcers. Findings include: On 4/3/17, at 2:08 p.m. when asked was there use of an indwelling Foley catheter, registered nurse (RN)-A stated Yes. When asked the reason for R35's catheter RN-A stated was related to urine retention. On 4/4/17, at 2:52 p.m. R35 was observed lying in bed on her back, lights out on room. When approached and asked about the catheter and when it had been put in place resident was not able to re-call however, stated the staff always did empty it for her. When asked if she had any pain/discomfort R35 stated no she stated she was able to use the bathroom for her bowel movements. The catheter bag was hanging on the right side of the bed at the time. R35's urinary incontinence and indwelling catheter Care Area Assessment (CAA) dated 11/27/16, indicated resident had a recent fall resulting in a right femur fracture, recent hospitalization and was admitted to the transitional care unit (TCU). The CAA indicated the Foley catheter had been discontinued on 11/28/16. R35's care plan dated 12/28/16, indicated resident was not able to complete activities of daily living (ADLs) independently at the time. The care plan indicated R35 had left a fracture, weakness and limited functional movement. The care plan directed staff to provide TOILETING: 1 assist to help with personal hygiene and clothing management. The care plan did not identify resident had a Foley catheter. R35's Physician order [REDACTED]. R35's [DIAGNOSES REDACTED]. In addition, the MDS indicated R35 had an indwelling catheter, required extensive assist of one for toilet use and personal hygiene and required extensive physical assistance of two staff with transfers and did not ambulate. R35's Physician Notes from 11/22/16 to 3/28/17, were reviewed and lacked documentation of rationale for the ongoing use of the indwelling catheter. In addition, it was revealed on some of the progress notes the provider had documented the family had indicated urine retention had been a problem for R35 following surgeries, with most recent hospital stay 12/24/16, through 12/28/16, after R35 had a fall and had sustained a right [MEDICAL CONDITION]. During further review of the physician and nurse practitioner notes it was revealed [MEDICATION NAME] (used to improve urination in men with [MEDICAL CONDITION]) had been discontinued on 1/9/17, however no recommendation was done to identify the cause of the retention. On 4/4/17, at 3:17 p.m. RN-A reviewed R35's care plan and verified the care plan did not address R35 had a Foley catheter Am totally embarrassed. RN-A acknowledged it was supposed to be in the care plan I have gone through this care plan several times. On 4/5/17, at 12:46 p.m. the director of nursing (DON) stated she would have expected care plan to be developed to address the catheter. The facility Indwelling Catheter policy revised 10/16, directed the following: 2) Each resident with a urinary catheter receives a comprehensive assessment and individualized care plan for the treatment or management of their catheter. Attention is given to minimize risk factors for infection. Continued need for the indwelling catheter is assessed periodically. Maintain a closed catheter system . The facility Individualized Care plan policy revised 12/13, directed 1. Upon admission, the nursing department begins the care plan and addresses the immediate needs of the resident in the initial care plan. The presenting problem and significant functional dependencies will be addressed . R39's Ebenezer initial Admit assessment dated [DATE], indicated R39 had sacral redness. R39's admission Minimum Data Set ((MDS) dated [DATE], indicated she was moderately cognitively impaired, was occasionally incontinent of bowel and bladder and required physical assistance for bed mobility, transfers and toileting. R39's care plan dated 2/3/17, identified a risk for alteration in skin integrity related to decreased mobility and back pain. A facility Braden and Skin Risk assessment dated [DATE], identified a history of pressure ulcers. A facility Weekly Pain and Bath Sheet, dated 1/25/17, indicated R39's skin was not intact and identified redness to the right and left iliac crests (the largest of the three bones that merge to form the hip bone) and redness to her groin. R39's Meadows on Fairview Progress Note dated 1/27/17 indicated: Patient complained of lower back and buttock pain today. Buttocks area red, blanchable, 3 small open areas on right buttock near intragluteal cleft. See skin charting. An Ebenezer Skin Integrity Documentation assessment dated [DATE], indicated new onset abrasion number one: no drainage, surrounding area, redness and pain. Abrasion number 2, surrounding area redness and pain, Abrasion number 3, small amount of exudate, surrounding area redness and pain. The assessment did not include