Every finding on record at MN Veterans Home Silver Bay

Based on observation, interview, and document review the facility failed to ensure medications weren't left at a resident bedside when the resident was assessed to be unable to self-administer medications. This affected 1 of 1 resident (R41) reviewed for self-administration of medications.Findings include: R41's quarterly Minimum Data Set (MDS) dated [DATE] indicated R41 was cognitively intact. Diagnoses included renal insufficiency, anxiety, and depression R41's Provider Order Summary Report undated, lacked orders to keep medications at bedside. R41's care plan undated, lacked information related to self-administration of medications. R41's Self Administration of Medications &/or Treatments (SAM) dated 3/20/26 indicated R41 did not want to self-administer medications. The SAM also indicated R41 was no longer able to self administration. During an observation on 4/13/26 at 3:45 p.m., two white pills what R41 stated were nicotine throat lozenges were on the bedside table. There were no staff in the room at that time. During an observation on 4/14/26 at 11:10 a.m., two nicotine throat lozenges were again observed on the bedside table and there were no staff present in the room. During an interview on 4/14/26 at 11:12 a.m., trained medication assistant (TMA)-A stated she very rarely leaves medications at bedside. I am not sure what all needs to be in place to be able to keep medications at bedside when staff are not present. TMA-A confirmed R41 had medication left at beside and confirmed they were nicotine throat lozenges. During an interview on 4/14/26 at 11:16 a.m., registered nurse (RN)-A state a SAM assessment and order needed to be in place before medications could be left at bedside so the resident could self-administer.During an interview on 4/16/26 at 7:58 a.m., the director of nursing (DON) stated the SAM assessment needed to be in place and indicate the resident wants to self-administer and is able to self-administer before medications could be left at bedside. An expectation was for staff to confirm the appropriate information was confirmed before medications were left at bedside.Facility policy Self Administration of Medications-Skilled Nursing last revised 2/27/25, indicated a comprehensive assessment would be completed to make sure the resident wanted to, and had the capability to self-administer medications and keep medications at bedside.

Based on interview and document review, the facility failed to report an allegation of staff on resident physical abuse within two hours to the State Agency (SA) for 1 of 4 residents (R54) reviewed for abuse. Findings include:Facility incident report dated 6/7/25, identified on the evening of 6/6/25 at approximately 8:00 p.m., R54 was handled roughly by a staff member, coming in contact with R54's left hand causing injury and pain.R54's progress note dated 6/6/25 at 10:39 p.m., identified staff called to room to assist with resident. Resident complained a nurse assistant (NA) in a not gentle manner grabbed the left hand and caused pain and injury.During an interview on 4/15/26 at 2:18 p.m., registered nurse (RN)-C stated R54 reported to her on 6/6/25 around 8:00 p.m., an NA had grabbed his left hand roughly and had caused pain and possible new bruising to the left hand. RN-C could not remember if she notified anybody right away about the concern of abuse.During an interview on 4/16/26 at 7:30 a.m., the infection preventionist (IP) stated she was working as the charge nurse on day shift on 6/7/25. The day nurse had made her aware of the complaint around 10:15 a.m., and that is when it was reported to the SA.Facility policy Vulnerable Adult-Resident Protection Plan dated 6/22/23, indicated all allegations of abuse, neglect, exploitation or mistreatment would be reported no later than two hours after the allegation was made.

Based on observation, interview, and document review the facility failed to follow provider orders and administer medications as ordered for 1 of 2 residents (R41) reviewed for quality of care.Findings include:R41's quarterly Minimum Data Set (MDS) dated [DATE], identified R41 was cognitively intact. Diagnoses included renal insufficiency, anxiety, and depressionR41's Provider Order Summary Report undated, identified an order for nicotine throat lozenge 4 milligrams (mg), give one lozenge by mouth every hour as needed.During an observation on 4/13/26 at 3:45 p.m., two white pills what R41 stated were nicotine throat lozenges were on the bedside table. During an observation on 4/14/26 at 11:10 a.m., R41 stopped registered nurse (RN)-A and requested two nicotine throat lozenges. Trained medication aide (TMA)-A walked into the room at the same time with a medication cup with two nicotine throat lozenges in the cup and gave them to R41.During an interview on 4/14/26 at 11:12 a.m., TMA-A stated medications should only be administered to the resident based on the provider's order and the only way more could be administered is if the provider changed the order. TMA-A confirmed she had given R41 two nicotine throat lozenges, and confirmed the order was only to receive one at a time every hour as needed. TMA-A stated all staff had been giving R41 two lozenges at a time and that is why she did it.During an interview on 4/14/26 at 11:16 a.m., RN-A stated medications should only be administered as per provider orders.During an interview on 4/16/26 at 7:58 a.m., the director of nursing (DON) stated an expectation staff only administered medications as ordered by the provider.Facility policy Medication Administration, last revised 12/4/24, indicated staff would ensure the correct medication and the correct dose was only administered based on the provider

Based on observation, interview, and document review the facility failed to implement and follow interventions in place for a resident who needed assistance with meals. This had the potential to affect 1 of 1 resident (R1) reviewed who required assistance with feeding.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact. Diagnoses included stroke, hemiplegia and dysphagia. R1's Care plan undated, identified a current diet of regular with thin liquids. All foods needed to be cut into bite size pieces. The care plan also indicated and assist of one with meals.The facility East Dining Assistance Roster identified R1 was an assist of one for meals.R1's care conference notes dated 3/4/26 at 12:39 p.m., identified R1 had agreed to a bite size diet and assist of one with meals and the care plan was updated.During an observation on 4/14/26 at 12:34 p.m., R1 was given a plate that consisted of mashed potatoes with gravy and a piece of meatloaf. The resident then began feeding himself. The meatloaf was not cut up into bite size pieces and there were no staff with him, assisting with the meal.During an observation on 4/15/26 at 8:29 a.m., R1 received a piece of coffee cake with his breakfast. It was not cut up and again he ate it without any staff around to assist him.During an interview on 4/15/26 at 9:00 a.m., cook (CK)-A stated R1 was supposed to have his food cut up into bite size pieces and the cooks were responsible for cutting up the food. CK-A stated the coffee cake was not cut up because she felt the coffee cake was soft enough, and he could cut it himself. CK-A also stated the nurse assistants were responsible for assisting residents who needed assistance with meals.During an interview on 4/15/26 at 10:02 a.m., nursing assistant (NA)-A stated she was not aware NA-A was an assist for all meals and did not stay with him while he ate his meal. There should be somebody trained in feeding assistance with all residents that need assistance with meals.During an interview on 4/15/26 at 10:43 a.m., registered nurse (RN)-B stated R1 had agreed to bite sized food and having assistance with meals during the last care conference. The care plan had been updated, and the staff should follow the care plan when a resident needed assistance with meals.During an interview on 4/16/26 at 7:58 a.m., the director of nursing (DON) stated an expectation the staff would follow the care plan and provide care based on the care plan.The facility policy Resident Assessment-Care Plan dated 4/22/25, indicated the care plan would be implemented to assist the residents reach the highest practical level of functionality and wellness.

Based on observation and interview, the facility failed to complete appropriate hand hygiene during cares for 1 of 1 resident (R1) reviewed for infection control. Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact. Diagnoses included stroke and cancer. The MDS indicated R1 was frequently incontinent of bladder and always incontinent of bowel. R1 needed maximum assistance with toileting needs.R1's care plan undated, identified R1 had an alteration in elimination due to incontinence of urine and bowel. interventions included to check and change brief and provide perineal care.During an observation on 4/15/26 at 8:29 a.m., nurse assistant (NA)-A entered R1's room and told R1 she was going to check to see if the brief was dirty, and if so, change his brief, clean him up, and get him dressed for the morning. NA-A washed her hands and donned gloves. NA-A gathered wipes, cream, and a new brief from the R1's closet. R1's brief was undone and NA-A confirmed R1's brief was saturated with urine. NA-A removed R1's dirty brief and washed the front of his peri area with wipes. R1 was rolled to the right side and NA-A cleaned the buttock region. The dirty brief was rolled halfway under R1, and the clean brief was rolled to the other half of the R1, coming in contact with the soiled brief. R1 was then rolled to the left, the dirty brief was removed, and the clean brief was rolled the rest of the way under R1 with the dirty disposable chuck still under R1. The disposable chuck was observed to have wet areas on the pad where the peri-area would be located. With the contaminated gloves still on, NA-A then placed the new brief on R1 and secured it in place. NA-A proceeded to transfer R1 to the wheelchair and place R1's clean clothes on him. Lastly NA-A was observed placing the peri area cleaning supplies back into R1's closet, touching several items, with the contaminated gloves still on. The gloves were removed, hands washed, and R1 was taken to the dining hall.During an interview on 4/15/26 at 10:01 a.m., NA-A stated gloves would be changed if there was visible soiling noted or any time they went from a dirty area to clean area.During an interview on 4/15/26 at 10:43 a.m., registered nurse (RN)-B stated when doing cares gloves should always be changed when going from dirty parts, such as cleaning the peri area, to clean parts such as placing a new brief or clean clothes on the resident.During an interview on 4/16/26 at 7:30 a.m., the infection preventionist (IP) stated not following appropriate hand hygiene and not changing gloves when going from dirty to clean can increase the resident's risk of getting an infection.During an interview on 4/16/26 at 7:58 a.m., the DON stated all staff should change gloves when doing cares anytime they change from dirty parts of the process to clean parts of the process.Facility policy Hand Hygiene last revised 9/17/24, indicated staff would only perform hand hygiene before and after resident cares.

