Every finding on record at MN Veterans Home-Luverne

Based on interview and document review, the facility failed to ensure a change of condition was identified and assessed by a nurse to determine what, if any, additional intervention maybe needed for 1 of 2 residents (R1) reviewed. R1 developed audible gurgling and potential respiratory impairment on [DATE] in the mid-afternoon which was not comprehensively assessed by a nurse until several hours later. Findings include: On [DATE] at 11:46 a.m., an interview was held with emergency medical technician (EMT)-E who stated they were on a crew that responded to the care center for R1 on [DATE], with reported respiratory distress. They arrived and found R1 lying in bed and very clearly in respiratory distress. The staff members present reported R1's condition onset about 2:00 p.m., which EMT-E then questioned aloud, Why did it take eight hours [to call]!? R1 had just had oxygen placed via cannula at 2 liters per minute (LPM) as EMT arrived and R1's oxygen saturations were poor when they checked them. EMT-E stated R1 was then transported to the hospital where she was found to have a very intense pneumonia in her lungs. R1's Physician Orders for Life Sustaining Treatment (POLST), dated 1/2024, identified R1 had wishes for selective treatment marked but was agreeable to limited interventions such as IV/IM antibiotics or a defined trial of artificial nutrition. R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had both long and short-term memory impairment and a history of previous stroke. R1 did not have a history of respiratory failure recorded. R1's care plan, last reviewed [DATE], identified R1 had an activity of daily living (ADL) self-care deficit and was dependent on staff for most care. The care plan lacked evidence R1 had any current respiratory issues or concerns such as wet-sounding voice or 'gurgling' with spoken wordR1's Respiration / Pulse / O2 Sat Summaries, printed [DATE], identified the recorded vital signs for R1 over the previous 90-day period. These vitals were recorded: [DATE] - 18 respirations per minute (RPM), 53 beats per minute (BPM), and 92% on room air (RA). [DATE] - 18 RPM, 62 BPM, and 93% on RA. R1's progress note, dated [DATE] at 10:19 a.m., identified R1 was seen by medical doctor (MD)-D and no new orders were written. R1's corresponding Family Medicine Progress Note, dated [DATE], identified R1 was seen for a routine 60-day examination. MD-D recorded himself as having a hard time understanding R1's speech but R1 had been eating okay. The note identified R1 had a previous choking episode but the congestion . seems to be better at this time. The note recorded R1 had no cardiopulmonary symptoms present and a physical exam was done which recorded R1's vital signs as 110/62 (BP), 62 BPM, and 16 breaths per minute. R1's lung sounds were listed as clear and R1 was in no acute distress. However, R1's subsequent progress note, dated [DATE] at 9:45 p.m., identified the staff had noticed R1 sounded gurgle [sic] when getting her up for the supper meal. R1 was alert and ate 25% of her supper meal. The note then recorded, By the time she was assisted to bed. She started to cough more and sounded even more gurgle [sic]. She looked pale and was difficult to arouse. She said she was tired . was afebrile with 96.5 [F], P 67 and went up to 161, R 35 and irregular. O2Sat ranged from 75 to 80% [on] RA. After administering O2 [oxygen] per [cannula] it increased to 85% at 2 L [liters per min] . Family called to communicate resident's change of condition. EMS was then called and R1 was transported to the hospital at 10:18 p.m. Registered nurse (RN)-B authored the note, however, the note lacked what, if any, assessment had been completed of R1's respiratory system when the staff had initially identified the gurgle noise when getting her up from bed before the meal. When interviewed on [DATE] at 11:28 a.m., licensed practical nurse (LPN)-D stated they had worked with R1 prior to her hospitalization and recalled R1 as needing help to complete most cares. R1 was also talkative but often didn't make sense with the conversation flow. LPN-D stated they [couldn't] say for certain if R1 had a normal 'wet' voice or audible ongoing cough. R1 was on thickened fluids so at times people will hear that. LPN-D stated they felt R1 having audible 'gurgling' noises at rest would be definitely different for her. If that was reported to the nurse, then the nurse should evaluate the lung sounds and check vital signs. That evaluation should then be recorded in the progress notes. LPN-D stated they were not sure what happened to R1 causing her hospitalization but added they were quite shocked when they came to work and heard R1 subsequently died at the hospital as R1 was not terminally ill or on hospice care. When interviewed on [DATE] at 12:32 p.m., nursing assistant (NA)-B stated they were assigned to help care for R1 on [DATE] for the evening (PM) shift. NA-B and NA-C got R1 up from bed around 3:30 p.m. and at that time noticed R1 was a little gurgly sounding. NA-B stated it caused them to wonder if something was a little off but the noise was not very prominent. R1 was taken to the commons area and NA-B stated they told the nurse, RN-B, about the noise R1 had been making. RN-B responded aloud, OK, and NA-B stated they were not sure what actions RN-B did after that with R1. NA-B stated there were no visible secretions on or around R1's mouth when they noticed the noise. When supper time arrived, NA-B stated they helped R1 with eating and R1 then again seemed more gurgly sounding. This was again reported to RN-B who stated they just wanted to watch her and keep monitoring it. NA-B stated the gurgling noise R1 was making was definitely new to me [hearing it]. Then, later in the evening, as they helped R1 to bed the audible gurgling noise was still present, so they raised the head-of-the-bed after R1 was laid down. NA-B stated they again notified the nurse who went into the room around 7:30 or 8:00 p.m. they thought. The nurse attempted to do vital signs but couldn't locate the pulse oximeter right away which caused a delay adding, That took a while. Then around 9:30 p.m., the nurse finally got one and took vital signs, then everything was low and R1's vitals were abnormal. NA-B recalled that R1's family was then called and then she was sent to the hospital with EMS. NA-B stated R1 didn't look too good when she left for the hospital. NA-B reiterated the main nurse helping with R1 that shift was RN-B.When interviewed on [DATE] at 12:53 p.m., NA-C stated they recalled working with R1 on [DATE] in the PM. R1 had sounded like she was really gurgly when they helped her up from bed in the afternoon and felt a little warm to touch. NA-C stated RN-B was told about these issues and responded to keep an eye on her and keep R1 upright in the chair for a while. NA-C stated they were unsure what actions RN-B took to evaluate R1 as they had other people to help care for and left the area. NA-C then helped NA-B put R1 to bed around 7:00 p.m., and R1 again sounded gurgly so the head-of-the-bed was raised up. RN-B was again told of R1 but NA-C was unsure what, if any, follow up was done as they went and helped other people. NA-C recalled that around 8:30 p.m. to 9:00 p.m., RN-B was in R1's room and trying to get vital signs but they were having trouble getting the oxygen levels due to the oximeter being missing. When they finally got it, R1's oxygen level was like 80's [%] and the nurse was super concerned. The nurse then applied oxygen to R1 to help her, but this was just before she left with EMS. R1's medical record was reviewed and lacked evidence what, if any, nursing assessment of R1's respiratory condition was completed around 3:30 p.m., when the NA staff members first identified a possible change in condition of R1's respiratory status. The record lacked any record vital signs or assessment until 9:45 p.m., then the progress note identified RN-B's actions and care provided. When interviewed on [DATE] at 1:04 p.m., RN-B stated they were not told any concerns about R1 in the verbal report from the previous shift on [DATE], but only R1 had been seen by the MD and there were no new orders. RN-B stated R1 had a history of aspiration and would once in a while have a cough they noted. RN-B verified the NA staff reported R1 as sounding gurgly when they got her up before supper. RN-B stated she did a visual look of R1 at that time and R1 appeared at her baseline. RN-B stated they did not obtain vitals or listen to R1's lung sounds when first told as R1 appeared visually to be fine. If she had not looked fine, then RN-B would have done a whole assessment. RN-B stated they did not recall the NA reporting anything concerning R1 at the supper meal. RN-B then explained they saw R1 again after she had been placed into bed. RN-B entered the room and R1 voiced feeling tired, so RN-B turned on the room light. R1 looked pale and her respirations were irregular. RN-B stated it was at that time when they did a whole assessment of R1 and found her to have some faint expiratory wheezing and a very high pulse rate. R1 also had a fluid in her throat sound present. RN-B notified the other nurse working to help evaluate R1 and got a second opinion. The other nurse felt R1 didn't look good, and a decision was made to call the family and seek permission to send R1 to the ED. RN-B verified the first time they listened to R1's lung sounds was after the supper meal when R1 had been placed back into bed. RN-B also verified they did not update the MD about the gurgling noise prior to R1 being sent to the hospital. RN-B stated since this had happened, nobody from management had talked with them about it but reiterated it was not the first time R1 had a wet-sounding voice or noise with breathing adding, It's not like it's never happened before. When interviewed on [DATE] at 1:54 p.m., the director of nursing (DON) stated they felt it would not have been out of the ordinary for R1 to have a wet-sounding voice or gurgle with her speech. R1 had a history of swallowing issues and RN-B did a visual look of R1 and didn't see anything concerning to warrant a full assessment at that point in the early afternoon on [DATE]. DON verified this wet-sounding voice or breathing was not something care planned as normal for R1. DON stated their expectation would be to take a look at R1 and if the nurse felt something was [NAME], to then do a full assessment and chart their findings in the record. DON reiterated they felt a visual assessment would be appropriate and going beyond that depends on the nurse and their nursing judgement. DON stated they had visited with some of the staff members working on [DATE] during the AM shift who felt R1 was her baseline self. DON acknowledged the charting by RN-B did not have a nice timeline of the actions or events and felt it could have been more thoroughly documented. When asked about the regulatory expectations for notification to the physician, DON stated that in that framing and hindsight, she wished RN-B had done a full assessment at 3:30 p.m. when first told of R1's potential issue but reiterated the direct care staff know the residents and she had to rely on the nurses' judgement in the situation. DON stated RN-B was a good nurse and it was concerning there was discrepancies between the NA and nurse about R1's presentation on [DATE]. DON stated they did not feel action sooner, such as a full assessment being done by the nurse at 3:30 p.m., would have changed R1's outcome as R1 was very compromised in her overall condition. DON stated it was important to ensure actions taken with a potential change-of-condition were recorded in the medical record to ensure credit is provided with care given and we want to be able to defend ourselves. On [DATE] at 2:39 p.m., an interview with MD-D was attempted but they were out of the office. MD-F was present who had also been involved with R1's care in the past. MD-F was interviewed at 3:23 p.m. and explained they were part of a team of physicians who round on patients many patients, including R1, who were at the care center. MD-F described R1 as being complicated but stable when they had last evaluated her at the care center. MD-F did not recall R1 as ever having a major respiratory illness, such as COPD or asthma, but stated from his memory that he could envision R1 as having a potential 'wet-sounding' voice at baseline just given her medical history. R1 had a history of stroke and could have a harder time clearing secretions in her throat as a result. When asked if earlier notification to the physician would have changed R1's outcome, MD-F stated R1's clinical picture seemed to change so quickly after MD-D's visit that listening to the lungs and checking vital signs, such as oxygen levels, would have made sense. If those were fine, then notification to the provider was not likely needed right then. MD-F stated an update from the staff about R1 having sudden gurgle noises was also likely not needed, but reiterated that if such happened, then if or when the nurse evaluated R1 and found some objective findings which showed a decline (i.e., poor lung sounds, vital signs out of normal range) then an update would become more appropriate. MD-F stated R1 had a goal of care for more comfort-focused treatments and not super aggressive measures so perhaps a telephone call from the nurse to the family earlier on [DATE] with an update of any assessment findings would have maybe been more appropriate. From that, then the staff could update the provider team for further guidance depending on the family's wishes for care. A facility Notification of Resident Changes policy, dated 12/2024, identified the expectations for when to notify the resident's physician. This included when there was a significant change in resident health. However, it lacked guidance or direction on how nursing was expected to evaluate a potential change of condition or document their actions with such.

Based on interview and document review, the facility failed to provide safe transfer for 1 of 1 resident (R1) who required the use of a mobility van mechanical lift. This resulted in actual harm when R1 fell from the mobility van to the ground which resulted in significant ongoing pain, administration of pain narcotics and a decrease in activities of daily living (ADL)s. The facility implemented corrective action prior to the investigation, so the deficiency was issued at Past Noncompliance. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had moderately impaired cognition, no behaviors, and no rejection of cares. R1 required staff assist with dressing, personal hygiene, and transferring. R1 required a manual wheelchair but was independent with mobility. R1's diagnoses included heart failure, arthritis, aphasia (language disorder that affects how you communicate), hemiplegia (paralysis on one side of body), and seizure disorder. R1 denied having pain but did receive scheduled pain medication.R1's pain assessment dated [DATE], identified R1 did not have any pain or hurting in the five days prior with no other information provided. R1's care plan revised on 9/12/25, directed assist of one to two staff with stand-aid lift, and large harness and one staff assist with upper and lower body dressing.On 12/22/25 at 12:50 p.m., a Plan of Care Note indicated R1 had a fall while getting out of the facility van at his appointment destination. The note further identified the facility van driver noted R1 to have a laceration to back of head, right wrist, and ambulance was called.Hospital ED noted dated 12/22/25 at 1:46 p.m., identified R1 had mild wedging (wedge fracture) of T1, L1, and moderate wedging of LA. The report also identified the fractures are age indeterminate (unsure of age), old but there were no comparison studies. The bones are demineralized which limits detection of nondisplaced acute fracture; with the limitation, there is no definite acute fracture or dislocation identified in the cervical spine.Hospital discharge notes dated 12/25/25 at 10:38 a.m., indicated back pain was musculoskeletal pain; imaging did show some concern of wedging though uncertain on chronicity (age of fracture). Supportive care with plan for therapy consults and pain medication was needed.On 12/26/25 at 1:08 p.m., a Hospital Return Note identified R1 returned to facility after hospitalization for chronic obstructive pulmonary disease (COPD) exacerbation, pneumonia, right wrist wound, and lower back pain. The note further identified R1 was not alert or oriented per baseline and complained of lower back pain during transferring and rolling in bed. R1 was unable to rate pain due to cognition but did attempt to swing out at staff related to the pain and Hydrocodone (narcotic pain medication) ordered for pain. R1 returned with a large hematoma and jagged skin tear to his right hand and a red area to the back of his head.On 12/26/25 on 3:07 p.m., therapy note indicated R1 transferred poorly, demonstrated increased confusion, and had some pain. R1 to utilize a full body lift for transfers and care plan updated.On 1/1/26, R1 required assistance with eating and pain with repositioning was 5-6/10 (pain scale of zero as no pain and ten as the worst pain).Physician visit note dated 1/2/26 at 10:45 a.m., identified R1's physician saw him for the one-week post fall visit and indicated when R1 fell from the facility van, he suffered from a new onset of back pain. Physician review of the hospital notes indicated the concern was for chronic vertebral compression fractures, lumbar region times two but also concerned because he had over this area. The note also identified R1 had become more lethargic and not eating well after the start of the fentanyl patch and discontinued the medication and reassess the next week. Noted that R1 had changed from his baseline. Impression noted as recent fall with new compression fractures versus back pain and chronic compression fractures.On 1/2/26 at 6:55 p.m., assessment reference date (ARD) Charting identified R1 was needing more assistance with ADLs; assist of 1-2 staff with dressing, transfers, and repositioning; assist of 2 staff needed for bed mobility and changing incontinent products; 2 staff needed for transferring with full body lift; and staff assist needed with locomotion. R1 has had increased pain but had improved slightly.R1's Pain Interview for MDS dated [DATE], identified R1 had frequent pain that interfered with therapy and day to day activities almost constantly. R1 rated his pain a 9 on a 0-10 pain scale and verbal descriptor identified very severe, horrible as the intensity of his pain.On 1/6/26 at 1:21 p.m., registered nurse (RN) manager follow up post incident note identified the facility van driver had lowered the lift ramp to the ground and went inside to assist resident onto lift, not realizing lift was on the ground and pushed R1 backwards and off the edge, causing wheelchair to tip over backwards. R1 landed on his hands and knees on the lift ramp and 911 was called to take R1 to emergency room (ER) for evaluation. Outcome showed no broken bones or internal bleeding noted; R1 sustained abrasion to posterior scalp and skin tear to right hand/wrist; complained of back pain but no acute injuries noted on imaging. A change of condition MDS initiated related to resident pain and change in transferring abilities.Physician visit note dated 1/6/26 at 2:00 p.m., identified R1 was seen for follow up to back pain and increase somnolence (sleepiness) and staff needed to move R1 every four hours and that triggered pain. The note further indicated R1's compression fracture was thought to possibly be new but was hard to say; at the very least it was exacerbated by his recent injury. Plan was to increase the Norco (hydrocodone with acetaminophen) to every four hours as needed.R1's care plan updated 1/9/26, maximal assistance of 2 with upper and lower body dressing using the log roll due to back pain; transfer with stand-aid lift with 1-2 and large harness and full body lift with assist of two and large sling as needed; and maximum assistance with rolling in bed, maximum assist with sitting to lying and lying to sitting on the side of the bed related to back pain.1/9/26 2:56 p.m., physician notified that R1 continues to have 5-9 (out of 10) pain ratings at times since fentanyl patch (narcotic pain patch) was discontinued.1/9/26 at 10:36 p.m., R1 refused to get up from bed for supper after multiple attempts and reapproaching resident. R1 did not want to eat when offered as he stated, pain bad with a yelling voice and pushed staff away.R1's December 2025 medication administration record (MAR) identified:-Acetaminophen 1000 mg twice daily for polyosteoarthritis and only identifying pain level of 2 during 9 of 43 administrations and pain level of 3 during 1 of 43 administrations, with an average pain level of .50 over the 21 day period (42 administrations) until 12/26/25 hospital return. R1's documented pain levels ranged from 2-9 from 12/26/25 to 12/31/25, which averaged a pain level of 4.27. -Start date of 12/26/25, fentanyl transdermal patch (narcotic analgesic) 72 micrograms per hour (mcg/hr.) every 72 hours for severe back pain;-Lidocaine (medication to block pain signals to the brain) external patch 5% to back one time a day related to low back pain to apply two patches daily and remove per schedule- hydrocodone-acetaminophen (narcotic analgesic) 5-325 milligrams (mg) one tablet every six hours as needed for pain greater than a 4 out of 10 (received eleven as needed doses between 12/26/25 and 12/30/25)R1's January 2026 MAR indicated (1/1/26-1/16/26): -lidocaine external patch twice daily;- acetaminophen 1000 mg twice daily; with pain rating from 1-10, and an average pain level of 5 over 16 days.-fentanyl transdermal patch every 72 hours until 1/2/26.As Needed (PRN) Medications-hydrocodone -acetaminophen 5-325mg one tablet every six hours as needed for low back pain and was increased to every four hours on 1/6/26. R1 received 21 as needed doses for pain ratings that ranged from 1 to 10 between 1/1/26 and 1/13/26, with an average pain level of 6.7. -oxycodone (narcotic pain medication) one tablet every four hours as needed for pain was ordered on 1/9/26. R1 received ten as needed doses for pain ratings ranging from 2-8 between 1/9/26 and 1/12/26.Observation on 1/13/26 at 1:30 p.m. and 2:40 p.m., R1 was noted to be in recliner chair with eyes closed and headphones on. R1 did open his eyes to voice but then closed them again. Follow up observation on 1/14/26 at 11:13 a.m., noted R1 to bed in bed with eyes closed and did not respond to voice.Interview on 1/14/26 at 11:32 a.m., family member (FM)-A indicated R1 had a fall and was having back pain and was not coming back like he was. FM-A stated R1 had three vertebrae that had hairline fractures but was not sure if they were new or old ones [fractures].During an interview on 1/13/26 at 1:30 p.m., the facility safety officer (SO) indicated he did all the training for the staff regarding the facility mobility van and lift when new staff was hired or began to use the van. The SO denied doing yearly refresher trainings, competencies, or that he had any documentation or proof of training or competency on the employees that are authorized to drive the van and wheelchair lift. The SO stated he was in the process of coming up with one. The SO identified he was aware of R1' fall off the van's wheelchair lift and described it as the driver (D)-A unfolded and lowered the lift to the ground instead of just unfolding it and did not attach the safety belt so when R1 was pushed out of the van, the lift platform was not there and R1 and the wheelchair fell to the ground. The SO stated he inspected the van and lift following R1's fall from the van and found it to be in normal working order. The SO denied having a policy or lift manual for the vehicle but demonstrated the lift instructions posted on the van doors.During an interview on 1/14/26 at 10:40 a.m., D-A had been driving the facility van for approximately four years and received training when he started driving the van but just recently did some retraining on the facility van after R1's fall. D-A further indicated the facility was short of van drivers, and he had been working quite a few extra shifts. D-A stated he was overworked, stressed out and was distracted while unloading R1 from the van after transporting him to an appointment. D-A further stated, while unloading R1 from the facility van, he had lowered the lift platform to assure it was on level ground but forgot to bring the lift back up to the van; he entered the van and pushed R1's wheelchair backward and the lift platform was not there so the resident fell out backward with the wheelchair landing on top of him on the ground. D-A immediately went into the clinic to get R1 help and called 9-1-1. D-A stated the training stated he should have properly turned R1 around so he was forward facing and did not apply the safety belt. D-A expressed remorse about R1's fall incident and has since received retraining and cut back on driving hours.During an interview on 1/13/26 at 3:50 p.m., D-B identified as an authorized driver of the facility vans and used the wheelchair lift on the van for approximately seven years. D-B stated she received training from her supervisor when she first started driving and when the facility got a new van, they received a quick rundown on operating the van but did not include any wheelchair lift training. D-B also denied receiving a formal competency training or annual training, but the facility has implemented annual training and competency for all staff that are authorized to drive the van after R1's fall from the van.During an interview on 1/14/26 at 11:32 a.m., family member (FM)-A stated she was aware of R1's fall from the van and that R1 had been having a lot of pain in his back especially bad when he moves. FM-A stated the x-rays found R1 had three hairline fractures in his vertebrae but was not sure if they were old or new fractures. FM-A further stated, it is hard to visit him now because he is so sleepy, further identified that the facility staff were having a hard time controlling R1's pain and the pain medications were making him too sleepy so they cut back on the pain medications and then he had horrible pain so they put him back on the pain medications. FM-A stated, I am very uneasy about his [R1's] progress; he is just not coming back like he was.During an interview on 1/14/26 at 1:51 p.m., registered nurse (RN)-A identified R1 had some back and leg pain prior to his fall from the van lift but not to the extent R1 has pain now after the fall. RN-A further identified R1 had significant pain when staff reposition or transfer him. RN-A further indicated R1 had a change in condition after the fall from the van lift as he was usually alert and oriented but is now very confused and did not even know who his wife was. R1 required more assistance with activities of daily living (ADL)s, not eating well, did not have the stamina he used to have, not going to activities like he used to, more constipation issues, and was very sleepy when he got his pain medications. RN-A stated R1 still had significant bruising on his right arm, and they were still treating the injury on his right hand but the bruising on the back of his head had improved.During interview on 1/13/26 at 4:11 p.m., the administrator identified that during the root cause analysis (RCA) following R1's 12/22/25 fall from van wheelchair lift, the facility noted there was no annual training and no policy on the van's wheelchair lift.The facility provided a list of six staff that were authorized to use the facility mobility vans and wheelchair lifts. The facility also has three mobility vans with lifts in use.The facility did not have policies on the operation of the van, the wheelchair lift, or on transporting residents outside of the facility.The Past Noncompliance began on 12/22/25. The deficient practice was corrected by 12/31/25, after the facility implemented a systemic plan that included the following actions: D-A and all facility van drivers and wheelchair lift operators were retrained and assured competent prior to allowing staff to transport residents. Additionally, a standard of work (policy) was formulated on 1/9/26 to ensure staff have the proper protocol in writing to follow the van/transporting residents; initiated annual training and competency to all van operators; and the SO was educated on his requirement to ensure proper documentation for qualifications, education, and competency of the van operators.

