Every finding on record at Park View Health Care Center

Based on observation, interview, and document review, the facility failed to ensure proper infection control practices were followed for 1 of 1 residents (R82) when exiting the residents room with a COVID-19 positive diagnosis during medication observation. This deficient practice had the potential to affect all 84 residents who were currently residing in the facility, staff and visitors. Per the Center for Disease Control (CDC), Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. This would include Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. The CDC further identified contact precaution use for a COVID-19 infection included use of designated or disposable patient care equipment. Findings include: R82's admission Minimum Data Set (MDS) identified R82 had intact cognition with diagnoses of bladder mass, weakness, rheumatoid arthritis, urinary tract infection and receiving palliative care. The MDS further identified R82 required extensive to total dependence of staff for activities of daily living (ADL's) which included bathing, toileting, dressing and wheelchair mobility. On 12/30/24, R82 tested positive for COVID-19. R82's care plan revised 1/7/25, lacked documentation of R82's COVID-19 diagnosis and contact precautions. R82's physician order report signed 1/8/25, identified R82 was to receive the following medications. Calcium 600 mg with Vitamin D3 by mouth twice daily, Nicotine patch 14 mg/24 hours once daily and remove old patch before applying new patch, Senna-S 8.6 mg by mouth daily, Tylenol 325mg two tablets by mouth four times a day, Nitrofurantoin 100 mg by mouth twice daily, Oxycodone 2.5 mg/0.125 ml by mouth every twelve hours. During an observation on 1/8/25 at 7:02 a.m., licensed practical nurse (LPN)-A prepared the following medications for R82 at the medication cart stationed in the hallway near the dining room. Calcium 600 milligrams (mg) with Vitamin D, Nicotine patch 14 mg, Senna-S 1 tablet, Tylenol 325mg two tablets, Nitrofurantoin 100 mg, Oxycodone 100 mg/5 milliliters (ml). LPN-A opened the locked drawer in the medication cart and removed a box with an oral syringe inside the box. LPN-A drew up 0.125 ml equal to 2.5 mg and set the syringe in a plastic cup. LPN-A put the box and medication back into the locked drawer, locked medication cart and brought prepared medications towards R82's room. LPN-A put on (PPE)in the hallway outside of R82's room; gown, gloves, N95 mask and goggles and entered R82's room. LPN-A put the syringe of Oxycodone into R82's mouth and handed R82 a plastic glass of water. LPN-A gave R82 the other medications on a spoon into R82's mouth, R82 drank the water and handed the glass back to LPN-A who set the syringe into the empty glass. LPN-A proceeded to remove an old nicotine patch off R82's back and placed a new nicotine patch to R82's left back/shoulder area. LPN-A left R82's room and placed the empty plastic glass with the syringe in it on the (PPE) bin outside of R82's room in the hallway. LPN-A removed his gown and gloves and discarded them, sanitized his hands, removed goggles and N95 mask and discarded them, sanitized hands, put a surgical mask on and used sanitizing wipes to clean goggles and placed back in the (PPE) bin. LPN-A picked up the plastic glass and brought back to the medication cart and placed on top of the cart. LPN-A opened the medication cart and the locked drawer, placed the syringe back into the box of Oxycodone, locked the drawer and the medication cart, threw the cup away and sanitized his hands. During an interview on 1/8/25 at 11:30 a.m., LPN-A stated the facility policy was to sanitize any item that was put back into the medication cart if it was in a residents room. LPN-A further stated if a resident had COVID-19 that nothing would be returned to the cart but should be left in the residents room. LPN-A confirmed R82 was positive for COVID-19 and supplies brought into the room that R82 touched were returned to the medication cart and not sanitized. LPN-A verified it was important to clean any items returning to the cart to get rid of germs and prevent the spread of germs to other residents or staff. During an interview on 1/8/25 at 11:37 a.m., registered nurse (RN)-A confirmed R82 was positive with COVID-19 and that supplies should not be leaving the residents room when in isolation. RN-A stated the (PPE) cart in the hallway was a clean area and supplies from a residents room should not be placed on the cart to prevent contamination. RN-A verified the plastic glass and syringe used for R82 should have been thrown away in the residents room to prevent the spread of germs or COVID-19 to others. During an interview on 1/8/25 at 11:52 a.m., clinical support interim director of nursing (DON) confirmed any disposable items should be discarded in a positive COVID-19 resident room. DON stated items used in a residents room would not be placed on the (PPE) bin in the hallway as that was considered a clean space. DON verified this was important to reduce the risk of Covid-19 exposure and cross contamination from clean to dirty items. A facility policy titled Infection Prevention and Control Program revised 8/12/22, identified transmission based precautions and enhanced barrier precautions would be provided for residents requiring additional precautions if the facility was able to meet the resident's needs and infection control recommendations. Multiple use equipment would be sanitized per manufacturer's instructions and per procedure. A policy for use of transmission based precautions was requested from the facility and not received.

**** REVISED 2567 as a result of an Informal Dispute Resolution (IDR) Based on interview and document review, the facility failed to appropriately update the physician and document respiratory assessments for 1 of 3 residents (R1) after a new onset change of condition when oxygen therapy was initiated due to low oxygen saturation identified after a fall. Findings include: R1's Admission Record dated 8/2/22, indicated R1's diagnoses included diabetes mellitus type 1, chronic kidney disease, polyneuropathy (damage to the nerves in the hands and feet/legs), atherosclerotic heart disease and chronic pain syndrome. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had history of falls, required extensive assist of two persons for transfers, limited assistance with activities of daily living (ADLs) and had intact cognition. R1's care plan initiated 8/2/22, indicated R1 had type one diabetes mellitus and was at risk for decline in medical condition. Staff intervention included monitor for change of condition and notify provider and resident representative as indicated and administer medications and treatments per provider order. R1 had history of falls and scored 16 on the John Hopkins fall risk assessment tool indicating R1 was at high risk for falls. R1 required extensive assist of two persons for transfers using standing lift. R1 vital signs were stable, and she was on room air. R1's Provider Orders for Life-Sustaining Treatment (POLST) dated 8/11/22 indicated R1 was a Do Not Resuscitate (DNR) resuscitation status, with comfort-focused treatment which directed nurses to transfer R1 if comfort needs could not be met in current location. R1's oxygen saturation levels never got above 88% (normal is 90% or above) on 4 Liters of oxygen from 6:00 a.m. to 9:30 a.m. R1's medical record lacked evidence of other interventions implemented to alleviate her respiratory distress, or documented assessment of respiratory status after oxygen therapy was administered. R1's 3/12/24, vital sign documentation identified her normal oxygen saturation on room air, (pre-fall) was 95%. On 3/15/24 at 7:12 a.m., a progress note indicated R1 had unwitnessed fall with 0.5 centimeter (cm) x 0.4 cm bruise at right side of her forehead in her room at 4:59 a.m. She was disoriented, alert and had mild lack of energy. R1's vital signs and blood glucose (BG) levels dated 3/15/24 revealed the following: -5:00 a.m.: blood pressure (BP) 95/59; temperature (temp) 97.1; pulse 126; respirations (RR) 28 -5:15 a.m.: BP 103/61; temp 97.2; pulse 113; RR 25 -5:30 a.m.: BP 110/70; temp 97.2; pulse 109; RR 25 -5:45 a.m.: BP 101/63; temp 97.2; pulse 101; RR 27 -6:00 a.m.: BG 521 mg/dl -6:15 a.m.: BP 101/65; temp 97.2; pulse 101; RR 23 -6:45 a.m.: BP 108/63; temp 97.3; pulse 120; RR 21 -6:56 a.m.: BG 489 mg/dl -7:37 a.m.: BG 479 mg/dl -7:45 a.m.: BP 113/71; temp 97.4; pulse 119; RR 22, oxygen saturation (O2 sats) 84% -9:30 a.m.: BG 544; BP 82/54; temp 97.7; pulse 117; RR 16; O2 sats 74% There was no documentation to support staff had appropriately documented respiratory assessments had been completed after the initiation of new supplemental oxygen therapy. On 3/15/24 at 8:25 a.m., a progress note indicated R1 had at 6:00 a.m. blood glucose reading of 512 mg/dl, O2 sats of 80-81%, oxygen 4-5 L was applied via nasal canula, but her O2 sats remained at 83-85%. The note also indicated the on-call provider (MD)-A was notified, and ordered to give scheduled 10 units insulin, continue monitoring the resident's condition, and update the nurse practitioner (NP)-A for any sudden changes on R1's status. The note indicated family member (FM)-A was updated and aware of the resident's condition and agreed to send R1 to the hospital for evaluation if needed. On 3/15/24 at 9:30 a.m., a progress note indicated R1 had crackles to her lungs upon auscultation. R1 was lethargic, in respiratory distress with O2 sat at 69 to 74% on 4L of O2. The note also indicated NP-A was notified and ordered R1 to be sent to the hospital per family request. On 3/15/24 at 11:30 a.m., a progress note indicated R1 had passed away at the hospital with the family at the bedside. R1's hospital Patient Discharge Note dated 3/15/24 at 12:11 p.m. indicated R1 had coarse breath sounds bilaterally right worse than left, gasping for air, was unresponsive and was requiring bag-valve-mask (BVM), a handheld tool to deliver positive pressure ventilation support to maintain O2 sats upon arrival at the hospital. It was suspected R1's hyperglycemia (high blood glucose level) was from severe sepsis/septic shock from pneumonia. The note also indicated R1 passed away at 11:38 a.m. on 3/15/24. MD-A's progress note dated 3/15/24 at 6:33 a.m. indicated R1 was found down on the floor with a BG of 552, systolic BP of 95, pulse 104, and O2 sats of 80-84% on 4 L of O2. R1 had a few basilar crackles, an abnormal breath sounds at the bases of the lungs with no apparent injuries. The note also indicated to update primary team in two hours depending upon BP, and anything further regarding BG and O2 sats. NP-A's note dated 3/15/24 at 1:06 p.m. indicated R1 had unwitnessed fall in her room at 5:00 a.m., received a head strike and had an acute change in condition. Family did not want to send R1 to the hospital at that time. NP-A observed R1 sitting slumped over in bed, with the head of the bed (HOB) elevated because of labored/congested breathing. R1 was unresponsive and appeared at the end of life. On 4/8/24 at 12:42 p.m. family member (FM)-A stated she got a call from the facility around 7:00 a.m. on 3/15/24 regarding R1's fall. She told the facility to send R1 to the hospital for further evaluation. At around 10:00 a.m. she got another call again from NP-A who told her R1 was at the end of life. She requested R1 to be sent to the hospital for further care. On 4/9/24 at 8:14 a.m. registered nurse (RN)-A stated nurses were responsible for monitoring residents. RN-A stated R1 was found on the floor in her room at 5:00 a.m. and sustained an injury on her forehead. R1's BP was 90/69, her O2 sats were below 90%, O2 was applied at 4L and her O2 sats increased to 86% but remained below 90%. She acknowledged she did not document the O2 sats. She called MD-A at 6:00 a.m. and was directed to hold R1's BP medications, continue supplemental oxygen, encourage R1 to do deep breathing, and to continue monitor R1's respiratory status. She was to update the primary team in two hours. On 4/9/24 at 11:51 a.m. RN-C stated if a resident had a change of condition, she would assess the resident. Based on the findings, she would notify the provider and the family, and would continue to monitor the resident every 15 minutes. If the resident's condition had not improved, she would call the provider to request sending the resident to the hospital for further care, and document everything. There was no mention of how long staff should wait if a resident's condition had not improved before they were to call the physician and update them on the residents' condition. On 4/9/24 at 1:33 p.m. NP-A stated RN-B updated her about R1's deteriorating condition. She arrived at the facility at about 8:30 a.m. Upon assessment, R1 appeared at the end of life, she was unresponsive, pale, diaphoretic, hypotensive and had agonal breathing with 4 L of O2 on. She directed RN-B to update the family as R1's condition looked poor. She ordered to send R1 to the hospital per family request. On 4/9/24 at 3:05 p.m. MD-A (the on-call physician) stated he did not recall the nurse informing him of any injury to R1. He gave orders to manage R1 comfort based on the information provided by the nurse. The plan was to manage R1's BG, to continue with supplemental O2, and update the primary care team in two hours. The plan was to focus on comfort care according to R1's advance directives. MD-A stated nurses could call back anytime if a resident was having significant change in condition, but agreed staff should have called back if R1's status failed to return to baseline per acceptable standards of practice. MD-A stated the plan was to focus on comfort care according to her advance directives, however, MD-A acknowledged not directing the nurse to ask R1 if she wanted to go to the hospital or transition to comfort care in the facility. On 4/10/24 at 9:59 a.m. RN-B stated the last respiratory assessment she did on R1 was around 7:45 a.m. with O2 sats of 84% on 4L of O2. She called the unit manager around 8:15-8:30 a.m. to come and assess R1. R1 was lethargic with O2 sats of 74% to 69% around 9:00 a.m. and she immediately notified NP-A who was on site. On 4/10/24 at 10:51 a.m. RN-D (the unit manager) stated when RN-B told him about R1's change in condition, he went to see R1 in her room but did not do a full assessment. RN-D stated he just wanted to check R1's cognition, and she was able to tell him his name, but was still having hard time breathing. He did not know what R1's O2 sats were when he got to her room, nor did he check. He left R1 and went to his office to be prepare for his daily meeting. Around 9:15 a.m. he saw NP-A who told him R1 was actively dying, and he was surprised. R1 was unresponsive when emergency medical service (EMS) arrived, and EMS put R1 on high flow O2 with BVM support. After a fall with a head strike, nurses should initiate neuro check and vital signs (VS) which would include O2 sats every 15 minutes. On 4/10/24 at 12:22 a.m. the director of nursing (DON) stated she got a report from RN-B between 8:00 a.m. and 9:30 a.m. regarding R1's fall and was not told of any respiratory distress. After a fall with a head strike, nurses should initiate neuro checks and full VS every 15 minutes, assess the resident frequently, and report to the provider and the family. The facility Fall Assessment and Managing Fall Risk policy revised 11/6/23 directed nurses to assess the resident VS and to complete the neuro checks form every 15 minutes (min) times (x) 1 hour, every 30 min x 1 hour, every hour x 1 hour, and then every 4 hours until 24 hours post fall. Notify the provider and resident representative of the fall for residents with unwitnessed fall. Review of the March 2022, Standing Orders identified staff could initiate and titrate supplemental oxygen from 1-4 liters per min (L/min) via nasal canula as needed for O2 saturation less than 88% immediately upon updating the physician with a nursing assessment. There was no mention of when staff should notify the physician if therapy had not improved the residents' symptoms if a resident failed to return to their baseline after initiation, nor did it mention how often staff should assess a resident or document respiratory assessments. The facility Notification to Physician/Family/Resident Representative of Change in Resident Health Status policy reviewed 4/14/23 defined a significant change of condition as a major decline or improvement in the resident's status which will not normally resolve itself without intervention by staff or by implementing standard disease related clinical intervention. The policy directed nurses to make detailed observations and gather relevant and pertinent information for the provider. There was no mention when staff should notify the physician for failure to return to baseline after new onset treatment to determine if a medical examination was warranted, or the resident should be referred for a higher level of care.