measurements, assessment of the wound bed or staging. An Ebenezer Skin Integrity Documentation assessment dated [DATE], identified a skin issue on R39's left buttock had healed, however there was no prior documentation of the skin issue. While R39 initial assessment identified redness to her sacrum and required assistance to complete activities of daily living, a care plan for pressure ulcers was not developed until R39 had already acquired a pressure ulcer. R56's 60 day Minimum Data Set ((MDS) dated [DATE], indicated she was cognitively intact and required extensive assistance with bed mobility, transfers and toileting, R56's care plan dated 11/5/16, indicated a need for physical assistance related to cerebral vascular attack ([MEDICAL CONDITION]) with left sided weakness. The care plan further indicated an alteration in skin integrity and indicated a new pressure injury, stage II, left tuberosity (one of two bony swellings found on the lower back part of the hip bone,) identified on 1/12/17. A review of a facility Pressure Wound Documentation assessment, dated 1/12/17, identified a stage II pressure injury (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) on R56's left buttock measuring 0.5 centimeters (cm) x 0.3 cm. R56 remained in the facility until 1/24/16, there was no evidence the facility completed any additional assessments of her pressure ulcer. During an interview on 4/4/17, at 3:19 p.m., licensed practical nurse (LPN)-B stated if a skin concern was identified, staff open a skin assessment. LPN-B stated open areas are measured and documented weekly by the nurse on duty. R56 admitted to the facility with risk for skin breakdown, there was no evidence the facility nictitated a care plan until R56 had already acquired a pressure ulcer. During an interview on 4/5/17, at 9:15 a.m., registered nurse (RN)-B stated skin assessments were completed on admission and if a new skin issue was found. RN-B stated if a skin concern was identified, staff would monitor daily and assess weekly including measurements and weekly progress notes. She stated every resident should receive a skin assessment each week and document on the Weekly Pain and Bath Day Sheet. During an interview on 4/5/17, at 10:34 a.m., RN-A stated she was responsible for starting the initial plan of care and the nurses should keep it up to date. She stated a care plan for skin should have been in place for both R39 and R56 on admission. During an interview on 4/5/17, at 1:00 p.m., the director of nursing stated she would expect staff to initiate a plan of care for activities of daily living, pain and skin on admit.

Based on interview and record review, the facility failed to accurately assess pressure ulcers for 2 of 2 resident (R39, R56) reviewed for pressure ulcers. Findings include: R39's initial Admit assessment dated [DATE], indicated R39 had sacral redness. There were no measurements, no indication of whether the area was blanchable, no staging, nor was there evidence of ongoing monitoring. A facility Braden and Skin Risk assessment dated [DATE], identified a history of pressure ulcers. R39's admission Minimum Data Set ((MDS) dated [DATE], indicated she was moderately cognitively impaired, was occasionally incontinent of bowel and bladder and required physical assistance for bed mobility, transfers and toileting. A facility Weekly Pain and Bath Sheet dated 1/25/17, indicated R39's skin was not intact and identified redness to the right and left iliac crests (the largest of the three bones that merge to form the hip bone) and redness to her groin. A Progress Note dated 1/27/17, included: Patient complained of lower back and buttock pain today. Buttocks area red, blanchable, three small open areas on right buttock near intragluteal cleft. See skin charting. A Skin Integrity Documentation assessment dated [DATE], indicated: new onset abrasion number one: no drainage, surrounding area, redness and pain. Abrasion number 2, surrounding area redness and pain, Abrasion number 3, small amount of exudate, surrounding area redness and pain. The assessment did not include measurements, assessment of the wound beds or staging. A Skin Integrity Documentation assessment dated [DATE], indicated an area of skin on R39's left buttock had healed, however there was no prior documentation of what the skin issue had been. R39's care plan dated 2/3/17, identified a risk for alteration in skin integrity related to decreased mobility and back pain. Registered nurse (RN)-A stated she recalled having seen R39's skin, and stated it was noted on 1/17/17, but stated nothing was done about it until the 25th of January. R56's Progress Notes indicated R56 remained in the facility until 1/24/16, and there was no evidence the facility had completed any additional assessments of her pressure ulcer. R56's 