Based on observation, interview and document review the facility failed to ensure 1 of 1 narcotic emergency kit (E-Kit) was replaced prior to the pharmacy date of expiration documented on top of kit. This had the potential to affect all residents. Findings include: Observation on [DATE] at 4:40 p.m. with registered nurse (RN)-A of the [NAME] Wing medication room, identified the narcotic E-Kit, with a red numbered tag lock, and a bright green pharmacy sticker which listed the expiration date of [DATE]. The label directed to notify pharmacy 7 days prior to this date for replacement. Interview on [DATE] at 4:42 p.m. with RN-A reported the narcotic E-Kit was checked during each shift narcotic count, but there was no individual log signed that the E-kit had been checked and verified the medication had not expired. She reported the only documentation that the count was accurate was in the narcotic book that was signed by both the on-coming and off-going staff members. RN-A reported the expiration sticker should have been noted and the pharmacy notified of the need to provide a new E-Kit as directed on the sticker dated [DATE]. Observation and interview with the director of nursing (DON) identified the narcotic E-Kit contained two outdated medications: Morphine Sulfate 20 milligrams/milliliter (mg/ml) (pain medication) 15 ml bottle with the pharmacy label identifying an expiration date of [DATE], Lorazepam 1 mg tablets (6) with expiration dates of [DATE] (anti-anxiety medication). The DON reported her expectation was for staff to observe the label on the outside of the E-Kit when it was checked with each narcotic count. She was unaware of how the label noting an expiration date of [DATE] was not caught between the multiple shift narcotic counts that had taken place between [DATE] and [DATE]. The DON reported the consultant pharmacist was in the facility monthly, but she was not aware of how often they checked the E-Kits but there should be a system of the pharmacy being aware of when the E-Kit needed to be replaced. Interview on [DATE], at 4:51 p.m. with the consultant pharmacist reported she performed medication review at the facility monthly, but she had not checked the E-Kits and reported they should have been checked for expiration dates. Interview on [DATE] at 8:32 a.m. with the Minnesota Veterans Home Pharmacy manager reported the pharmacy supplied the E- Kits. He would expect the consultant pharmacist to monitor the E-Kits for outdates in addition to the nursing staff while performing narcotic counts on a per shift basis. He reported the pharmacy should have been notified 7 days prior to the expiration date to allow time for a replacement kit to be provided to the facility. Review of the [DATE] Minnesota Department of Veterans Affairs Medication Storage and Security policy identified medication storage areas were to be routinely monitored by nursing staff to prevent use of outdated or discontinued medications. Review of the [DATE] Operating procedure for pharmaceutical services identified both the registered pharmacist and the consulting pharmacist who provided monthly in facility medication reviews were responsible for the provision of pharmacy services. An E-Kit was supplied by the central pharmacy and scheduled II-IV medications were to be reconciled with each shift change. The consulting pharmacist was to review the E-Kit during the monthly review.

Based on interview, and record review the facility failed to ensure 1 of 1 package of routine and controlled narcotic medication, delivered by a package delivery service, was immediately secured into staff custody upon arrival, and when transported by staff and delivered to another unit. Findings include: Interview on 7/10/24 at 1:42 p.m., with LPN-C identified on 6/15/24, she realized medication had not been delivered to the wing, so she went to check if they had been left at the door. She found the medication delivery containing the narcotic E-kit had been left at the door unattended. The bin was secured with 2 plastic zip ties. She delivered the medications to the appropriate wings. She told licensed practical nurse (LPN)-A that she placed the newly delivered medication on the table in the unlocked report room. LPN-A responded verbally she would take care of it. LPN-C. LPN-C failed to notify the DON or administrator of the lack of the delivery driver to drop off medication in a hand off and not leave the medication unattended where potential diversion could occur from passers-by. Interview on 7/10/24 at 11:31 a.m., with DON identified she had not been notified of the unsecured medication left by the delivery driver at the time LPN-C became aware. She also discovered during her investigation medications had been left unsecured in the break room by LPN-C and LPN-A and were not directly handed off to be secured immediately by staff. She agreed medications had the potential to be diverted if not secured appropriately upon arrival to the facility and once at the facility. She had not educated staff. She did however, notify the pharmacist of the medications being left unsecured at the door to the pharmacist. Interview on 7/10/24 at 2:46 p.m., with the pharmacist identified the facility notified him of the medications being delivered and left by the door unattended. He notified the package delivery company of the concerns and directed them to ensure medications delivered to the facility in the future must be handed off to a person and not left unattended. Review of the 3/30/23, Controlled Medication Policy identified that all new schedule II-IV medications (narcotic) orders will be entered into a bound narcotic book upon arrival and count will be verified. Licensed nurses will account for all narcotic medications and verify the count at the end of each shift. If any discrepancies are noted, the nurse manager was to be notified. There was no mention of ensuring immediate custody occurred as soon as medication was brought from the delivery driver, nor was there any indication for staff to report immediately to management if that occurred in the future so immediate action and education could be provided.

Based on interview and record review, the facility failed to compete a thorough investigation when it was reported a potential misappropriation of resident property/potential drug diversion had occurred. Findings include: Review of the 6/18/24 at 11:21 a.m., report to the State Agency (SA) and the 5-day investigation identified LPN-C had found a green tote containing medication including narcotics had been left by the delivery driver inside one of the doors at the facility unattended. LPN-C retrieved the bin and delivered the medication to each wing. When she delivered the medication from the bin to the [NAME] Wing (GW), she was unable to locate the RN so she told LPN-A that she was placing the medication delivery on the table in the report room. LPN-A responded verbally that she would take care of it. The medication was left on the table for an unknown length of time, unattended and not locked. Later that day the after shift report LPN-B went into the medication room and opened the cupboard that holds the narcotic medication emergency kit (E-kit). There were 2 kits in the cupboard, the new one and the old one. He reached up to remove the two kits from the cupboard and the red zip tie lock fell of the new E-kit. The zip tie appeared to have been cut. He noted the E-kit had not been verified and he added it to the narcotic count book. He called the evening supervisor a RN-B and reported the incident. RN-B, RN-C, and LPN-B completed a count of the narcotic E-kit and found it to be short 1 hydrocodone (narcotic used for pain relief) tablet. The E-kit count was then counted again by LPN-B, and the director of nursing (DON) and it was confirmed that the e-kit was short one hydrocodone tablet. Review of the narcotic medication logbooks identified inconsistencies in R1's medication count page 29. The page had 4 entries all signed by LPN-A. The numbers in the column titled amount remaining had been written over with black ink several times and the numbers appeared to have been changed. The entries were no longer legible. The page had been torn out of the bound book and then taped back in and line was drawn through the page with a note transferred to page 31 written at the bottom. The facility investigation identified in an interview with LPN-A that she was not aware that she could not alter the entries or tear a page out of the narcotic logbook. LPN-A identified that she realized during her shift that R1's hydrocodone medication was short 1 tablet, so she went into the med room and cut the zip tie lock off the E-kit and removed a hydrocodone tablet, she did not sign the narcotic medication out and did not notify anyone at the facility at that she had removed it. She later found the missing tablet partially punched out of R1's blister pack of hydrocodone and taped it back in. She left the other hydrocodone tablet that she had removed from the E-kit in the medication cart and planned to destroy it later that day but forgot. The next day 6/16/24, a clear medication cup was found in another wing on a medication tray. LPN-A said when she came in that morning, she found the cup in the med cart but did not know that was the hydrocodone tablet and she placed the tablet on the tray. LPN-A said she was not always completing her triple checks while administering medication. The investigation noted finding that staff had violated several facility medication policies. Interview on 7/10/24 at 1:42 p.m., with LPN-C identified she realized that morning the medication had not been delivered so she went to check if they had been left at the door. She found the medication delivery containing the narcotic E-kit had been left at the door unattended, the bin was secured with 2 zip ties. She delivered the medications to the appropriate wings. When she delivered GW medications and E-kit the RN on that wing was not available so she told LPN-A that she placed the medications on the table in the report room, LPN-A responded verbally she would take care of it. She then left the area. She identified that following this incident she had received an email reminding staff to complete narcotic count at the end of each shift with 2 licensed staff and narcotics can never be left unattended prior to being double locked but did not recall seeing the DON complete any additional training, audits, or competencies. Interview on 7/10/24 at 3:15 p.m., with LPN-B agreed with the above findings and he recalled receiving training via email from the DON to complete counts with 2 licensed nurses at the end of each shift, but did not recall any additional training, audits, or competencies being completed with him following the incident. Interview on 7/10/24 at 11:31 a.m., with DON agreed with the above findings and identified she audited all of the narcotic count logbooks in the facility of the current medication counts, but made no documentation to show that had been completed. She ensured the narcotic count was being completed by 2 licensed nurses at the end of each shift and she looked at the administration records of the other residents who used narcotic pain medication but did not document her findings anywhere. She agreed that she should have included that information in her final investigation summary. Interview on 7/10/24 at 4:09 p.m., with the consulting pharmacist identified she was not aware the facility had an incident of potential diversion. No one had called her to notify her or to request any guidance in this matter. If the facility had called her, she would have reviewed the investigation, the narcotic count, the facility policies, and offered guidance to the facility. Depending on her findings She would have likely recommended re-training, and ongoing documented audits for a period of time. She identified the facility does not typically notify her until the next QAPI meeting and that meeting had not taken place yet. Review of the 6/22/23. Vulnerable Adult-Resident Protection Plan policy identified misappropriation of resident property (aka their medication) was defined as a deliberate misplacement, exploitation, temporary, or permanent use of a resident's belonging or money without the resident's consent. Any staff who become aware of an allegation of misappropriation were to report the incident to their supervisor and facility leadership, and state agency and federally required entities. The investigation policy does note in the event of a suspicion of a crime, it is to be reported to law enforcement. It does not it state nurses involved who are terminated as a result of their practice or concerns over an investigation will be reported to their Board of Nursing.

Based on interview and record review, the facility failed to report to the law enforcement a suspicion of potential drug diversion and failed to notify the Board of Nursing for 1 of 1 nurse (licensed practical nurse (LPN)-A) whose employment was terminated. Findings include: Review of the 6/18/24 at 11:21 a.m., report to the State Agency (SA) identified on 6/15/24, the director of nursing (DON) received a call from the on-call registered nurse (RN)-A, notifying her that a hydrocodone (narcotic pain medication) was missing from the emergency narcotic medication kit (E-Kit). Licensed practical nurse (LPN)-B reported a new E-kit had been delivered earlier that day. After shift report, he had entered the medication room, unlocked the cabinet, and found the old E-kit and the new E-kit were stacked on top of one another. He reached up to remove the E-kits and the lock fell off the old E-kit. He identified that the red zip tie lock appeared to have been cut. He then realized the narcotic E-kit contents had not been verified. LPN-B then called the evening supervisor (RN-B) to report his findings. RN-B and RN-C reviewed the narcotic count books against the actual narcotic pill count for each medication. The narcotic book showed inconsistencies and had been signed out by LPN-A for the day shift of 6/15/24. The narcotic count was correct for 26 tablets, but the 26th dose foil seal was noted as broken and a tablet was taped back into the blister pack. RN-B and RN-C reported their findings to the director of nursing (DON). The DON interviewed LPN-B, RN-B, and RN-C then verified and added the counts from the narcotic E-kit to the narcotic count book. The old E-kit was short 1 hydrocodone tablet and contained 6 hydrocodone tablets but only contained 5. It was reported that earlier that day RN-C delivered the E-kit to the [NAME] Wing (GW) to LPN-A. Several entries in the narcotic book for R1's hydrocodone had been written over by LPN-A. The page had a line through it and the count had been transferred to another new page by LPN-A. DON and LPN-B then examined the blister pack containing R1's hydrocodone tablets and identified the blister pack foil seal of the 26th dose had been broken and a tablet had been taped back in. The DON and LPN-B destroyed the 26th dose because the seal had been compromised. DON then called RN-C to review the findings. During that call, RN-C reported LPN-C had delivered the medications from the pharmacy delivery to the green wing, RN-C did not receive them from LPN-C but when she returned from a resident room at approximately 10:30 a.m., she found the medications were sitting on the back desk in the report room. She reported she saw that there was a narcotic e-kit there with an intact red lock tag on it. She placed the E-kit in the locked medication room. On 6/16/24, the DON returned to the facility to investigate further. RN-C reported on 6/15/24 at approximately 9:15 a.m., she had been in the special care unit (SCU) and found a clear medication cup on a tray with an opened, single-pill blister pack of hydrocodone labeled Found floor-MJ with a pill inside. RN-C observed Page 29 of the green wing narcotic book (the log sheet containing R1's hydrocodone narcotic count) had been ripped out and then taped back in. Before LPN-A could be interviewed by facility management on 6/16/2, she left the facility that morning reporting a family emergency and did not return and could not be reached for interview. LPN-A was notified via phone that she would be placed on investigatory leave effective immediately and pending the outcome of the investigation. There was no mention that facility had notified law enforcement, or that they had verified the medication that had been found in the compromised packaging prior to destroying them. Review of the 6/21/24, 5-day investigation report to the SA identified on 6/20/24 at 9:00 a.m., LPN-A was contacted for interview. LPN-A reported she was not certain if she was present when the new narcotic medications had been delivered to the facility and had not accepted any medications to stock. LPN-A then noted she may have received the medication delivery. LPN-A admitted she had cut the lock on the old narcotic E-kit because when she had counted her medications in her cart, she found she was short 1 hydrocodone for R1. She reported she decided to take 1 from the E-kit to replace it so her count would be correct. LPN-A then stated she went back to the cart with the hydrocodone medication from the E-kit. When she proceeded to do the count again, she stated R1's hydrocodone was partially punched out and hanging from the back of their blister pack card. She reported she taped the back of the blister pack and placed the extra single dose from the E-kit in her pocket. She then reported later that morning she placed the extra dose in a med cup and wrote Destroy on the cup and left it in the med cart. She said she forgot to tell anyone about it. LPN-A never reported to any staff the count was allegedly off or that she had taken a single dose of hydrocodone from the E-Kit. She did admit to altering the narcotic logbook on page 29 of R1's hydrocodone medication, in an attempt to make the count right and had ripped page 29 out of the logbook but then taped it back into the book. She reported she did not know she could not change, alter, or write over entries in a narcotic count logbook or tear pages out. The DON had reviewed R1's medical record and identified he had not shown any signs or symptoms of increased pain, or distress, she re-educated staff via email reminding them to not leave narcotic medication unattended and to always use two licensed nurses to count narcotics at the end of each shift. The investigation made no mention the facility notified law enforcement. Interview on 7/10/24 at 1:42 p.m., with LPN-C identified she realized that morning on 6/15/24, the medication had not been delivered so she went to check if they had been left at the door. She found the medication delivery containing the narcotic E-kit had been left at the door. The bin was secured with 2 zip ties. She delivered the medications to the appropriate wings. When she delivered medications and E-kit, the RN on that wing was not available so she told LPN-A she placed the medications on the table in the report room. LPN-A responded verbally she would take care of it. LPN-C then left the area. Following the incident, she had received an email reminding staff to complete narcotic count at the end of each shift with 2 licensed staff and narcotics can never be left unattended prior to being double locked. Interview on 7/10/24 at 3:15 p.m., with LPN-B agreed with the above findings and reported that he came in for his shift and when he went into the medication room and unlocked the cupboard there was the new kit and the old kit. He reached up to grab them out of the cupboard and the zip tie fell off the E-kit. The tail end of the zip tie was not long like it normally was, and it was obvious it had been cut. He reported it to the on-call RN. He and the DON completed the count of R1's hydrocodone tablets and found the last dose had been opened. He and the DON had to destroy it because the package had been compromised. He recalled receiving training via email from the DON to complete counts with 2 licensed nurses at the end of each shift, but did not recall any additional training, audits, or competencies being completed with him following the incident. There was no indication the medication had been left for law enforcement as potential evidence of a crime, as the actual pill inside had not been verified to be hydrocodone. Interview on 7/10/24 at 11:31 a.m., with the DON identified she agreed with the above findings. She noted she audited all of the narcotic count logbooks in the facility. She ensured narcotic count was being completed by 2 licensed nurses at the end of each shift and she looked at the administration records of the other residents who used narcotic pain medication but did not document it anywhere. She agreed that she should have included that information in her final investigation summary. She identified R1's hydrocodone tablet and the tablet found on the counter in the report room both had to be destroyed because the integrity of the packaging had been broken. She did not report the findings to the police, the pharmacy consultant who provides oversite to the facility, or the board of nursing because she could not determine if LPN-A had taken the narcotic medication out of the facility, and she believed the two tablets that were found were likely the 2 tablets that were missing. LPN-A had been terminated as a result of the incident. The DON had only reviewed the current narcotic count and had not looked at past resident administrations LPN-A had administered to see if there was potential increase in pain over shifts she had worked where medication was otherwise not normally given, or if there had been other instances of errors/documentation issues from LPN-A in the counting of narcotics. Interview on 7/10/24 at 4:09 p.m., with the consulting pharmacist identified she was not aware the facility had an incident of potential diversion. No one had called her to notify her or to request any guidance in this matter. If the facility had called her, she would have reviewed the investigation, the narcotic count, the facility policies, and offered guidance to the facility. Depending on her findings, she would have likely recommended re-training, and ongoing documented audits for a period of time. She identified the facility does not typically notify her until the next QAPI meeting and that meeting had not taken place yet. Review of the 6/21/23 facility Vulnerable Adult-Resident Protection Plan Policy identified the facility will report to the state licensing authorities (board of nursing) and to law enforcement any knowledge it has of actions which may need to be reported to the licensing board which would indicate unfitness for services as a licensed professional.

Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1), was free from potential misappropriation of property and/or potential drug diversion of ordered narcotic pain medication. Findings include: Review of the 6/18/24 at 11:21 a.m., report to the State Agency (SA) identified on 6/15/24, the director of nursing (DON) received a call from the on-call registered nurse (RN)-A, notifying her that a hydrocodone (narcotic pain medication) was missing from the emergency narcotic medication kit (E-Kit). Licensed practical nurse (LPN)-B reported a new E-kit had been delivered earlier that day. After shift report, he had entered the medication room, unlocked the cabinet, and found the old E-kit and the new E-kit were stacked on top of one another. He reached up to remove the E-kits and the lock fell off the old E-kit. He identified that the red zip tie lock appeared to have been cut. He then realized the narcotic E-kit contents had not been verified. LPN-B then called the evening supervisor (RN-B) to report his findings. RN-B and RN-C reviewed the narcotic count books against the actual narcotic pill count for each medication. The narcotic book showed inconsistencies and had been signed out by LPN-A for the day shift of 6/15/24. The narcotic count was correct for 26 tablets, but the 26th dose foil seal was noted as broken and a tablet was taped back into the blister pack. RN-B and RN-C reported their findings to the DON. The DON interviewed LPN-B, RN-B, and RN-C then verified and added the counts from the narcotic E-kit to the narcotic count book. The old E-kit was short 1 hydrocodone tablet and contained 6 hydrocodone tablets but only contained 5. It was reported that earlier that day RN-C delivered the E-kit to the [NAME] Wing (GW) to LPN-A. Several entries in the narcotic book for R1's hydrocodone had been written over by LPN-A. The page had a line through it and the count had been transferred to another new page by LPN-A. DON and LPN-B then examined the blister pack containing R1's hydrocodone tablets and identified the blister pack foil seal of the 26th dose had been broken and a tablet had been taped back in. The DON and LPN-B destroyed the 26th dose because the seal had been compromised. DON then called RN-C to review the findings. During that call, RN-C reported LPN-C had delivered the medications from the pharmacy delivery to the green wing, RN-C did not receive them from LPN-C but when she returned from a resident room at approximately 10:30 a.m., she found the medications were sitting on the back desk in the report room. She reported she saw that there was a narcotic e-kit there with an intact red lock tag on it. She placed the E-kit in the locked medication room. On 6/16/24, the DON returned to the facility to investigate further. RN-C reported on 6/15/24 at approximately 9:15 a.m., she had been in the special care unit (SCU) and found a clear medication cup on a tray with an opened, single-pill blister pack of hydrocodone labeled Found floor-MJ with a pill inside. RN-C observed Page 29 of the green wing narcotic book (the log sheet containing R1's hydrocodone narcotic count) had been ripped out and then taped back in. Before LPN-A could be interviewed by facility management on 6/16/2, she left the facility that morning reporting a family emergency and did not return and could not be reached for interview. LPN-A was notified via phone that she would be placed on investigatory leave effective immediately and pending the outcome of the investigation. There was no mention that facility had notified law enforcement, or that they had verified the medication that had been found in the compromised packaging prior to destroying them. Review of the 6/21/24, 5 day investigation report to the SA identified on 6/20/24 at 9:00 a.m., LPN-A was contacted for interview. LPN-A reported she was not certain if she was present when the new narcotic medications had been delivered to the facility and had not accepted any medications to stock. LPN-A then noted she may have received the medication delivery. LPN-A admitted she had cut the lock on the old narcotic E-kit because when she had counted her medications in her cart, she found she was short 1 hydrocodone for R1. She reported she decided to take 1 from the E-kit to replace it so her count would be correct. LPN-A then stated she went back to the cart with the hydrocodone medication from the E-kit. When she proceeded to do the count again, she stated R1's hydrocodone was partially punched out and hanging from the back of the their blister pack card. She reported she taped the back of the blister pack and placed the extra single dose from the E-kit in her pocket. She then reported later that morning she placed the extra dose in a med cup and wrote Destroy on the cup and left it in the med cart. She said she forgot to tell anyone about it. LPN-A never reported to any staff the count was allegedly off or that she had taken a single dose of hydrocodone from the E-Kit. She did admit to altering the narcotic logbook on page 29 of R1's hydrocodone medication, in an attempt to make the count right and had ripped page 29 out of the log book but then taped it back into the book. She reported she did not know she could not change, alter, or write over entries in a narcotic count logbook or tear pages out. The DON noted she had reviewed R1's medical record and identified he had not shown any signs or symptoms of increased pain, or distress, she re-educated staff via email reminding them to not leave narcotic medication unattended and to always use two licensed nurses to count narcotics at the end of each shift. The investigation made no mention that they had notified their consulting pharmacist for guidance, that they notified law enforcement of the suspicion of a crime, or completed any audits or competencies to ensure deficient practice had been corrected. R1's 6/19/24, Minimum Data Set (MDS) assessment identified he had admitted to the facility in March of 2023. R1 was dependent on staff for all activities of daily living (ADL's) and had diagnosis of lower back pain and neuropathy. R1's June 2024 administration record identified he was administered one hydrocodone 5/325 milligrams (mg) three times daily. The administration record identified LPN-A had signed off in the electronic medical record that she had administered the medication on 6/15/24 at 8:00 a.m., and 12:00 p.m. Review of the narcotic book page 29 identified R1's hydrocodone medication, 1 tablet had been signed out as given by LPN-A on 6/15/24 at 8:56 a.m., and 1 tablet was signed out as given at 12:00 p.m. There were 4 entries on the page, under the column labeled Amount Remaining listed the number of tablets left after each administration. The numbers were clearly hand-written over several times with black ink and barely legible. Each of the entries were signed in black ink by LPN-A The page had been torn out of the bound book, then taped back in. The page had a line through it with a note transferred to page 31. Interview on 7/10/24 at 1:42 p.m., with LPN-C identified she realized that morning on 6/15/24,the medication had not been delivered so she went to check if they had been left at the door. She found the medication delivery containing the narcotic E-kit had been left at the door. The bin was secured with 2 zip ties. She delivered the medications to the appropriate wings. When she delivered medications and E-kit, the RN on that wing was not available so she told LPN-A she placed the medications on the table in the report room. LPN-A responded verbally she would take care of it. LPN-C then left the area. Following the incident, she had received an email reminding staff to complete narcotic count at the end of each shift with 2 licensed staff and narcotics can never be left unattended prior to being double locked but did not recall seeing the DON complete any additional training, audits, or competencies. Interview on 7/10/24 at 3:15 p.m., with LPN-B agreed with the above findings and reported that he came in for his shift and when he went into the medication room and unlocked the cupboard there was the new kit and the old kit. He reached up to grab them out of the cupboard and the zip tie fell off the E-kit. The tail end of the zip tie was not long like it normally was, and it was obvious it had been cut. He reported it to the on-call RN. He and the DON completed the count of R1's hydrocodone tablets and found the last dose had been opened. He and the DON had to destroy it because the package had been compromised. He recalled receiving training via email from the DON to complete counts with 2 licensed nurses at the end of each shift, but did not recall any additional training, audits, or competencies being completed with him following the incident. There was no indication the medication had been left for law enforcement as potential evidence of a crime, as the actual pill inside had not been verified to be hydrocodone. Interview on 7/10/24 at 11:31 a.m., with the DON identified she agreed with the above findings. She noted she audited all of the narcotic count logbooks in the facility. She ensured narcotic count was being completed by 2 licensed nurses at the end of each shift and she looked at the administration records of the other residents who used narcotic pain medication but did not document it anywhere. She agreed that she should have included that information in her final investigation summary. She identified R1's hydrocodone tablet and the tablet found on the counter in the report room both had to be destroyed because the integrity of the packaging had been broken. She did not report the findings to the police, the pharmacy consultant who provides oversite to the facility, or the board of nursing because she could not determine if LPN-A had taken the narcotic medication out of the facility, and she believed the two tablets that were found were likely the 2 tablets that were missing. LPN-A had been terminated as a result of the incident. The DON had only reviewed the current narcotic count and had not looked at past resident administrations LPN-A had administered to see if there was potential increase in pain over shifts she had worked where medication was otherwise not normally given, or if there had been other instances of errors/documentation issues from LPN-A in the counting of narcotics. Review of the facilities 7/13/23, Drug Disposition policy identified diversion of medications is the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use. Medications will be disposed of if it was dispensed in error and the medication will be destroyed. Staff were to follow the facility policy for medication destruction and use 2 licensed nurses to destroy the medication and record it in the narcotic logbook. Review of the 8/2/19, Operating Procedure: L Controlled Medication Record policy identified staff were to properly record and reconcile controlled narcotic medication each shift with 2 nurses verifying each record. Discrepancies were to be reported. There was no mention of what staff should do if there was a suspicion of a crime, potential evidence gathering, notification of law enforcement etc.

Based on observation, interview, and document review, the facility failed to ensure side rails were assessed to determine appropriateness and safety of use for 4 of 4 residents (R9, R16, R30 and R31) who was observed to have a side rails affixed to their beds. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 was cognitively intact and required extensive assistance with bed mobility and transfers. R9's diagnoses included traumatic brain dysfunction (head injury causing damage to the brain by external force or mechanism), hemiplegia (condition that causes paralysis or weakness on one side of the body) and contracture of muscle, multiple sites. R9's care plan dated 7/7/23, included that R9 utilized bilateral assist device bars on bed to assist with bed mobility. Additionally, the care plan included that R9 needs assistance of two staff to boost up in bed. On 10/2/23 at 2:25 p.m., Observed R9's bed had 1/2 side rails affixed to the head of bed on both sides of bed. R9's medical record lacked evidence an assessment had been completed to determine necessity and whether R9 could safely use side rails. Additionally, R9's medical record lacked evidence alternatives were tried prior to installing the side rails, the resident or representative were educated on the risk of having a side rail on bed, if a consent form was completed and a order from the provider was obtained. R16's annual MDS dated [DATE], identified R16 had moderate cognitive impairment and required extensive assistance with bed mobility and transfers. R16's diagnoses included Alzheimer's Disease (type of brain disorder that causes problems with memory, thinking and behavior), non-Alzheimer's dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems due to causes other than Alzheimer disease), anxiety disorders and repeated falls. R16's care plan dated 9/26/23, included that R16 needs assistance of two staff with bed mobility and transfers. Care plan does not indicate bed rails. On 10/2/23 at 1:59 p.m., Observed R16's bed had 1/2 side rails affixed to the head of bed on both sides of bed. R16's medical record lacked evidence an assessment had been completed to determine necessity and whether R16 could safely use side rails. Additionally, R16's medical record lacked evidence alternatives were tried prior to installing the side rails, the resident or representative were educated on the risk of having a side rail on bed, if a consent form was completed and a order from the provider was obtained. R30's quarterly MDS dated [DATE], identified R30 had moderate cognitive impairment and required extensive assistance with bed mobility and transfers. R30's diagnoses included stroke (occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), hemiplegia affecting left side of body. R30's care plan dated 9/15/23, included that R30 utilized bilateral assist device bars on bed to assist with bed mobility. On 10/2/23 at 5:07 p.m., Observed R30's bed had 1/2 side rails affixed to the head of bed on both sides of bed. R30's medical record lacked evidence an assessment had been completed to determine necessity and whether R30 could safely use side rails. Additionally, R30's medical record lacked evidence alternatives were tried prior to installing the side rails, the resident or representative were educated on the risk of having a side rail on bed, if a consent form was completed and a order from the provider was obtained. R31's quarterly MDS dated [DATE], identified R31 was cognitively intact and required supervision with bed mobility and transfers. R31's diagnoses included chronic kidney disease. R31's care plan dated 9/11/23, included that R31 is independent with bed mobility and transfers. Care plan does not indicate bed rails. On 10/2/23 at 4:59 p.m., Observed R31's bed had 1/2 side rails affixed to the head of bed on both sides of bed. R31's medical record lacked evidence an assessment had been completed to determine necessity and whether R31 could safely use side rails. Additionally, R31's medical record lacked evidence alternatives were tried prior to installing the side rails, the resident or representative were educated on the risk of having a side rail on bed, if a consent form was completed and a order from the provider was obtained. On 10/4/23 at 10:22 a.m., nursing assistant (NA)-B stated R9 is minimally able to reposition self while in bed. NA-B stated R16 is dependent on all activities of daily living (ADL's) and is not able to reposition self in bed. NA-B stated R30 is moderately able to reposition self in bed. R30 can roll to the left and is able to use side rail for turning. NA-B stated R31 is independent with all ADL's and uses the side rails to get in and out of bed. On 10/4/23 at 10:41 a.m., registered nurse (RN)-C stated that she was not sure who was responsible for assessments of the side rails and indicated that therapy may perform them. On 10/4/23 at 11:28 a.m., the director of nursing (DON) stated physical therapy are to assess for side rails. DON stated once physical therapy assesses resident and deemed it appropriate for resident to use side rail, then an assessment would be completed by the nurse. Care plan would be updated, risks/benefits would be discussed with resident and/or resident's representative and a consent form would be obtained. DON stated this is a new process and confirmed that R9, R16, R30 and R31 did not have assessments and/or risk/benefits completed. DON stated assessment of side rails is important to ensure appropriateness and safety for the resident. The Bed Inspection policy dated 5/10/18 indicated residents will be screened to determine the level a resident's independence with bed mobility. Staff were to assess the need for special equipment or accessories (e.g., positioning bar, half, or quarter rail for positioning). Assess the resident to identify appropriate alternative(s) prior to installing bed rails, and assess the resident for risk of entrapment from bed rails prior to installation. The increased risk would be largely due to unsafe moving about the bed, or ill-advised attempts to exit from the bed. Additionally, untimely responses to care increased the risk of entrapment. No matter the purpose for use, bed rails and other bed accessories, although prescribed to improve functional independence with bed mobility and transfers, may increase resident safety risk. Staff were to review the risk and benefits with resident and resident representative and obtain informed consent.

Based on observation, interview, and document review, the facility failed to ensure nursing assistant (NA) staff correctly transferred 1 of 1 resident (R47) resident with use of 2 staff during a mechanical sit to stand lift transfer to ensure his safety. Findings included: On 10/2/23 at 1:52 p.m., R47 stated that he needs two staff to assist him with transferring, with the mechanical lift, when he gets in and out of recliner. On 10/2/23 at 2:31 p.m., nursing assistant (NA)-A brought a mechanical lift into R47's room and assisted R47 with transferring from recliner to wheelchair with one staff. R47's annual Minimum Data Set (MDS) dated [DATE], identified R47 was cognitively intact and required extensive assistance from two staff for transfers. R47's diagnoses included Parkinson's disease (condition that affects the brain and causes problems with movement, balance, and coordination), myasthenia gravis (neuromuscular disorder that leads to weakness of skeletal muscles) and dependence on other enabling machines and devices. R47's care plan dated 8/11/23, identified R47 needed assistance of two staff with a stand-aid lift (mechanical sit to stand lift) for transfers. On 10/4/23 at 10:22 a.m., NA-B stated R47 utilizes a mechanical lift with assistance of two staff at all times for transfers. On 10/4/23 at 10:41 a.m., registered nurse (RN)-C stated that R47 is an assist of two staff with the mechanical lift for all transfers. On 10/4/23 at 11:28 a.m., director of nursing (DON) stated that staff are aware of what type of assistance a resident need from the care plan. DON confirmed that R47's care plan indicated that R47 needs two staff for transfers with the mechanical lift. The DON stated it is important to ensure staff are following the care plan for resident's safety. The Transfers policy dated 5/4/23, indicated residents will be prepared for a transfer and complete the transfer by referring to the resident's care plan for specific transfer directions.

Based on interview and document review, the facility failed to notify the county (designated State Mental Health Authority) for 1 of 1 resident (R49) with new onset of mental illness. Findings include: R49's 4/5/23, Initial Pre-Admission Screening (PAS), did not identify a diagnosis of mental illness and did not indicate the need for a Level II PASARR to be completed. R49's 4/12/23, admission Minimum Data Set (MDS) assessment identified R49 was admitted on [DATE]. R49's cognition was intact with diagnoses of anxiety, depression and Post Traumatic Stress Disorder. R49 had disorganized thinking, felt tired and having little energy, feeling bad about himself or feeling like he let his family down, and had trouble concentrating during the 14-day assessment period. Additionally, R49's 7/13/23, quarterly MDS identified R49 continued to have disorganized thinking, had little interest or pleasure in doing things, feeling down, depressed or hopeless, thought he would be better off dead, or of hurting himself in someway during the 14-day assessment period. R49's 4/12/23, progress note identified social services had assessed R49 following a conversation he had with the therapist that day. The mental help provider had been contacted and R49 had a crisis assessment completed to determine a need for crisis counseling or if a session could wait until Monday. R49's 4/17/23, Mental Health Consult note identified R49 had been seen and had a history of working with a psychiatrist in the past related to suicidal thoughts. R49 plan to continue to work with the Mental Health provider here at the facility. R49's undated, Medical Diagnoses identified upon admission he had diagnoses of anxiety, depression, obsessive-compulsive personality disorder. On 5/11/23 a new diagnosis of suicidal ideation was noted. Interview on 10/3/23 at 11:38 a.m., with licensed social worker (LSW)-A identified if a resident was to receive a new mental health diagnosis, she would contact Senior Linkage to see if a Level II Preadmission Screening and Annual Resident Review (PASARR) would need to be completed. The LSW noted R49's suicidal statements were to be taken seriously, and the facility completed a suicidal risk assessment and made a referral to a mental health provider. She confirmed R49 had received a new diagnosis of suicidal ideation on 5/11/23, and she had not notified senior linkage of the new diagnosis for a Level II screening for additional services that may be needed. Review of 1/20/23, (PASARR) Policy identified a mental disorder was often associated with significant distress or disability. A resident with a new possible serious mental disorder or related condition should be referred for a level II screening to Senior Linkage.