Based on observation, interview, and documentation review the facility failed to ensure expired food items were discarded appropriately from the kitchen and kitchenette. This had the potential to affect 87 of 91 residents. The facility also failed to properly clean the ice and water dispenser in the Northwoods kitchenette. This had the potential to affect 40 residents. Findings include: During observation and interview on [DATE], at 10:33 a.m. tour of kitchenettes and kitchen conducted with Chef and Registered Dietician (RD). - Non-dairy creamer in kitchen dry storage had delivery date of [DATE]. No expiration date indicated. -Two boxes of devil's food cake mix with expiration date of [DATE] on the shelf in the dry storage area in the kitchen. -Four plastic bags of light brown powder mix without labels, located on top of coffee cake mix. -Northwoods kitchenette water and ice dispenser was covered with a white scaly substance over the front, the tray, and outer edges. - The Main Lane kitchenette refrigerator contained a plastic bag labeled room [ROOM NUMBER]. The bag contained a cucumber, a clear plastic container with carrots and broccoli, and vegetable dip. The cucumber had multiple small circles with a white and fuzz-like matter. The container of carrots and broccoli were dated [DATE]. The vegetable dip was dated [DATE]. -Main Lane refrigerator also contained pudding labeled with expiration date [DATE] and jello labeled with expiration date [DATE]. During an interview on [DATE] at 10:40 a.m. Chef stated that the refrigerator, freezer, and dry strorage contents were reviewed daily by either a dietary aide, kitchen manager, or chef weekly. Chef stated resident personal food items were disgarded after seven days, the residue on the ice dispenser was from hard water and confirmed residents were served from the dispenser. Chef stated the plastic bags contained coffee cake topping, but there was no way to confirm contents or expiration date. He stated box top should have been retained for reference. RD stated per the distributor the expiration date of the creamer was 365 days after it was produced and the cake mix should have been removed and discarded. Review of policy titled Refrigerator and Freezer Storage, dated [DATE], last revised [DATE] stated Food and Nutrition services, or other designated staff, will maintain clean food storage areas at all times.

Based on observation, interview and record review, the facility failed to ensure staff disinfected personal protective equipment (PPE) upon exiting a COVID-19 positive resident room. This had the potential to affect all 91 residents that resided in the facility. Findings include: During observation on 12/05/22, at 6:21 p.m. a transmission based precaution (TBP) cart was next to R385's door. A sign was posted on the door indicating contact and droplet precautions and staff were to wear PPE including a face shield when entering R385's room. During interview on 12/06/22, at 10:44 a.m. the infection preventionist (IP) stated staff were instructed to wear full PPE including a face shield when entering a COVID-19 positive residents room. During observation on 12/7/22, at 8:59 a.m. licensed practical nurse (LPN)-A exited R385's room. LPN-A removed and placed her dirty face shield and N-95 mask on the top of the TBP cart. LPN-A used hand sanitizer after she removed the rest of the PPE. LPN-A picked up the dirty N-95 mask and face shield, carried them to the medication (med) cart, and placed the face shield on a narcotic book on top of the cart. LPN-A placed the N-95 in a paper bag, carried the bag back to the TBP cart and placed the bag inside the cart. The dirty face shield was still on top of the med cart. LPN-A returned to the med cart and proceeded to dispense another residents medication. During observation on 12/8/22, at 9:27 a.m. nursing assistant NA-C exited R385's room wearing PPE including a face shield. NA-C was not wearing gloves. NA-C removed the dirty face shield, placed it on top of the TBP cart and removed the gown and N-95. NA-C picked up and placed the face shield in a paper bag and put it inside the TBP cart. NA-C was not observed to disinfect the top of the dirty TBP cart prior to walking away. During interview on 12/7/22, at 9:03 a.m. LPN-A stated she should have, but had not sanitized the face shield right away after exiting the R385's room. During joint interview on 12/8/22, at 9:27 a.m. NA-C stated she removed her gloves upon exiting R385's room and should have removed them prior to exiting the room. NA-C was not observed to use hand sanitizer and was not observed to sanitize the top of the TBP cart after placing the dirty face shield on top of the cart. During interview on 12/8/22, at 9:39 a.m. the IP stated she was going to have a discussion with the staff regarding properly disinfecting PPE. The facilities Clean-disinfect equipment policy directs staff to disinfect equipment per current COVID-19 guidelines. The facilities Personal Protective equipment - Infection Control policy directs staff certain PPE may be required, such as eye protection, during a respiratory virus pandemic.

