Every finding on record at Sanford Health Sylvan Court

Based on observation, interview and document review, the facility failed to ensure 1 of 1 medication, Docusate Sodium, (Colace-stool softener), was not outdated prior to administration for 1 of 25 medication administration observations. Findings include: Observation and interview on [DATE] at 8:45 a.m., with trained medication aide (TMA)-A as she prepared to administer R42's morning medications including Docusate Sodium (Colace) 100 milligram (mg) soft gels from the stock bottle in the medication cart. TMA-A retrieved the bottle of Docusate Sodium removed 2 soft gel capsules and placed them into the medication cup with the other medications. TMA-A then delivered the medications to R42 who took the medication. Upon returning to the medication cart and examining the bottle she observed the printed date of expiration of February 2026. TMA-A reported she had not checked the date of expiration prior to administering the medication and confirmed she should have checked the expiration date. Observation and interview on [DATE] at 9:00 a.m. with licensed Practical nurse (LPN)-A observed the expiration date of February 2026 printed on the bottle of Docusate Sodium 100 mg soft gels and identified they should have been replaced at the end of February. LPN-A retrieved the bottle of Docusate Sodium and took it to the medication room for disposal. She identified she would immediately notify the MD that R42 had received expired medication and complete the Medication Variance Communication report. Review of R42's medication administration record (MAR) identified she received Colace according to current physician orders 2 capsules (200mg) by mouth every morning. TMA-A and LPN-A confirmed the medication would have been administered from the outdated stock bottle stored in the medication cart for a total of 24 doses. Interview on [DATE] at 8:26 a.m. with the director of nursing (DON) identified her expectation for staff to follow the 5 rights of medication administration and not administer an outdated medication. She identified that the expired medication should have been caught and not continued to be administered. Interview on [DATE] at 1:30 p.m. with the facility pharmacist identified He Expected staff to follow the five rights of medication administration. The Expired medication should have been identified and replaced to avoid administration of an outdated medication. Review of the [DATE], Medication Errors Policy defined outdated medication as administration of a medication when the composition or effectiveness of the medication could be affected by the date of expiration. Medication errors were to be documented on the Medication Error Report Form. A policy for monitoring medication carts for discontinued or outdated medications was requested but not provided by the end of the survey period.

Based on observation and interview, the facility failed to ensure frozen food items were safely stored off the floor in 2 of 2 walk in freezers located in the kitchen. This had the potential to affect all 43 residents. Findings include: Observation on 2/10/25 at 10:48 a.m., during the initial kitchen tour with the dietary manager (DM) present identified they had 2 walk-in freezers. Upon entering the 1st walk-in, there were multiple boxes of frozen food including sweet potato fries, corn bread, Swedish meatballs, cheese tortellini, potato cubes, breaded chicken, and chili observed on the floor under the bottom shelf. Observation of the 2nd walk-in freezer identified frozen fruit smoothies, enchiladas, assorted pies, queso triangles, slider buns, hoagie buns, and muffin batter stored on the floor. Interview on 2/10/25 at 11:08 a.m., with the DM identified she was aware they were not supposed to store foods on the floor. The facility had storage issues related to having enough room due to additional diet requirements of residents and had identified they needed more freezer space. Interview on 2/11/25 at 3:30 p.m., with the administrator identified he was aware of the concerns and thought it may be related to over-ordering. He was made aware of the concern after the DM notified him, and the freezer had been re-organized to provide room for all items to be stored on the shelves and off the floor. He agreed food should not be stored on the floor. Review of the facilities undated Food Storage Standards policy identified that all foods were to be stored on a shelf at least 6 inches above the floor.

Based on record review and interview, the facility failed to ensure medications were coded accurately on their Minimum Data Set (MDS) assessment for 1 of 5 residents (R43) reviewed for medications. Findings include: R43's 1/22/25, admission MDS admission assessment identified he had a diagnosis of diabetes. R43 was noted to have received one injection of insulin during the look back period. R43's current, physician orders identified no insulin was ordered. The physician orders did include a once weekly dose of Ozempic 0.5 milligrams (mg) injection (a non-insulin medication used to improve blood sugar control). Review of the 11/19/24, RxList, Ozempic Drug Summary, located at https://www.rxlist.com/ozempic-drug.htm, identified Ozempic Injection is a glucagon-like peptide 1 (GLP-1) receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Review of the October 2024, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Section N identified on question 0350 A and B, only insulin should be coded here. Interview on 2/13/25 at 8:03 a.m., and later RAI manual review , with the MDS coordinator identified she understood if Ozempic was used to treat diabetes, it could be coded as an insulin injection on the MDS. She later reviewed the RAI manual and confirmed the Ozempic injection should not have been coded as insulin. A policy related to accuracy of assessments was not provided by end of survey.