Based on interview and document review, the facility failed to ensure medications were administered to the correct resident for 1 of 3 residents (R1) reviewed for medication errors. This failure resulted in actual harm for R1 when she developed bradycardia (abnormally slow heart rate) and became hypotensive (abnormally low blood pressure) which required ongoing monitoring in the emergency department (ED). The facility had implemented appropriate corrective action prior to the onsite investigation, so the deficiency is being cited at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, and had diagnoses of chronic kidney disease stage 3b (moderate to severe loss of kidney function), hypertension (high blood pressure), heart failure (heart muscle does not pump blood effectively), hyponatremia (low blood sodium), anemia (low red blood cells), and polymyalgia rheumatica (inflammatory disorder that causes muscle pain and stiffness) . A facility report to the State Agency (SA) on 1/7/25 indicated on 1/6/25 at 7:45 a.m. R1 received another resident's medications, and had been sent to the hospital. On 1/6/25 at 9:14 a.m., a progress note written by nurse practitioner (NP)-A, indicated R1 had symptomatic hypotension and bradycardia following a medication error. R1 reported severe dizziness. Order written for evaluation and treatment at the ED. R1's Weights and Vitals Summary dated 1/6/25, indicated R1 had a blood pressure of 67/40 and pulse was 47 at 9:14 a.m. At 9:39 a.m. R1's blood pressure was 61/40 and her pulse was 41 bpm. R1's Emergency Department Note dated 1/6/25, indicated R1 was given the following medications the morning of 1/6/25: acetaminophen 650 milligrams (mg), apixaban (blood thinner) 5 mg , carvedilol (heart medication) 25 mg, divalproex sodium (seizure medication) 125 mg, furosemide (diuretic) 40 mg, metformin (diabetic medication) 1000 mg, sacubitril-valsartan (heart medication) 97-103 mg, allopurinol (uric acid reducer) 100 mg, amlodipine (blood pressure medication) 100 mg, empagliflozin (diabetic medication) 10 mg, ferrous sulfate (iron) 234 mg, isosorbide mononitrate extended release (heart medication) 60 mg, paroxetine (antidepressant) 20 mg, tamsulosin (prostate medication) 0.4 mg, and zinc sulfate 220 mg. R1's hospital History and Physical Summary dated 1/6/25, indicated R1 was accidentally given the wrong medications on the morning of 1/6/25. R1 had the following symptoms: lightheadedness, weakness, hypotension, and sinus bradycardia with rate in the mid to upper 40s. Poison control was contacted and didn't have further recommendations other than monitoring R1's blood pressure and heart rate. R1 was placed on telemetry, vital signs were completed every 2 hours, intravenous (IV) therapy was started with normal saline at 100 cubic centimeters per hours (cc/hr). Creatinine level (indicates how well the kidneys are functioning) was within baseline at 1.6 milligrams per deciliter (mg/dL). Hemoglobin (a protein in red blood cells) was stable at 9.4 grams per deciliter (g/dL). Orders were placed to recheck hemoglobin on 1/7/25. Electrolytes were within normal limits. On 1/14/25 at 11:52 a.m., R1 stated on 1/6/25 in the morning, she was told by staff that she got the wrong medications. R1 stated she felt dizzy and weak in her legs a few hours after taking the wrong medications. R1 stated she had to go to the hospital overnight because she was not feeling well. On 1/15/25 at 8:46 a.m., registered nurse (RN)-A stated on 1/6/25 during the morning medications pass, she set up three different residents' medication in the medication room, and placed them on a tray. She took the tray and went into R1's room to give R1 her medications. She gave R1 the wrong medications, but did not realize until she went to the second resident's room and his medications were not on the tray, but R1's medications were still on the tray. She went and told the charge nurse right away. The charge nurse then took over caring for R1. RN-A was removed from passing medications to being a nursing assistant for the day. During her lunch, she was told she needed to leave the facility pending investigation, and has not been back to the facility since the incident. She had since been re-educated, and was now aware that pre-preparing medications was not an acceptable practice, and she would not be doing it in the future. On 1/15/25 at 9:56 a.m., consultant pharmacist (P)-A stated after she reviewed the medications R1 received in error, she was concerned about R1's blood pressure as she received high doses of blood pressure medications. It would not be acceptable for nurses to prepare more than one person's medications at one time ever. On 1/15/25 at 11:48 a.m., NP-A stated she found out R1 was given the wrong medications on the morning of 1/6/25, and became worried about R1's blood pressure, pulse, alertness, and level of consciousness. She told the facility to send R1 to the ED when her blood pressure and pulse dropped, and she was complaining of dizziness. She would expect staff to complete one resident's medications at a time. It would never be accepted to do set up multiple resident medications at one time. On 1/15/25 at 12:04 p.m., the director of nursing (DON) stated the process of staff passing medications was to follow the medication rights, and do prepare medications for one resident at a time. The policy was not followed by RN-A on 1/6/25. The facility had reviewed the medication administration and medication incident policy, revised the medication administration standards policy, reviewed R1's care plan, started medications administration audits, provided education to nurses in regards to medication pass expectations, and P-A would be coming on 1/30/25 to do more education on medication administration. The facility Medication Administration policy revised 12/4/24, identified staff administering medication would ensure the correct medication was administered in accordance with the manufacturer's specifications or provider's order, to the correct person via the correct route in the correct dosage form, and at the correct time. The facility implemented corrective action to prevent recurrence by 1/14/25 when the facility completed the following: Reviewed and revised medication administration policies, provided education to all staff members responsible for medication administration, which included administration of medications and ensuring the six rights of medication administration was being followed, and completed medication administration audits. Verification of corrective action was confirmed by observation, interview, and document review on 1/14/25 and 1/15/25.

Based on interview and document review, the facility failed to allow residents to receive visitors. This practice had the potential to affect all 58 residents who resided at the facility, and their families. Findings include: On 2/2/21, at 1:07 p.m. the director of nursing (DON) stated the facility had no residents or staff diagnosed with [REDACTED]. On 2/3/21, at 10:33 a.m. the DON stated the last facility resident tested positive for COVID-19 on 12/18/20, and the last staff-person tested positive on 1/4/21. On 2/3/21, at 10:53 a.m. the DON was interviewed and states she believed the facility was in crisis staffing. The DON stated under guidance, certain exceptions to visitation were allowed which included crisis staffing. The DON stated since the facility had mandated staff, the facility was staffed appropriately to provide resident care. The DON stated crisis staffing was when the facility was unable to provide resident cares. The DON verified the required 14-day quarantine would had allowed the facility to permit visitation after 1/18/21. The DON confirmed the facility was only allowing virtual visits, essential caregiver visits, and [MEDICATION NAME] care givers visits. On 2/3/21, at 11:06 a.m. R5's family member (FM)-A was interviewed and stated the facility was only allowing essential caregiver visits. FM-A stated she had asked for additional family members to be allowed to visit R3, however, she was told only essential caregivers and [MEDICATION NAME] care visits were allowed. FM-A stated R3's health had declined, and she felt it was important for additional family members to visit R3. On 2/3/21, at 11:28 a.m. R6's family member (FM)-B was interviewed and stated the facility only allowed one essential caregiver to visit R6. FM-B stated he wished his wife could visit R6. FM-B stated he was told only one essential caregiver could visit. On 2/3/21, at 1:00 p.m. the social worker (SW)-A was interviewed and stated the facility was only allowing essential caregiver visits and [MEDICATION NAME] caregiver visits. SW-A stated the facility was trying to limit how many outside visitors were entering the facility. The Centers for Medicare/Medicaid services (CMS) Quality Safety and Oversight (QSO) memo 20-39-NH (nursing homes) dated 9/17/20, directed, .facilities may not restrict visitation without a reasonable clinical or safety cause, consistent with §483.10(f)(4)(v). For example, if a facility has had no COVID-19 cases in the last 14 days and its county positivity rate is low or medium, a nursing home must facilitate in-person visitation consistent with the regulations, which can be done by applying the guidance stated above. Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a potential violation of 42 CFR 483.10(f)(4), and the facility would be subject to citation and enforcement actions. The facility policy titled MN Veterans Home - Essential Caregiver Visit Protocol dated 8/27/20, directed, The facility will work with each individual resident and family to designate 1 essential caregiver for each resident.

Based on interview and document review, the facility failed to readmit a resident after transferring the resident to an emergency department (ED) for 1 of 3 residents (R1) reviewed for hospitalization s. Findings include: R1's Admission Record indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/15/20, at 10:33 p.m. a progress note indicated R1 had aggressive behaviors, and was sent to the ED. R1 was subsequently admitted to the hospital. On 9/15/20, a verbal consent was obtained for a Bed Hold by R1's family member (FM)-A. The form indicated R1's family had requested the facility to hold R1's bed. On 10/2/20, at 2:40 p.m. a progress note indicated the hospital where R1 was admitted to had attempted to coordinate R1's return to the facility. The note further indicated social worker (SW)-A had spoken with both the director of nursing (DON) and the administrator. It was determined the facility was unable to readmit R1, as a quarantine bed was unavailable. On 10/9/20, at 7:14 p.m. a progress note indicated R1 was admitted to a different skilled nursing facility. On 2/3/21, at 1:00 p.m. SW-A stated she was the primary contact between the facility and the hospital. SW-A stated R1 was transferred to the ED on 9/15/21, due to having aggressive behaviors. SW-A verified R1's family had requested a bed hold be put in place. SW-A stated the facility did not allow R1 to return to the facility, per the family request, as indicated on R1's bed hold. SW-A stated R 1 was not allowed to return to the facility when the hospital had indicated R1 was ready for discharge. SW-A stated she had discussions with the administrator and the DON, and the decision was made that R 1 was unable to return to the facility due to a COVID-19 outbreak at the facility. On 2/3/21, at 1:38 p.m. the DON was interviewed and confirmed R1 had been sent to the ED to be evaluated for increased aggressive behaviors. The DON stated R1 had been involved in two different resident to resident incidents, and was sent out for a mental health evaluation, and to manage his aggressive behaviors. The DON stated the intent was to have R1 return to the facility, however, when R1 was stable and ready to discharge back to the facility, there had not been a room for R1 to quarantine for 14 days due to the facility in a COVID-19 outbreak. A policy on readmission was requested and not provided.