Based on observation, interview, and documentation review the facility failed to ensure safe food temperatures on the Northwoods unit. This had the potential to affect 38 of 40 residents. Findings include: During observation and interview on 12/07/22, at 7:21 a.m. Dietary Aide (DA)-A checked temperature of foods on steamtable. DA-A stated she was looking for temperatures to be over 120. Food thermometer read 168 degrees Fahrenheit for pureed eggs. Food thermometer read 115.7 degrees Fahrenheit for Croissant egg and cheese sandwich, below required tempurature. Food thermometer read 130.4 degrees for scrambled eggs, below required temperature. DA-A documented food temperatures on the Final Cooking Temperatures form. DA-A did not check temperatures for the oatmeal, bacon or sausage as required. DA-A stated temperatures not within acceptable temperatures must be reported to the chef or kitchen supervisor. However, she did not report low temperatures as required. DA-A stated that new steamtables were on order. Record review of form titled Final Cooking Temperatures form does not indicate temperatures documented for Sunday or Monday breakfast. During observation and interview on 12/7/22, at 7:26 a.m. Chef stated that steamtable foods were to be checked for temperatures to be at least 135 degrees Fahrenheit. DA-A showed Chef food temperature log. Chef instructed for the scrambled eggs to be discarded. He checked the temperature of the sausage. Food thermometer read 125 degrees Fahrenheit. Chef indicated that the sausage and bacon was double-stacked in the steamtable. He discarded the sausage and bacon. The oatmeal temperature read 175 degrees Fahrenheit. Chef stated the kitchen would make food to replace discarded food for the residents. During interview on 12/7/22, at 7:54 a.m. Registered Nurse (RN)-A stated that foods are always checked for temperatures. She reported there had not been any gastro-intestinal illnesses in the previous three months. She stated foods were to be at 135 degrees to be served from steamtable. She stated 40 residents are served from the Northwoods kitchenette. During an interview on 12/7/22, at 7:57 a.m. the Director of Nursing (DON) stated that food temperatures are expected to be at 135 degrees to serve from the steamtable. During an observation on 12/7/22, at 8:02 a.m. the chef reviewed temperature expectations with DA-A, to be at 135 to serve from the steamtable. During an interview on 12/7/22, at 8:15 a.m. the Chef stated the reason the temperatures must be at 135 degrees or above to keep things out of the danger zone, so that no pathogens are growing. He stated that foods are checked for temperatures in the kitchen prior to being brought out to the kitchenette. Breakfast is the only meal served from the steamtable. Lunch and supper trays are prepared in the kitchen and served to the units on carts. He stated that there are steamtables on order and expected to arrive soon. During an interview on 12/7/22, at 1:26 p.m. Certified Dietary Manager (CDM) stated her responsibilities were on the clinical end, not food production. She stated that Chef and kitchen supervisor are responsible for the food production. Requested original documented food temperature log from Administrator on 12/8/22, at 12:20 p.m. Admin reported that the sheet that the form the steamtable food temperatures was documented on 12/8/22 was not located.

Based on observation, interview and document review, the facility failed to provide a dignified experience for 1 of 4 residents (R73) observed for dining. Findings include: R73's admission Minimum Data Set (MDS) dated [DATE], identified R73 had a severe cognitive impairment and diagnoses included Alzheimer's disease with early onset, psychotic disorder with delusions, depression, anxiety, and weight loss. R73 was on Hospice care and required extensive staff assist for eating. R73's care plan dated 10/11/22, identified R73 required assistance with Activities of Daily Living (ADLs). Staff were directed to provide extensive assistance with eating. During an observation on 12/7/22, at 11:35 a.m. R73 was sitting in her tilt-in-space chair. R73 was in the dining room, at a table, watching TV. The noon meal had already began and R61 was sitting on R73's left side. R61 was eating her meal; however, R73 had not been served her meal. - At 12:27 p.m. R61 had finished eating her meal and pushed away from the table. However, R73 continued to wait for her meal to be served. - At 12:39 p.m. R73's meal was placed in front of R73 without the dome cover removed. - At 12:40 p.m. activity aide (AA)-A sat down with R73 and asked if R73 was ready to eat. R73 then grimaced and let out a long moan, but no words were spoken. AA-A began assisting R73 to eat her meal. During an interview on 12/7/22, at 1:59 p.m. nursing assistant (NA)-C stated there were nine residents who required assistance to eat in the memory care unit. Someone had to wait and it was a normal practice to bring all the residents to the dining room at the same time. NA-C stated she had to be honest and some residents just had to wait until someone was able to help them. During an interview on 12/7/22, at 2:12 p.m. licensed practical nurse (LPN)-A stated they just didn't have staff to assist all the residents with eating at the same time. LPN-A then stated she wouldn't want to sit and watch others eat and not be able to eat herself. During an observation on 12/8/22, at 8:47 a.m. R73 was sitting in her tilt-in-space chair in the middle of the dining room while other residents were eating breakfast meal. NA-C asked trained medication aide (TMA)-A if any staff were going to come to the dining room to assist residents. TMA-A stated she thought clinical manager (CM)-B would. - At 9:11 a.m. R73 continued to sit in the middle of the dining room. NA-C and AA-B were assisting other residents to eat. CM-B stepped into the dining room, but left. No staff offered or assisted R73. - At 9:40 a.m. AA-B assisted R73 to the dining table. R73's meal was placed in front of her, but the dome cover remained in place. - At 9:46 a.m. AA-B sat down and began assisting R73 with her meal. During an interview on 12/8/22, at 3:11 p.m. CM-B stated the facility did not have expectations regarding how long a resident waited to eat their meal. CM-B then stated he did not have enough staff for all residents to eat at once, but no food was placed in front of a resident until they were able to eat. The facility had tried to have separate dining times, but then things were happening in the other resident areas and staff were unaware because they were in the dining room. Further, it was just easier to supervise everyone in the dining room. CM-B stated there were no nursing assistants in the building who were available to float to the memory care unit to assist. CM-B then stated R73 probably waited because she was patient and did not make noise. CM-B stated he would not want to wait for his meal and residents should be allowed to eat in a reasonable amount of time. During an interview on 12/8/22, at 4:57 p.m. the director of nursing (DON) stated it was the first time she had been informed staff were not able to assist residents with eating in a reasonable amount of time. Meals could be staggered or another alternative could be found to prevent a resident needing to watch others eat for approximately 1.5 hours before eating themselves. The DON further stated eating within a reasonable time upon arrival to the dining room was expected. The facility policy Dining Room Services revised 3/17/21, identified individuals would be provided with nourishing, palatable, attractive meals that met daily and special nutritional needs. Individuals would be provided with services to maintain or improve eating skills. The dining experience would enhance the individual's quality of life and be supportive of the individual's needs during dining. The policy directed staff to assist as needed to assure adequate intake of food and fluid at the meal. Individuals would be assisted promptly and in a timely manner after the meal arrived.

Based on interview and document review, the facility failed to report allegations of abuse to the State Agency (SA) within two hours of the allegation for 1 of 1 residents (R1), reviewed for resident to resident abuse. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was severely cognitively impaired; however, was free of communication impairments. He required supervision with mobility and was diagnosed with [CONDITION(S)] (progressive dementia which affected movement, thinking skills, mood, memory and behavior), behavioral disturbances, hallucinations (perception of things not really present), and delusional disorder (mental illness where a person cannot tell real from imagined). R2's quarterly MDS dated [DATE], identified R2 was unable to complete the cognitive assessment; however, staff assessment indicated R2 was severely cognitively impaired. R2's speech was unclear. He was sometimes understood and sometimes was able to understand others. He required supervision for ambulation; however, he required extensive physical assist of staff for the rest of his mobility and activities of daily living (ADLs). R2 was diagnosed with vascular dementia (lack of blood to the brain which affected reasoning, planning, judgement, and memory). A Common Entry Point (CEP) incident report was submitted to the SA on 9/21/21, which identified on 9/18/21, during the breakfast meal, R1 screamed at and threatened other residents while in the dining room. R1 took silverware from his breakfast tray and stated he was going to slice open his roommate's [R2] neck as he believed R2 slept with his wife. R2 was present in the dining room during R1's threats. After R1 was removed from the dining room to an adjacent area, per the report he continued to make paraphrased comments: I hate this place; I can't do anything; I might as well shoot him [R2] with a gun. That might solve the issues here; Killing people here might make this place better. The report indicated Many residents didn't want him around, was scared that [R2] was close and a few didn't want to eat in the dining center. R1 was sent to the emergency room (ER) via ambulance. During interview on 9/24/21, at 12:29 p.m. nursing assistant (NA)-A stated she worked 9/18/21 on the secured memory care unit and witnessed R1 as he threatened other residents and staff. She explained she entered the dining room and heard R1 as he stated he was going to take the knife in his hand and slit [R2's] throat as he thought R2 slept with his wife. He scared me on [9/18/21]. He was charging me. He was walking around and would not stop with the threat talking, and so we called the police. NA-A stated any type of verbal abuse was to be reported right away. When interviewed on 9/24/21, at 1:33 p.m. NA-B stated she was present in the dining room on 9/18/21 when R1 entered it. When R1 witnessed R2 in the dining room being assisted to eat breakfast R1 grabbed a knife off of his breakfast tray and stated he was going to slit [R2's] throat as he commented she was good the night before and then that day she was sad. R1 made additional comments that [R2] always gets fed and why did staff not feed him. As R1 continued to make further comments directed at R2 and staff, he also attempted to propel his wheelchair toward R2. When staff attempted to move his wheelchair out of the dining room, R1 stood up: We thought he would go after [R2]. NA-B explained, I was scared. When he gets like that there is no redirection for him. The residents were scared. I know they have dementia but they can hear and know what is going on. She stated verbal abuse was abuse that was reported right away. When interviewed on 9/24/21, at 2:58 p.m. unit manager (RN)-A stated verbal abuse included yelling at someone; however, if no physical contact was made during the verbal abuse, the verbal abuse was not reported to the SA: We get a lot of accusatory statements just as a nature of dementia. Sometimes they [the residents] make accusations .I cannot make that many VA's [reports to the SA]. RN-A explained if the interaction included emotional abuse then that was reported to the SA, in which emotional abuse may be identified if there was a negative reaction by one resident when another walked by them, altered body position, and/or guarding. RN-A explained it was not their decision for what was reported and what was not despite the ability to file a VA report with the SA. The DON and administrator filed the VA reports to make sure it is up to state standards. RN-A indicated a VA report was not filed on 9/18/21, or after, by administration. RN-A explained staff contacted them on 9/18/21 after R1 returned from the ER that same day: It is a serious matter. Even though we did not report, we did things about it. During interview on 9/24/21, at 3:33 p.m. the DON stated abuse was the willful attempt to hurt someone verbally, physically . She explained a VA report was not submitted on 9/18/21 because this was one sided .it was not a sparing back and forth. If two residents are swearing at each other and they interact, separate them and lets file a VA. She indicated staff contacted her at 7:55 a.m. on 9/18/21 about R1's behaviors. She explained staff were so focused on [R1], his behaviors, and attempts to find him a different setting: [R1] is causing a lot of chaos right now on the unit. If we got him into another place I think things would settle down. She expressed, hindsight is 20/20 and R1's behaviors on 9/18/21 did require reporting to the SA on 9/18/21. During interview on 9/27/21, at 12:50 p.m. the administrator stated he was made aware on 9/18/21, of R1's behaviors. He denied a VA report was submitted that day. He indicated R1's behaviors were verbally abusive in nature and verbal abuse was required to be submitted to the SA within two hours of the incident. A Cassia Vulnerable Adult-MN policy, dated 11/21/18, identifies each employee is responsible to report suspected/alleged violations of resident abuse immediately (as soon as possible after discovery of the incident), but no later than 2 hours after the allegation is made, to the SA and all other agencies as required, if the events that cause the allegation involve abuse or result in serious bodily injury. The policy defined verbal abuse as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .or within their hearing distance, regardless of age, ability to comprehend, or disability. An example of verbal abuse was identified as threats of harm. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.