60 day MDS dated [DATE], indicated she was cognitively intact and required extensive assistance with bed mobility, transfers and toileting, R56's care plan dated 11/5/16, indicated a need for physical assistance related to [MEDICAL CONDITIONS] with left sided weakness. The care plan further indicated R56 had an alteration in skin integrity and indicated a new pressure injury, stage II (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister), on the left tuberosity (one of two bony swellings found on the lower back part of the hip bone) had been identified on 1/12/17. A review of a Pressure Wound Documentation assessment dated [DATE], identified a stage II pressure ulcer on R56's left buttock measuring 0.5 centimeters (cm) x 0.3 cm. During an interview on 4/4/17, at 3:19 p.m., licensed practical nurse (LPN)-B stated if a skin concern was identified, staff would initiated a skin assessment. LPN-B further stated open areas are measured and documented on weekly by the nurse on duty. During an interview on 4/5/17, at 9:15 a.m., RN-B stated skin assessments were supposed to be completed on admission and any time a new skin issue was found. RN-B stated if a skin concern was identified, staff would monitor daily and assess weekly including measurements and weekly progress notes. In addition, RN-B stated every resident should have a skin assessment conducted each week which would be documented on the Weekly Pain and Bath Day Sheet. During an interview on 4/5/17, at 10:34 a.m., RN-A stated staff were supposed to complete a skin check each week on bath day and document on the Weekly Pain and Bath Day sheet. She stated if a skin concern was identified, staff would initiate skin integrity documentation. RN-A stated R56's skin alteration was noted as an abrasion and that it was likely due to a lack of a better description on the assessment. RN-A stated education on skin issues was likely needed. During an interview on 4/5/17, at 1:00 p.m., the director of nursing stated nurses complete a full body skin assessment on admit. She stated if any alterations were noted they should be documented on until healed, including descriptions with measurements and any blanching. A facility policy for skin assessment and documentation was requested but not received.

Based on observation, interview and document review, the facility failed to ensure a temporary care plan was developed following admission for 1 of 2 residents (R90) reviewed for pain. Findings include: R90's [DIAGNOSES REDACTED]. On 4/3/17, at 1:29 p.m. during interview when asked do you have any discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief, My neck, back and legs sometimes they tell me it's not time for the pain medications. I have an appointment with the pain clinic on Wednesday. During the interview, R90 was observed rubbing the back of the neck and indicated she was not able to turn her neck due to the pain and requested for a warm pack. On 4/4/17, at 8:24 a.m. licensed practical nurse (LPN)-B went to room to check the blood sugar when R90 stated she was in a lot of pain on her neck. At that time a white adhesive patch was observed on the back of the neck area peeled off. When surveyor told the LPN-B about the patch, LPN-B stated she would get skin prep to adhere it to the skin. LPN-B indicated to R90 she had just received [MEDICATION NAME] and would be getting the next dose at noon. At 8:40 a.m. LPN-B returned to room observed resident lying in bed and LPN-B indicated to R90 she had all the morning meds and the breakfast tray was coming. R90 was observed get herself up and sat on the edge of the bed, removed her oxygen and stated she had a headache. LPN-B stated she would get her some Tylenol (a mild [MEDICATION NAME]) then continued to administer the medications. R90 brought up the concern of not being sure if she was going to get to the appointments she had scheduled in Maple Grove which included the pain clinic one. LPN-B stated she would follow up on it. LPN-B then asked R90 if she wanted a heat pack. LPN-B attempted to apply the [MEDICATION NAME] gel (topical gel for pain) however, R90 declined stated she would wait until she had a shower. On 4/5/17, at 9:22 a.m. to 9:27 a.m. R90 was observed propelling her wheelchair from the dining room to her room. When asked about her pain, R90 stated she had in the past two rotator cuff repairs, had a spinal fusion, she had [MEDICAL CONDITION] in her feet which was bad at times and had arthritis. R90 stated she had been working with her regular family practice doctor who had referred her to the pain clinic. R90 stated because of constipation there was issues with adjusting or increasing the pain medications. R90 stated in the past she had used [MEDICATION NAME] (narcotic) or [MEDICATION NAME] ([MEDICATION NAME] pain reliever) for break