Based on interview and document review, the facility failed to ensure 12 of 18 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R12, and R13) reviewed for drug diversion were free from exploitation when a staff member took resident's narcotic pain medications for personal use. Findings include: R1's Admission Record printed on 7/9/20, indicated R1 had [DIAGNOSES REDACTED]. R1's Order Summary Report printed on 7/9/20, indicated an order for [REDACTED]. R2's Admission Record printed on 7/9/20, indicated R2 had [DIAGNOSES REDACTED]. R2's Orders Summary Report printed on 7/9/20, indicated an order to offer as needed (PRN) [MEDICATION NAME] (narcotic pain medication) during night if resident is displaying pain. [MEDICATION NAME] HCL tablet 5 mg give by mouth as needed for pain related to bilateral primary [MEDICAL CONDITION] of knee not to be used during the day. [MEDICATION NAME] (HCL) tablet 5 mg give by mouth four times a day related to bilateral primary [MEDICAL CONDITION] of knee. R3's Admission Record printed on 7/9/20, indicated R3 had [DIAGNOSES REDACTED]. R3's Orders Summary Report printed on 7/9/20, indicated an order to give 8 mg of [MEDICATION NAME] (narcotic pain medication) one half hour before scheduled and PRN dressing changes. [MEDICATION NAME] HCL tablet 8 mg, give 8 mg by mouth every four hours as needed for chronic pain. [MEDICATION NAME] (antianxiety medication) 0.5 mg, give 0.25 mg by mouth every four hours as needed for anxiety by mouth oral or sublingual (under the tongue). Max one dose every four hours. R4's Admission Record printed on 7/9/20, indicated R4 had [DIAGNOSES REDACTED]. R4's Order Summary Report printed on 7/9/20, indicated an order for [REDACTED]. R5's Admission Record printed on 7/9/20, indicated R5 had [DIAGNOSES REDACTED]. R5's Order Summary Report printed on 7/9/20, indicated an order for [REDACTED]. R6's Admission Record printed on 7/9/20, indicated R6 had [DIAGNOSES REDACTED]. R6's Order Summary Report printed on 7/9/20, indicated an order for [REDACTED]. R7's Admission Record printed on 7/9/20, indicated R7 had [DIAGNOSES REDACTED]. R7's Order Summary Report printed on 7/9/20, indicated R7 had orders for [MEDICATION NAME] HCL 4 mg, give by mouth every one hours as needed for pain/shortness of breath, max one dose hourly. [MEDICATION NAME] 5 mg, give 2.5 mg by mouth every 12 hours for control of pain. [MEDICATION NAME] 0.5 mg, give by mouth every four hours as needed for anxiety or nausea, restlessness, related to unspecified dementia with behavioral disturbance. R8's Admission Record printed on 7/9/20, indicated R8 had [DIAGNOSES REDACTED]. R8's Order Summary Report printed on 7/9/20, indicated R8 had orders for [MEDICATION NAME] HCL 10 mg, give by mouth three times a day related to other chronic pain. [MEDICATION NAME] tablet (narcotic pain medication) give 30 mg by mouth every one hours as needed for pain or shortness of breath. [MEDICATION NAME] tablet 1 mg, give by mouth every day and evening shift related to generalized anxiety disorder. [MEDICATION NAME] 1 mg, give one tablet by mouth every four hours as needed for anxiety. R9's Admission Record printed on 7/9/20, indicated R9 had [DIAGNOSES REDACTED]. R9's Order Summary Report printed on 7/9/20, indicated R9 had orders for [MEDICATION NAME] HCL 2 mg by mouth every one hours as needed for pain or shortness of breath, max one dose per hour. [MEDICATION NAME] HCL tablet 5 mg, give 2.5 mg by mouth at bedtime for pain. [MEDICATION NAME] tablet 0.5 mg, give 0.25 mg by mouth every four hours as needed for anxiety or restlessness. R10's Admission Record printed on 7/9/20 indicated R10 had [DIAGNOSES REDACTED]. R10's Order Summary Report printed on 7/9/20, indicated R10 had orders for [MEDICATION NAME] sulfate solution 20 milligram per milliliter (mg/ml), give 5 mg by mouth every two hours as needed for pain or respiratory distress. [MEDICATION NAME] tablet 0.5 mg, give 0.25 mg by mouth every four hours as needed for anxiety. R12's Admission Record printed on 7/9/20, indicated R12 had [DIAGNOSES REDACTED]. R12's Order Summary Report printed on 7/9/20, indicated R12 had an order for [REDACTED]. R13's Admission Record printed on 7/9/20, indicated R13's [DIAGNOSES REDACTED]. R13's Order Summary Report printed on 7/9/20, indicated R13 had an order for [REDACTED]. On 7/8/20, at 11:30 a.m. nurse practitioner (NP)-A was interviewed. NP-A stated several months ago she had concerns about the amount of narcotics LPN-A was giving to residents. NP-A stated she alerted the director of nursing (DON) that LPN-A was giving more PRN narcotic pain medication than any other nurse. NP-A stated she heard that LPN-A had spoken to R3's hospice nurse, and asked her to have R3's [MEDICATION NAME] increased to double the amount of the pain medication, prior to dressing changes. The hospice nurse had the order increased to [MEDICATION NAME] 8 mg on 5/26/20, at 5:01 p.m. NP-A stated she spoke to the wound care nurse about R3's dressing changes being more painful. The wound care nurse told NP-A she did not agree that R3 was having more pain with the dressing changes. NP-A stated she then changed R3's order back to [MEDICATION NAME] 4 mg, 30 minutes prior to dressing changes on 5/26/20, at 5:26 p.m. On 7/8/20, at 1:29 p.m. LPN-A was interviewed. LPN-A stated after she had dental work done in 12/19, it was painful, and she kind of got addicted to pain medicine. LPN-A stated she started taking residents narcotic pain medications in May 2020, and she stated she only took their PRN narcotic medications. LPN-A stated if resident's needed something for pain, she made sure they got it. LPN-A stated, It was just so easy. On 7/9/20, at 11:32 a.m. the administrator, the DON, and the assistant director of nursing (ADON) were interviewed. The DON stated the concerns with LPN-A began in June 2020, after NP-A came to her with concerns about the amount of narcotics LPN-A was giving. The ADON recalled that she heard LPN-A had asked the hospice nurse to increase R3's pain medication prior to the dressing change, and the wound care nurse did not agree that the dressing changes had become more painful. Both the DON and the ADON stated they would expect the registered nurse (RN) to talk with the hospice nurse about the need to increase pain medications. The DON stated there were no progress notes to indicate R3 was having increased pain with dressing changes. The DON stated she suspected narcotic diversion after viewing video surveillance in June, following her conversation with NP-A. The DON stated they could not find any narcotic discrepancies to support their suspicion, however, they found LPN-A was giving narcotics without a pain assessment. On 3/5/20, the facility met with LPN-A, but their concern was about over-medicating residents, and not drug diversion. The administrator stated they were not concerned about narcotic diversion until after viewing surveillance video. The DON stated surveillance video indicated LPN-A was preparing narcotic pain medications for residents without first looking at the residents or looking at their medication records in the computer, and preparing narcotic pain medications immediately after completing the narcotic count. LPN-A's employee file indicated the following: On 7/22/19, LPN-A received counseling on 7/22/19, for destroying narcotics without a second nurse present. On 2/5/20, LPN-A received a performance amendment/letter of expectation on 2/5/20, with expectations for immediate improvement. The letter indicated, Medications will always be set up and administered following the 5 Rights of Administration. You will click on each medication after setting up and then approve after administration. PRN medication will be dispensed only after physical evaluation of the resident and after use/documentation on non-medication interventions. PRN's will be provided per the order medication indications in coordination with the resident's care plan. Multiple PRN medications will not be provided at one time. For 1-month PRN use must be assessed and approved by the RN prior to administration. LPN-A was encouraged to contact staff development if she needed additional training. On 4/15/20, LPN-A received training about charting non-medication pain relieving interventions before giving pain medications. On 6/3/20, LPN-A was called into the DON's office, and given a letter and explanation that she was being placed on an investigatory leave for failure to follow medication administration processes. On 6/4/20, LPN-A terminated her employment with the facility. The facility reported nine complaints to the state agency (SA) for potential medication diversion. The initial report was filed by the facility on 6/4/20, for a potential medication diversion of controlled substances (narcotic pain medications) on 6/1/20. The eight other complaints were filed on 7/1/20, for a potential of medication diversion(s) of controlled substances (narcotic pain medications) on 6/4/20. All the involved residents resided on a secured dementia unit, and had narcotic pain medications both at scheduled times and PRN. The facility policy Vulnerable Adult/Resident Protection Plan dated 11/19/19, defined abuse as also including the deprivation by an individual, including a caretaker, of goods. Misappropriation of resident property was also defined as permanent use of a resident's belongings or money without the resident's consent. The policy indicated they would train employees, through orientation and on-going sessions, on issues related to abuse and prohibition practices. They would monitor for staff burnout, which could lead to potential maltreatment of [REDACTED].

Based on observation, interview, and document review, the facility failed to ensure controlled medications were accurately reconciled for 1 of 1 residents (R7) while waiting for destruction to prevent the potential loss and/or diversion in 2 of 4 controlled medication counts. Findings include: R7's Face Sheet dated 7/9/20, indicated R7's [DIAGNOSES REDACTED]. R7's Physician order [REDACTED]. On 7/7/20, at 2:44 p.m. the Birch units narcotic count was observed with license practical nurse (LPN)-C and LPN-B. LPN-B began to reconcile (count) controlled medications that were being stored in a green bin waiting for destruction. The controlled medications that were in destruction bin were single pills stored in individual clear plastic baggies that were stapled shut. Each clear plastic baggie was labeled with the resident's name, name and dosage of the medication, date the medication was placed in the baggie, reason medication was not given, and page number to locate the medication in the narcotic book. LPN-C was unable to find R7's [MEDICATION NAME] and [MEDICATION NAME] in the narcotic book to ensure the number of medications were correct. LPN-C stated all the units received new narcotic books in June, 2020, and R7's [MEDICATION NAME] and [MEDICATION NAME] were logged in the old narcotic book that were in the director of nurse's (DON) office. LPN-C verified R7's [MEDICATION NAME] and [MEDICATION NAME] were not being reconciled since the units received new narcotic books in June. LPN-B placed R7's [MEDICATION NAME] and [MEDICATION NAME] back into the green destruction bin in the locked medication cabinet. R7's [MEDICATION NAME] and [MEDICATION NAME] were not reconciled. On 7/8/20, at 3:14 p.m. a second observation of Birch unit's narcotic count was completed with registered nurse (RN)-A and LPN-C at change of shift. LPN-C grabbed a green bin labeled destruction from the top shelf of the locked medication cabinet. The green bin contained small clear plastic baggies with individual controlled medications that were waiting to be destroyed. RN-A was unable to find R7's [MEDICATION NAME] and [MEDICATION NAME] in the new narcotic book, and stated R7's [MEDICATION NAME] and [MEDICATION NAME] must be logged in the old narcotic book that was in the DON's office. RN-A retrieved the old narcotic book from the DON's office, and LPN-C and RN-A reconciled R7's [MEDICATION NAME] and [MEDICATION NAME] with the old narcotic book. RN-A stated the new narcotic book was put in place around 6/9/20, and further stated she thought the narcotics in the green destruction bin were already destroyed so she had not been counting them at change of shift. On 7/8/20, at 3:28 p.m. RN-B stated Birch unit's old narcotic book was in the DON's office for an unknown length of time. RN-B stated R7's [MEDICATION NAME] and [MEDICATION NAME] were not being reconciled at change of shift since the old narcotic book was in the DON's office. RN-B verified R7's [MEDICATION NAME] and [MEDICATION NAME] were not transferred into the new narcotic book. RN-B further stated R7's [MEDICATION NAME] and [MEDICATION NAME] should have been transferred into the new narcotic book and counted at each shift. On 7/9/20, at 10:20 a.m. the consultant pharmacist stated all controlled medications in the facility should be counted at every shift until they are disposed of to prevent opportunities for medication diversion. On 7/9/20, at 11:33 a.m. the DON stated R7's [MEDICATION NAME] and [MEDICATION NAME] should have been transferred and logged into the new narcotic book. The DON stated all units received new narcotic books on 6/9/20, and the old books had been stored in her office since that date. The DON further stated nursing staff on Birch unit had not been requesting the old narcotic book to reconcile R7's [MEDICATION NAME] and [MEDICATION NAME]. The DON stated the importance of tacking all narcotics would be to avoid drug diversion. The facility policy Drug Disposition revised date 12/17/20, directed Controlled Substance-Class II, III, IV, or V medications required nursing documentation for use, have system requirements for security, and required tracking for their disposition or destruction to prevent unwarranted use and provide for reconciliation.