Based on interview and record review, the facility failed to ensure consent for COVID-19 testing was obtained in writing and or verbal confirmation was documented from the resident and/or resident representative for 1 of 1 residents (R15) who's family voiced concern with COVID-19 testing when the resident could not consent. This had the potential to affect all 81 residents residing in the facility. Finding include: R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 had severe cognitive impairment. R15's undated face sheet included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's facility grievance form dated 8/23/21, identified R15's family filed a grievance for a COVID-19 test obtained from R15 on 8/16/21, without resident representative consent. R15's medical record lacked evidence verbal or written consent was obtained for COVID-19 testing from R15's resident representative. During interview on 9/1/21, at 10:59 a.m. registered nurse manager (RN)-B stated the nurse managers/unit nurses complete COVID-19 testing on their own units; however, on 8/16/21, RN-B helped out with testing residents on R15's unit. Helping other units with testing was especially difficult because she did not know the residents and would not know if a family member or a resident would want the testing completed. RN-B stated the nurses obtained verbal consent from each resident at the time they tested , including cognitively impaired residents; however, the verbal consents were not documented. During interview on 9/1/21, at 12:25 p.m. director of nursing (DON) stated written consents were not completed for any of the residents for COVID testing. Instead, the nurse explained the purpose and procedure when they entered the residents' rooms, and the resident said yes or no at that time. If the resident was cognitively impaired the nurse would have gone by the family's wishes, and it depended on the resident's cognitive ability and ability to say yes or no. At 1:35 p.m. she stated verbal consents provided by the resident or resident representative were not documented for any of the residents, and the testing process was not explained to residents/resident representatives upon admission. During interview on 9/2/21, at 11:53 a.m. R15's daughter (FM)-A stated she was present during all prior COVID-19 testing except the testing on 8/16/21, and testing was refused every time. Further, FM-A was not asked to provide written consent, but made sure the nurse documented in R15's chart to never test her again. During interview on 9/2/21, at 2:23 p.m. registered nurse manager (RN)-C stated she was R15's unit nurse manager and FM-A and R15 had agreed to testing once, after RN-C told them R15 could get COVID-19 again and she would only swab the nostrils and not all the way up. RN-C stated for testing, we start at one end [of the hallway and ask each resident prior to testing] and ask, and they can say yes or no. During follow-up interview on 9/2/21, at 3:03 p.m. DON stated the facility was looking at a system change to start using written consents for resident COVID testing. The Facility Investigation regarding R15 indicated written education was provided to all licensed nurses from 8/19/21 through 8/31/21. The written education included obtaining consent for the procedure and inlcuded the following steps: 1) Introduce self, 2) Explain what you need to do, 3) Explain procedure, and 4) Ask are you okay with this? Yes or No. The written education did not include obtaining written consent, nor did it direct the nurses to document verbal consent. The Cassia COVID-19 Protocol - SNF revised 8/27/21, did not provide guidance related to resident/resident representative consent. The COVID-19 Testing Information for Long Term Care Facilities: Frequently Asked Questions dated 7/12/21, identified residents/resident representatives must have consented to testing, and all verbal consents, if unable to obtain written concent, should be documented in writing. Additionally, facilities must have established protocols for acquisition, documentation, and retention of forms used to obtain consent from residents/resident representatives.

Based on interview and document review, the facility failed to report allegations of abuse to the State Agency (SA) within two hours of the allegation for 2 or 2 residents, (R1, R2) reviewed for employee to resident abuse. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had moderately impaired cognition and required extensive physical assist of two staff for bed mobility, transfers, and toileting activities of daily living (ADLs). In addition, the MDS identified R1 had bowel control and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's quarterly MDS, dated [DATE], identified R2 had severely impaired cognition and required extensive physical assist for ADLs. In addition, the MDS identified R2 had delusions (fixed, false belief that conflicts with reality) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report was submitted by the director of nursing (DON) to the SA on 5/25/21, at 5:05 p.m. which identified R2 had alleged, That guy keeps coming in my room and was rough with me. I'm scared. The report indicated after trained medication aide (TMA)-A had questioned nursing assistant (NA)-A on R2's behaviors after R2's comments that night, NA-A had stated, I said something I wasn't supposed to say. I told her [R2] if you don't be quiet right now or I'll shut the door and turn off the lights. The report indicated the allegation incident had occurred on 5/20/21, at 1:30 a.m. A subsequent incident report was submitted by the administrator to the SA on 5/25/21, at 5:47 p.m. which identified R1 had alleged NA-A had told him to[OBSCENITY]himself and she [NA-A] would clean him up later. The report indicated the allegation incident had occurred on 5/20/21, at 11:00 pm. When interviewed on 5/27/21, at 12:54 p.m. staffing coordinator (SC)-A stated she and NA-B conversed on the evening of 5/24/21 regarding the allegations reported by R1 and R2. SC-A explained she had updated the DON of these two allegations the morning of 5/25/21 when she (SC-A) had arrived to work. SC-A confirmed she is expected to update the DON and/or administrator right away when she is aware of abuse allegations and she acknowledged, Telling a resident to poop their pants is not okay, and that it was cruel punishment to make someone scared of the dark; however, SC-A explained she had waited until 5/25/21 as this had happened a few days ago and felt it was okay to wait until the following morning. During interview on 5/27/21, at 3:40 p.m. the DON stated SC-A had initially reported R1 and R2's allegations to her on 5/25/21, during the .morning/midmorning .probably before noon hour time frame in which she had then spoken to the administrator right away. The DON voiced, If it truly happened [R1, R2's allegations] with NA-A, yes I would consider this abuse. When questioned on the time frames for having reported the allegations to the SA, the DON explained she had needed certain staff interviews to ensure all the required information was present before she filled out the SA incident report. Further, the DON explained her initial thought process had been one employee against another employee and during the morning of 5/25/21 she initially did not have enough meat to say that this was truly a VA and who was involved in it. If I am going to suspend people, I need to know who I need to suspend. The DON stated the incident report had been reported to the SA within two hours of her awaited interview with TMA-A; however, she acknowledged, We know that it was late reporting [based on SC-A's having reported it more than five hours prior to SA reporting]. When interviewed on 5/27/21, at 4:27 p.m. the administrator stated he expected any allegations of abuse or neglect to be reported to himself and the DON immediately and acknowledged the facility had two hours to report allegations of abuse to the SA. The administrator voiced he had been unsure as to the time frame he initially was updated by the DON on R1 and R2's abuse allegations; however, he acknowledged the SA had not been reported to within the required two hour time frame. He explained that he and the DON had needed to understand the situation as sometimes situations .can be shades of gray in relation to the staff involved and what the allegations may center around, and with this situation he and the DON initially had third and fourth hand information and felt additional staff interviews were needed in order to correctly complete the SA incident report. A Cassia Vulnerable Adult-MN policy, dated 11/21/18, identifies each employee is responsible to report suspected/alleged violations of resident abuse immediately (as soon as possible after discovery of the incident), but no later than 2 hours after the allegation is made, to the SA and all other agencies as required, if the events that cause the allegation involve abuse or result in serious bodily injury. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.

Based on observation, interview, and document review, the facility failed to appropriately disinfect multi-resident use equipment between use by 1 of 1 staff (trained medication aide (TMA)-A) during a Focused Infection Control survey for COVID-19. Findings include: During an observation on 5/14/20, at 10:19 a.m. TMA-A took a resident's vitals using a infrared thermometer (non-touch thermometer) and oximeter (oxygen machine used to check oxygen levels) then, without sanitizing the thermometer or oxygen machine, proceeded to check another resident's temperature and oxygen levels. TMA-A was interviewed following the observation at 10:20 a.m. TMA-A stated she was checking temperatures, oxygen levels, and resident pulses and the she would typically use sani wipes on the oximeter, but not on the thermometer as this does not actually touch the residents. TMA-A revealed she forgot to clean the oximeter between residents but stated it is important to clean equipment to prevent the spread of germs. Interview on 5/14/20, at 11:20 a.m. with registered nurse (RN)-A stated all equipment (vital sign machines and lifts) should be cleaned after each use. Interview on 5/14/20, at 12:39 p.m. RN-B stated oximeters should be clean in between residents use with sani-cloths. The facility policy COVID-19 Outbreak management---Phase 1 all locations revised 5/7/20, shared equipment is disinfected between residents, this includes lifts, oximeters, and other shared equipment. The facility policy Clean-disinfect equipment 10/7/2019, Disinfect all equipment after use on residents with transmission-base precautions.