Based on interview and document review the facility failed to conduct infection control surveillance immediately upon discovering 2 staff members developed COVID-19-like symptoms, to prevent the spread of COVID-19 according to Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice had the potential to effect 39 out of 62 residents at the facility. The facility also failed to ensure all staff COVID-19 rapid self-test results were documented according to CDC guidelines and failed to appropriately disinfect 1 of 1 glucometer in between resident use. Finding include: SURVEILLANCE Review of the Employee Illness Tracking Form dated 12/11/22, indicated RN-M called in sick for her shift from 3:00 p.m. to 11:00 p.m. due to symptoms including a cough, muscles aches, and a sore throat. The symptoms began on 12/10/22, and her COVID-19 test was negative. During an interview on 12/13/22, at 1:46 p.m. nursing assistant (NA)-A stated prior to her overnight shift on Friday, 12/9/22, she began feeling dizzy and thought she had a fever. NA-A called the facility and was advised by registered nurse (RN)-D to go to the emergency room (ER) to be tested for COVID-19. NA-A tested positive for COVID-19 that evening and notified licensed practical nurse (LPN)-D of the results. NA-A called the facility again on 12/10/22, to ensure her shift for that night was also covered and notified RN-E of her positive COVID-19 result the night before. RN-E advised NA-A that she was already aware of her positive COVID-19 test and her weekend shifts were covered. NA-A was told to call back on Monday 12/12/22, to advise the director of nursing (DON) that she had tested positive for COVID-19. During an interview on 12/13/22, at 3:42 p.m. RN-D stated NA-A called her at the facility on 12/9/22, and told RN-D she had a low grade fever despite taking Tylenol, and her ears were plugged. NA-A stated she would not be coming into work that night and RN-D advised NA-A to go to the ER because COVID-19 and influenza were going around. RN-D stated staff could test themselves with a rapid COVID-19 test if they were feeling ill; however, RN-D did not know if there was a policy for staff testing or if there was a log to record the test results on. RN-D further stated she did not know the policy for staff leaving if they began feeling ill while at the facility and assumed it would be based on how bad the symptoms are. During an interview on 12/13/22, at 3:08 p.m. RN-E stated NA-A called her on Saturday 12/10/22, and told RN-E she tested positive for COVID-19 the previous evening. RN-E advised NA-A to call back on Monday 12/12/22, to notify the DON of her test results. RN-E stated she covered NA-A's shift herself on Saturday 12/10/22; however, RN-E stated she began having a sore throat on the evening of 12/10/22, and called in sick on 12/11/22. RN-E performed a rapid COVID-19 test on herself at the facility on 12/10/22 when the sore throat began but since the results were negative, RN-E finished working her shift. RN-E stated she had developed a dry cough and did not know if she needed to take another COVID-19 test prior to her next shift that week. During an interview on 12/13/22, at 3:52 p.m. the infection preventionist (IP) stated she was unaware of NA-A's positive COVID-19 result until 12/12/22, when she checked the ill slips in her mailbox. The IP stated she would have expected the staff to notify herself, the DON, the assistant director of nursing (ADON), and/or the administrator as soon as they were aware of the positive result so they could conduct contact tracing to determine if other staff and/or residents had a high-risk exposure. The IP was unaware of a policy or procedure related to ongoing testing of symptomatic staff whose initial test for COVID-19 was negative. The IP further stated anytime a staff performed a rapid self-test for COVID-19, they should document the result on the Staff BinaxNOW Rapid Test Log. The IP verified the log lacked documentation of any test results for the month of December 2022. During an interview on 12/14/22, at 10:00 a.m. the IP stated RN-E was also positive for COVID-19. Although RN-E had called in sick on Sunday 12/11/22, with symptoms of a cough, muscle aches, and a sore throat, the IP did not expect staff to notify her or other management team members, nor did she feel she needed to interview RN-E immediately to determine if other staff and/or residents could have had a high risk exposure because RN-E's rapid self-test at the time of symptom onset, was negative. During an interview on 12/12/22, at 1:31 p.m. the DON stated she was informed that morning of NA-A's positive COVID-19 test result on 12/10/22, and would have expected to be notified immediately to determine if other staff or residents had a high risk exposure and might require testing. The DON further stated staff had recently been trained to perform their own rapid COVID-19 tests and to log all results on the Staff BinaxNOW Rapid Test Log. Centers for Medicare & Medicaid Services (CMS) QSO-20-38-NH dated 9/23/22, indicated swift identification of confirmed COVID-19 cases allowed facilities to take immediate action to remove exposure risks to nursing home residents and staff. Facilities must test any individual with symptoms consistent with COVID-19 or with known or suspected exposure to COVID-19. Testing for COVID-19 must be consistent with current standards of practice and each instance of testing must be documented that the testing was completed and include the results of each staff test. The facility is required to obtain documentation that the COVID-19 tests were completed. Regardless of staff vaccination status, staff are to report a positive viral test for SARS-CoV-2, symptoms of COVID-19, or a high-risk exposure to someone with SARS-CoV-2 to the facility. Staff with signs or symptoms of COVID-19, regardless of vaccination status, must be tested as soon as possible and are expected to be restricted from the facility pending the results. Staff who do not test positive, but have symptoms, should follow the facility guidelines to determine when they can return to work. Review of the RN/LPN Meeting Minutes November 16, 2022, competencies for BinaxNOW were completed for all staff in attendance. Staff were able to test staff if they came to work symptomatic or have symptoms start during their work shift. All staff testing results completed at the facility were to be recorded on the Staff BinaxNOW Rapid Test Log clipboard by the main entrance. Review of the Staff BinaxNOW Rapid Test Log indicated no test results were documented for the month of December 2022. Review of the facility Infection Prevention and Control Program policy dated 2/1/21, indicated any emerging pathogens that are identified that pose a risk to residents or staff, will be managed according to the CDC and Minnesota Department of Health (MDH) guidelines. The facility will maintain an active line list to readily identify outbreaks as they occur. The facility will adhere to federal and state standards to protect healthcare workers against transmission of infections agents. A facility policy related to staff testing for COVID-19 was requested but not received. 38687 GLUCOMETER DISINFECTION Observation on 12/13/22 at 11:50 a.m. of R7's blood sugar check with licensed practical nurse (LPN\)-C identified she obtained a multi-resident use glucometer from a tub on her medication cart. LPN-C then proceeded to check R7's blood glucose. LPN-C then brought the contaminated glucometer back to her cart, and proceeded to wipe it with a Sani-wipe disinfecting cloth for approximately 15-20 seconds and placed it back into the container on her medication cart. Interview and manufacturer label review on 12/13/22 at 1:29 p.m., identified LPN-C noted the Sani-wipe container had a 1 minute wet-contact time. LPN-C stated she thought the product disinfected after 1 min, and was unaware the product needed to remain wet for 1 min to ensure appropriate disinfection. Review of the March 2010, Blood Glucose Monitoring Cleaning policy identified after use, staff were to place the monitor back into the tote and allow the solution to dry for 2 minutes. There was no indication the policy had been updated to follow current manufactures guidelines on the label for wet-contact time.

Based on interview and document review, the facility failed to ensure 1 of 1 resident (R22) had an appropriate diagnosis for narcotic pain medication use. Findings include: Observation on 12/13/22 at 2:07 p.m., of R22 identified R22 appeared to be easily confused. R22's current, undated medical diagnoses list identified R22 had chronic obstructive pulmonary disease (COPD), a history of pneumonia, depression, phobic anxiety disorder, dementia without behavioral disturbances, and adult failure to thrive. There were no diagnoses to indicated R22 had a diagnosis of terminal dyspnea. R22's 11/26/22, physician order identified oxycodone HCL concentrate (narcotic pain medication), with instructions to give R22 0.25 milliliters (ml) orally every 6 hours as needed for dyspnea (difficulty breathing). There was no indication R22 had an order for end-of life treatment. Review of the August, 2021, article: How Successful Is Parenteral Oxycodone for Relieving Terminal Cancer Dyspnea Compared With Morphine? A Multicenter Prospective Observational Study, located at https://pubmed.ncbi.nlm.nih.gov/33290857/#:~:text=Conclusion%3A%20Parenteral%20oxycodone%20may%20be,than%20morphine%20for%20terminal%20dyspnea, identified the conclusion was noted to whereas oxycodone may be equally effective and safe as morphine in the treatment of terminal dyspnea in cancer patients. Future randomized controlled trials should confirm the efficacy and safety of opioids other than morphine for terminal dyspnea. There was no mention of appropriate use for routing dyspnea in the absence of a terminal diagnosis. R22's pharmacy reviews identified R22 had no pharmacy review after the 11/26/22 order above to assist the facility in identifying appropriate associated diagnoses with medication management. R22's 11/25/2022, physician visit note identified R22 was 90-day post hospital from having pneumonia. R22 was noted as having had quite a bit of behaviors. R22's family was refusing the Ativan (anti-anxiety medication). R22 has also had some pain which was generalized and noted to be everywhere. R22 was refusing. The hospital recommended Roxanol at that time for his shortness of breath (related to his COPD). His morphine had helped with that but [R22] was refusing that medication. R22 was also noted to be hallucinating. There was no mention of the new order for oxycodone for R22's pain. R22's progress notes identified on 11/26/22 at 2:25 p.m., staff noted they received call from the emergency room where R22 was sent for medical examination ER that they discussed R22's morphine use. Staff were directed to discontinue that and start oxycodone. The ER doctor discussed the medication regimen with R22's spouse, and she was in agreement. There was no indication staff clarified the order as to the purpose of R22's newly ordered pain medication to identify an appropriate diagnosis was associated. R22's 11/28/22, psychiatric note noted apparently there is talk of consideration of palliative care, but the meeting is sched for tomorrow. Interview on 12/14/22 at 12:44 p.m. with the assistant director of nursing (ADON) identified the palliative care meeting was rescheduled to 1/6/23 because R22 was sick. R22 often refused his morphine because he didn't like the way the morphine made him feel. R22 had sometimes complained of tailbone pain. There was discussion of hospice, but R22 has declined. The ADON agreed dyspnea was not an approved diagnosis for narcotic pain medication in the absence of a terminal diagnosis. Review of the 11/30/22, Medication Management policy identified each resident's drug regimen was to be free of unnecessary drugs. An unnecessary drug was a drug that had no adequate indications for use.

Based on interview and document review the facility failed to comprehensively reassess nursing interventions and notify a provider of a new and worsening pressure ulcer for 1 of 1 (R35) resident. Findings include: R35's quarterly Minimum Data Set (MDS) dated [DATE], indicated R35 was unable to complete the Brief Interview for Mental Status (BIMS). R35 felt or appeared down, depressed or hopeless for 12-14 days during the assessment period and exhibited no behaviors. R35 required supervision after set-up for eating and extensive assistance of two staff for all other activities of daily living (ADLs). R35 was frequently incontinent of bowel and bladder but was not on a toileting program. R35 also reported no pain during the assessment period. R35 was at risk for pressure ulcers and had a stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) pressure ulcer at the time of the assessment R35's diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary edema (COPD), chronic kidney disease (CKD), dementia, failure to thrive, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (an enlarged prostate gland causing urine retention and increased frequency to urinate), above the knee amputation right leg and constipation. R35's Care Area Assessment (CAA) dated 1/11/22, indicated R35 triggered for ADLs, urinary incontinence, nutritional status, and pressure ulcers. R35's care plan dated 12/12/22, indicated R35 was frequently incontinent of bowel and bladder. Interventions included R35 wearing an incontinent brief at all times, and staff assisting R35 with his toileting needs upon rising, before and after meals, at bedtime and as needed. The care plan also indicated R35 had an open area on his right buttocks and was at risk for further breakdown related to decreased mobility, noncompliance with repositioning, cervical spine stenosis (a narrowing of the spinal column in the neck), swelling to R35's lower extremity, and an above the knee amputation to R35's right leg. R35 had a history of open areas on both buttocks, the tip of his penis, and bleeding hemorrhoids. Interventions included to follow the facility skin protocol for documentation and treatment to an open area on R35's left buttock, keeping skin clean, dry and free from pressure, reposition R35 every two hours, and assess and document R35's skin condition weekly per facility protocol. The care plan also indicated R35 had a nutrition-hydration potential for less than body requirements related to left vocal cord and larynx paralysis, dementia, failure to thrive, depression and a history of weight loss; however, the care plan lacked nutritional interventions to address R35's skin breakdown. R35's nursing orders dated 12/7/22, indicated to reposition R35 into bed after breakfast and after noon meal for at least an hour then R35 may go to his recliner. Apply Triad to small open area on left buttocks two times a day. R35's treatment administration record (TAR) dated October and November 2022, indicated R35 had Triad cream applied to his left buttock twice a day beginning on 10/28/22, at 8:00 p.m. to 11/12/22, at 11:37 a.m. R35's TAR dated December 2022, indicated R35 had Triad cream applied to a small open area on his left buttocks twice a day for assessment from 12/7/22, at 8:00 p.m. to 12/14/22, at 7:00 a.m. R35's Skin & Wound Evaluation dated 10/28/22, indicated R35 had a new, open lesion on his left buttock that was acquired at the facility. The wound bed was filled with 100% granulation (new tissue on a wound to indicate healing) with light exudate (drainage). The edges were flush with the wound bed or had a sloping edge, and there was no induration (thickened skin or tissue indicating a possible infection) or swelling. The temperature surrounding the wound was normal. Interventions included a cushion and Triad cream (a wound dressing cream). The evaluation lacked wound bed measurements and no notification to the provider, resident/responsible party, dietician, and/or therapy was indicated. R35's Skin & Wound Evaluation dated 11/5/22, indicated R35's open lesion on his left buttock remained 100% filled with granulated tissue, with light serous (thin, yellowish) drainage. The wound edges were flush with the wound bed with no induration. The surrounding tissue was blanchable (whitening of external tissue upon compression) and a normal temperature, with no swelling. Interventions included using a generic wound cleanser, incontinence management, a turning and repositioning program, and applying Triad cream. The evaluation also indicated the wound was improving. The evaluation lacked wound bed measurements and no notification to the provider, resident/responsible party, dietician, and/or therapy was indicated. R35's Skin & Wound Evaluation dated 11/13/22, indicated R35's open lesion on his left buttock measured a total area of 0.5 centimeters (cm), a length of 0.6 cm by a width of 0.6 cm. The evaluation lacked indication of the wound bed tissue, presence or absence of exudate, wound edge description, presence or absence of induration or swelling. Interventions included using a generic wound cleanser and a film membrane. The evaluation further indicated the wound had resolved and no notification to the provider, resident/responsible party, dietician, and/or therapy was indicated. R35's Skin & Wound Evaluation dated 12/7/22, indicated R35 had a new, open lesion on his left buttock acquired at the facility. The wound measured a total area of 0.2 cm squared, a length of 0.4 cm by a width of 0.6 cm. The wound bed was filled 100% with granulated tissue with no exudate. The evaluation further indicated R35's pain was 0/10. The evaluation lacked indication of the wound edges, surrounding tissue, or the presence or absence of induration or swelling. The evaluation also lacked interventions and no notification to the provider, resident/responsible party, dietician, and/or therapy was indicated. R35's Skin & Wound Evaluation dated 12/10/22, indicated R35's open lesion on his left buttock measured a total area of 0.4 cm squared by a length of 0.7 cm and a width of 0.7 cm (worsening from three days before). The wound bed was 100% filled with granulated tissue, however, the evaluation also indicated the wound bed had an unknown amount of epithelial tissue (new skin generation). The wound had no exudate, and the wound edges were flush with the wound bed. The surrounding tissue was fragile and at risk for breakdown, but intact. The wound had no induration or swelling and was a normal temperature. The evaluation further indicated R35's pain was 4/10 with an occasional moan or groan. R35 also indicated he was sad/frightened/frown and was tense. Interventions included using a generic wound cleanser and a film membrane. Although R35's wound size and pain had increased, the evaluation indicated R35's wound was stable and no notification to the provider, resident/responsible party, dietician, and/or therapy was indicated. During an interview on 12/14/22, at 1:28 p.m. registered nurse (RN)-C stated the pressure ulcer on R35's left buttock appeared to be worse and stated a provider should have been notified whenever a resident developed a new, open skin lesion (pressure ulcer). RN-C stated the interventions for R35's pressure ulcer were nursing orders and confirmed there was no indication a provider had been notified of R35's new, open lesion, or that it had worsened despite the nursing interventions. During an interview on 12/14/22, at 3:55 p.m. medical doctor (MD)-A stated she was unaware of R35's worsening pressure ulcer on his left buttock and verified there was no mention of the wound during the last provider's assessment in December 2022. No facility policy related to pressure ulcers was provided by the end of the survey.