Based on observation, interview, and document review, the facility failed to cancel all group activities. In addition, the facility failed to ensure all residents wore a face mask covering for source control whenever they left their room or were around others. This had the potential to effect all 79 residents who resided in the facility. Findings include: On 4/23/20, at 8:38 a.m. on the Blue Spruce neighborhood, R1 and R3 were observed seated at a dining room table eating breakfast, and were seated diagonally from each other approximately three feet apart. On 4/23/20, at 10:07 a.m. a communal reading group activity took place in the living area off of the main entrance. Residents attending were not wearing masks. The following residents were in attendance: R6, R7, R1, R5, R12, R11, R3, R2, R8, R4, R9, and R10. On 4/23/20, at 10:21 a.m. a communal reading group took place in the Evergreen dining room. Residents attending were not wearing masks. The following residents were in attendance: R13, R14, R15, and R16. On 4/23/20, at 2:12 p.m. a communal activity of a movie was being shown in the great chapel room. Residents were not wearing masks. The following residents were in attendance: R5, R20, R21, R9, and R12. On 4/23/20, at 10:26 a.m. licensed practical nurse (LPN)-A stated they determined if residents were seated six feet apart by estimating the distance. On 4/23/20, at 11:25 a.m. R23 was interviewed and stated he does not wear a mask when he leaves his room to go to the smoking room. R23 stated he wears a mask if he attends Bingo. R23 pointed out his mask which was hanging on a hook on the side of his refrigerator, stating he's had it since the beginning of March, or so. On 4/23/20, at 11:40 a.m. R22 stated wearing a mask is up to the residents. R22 stated he had not been wearing one when he left his room, but if he asked, a mask would be provided. On 4/24/20, at 11:49 a.m. LPN-B stated residents needed to wear masks if they were going to be less than six feet apart. On 4/24/20, at 12:00 p.m. human services technician (HST)-A was interviewed and stated residents were required to wear masks if they insisted on sitting next to each other at Bingo, otherwise no masks were required if residents were six feet apart. On 4/24/20, at 12:08 p.m. registered nurse (RN)-F stated residents were wearing masks when they attended activities. On 4/24/20, at 12:14 p.m. recreation program assistant (RPA)-A stated they had been told by the facility that residents need to wear masks, and be six feet apart. RPA-A stated the residents frequently take their masks off. On 4/24/20, at 12:22 p.m. physical therapy assistant (PTA)-D stated it was his understanding that it was optional for residents to wear a mask when they were out of their rooms. On 4/24/20, at 1:24 p.m. an interveiw was conducted with the director of nursing (DON). The DON stated the Centers for Disease Control (CDC) website was being monitored daily by the quality nurse and herself. The DON stated she was familiar with the CDC's Key Strategies to Prepare for COVID-19 in Long-term Care Facilities (LTFCs) specifically in regards to preventing the spread of COVID-19. The directions were to cancel all group activities and communal dining, and ensure all residents wear a cloth face covering for source control whenever they leave their room or around others. The DON stated they were meeting this by enforcing social distancing. The DON verified they had not stopped communal group activities, but stated the groups were 10 residents or less. The DON stated residents were offered a mask and told why they need to wear them. On 4/24/20, at 1:48 p.m. the recreation therapist coordinator (RTC)-C stated they had not canceled all of the group activites. RTC-C stated residents were still offered a choice of wearing a mask, and were not be mandated to wear a mask when out of their rooms. An undated memo to the MN Veterans Home-Silver Bay Employees, Residents and Families from the adminstrator indicated the following: Continue to protect other Residents by maintaining distance between Residents, including during meal times. For now, we will continue to provide activites and interactions with Residents, but this will occur more on a one-on-one basis. The Center for Medicare and Medicaid Services (CMS) Quality, Safety & Oversight (QSO) memo 20-14 dated 3/13/20, guidance directed Cancel communal dining and all group activities, such as internal and external group activities.

Based on observation, interview, and document review, the facility failed to provide nail care for 1 of 3 residents (R66) who was dependent on staff for assistance with activities of daily living (ADLs). Findings include: R66's Face Sheet printed on 8/28/19, included [DIAGNOSES REDACTED]. R66's admission Minimum Data Set ((MDS) dated [DATE], identified R66 had severe cognition impairment, and required extensive assistance of one with personal hygiene. R66's Care Area Assessment (CAA) for ADLs dated 5/23/19, identified R66 required extensive assist with all ADLs except eating. R9's undated bathing sheet indicated R9 was to have nail care completed weekly on scheduled bath days. R66's care plan dated 8/16/19, indicated R66 was to have assist with all grooming due to self-performance deficit. On 8/27/19, at 7:34 a.m. R66 was observed to have long, yellow, jagged nails with a brown substance under his fingernails on both hands. On 8/27/19, at 7:59 a.m. registered nurse (RN)-D stated fingernails were to be trimmed weekly with the resident's bath. RN-D stated R66's bath sheet from the previous was not in the folder so there would be no way of telling if nail care was provided. On 8/27/19, at 8:07 a.m. RN-D verified R66's nails on both hands were in need of a trimming and cleaning. On 8/28/19, at 1:35 p.m. the director of nursing (DON) stated fingernails were to be trimmed and cleaned weekly with the resident's bath, and more often if needed. The DON stated the lack of grooming for a resident was a dignity issue, and could also be a source of infections. The DON stated resident cares are to be provided according to their individual care plans. The DON indicated she was not made aware of refusal of cares for R66. A copy of the facility bathing tasks sheets and documentation logs were requested but not provided. A copy of the policy for ADL assistance was requested but not provided.