Based on interview and document review, the facility failed to complete a comprehensive discharge summary for 1 of 1 residents (R86) reviewed for discharge. Findings include: R86's Resident Face Sheet dated 6/14/19, identified R86 was admitted to the facility on [DATE], and was discharged from the facility on 6/7/19. The document indicated R86's [DIAGNOSES REDACTED]. Although the Face Sheet identified R86 was discharged on [DATE], the areas which identified: Discharge Reason; and Condition on Discharge lacked any information. The area identified as discharged To only indicated Other Skilled Nursing Facility. R86's progress note(s) identified the following: - Documentation identified as Admission Note dated 4/30/19, indicated R86 was admitted to receive rehabilitation to improve strength and return to previous living situation. - A subsequent note of 5/1/19 indicated R86 was followed by PT/OT (Physical Therapy and Occupational Therapy). -A progress note, labeled as Admission Medication Orders Reconciliation was completed, as documented on 5/3/19, and indicated that medications were reviewed and required no changes. In this narrative, it was identified R86 was also receiving ST (Speech Therapy) and was receiving a pureed diet with nectar thickened liquids. -On 5/4/10, the progress note identified R86 was drinking out of the water fountain, which was not allowed due to need for nectar thick liquids. R86 was also identified as having attempted to leave the facility on multiple occasions. A personal alarm was placed on R86's to alert staff of resident attempts to leave the facility. -R86 continued to exhibit attempts to leave the facility as identified in progress notes of 5/5/19. -R86 was identified as experiencing a fall in progress notes of 5/6/19 related to attempted self transfer. R86 stated he was trying to Get out of here when asked what he had been doing. R86 did not experience any injuries related to the fall. The narrative notes of 5/6/19 identified R86 continued to attempt to leave the facility. R86 reported problems with sleeping at night related to roommate and a room change was offered to R86 and spouse. -On 5/7/19, the SS (Social Services) Admission Note indicated R86 exhibited impaired cognition, as well as demonstrating attempts to elope (identified in notes as a minimum of nine attempts to leave the facility). R86 was identified as having sleep difficulties and was started on Trazadone (an antidepressant medication). Additionally, the note identified R86 had exhibited behaviors which had included resistance of cares, throwing medications, grabbing the arm of a nurse attempting to redirect, and making the statement he enjoyed slapping women. -Upon review of narrative notes, R86 was noted to attempt to drink from the water fountain on 5/9/19. Additionally, the document reflected R86 was observed attempting self transfers on multiple occasions, lacking awareness of personal risks of not following dietary restrictions and attempting self transfers. -R86 continued to display attempts of elopement as indicated in documentation of 5/12/19 and 5/14/19. -On 5/15/19, R86 was moved to the secured unit due to multiple attempts of elopement and lack of awareness regarding personal safety and own limitations. -On 5/19/19, progress notes reflected R86 had packed his belonging and wished to leave the facility with spouse. -On 5/23/19, R86 was observed with elopement attempts, with limited effectiveness of interventions offered which included toileting, offering of a snack, and offering of a blanket. R86 was later redirected to participate in an activity. R86 was noted to exhibit this behavior again on 5/26/19, 5/27/19, and on 5/28/19. On 6/2/19, R86 was observed in front of a coded door, trying to open the door. Although redirected to an activity, R86 continued to observe use of the elevator. R86 proceeded to attempt to remove the door lock to leave facility. R86 became upset with intervention of staff, and began to strike staff, grabbing nursing assistant finger and bending it backward, with a crack heard. -On 6/4/19, R86's spouse requested and initiation of referral process for R86 to move to a facility closer to home. This referral was provided as requested. -On 6/5/19, R86 was up and wandering in the halls during the night, attempting to leave. This behavior was noted to be exhibited for over an hour. -On 6/7/19, R86's progress notes reflected that he was discharged from the facility via transportation agency to facility closer to home. The notes identified all medications were counted and sent with wife. A provider note of 5/31/19 indicated R86 was on [MEDICATION NAME] at the time of admission. While in the temporary care unit, R86 was started on [MEDICATION NAME] (an antipsychotic medication) due to escalating behaviors and elopement risks. The provider indicated R86 continued to exhibit sleep disturbances and exit seeking behaviors. The provider note indicated [MEDICATION NAME] was resumed as had received previously. An undated document titled discharge summary was reviewed and the section titled summary of course of treatment while in nursing home for strengthening identified Rehabilitation therapy for strengthening. The section identified as Discharge Record included date of discharge, time, and date of admission. The areas identified as physician's orders [REDACTED]. A review of R86's record lacked a complete recapitulation of stay. Although R86 had orders in place for physical, occupational, and speech therapy when he was admitted for rehabilitation, the discharge note lacked a summary of therapy provided, response to therapies, and ongoing recommendations. Additionally, the documentation lacked identification of behaviors exhibited and treatment implemented, including use of antidepressant and antipsychotic medication. The documentation lacked a review of medication therapy in place prior to admission, while at the facility and upon discharge. On 6/14/19, at 10:10 a.m. registered nurse (RN)-D stated R86 was transferred to another skilled nursing facility, therefore, a recapitulation of stay was not completed. RN-D stated a recapitulation of stay was done for those residents who discharged to home. RN-D stated the information had been sent for review prior to R86's acceptance to the skilled facility, however, was unable to recall specifically had been sent. On 6/14/19, at 10:54 a.m. social services (SS)-A stated discharge planning is initiated upon admission to the facility. SS-A stated R86's discharge plan was initially to return to prior living situation, however, as time went on, a need for long term care was determined. R86's family chose to transfer closer to their home. SS-A stated the medical provider reviewed R86's status and an admission history and physical was completed on 5/31/19 which was provided to the receiving facility. This information was considered to be part of the discharge summary. The facility policy Discharge Planning and Ombudsman Notification, dated 12/5/18, indicated the nursing staff will complete a discharge medication reconciliation of all pre-discharge medications with the resident's post-discharge medications, including prescription and over the counter medications. The policy also stated to promote optimal continuity of care the facility will provide a summary of the Discharge Record which includes medication and treatment records and physician orders. This information was to include diet, and activity tolerance.

Based on observation, interview, and document review the facility failed to ensure facial hair was removed for 1 of 4 residents (R1) reviewed for activities of daily living (ADL) who was dependent on staff for assistance with ADL care. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had severe cognitive impairment, and required extensive assistance for ADL, which included grooming. R1's face sheet undated, indicated [DIAGNOSES REDACTED]. R1's care plan dated 6/10/19, indicated R1 needed extensive assistance with grooming. During an observation on 6/11/19, at 11:26 a.m. R1 had numerous facial hairs on R1's chin. During an observation on 6/12/19, at 9:04 a.m. R1 had numerous facial hairs on R1's chin. During an observation on 6/12/19, at 1:32 p.m. R1 was sitting in the wheelchair in R1's room looking down and when looked up had numerous one quarter inch hairs on R1's chin. R1 stated R1 had a bath tomorrow and would have hair washed then. During an interview on 6/12/19, at 2:21 p.m. nursing assistant (NA)-A stated we should offer shaving every morning with cares. NA-A stated I would not want chin hairs. At 2:28 p.m. R1 told NA-A where the electric razor was and allowed NA-A to shave the chin hairs. During an interview on 6/14/19, registered nurse (RN)-A stated it is our expectation that males and females are offered shaving with daily cares. Although requested, a policy for grooming was not provided.

Based on interview and document review, the facility failed to ensure the nursing staff and medical doctor was notified upon recognition of a change in condition for 1 of 1 residents (R45) reviewed who had a transient ischemic attach (stroke). Findings include: R45's admission Minimum Data Set ((MDS) dated [DATE], identified R45 had a basic interview for metal status (BIMS) with a score of 99, (indicative of a patients refusal to answer or 4 or more areas were scored as 0 due to refusal or inability to answer). The MDS further indicated R45 was able to respond to questions that R45 was on a therapeutic diet and had no signs or symptoms of a swallowing disorder. R45's quarterly MDS dated [DATE], identified R45's BIMS was a score of 10, indicating moderate cognitive impairment. R45 had a [DIAGNOSES REDACTED]. A progress note dated 6/4/19, at 3:44 a.m. by registered nurse (RN)-B indicated R45 was slurring words and unable to make complete sentences. This was initially noted by nursing assistant (NA)-B at 2:30 a.m. The Progress note indicated, RN-B assessed R45 on 6/4/19, at 3:44 a.m. Documentation indicated R45 was unable to say the color blue, yellow and green. RN-B also documented R45 showed frustration knowing R45 was unable to say the words R45 wants to say. Vital signs were obtained and RN-B called 911 and was transported to the emergency room . RN-B notified R45's physician on 6/4/19, at 3:42 a.m. as well as notified R45's family on 6/4/19, at 3:48 a.m. A progress note on 6/4/19, at 7:59 a.m. by RN-B indicated RN-B contacted director of nursing (DON) and filed an incident report to the Minnesota Office of Health Facility Complaints (OHFC). A document titled Re-Education Required/Reporting Change in Condition dated 6/4/19, signed by NA-B and RN-C. NA-B was contacted by RN-C regarding the incident and R45's change of condition. The document indicated NA-B understood to report any change in condition to nursing staff immediately. NA-B further stated no little change will go unnoticed. NA-B was assigned an on-line competency based test titled Observation, Reporting and Documentation. NA-B was to complete the module by 6/5/19. A document titled Relias Certification of Completion indicated NA-B successfully completed the on-line module on 6/4/2019. A progress note dated 6/5/19, at 2:30 p.m. by RN-G indicated R45 was readmitted to facility from Buffalo Hospital. R45 was evaluated and treated for [REDACTED]. RN-G further indicated R45 is alert and oriented and denies pain. R45's care plan dated 6/5/19, indicated R45 has a [DIAGNOSES REDACTED]. R45's care plan further indicated staff to report slurred speech, word placement issues. R45's new orders dated 6/6/19, included [MEDICATION NAME] 75 mg every day and aspirin 81 mg every day for 30 days for TIA. During interview on 6/13/19, at 10:37 a.m. RN-B stated she was informed of R45's change in neurological status on 6/4/19, at 3:30 a.m. by licensed practical nurse (LPN-A). RN-B completed a neurological exam, R45 was unable to make complete sentences and was slurring words. RN-B further stated NA-B noted neurological changes on 6/4/19, at 2:30 AM and did not notify nursing staff until 6/4/2019, at 3:30 a.m. R45 was sent to the emergency department and RN-B notified the family. RN-B stated NA-B was re-educated on the importance of immediate notification to nursing staff with any changes in neurological status. During interview on 6/13/19, at 11:59 a.m. RN-A stated she was aware of the incident and has spoken with NA-B. RN-A further indicated NA-B has had no previous performance concerns and stated I know NA-B will never do it again. RN-A further stated she had spoken with staff on the 200 unit on the importance of immediate notification to nursing staff on any resident's change in condition. During interview on 6/13/19, at 2:41 p.m. DON stated NA-B was placed on administrative leave until the investigation was complete and that NA-B visited with DON earlier on 6/13/19. NA-B stated appreciation of the re-education and discussions with facility staff regarding the incident. NA-B further stated an understanding of the importance of immediate notification to nursing staff when there is a resident change in condition. DON further indicated the night nursing staff will initiate informal check-ins with NA-B to ensure compliance. DON stated a mandatory in-service is scheduled for 7/8/2019. DON further stated once the training is completed the DON will establish an auditing process. Additionally, DON provided documents titled Parkview Education dated 6/12/19, the document indicated it was a verbal communication plan for nursing assistants to report any changes in condition immediately to nursing staff, the document provided examples of change in condition. The document included a reminder to nursing staff to reinforce the importance of reporting any change in condition and to immediately assess residents with a change in condition. Further the document indicated documentation and notification requirements. The document was signed by 35 of 129 nursing staff as of 6/13/2019. A policy titled Change in Condition dated 12/31/2018, indicated nursing staff will contact the resident's physician when there has been a change in condition. The document outlined the procedure to follow as well as examples of when to notify the physician and included changes in resident's neurological status.