through pain and this really did help and she was going to ask the pain clinic doctor later that day at the appointment. As R90 spoke to surveyor her fingers on both hands were observed swollen and deformed. When asked about her fingers R90 stated she had arthritis which was sometimes really bad and like yesterday I was not able to pick up a piece of bacon. R90 stated the pain at time was so bad and she had noticed her pain medications had been changed since being at the facility and she was going to discuss this with the pain clinic doctor. R90 also stated her pain most of the time was rated between a 7-10 since she admitted to the facility before the pain medications and her tolerable pain threshold was 2-3. When asked about the pain medications, R90 stated she used the [MEDICATION NAME] (narcotic pain patch) which she thought was 25 microgram (mcg). R90's Physician order [REDACTED]. -[MEDICATION NAME] Patch 72 Hour 25 mcg/HR Apply 1 patch [MEDICATION NAME] every 48 hours for pain and remove per schedule -[MEDICATION NAME] (migraine medication) 50 mg by mouth as needed for migraine may repeat after 2 hours. Do not exceed 200 mg/24 hr. -[MEDICATION NAME] Patch 5% Apply to painful areas topically one time a day for Pain 1-3 patches. On Am and Off HS and remove per schedule -[MEDICATION NAME] 10 mg 1 tablet by mouth four times a day for pain give every 6 hours. On 4/4/17, during review of the initial temporary care plan which was fours after admission to the facility, it was revealed even though, R90 had scheduled pain medications and had complained of pain the medical record lack a temporary care plan addressing her pain. On 4/5/17, at 12:29 p.m. registered nurse (RN)-A reviewed the initial care plan and verified there was no pain care plan initiated. RN-A stated usually on admit she would be the one who would initiate the care plan then other staff would go in and add to it. When asked if she had been at the facility on 3/31/17, when R90 admitted RN-A stated Yes. It should have been done. On 4/5/17, at 12:44 p.m. the director of nursing stated she would expect the initial temporary care plan to be developed especially to addressing pain and skin care areas right away and other care areas identified with each resident. The facility Individualized Care plan policy revised 12/13, directed 1. Upon admission, the nursing department begins the care plan and addresses the immediate needs of the resident in the initial care plan. The presenting problem and significant functional dependencies will be addressed .

Based on interview and document review, the facility failed to revise the care plan to include fall interventions for 1 of 2 residents (R15) who had experienced a fall in the facility. Findings include: R15's Admission Minimum Data Set ((MDS) dated [DATE], indicated she was cognitively intact and required extensive assistance with all activities of daily living. A care area assessment (CAA) dated 11/3/16, indicated a risk for falls. R15's care plan dated 10/22/16, did not identify falls. An Ebenezer Fall Risk Tool dated 10/23/16, indicated R15 was at risk for falls. A review of R15's(NAME)on Fairview Progress Note dated 10/22/16, indicated R15 admitted to the facility on that date. She required assistance of 1 staff to complete activities of daily living, was using a walker and wheel chair for long distances and was continent of bowel and bladder. A(NAME)on Fairview Progress Note dated 10/25/15, identified a fall in her bathroom. The progress note indicated R15 was found on the floor in her bathroom facing the toilet. She stated she did not hit her head, but did hit her upper arm on her walker when she fell . R15 was noted to have a 10 centimeter (CM) x 5 cm bruise on her upper arm. R15 stated she felt wobbly and lost her balance. During an interview on 4/5/16, at 10:50 a.m., registered nurse (RN)-A sated R15 had been independent prior to her fall and had been participating in therapy. She stated the facility usually does a follow- up after a fall but stated there was not one done for R15. RN-A stated, we missed it. RN-A stated, she was responsible for developing the care plans and stated R15's care plan should have identified falls. During an interview on 4/5/17, at 1:00 p.m., the director of nursing stated she would expect staff to initiate a plan of care on admit. The facility Individualized Care plan policy revised 12/13, directed 1. Upon admission, the nursing department begins the care plan and addresses the immediate needs of the resident in the initial care plan. The presenting problem and significant functional dependencies will be addressed . While R15 admitted to the facility for therapy and had an identified risk for falls, there was no evidence of care planned interventions for fall prevention even after R5 sustained a fall.