Based on observation, interview, and document review, the facility failed to reassess off-loading, repositioning frequency, skin tissue tolerance, and effectiveness of a change in wheelchair seating surface for 1 of 2 residents (R18) with impaired skin integrity, who was at risk for pressure ulcers. In addition, the facility failed to provide timely repositioning to prevent development of a pressure ulcer for 1 of 2 residents (R32) who was at risk for pressure ulcers. Findings include: R18's Admission Record printed 8/28/19, indicated R18's [DIAGNOSES REDACTED]. R18's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R18 was cognitively intact, had no rejection of care behaviors, required extensive assistance of 2 staff for bed mobility, transfers, and toilet use, and did not ambulate. R18's MDS further indicated R18 was unsteady moving from surface to surface and required staff assistance to stabilize, had an indwelling urinary catheter, was continent of bowel, did not have any unhealed pressure ulcers, had no other skin conditions. The MDS also indicated R18's interventions included a pressure reducing bed and chair cushion, R18 received dressing changes, and was on a turning and repositioning program. R18's Care Area Assessment (CAA) for activities of daily living (ADLs) dated 3/29/19, indicated R18 was repositioned in bed and wheelchair every 2 hours and as necessary. The CAA for pressure ulcer/injury dated 3/29/19, indicated R18 had no existing pressure ulcers, but had a history of [REDACTED]. R18's CAA indicated R18 was able to make minor changes in position independently, and required assistance from staff with repositioning every 2 hours and as needed. R18 had a foam cushion on his wheelchair, but was evaluated with pressure mapping by occupational therapy (OT), and his cushion would be changed to one that provided improved pressure relief. R18's CAA further indicated R18 had a history of [REDACTED]. R18's care plan reviewed 7/1/19, indicated R18 had impaired mobility, and required a stand lift assist with 2 staff for transfers, used a power wheelchair with a personal foam cushion, and a wheelchair with a ROHO cushion (pressure relief cushions made of soft, flexible air cells connected by small channels, providing even support). R18's care plan further indicated R18 had the potential for skin breakdown related to a history of pressure ulcers and immobility, required assistance with turning and repositioning in bed using a right half side rail, and directed staff to provide a pressure relieving cushion in the wheelchair and alternating air mattress in bed, daily checks on ROHO cushion inflation, and reposition every 4 hours while in bed and in wheelchair. R18's care plan further indicated R18 had a [DIAGNOSES REDACTED]. R18's Bedside Kardex Report (nursing assistant care guide) printed 8/25/19, directed staff to provide a ROHO cushion in his standard wheelchair, and directed staff to reposition every 4 hours in bed and in wheelchair. R18's admission Skin Risk Factors evaluation dated 3/19/19, indicated R18 had several risk factors, including a history of pressure ulcers, and was at risk for skin breakdown. R18 was wheelchair bound, required assistance for complete off-loading. R18's Tissue Tolerance (TT) assessment dated [DATE], indicated R18 had a wheelchair with a gel cushion and pressure relief mattress in bed. R18 had a blanchable [DIAGNOSES REDACTED] (skin becomes white when pressed and returns to red when pressure released) after 2 hours in bed and in wheelchair. R18's TT assessment documented a history of pressure ulcers on his buttocks, no open areas at that time. R18 was noted to have pink scar tissue present with no areas of concern to bony prominences, and slight blanchable redness to buttocks. R18 was able to make slight changes in position but required assist to offload (relieve pressure from an area of the body), and was recommended to be turned and repositioned every 2 hours. R18's TT assessment dated [DATE], indicated R18 had a wheelchair with a gel cushion, and had blanchable [DIAGNOSES REDACTED] after 2 hours in bed and wheelchair. R18's assessment summary indicated R18 had a reddened rashy area over buttocks, and education was done regarding the importance of offloading to buttocks every 2 hours repositioning in wheelchair, using pillows behind his back to help him position on his side when in bed. R18's TT assessment dated [DATE], indicated R18 had a standard wheelchair, a gel cushion in the chair, and an air mattress in bed. R18's TT assessment indicated R18 had no alteration in skin condition after 4 hours in wheelchair or bed, was able to reposition self in bed, and was admitted with excoriation on his buttocks and was being treated with [MEDICATION NAME] boarder dressing. R18's rehabilitation Therapy progress notes dated 4/4/19, indicated R18 had received and alternating air mattress and pressure mapping was completed for pressure relief and comfort. R18's Medical Services Progress Notes by a nurse practitioner dated 4/23/19, indicated nursing staff had informed her R18 did not like to be repositioned every 2 hours while in bed, and tissue tolerance (assessment of how long a person can be on one area of the body without showing injury to the tissue) showed no concerns after 4 hours, so nursing questioned if it would be okay to reposition R18 every 4 hours instead. R18's signed nurse practitioner order dated 4/23/19, approved repositioning every 4 hours instead of every 2 hours per his request. R18's Order Summary Report for active orders as of 8/28/19, included orders for: Left buttock, clean open area with dermal wound cleanser, cover with a piece of calcium alginate Ag (fight bacteria and a broad spectrum of microorganisms while absorbing and containing exudate in a moist healing environment) then large piece of [MEDICATION NAME] foam (sterile dressing used to cover acute and chronic wounds that are excreting pus or other fluids) dressing to secure placement every day and every evening. Signed nurse practitioner orders dated 5/2/19, indicated this order was for a [DIAGNOSES REDACTED]. R18's Evaluation Summary in progress reports dated 6/17/19, identified R18 as being at risk for pressure ulcers related to several [DIAGNOSES REDACTED]. R18's summary indicated R18 was able to verbalize care needs, was non-ambulatory, and used a standard wheelchair with a ROHO cushion. R18 transferred with a stand assist lift. R18's documented skin condition at that time included an abraded area on the left buttock, and indicated R18 had a catheter in place, an alternating air mattress, and participated in a physical therapy (PT) program for strengthening. R18's summary indicated R18's goal would be to have intact skin by the next review. R18's progress note dated 6/30/19, indicated R18's left buttock wound had re-opened and measured 0.8 x 0.6centimeters (cm) with bridging partial thickness, and a bright red wound base. R18 had a light amount of serous drainage from the wound, and edges were noted to be distinct and attached. R18 was also noted to have a superficial slit between the buttocks with pale pink non-granulating (without new, healing tissue) wound base, and a scant amount of serous drainage. R18's progress note dated 7/18/19, indicated R18's left buttock wound was healing with no signs of infection. R18's progress note dated 8/8/19, indicated R18 had a pink coccyx (tailbone) area, but was not open. R18's progress note dated 8/19/19, indicated R18 had a left upper buttock partial thickness wound measuring 3.4 x .5 cm with moderate amount of serosanguinous (yellowish with small amounts of blood) drainage with some pain at the wound site. R18's rehabilitation therapy progress note dated 8/19/19, indicated R18 completed a trial using a power wheelchair and demonstrated safe use. R18's progress note lacked evaluation of R18's change in seating surface/cushion with change in wheelchair. R18's progress note dated 8/23/19, indicated R18 had a clean open area on the left buttock and had a treatment twice daily as ordered. R18's rehabilitation therapy progress note dated 8/27/19, indicated R18 preferred using his personal power wheelchair and preferred his own cushion rather than using the ROHO hybrid cushion he used in the standard wheelchair. R18's progress notes lacked evidence of evaluation of R18's tissue tolerance with the change in seating surface/cushion. R18's Wound Summary printed 8/28/19, indicated R18 had an abrasion on left ischial tuberosity upon admission measuring 2.0 cm x 1.5 cm with superficial bright beefy, red floor and scant bloody drainage. R18's wound healed on 4/10/19. R18's Wound Summary printed 8/28/19, indicated R18 had an abrasion upon admission on right ischial tuberosity measuring 2.0 cm x 0.3 cm with bright red floor, and no drainage. R18's right ischial wound healed on 4/10/19. R18's Wound Summary printed 8/28/19, indicated R18 had a facility-acquired abrasion on the left buttocks that was superficial with a bright pink/red floor measuring 2.0 cm x 2.0 cm x 0.1 cm. R18's left buttock open area remained stable until closing on 6/27/19, and re-opened on 6/30/19, measuring 0.8 cm x 0.6 cm x 0 .1 cm and was categorized as a partial thickness with a bright pink/red floor and light serosanguinous (liquid part of blood with blood) drainage. R18's wound summary further indicated R18's left buttock closed on 7/27/19, and re-opened on 8/17/19. On 8/28/19, R18's superficial left buttock wound measured 3.4 cm x 0.5 cm with a pale pink/red [MEDICATION NAME] skin and light serosanguinous drainage. On 8/25/19, at 3:32 p.m. R18 said he had sores on his bottom, that he had when he was admitted to facility. R18 stated they thought it was a bed sore, but then decided it wasn't. R18 stated he cannot get rid of the open area. R18 stated he did not have a special cushion in his chair, and said the nurse was going to get him his cushion from his other chair. R18 stated he had gotten the new chair about a week ago. R18 stated his bottom hurts, but he shifts his weight and it helps. R18 stated the staff will reposition him when he asks; they have him stand up when in his chair. On 8/27/19, at 7:48 a.m. R18 was in his power wheelchair and did not have a ROHO cushion. On 8/27/19, at 10:08 a.m. R18 came back from therapy and said he had done a lot of exercises and got out of his wheelchair to do exercises on the bike. On 8/27/19, R18 was observed to not have a ROHO cushion on his electric wheelchair. On 8/27/19, at 1:11 p.m. R18 was back in his room after eating lunch and stated he gets off his bottom when he asks. R18 stated he usually gets up once or twice during the day. R18, then said he was up every 2 to 3 hours, but said he had not gotten up since before lunch. On 8/27/19, at 2:08 p.m. R18 stated he had gotten out of his chair when the doctor saw him and injected his arm. R18 said they stood him for a minute to get the blood flowing and told him it was good to do that. R18 said he needs to do that more. On 8/27/19, at 2:15 p.m. health services technician (HST)-B stated they reposition R18 when he asks, but thought it was every 2 hours. HST-B then went to look it up and came back to report R18 was to be repositioned. On 8/27/19, at 2:21 p.m. HST-B came back and said R18's repositioning had been upgraded to every 4 hours. HST-B stated she entered R18's room and asked if he wanted to be repositioned, and he did, so she repositioned him. On 8/28/19, at 9:11 a.m. licensed practical nurse (LPN)-A stated R18's wound care was done early in the morning before he gets up. LPN-A stated R18's left buttock wound was a dry [MEDICATION NAME] wound and was not open, though called it a Stage 2 pressure-related wound. On 8/28/19, at 9:52 a.m. occupational therapist (OT)-crystal stated she had assessed him for his scooter. Stated he did not have the ROHO cushion in his scooter and thought maybe he did not like it, but said she had thought he should have a better cushion for pressure relief. On 8/28/19, at 9:53 a.m. registered nurse (RN)-B stated R18 did have a change in the cushion, but she had not been aware of it. RN-B stated a new tissue tolerance assessment would usually be done with a change in cushion. RN-B stated R18's wound on his buttocks was not a pressure area. RN-B stated the area opens with moisture, though was better with his catheter in place. RN-B stated they had a skin certified nurse who determined it was not a pressure-related area. RN-B stated she was not sure why he would have been changed to every four hour repositioning when he had an open area. On 8/28/19, at 10:32 a.m. RN-C, verified a new tissue tolerance was not done with the new cushion in R18's electric wheelchair. RN-C stated R18 had requested to be changed to every 4 hour repositioning in bed because he was not getting much sleep with every 2 hour repositioning. RN-B then verified a new tissue tolerance should be done with the new seating surface, especially with someone who has a compromised area. On 8/28/19, at 3:50 p.m. director of nursing (DON) stated she would expect a tissue tolerance to be completed with a change in seating surface. DON stated R18 made the choice to not have the ROHO in the scooter. DON verified R18 had a history of [REDACTED]. The facility policy Skilled Nursing Skin Management revised 12/17, directed licensed nursed to complete an assessment of the resident's skin, tissue tolerance and skin risk assessment per the Veterans Home protocols, done on admission, weekly for the first 30 days and then monthly. Therapy assessments and interventions for bed and chair surfaces were to be utilized as needed and documented in the medical record per provider orders. Findings included: R32's Face Sheet printed 8/28/19, indicated R32's [DIAGNOSES REDACTED]. R32's admission MDS dated [DATE], indicated R32 had severe cognitive impairment. The MDS further identified R32 was frequently incontinent of bladder and bowel, and was also was at risk for pressure ulcers. R32's Care Area Assessment (CAA) for pressure ulcers dated 4/15/19, indicated R32 was at risk of developing pressure ulcers due to incontinence, and impaired bed mobility. R32's care plan revised 7/19/19, directed staff to reposition R32 every two hours and as needed while in bed or wheelchair due to self-care performance deficient. Interventions for staff included the use of repositioning sheet and mechanical lift for bed mobility if R32 was fatigued and unable to help. R32's Care Card (nursing assistant care guide) undated, directed staff to reposition R32 every two hours while in bed and while in wheelchair. Record review for R32 revealed a tissue tolerance was last completed on 4/19/19, which indicated R32 had no skin concerns noted, no redness, irritation or breakdown noted. Risk for shearing and friction r/t impaired mobility & moisture due to bladder incontinence. Resident is able to reposition self in bed and wheelchair but has been requiring assist of 2 to transfer with the lift r/t weakness. On 8/27/19, during continuous observations beginning at 7:33 a.m. when staff exited R32's room, R32 had been lying quietly in bed on his back. At 10:06 a.m. HST-C entered R32's. R32 was observed lying on back in same position since 7:33 a.m. (2 hours and 39 minutes). HST-C pulled back R32's covers and stated the line on R32's brief incited he was only 25-30 percent wet, and his brief was made for 12 hour usage. HST-C further stated R32 was allowed to sleep till 11:00 a.m. per care plan, but was to be repositioned every 2 hours and as needed per care sheet. On 8/27/19, at 2:20 p.m. RN-D verified R32 required extensive assistance with bed mobility and repositioning. RN-D stated per R32's care plan he was to be repositioned every 2 hours. RN-D stated repositioning was important for skin preservation and residents comfort. On 8/28/19, at 1:35 p.m. the DON stated staff was to follow individualized care plans which included repositioning every two hors for R32. The DON stated repositioning was important to maintain resident's skin integrity, and prevent further skin breakdown.