Based on observation, interview, and document review, the facility failed to comprehensively assess and implement interventions to promote healing, and prevent deterioration of an unavoidable pressure ulcer for 1 of 2 residents (R19) reviewed for pressure ulcers. Findings include: The National Pressure Ulcer Advisory Panel (NPUAP) identifies a pressure injury (pressure ulcer) as localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer. R19's care plan printed 6/14/19, indicated R19 was at risk for pressure ulcers due to a history of pressure ulcers and a decline in ambulation and mobility. In addition the care plan indicated a pressure ulcer to the left of the coccyx had healed on 7/21/18. Interventions identified for implementation 6/28/18, included to turn and reposition R19 every 2 hours- side to side- with extensive assistance while in bed. A pressure guard custom care mattress and electric alternating pressure air pump were also identified as interventions. R19's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R19 had severe cognitive impairment, and was at risk for pressure ulcers with no current pressure ulcers. The MDS indicated interventions to prevent development of pressure ulcers were utilized including a pressure reducing chair and bed, along with nutrition and hydration. An initial Skin Integrity Event Report document dated 3/18/19, identified an area of [DIAGNOSES REDACTED] (redness) which was blanchable (skin loses redness with pressure) to the left lower flank (between ribs and hips). The area was described as measuring 1.9 cm (centimeters) x 1.2 cm. In the middle of the [DIAGNOSES REDACTED] was a small black center appearing to be similar to a blackhead. No open areas. The event identified the type of skin alteration as skin impairment/blackhead. The following were progress notes included in the event report: -3/24/19: Left flank-tailbone area open measuring 0.5 cm x 0.5 cm due to moisture associated skin damage and poor nutrition per R19's choice. On hospice. Applied silicone foam dressing to area. R19 on hospice. .will continue comfort cares and turn and repositioning every 2 hours and prn (as needed). Continuation of 3/18/19 Skin Integrity Event progress notes: -3/25/19: Open area to left of sacrum, measures 1.0 cm x 0.7 cm. Base of area is 100% granulated (new formed tissue), surrounding skin is blanchable. Resident has no c/o pain in area. Staff will continue to monitor. Area was cleansed with NS (normal saline), [MEDICATION NAME] (skin protectant) was applied and new dressing was applied. R19's Physician order [REDACTED]. 1. Cleanse with NS (normal saline) and pat dry. 2. Apply [MEDICATION NAME] (skin protector) allow to dry. 3. Cover with [MEDICATION NAME] foam adhesive dressing. 4. Change every 3 days and as needed. R19's 3/27/19 significant change MDS, indicated R19 required extensive assist with bed mobility and was at risk for pressure ulcers, with no current pressure ulcers. R19's 4/2/19 Care Area Assessment, indicated R19 was at risk for pressure ulcers due to the need for extensive assistance with bed mobility and significant weight loss. Interventions to prevent the development of pressure ulcers included: daily skin checks with cares and weekly clinical skin checks, nutritional approaches, repositioning plan, and use of pressure reducing wheelchair cushion and mattress. Continuation of the 3/18/19 initial Skin Integrity Event progress notes: -3/29/19: Wound to left sacrum is 100% scabbed, eschar tissue. Wound measures 0.9 cm by 0.6 cm. No reports of pain, no s/sx (signs or symptoms) of infection, no surrounding [DIAGNOSES REDACTED] noted. -4/4/19: Area to left sacrum is 100% scabbed. Area measures 0.4 cm by 0.5 cm. Tissue surrounding area is pink and blanches. No reports of pain with dressing change. No s/sx of infection. -4/10/19 identified a new small area of redness right to distal coccyx area. Skin intact and blanchable. Frequent position changes to be done throughout the shift to help alleviate pressure to area to prevent breakdown. The note lacked documentation of an assessment of the wound left of the sacrum/flank-tailbone area. -4/19/19. Coccyx area is red, new dressing applied to area. -4/22/19: Open wound to coccyx measured today. The note indicated there were no signs or symptoms of infection. Wound to coccyx dressed with [MEDICATION NAME] foam dressing for protection. Note indicated measurements documented in EMAR (electronic medical record) event; however, R19's medical record lacked wound measurement documentation for 4/22/19. -5/3/19 1 cm x 0.8 cm scab to lower left back. R19 has an extensive history of ulcers to this area. [MEDICATION NAME] foam applied. -5/10/19: Scabbed area to left lower back healing well at .3 cm x .3 cm . Also identified an area to left flank healing with measurements of 0.3 cm x 1 cm. [MEDICATION NAME] foam to area changed every 3 days. Both areas are healing well . -5/17/19: .continues with the open area to the left lower back. This measures 1 cm x 0.4 cm x 0.1 cm. The base is 100% granulation tissues. -5/22/19: the open area measured 0.6 cm x 0.3 cm x 0.1 cm. Surrounding area is reddened and blanchable. -5/24/19: .open sore to upper left back/buttocks. Area is 1 cm x 0.5 cm. Area is pink in the center and pink clear tissue surrounding. -5/31/19: Open area on lower back, dressing changed to site. Reddened area measures 3 cm long by 5 cm wide, surrounding the open area. Dressing had drainage on it. A 5/24/19 nurse practitioner note included: Unavoidable skin fragility. Poor wound healing secondary to decline in condition. On hospice. Added, pressure/offload. Although the resident's pressure area was determined to be unavoidable, the provider did not assess or implement interventions to reduce risk for deterioration. Documentation identified the skin to the left flank-tailbone (bony prominence) was no longer intact on 3/24/19, R19's medical record lacked identification of the area as a pressure ulcer until 6/3/19 and lacked consistent weekly comprehensive assessments between 3/24/19 to 6/3/19 to include: pressure ulcer staging, wound measurements, wound bed characteristics, if drainage, signs and symptoms of infection, odor, wound edges and surrounding tissue. On 6/3/19 registered nurse (RN)-E completed an initial wound tracking Skin Integrity Events, Pressure Injury Documentation form identifying the wound as a stage 2 pressure injury on the left side of coccyx. Measured 1.7 cm x 1.1 cm x 0.2 cm. Wound bed 85% granulation and 15% red/pink. No drainage. Surrounding skin red and scarred. No signs and symptoms of infection. No odor. Interventions pressure reducing wheelchair cushion and alternating air mattress and electrical air pump. R19's care plan, indicated a new pressure injury on coccyx was identified 6/3/19. Interventions added 6/3/19 included: Resident is to lay in bed on left side after breakfast and lunch for 1 hour or longer to reduce pressure on coccyx. Side to side lying only. No positioning pillows on Coccyx. Only fitted sheet between bed and resident. Staff to write PN (progress note) if refuses, including number of times approached and the type of approach used. 6/10/19 weekly Skin Integrity Events, Pressure Injury Documentation of pressure ulcer left of coccyx. Stage 2. Measured 1.7 cm x 0.2 cm. Wound bed 85% granulation and 15% red/pink. No drainage. Surrounding skin red. No signs and symptoms of infection. No odor. Interventions remained unchanged. R19's (MONTH) 2019 treatment administration record (TAR) indicated open area to lower back-open area left of sacrum cleanse with normal saline and pat dry, apply [MEDICATION NAME] allow to dry, cover with [MEDICATION NAME] form dressing, and change every 3 days and as needed. Documentation indicated R19's dressing last changed on 6/12/19. During observations on 6/13/19, at 10:20 a.m. R19 was laying on the bed. Bed was made. R19 was laying on top of the comforter. From the waist up, R19 was turned to the right side; however, from the waist down, R19 was laying on her buttocks, with the coccyx in contact with the bed. An alternating air mattress was noted to be in use on the bed. During an interview on 6/13/19, at 10:22 a.m. RN-E stated R19 had a long history of pressure ulcers and had undergone surgery which removed her sacrum and coccyx. RN-E stated R19 has a lot of scar tissue in the coccyx area. RN-E stated R19's current coccyx pressure ulcer did not start as a pressure ulcer, but a black pinpoint dot to her coccyx, which was not open. RN-E stated when the physician was notified, a treatment had been initiated for a [MEDICATION NAME] foam dressing every 3 days and as needed. RN-E stated the treatment has remained unchanged. RN-E stated nurses monitored the site weekly. RN-E stated the area opened and became a slit which was declining. On 6/3/19, RN-E stated he asked the director of nursing (DON) to look at the wound. RN-E stated the DON indicated the area was a pressure ulcer. RN-E stated additional interventions to ensure healing were put into place. RN-E stated interventions had been implemented for R19 not to lay on her back, but rather to have only side to side positioning with no pushing of a pillow behind her buttocks that could cause pressure to the area. RN-E stated staff had been educated R19 needed to be positioned totally on her side when in bed. Additionally, RN-E stated staff were educated not to lay R19 on top of the covers in bed, as the covers would interfere with the effectiveness of the air mattress in place to promote healing of the pressure ulcer. Further, RN-E stated staff turn and reposition the resident every 2 hours. During an interview on 6/13/19, at 10:55 a.m. nursing assistant (NA)-C stated R19 is to be side lying in bed and repositioned every 1-2 hours. R19 stated this was a recent change due to a sore on R19's bottom. NA-C stated R19 is laid down in bed after breakfast. NA-C stated R19 was not suppose to lay on her back. However, NA-C stated it was standard for staff to lay residents on top of their blankets for naps once the bed was made. R19 stated a work sheet gives directions on each of the resident's cares. NA-C pulled the work sheet titled Country Lane Resident Care Information, List 2, from her pocket. NA-C reviewed the list. The list indicated Only fitted sheet between bed and resident. NA-C stated she had laid R19 down for a nap after breakfast with nursing assistant NA-D, and was unaware she shouldn't have laid her on the bedspread, so did not do it correctly. At that time, NA-D also stated she was unaware R19 could not be laid on top of the blankets. On 6/13/19, at 11:03 a.m. NA-C was asked to view R19's positioning in bed. NA-C observed R19 laying in bed. R19 was laying on top of the blankets. R19 remained in the same position as observed at 10:20 a.m From the waist up R19's body appeared to be turned to the right. From the waist down, R19 was laying on her buttocks with her coccyx touching the bed. However, NA-C stated R19 was laying on her side. NA-C then left the room and informed a fell ow staff member she was leaving on break. NA-C did not reposition R19's coccyx off the bed, and did not reposition R19 under the blankets. On 6/13/19, at 11:18 a.m. RN-E was asked to observe R19's position in bed. RN-E confirmed R19 was not in a side laying position and had pressure to her coccyx area with the mattress. RN-E further stated R19 should not be laying on top of the blanket. RN-E repositioned R19 onto her right side. R19's coccyx was not in contact with the bed after the repositioning. RN-E stated he needed to find someone to assist with repositioning R19, so R19 would also not be laying on top of the blankets. RN-E used the Walkie (communication device) to request NA-C's assistance. Staff responded NA-C was on break. Approximately 20 minutes later, R19 was observed to have been repositioned so she was under the covers laying on her right side. During observation and interview on 6/14/19, at 8:17 a.m. the surveyor requested to observe a dressing change to coccyx area to view the pressure ulcer. RN-E and RN-F entered R19's room to complete the dressing change and assess the area. RN-E observed the dressing on R19's coccyx and stated R19 had the incorrect dressing applied to her coccyx. RN-E stated the dressing was a [MEDICATION NAME] dressing, used for debridement. RN-E stated, (R19) has orders for a [MEDICATION NAME] foam dressing. RN-E measured the slit, located directly on R19's coccyx. The area measured 0.7 cm x 0.2 cm x 0.2 cm. Directly below the slit was an open area which measured. 1.5 cm x 1.2 cm. RN-E stated on 6/10/19, the area below the slit was reddened, but not open. The wound bed was covered with 40% slough and 60 % [DIAGNOSES REDACTED] (red) tissue. RN-E stated, With slough in the wound bed, the pressure ulcer is now unstageable. RN-E stated the [MEDICATION NAME] dressing is now an appropriate dressing for the pressure ulcer for debridement. RN-E placed a [MEDICATION NAME] dressing over the pressure ulcer, stating he would update the nurse practitioner and get an order for [REDACTED].>During an interview on 6/14/19, at 1:26 p.m., RN-E stated when the area to R19's coccyx opened on 3/25/19, he did not stage the area as a pressure ulcer, since R19 had her sacrum/coccyx removed and no longer had a bony prominence. RN-E stated the removal of R19's sacrum/coccyx occurred prior to R19's admission to the facility. RN-E reviewed R19's medical record and stated he could not locate documentation of the surgery.There was no evidence in R19's medical record of the surgery. During an interview on 6/14/19 at 2:59 p.m., the DON stated she had been asked by RN-E to assess R19's coccyx wound on 6/3/19. The DON stated, she assessed the coccyx wound on 6/3/19 stating It was definitely a pressure ulcer, you can feel the bone, it was right on her coccyx. The DON further stated the pressure ulcer was an open stage 2, with 100% [MEDICATION NAME] tissue. The DON also stated when she'd observed the pressure ulcer, R19 was laying in bed, on top of her covers. The DON confirmed the resident needed to be under the covers when in bed so the air bed could be effective. The DON stated staff were provided education on 6/5/19 to make sure R19 was completely on her side when in bed and not to lay R19 on top of the covers. Although the DON stated staff were educated on the new interventions, 6/13/19 observations identifed the new interventions were not being implemented and interviews with NA-C and NA-D, who provided cares to R19 on 6/13/19 stated they did not receive the education not to lay R19 on top of the covers. An inservice documentation record, indicated 18 staff had received education on Resident Positioning on 6/5/19. The list lacked the names of NA-C and NA-D. The education was not specific to R19 and lacked education related laying residents on top of covers. During a follow up interview on 6/14/19 at 4:21 p.m., the DON verified the presence of slough in R19's pressure ulcer would change the pressure ulcer to unstageable. The facility's policy Skin Integrity, dated 8/6/18, indicated A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of soft tissue. MD notification of new wounds. Implement appropriate treatment from wound care protocol, or physician's orders [REDACTED]. Non pressure injuries weekly documentation with visual head to toe skin observations.