Based on interview and document review, the facility failed to assess and implement interventions related to falls for 1 of 2 resident (R15) reviewed for accidents. Findings include: R15's Admission Minimum Data Set ((MDS) dated [DATE], indicated she was cognitively intact and required extensive assistance with all activities of daily living. A care area assessment (CAA) dated [DATE], indicated a risk for falls. R15's care plan dated [DATE], did not identify falls. An Ebenezer Fall Risk Tool dated [DATE], indicated R15 was a low fall risk. R15's Meadows on Fairview Order Summary Report, dated [DATE], identified the use of Warfarin.(Warfarin is an anticoagulant used to prevent heart attacks, strokes, and blood clots.) The Plan of Care did not address anti-coagulant monitoring. A review of R15's Meadows on Fairview Progress Note dated [DATE], indicated R15 admitted to the facility on that date. She required assistance of 1 staff to complete activities of daily living, was using a walker and wheel chair for long distances and was continent of bowel and bladder. A Meadows on Fairview Progress Note dated [DATE], indicated R15 was alert and oriented x 3 and independent with activities of daily living. A Meadows on Fairview Progress Note dated [DATE], identified a fall in her bathroom. The progress note indicated R15 was found on the floor in her bathroom facing the toilet. She stated she did not hit her head, but did hit her upper arm on her walker when she fell . R15 was noted to have a 10 centimeter (CM) x 5 cm bruise on her upper arm. R15 stated she felt wobbly and lost her balance. A Meadows on Fairview progress note dated [DATE], indicated R15 was having increased confusion and weakness and needed total assist with cares and assistance with feeding. A Meadows on Fairview Progress Note dated [DATE], indicated R15 had signed on to hospice. A meadows on Fairview Progress Note dated [DATE], indicated R15 expired at the facility. During an interview on [DATE], at 10:50 a.m., registered nurse (RN)-A sated R15 had been independent prior to her fall and had been participating in therapy. She stated the facility usually does a follow- up after a fall but stated there was not one done for R15. RN-A stated, we missed it. RN-A stated, after R15 fell she was refusing to get out of bed and go to therapy. RN-A further stated R15 should definitely have been on monitoring for anti-coagulant use. During an interview on [DATE], at 1:04 p.m., the director of nursing stated when a patient falls there should be an incident report and a follow up within 24 hours. She stated she would expect staff to assess the patient for injury and stated if the patient was on anti-coagulants, staff should be monitoring for bruising and bleeding. While R15 admitted to the facility for therapy and had an identified risk for falls, there was no evidence of care planned interventions for fall prevention and while she was receiving anti-coagulating medications, there was no evidence the facility was monitoring for side effects, even after R5 sustained a fall. Further, there was no evidence the facility re-assessed R15's risk for falls after she sustained a fall on [DATE], even though she declined from an independent status to no longer able to get out of bed. A facility policy for falls was requested but not received.