Based on observation, interview, and document review, the facility failed to take appropriate corrective action to prevent the subsequent abuse of 1 of 1 resident (R1) who was at high risk for further abuse by 2 of 2 residents (R2 and R3). Findings include: Review of the 11/6/20 at 11:37 a.m., report to the state agency (SA) identified the NA-A was walking up the hallway of the special care unit (SCU) and observed R2 sitting next to R1 with his hand in her shirt. R2 was unable to verbalize what he was doing and was removed from the area. NA-A noticed the registered nurse (RN) on duty. The residents were to remain separated from each other. Review of the 11/10/21 at 11:37 a.m., investigation summary submitted to the SA identified NA-A was walking up the hallway and observed R2 sitting next to R1 with his hand in her shirt. Staff immediately separated the residents and notified the RN on duty. R2 was last seen in the hallway a few minutes prior to the incident. R2 had dementia and was unable to verbalize details of the incident. There were no prior incidents between the R1 and R2, all parties contacts were notified appropriately. There were no signs of distress from either resident following the incident. R2's care plan was updated to keep supervised interactions with female residents to remove resident from situations if inappropriate behavior occurs. R2 was to be offered distractions and activity when behaviors occurred. Review of the 1/23/21 at 2:03 p.m., report to the SA identified licensed practical nurse (LPN)-C was providing supervision in the SCU dining area. R1 was seated in a chair with an over-bed table in front of her and R2 was seated at a table adjacent to R1. LPN-C left the dining area to wake another resident for the noon meal. Upon LPN-C's return, R2 was sitting in front of R1 with his right hand on R1's knee and his left hand was reaching with his left hand was reaching for R1's breast. LPN-C was unsure if R2 actual contact occurred. Neither resident was upset at the time of the incident. R2 was immediately removed from the area. Both residents had no signs of distress and neither were able to be interviewed related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 and R2 were to be kept separate from one another. Review of the 1/27/21 at 3:32 p.m., 5-day investigation report submitted to the SA identified both residents were separated at the time of the incident but could have been separated further. Neither resident had symptoms of distress following the incident, and neither were able to recall the event. Immediate interventions included immediate separation of R2 from R1. R2 was reassigned to sit in the solarium out of sight of R1 during meals. R2 was placed on frequent visual checks. R2's care plan and treatment administration record were revised to include scheduled documentation for staff visualize his location. The interdisciplinary team (IDT) met on 1/25/21, to discuss the incident and decided to move R2 from the SCU. R2 was placed on a unit separated from the SCU where only male residents resided. The report made no mention of any interventions of whether R1's care plan was reviewed and interventions added to prevent further abuse from occurring. R2's 1/24/21, quarterly Minimum Data Set (MDS), identified he had mild cognitive deficits. R2 had physical behaviors directed towards others that occurred 1 to three days. R2 required extensive assistance of 1 staff to transfer. R2 was able to move independently on and off the unit with a wheelchair. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's 1/26/21, care plan identified R2 had impaired cognitive function related to a history of a benign [CONDITION(S)] removal. R2 has a history of inappropriate sexual behaviors towards staff upon admission. Staff were to distract R2 with a walk, snacks, and other activities. Staff were to monitor R2 for behaviors and document every shift when R2 was sexually inappropriate, wandering or exit seeking. Staff were to supervise R2 around female residents and remove R2 if inappropriate behaviors occurred. R2 preferred to rise around 6:30 a.m., and staff were to keep R2's routine consistent. Review of R2's progress notes identified on: 1) 12/20/20, R2 was sexually inappropriate and attempted to grab staff's breasts during assistance to transfer. 2) 1/23/21, R2 was sexually inappropriate towards staff and grabbed staff in the groin area during morning cares. 3) 1/28/21, R2 attempted to get into the SCU because his believed his wife was in the SCU. 4) 1/31/21 R2 was very sexual during during a.m. cares and at lunch grabbed a staff member's buttocks. 5) 2/11/21, R2 put his hand between an NA's legs and made sexually inappropriate comments. Staff redirected R2. 6) 3/3/21, R2's behavior review charting identified R2 continued to have occasional sexual behaviors. R2 had 11 shifts with behavior documented over 5 weeks. Three shifts included sexual comments and grabbing at a staff member. During an interview on 3/17/21 at 9:50 a.m. with RN-A identified R2 had poor cognition and insight. R2 used to reside on the Red wing prior to moving to the SCU. R2 had a history or being sexually inappropriate with staff. R2 also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He was then moved to the Green Wing (all male) and has had less behaviors. During an interview on 3/17/21 at 10:31 a.m. with NA-A identified R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had a couple encounters with R1 where he was sexually inappropriate. One occurred a long time ago. NA-A was unable to recall the date but was working the day shift in the unit on the day it occurred. The night staff had gotten R2 up in the morning. NA-A had instructed the night staff to place R2 at a table and provide him with poker chips to keep him occupied while staff assisted resident with a.m. cares. R1 was in the last recliner on the right side of a bank of recliners in the common area. The night staff placed R2 on the opposite side of the recliners where R1 was sitting. As NA-A was coming down the hallway, she observed R2 sitting next to R1 with his hand up R1's shirt. She separated the residents and reported the incident to the nurse immediately. After the incident staff were to supervise R2 when he was around other female residents. Staff were to also keep R1 separated from R2, and provide R2 with distractions, puzzles, and other activities. R2 had another more recent encounter with R1 during the noon meal. R2 was transferred to the Green wing following the incident as that was an all male unit. During an interview on 3/17/21 at 3:21 p.m., with the director of nursing (DON) identified R1 and R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/23/21, R2 was left unattended in the SCU dining area. R2 approached R1 and was observed being sexually inappropriate. R2 was sexually inappropriate towards staff only prior to 11/6/21, and was not on the radar for sexual inappropriateness towards residents until 11/6/21. R2 was able to motivate independently in the unit and at times attempted to enter other resident's rooms. Staff were to redirect him and supervise him around female residents. Staff were trained to redirect him when he had behaviors. R2's second encounter was less than one minute, and the action took place outside of R1's clothing. Neither resident had signs of distress during or after the encounter. R2 was transferred to a separate male unit and had no attempts to return to the SCU or to find R1. Review of the 3/13/21, report to the SA identified R3 wheeled over to R1 who was sitting in recliner and placed one hand on her breast and appeared to be reaching to get under R1's shirt with other hand. Staff had taken another resident to the dining area and had been gone approximately 1 minute before returning to find R3 next to R1. Staff intervened and moved R3 to the dining area and initiated an activity to distract R3. R1 showed no signs of distress, pain, or injury. R1 had laughed and smiled when staff approached R1. Both residents lack capacity of consent/understanding. R1's 3/3/21, quarterly MDS identified R1 had severe cognitive impairment. R1 had no behaviors during assessment period, required extensive assist with toileting, dressing, and bed mobility, total assistance with eating, and limited assistance with ambulation and transfers. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R1's undated care plan identified R1 had impaired cognitive functions and thought process related to dementia. R1 was not aware of place, time, or situation. R1 was not able to communicate her needs. On 11/6/20, an intervention was added that staff were to keep R2 away from R1. On 1/26/21, an intervention was added that identified staff were to keep R1 and R2 apart from each other and supervise any interaction between the two residents. On 3/15/21, an intervention was added for staff to keep R3 away from R1 and supervise any interactions between the two. R1's progress notes identified following the sexual abuse perpetrated on R1 by R, staff were to keep R1 and R2 apart and provide appropriate supervision. Staff failed to do so, which resulted in a second sexual abuse event on 1/26/21. R1 was sexually assaulted on 3/13/21 a third time by another resident R3. There was no mention the facility identified R1 was at increased risk for abuse related to her dementia and required increased supervision to prevent further abuse from occurring, nor identified residents with known sexual behaviors towards staff were at increased risk to focus those behaviors towards other residents. Review of R1's 3/1/21, vulnerability assessment identified she had cognitive impairment, physical limitation, and sensory/communication limitations. The assessment indicated to see care plan for maltreatment prevention plan. There was no mention she was at increased risk for abuse following the 11/6/21 incident. R3's 1/25/21, quarterly MDS identified he had severe impairment. No behaviors were noted during the assessment period. R3 ate independently, was independent with locomotion once in his wheelchair, and required extensive assist with Activities of Daily Living (ADL). R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's current, undated care plan identified R3 had impaired cognitive function related to dementia and impaired thought processes related to history of a motor vehicle accident that resulted in TBI. R3 also had mood affective disorder, sexual and anxiety disorders. R3 made impulsive decisions and comments that were sexually inappropriate. On 7/27/18, staff were to redirect R3 firmly if he was being sexually inappropriate and if behaviors continued, staff were to remove him to a safe place and re-approach later. Staff were to try different staff members or use 2 staff if needed to lessen sexually inappropriate behaviors. On 3/13/21, an intervention was added that staff were to supervise interactions with female residents and remove R3 from situation if inappropriate behaviors occurred. Staff were to distract R3 with an activity in a separate area if behaviors were present. The facility failed to identify R3 was at risk for potential inappropriate behaviors with residents knowing he had the behaviors with staff in 2018. Review of R3's 1/25/21, vulnerability assessment identified he had inappropriate sexual comments, cognitive impairment, physical limitations, sensory and communication limitation. He was assessed to have no indicators for increased risk of maltreatment towards other residents. There was no indication staff accurately assessed R2 for known sexual inappropriate behaviors beginning in 2018, and was therefore at increased risk for potential abuse of other residents. R3's 3/17/21, staff Resident Care Sheet identified R3 had special needs as staff were to supervise all interactions with female residents. If sexual, staff were to redirect behavior or comments. There was no indication staff were alerted to ensure R3 was distanced and appropriately supervised when around female residents prior. Review of R3's behavior notes from 1/1/21 through 3/16/21 identified the following. On: 1) 1/7/21, R3 made several attempts to grab at staff inappropriately and made sexual comments. 2) 1/10/21, R3 made sexual comments to staff during cares. 3) 1/13/21, R3 was making sexual comments to the staff during cares. 4) 1/15/21, R3 was making sexual comments to the staff. 5) 1/27/21, R3 had many sexual comments during the evening shift. 6) 2/1/21, R3 asked staff to come over so he could squeeze staff breast. 7) 2/2/21, R3 made sexual comments and statements towards staff during cares. 8) 2/3/21, R3 making sexual comments and grabbing at staff during cares. When staff no longer in R3 reach comments and advancements stopped. 9) 2/4/21, R3 made several sexually inappropriate comments towards staff. 10) 2/6/21, R3 made sexual remarks to staff during cares. 11) 2/22/21, R3 tried to touch staff inappropriately 2 times this shift. 12) 2/23/21, R3 had sexual comments and attempts to inappropriately touch staff 2 times. 13) 3/7/21, R3 called staff names and told staff to pull down their pants . 14) 3/13/21 (1:58 p.m.) R3 tried to grab a female resident's breast that day. 15) 3/13/21 (10:04 p.m.) R3 attempted to approach another female resident sexually. Staff redirected to another unit to watch TV. R3 would periodically ask how about that little girl . referring to a female resident. 16) 3/14/21, R3 was noted attempting to grab at a staff members breast during transfer. 17) 3/14/21, R3 made several sexual comments towards female staff through the evening shift. 18) 3/15/21, R3 noted to make frequent sexual comments to staff throughout shift. Interview on 3/17/21 at 9:15 a.m., with nursing assistant (NA)-A identified she was the one who witnessed the event between R1 and R3 that occurred in the common area of the Special Care Unit (SCU). R1 was sitting in the recliner in the common area and R3 was sitting in his wheelchair parked by wall in front by R1. NA-A had taken another resident to the dining area and upon returning to the common area, witnessed R3 with his hand on top of R1's shirt over her breast. She cued R3 to stop as she walked towards them. R3 replied she likes me. She confirmed R1 was nonverbal and smiled when she approached her to remove R3 from the area. A nurse, LPN-A was also in the area but had her back towards R1 and R3, as she was assisting another resident at the time. LPN-A did hear NA-A's verbal cues directed at R3 and assisted with intervening. The nurse instructed us to keep a close eye on R3 after that. NA-A revealed R3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed R3 was able to wheel his self around in his wheelchair. Observation on 3/17/21 at 9:35 a.m., of R1 identified she was sleeping in the recliner located in the common area on the SCU. No concerns were noted at that time. Observation on 3/17/21 at 10:05 a.m., of R3 identified he was sleeping while sitting in his wheelchair off to the side of the room in the dining area where an activity was taking place. No female residents were near. Staff were in the immediate area. Interview on 3/17/21 at 11:50 a.m., with licensed practical nurse (LPN)-A identified she had been in the common area on the SCU assisting another resident when R3 touched R1 in the breast area. She reports she had her back towards the two residents at the time but had heard NA-A comment to R3 you cannot touch women like that and turned to go assist with separating the two. She revealed the staff then kept R1 and R3 separated the rest of the weekend and staff kept R3 in eyesight. Observation on 3/17/21 at 12:42 p.m. through 1:00 p.m., of the common area identified R3 was sleeping in a recliner. R1 was sitting at a small table behind R3. Staff were observed frequently walking through the common area for supervision of R3, however, staff were not consistently in the area. Interview on 3/17/21 at 12:50 p.m., with NA-A identified the only resident on the SCU that had any sexual behaviors was R3. Staff supervise R3 unless he is resting in a stationary chair as he does not attempt to get out. During that time, staff could assist others and not be in the common area consistently. Observation on 3/17/21 at 2:00 p.m., identified R1 was sleeping in a recliner in the common area and R3 was seated in a recliner with staff doing an one-to-one activity with R3. Interview on 3/17/21 at 2:05 p.m., with registered nurse (RN)-B identified she was the evening supervisor on 3/13/21. Earlier in the day, R3 had an incident with R1 where he touched R1's breast. Later on that same day in the evening, an LPN had reported to her R3 was talking to R1 making comments of that little girl and pointing at R1 so the staff moved him to another unit to watch a game on TV. R3 did not get close to R1 and confirmed the unit was always staffed with one person in the common area for constant supervision of R3 during the evening shift. RN-A confirmed that R3 was now to be appropriately supervised while he was around other residents to ensure R1's safety and any other resident's. Review of memo to staff dated 3/13/21, identified staff were to supervise all interactions with R3 and female residents. Staff are to remove R3 and report to the RN immediately if any inappropriate discussion or actions are witnessed. Interview on 3/17/21 at 4:17 p.m., with administrator revealed if a resident had identified sexual abuse he would expect interventions to be put into place to ensure the safety of the resident involved to prevent reoccurrence. Staff put interventions into place for R2. After the second incident of the same nature, R2 was moved off of the unit. He agreed the care plan had not been followed for R1 and R2 immediately preceding the second incident. The intervention identified they were not to be together. R1 and R2 had been left alone at the table and the second event occurred. He identified the third incident with R1 involving R3 could not of been predicted as the facility could not predict that kind of behavior. The facility has policies in place to protect the residents and we do not want to move them off of the beneficial SCU unit if we do not need to. He stated R1 had no signs of fear and R3 was unable to recall the event. He disagreed that the facility did not protect R1 and prevent reoccurrence. You cannot care plan every resident and predict every event. He agreed there was nothing added to R1's care plan after the first incident with R2, identifying she was already a victim of abuse and required increased supervision. Staff focused on R2 and R3's care plans. He agreed the facility should have prevented the second incident between R1 and R2 but felt there was no way to predict R3, even though staff documented R3 had known sexual behaviors to staff prior to the incident with R3. The Administrator identified the only resident on the SCU that had any inappropriate sexual behavior was R3. Review of the 11/19/19, Vulnerable Adult and Resident Protection Plan policy identified sexual abuse was any non-consensual sexual contact with a resident. Willful meant deliberate actions of an individual, not whether an individual intended to inflict injury or harm. When any nursing home employee or volunteer became aware of abuse, they were to report it immediately to the supervisor or officer of the day. That staff was to immediately ensure the proper notifications were made to the facility leadership and state agency per state and federal requirements. Seven components were in place to prevent abuse. All staff were responsible for preventing abuse and were educated on how to report abuse. Staff were to assess, plan care and services, and monitor residents with needs and behaviors. Risk factors for abuse included a history of cognitive and sensory deficits, aggressive behaviors, behaviors such as entering other residents' rooms, wandering, and being socially inappropriate. Additional risk factors included communication disorders, nonverbal, and residents requiring heavy care or are totally dependent on staff. Appropriate interventions were to be identified and implemented for the resident involved and all other residents to prevent future occurrences. Residents were to be protected from the alleged offenders. Additional attention was to include consideration to provide safety for other residents as appropriate. If the resident could be at risk in the same environment, considerations to be made included changes in location. The facility failed to review the policy annually as required by federal regulation.

Based on interview and document review the facility failed to ensure 1 of 2 resident (R1)'s allegation of abuse was reported within 2 hours to the State Agency (SA). Findings include Review of the 11/6/20 at 11:37 a.m., report to the state agency (SA) identified at 7:00 a.m., the NA-A was walking up the hallway of the special care unit (SCU) and observed R2 sitting next to R1 with his hand in her shirt. R2 was unable to verbalize what he was doing and was removed from the area. NA-A notified the registered nurse (RN) on duty. The residents were to remain separated from each other. Interview on 3/17/21 at 10:31 a.m., with NA-A identified on 11/6/20, she observed the interaction between R1 and R2. The charge nurse was notified immediately after the residents were separated. Interview and document review, on 3/17/21 at 3:49 p.m., with the social worker (SW) identified she was asked to complete the investigation of the incident on 11/6/21 by either the administrator or the director of nursing (DON). She was notified at some time in the morning after she arrived to work. The SA report identified the incident occurred at 7:00 a.m. and indicted the SW was the person submitting the SA report. The SW identified she had worked on the investigation for quite some time before she reported the incident to the SA at 11:37 a.m. that day. Interview and document review, on 3/17/21 at 4:01 p.m., with the DON identified she was unable to recall when she was notified of the incident on 11/6/21. The incident report provided identified she was notified at 12:25 p.m., after the SW reported the incident to the SA. The DON agreed the report was not made within 2 hours. Interview on 3/17/21 at 4:18 p.m., with the administrator identified he was not employed with the facility at the time of the incident but expected any allegation of abuse to be reported immediately but no later than 2 hours of notification for abuse. Review of the 11/19/19, Vulnerable Adult and Resident Protection Plan identified sexual abuse as nonconsensual sexual contact with a resident. The policy was to protect residents from maltreatment and comply with existing laws by including the seven-step approach to preventing abuse, including sexual abuse, and prevention. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report the incident to their supervisor or the officer of the day. Staff were to report allegations of abuse immediately to the supervisor, who was to report allegations immediately to the administrator or designee. The administrator or designee with training and security password access for reporting was to report allegations of abuse to the SA within two hours.