Based on observation, interview, and document review, the facility failed to ensure a call light was provided and wheelchair breaks were locked for 1 of 4 residents (R30) reviewed for falls. Findings include: R30's Admission Record dated 8/28/19, indicated R30's [DIAGNOSES REDACTED]. R30's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R30 had severely impaired cognition. R30's MDS further identified he required supervision with transfers, and was not steady moving from a seated to standing position and turning around and facing the opposite direction. R30 used a wheelchair, and had two or more falls without injury since the prior assessment was completed. R30's care plan reviewed 7/18/19, indicated R30 was at risk for falls related to unsteady gait, sensory loss, cardiac medications, and pain. R30's goal was to remain free from injury. Interventions included contour mattress, keep call alert button in reach when in bed, relocate to public place when reading, Velcro straps attaching mattress to bed frame, gripper socks, and fall matt. On 8/25/19, at 6:32 p.m. R30 was observed self-transferring from a wheelchair to his bed. A concave mattress was noted in addition to a fall mat on the left side of R30's bed. A call light module was located on the right side of R30's bed, and the call light was handing down towards the floor out of R30's reach. On 8/27/19, at 9:46 a.m. R30 was observed in his bed and lying on his right side. R30 appeared to be asleep. R30's call light was hanging down from the module, on the right side of R30's bed out of R30's reach, and was on the floor under the section nearest the head of the bed. On 8/27/19, at 9:57 a.m., an interview was conducted with human services technician (HST)-[NAME] HST-A confirmed R30's call light was on the floor and out of the reach of R30 however, stated R30 used a wireless call button, located on his wrist, and did not use the call light connected to the module in his room. R30's wrist was unable to be observed at this time as he was covered with a blanket and appeared to be sleeping. On 8/28/19, at 11:17 a.m. an interview was conducted with registered nurse (RN)-[NAME] RN-A stated R30 had fallen in (MONTH) and June. RN-A stated in both instances R30 had fell out of his bed. RN-A verbalized R30's mattress was fastened to his bed and a concave mattress was placed to prevent recurrence. On 8/28/19, at 11:57 a.m. a transfer of R30 was observed. NA-A and RN-A were in presence of R30. The call light connected to the module on the right side of R30's bed, was noted to be clipped to the right side of R30's bed. R30 did not have a wireless call button attached to his wrist. NA-A pushed a wheelchair towards the right side of R30's bed. R30 independently transitioned himself to a sitting position on the right side of his bed. R30 then used his arms and pushed himself to a standing position. A white sheet was wrapped around R30's legs when R30 rose to a standing position. Staff did not attempt to remove the sheet from R30's legs. R30 then approached the wheelchair, placed his arms on the wheelchair arm rests, and lowered himself to a seated position. The wheelchair slid backwards approximately 6 inches when R30 sat down. The wheelchair breaks were observed to be unlocked. On 8/28/19, at 2:20 p.m. an interview was conducted with HST-[NAME] HST-A confirmed R30's wheelchair breaks were not locked during the transfer, and the wheelchair had slid backwards. HST-A stated she had forgot to lock the breaks. NA-A was asked where R30's wireless call button was located and did not offer a response however, stated she had clipped R30's wired call light to the right side of his bed. On 8/28/19, at 2:20 p.m. an interview was conducted with the director of nursing (DON). The DON stated the facility expectation was a resident's wheelchair breaks were to be locked during a transfer, unless the resident had anti-rollback breaks. The DON verbalized failure to engage wheelchair breaks could result in a fall. The facility policy Fall Management revised 10/9/18, directed The resident environment remains as fee of accident hazards as possible, and each resident is assessed for fall risk and have preventative measures in place that maintain the resident's highest level of independence.

Based on observation, interview, and document review, the facility failed to ensure timely incontinence care was provided for 1 of 1 residents (R32) reviewed for bowel and bladder incontinence. Findings Include: R32's Face Sheet printed 8/28/19, indicated R32's [DIAGNOSES REDACTED]. R32's admission Minimum Data Set ((MDS) dated [DATE], indicated R32 had severe cognitive impairment. R32's MDS further identified R32 was frequently incontinent of bladder and bowel. R32's Care Area Assessment (CAA) for mobility dated 4/15/19, indicated R32 had an impaired mobility and functional ability, and required staff assist with toileting, transfers, and mobility. R32's care plan revised 7/19/19, directed staff to toilet or check and change R32 every two hours and as needed. R32's care plan was updated on 7/19/19, to include R32 had a history of [REDACTED]. R32's Care Sheet (nursing assistant care guide) undated, directed staff to check and change R32 every two hours. On 8/27/19, during continuous observations beginning at 7:33 a.m. when staff exited R32's room, R32 had been lying in bed on his back. At 10:06 a.m. human services technician (HST)-C entered R32's (2 hours and 39 minutes). HST-C stated she was going to check R32's incontinent brief at that time. HST-C pulled back R32's covers, and stated the line on R32's incontinent brief indicted he was only 25-30 percent wet, and his brief was made for 12 hour usage. HST-C further stated R32 was to have incontinence cares every 2 hours, and as needed per care sheet. On 8/27/19, at 2:20 p.m. registered nurse (RN)-D verified R32 should be checked and changed every two hours per the care plan. On 8/28/19, at 1:35 p.m. the director of nursing (DON) stated staff was to follow individualized care plans which included 2 hour incontinence cares for R32. DON stated staff are to be checking and providing perineal care to prevent skin breakdown. A facility policy regarding perineal and incontinence are was requested but not provided.

Based on interview and document review, the facility failed to ensure incidents of alleged resident to resident abuse had been reported to the administrator and the State Agency (SA) for 9 of 10 residents (R27, R281, R79, R16, R44, R6, R2, R26, and R55) who resided on the memory care units and had been involved in resident to resident altercations with R27. Findings include: R27's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R27 had severe cognitive impairment, and had [DIAGNOSES REDACTED]. The MDS also indicated R27 had the ability to ambulate without assistance, and displayed verbal and physical aggressive behaviors on one to three days during the assessment period. R27's behavioral Care Area Assessment (CAA) dated 1/2/18, indicated R27 had a history of [REDACTED]. The CAA indicated R27 displayed disorganized thinking that fluctuated. R27's Vulnerabiltiy assessment dated [DATE], indicated R27 had a history of [REDACTED]. The assessment indicated R27 was at risk for abuse from others due to difficulty findings words, confusion, and disorientation that made him unable to report abuse. The plan directed the staff to prove a save environment for R27. R27's Care Plan provided on 6/14/18, indicated R27 displayed depressive statements, visual hallucinations due to [MEDICAL CONDITION], and [MEDICAL CONDITION]. The plan directed staff to offer behavioral interventions such as gardening, snacks, listening to stories or books, movies, redirect to tasks or activities when agitated, or pet therapy. The plan directed the staff monitor and intervene when R27 displayed behaviors. Review of R27's incident reports from 1/1/18, through 6/14/18, on 6/14/18 at 8:20 a.m. with the director of nurses (DON) and registered nurse (RN)-A revealed the following information: 1. On 1/19/18, at 5:25 p.m. R27 grabbed R281's right forearm and squeezed it. R27 would not let go of R281's arm, and staff members had to remove R27's hand off of R281. Neither resident sustained [REDACTED]. RN-A added R27 was not that strong so he was unable to Cause harm to others. 2. On 1/21/18, at 6:59 p.m. R27 was found in R79's room. R79 had R27 pushed up against a closet door and proceeded to Punch (R27) in the stomach. Staff separated the residents, and no physical injury was noted. RN-A stated she had investigated the incident on 1/22/18, and determined the direct care staff had not witnessed a punch between the two residents therefore, the incident was not reportable. RN-A stated staff members were provided education regarding appropriate and accurate documentation. 3. On 1/30/18, at 5:48 p.m. R281 reached across the dining room table to remove an item from R27's plate. R27 became agitated, and the two residents began yelling at each other. They stood up and R27 grabbed and pinched R281's arm and grabbed onto R281's shirt, and would not let go. Staff members intervened to separate the residents and redirect them. RN-A stated the incident did not cause physical harm, so the incident was not reportable. 4. On 2/2/18 at 5:10 p.m. R27 was observed ambulating towards R16. When the two resident's paths crossed, R16 Lunged his walker towards R27, Took a few swings at (R27) and made contact. No injury was noted. RN-A stated R27 was not injured as a result of the incident, therefore it was not reportable. On 2/5/18, the interdisciplinary team reviewed the incident, contacted R27's physican for possible pain medication changes, and the psychologist was updated. 5. On 2/9/18, at 7:00 p.m. R27 entered R44's room while he was in the bathroom brushing his teeth. R27 argued briefly with R44, then struck R44 several times in the back of his arm and chest. Neither resident sustained [REDACTED]. RN-A stated no injury was noted therefore, the incident was not reportable. A STOP sign was added to R44's door to deter wandering residents from entering R44's room. 6. On 2/17/18, at 10:00 p.m. R16 was walking through the neighborhood living room when he crossed paths with R27. R16 had a verbal altercation with a staff member and threw his walker at R27. The walker hit R27's arm. R16 and R27 then became verbally aggressive towards each other. R27 grabbed R16's walker, and a staff member had to pry R27's hands off of R16's walker. RN-A stated the altercation was not reportable as no injury was sustained as a result of the altercation. 7. On 4/21/18, at 8:01 p.m. R27 approached R16 who was seated in a recliner in the neighborhood living room. R27 attempted to get R16's attention by tapping him on the chest. R16 responded by swinging his arms and kicking at R27 . R27 was struck More than once in his upper leg area. RN-A stated the altercation did not result in injury, therefore it was not reportable. 8. On 4/28/18, at 8:49 p.m. R27 was packing in the neighborhood living room. R27 was holding a handled cup as he approached R6. R27's cup got entangled in R6's shirt and R27 was unable to get it out. R6 grabbed R27's wrist and would not let go. Staff members had to separate R27 and R6. No injury was sustained. RN-A stated the altercation did not result in injury, therefore it was not reportable. The DON stated R27 had been temporarily moved off of the Birch neighborhood during a construction project. After this occurred, R27 was transferred back to the Birch neighborhood. 9. On 5/12/18, at 7:18 p.m. R2 grabbed R27's wrist while he was sitting in the living room. Staff members had to redirect R2 away from R27. R27 was not injured. RN-A stated the altercation did not result in injury, therefore it was not reportable. 10. On 5/22/18, at 6:25 p.m. R27 approached R26 while R26 was seated in a wheelchair. R27 began yelling at R26 and Put his hands in R26's face, and grabbed his lift wrist. Direct care staff redirected R27 away from R26. No injury was noted. RN-A stated the altercation did not result in injury, therefore it was not reportable. On 6/14/18, at 9:28 a.m. RN-A stated the aforementioned incidents did not result in physical injury or mental anguish, therefore, none of the incidents were required to be reported to the facility administrator of the State Agency. On 6/14/18, at 9:30 a.m. the DON stated R27 suffered from severe dementia, therefore, his actions could not be considered willful. The DON stated the altercations did not result in injury or mental anguish, therefore, they were not required to be reported to the State Agency. Upon further discussion, the DON confirmed residents who suffered from dementia did have the ability to make willful actions therefore, the identified incidents should have been reported to the administrator and the SA as directed by the facility policy. The facility Vulnerable Adult/Resident Protection Plan policy dated 2/23/17, directed staff to report allegations of abuse in accordance to the federal and state laws. The policy further directed abuse allegations are reported immediately. The policy defined willful abuse as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy further directed staff to report the allegations immediately to their supervisor, facility administrator, and other individuals in accordance to the State and Federal law.