Based on interview and record review the facility failed to complete a gradual dose reduction (GDR) attempt annually or document a rationale for no gradual dose reduction (GDR) for 2 of 5 residents (R2 and R11) reviewed for unnecessary medications. Findings include: R2's 1/18/24, annual Minimum Data Set (MDS) identified R2 had adequate hearing, his speech was unclear, and he had some difficulty communicating some words or finishing thoughts, but he was able to make his needs understood. R2 was able to understand others. R2's cognition was moderately impaired. R2 was identified during the assessment period to feel down and depressed. R2 displayed no behaviors. R2 was dependent on staff for assistance with grooming and transfers. R2 had diagnoses of hypertension, neurogenic bladder, dementia, seizure disorder, traumatic brain injury, and depression. R2 took a antipsychotic and antidepressant daily. The assessment identified that a gradual dose reduction had not been attempted and the physician had not documented GDR as clinically contraindicated. R2's 5/1/24, physician orders identified Sertraline 200 milligrams (mg) every day (anti-depressant) with a start date of 2/24/23 and Olanzapine 15 mg (anti-psychotic) at bedtime with a start date of 1/24/19. Interview on 4/29/24 at 6:21 p.m., with licensed practical nurse (LPN)-A reported he used to have behaviors, but he was good now. She stated he used to be aggressive with staff and other residents at one time. H was not the one to provoke but he would hit out if provoked as he used to be a boxer. His medication has helped with his behaviors but also the residents have changed that live here and that also had helped. She identified he did have dementia and he was followed by psychiatry. Interview on 4/30/24 at 10:42 a.m., with nursing assistant (NA)-B who reported that R2 did not have behaviors other than he wanted to call his mom late at night. She reported when another one of the residents first came here that resident used to care for his wife, and he had confusion and accidentally went into R2's room and she said she had to get between them, but she had not witnessed R2 having any other behaviors after that. Review of 3/8/24, psychiatry visit notes identified the provider had reviewed his medication and made no changes to his Sertraline 200 mg daily (anti-depressant), Olanzapine 15 mg (anti-psychotic) at bedtime daily, or Depakote 500 mg twice a day (anti-convulsant). The note identified that R2 had been compliant with his medications and no side effects had been noted. R2 had no stressors since last visit and R2 reported being happy, he denied feeling sad/down or anxious. Review of 4/10/24, physician visit progress note identified R2 had reported no concerns, he was feeling sad for the loss of his wife and later mentioned his mother had recently passed. No changes to his Sertraline 200 mg, Olanzapine 15 mg at bedtime or his Depakote 500 mg twice a day. Review of the pharmacy recommendations from 4/19/23 through 4/4/24, identified the pharmacist had documented on: 1) 4/19/23, pharmacist results of review that on 4/3/23, psychiatry visit with no change wanted and recheck in 3 months. No other significant findings. 2) 7/3/23, pharmacist results of review identified: resident seen on 4/3/23, by psychiatry with no change wanted. He is currently on olanzapine 15 mg/day, sertraline 200 mg/day (increased 10/22), Depakote 100 mg/day. No other significant findings noted. 3) 1/2/24 pharmacist results of review identified: resident continues of Depakote 100 mg/day, sertraline 200 mg/day, and olanzapine 15 mg/day with next psychiatry visit in March. Provider monitoring blood pressures. 4) 4/4/24, pharmacist results of review identified: psych visit on 3/8/24, waiting on notes. No GDR were recommended during the 12-month period. Interview on 5/1/24 at 9:24 a.m., with pharmacist identified that the psychiatrist followed R2, and they did not always document details about medications. He reported that the primary physician received his recommendations, and the psychiatrist did not receive the recommendations. The primary provider typically did not adjust doses for psych medications if the resident was followed by psychiatry. Pharmacy makes recommendations and the nurse ensures the provider addresses the recommendation during rounds at the facility. Interview on 5/1/24 at 10:21 a.m., with registered nurse (RN)-A who identified as the care coordinator reported she completed rounds with the providers and would present the pharmacy recommendations to the provider at that time. She confirmed that the provider typically did not address psych medication if the residents was being followed by the psychiatrist. She reported that she did not forward pharmacy