Based on observation, interview, and document review, the facility failed to prevent sexual behaviors and implement interventions for 1 of 1 resident (R2) with known sexual behaviors who inappropriately touched R1 during 2 of 2 incidents of sexual abuse. Additionally, the facility failed to identify R1 was at increased risk for further abuse by another resident (R3) who also touched R1 inappropriately and had known sexual behaviors. Findings include: Review of the 11/6/20 at 11:37 a.m., report to the state agency (SA) identified the NA-A was walking up the hallway of the special care unit (SCU) and observed R2 sitting next to R1 with his hand in her shirt. R2 was unable to verbalize what he was doing and was removed from the area. NA-A noticed the registered nurse (RN) on duty. The residents were to remain separated from each other. Review of the 11/10/21 at 11:37 a.m., investigation summary submitted to the SA identified NA-A was walking up the hallway and observed R2 sitting next to R1 with his hand in her shirt. Staff immediately separated the residents and notified the RN on duty. R2 was last seen in the hallway a few minutes prior to the incident. R2 had dementia and was unable to verbalize details of the incident. There were no prior incidents between the R1 and R2, all parties contacts were notified appropriately. There were no signs of distress from either resident following the incident. R2's care plan was updated to keep supervised interactions with female residents to remove resident from situations if inappropriate behavior occurs. R2 was to be offered distractions and activity when behaviors occurred. Review of the 1/23/21 at 2:03 p.m., report to the SA identified licensed practical nurse (LPN)-C was providing supervision in the SCU dining area. R1 was seated in a chair with an over-bed table in front of her and R2 was seated at a table adjacent to R1. LPN-C left the dining area to wake another resident for the noon meal. Upon LPN-C's return, R2 was sitting in front of R1 with his right hand on R1's knee and his left hand was reaching with his left hand was reaching for R1's breast. LPN-C was unsure if R2 actual contact occurred. Neither resident was upset at the time of the incident. R2 was immediately removed from the area. Both residents had no signs of distress and neither were able to be interviewed related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 and R2 were to be kept separate from one another. Review of the 1/27/21 at 3:32 p.m., 5-day investigation report submitted to the SA identified both residents were separated at the time of the incident but could have been separated further. Neither resident had symptoms of distress following the incident, and neither were able to recall the event. Immediate interventions included immediate separation of R2 from R1. R2 was reassigned to sit in the solarium out of sight of R1 during meals. R2 was placed on frequent visual checks. R2's care plan and treatment administration record were revised to include scheduled documentation for staff visualize his location. The interdisciplinary team (IDT) met on 1/25/21, to discuss the incident and decided to move R2 from the SCU. R2 was placed on a unit separated from the SCU where only male residents resided. The report made no mention of any interventions of whether R1's care plan was reviewed and interventions added to prevent further abuse from occurring. R2's 1/24/21, quarterly Minimum Data Set (MDS), identified he had mild cognitive deficits. R2 had physical behaviors directed towards others that occurred 1 to three days. R2 required extensive assistance of 1 staff to transfer. R2 was able to move independently on and off the unit with a wheelchair. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's 1/26/21, care plan identified R2 had impaired cognitive function related to a history of a benign [CONDITION(S)] removal. R2 has a history of inappropriate sexual behaviors towards staff upon admission. Staff were to distract R2 with a walk, snacks, and other activities. Staff were to monitor R2 for behaviors and document every shift when R2 was sexually inappropriate, wandering or exit seeking. Staff were to supervise R2 around female residents and remove R2 if inappropriate behaviors occurred. R2 preferred to rise around 6:30 a.m., and staff were to keep R2's routine consistent. Review of R2's progress notes identified on: 1) 12/20/20, R2 was sexually inappropriate and attempted to grab staff's breasts during assistance to transfer. 2) 1/23/21, R2 was sexually inappropriate towards staff and grabbed staff in the groin area during morning cares. 3) 1/28/21, R2 attempted to get into the SCU because his believed his wife was in the SCU. 4) 1/31/21 R2 was very sexual during during a.m. cares and at lunch grabbed a staff member's buttocks. 5) 2/11/21, R2 put his hand between an NA's legs and made sexually inappropriate comments. Staff redirected R2. 6) 3/3/21, R2's behavior review charting identified R2 continued to have occasional sexual behaviors. R2 had 11 shifts with behavior documented over 5 weeks. Three shifts included sexual comments and grabbing at a staff member. During an interview on 3/17/21 at 9:50 a.m. with RN-A identified R2 had poor cognition and insight. R2 used to reside on the Red wing prior to moving to the SCU. R2 had a history or being sexually inappropriate with staff. R2 also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He was then moved to the Green Wing (all male) and has had less behaviors. During an interview on 3/17/21 at 10:31 a.m. with NA-A identified R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had a couple encounters with R1 where he was sexually inappropriate. One occurred a long time ago. NA-A was unable to recall the date but was working the day shift in the unit on the day it occurred. The night staff had gotten R2 up in the morning. NA-A had instructed the night staff to place R2 at a table and provide him with poker chips to keep him occupied while staff assisted resident with a.m. cares. R1 was in the last recliner on the right side of a bank of recliners in the common area. The night staff placed R2 on the opposite side of the recliners where R1 was sitting. As NA-A was coming down the hallway, she observed R2 sitting next to R1 with his hand up R1's shirt. She separated the residents and reported the incident to the nurse immediately. After the incident staff were to supervise R2 when he was around other female residents. Staff were to also keep R1 separated from R2, and provide R2 with distractions, puzzles, and other activities. R2 had another more recent encounter with R1 during the noon meal. R2 was transferred to the Green wing following the incident as that was an all male unit. During an interview on 3/17/21 at 3:21 p.m., with the director of nursing (DON) identified R1 and R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/23/21, R2 was left unattended in the SCU dining area. R2 approached R1 and was observed being sexually inappropriate. R2 was sexually inappropriate towards staff only prior to 11/6/21, and was not on the radar for sexual inappropriateness towards residents until 11/6/21. R2 was able to motivate independently in the unit and at times attempted to enter other resident's rooms. Staff were to redirect him and supervise him around female residents. Staff were trained to redirect him when he had behaviors. R2's second encounter was less than one minute, and the action took place outside of R1's clothing. Neither resident had signs of distress during or after the encounter. R2 was transferred to a separate male unit and had no attempts to return to the SCU or to find R1. Review of the 3/13/21, report to the SA identified R3 wheeled over to R1 who was sitting in recliner and placed one hand on her breast and appeared to be reaching to get under R1's shirt with other hand. Staff had taken another resident to the dining area and had been gone approximately 1 minute before returning to find R3 next to R1. Staff intervened and moved R3 to the dining area and initiated an activity to distract R3. R1 showed no signs of distress, pain, or injury. R1 had laughed and smiled when staff approached R1. Both residents lack capacity of consent/understanding. R1's 3/3/21, quarterly MDS identified R1 had severe cognitive impairment. R1 had no behaviors during assessment period, required extensive assist with toileting, dressing, and bed mobility, total assistance with eating, and limited assistance with ambulation and transfers. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R1's undated care plan identified R1 had impaired cognitive functions and thought process related to dementia. R1 was not aware of place, time, or situation. R1 was not able to communicate her needs. On 11/6/20, an intervention was added that staff were to keep R2 away from R1. On 1/26/21, an intervention was added that identified staff were to keep R1 and R2 apart from each other and supervise any interaction between the two residents. On 3/15/21, an intervention was added for staff to keep R3 away from R1 and supervise any interactions between the two. R1's progress notes identified following the sexual abuse perpetrated on R1 by R, staff were to keep R1 and R2 apart and provide appropriate supervision. Staff failed to do so, which resulted in a second sexual abuse event on 1/26/21. R1 was sexually assaulted on 3/13/21 a third time by another resident R3. There was no mention the facility identified R1 was at increased risk for abuse related to her dementia and required increased supervision to prevent further abuse from occurring, nor identified residents with known sexual behaviors towards staff were at increased risk to focus those behaviors towards other residents. Review of R1's 3/1/21, vulnerability assessment identified she had cognitive impairment, physical limitation, and sensory/communication limitations. The assessment indicated to see care plan for maltreatment prevention plan. There was no mention she was at increased risk for abuse following the 11/6/21 incident. R3's 1/25/21, quarterly MDS identified he had severe impairment. No behaviors were noted during the assessment period. R3 ate independently, was independent with locomotion once in his wheelchair, and required extensive assist with Activities of Daily Living (ADL). R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's current, undated care plan identified R3 had impaired cognitive function related to dementia and impaired thought processes related to history of a motor vehicle accident that resulted in TBI. R3 also had mood affective disorder, sexual and anxiety disorders. R3 made impulsive decisions and comments that were sexually inappropriate. On 7/27/18, staff were to redirect R3 firmly if he was being sexually inappropriate and if behaviors continued, staff were to remove him to a safe place and re-approach later. Staff were to try different staff members or use 2 staff if needed to lessen sexually inappropriate behaviors. On 3/13/21, an intervention was added that staff were to supervise interactions with female residents and remove R3 from situation if inappropriate behaviors occurred. Staff were to distract R3 with an activity in a separate area if behaviors were present. The facility failed to identify R3 was at risk for potential inappropriate behaviors with residents knowing he had the behaviors with staff in 2018. Review of R3's 1/25/21, vulnerability assessment identified he had inappropriate sexual comments, cognitive impairment, physical limitations, sensory and communication limitation. He was assessed to have no indicators for increased risk of maltreatment towards other residents. There was no indication staff accurately assessed R2 for known sexual inappropriate behaviors beginning in 2018, and was therefore at increased risk for potential abuse of other residents. R3's 3/17/21, staff Resident Care Sheet identified R3 had special needs as staff were to supervise all interactions with female residents. If sexual, staff were to redirect behavior or comments. There was no indication staff were alerted to ensure R3 was distanced and appropriately supervised when around female residents prior. Review of R3's behavior notes from 1/1/21 through 3/16/21 identified the following. On: 1) 1/7/21, R3 made several attempts to grab at staff inappropriately and made sexual comments. 2) 1/10/21, R3 made sexual comments to staff during cares. 3) 1/13/21, R3 was making sexual comments to the staff during cares. 4) 1/15/21, R3 was making sexual comments to the staff. 5) 1/27/21, R3 had many sexual comments during the evening shift. 6) 2/1/21, R3 asked staff to come over so he could squeeze staff breast. 7) 2/2/21, R3 made sexual comments and statements towards staff during cares. 8) 2/3/21, R3 making sexual comments and grabbing at staff during cares. When staff no longer in R3 reach comments and advancements stopped. 9) 2/4/21, R3 made several sexually inappropriate comments towards staff. 10) 2/6/21, R3 made sexual remarks to staff during cares. 11) 2/22/21, R3 tried to touch staff inappropriately 2 times this shift. 12) 2/23/21, R3 had sexual comments and attempts to inappropriately touch staff 2 times. 13) 3/7/21, R3 called staff names and told staff to pull down their pants . 14) 3/13/21 (1:58 p.m.) R3 tried to grab a female resident's breast that day. 15) 3/13/21 (10:04 p.m.) R3 attempted to approach another female resident sexually. Staff redirected to another unit to watch TV. R3 would periodically ask how about that little girl . referring to a female resident. 16) 3/14/21, R3 was noted attempting to grab at a staff members breast during transfer. 17) 3/14/21, R3 made several sexual comments towards female staff through the evening shift. 18) 3/15/21, R3 noted to make frequent sexual comments to staff throughout shift. Interview on 3/17/21 at 9:15 a.m., with nursing assistant (NA)-A identified she was the one who witnessed the event between R1 and R3 that occurred in the common area of the Special Care Unit (SCU). R1 was sitting in the recliner in the common area and R3 was sitting in his wheelchair parked by wall in front by R1. NA-A had taken another resident to the dining area and upon returning to the common area, witnessed R3 with his hand on top of R1's shirt over her breast. She cued R3 to stop as she walked towards them. R3 replied she likes me. She confirmed R1 was nonverbal and smiled when she approached her to remove R3 from the area. A nurse, LPN-A was also in the area but had her back towards R1 and R3, as she was assisting another resident at the time. LPN-A did hear NA-A's verbal cues directed at R3 and assisted with intervening. The nurse instructed us to keep a close eye on R3 after that. NA-A revealed R3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed R3 was able to wheel his self around in his wheelchair. Observation on 3/17/21 at 9:35 a.m., of R1 identified she was sleeping in the recliner located in the common area on the SCU. No concerns were noted at that time. Observation on 3/17/21 at 10:05 a.m., of R3 identified he was sleeping while sitting in his wheelchair off to the side of the room in the dining area where an activity was taking place. No female residents were near. Staff were in the immediate area. Interview on 3/17/21 at 11:50 a.m., with licensed practical nurse (LPN)-A identified she had been in the common area on the SCU assisting another resident when R3 touched R1 in the breast area. She reports she had her back towards the two residents at the time but had heard NA-A comment to R3 you cannot touch women like that and turned to go assist with separating the two. She revealed the staff then kept R1 and R3 separated the rest of the weekend and staff kept R3 in eyesight. Observation on 3/17/21 at 12:42 p.m. through 1:00 p.m., of the common area identified R3 was sleeping in a recliner. R1 was sitting at a small table behind R3. Staff were observed frequently walking through the common area for supervision of R3, however, staff were not consistently in the area. Interview on 3/17/21 at 12:50 p.m., with NA-A identified the only resident on the SCU that had any sexual behaviors was R3. Staff supervise R3 unless he is resting in a stationary chair as he does not attempt to get out. During that time, staff could assist others and not be in the common area consistently. Observation on 3/17/21 at 2:00 p.m., identified R1 was sleeping in a recliner in the common area and R3 was seated in a recliner with staff doing an one-to-one activity with R3. Interview on 3/17/21 at 2:05 p.m., with registered nurse (RN)-B identified she was the evening supervisor on 3/13/21. Earlier in the day, R3 had an incident with R1 where he touched R1's breast. Later on that same day in the evening, an LPN had reported to her R3 was talking to R1 making comments of that little girl and pointing at R1 so the staff moved him to another unit to watch a game on TV. R3 did not get close to R1 and confirmed the unit was always staffed with one person in the common area for constant supervision of R3 during the evening shift. RN-A confirmed that R3 was now to be appropriately supervised while he was around other residents to ensure R1's safety and any other resident's. Review of memo to staff dated 3/13/21, identified staff were to supervise all interactions with R3 and female residents. Staff are to remove R3 and report to the RN immediately if any inappropriate discussion or actions are witnessed. Interview on 3/17/21 at 4:17 p.m., with administrator revealed if a resident had identified sexual abuse he would expect interventions to be put into place to ensure the safety of the resident involved to prevent reoccurrence. Staff put interventions into place for R2. After the second incident of the same nature, R2 was moved off of the unit. He agreed the care plan had not been followed for R1 and R2 immediately preceding the second incident. The intervention identified they were not to be together. R1 and R2 had been left alone at the table and the second event occurred. He identified the third incident with R1 involving R3 could not of been predicted as the facility could not predict that kind of behavior. The facility has policies in place to protect the residents and we do not want to move them off of the beneficial SCU unit if we do not need to. He stated R1 had no signs of fear and R3 was unable to recall the event. He disagreed that the facility did not protect R1 and prevent reoccurrence. You cannot care plan every resident and predict every event. He agreed there was nothing added to R1's care plan after the first incident with R2, identifying she was already a victim of abuse and required increased supervision. Staff focused on R2 and R3's care plans. He agreed the facility should have prevented the second incident between R1 and R2 but felt there was no way to predict R3, even though staff documented R3 had known sexual behaviors to staff prior to the incident with R3. The Administrator identified the only resident on the SCU that had any inappropriate sexual behavior was R3. Review of the 11/19/19, Vulnerable Adult and Resident Protection Plan policy identified sexual abuse was any non-consensual sexual contact with a resident. Willful meant deliberate actions of an individual, not whether an individual intended to inflict injury or harm. When any nursing home employee or volunteer became aware of abuse, they were to report it immediately to the supervisor or officer of the day. That staff was to immediately ensure the proper notifications were made to the facility leadership and state agency per state and federal requirements. Seven components were in place to prevent abuse. All staff were responsible for preventing abuse and were educated on how to report abuse. Staff were to assess, plan care and services, and monitor residents with needs and behaviors. Risk factors for abuse included a history of cognitive and sensory deficits, aggressive behaviors, behaviors such as entering other residents' rooms, wandering, and being socially inappropriate. Additional risk factors included communication disorders, nonverbal, and residents requiring heavy care or are totally dependent on staff. Appropriate interventions were to be identified and implemented for the resident involved and all other residents to prevent future occurrences. Residents were to be protected from the alleged offenders. Additional attention was to include consideration to provide safety for other residents as appropriate. If the resident could be at risk in the same environment, considerations to be made included changes in location. The facility failed to review the policy annually as required by federal regulation.