Based on observation, interview and document review, the facility failed to ensure the physician was notified for a change in a resident weights for 1 of 1 resident (R94) reviewed for notification of change. Findings include: R94's [DIAGNOSES REDACTED]. On 4/4/17, at 1:05 p.m. when approached and asked about all his medications, R94 stated the staff at the facility managed all that for him. When asked about anxiety R94 stated that had gotten better with the medications and he was getting stronger that before and the [MEDICAL CONDITION] was getting well managed at that time. At 1:30 p.m. R94 was observed sitting on a regular chair in his room looking at his cell phone. When approached and asked about [MEDICAL CONDITION] in the lower extremities, R94 stated he had improved a whole lot and there was none around his legs and ankles however thought his toes were still swollen. When asked about being short of breath with activity, R94 stated the shortness of breath was much better now compared to before however still did experience some. During review of the Physician order [REDACTED]. -Daily weights-call MD (medical doctor) with weight gain of 2 pounds in 24 hours or 5 pounds in a week, every day shift for [MEDICAL CONDITIONS] -Carvedilol (anti-hypertensive) 3.125 milligram (mg) give 1 tablet by mouth two times a day for [MEDICAL CONDITION] give with meals -[MEDICATION NAME] (water pill-diuretic) 40 mg give 1 tablet by mouth in the morning for heart failure -Ramipril (anti-hypertensive) 10 mg give 1 capsule by mouth in the morning for hypertension During review of the electronic treatment administration record (ETAR) for March 2017 and April 2017, weights had been obtained as follows: -3/28/17: 170 pounds (#) -3/29/17: 173# (3# gain from previous day) -3/30/17: 174# -3/31/17: 171.8# -4/1/17: 173.4# -4/2/17: 171.4# -4/3/17: 174# (2.6# gain from previous day) -4/4/17: 174# R94's medical record lack documentation of the medical doctor and/or nurse practitioner being notified of the weight gains on 3/29/17, and 4/3/17, as directed by the physician order. R94's dehydration Care Area Assessment (CAA) dated 3/30/17, indicated R94 received a diuretic daily for [MEDICAL CONDITION], had [MEDICAL CONDITION] to both lower extremities (BLE) and staff encouraged resident to elevate BLE when in bed and chair. CAA directed staff to continue to observe for changes and update MD as needed. On 4/4/17, at 3:39 p.m. registered nurse (RN)-A verified the weight gain in the ETAR for March and April 2017, reviewed the interdisciplinary notes and verified MD had not been notified. RN-A stated she would expect the MD to have been notified because it was a specific physician order [REDACTED]. On 4/5/17, at 7:43 a.m. when asked about weights nursing assistant (NA)-A stated R94 was a daily weight and she had weighed him and had put it in the computer and would let the nurse know the weight. On 4/5/17, at 1:51 p.m. the director of nursing stated she would have expected the doctor to be notified regarding the weight gain as directed by the physician order. On 4/5/17, a physician's orders [REDACTED]. The facility Change of Condition/Notification policy revised 12/16, directed staff to notify the attending physician/nurse practitioner or on-call immediately of residents change in condition/health status change based on a comprehensive assessment.

Based on interview and document review, the facility failed to confirm pneumococcal vaccination status and administration if indicated for 2 of 5 residents (R41, R68) reviewed for infection control. Findings include: R41's Admission Record dated 1/15/16, identified R41's [DIAGNOSES REDACTED]. R41's admission Minimum Data Set ((MDS) dated [DATE], indicated R41's pneumococcal vaccination was not up to date. R41's Immunization Report indicated R41 received the influenza vaccination on 1/6/15, however lacked documentation of if/when R41 had received the pneumococcal vaccination. R68's Admission Record dated 2/20/16, identified R68's [DIAGNOSES REDACTED]. R68's Immunization Report indicated R68 received the influenza vaccination on 2/19/16, however lacked documentation of if/when R68 had received the pneumococcal vaccination. On 2/23/16, at 11:23 a.m. registered nurse (RN)-A confirmed all vaccinations given to R41 and R68 would be documented in the Immunization Report. RN-A stated the pneumococcal vaccinations were not being administered as residents on the unit were short term stay. RN-A reported when staff request an order to give the pneumococcal vaccination from a physician, they are told the resident can obtain the vaccination at their regular clinic at a later date. On 2/24/16, at 4:10 p.m. the director of nursing (DON) confirmed R41 and R68's medical record lacked documentation of pneumococcal vaccination history or refusal of vaccination. The DON confirmed R41 and R68 should have been offered the pneumococcal vaccination. The DON stated staff was expected to document in the medical record any prior vaccinations or refusals of vaccinations. Further, the DON confirmed all residents less than [AGE] years of age should also be offered the pneumococcal vaccination. The facility's Standing House Orders dated 1/27/15, indicated the orders were applicable for all residents admitted to the facility and directed staff to administer the pneumococcal vaccination if not contraindicated. The facility's Resident Pneumococcal Vaccine policy dated 9/13, indicated each resident would be offered the vaccine unless medically contraindicated, refusal or already immunized.