Based on interview and document review, the facility failed to ensure a gradual dose reduction (GDR) was attempted or a provider rationale which clinically contraindicated a GDR for a [MEDICAL CONDITION] medication was completed for 1 of 5 residents (R27) reviewed for unnecessary medication. Findings include: R27's annual Minimum Data Set ((MDS) dated [DATE], indicated R27 was cognitively intact. R27's [DIAGNOSES REDACTED]. R27 receive anti-anxiety medication. R27's Care Area Assessment for [MEDICAL CONDITION] medication dated 4/10/19, indicated R27 received anti-anxiety medication. GDR's will be done per policy with MD (medical doctor). R27's care plan, dated 6/5/19, indicated R27 received [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The care plan directed to maintain a calm environment and approach to R27. Assess if the behavioral/mood symptoms present a danger to R27 and others. Intervene as needed. Contact medical staff to reduce or discontinue medication if any signs of adverse consequences emerge. Update MD on documentation with each visit for potential dose reductions. Document R27's behavior/mood or complaints of anxiety or panic in point of care (P[NAME]) or nurses notes when they are reported by R27 or observed. R27's physician order [REDACTED]. R27's (MONTH) 2019 Medication Administration Record [REDACTED]. R27's medical record, including monthly pharmacy reviews and provider documentation lacked evidence of an attempted GDR or MD rationale indicating a GDR was clinically contraindicated during the last 12 months. During an interview on 6/14/19, at 11:46 a.m., R27 stated she has been taking [MEDICATION NAME] since 1974. R27 stated the [MEDICATION NAME] helps with tremors and pain. R27 denied having feelings of anxiety. During an interview on 6/14/19 at 11:34 a.m. consultant pharmacist (CP)-C stated a GDR for R27's [MEDICATION NAME] is to be attempted or a rationale why a GDR would be contraindicated is to be completed at least annually. CP-C stated he reviewed his notes and stated it was missed. Stated the [MEDICATION NAME] was coded for tremors so it did not trigger on my end. CP-C stated in reviewing the notes, he could see the [MEDICATION NAME] was being used for anxiety as well. CP-C stated he would review the [MEDICATION NAME] on his next visit. During an interview on 6/14/19, at 2:59 p.m., the director of nursing (DON) indicated a [MEDICAL CONDITION] medication committee was recently started at the facility, last meeting in (MONTH) 2019. Recommendations from the pharmacist is part of the committee. At 4:21 p.m. the DON stated she followed up with the pharmacist and GDR was missed. A policy related to GDR of [MEDICAL CONDITION] medication was requested and not provided.

Based on observation, interview, and document review, the facility failed to ensure Hormel brand Mighty Shakes were disposed of when past the expiration date, per manufacturer recommendations, for 1 of 2 medication room refrigerators (Heritage Square). This had the potential to affect three residents with ordered Mighty Shakes on the Heritage Square unit. Findings include: On 6/14/19, at 9:10 a.m. during review of the medication refrigerator in the Heritage Square medication storage room with trained medication assistant (TMA)-A, four Mighty Shakes (4 fluid ounces) were observed on the top shelf and three Mighty Shakes (4 fluid ounces) with no sugar added, were observed in the door of the medication refrigerator. The Mighty Shakes were unfrozen and had a small sticker placed on the top of the carton with two dates. The stickers on the four Mighty Shakes included sticker dates of 6/6 and 6/20, and 6/8 and 6/22, however, the dates on one of the Mighty Shakes with no added sugar carton included the dates 5/15 and 5/29, and the other two Mighty Shakes with no added sugar cartons had stickers that included dates of 5/20 and 6/4. When interviewed on 6/14/19, at 9:15 a.m. registered nurse (RN)-D and TMA-A stated they did not know what the dates on the stickers meant. TMA-A stated the kitchen staff delivered the cartons of Mighty Shakes to the main refrigerator in the kitchen area of the Heritage Square unit and staff would bring a few cartons into the medication storage room and put them into the medication refrigerator. When asked how long the Mighty Shakes could be kept in the refrigerator, TMA-A stated the staff watched the date stamped on the top seam of the carton and used that as the expiration date, however, stated the cartons were used quickly and using them before the stamped expiration date wasn't an issue. During an interview on 6/14/19, at 9:21 a.m. the dietary manager (DM) stated the Hormel brand Mighty Shakes were shipped and stored frozen, and when the Mighty Shakes were pulled from the freezer, stickers were placed on the Mighty Shake cartons by the dietary staff, with two dates. The top date indicated when the carton was pulled from the freezer and allowed to thaw. The second date on the sticker was 14 days later, and indicated the day the carton should be thrown due to the manufacturer's recommendation of a shelf life of 14 days, once thawed. DM stated the dietary staff monitored the dates on the Mighty Shakes cartons in the main refrigerator on the unit, but was not aware that unit staff were bringing some cartons into the medication storage room and placing the cartons into the medication refrigerator, therefore these were not being monitored by dietary staff. The Mighty Shakes manufacturer's recommendation, as printed on the Mighty Shakes carton, noted a shelf life of 14 days once thawed. Review of the facility's policy, Frozen Supplements, dated 1/1/19, included the policy was to ensure safe storage and distribution of supplements. The policy also included, 2. Staff will pull supplements from freezer based on usage list and note date pulled on each tray. Once thawed, each individual carton will be dated with the thaw date. Trays will be delivered to each unit based on usage list. 3. Supplements must be used within 14 days of thaw date.