Based on interview and document review, the facility failed to provide appropriate care and services including assessment, monitoring and intervention for 1 of 1 resident (R9) with a fall with severe head injury. R9 experienced changes in physical and mental condition but treatment was delayed. This resulted in an Immediate Jeopardy (IJ) situation for R9 who experienced increased pain and subsequent death. The IJ began on [DATE], when R9 experienced a fall with head injury and the facility failed to appropriately assess, monitor and intervene resulting in R9's death. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 2:30 p.m. The IJ was removed on [DATE] at 12:30 p.m., when it could be verified by interview and document review, the facility had taken steps to remove the immediacy however, non-compliance remained at the scope and severity of G, isolated-actual harm that is not immediate jeopardy. Findings include: R9's quarterly Minimum Data Set ((MDS) dated [DATE], identified R9 had moderate cognitive impairment. R9 required extensive assistance of 1 staff person for bed mobility, transfers, locomotion on the unit, dressing, toileting, and personal hygiene. Limited assistance with a walker for ambulation in room and hall. The [DATE], Care Area Assessment (CAA) identified R9 was at risk for falls due to balance problems and unsteadiness when moving from a sit to stand position. The residents MDS indicated R9's [DIAGNOSES REDACTED]. R9's [DATE], care plan identified he had impaired mobility due to history of a stroke. He was able to ambulate short distances with assist of one staff, a walker, and gait belt. The care plan also indicated R9 was at risk for falls and was utilizing a blood thinning medication, [MEDICATION NAME]. Review of facility report to the State Agency (SA) dated [DATE], identified on [DATE] at 6:25 a.m., nursing assistant (NA)-A was assisting R9 to the toilet when she left him unattended to open the bathroom door. R9 was utilizing his walker, took a couple of steps, and fell backwards from a standing position, striking his head against the floor with a loud crack sound. Registered nurse (RN)-A was summoned to the room, assessed R9 and noted a large lump located at the base of R9's skull. Vital signs (VS) and neurological status were documented as stable at that time. R9 was not able to state to staff what had happened, but remarked that hurt. R9 was transferred into bed using a sling lift. At approximately 7:00 a.m., that same day, R9 complained of new onset headache and low back pain. Staff administered Tylenol and an ice pack to R9 for comfort. There was no mention staff had assessed the size or description of the lump located at the base of R9's skull or appropriately notified the provider of the severity of the fall. Review R9's [DATE], nursing progress and incident notes included: 1) 6:25 a.m., NA-A was assisting R9 to toilet. NA-A stepped around and in front of R9 to open the closed bathroom door. NA-A and NA-B (who was assisting R9's roommate) were not close enough to intervene when R9 fell to the floor. NA-A went to summon RN-A to the room as NA-B remained with R9. RN-A performed an assessment, noted a lump on the back of R9's head. R9 denied pain and was not able to state what had happened, only that it hurt. R9 was able to move all extremities and was transferred into bed with the use of a sling lift and assistance of the 2 NAs and the RN. VS were reported as normal at that time. There was no mention staff had immediately called R9's provider or EMS at that time. 2) 7:00 a.m., R9 complained of a headache and would not speak with NA-B. RN-A administered Tylenol and provided an ice pack for the back of R9's head. 3) 7:16 a.m., R9 complained of lower back pain. Staff elevated R9's head of bed. R9 was given an ice pack to back of his head. R9 was observed rubbing the top of his head. R9 followed commands of squeezing hands. R9 displayed facial grimacing when his hip area was touched. 4) 7:24 a.m. RN-A sent a faxed notification to the provider of R9's fall. 5) 7:47 a.m., staff documented R9 was ambulating with walker at the time of his fall, lost his balance falling backwards hitting his head. Staff had to open R9's bathroom door and were not immediately at his side when the incident occurred. A lump was immediately noted at the base of his skull. R9 initially denied pain, then complained of head and back pain 30 minutes later. 6) 8:24 a.m., family was called and updated on the fall and pain in back and neck. VS and neurological signs were noted to be within normal limits at that time. 7) 9:24 a.m., staff administered 650 milligrams (mg) Tylenol for pain and noted it was effective. 8) 9:40 a.m., during assessment, R9 was observed as Sleepy. Does not wake enough for the neuros (neurological checks). Resident does not follow commands of squeeze this writer's hands. R9's VS at that time were blood pressure (BP) ,[DATE] millimeters of mercury (mm/hg), pulse (P) was 113 beats per minute ( normal ,[DATE]), Oxygen saturation (SpO2) was 92% (normal ,[DATE]), and temperature was 96.9 degrees Fahrenheit (F). R9 appeared comfortable. There was no indication staff reached out to the resident's medical provider. 9) 10:09 a.m., R9's family was called to update on R9's condition since his fall. Staff noted they discussed possible signs and symptoms of a head injury from the fall. Family was made aware of the possibility will give Tylenol TID (three times per day) for 7 days. 10) 12:05 p.m., R9 was noted to open his eyes for a short period of time, then close. R9 could not follow simple commands. Staff then documented they made measurements of the raised bruise on back of his head measuring 5 centimeters (cm) in circumference. Staff noted they would monitor that area until healed. An ice pack was applied to the area 2 times that shift. R9's respirations increased to ,[DATE] respirations per minute (normal ,[DATE]). R9's family was called and updated. Family reportedly wished for R9 to be kept comfortable and would come to the facility around 1:00 p.m. to decide how to proceed with care. There was no mention on what R9's family had been updated on. There was no indication R9's medical provider was updated. 11) 12:20 p.m., R9 was attempting to throw his legs out of his bed. R9 was then assisted to sit up on edge of bed and into his wheelchair. R9 was given Tylenol again, and ate some cereal. Shortly after eating, R9 began gagging and spitting up. R9's SpO2 decreased to 70% and had upper airway gurgle. Family was again called and updated and requested he be sent to ER. There was no mention staff had assessed R9's throat to identify what was causing the gurgle, why R9 was gagging or spitting up. There was no indication R9's medical provider was updated, nor that EMS had been contacted immediately for transport. 12) 1:24 p.m., a call placed to the ER and an ambulance paged. There was no documented indication as to they delay in accessing EMS. 13) 1:48 p.m., EMS arrived to transport R9 to the ER. 14) 3:15 p.m., a call was received from the ER, R9 had been admitted for comfort cares. R9's CT scan showed a significant brain bleed. Family was at his bedside. R9 was unresponsive at that time. 15) 4:08 p.m., documentation identified R9 had a change in mentation and family had been notified earlier that day at at 10:10 a.m Family opted to have staff watch R9 at that time. R9 became restless, sat up, ate, and had vomited and was declining from his baseline. R9 was sent to ER per family request and had been admitted for comfort cares with a brain bleed. 16) 4:47 p.m., a call was received from the hospital notifying staff R9 would be returning to facility on comfort cares. Family was agreeable and a potential hospice consult was ordered for the following day. 17) R9 returned to the facility around 6:00 p.m. 18) 7:30 p.m., R9 was noted as resting quietly with family at his bedside. R9 required oxygen and remained unresponsive, breathing more labored. 19) 9:00 p.m., R9 passed away. Review of the [DATE], physician (MD)-B progress note of the events surrounding R9's fall identified R9 was used a walker with a nurse aid (NA) and nurse to the toilet. They were assisting him. R9 usually walked with the walker just fine. He showed no identified health concerns at that time. R9 had requested to use the toilet. Staff got R9 up and walking toward the bathroom. The bathroom door had been closed. As the NA reached to open the door, R9 spoke out quickly and fell directly back onto his head and back. According to MD-B, R9 was monitored throughout the next couple hours by the nursing staff and had continued decline in his mental status and also his breathing status. Staff reported they had consulted with family and at first, family had not wanted him evaluated, but staff later sent R9 to the ER. At that time, R9 was noted that he had a pneumonia. During his ER evaluation he continued to have troubles with breathing. It was decided to do comfort measures while he was undergoing CT scan (medical imaging procedure). The CT of his head showed mixed subdural hematoma (brain bleed). Also, a large amount of subarachnoid hemorrhage (life-threatening condition caused by bleeding in brain). R9 had hemorrhagic contusions (bleeds from trauma). In addition R9 had a large posterior (back of head) scalp hematoma (blood pooling under surface of skin) with an underlying occipital bone (back of head) fracture extending into the base of his skull. R9's cause of death was the brain bleeds, however MD-B felt R9 had an underlying issue of the pneumonia was his cause for the fall. Primarily the cause of the fall was the pneumonia, and hemorrhage and skull fracture are secondary to the pneumonia. Review of the [DATE], hospital radiology report identified R9 had a [DIAGNOSES REDACTED]. The findings were discussed with family by the ED medical provider and the decision was made to keep R9 comfortable. Interview on [DATE] at 9:51 a.m., with the assistant director of nursing (ADON), identified NA-A was assisting R9 with toileting and stepped away from R9 to open the bathroom door. As NA-A turned she observed R9 lose his balance, falling backwards, striking his head on the floor. NA-A was not close enough to assist R9 to potentially decrease the severity of his fall. R9 was noted to have a large hematoma (area of blood pooled under skin) on the back of his head immediately after the fall. RN-A responded to R9's room and completed vital signs and a neurological assessment which had been documented as normal. The fall was reported as having occurred during morning cares between 6:00 and 7:00 a.m RN-A had faxed notification of the fall to the provider at 7:24 a.m. R9's change in condition occurred with a change in mentation documented at 10:00 a.m. Family member (FM)-A was initially contacted and notified of the fall at 8:24 a.m. by RN-B, and again following the 10:00 a.m. assessment. FM-A was updated of R9 being drowsy and not wanting to get out of bed. FM-A voiced agreement for the facility to continue to observe R9. If he still had not wanted to get up by around 12:00 noon, the family advised staff they would come to the facility to see if they could convince him to get up. Between 11:00 a.m. and 12:00 noon R9 became restless, and was assisted into his wheelchair. He was offered hot cereal and coffee by staff and following eating, began gagging. He declined in mental status and his VS were abnormal His SpO2 was 70%. R9 was administered supplemental oxygen. FM-A was contacted around 12:30 p.m. with an update and requested R9 be sent to the ER. RN-A had informed the MD via fax following the incident at 7:24 a.m., however, the facility did not maintain documentation of the fax being sent, nor did the facility receive conformation the fax had been received or reviewed by the provider. There was no additional documentation of the medical provider being updated on R9's condition until about 1:34 p.m. along with notification of the ambulance prior to his transfer to the ED. Staff had not called EMS when the incident occurred or placed a call to R9's physician. Interview on [DATE] at 2:06 p.m., with NA-B identified she was present in R9's room the morning of his fall and had been providing care for his room mate. NA-B observed R9's fall. NA-B observed NA-A assist R9 to sit on the side of the bed, place his walker in front of him, pull back his privacy curtain, and walked over to bathroom door and held door open for R9. R9 stood up independently without NA-A's assistance, took about 3 steps, and fell straight back holding his walker. NA-B reported R9 fell like a tree. He fell straight back, first striking his shoulders, then his head., making a loud, cracking sound. NA-B was unable to reach him in time to prevent his fall. Immediately after the fall, R9's eyes were open but he failed to respond to verbal prompts. R9 was transferred by staff into bed using a total body lift. RN-A completed the initial assessment for injury. RN-A left to complete a fall risk assessment, and NA-A left to continue providing cares to other residents. NA-B remained at R9's bedside as she was not comfortable leaving him alone. R9 had a soft ball sized swelling at the base of his skull. RN-A returned with an ice pack and placed it on the back of R9's head. At the time of injury R9 denied pain, but after a short time he complained of pain in his head. NA-B had reported R9 was having pain and due to his hitting his head so hard, questioned RN-A if he was going to be sent to the ER. RN-A responded he wasn't going to be sent to the ER as he would just be sent back. Staff could watch him in the facility. There was an immediate change in R9's status as he would usually answer her questions and carry on a conversation. Following the fall, R9 would only respond with one word answers and closed his eyes and kept them closed even when responding to a question. R9 would open his eyes periodically when asked to, but closed them again right away. Interview on [DATE] at 2:34 p.m., with NA-A identified she was providing morning cares for R9 and was assisting him to the toilet. NA-A identified the bathroom door was closed so she stepped ahead of R9, leaving him unassisted, to open the door. She had not been utilizing a gait belt or provide extensive assistance as was identified in the care plan. When NA-A turned after opening the door, she observed R9 fall backward from a standing position striking his head against the floor. R9's fall happened so quickly she did not have time to intervene. R9 was holding his walker and fell backward without attempt to break his fall. RN-A assessed R9, but he was not able to describe what had happened and stated, that hurt. R9 was transferred into bed with the use of a total body lift with staff assist of three. R9 had denied pain when placed in bed. Interview on [DATE] at 8:45 a.m., with FM-A identified R9's family was concerned about his death and she discussed the incident with the head nurse (DON). FM-A had been telephoned by RN-B between 8:00 a.m. to 8:30 a.m. on [DATE], and informed R9 had taken a hard fall and was doing ok. FM-A was told R9 complained of lower back pain and staff were watching his VS which were reported to be elevated. R9 had received Tylenol and was advised by RN-B, elevated vital signs often corresponded with pain. FM-A identified she was ok with the limited information regarding R9's condition at the time. FM-A requested RN-B keep her updated. FM-A later received a call from RN-B at approximately 10:30 a.m. with the update R9 was still resting with no changes, but was drowsy and didn't want to get up. FM-A advised staff if R9 still was not out of bed by noon family members would come to assist with getting him up. Between 11:00 a.m. and 12:30 p.m., RN-B called to update FM-A R9 was restless so staff had gotten him up and assisted him to eat cereal and coffee. R9 then he had vomited. RN-B remarked to FM-A she didn't think he was going to last long. RN-B asked FM-A if she wanted R9 to be sent to the hospital or stay at the facility and be kept comfortable. FM-A advised RN-B to send R9 to the ER. FM-A would pick up R9's spouse and go to the hospital. Upon arrival at the ER, The family was met by the ER physician who explained R9 did not look good:. The physician explained R9 had a brain bleed, a skull fracture with probable fractures in his neck and back as well. When the family entered R9's ER room, R9 was not able to communicate and health had deteriorated. the physician had discussed options for treatment. Due to his age and medical condition, he didn't feel surgery was an option. R9's family did not want to prolong his suffering. R9 was experiencing more pain as time progressed, and had difficulty breathing. The decision was made to control R9's pain and place him on comfort cares. At around 6:00 p.m., R9 was transported back to the facility with hospice orders in place. At 7:30 p.m. R9 was at the facility with FM-A in attendance. R9's breathing sounded like gurgling. At approximately 9:00 p.m. she thought, R9 no longer was breathing, had no heart beat and was pronounced dead. FM-A was upset and reported he shouldn't have had to suffer and died . Continued interview with FM-A further identified, a couple of weeks after R9's death, she wanted to find out more about his fall and had requested a copy of his medical record. She stated the DON had returned a call to discuss R9's fall. FM-A stated the DON had described R9 was walking to the toilet when he had called out and fallen backward striking his head on the floor. FM-A stated she'd questioned why R9 had fallen so hard when staff were to have assisted him and were to use a gait belt to help him walk. FM-A stated the DON confirmed the NA assisting R9 on the morning of his fall had not used a gait belt, and had stepped away to open the bathroom door when he fell . FM-A voiced concern about whether R9 would have had appropriate assistance with walking to the bathroom, he would possibly not have fallen so hard. FM-A verified she was not made aware of the severity of R9's fall when she was initially contacted at either the 8:24 a.m. or the 10:30 a.m FM-A expressed regret about not having gone to the facility sooner, and stated she would have if she had been made aware of the severity of R9's fall with subsequent head injury. In addition, FM-A stated had she had been made aware of the severity of his injuries, she would have immediately requested he be sent to the ER. Interview on [DATE] at 11:00 a.m., with RN-B identified she was the day shift charge nurse on [DATE], working from 6:45 a.m. to 3:45 p.m. Upon arrival to the facility RN-B received report from RN-A, R9 had fallen while walking to the toilet. She was informed R9 had hit his head and was resting in bed after the fall with an ice pack on the back of his head. Upon arrival at R9's room RN-B identified R9 was talking per his usual behavior, denied pain, but had a large goose egg on the back of his head. RN-B described the lump as between golf-ball and base ball size, but made no assessment for measurements or severity of his injury. RN-B's assessments that day included vital signs, pupils, hand grasps, extremity movements, and pain which were all felt to be within R9's normal range. RN-B described the procedure for checking neuro checks as at the time of the incident, 30 minutes later, and then hourly and progressing to longer time frames. RN-B had notified FM-A around 8:00 a.m. to 8:30 a.m. that day that R9 had fallen, had a goose egg on his head but was talking and his VS and neuro's were normal. R9's VS did not become abnormal until sometime after lunch. FM-A requested to be updated so she had spoken to her after VS and neuro's were taken that morning around 10:00 a.m., and reported to the family there was no change in condition. RN-B had not notified R9's physician of the fall. R9's family members requested he be sent to the ER after RN-B noticed significant changes in VS and decline sometime around 12 noon. RN-B identified she should have notified the provider on-call when there was a change in status around 9:00 a.m., but had failed to do so. R9 routinely received [MEDICATION NAME] for his history of stroke. RN-B agreed she had not identified this placed R9 at increased risk of bleeding after an injury. The facility had a policy and procedure manual located at the nursing station, in addition to multiple manuals utilized as standards of practice for care. RN-B identified an emergent situation would include a fall with new onset pain, changes in level of consciousness or VS, fever, cough, and or shortness of breath or difficulty breathing. RN-B had offered to send R9 to the ER when she had spoken with FM-A, but they wanted him kept comfortable. RN-B could not recall details of her assessment she had provided to FM-A. RN-B agreed R9's hematoma was a serious concern, but admitted she failed to contact the provider or requested ER transfer. RN-B identified the changes in VS, decreased LOC, headache, lump on back of head, emesis would all be indications of head injury. RN-B stated in hind sight, she should have contacted the on-call physician both initially when she came on duty and was made aware of his fall with head injury and again when R9 developed a change in condition. Interview on [DATE] at 1:40 p.m., with MD-A identified she had been the doctor on-call for the ER physician who providing care to R9 in the ED on [DATE], when R9 was transferred following his fall. MD-A was also the MD on call on [DATE]. As an on-call provider, her duties included to assume care for those patients who required acute admission to the hospital or ER, provide consultation if requested, and follow a patient admitted for end-of-life or hospice services. MD-A identified she should have been notified immediately after R9's fall and subsequent head injury for consultation on method of treatment. When R9 had fallen, and later when he demonstrated a change in condition at 9:00 a.m. with unequal hand grips, pupillary changes, and change in the level of consciousness, she should have been called immediately. MD-A was not able to identify the cause of the delay of approximately one hour from when FM-A requested R9 be transferred to the ER, but the usual time for EMS response from initiation of call to arrival at the ED was 30 minutes or less. Failure by he facility staff to identify and assess changes in physical and mental status, prevented critical emergency assessment, pain management and comfort measures for R9 following his significant head injury. Subsequent interview with the ADON on [DATE], at 2:20 p.m., identified the fax notification of R9's fall was sent at 7:44 a.m. on [DATE], by RN-A. The ADON agreed there were no additional updates or communication to a medical provider until the ED was contacted at 1:24 p.m. with the intent to transfer via EMS. The ADON agreed R9 had an emergent condition and stated normally, the facility process was to first check with family prior to initiating an emergency transfer. The determination to consult with the provider would be dependent on what the family wanted done with regard to resident expected outcome. The ADON identified in hind sight, the RN should have provided an update to the medical provider of R9's status immediately following a head injury and again with his change in condition. During interview on [DATE] at 3:40 p.m., MD-B (the facility's Medical Director) identified she reviewed R9's medical record following his death. R9 experienced a fall with hematoma and new onset pain or changes in condition warranted an emergency situation due to a head injury. Her expectation was the nurse on duty at the time of the fall was to have immediately notified the physician or on-call physician to identify immediate treatment need. A fax notification was appropriate for updates such as a minor fall without injury, a skin tear, or an FYI. A fall with R9's degree of severity and injury should have been communicated to the medical provider via phone at that time. The delay in notification prevented possible interventions that could have provided comfort to both the patient and family. The ultimate outcome was likely not preventable due to the severity of the fall, but earlier interventions could have been provided to ensure comfort and faster evaluation of his medical status. The MD-B identified that was not the standard she normally saw provided by the facility, and was surprised the facility had not notified the physician immediately. MD-B agreed R9 was to have assistance of 1 staff while using his walker including gait belt use for safety. R9's severity of his injuries resulting from the fall could have likely been decreased if the plan of care had been followed and the NA had not stepped away and actively assisted in R9's transfer. Review of the [DATE] and [DATE], Gait Belt and Ambulation policies identified staff would receive training in use of a gait belt during orientation. A gait belt was to be used for all residents needing assist with transfers and ambulation. Before assisting a resident with ambulation, staff were to know their resident, be alert to changes, and check the resident's care plan. While ambulating, staff were to walk beside the resident with a firm grasp on the gait belt. Review of the [DATE], Notification of Change: Significant Change policy identified residents and/or resident's representative will be notified of changes in care or condition, as appropriate. Physicians and/or delegated non-physician practitioners were to be appropriately notified of condition changes. Staff were to immediately inform the resident, consult with the resident's provider, and notify the resident's representative (s) when there was an incident involving the resident which results in injury and has the potential for requiring physician intervention, a significant change in the resident's physical, mental, or psychosocial status to include a deterioration in health mental, or psychosocial status in either life-threatening conditions or clinical complications. The IJ was removed on [DATE] when it could be verified through documentation review and interview, the facility had revised policies for ensuring medical care would be provided timely including access to physician orders [REDACTED]. In addition, the facility's 24 hour report system was re-evaluated and staff were educated to revised processes.