Based on observation, interview, and document review, the facility failed to ensure grievances were sufficiently acted upon for 1 of 2 residents (R33) reviewed for grievances. Findings include: On 6/11/18, at 2:39 p.m. R10 was observed sitting at a dining room window eating lunch. Strong body odors were noted coming from R10 that could be smelled into the connecting lounge area. On 6/12/18, at 11:15 a.m. during the resident council meeting, R33 stated he was unhappy with his roommate's (R10) personal body odor. R33 stated he did not like to be around R10 because of the pervasive body order, and none of the staff could get R10 to take a bath. R33 stated all of the staff were aware of R10's body odor, and nothing had been done about it. R33's Admission Record printed 6/14/18, indicated R33's [DIAGNOSES REDACTED]. R33's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R33 was cognitively intact, had mild depressive symptoms, and displayed no behaviors. R33's undated care plan printed 6/14/18, indicated R33 had the potential for behavioral symptoms and had minimal symptoms of depression. R33's care plan directed staff to encourage R33 to express feelings, allow him time to talk when he initiated conversation, and offer to sit with him when he was feeling anxious and paranoid. R33's target behaviors included irritability, and use of negative language toward others. R10's admission record printed 6/14/18, indicated R10's [DIAGNOSES REDACTED]. R10's annual MDS dated [DATE], indicated R10 was independent with cognitive skills for daily decision making, and had no signs or symptoms of depression, no [MEDICAL CONDITION], and no rejection of care. R10's MDS indicated he was independent with activities of daily living, preferred sponge baths and did not bathe during the assessment period. R10's care plan initiated 6/13/18, directed staff to record occurrences of paranoia. R10's care plan indicated R10 required one assist to supervise and set up for bathing or showering, but R10 often declined weekly bathing or showers, and preferred to wash himself at the skink with personal hygiene wipes. R33's progress notes dated 3/28/18, indicated R33 had reported to a nurse that he had concerns about the difficulty he had being around his roommate. R33 stated, He (R10) really needs a bath. It's getting so I can hardly barely stand to be in my room. It makes it hard to live here. The nurse documented that his concerns would be passed along. R33's medical services progress notes dated 6/5/18, indicated R33 expressed concern regarding his roommate's poor hygiene. R10's progress notes dated 6/5/18, indicated R10 was offered a bath weekly and as necessary, was provided cleansing cloths and encouraged to use them, continued to refuse to bathe, and would be continued to be encouraged to bathe. R10's progress note dated 6/1/18, indicated R10 frequently refused bathing, was provided with wipes, and skin would be examined as he allowed. R10's progress note dated 5/15/18, indicated R10 had not bathed in past 7 days, and refused bathing and was approached by 2 different staff. R10's progress notes from 4/18/18, through 6/14/18, indicated R10 continuously refused a bath. R10's Medical Services progress note by the nurse practitioner (NP) dated 4/25/18, indicated R10 was disheveled, had ripped clothing, had long dirty hair, and continued to refuse bathing, though staff were trying to provide different bathing options. On 6/13/18, at 7:51 a.m. R33 walked out of his bedroom with a walker, and stated he was still not sleeping. An strong body odor came from the room into the hallway. On 6/13/18, at 7:52 a.m. human services technician (HST)-F stated she tried to get R10 to shower or wash up every day, and set out clean clothes for him. HST-F stated the facility has tried different interventions. HST-F stated the nurse told her R33 disliked his roommate. HST-F stated she has told R33 to report his concerns to social services. HST-F stated she feels R33 is also a vulnerable adult. HST-F stated she reported R33's concerns to the nurse, as she was directed. On 6/13/18, at 2:10 p.m. social worker (SW)-A was interviewed and stated residents have not filed a grievance regarding R10's odor, and there was no official grievance form for R33's concerns. SW-A stated the facility has offered R33 a different room, but he did not want a different room. SW-A stated he has spoken with R10 about his odor and told R10 about visitor's concerns regarding his odors. SW-A stated the facility has tried providing different shower and clothing options for R10. SW-A stated it was very much a team effort. On 6/13/18, at 2:26 p.m. SW-B stated she has explained to R33 that R10 has rights, and R33 had not wanted to file a grievance. SW-A stated R10's odors have been brought up by other residents, and she reviewed the resident's rights with these residents. SW-B stated they continue to try different options for R10. SW-A stated they are trying to provide some guidelines for R10, while allowing him to be independent as much as possible. On 6/14/18, at 9:09 a.m. outside of R33 and R10's room, a strong body odor was noted into the hallway. On 6/14/18, at 9:21 a.m. R33 stated his roommate needs to take a shower stating, It is annoying. R33 stated he gets enough sleep. R33 stated he did not remember being offered a different room, but wanted to stay in the room he is in, and wanted a different roommate. R33 stated he was sure others complained about R10's odors also. R33 stated the staff give R10 clean clothes, but he won't change. R33 stated he had talked to one of the employees, and he was told R10 had rights. R33 stated he feels his rights are infringed upon when R10 doesn't take a shower. R33 stated everyone had been patient with R10, and the nurses leave clothes out for R10, but he won't take their suggestions. On 6/14/18, at 9:35 a.m. registered nurse (RN)-C stated they have tried a lot of things to manage R10's body odors. RN-C stated R10 bathes yearly and R33, along with other residents in the area have complained. RN-C stated she wonders about R33's rights and other resident's rights. RN-C stated they had not tried things like air fresheners/[MEDICATION NAME], and was not sure if a private room for R10 had been offered. On 6/14/18, at 4:08 p.m. the director of nursing (DON) stated they listen to a resident express a grievance, think about how they would resolve it, and document on a grievance form. The DON stated if a resident just wants to talk, they just talk, and do not do a formal grievance. The DON stated they had tried supplying R10 with bath wipes, offering a private shower, and other interventions. The DON stated they have offered R33 a room change. The DON stated they advocate for both residents' rights. The DON verified she had not filled out a tracking log for informal grievances. On 6/14/18, at 1:52 p.m. SW-A stated he did not know if a room deodorizer/[MEDICATION NAME] had been tried. SW-A stated private rooms were used for medical needs. SW-A acknowledged other residents' rights are being infringed upon, and stated R33 was in the SW office every day talking about his concerns with R10. On 6/14/18, at 3:00 p.m. SW-A stated he had ordered a room deodorizer, after asking R33 about it. SW-A stated they have not tracked informal resident concerns, so was unable to look at what the facility had done to address resident's concerns regarding R10's odors. SW-A stated they do not have many formal grievances. Review of grievance logs from 1/18, through the current date, indicated there had been only one formal grievance, and it was not R33's grievance with R10. The facility policy Resident Grievances dated 2/17, directed residents are encouraged to make their concerns and recommendations known, may file a verbal or written concern or grievance with any staff member, and every effort should be made to address verbal complaints. The policy directed the designated staff to report the resolution to the resident who originated the concern within three working days of the concern, and within seven working days for a grievance.