Based on observation, interview, and document review, the facility failed to ensure keys used to access controlled medication awaiting destruction were secure and failed to implement a system for prompt reconciliation of controlled medication awaiting destruction. This practice had the potential to affect all residents in the facility receiving controlled medication. Findings include: During observation and interview on [DATE], at 9:20 a.m. registered nurse (RN)-A used a key to unlock a medication cart, then used a key to unlock a drawer within the cart. The drawer contained controlled medication. RN-A stated the controlled medication were logged and tracked in a ledger. RN-A stated 2 nurses count and reconcile each controlled medication at the change of each shift. RN-A stated when a resident's controlled medication were discontinued, the discontinued medication was reconciled by 2 nurses, signed out on the ledger, and brought to the unit manager. RN-A stated the unit manager brings the controlled medication to the director of nursing (DON)'s office for storage until destroyed. During observation and interview on [DATE], at 9:46 a.m. the DON stated the unit manager brings the controlled medication to the DON's office for storage. The DON stated she gives the keys to the locked controlled medication drawer to the unit manager. The unit manager opens the drawer and documents the medication/strength, quantity, patient name, prescription number, and pharmacy on a form in the drawer. The DON stated after the unit manager placed the medication in the drawer, she counts and reconciles the medication with the unit manager. The DON stated the medication is not counted and reconciled again until the medication is destroyed. The DON stated she and the pharmacist count and reconcile the medication when the pharmacist comes to the facility monthly. The DON stated both she and the pharmacist then destroy the medication together and document the destruction on the form. The DON stated she has never had a medication discrepancy. When asked to observe the discontinued controlled medication in the drawer, the DON obtained keys from an unlocked drawer in her desk. The DON walked across the room to a drawer, located behind the DON's office entry door. The DON used the keys to unlock 2 locks on the drawer. Inside the drawer was a loose paper titled Certificate of Inventory and Destruction of Controlled Substances. The form included documentation of medication/strength, quantity, patient, prescription number, and pharmacy name. The following medication were documented on the form: -[MEDICATION NAME] 100 mg/5 ml with a quantity of 12.5 ml. -[MEDICATION NAME] 2 mg/ml with a quantity of 30 ml. -[MEDICATION NAME]-[MEDICATION NAME] with a quantity of 30 tablets -[MEDICATION NAME] 5 mg with a quantity of 19 half tablets -[MEDICATION NAME] 50 mg with a quantity of 3 tablets -[MEDICATION NAME] 5 mg with a quantity of 12 tablets -[MEDICATION NAME]-[MEDICATION NAME] ,[DATE] mg with a quantity of 57 tablets -[MEDICATION NAME] 5 mg with a quantity of 30 half tablets -[MEDICATION NAME]-[MEDICATION NAME] with a quantity of 23 tablets -[MEDICATION NAME] 5 mg with a quantity of 29 tablets All 10 medications were prescribed to 10 different residents. When asked about access to keys, the DON stated she and the administrator had keys to the DON's office. The unit manager would get the keys to my office from the administrator when she was not in the facility. The drawer that contains the keys to the controlled medication was kept in an unlocked drawer in the DON's desk. During observation and interview on [DATE], at 10:05 a.m. unit manager, registered nurse (RN)-B stated when a resident's controlled medication was discontinued or a resident with controlled medication was discharged , the controlled medication was removed from the medication carts and brought to the DON's office to await disposal. RN-B stated she obtains the keys to open a double locked drawer in the DON's office from the DON. RN-B stated she opens the drawer and logs the controlled medication on a sheet of paper in the drawer. RN-B stated the DON then reconciles the medication. RN-B went on to say when the DON was not in the facility, she goes into gets the keys to the DON's office from office manager (OM)-A's office. When asked to observe the key, RN-B walked into OM-A's office. Behind the office door stood a metal cabinet. RN-B opened the metal cabinet and took out a plastic index card container. Inside the container was a key. RN-B stated the key was to the DON's office. RN-B stated she uses the key to unlock the DON's door. RN-B stated she uses the keys in the DON's office drawer to unlock the controlled medication drawer in the DON's office, and logs the controlled medication onto the form. RN-B stated when the DON is not at facility, the medication was not counted or reconciled with another nurse when placing the medication in the drawer. During an interview on [DATE], at 10:15 a.m. OM-A stated the nurses have a key to her office as nursing supply's they need access to are kept in her office. During an interview on [DATE], at 10:21 a.m. housekeeper-A stated she had a key to OM-A's office. During a follow up interview on [DATE], at 10:43 a.m. the DON stated it was not common knowledge there was a key in OM-A's office. The DON stated the key in OM-A's office was unmarked. The DON stated she was having a locked box with a code installed in her office today. The facility's policy Controlled Substance Disposal & or Destruction, revised [DATE] indicated Controlled substance medications remaining in the facility after a resident has been discharged , becomes deceased , or the order is permanently changed/discontinued, are disposed of using a method in accordance with state and federal regulation.

Based on observation, interview, and document review, the facility failed to ensure nebulizer equipment was rinsed and dried after each use to reduce the risk of infection for 2 of 2 residents (R87, R96) observed during nebulizer (drug inhalation delivery device) medication administration. Findings include: R87's Annual Minimum Data Set (MDS), dated [DATE] identified R87 had a [DIAGNOSES REDACTED]. R87 was cognitively intact. R87's physician orders [REDACTED]. Administer 4 times daily. (MONTH) self administer after set up. The order directed to rinse and dry equipment after each treatment. During observations of a medication pass on 4/18/18, at 7:29 a.m. with registered nurse (RN)-C. RN-C listened to R87's lungs using a stethoscope. RN-C donned (put on gloves), opened a Rubbermaid container located on a table in R87's room, and took out the nebulizer equipment. RN-C stated the nebulizer equipment was cleaned by the night nurse. RN-C emptied the vial of [MEDICATION NAME]/[MEDICATION NAME] 0.5 mg/3 mg 3 ml vial into the nebulizer equipment. RN-C placed the mask over the R87's nose and mouth and instructed R87 to look at her watch and keep the mask of for 10 minutes. RN-C doffed (removed) her gloves, washed her hands and left the room. RN-C stated she was going to administer R96's nebulizer. R96's 5 day MDS, dated [DATE], identified R96 had a [DIAGNOSES REDACTED]. R96 was cognitively intact. R96's physician orders [REDACTED]. During observations and interview of a medication pass on 4/18/18, at 7:38 a.m. RN-C entered R96's room. RN-C donned gloves. RN-C listed to R96's lungs and check an oxygen level using an oximeter. RN-C removed the nebulizer equipment from a canister located on shelf in R96's room. RN-C emptied the vial of [MEDICATION NAME] sulfate 2.5 mg 3 ml vial in the nebulizer equipment and placed the mask over R96's nose and mouth. RN-C stayed with R96 during the administration of the [MEDICATION NAME]. RN-C stated the night nurses wash all the nebulizer equipment with soapy water at the beginning of their shift and lay it out to dry. At the end of the night nurses shift, the nurses put the nebulizer equipment together and place it back in the container. At 7:51 a.m., RN-C turned off R96's nebulizer, and removed the nebulizer equipment. RN-C put the nebulizer device back into the canister. RN-C did not rinse out the nebulizer equipment. RN-C doffed her gloves, washed her hands and left the room. RN-C walked back to the medication cart. During observations on 4/18/18 at 7:54 a.m., after walking out of R96's room, back to the medication cart, R87's nebulizer equipment was observed to be laying on top of the nebulizer machine in her room. R87 was not in the room. During an interview on 04/18/18 at 07:58 AM RN-C was standing next to the medication cart and stated she was done with R87's and R96's nebulizer treatments. When asked if there was anything to do with the nebulizer equipment RN-C stated not on my shift. RN-C went on to say We found when you rinse it (nebulizer equipment) in between there is a higher risk for infection. During an interview on 4/18/18, at 10:43 a.m., the DON stated the nurses are to rinse out the nebulizer equipment after each use, then set out the equipment to dry on a paper towel. The DON went on to say this was the facility's policy. Manufacturers instructions for the Pulmonate nebulizer directed Clean after every use: 1. With power switch in the off position, unplug power cord from wall outlet. 2. Disconnect tubing from the air-inlet connector and set aside. 3. Disassemble mouthpiece or mask from cap. Open nebulizer by turning cap counterclockwise and removing baffle. 4. Wash all items, except tubing, in warm water/dishwashing detergent solution. Rinse under warm tap water for 30 seconds to remove detergent residue. Allow to air dry. The facility's policy Nebulizer Care & Cleaning, revised 2-08 directed to: 1. Disconnect the oxygen tubing and set aside 2. Take apart the neb cup and attachments 3. Rinse each piece with warm water. 4. Let them air dry by tilting them on a clean paper towel so that moisture drains out of the cup sections. Cover with another paper towel to keep dust off. 5. When pieces are dry, reassemble nebulizer for next use. 6. Wipe out face mask with clean cloth.

Based on observation, interview, and document review, the facility failed to provide a dignified dining experience for 3 of 18 residents (R149, R168, R143) reviewed for dignity. Findings include: R149's face sheet, undated, indicated R149 had [DIAGNOSES REDACTED]. R149's quarterly Minimum Data Set (MDS), dated [DATE], indicated R149 had severe cognitive impairment and required extensive assistance for toileting. R168's face sheet, undated, indicated R168 had [DIAGNOSES REDACTED]. R168's admission MDS, dated [DATE], indicated R168 had severe cognitive impairment and required extensive assistance for toileting. R143's face sheet, undated, indicated R143 had [DIAGNOSES REDACTED]. R143's quarterly MDS, dated [DATE], indicated R143 had severe cognitive impairment and required extensive assistance for toileting. During a dining observation on 6/26/17, at 5:40 p.m. seventeen residents were eating supper in the Heritage Square dining room. R149 was seated in a wheelchair at a table with two female residents, one male resident, and registered nurse (RN)-A, who assisted and encouraged the residents at the table to eat. R149 attempted to push away from the table several times, and RN-A encouraged him to continue to eat. At 5:46 p.m. nursing assistant (NA)-A walked into the dining room, pushing a female resident to a table on the opposite side of the dining room from R149's table. RN-A loudly announced to NA-A that R149 had to go potty and asked that she take him to the bathroom. R149 was wheeled out of the dining room. At 6:18 p.m. R168 was finished eating and stood up from her wheelchair. NA-A loudly announced to NA-C that R168 needed to go to the bathroom. NA-C asked R168, loud enough for others to hear, if she needed to go to the bathroom, and pushed her out of the dining room. During another dining observation on 6/28/17, at 8:48 a.m. fourteen residents were eating breakfast in the Heritage Square dining room. R149 was sitting in a wheelchair at the table and had finished his breakfast. NA-B walked into the dining room and attempted to push R149 out of the dining room in his wheelchair. While taking R149 out, NA-B stated several times, in a tone of voice loud enough for others to hear, that she wanted to take him to the bathroom. R149 stopped the wheelchair with his feet and stated he didn't need to go to the bathroom. NA-B walked away from R149 and stated in a tone of voice loud enough for others to hear, Let's see .(R143) would be a good one to take out, and loudly asked R143 if he needed to go to the bathroom. R143 nodded and NA-B wheeled him out of the dining room. During an interview on 6/28/17, at 1:24 p.m. NA-B stated residents didn't always understand why they were being pushed out of the dining room, so she felt the need to tell them. NA-B stated, It's probably not appropriate to do that. When interviewed on 6/28/17, at 1:31 p.m. licensed practical nurse (LPN)-A stated, I hear it a lot too. They should be taking them (residents) aside and asking them. During an interview on 6/28/17, at 1:34 p.m. RN-A indicated it would be ideal to not ask residents about personal issues in front of others, and stated, I really hadn't thought about it being a dignity issue. We do it .We probably should be more discreet. When interviewed on 6/29/17, at 11:23 a.m. the director of nursing (DON) indicated it was never appropriate to ask residents about using the restroom in front of others. Review of the facility's undated Dignity Policy, included, Residents shall be treated with dignity and respect at all times. The policy further directed, Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.

Based on observation and interview the facility failed to ensure the most recent survey results were posted for review. This had potential to affect all 108 residents, visitors and staff who wished to examine this information. Findings include: During an initial tour of the facility on 6/26/17, at 1:10 p.m. a copy of the Minnesota Department of Health survey results was observed in a clear plastic filing shelf mounted to the wall of the main entrance across from the reception desk. The survey results contained inside were dated 5/4/15 through 5/7/15. The survey results lacked the more recent survey conducted 4/18/16 through 4/21/16. During an interview on 6/28/17, at 12:48 p.m. the administrator confirmed that the survey results posted was not the most recent survey report. The administrator stated 3 years of survey results were readily available and typically were posted. The administrator stated someone may have taken the 4/16 survey results and not put them back.