Based on observation, interview, and document review, the facility failed to cancel communal dining and scheduled group activities, implement active screening of staff upon entry to the facility and source control masks, and daily ongoing surveillance of all infectious processes in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for COVID-19. Findings include: COMMUNAL DINING AND ACTIVITIES Interview on 3/30/20 at 11:10 a.m., with the life enrichment coordinator (LEC) identified communal resident activities continued to be offered but had been limited to 10 residents or less. Dining had been changed to keep residents in the unit they reside with meals continued to be served communally in each dining room located down Green hallway, main dining room, and special care unit. Each table has anywhere from 2 to 4 residents. Observation on 3/30/20 at 11:30 a.m., in the dining room of the Green hall identified residents were seated together for the noon meal. Tables were less than 6 feet apart and there were 3 to 4 residents seated at each table. Observation on 3/20/19 at 11:45 a.m., identified residents in the Red hall were congregating at the nurse station to wait for meal service to begin. Residents sat in close proximity, some shoulder to shoulder, in the entrance of the dining room near the nurses desk. Interview on 3/30/20 at 11:45 a.m., with TMA-A identified residents continued communal dining on the halls they resided. Residents were placed near the nurses station to wait for their meal and get their medication. Observation on 3/30/20 at 11:55 a.m., of special unit dining room identified 2 to 4 residents sitting at a table. Interview and document review on 3/30/20 at 12:20 p.m., infectious control (IC) identified residents continued to have communal dining and group activities and were not canceled as it was felt to have a potential negative effect of and depression and potential increased behaviors. Group sizes were decreased to a limit of 10 residents at each activity and social distancing was to be practiced. She was aware staff would push residents in wheelchairs into groups by the nursing station for medication pass while remaining ambulatory residents would wait in the same line for medication and agreed that failed to follow guidelines for appropriate COVID-19 related precautions. Interview on 3/30/20 at 12:52 p.m., with director of nursing (DON) identified staff were to keep residents as far apart as possible and avoid placing residents next to each other within 6 feet. DON identified canceling communal dining had been discussed but was not implemented as management felt it would be a burden for the resident's during this difficult time. The DON agreed staff the facility had not followed CMS guidelines to cancel all communal dining and group activities. There was the potential for an asymptomatic (no signs or symptoms) resident to spread the highly contagious infectious disease COVID-19 when dining activities were not canceled. Interview on 3/30/20 at 1:00 p.m., with activities director (AD) identified activities do not have a policy in place to stop all group activity and continued those activities. She had limited them to 10 or less residents. Interview on 3/30/20 at 1:05 p.m., with dietary manager (DM) identified dining room seating was the DM's responsibility. The DON had planned to space resident's further apart or even stagger meals but had not implemented any changes. The DM was unaware of CMS guidance to cancel communal dining. Review of the 3/20/20, COVID-19 Precautions Update email identified Red and Green halls and Special Care Unit residents were to dine at separate meal times in their own hall. Communal social hour was canceled in the main dining area. Activities staff were to reduce group sizes and conduct activities separately on each wing. Staff screening was to be moved to the employee entrance. SCREENING Observation on 3/30/20 at 10:30 a.m., of nurse aid (NA)-C identified she left the facility out of the Green Hall door exit and entered her car to leave for lunch break. Interview and observation on 3/30/20 at 11:04 a.m., with NA-A identified staff were to enter and exit the facility through the employee door located in the basement (lower level). Residents continued to have group activities. Residents come out to the dining room for communal meals with 2 to 3 residents seated at each table. Interview on 3/30/20 at 11:10 a.m., with the life enrichment coordinator (LEC) identified staff had been directed to use the Employee Entrance door downstairs to enter and exit facility. Each worker before starting their shift are to enter the building and proceed to either the Red or Green hall nurses station for screening before starting their shift. No staff were actively screened occurred at the entrance prior to walking into the building. An observation on 3/20/20 at 11:15 a.m., trained medication aid (TMA)-A entered through the Red-Wing's north entrance close to the staff parking lot. This entrance was not a designated entrance during COVID-19 infection prevention practices. Interview and observation on 3/30/20 at 11:20 a.m., with licensed practical nurse (LPN)-A identified staff were screened prior to the beginning of each work shift by entering the facility and reporting to the nurse's station at the hall they are scheduled to work on (Red or Green). Interview on 3/30/20 at 11:25 a.m., with housekeeper (H)-A identified all the facility doors were locked from the outside to prevent persons from entering the building. Staff were able to enter all doors using their name badges but were to enter through the basement or main entrance and report to their assigned nurse station to be screened. If a nurse was not available on their assigned hall, staff could go to the other hall to be screened. Interview on 3/30/20 at 11:35 p.m., with NA-B identified staff have been directed to enter and exit facility from employee entrance and report to a nurse's station for screening. There was a table at the employee entrance for staff to take their own temperature prior to coming into the facility to be actively screened at nursing station. Interview on 3/30/20 at 11:45 a.m., with TMA-A identified staff were were to enter the building through the basement entrance. Staff were screened for signs and symptoms of COVID-19 once inside the facility at the nurse station in their assigned hall at the beginning of their shift. During breaks and other times during the shift, staff were permitted to exit the building through the other doors during the shift because they were close to the parking lot. Interview on 3/30/20 at 12:52 p.m., with director of nursing (DON) identified staff were to enter and exit through the employee entrance and were not to use any other entrance. If staff left the facility for their break, it was her expectation they would reenter the building at the employee entrance. The DON agreed the above observation of staff using alternate doors other than the employee entrance was a concern. Interview on 3/30/20 at 2:15 p.m., with NA-C identified staff have been directed to enter and exit facility at employee entrance. NA-C had used the Green hall exit door to leave for lunch and return as she was running late. Observation and interview on 3/30/20 at 2:23 p.m., identified registered nurse (RN)-C entered the facility at the beginning of the shift through the Red hall entrance, walked through the wing to the nurse station, and took her own temperature. RN-C confirmed she entered through the Red hall door at the beginning of the shift. She verified resident rooms were located near that entrance. Staff used their name badges to unlock the doors to enter the building and were permitted to use the Red hall entrance to enter the building. Further interview on 3/30/20 at 2:45 p.m., with RN-B, the infection prevention nurse (RN-B), identified 2 entrances to the facility were utilized. The main entrance and the basement employee entrance. The main entrance had COVID-19 screening area where staff were to be screened prior to entering the building by administration staff. The employee entrance connected to the upper level by an elevator and a stairway. Both opened in the Red wing corridor. If staff used that door, they would have to walk past resident rooms in the Red hall to reach that nurses station. If they were to work in the Green hall, they would continue on across the common area to reach that nurses station. RN-B was unaware staff were required to be actively screened at the point of entry to the facility. All staff recorded their own respiratory symptom screening located on a roster in each hall. If a staff member was found to have a temperature, staff would be sent to the Green hall of the facility for additional screening. No oversight or monitoring was in place to ensure staff were actively screened at the point of entry. The nurses at each station were responsible to report to management any staff found to have a temperature greater than 100.0 degrees Fahrenheit (F) or respiratory symptoms of infection. No audits were completed to ensure staff were appropriately screened upon entrance or denied entry if those symptoms were present. The facility does not record temperature when staff were screened. It only included staff names, the date, and an X but no other information was documented. Review of the 3/30/20, Staff Accountability Roster identified staff documented an X in a box labeled COVID Temp. Please X DO NOT record temp. There was no indication on the form if an X indicated staff had or had not had a temperature over the recommended CDC guideline. The roster also included staff names and the times they entered and exited the building. Review of the 3/26/20, Screening Guide by Nurse/Clinical Staff policy identified all staff were to be stopped at the entrance of the building. 1) Staff or visitors were to be asked respiratory symptom questions and perform active screening for possible exposure to COVID-19. 2) Staff and visitors were required to supply the information. If refused, they were not permitted to enter the facilty. 3) If staff had a temperature over 100.0 degrees Fahrenheit (F), or answered Yes to any questions, A second-level screening was to be conducted. 4) The second level screening included the type and longevity of symptoms or if symptoms were of new onset, if staff had been on a cruise, in a level -3 COVID affected region in the past 14 days or in contact with a person who tested positive for COVID-19 in the past 14 days. 5) If staff or visitors answered 'Yes to any second-level questions, a third-level screen was to be completed. 6) Information identified during screening a document was to be kept on file at the facility. Review of the 3/26/20, Changes to Staff Covid-19 Screenings email identified a nurse was required to screen all staff who reporting to work. Staff were assigned to the Red and Green wings. Housekeeping, nurses, and homemakers were to report to the wing they were assigned to work. Dietary and laundry staff were to report to the Red wing for screening. Maintenance was to report to the Green wing for screening. All office staff who sign in at the front entrance were to report to the business office for screening by an RN. A nurse on duty was to ask questions and take staff temperatures. All staff were responsible to sign the accountability forms as proof screening occurred. There was no mention why the facility stopped active screening upon entrance to the facility as directed in the Screening Guide above. A 3/27/20, Changes to Staff COVID-19 Screenings email identified nurses were assigned to the main entrance starting at 7:15 a.m., Monday through Friday, to screen staff who entered though the main entrance. Staff entering the building before 7:15 a.m. were to go to the Red or Green hall nurses station to be screened. Each staff was responsible to sign the Accountability Rosters to identify they had been screened. Non-nursing staff were to sign the Accountability Rosters located in their departments. There was no mention how the facility would ensure oversight of the screenings to prevent potential symptomatic staff from entering the building. SOURCE CONTROL Interview on 3/30/20 at 10:45 a.m., with the administrator during the entrance conference, identified the facility had no suspected or confirmed cases of COVID-19. He received the Center for Medicare and Medicaid (CMS)'s Quality, Safety, and Oversight (QSO) memos related to COVID-19 guidelines. The facility had not initiated source control mask use in the facility as even though there was an ample supply of disposable personal protection equipment (PPE) masks. He was waiting for their new supply of cloth masks to be laundered prior to providing staff any source control masks. Observation on 3/30/20 at 10:45 a.m., in the Red hall identified several staff were providing care to residents. No masks were worn for source control by staff. Interview on 3/30/20 at 11:25 a.m., with housekeeper (H)-A identified staff were not required to wear masks. Interview on 3/30/20 at 11:45 a.m., with TMA-A identified staff were not required to wear masks for source control. There was no policy related to source control measure provided by the facility for the prevention of COVID-19. INFECTION SURVEILLANCE Interview on 3/30/20 at 3:20 p.m., with RN-B identified residents and staff who had potential signs or symptoms of COVID-19 were communicated to her by staff emails or verbal communication. Currently, no staff had presented with COVID-19 symptoms. Surveillance was completed by RN-B by checking with each nurse station several times daily, reviewing emails, and resident records. Although RN-B gathered information daily, it was not entered into the facility's spreadsheet to analyze patterns or trends in real time. Current data in the spreadsheet had ended February 2020. RN-B had yet to enter any data for March 2020. Her usual process was to enter data at the end of each month. The facility had no process on real-time tracking and trending or analysis of data. Review of the March 2020, Infection Monitoring Surveillance Record had no data entered into the spreadsheet. Interview on 3/30/20 at 3:30 p.m., with the administrator identified staff were to enter and exit the facility through the main entrance and basement entrance of the facilty. No other doors were to be entered by staff or visitors. Staff were to follow guidance provided by the MN Veterans Affairs, Centers for Disease Control (CDC), and CMS for guidance of infection practices for COVID-19. Review of the 3/10/20, Infection Prevention and Control Program policy identified the facility was to comply with regulatory requirements by following the recommendations of the professional infection control organizations, maintaining its infection control policies and procedures, and by providing ongoing staff education. The infection preventionist (RN-B) was responsible to direct day-to-day infection control activities and complete surveillance data collection, evaluation, tracking, reporting, auditing, and coordination. The surveillance program was to include assessing the population and facility risk, selecting outcome measures, collection, analysis, and reporting data as required to analyze trends and changes in infection rates in a timely manner. Outbreak prevention and management identified RN-B was to maintain an active line list and surveillance to readily identify outbreaks as they occurred.

Based on observation, interview and document review, the facility to ensure housekeeping followed appropriate glove use during the routine cleaning 3 of 3 double occupancy rooms and 1 unoccupied room, room [ROOM NUMBER], which affected 6 residents (R79, R3, R33, R26, R54 and R61) whom lived in these rooms. Findings include: During observation and interview on 7/17/19 at 8:44 a.m., housekeeper (H)-A was observed exiting R54 and R61's room wearing contaminated gloves. H-A pushed the cart down the hallway to room [ROOM NUMBER]. (1) In 257, H-A stated, staff continue to dust and clean an empty room to ensure it is ready for a new admission. Without removing her gloves and washing her hands, she obtained a rag that had been soaking in a bin of disinfecting solution (3M- 23 A). H-A wrung the extra solution from the rag with her same gloved hands. She proceed to enter room [ROOM NUMBER], and wiped each resident's bedside table top, the door handle on the bathroom, both sink handles, headboards, foot boards, nightstands, and windowsills. H-A exited the room after she finished her disinfection process, and took the soiled rag back out to her housekeeping cart, and discarded the rags into the linen bag. H-A proceeded to grab the floor duster and return to the room and dusted the floor. Without removing gloves or washing her hands, H-A returned to the cart and proceeded to R23 and R26's room. (2) Prior to disinfecting R23 and R26's room, H-A had not discarded her contaminated gloves or performed hand hygiene. She obtained a clean rag from the cleaning cart, and washed the door handles, sink, headboard, footboards and side rails along with windowsills, mirrors, bedside tables and night stands. H-A used the same rag between R23 and R26's room furnishings. H-A returned to the housekeeping cart and retrieved a duster with her contaminated gloves. H-A returned to R23 and R26's room, and proceed to dust. H-A forgot the wet floor sign she had used previously down the hall in R71 and R63's room. She had not removed her contaminated gloves or perform hand hygiene prior to entering the room and touching the door handle retrieving the sign. H-A proceeded grab the mop from the cart with her contaminated gloves, and mopped the floor in R23 and R26's room. H-A then left the room with the mop while still wearing her contaminated gloves and placed it back on the cart. (3) H-A then proceeded to R3 and R79's room. H-A entered the room and proceeded to collect the trash bags from the bins. H-A left the room with the trash bags and placed them into a larger bin on her cart. H-A grabbed clean trash can liners from the cart and replaced the trash bin liner bags. H-A then left the room, wearing the same gloves, and obtained a toilet brush from the cart. H-A went back into the room, cleaned the toilet, and returned the toilet brush to the cart. Without removing gloves or performing hand hygiene, H-A obtained a washcloth from the cart and reentered the room. H-A used the rag to first disinfect the toilet bowl rim, toilet seat, handles and outer toilet. Next, H-A wiped the sink basin, and faucet handles of the sink in the bathroom using the same rag. After disinfecting the bathroom, H-A exited the room and discarded the rag into the soiled linen bag on the housekeeping cart. Without removing her gloves or performing hand hygiene, H-A obtained a clean rag, entered R3 and R79's room and disinfected the room sink and faucet, R3's nightstand, bedside table, windowsill, and bed. (4) Without changing rags, H-A disinfected R76's nightstand, bedside table, windowsill, and bed. H-A exited the room and discarded the rag into the housekeeping cart lining bag. Without removing her gloves and performing hand hygiene, H-A retrieved the duster and dusted R3 and R76's belongings and placed the duster back on the cart. Without removing her gloves and performing hand hygiene, she grabbed the floor duster, dusted and mopped the floors, exited the room, and returned the duster to the housekeeping cart. (3) H-A proceeded to the tub room. Without removing her gloves and performing hand hygiene, H-A grabbed a rag from the housekeeping cart, entered the tub room, and wiped the sink and countertop. H-A identified housekeeping only disinfected the sink and mopped the floors in the tub room. H-A exited the tub room, and returned to the housekeeping cart. Observation and interview with H-A on 7/17/19 at 9:20 a.m., identified housekeepers were expected to change gloves only when they were visibly soiled or damaged. It was acceptable to use the same gloves from room to room and resident to resident because gloves were disinfected when they were dipped into the disinfectant to obtain wash rags to wipe down the rooms. Hand hygiene was performed after removing gloves, when hands were visibly soiled, and after contact with body fluids. H-A looked at her gloves and verified her glove was torn. H-A was unable to locate gloves on the housekeeping cart, and without performing hand hygiene, she entered the tub room, obtained a pair of gloves and put them on. H-A did not perform hand hygiene. An interview with infection prevention (IP) registered nurse (RN)-A on 7/17/19 at 12:08 p.m., identified she provided IP oversight for entire facility. Hand hygiene practices varied between departments. Housekeeping staff used single-use gloves only for protection from the disinfecting chemicals used to clean rooms. Housekeeping staff were not required to change gloves between disinfection of resident rooms, between resident areas in rooms, or after cleaning toilets. She expected housekeeping to remove gloves and perform hand hygiene when gloves were visibly soiled or damaged. Gloves used by housekeeping were indicated for single-use. All staff had received hand hygiene, and personal protective equipment (PPE) training on 4/29/19. She had not observed housekeeping hand hygiene or glove use to ensure appropriate hand hygiene and glove use. An interview with HM-A on 7/17/19 at 1:51 p.m., verified there were no housekeeping policies including handwashing and glove use. Housekeeping staff used the same polices and procedures as the nursing department for glove use and handwashing. Staff were not expected to remove gloves and perform hand hygiene between disinfection of resident rooms. Staff should remove gloves and wash hands between tasks. Review of the undated facilty's Exposure Control Plan policy indicated gloves were to be used when the employee's hand may contact blood or body fluids, or when handling or touching contaminated items or surfaces. Gloves should be changed and hands washed between each residnet contact and each site being cared for on an individual resident. Disposable, single use gloves are thrown away after use. Hand hygiene was to be performed with soap and water when hands were visibly soiled. Hands were to be sanitized immediately, or as soon as feasible after removal of gloves or other personal protective equipment (PPE).

Based on interview and document review, the facility failed to ensure the resident and/or resident's representative was informed of the bed hold policy at the time of hospitalization for 1 of 1 resident (R26) reviewed for hospitalization . Findings include: R26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/9-2/12/18, R26 was hospitalized with [DIAGNOSES REDACTED]. However, review of both the electronic medical record (EMR) and paper record lacked documentation of R26 having received a bed hold notice within 24 hours of being transferred to the hospital on [DATE]. R26's progress noted dated 2/9/18 at midnight, indicated R26 had been found passed out on the toilet with his extremities cyanotic (blue discoloration), drooling, and his eyes rolled back. The progress notes indicated R26 was unresponsive to stimuli and vital signs were recorded as blood pressure (BP) 70/43 beats per minute (BPM) (Normal values are 120/80), temperature (T) 94.6 degrees Fahrenheit (F) (Normal value 98.6 degrees F), respirations 10 breaths per minute (bpm) (normal 12-18 breaths per minute (BPM), heart rate (HR) 54 BPM, (Normal is 60-100 BPM), and his oxygen saturation was at 84% on room air, (Normal is 95 -100%). Emergency response was contacted and R26 was transferred to the local hospital. Progress notes indicated on 2/12/18 at 10:05 a.m., the long term care facility had been notified R26 would be returning to the facility. During interview with the assistant director of nursing (ADON) on 8/9/18 at 11:26 a.m., the ADON described the facility's procedure for giving residents information on bed-hold notices. The ADON stated the procedure included a packet being sent with the resident at the time of transfer which would contain the policy addressing bed holds and the need for the form to be signed. The ADON stated she was unaware whether the packet had been sent with R26 at the time of transfer, but confirmed there was no record bed hold information had been provided to the resident and/or representative. The ADON further indicated there was a note in the progress notes dated 2/9/18, that R26's son had been contacted about the resident's hospitalization , but no indication a bed hold had been obtained. The facility's Resident Financial-Bed Hold Rights policy dated 2/16/18, included: The MVH (Minnesota Veteran's Home) ensure residents at its facilities are provided opportunity to reserve residency upon a temporary absence due to hospitalization or therapeutic leave .1. Notice before transfer. Before MVH transfers a resident to a hospital or the resident goes on therapeutic leave, MVH staff shall provide written information to the resident or resident representative that specifies: a. The duration of the State bed-hold policy, during which the resident is permitted to return and resume residence in our home; b. The reserve bed payment policy; and c. Return requirements. 2. Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, MVH staff shall provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold and bed hold process according to the rules.

Based on record review and interview, the facility failed to ensure appropriate assistive devices were implemented to prevent accidents during transfer for 1 of 4 residents (R1) reviewed for safe transfers between a chair and bed. The failure to conduct a transfer using a full body mechanical lift in accordance with the resident's assessment, caused R1 to sustain actual harm, a fracture of the right humerus. The findings include: R1's care plan last reviewed 8/28/17, indicated R1 had impaired mobility related to right hemiparesis secondary to CVA (cerebral vascular accident). The care plan also indicated R1 used a wheelchair for mobility and required a full body lift for all transfers, and R1 was alert and oriented and able to make needs known. A nursing progress note from 9:45 a.m. 10/10/17, written by registered nurse (RN)-D, indicated that R1 returned from a haircare appointment at that time and wanted to be transferred back to bed. The note further indicates there was no lift sling under R1 so a four person transfer was done from the wheelchair to the bed; two staff assisting the upper body, one staff with lower body and one staff moving the wheelchair. According to the progress note, R1 immediately complained of right shoulder pain after the transfer. A nursing progress note dated 10/10/17 at 9:10 p.m., written by licensed practical nurse (LPN)-I, indicated R1 was experiencing pain rated at 10/10 in the right shoulder. The note reiterated R1 had been in her chair after hair care earlier that day with no lift sling under her, so staff had performed a four-person transfer back to bed, and immediately following the transfer R1 had reported pain in her right shoulder. The note indicated the resident had stated the pain was 'everywhere' and radiated down her elbow. A progress note by LPN-K dated 10/21/17 at 1:02 p.m., indicated R1 had returned from an appointment with her physician with a [DIAGNOSES REDACTED]. During an interview with nursing assistant (NA) at 2:00 p.m. on 10/23/17, NA-A verified the resident did not have a lift sling under her when she'd returned from a hair appointment 10/10/17 so staff had utilized a four person transfer. NA-B was interviewed on 10/23/17 at 2:19 p.m NA-B also verified R1 didn't have a lift sling under her when on 10/10/17, when staff were going to transfer her to bed. NA-B said RN-D had suggested the four person lift transfer to bed. NA-B also verified the resident had complained after the transfer the R1 that it had 'really hurt my arm'. During interview on 10/23/17 at 2:36 p.m., NA-C stated that R1 had not complained of any pain in her arm following her bath a short time prior to the incident 10/10/17. During interview with RN-D on 10/23/17 at 3:17 p.m., RN-D stated the facility provided lift training for staff. RN-D stated she was unsure why the lift sling was not in place under R1 in the wheelchair on 10/10/17. RN-D said when looking back, s/he would have conducted the transfer differently, but at the time it had seemed like the best choice because there was no sling underneath R1. The director of nursing (DON)-D was interviewed on 10/23/17 at 3:40 p.m DON-D stated staff should have attempted to place the sling underneath R1 and use the full body lift for the transfer 10/10/17. DON-D also said after the incident and investigation, staff involved in the inappropriate transfer 10/10/17 had received additional training, and all staff had been required to demonstrate how to perform a full body lift. During an interview on 10/23/17 at 3:53 p.m., physical therapist (PT)-F stated quarterly assessments are done on all residents to determine the appropriate level of transfer and mobility assist. PT-F stated R1 was at risk for injury on her affected side, because there was no muscle mass and the arm on that side was flaccid. When interviewed on 12/19/17 at 1:54 p.m., LPN-G verified that although R1 was care planned to be a full body lift, they'd done a four person lift on 10/10/17 and no one thought it would be unsafe. Physician (P)-H was interviewed on 1/8/18 at 11:02 a.m P-H stated the four person lift transfer caused R1's injury. P-H stated R1 had also seen an orthopedic specialist and continued with an arm sling for support as well as pain control. Family member (F)-J was interviewed on 11/2/17 at 4:13 p.m. F-J stated R1 was in pain 'big time' and she 'hurt like crazy'. A review of policies verified the facility had policies for all types of transfers and how to perform the transfers step by step. However, the policies do not state the care plan should be verified and followed prior to performing a transfer. SUGGESTED METHOD OF CORRECTION: The director of nursing or designee, could review all residents at who require special transferring assistance/devices to assure they are receiving the necessary treatment/services to prevent accidents. The director of nursing or designee, could conduct random audits of the delivery of care; to ensure appropriate care and services are implemented. TIME PERIOD FOR CORRECTION: Twenty one (21) days