Based on observation, interview, and document review, the facility failed to comprehensively assess suicidal/homicidal ideations, and failed to direct staff on how to handle these ideations for 1 of 1 residents (R75) who expressed thoughts of being better off dead, as well as thoughts of hurting himself and others. Findings include: R75's Admission Sheet dated 5/19/17, indicated R75 had [DIAGNOSES REDACTED]. R75's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R75 had moderate cognitive impairment, felt down, depressed, or hopeless nearly every day of the assessment period, had thoughts of being better off dead, or thoughts of hurting himself in some way several of the days of the assessment period. The MDS further identified R75 required extensive assistance with most activities of daily living (ADLs). R75's Care Area Assessment (CAA) note dated 12/4/17, indicated R75 had mild signs/symptoms of depression. The CAA also indicated R75 had thoughts that he would be better off dead, or harming himself 2-6 days during the review period. When reassessed 3/6/18, R75 triggered for moderate/severe signs and symptoms of depression. The plan was for R75 to have indicators of depression, anxiety, or sad mood less than daily. Social services was to follow as needed. R75 was being followed by psychiatry and physician. R75's Self Preservation assessment dated [DATE], included R75 was feeling down, depressed, or hopeless 12-14 days of 14 days, and thoughts that he would be better off dead, or of hurting self in some way 2-6 days of 14 days. The summary included R75 was at risk for abuse, but failed to address thoughts of being better off dead, or hurting himself. R75's care plan dated 5/31/18, included the problem, I am having difficulty adjusting to my environment. Staff were instructed to encourage R75 to participate in conversation with staff and other residents daily. R75's care plan also included antidepressant medication, and antipsychotic medication as ordered by the physician. Interventions included alerting the doctor if antidepressant was ineffective, and to monitor for side effects. Non-medication interventions included assuring R75 he was safe, visiting, assisting to make a phone call, validating feelings, listening to music or books on tape, reporting depressive symptoms to medical providers, offering tea, essential oils, and snacks, as well as ways to interact with resident. The care plan for hallucinations included a goal of not harming himself or others, and directed staff to offer time to reflect and share about experiences, and ways to interact with R75. The care plan for depression included interventions of taking prescribed medications, monitoring for side effects, notifying provider with concerns, and referral to behavioral services as needed. The care plan failed to direct staff on what to do if R75 has suicidal or homicidal ideations. On 6/12/18, at 8:52 a.m. R75 was interviewed and stated he had a lot of bad dreams and some hallucinations that bothered him, and he was here to die, and frequently thought about dying. When observed on 6/2/18, at 9:30 a.m. R75 had gotten up out of bed on his own, and had tipped his wheel chair over. R75 ambulated on his own out to the day room, and asked for direction back to his room. On 6/14/18, at 12:22 p.m. nursing assistant (NA)-E was interviewed, and stated she had heard R75 make hopeless statements such as, I won't be here long, and I don't want to be here. NA-E stated she would be to try to determine if R75 was mentally present or not; if he was hallucinating. If he was hallucinating, NA-E stated you,Can't get him to come back, he's gone. There is no redirection. If R75 was hallucinating, NA-E stated she would keep him safe. If R75 was not hallucinating and mentally present, NA-E stated she would ask him why he made statements like that, and tell him they love him, and don't want him to hurt anyone. NA-E stated she would let the nurse know about the suicidal or homicidal thoughts. NA-E or the nurse would alert the facility charge person if the threats were serious enough, and then it would be determined whether R75 needed to be put on a watch, with observations every 10 minutes, every 5 minutes, or whatever the facility charge person determined. NA-E stated she would alert other NA's by pulling them aside, and telling them to keep an eye on R75 because he was having bad thoughts. On 6/14/18, at 2:08 p.m. licensed practical nurse (LPN)-B stated she had written a progress note regarding R75 dated 6/12/18, which included, HST Alert: depressive statements: Res stated that I (sik) he wished that he wouldn't have got rid of his gun because he would use it on a few people and that (sik) him self. Res was easily redirected away from that conversation. LPN-B stated this documentation was flagged in the chart so that all nurses on duty would receive the information and be aware of the suicidal/homicidal ideation. LPN-B stated she was not concerned that R75 was seriously considering suicide or that he had the means to carry through with suicide or homicide. LPN-B stated R75 occasionally made suicidal statements, but was easily redirected. LPN-B had not followed the facility policy which indicated staff would perform an assessment to determine risk of suicide or homicide, because he was so easily redirected and had dementia. LPN-B stated if she had felt R75 was unsafe, she would have stayed with him and contacted his psychiatrist. LPN-B stated she did not know if R75's care plan directed exactly what to do if he made suicidal/homicidal statements, or when to redirect him versus assess him for suicide plan or potential. On 6/14/18, at 12:47 p.m. registered nurse (RN)-C stated when a resident voices suicidal ideation (SI) or homicidal ideation (HI), the staff was to ensure resident safety immediately. Then staff are to notify the nurse for further discussion. RN-C stated a staff member would, Talk it out with the resident to see if the resident had a plan, and update the psychiatrist and medical staff in case the situation escalated. If the resident could not be left alone, a staff member could press their alarm to call other staff to the site of the emergency. Once safety had been established, staff would update supervisors, social services, and psychiatry. If the emergency continued, staff would call 911. RN-C further stated if SI/HI became a target behavior for a resident, the resident's care plan would be updated to monitor the behavior all of the time, and non-medication interventions, such as checks, would be part of the care plan. RN-C stated staff would make sure recreation staff and life enrichment coaches were aware of the interventions so they could also provide support. RN-C continued to state there would be a team meeting, the interdisciplinary team (IDT) would assess the incident. RN-C reviewed an incident in R75's progress notes from 6/12/18, which indicated R75 stated he wished he had a gun to take out others and them himself. RN-C stated she had no idea this had occurred. RN-C stated it appeared a staff member heard the comments, and an LPN wrote the incident into the chart, but the person in charge was not notified and should have been. RN-C stated R75 had been thriving on the special care unit, he was sometimes impulsive, but now was much better, more quickly. RN-C verified R75's care plan lacked any direction to staff on how to approach R75 if he made suicidal or homicidal statements. On 6/14/18, at 1:21 p.m. the assistant director of nursing (ADON) was interviewed and was asked if there was anything about SI/HI on R75's care plan. The ADON stated there was a significant change MDS document completed for R75, and plans were written onto the sheet of care instructions that were left in his closet. The ADON stated staff can ask R75 if he is playing games, or if what he is talking about really exists. Staff could also reassure him. Regarding the 6/12/18, incident when R75 was talking about using a gun to shoot peers and himself, the ADON stated the incident did not get to R75's care plan because staff were able to redirect him. When asked if it would be appropriate for staff to ask if there was a plan for coping with R75's SI/HI verbalizations, the ADON stated the NAs would redirect R75 or hand the situation off to a supervisor. With the 6/12/18, incident, the NA did hand off the information to the LPN. Since there were no further behaviors, staff may have just not reported it further. If the behaviors continued, the ADON continued, staff would know to report further, as they always reported behaviors. Then staff have the ability to put custom alerts on the resident. When asked if she was comfortable with the care plan not having specific interventions identified for when R75 has SI/HI, the ADON answered if one would see staff redirecting or reorienting R75, one would see that staff were doing a good job with him. The ADON asserted the life enrichment coaches spend a lot of time with R75, and he is doing well with the extra attention he receives on his unit. The ADON stated residents with behaviors get extra attention. The ADON also noted staff report behaviors to the psychiatrist. R75's psychiatry notes from (MONTH) to (MONTH) (YEAR), failed to identify any suicidal or homicidal ideation. On 6/14/18, at 1:56 p.m. RN-B (a staff member responsible for updating the MDS, was asked why R75 had nothing on his care plan regarding SI/HI when the CAA of 11/25/17, and the significant change MDS of 2/22/18, indicated regular thoughts of suicide, but the care plan generated did not include any specific interventions or response to try when R75 spoke of SI or HI. RN-B checked the care plan and stated social services completes the mood section of the care plan and was responsible for that part of the care plan. On 6/14/18, at 2:07 p.m. social worker (SW)-A stated redirection was appropriate for R75 when he made suicidal or homicidal statements, but that was not addressed specifically on the care plan to direct staff. SW-A stated he was unsure why the facility policy was not being followed for R75. SW-A stated he would check with the other social worker regarding this. No further response was received from SW-A. The facility policy Resident Danger to Self and/or Others dated (YEAR), included a purpose to Provide guidelines for the implementation of timely, effective and safe assessment, and interventions while providing safety for all individuals within the facility at all times. The policy included guidelines for assessment and intervention of suicidal behavior/harm to self which directed staff to assess the risk by, a. Provide for privacy; either take the resident to a private place or remove all other residents from the area. b. Interview the resident to determine his or her intentions: i. Is the resident thinking about hurting him/herself? ii. Does he/she have a plan (i.e. time, place and opportunity, method selected and is the method readily available)? iii. What are, if any, the precipitating factors (i.e. recent losses/increased stresses/depression/difficulty with adaptation to life changes)? iv. Has the resident made any preparations for his/her death (i.e. suicide note, giving away possessions, making final arrangements)? v. Any presence of hallucinations (auditory or visual) encouraging suicidal or harm to self? The policy further directed the care plan and medical record was to be reviewed and the DON was to be notified. This would be followed by a debriefing session.

Based on observation, interview, and document review, the facility failed to provide staff protective gowns for sorting potentially contaminated laundry in the laundry room. This had the potential to affect 76 of 77 residents who had their personal laundry washed in the facility. In addition, the facility failed to ensure infection control practices were maintained for 1 of 7 residents (R74) who required assistance with eating in the Evergreen unit. Findings include: On 5/9/17, at 10:40 a.m. a tour of the laundry was conducted with laundry worker (LW)-A. No protective gowns were observed in the laundry for staff to wear when sorting dirty and potentially contaminated laundry. LW-A verified there were not any protective gowns available in the laundry room for the staff to wear when sorting dirty and potentially contaminated laundry. LW-A further stated potentially infectious clothing was brought to the laundry in red bags, and staff never wore protective gowns to protect their clothing from potentially being contaminated. On 5/10/17, at 12:11 p.m. general maintenance worker (MW)-A stated she worked in the laundry part time, and protective gowns were not available for staff to wear while sorting laundry. MW-A stated no one in the laundry ever wore protective gowns to protect their clothing when sorting dirty laundry. On 5/10/17, at 2:37 p.m. the building services supervisor (BSS) stated staff should be wearing protective gowns when coming in contact with potentially contaminated laundry. The BSS verified protective gowns were not available in the laundry room. On 5/11/17, at 9:48 a.m. the assistant director of nursing (ADON) stated she didn't know why the laundry staff were not using protective gowns when sorting laundry. The ADON further stated she expected laundry staff to wear protective gowns when sorting potential contaminated clothing, or when an illness was going around. The facility policy Employee Exposure Plan dated 8/20/09, directed protective clothing will be worn whenever there is the possibility of soiling clothing with blood or other potentially infections material. Employees who handle contaminated laundry will use personal protective equipment to prevent contact with blood or other potentially infectious material. The facility policy Linen Handling dated 4/17, directed soiled linen from residents in isolation precautions should be handled as appropriate for designated isolation precautions. R74's Admission Record printed 5/11/17, indicated R74's [DIAGNOSES REDACTED]. R74's significant change Minimum Data Set (MDS), dated [DATE], indicated R74 was rarely or never understood, had short and long term memory problems, and severely impaired decision making skills. R74's required total assistance of one staff with eating. R74's care plan dated 3/15/17, indicated R74 needed significant assistance for meal and fluid intake, and was not to be given anything to eat or drink independently. On 5/9/17, at 8:46 a.m. R74 was observed being fed in the Evergreen dining area by human services technician (HST)-C. HST-C was observed blowing on R74's spoonfuls of hot food prior to putting the food into R74's mouth. HST-3 blew on the spoonfuls of hot food throughout the course of the breakfast meal. On 5/9/17, at 4:19 p.m. HST-C verified he did he blow on R74's hot food to cool it down during breakfast that morning. HST-C verified he did this several times throughout breakfast for R74. HST-C stated he didn't remember being told not to do this. On 5/10/20, at 1:00 p.m. registered nurse (RN)-C was interviewed. RN-C verified blowing on food to cool it down would be unusual. RN-C's expectation was that it should not happen, and verified it was not an acceptable practice. On 5/10/17, at 1:24 p.m. the assistant director of nursing (ADON) verified blowing on food to cool it down just prior to feeding it to a resident was not acceptable. A policy on infection control practices on assisting with meals was requested, but was not provided.

Based on observation, interview, and document review, the facility failed to follow the care plan to ensure foot support/rests were used for 1 of 1 resident (R3) reviewed for wheel chair positioning. Findings include: R3's Admission Record printed 5/11/17, indicated R3's [DIAGNOSES REDACTED]. R3's annual Minimum Data Set ((MDS) dated [DATE], indicated R3 had severe cognitive impairment. R3 used a wheel chair for mobility, and required extensive assistance of staff in locomotion on and off unit. R3's care plan dated 4/29/17, indicated R3 had impaired mobility related to lower extremity weakness, was non-ambulatory and had dementia. R3's care plan directed staff to use bilateral foot rests when they were transporting him in the wheel chair. R3's Safety/Falls Care Area Assessment (CAA) dated 4/25/16, indicated R3 used bilateral foot rests for transportation in his wheelchair. R3's bedside kardex indicated R3 used bilateral foot rests for transportation in his wheel chair. On 5/8/17, at 5:22 p.m. R3 was observed being transported in the wheel chair out of his room, into the dining by human services technician (HST)-E. R3 did not have any foot rests on his wheel chair, and his feet dragged on the carpeted floor. R3 stated, Ouch. R3 was reminded by HST-E to lift his feet, which R3 did. On 5/9/17, at 8:26 a.m. HST-D transported R3 in the wheelchair from his room to the dining room. R3's wheelchair lacked foot rests. R3's had shoes on, and his feet dragged on the carpet. On 5/9/17, at 10:04 a.m. R3 was observed being transported in the wheel chair from his room, off the unit to worship service. R3 was being transported by a volunteer (V)-A. R3 was seated in his wheel chair, was wearing shoes, and did not have foot rests on the wheel chair. R3's feet kept on lowering to the carpeted floor, causing the wheelchair stop. This occurred five times. Each time V-A asked R3 to pick up his feet. V-A verified she was taking R3 to the worship service off of the unit. On 5/10/17, at 12:46 p.m. HST-D stated R3 needed to be transported in the wheel chair when going from his room to the dining room. HST-D stated sometimes staff put foot rests on R3's wheel chair, and sometimes they did not. On 5/10/17, at 1:03 p.m. registered nurse (RN)-C stated she would expect R3's foot rests would be applied to the wheel chair as directed by the care plan. RN-C stated she would also expect staff to apply the foot rests to the wheel chair prior to being transported to the great room or dining room. On 5/10/17 at 2:00 p.m. the director of nursing (DON) stated she would expect staff to follow the care plan. The facility's Resident Assessment- Care Plan policy dated 11/5/15, indicated the purpose of the policy was to ensure residents maintained the highest practical level of functionality and wellness.