recommendations for a GDR to the psychiatrist but should be doing so. She was unsure if R2 had any documented rationale for not completing a GDR. Interview on 5/1/24 at 11:37 a.m., with the director of nursing identified that she worked with the pharmacist, and they together would ensure that pharmacy would make a GDR recommendation at a minimum in the months of January and July. She confirmed that the primary providers did not like to make dose adjustments on psych medication if the resident was being followed by psychiatry. She reported that the psychiatrist should be receiving the recommendations for GDR as she typically requested information on the resident prior to their visit. She agreed that a GDR should be attempted annually and if contraindicated that rationale should be documented in his medical record. Interview on 5/1/24 at 11:45 a.m., with administrator who agreed that if R2 has been on the same dose of his Olanzapine 15 mg since 1/24/19, that should have been addressed and documented in his medical record within the last 5 years if it was contraindicated. He agreed that a GDR should be attempted annually and if not appropriate a rationale should be documented in the medical record. Review of the 5/1/24 1:31 p.m., communication between the pharmacist and the mental health provider identified that the mental health provider was not opposed to a trial of decreasing R2's dose however, R2 had an incident that could not for sure be determined if it was intentional or not so at his last appointment, she had continued his medications as is. She reported she would plan to reassess for potential dose reduction at the next appointment. The mental health provider failed to document in R2's medical record during the last visit the rationale for the continued dose of medications. 49336 R11's 2/29/24, quarterly Minimum Data Set (MDS) identified R11 had a diagnosis of dementia and depression. R11 had severe cognitive impairment and had taken antidepressants. R11's section M assessment, identified that a GDR had not been attempted and the physician had not documented a GDR as clinically contraindicated. R11's undated Physician Order Report, identifed he had taken mirtazapine 15 milligrams (mg) daily and escitalopram (for depression and anxiety) 10 mg daily for depression with a start date of 8/24/22. R11's 1/02/24, Pharmacist Drug Regimen Review Observation identified recommendations for a GDR for escitalopram had no psychiatry services. There was no mention of implementation for escitalopram's GDR recommendation to providers. R11's undated care plan, identified he was on antidepressants. R11's goal would be for him to have a therapeutic effect of the medication. Staff were to adminsitered the medication as ordered and medications were reviewed monthly by the pharmacist, director of nursing (DON), nursing and medial director (MD). Interview on 5/01/24 at 10:07 a.m., with pharmacist stated the facility did not attempt a GDR of R11's antidepressants and had difficulty with the process because of refusals from R11's wife. Interview on 5/01/24 at 11:28 a.m., with medical provider (MD) stated she had discussed with R11's wife of the GDR process with the need for dosage modification. She stated R11 had taken antidepressants for a long time and GDR attempts had been made with no success. She stated R11's wife would refuse the need for GDR attempts and would not allow the facility to implement changes. MD stated R11's treatment plans would need approval from the wife and had been that way for a long time. Interview on 5/01/24 at 12:33 p.m., with registered nurse (RN)-A stated R11 had taken Remeron for his appetitite in the past and was unsure if R11's remeron medication had been address to the medical provider. Review of R11's undate care plan, identified R11 had diabetes, vitamin D deficienciy, and dysphagia. Goal was for R11 to consume adequate calories to maintain body weight. Interventions were for staff to modify R11's consistency of diet, supplements use at the discretion of dietary supervisor, eats meals in the main dining room and to offer snack and document amount consumed. There was no mention of R11's use of remeron for appetite stimulant.Review of 3/28/24, Psychotropic (Psychoactive) Drug Documentation policy identified the pharmacist reviews use of all medication upon admission and if using psychotropic medications to review monthly for any needed adjustments and at least twice yearly for planned dose reductions. Review of 12/6/23, Psychotropic Medications policy identified that gradual dose reduction was the tapering of a dose to determine whether symptoms or conditions can be managed at a lower dose or if a medication can be discontinued. Gradual dose reductions must be attempted annually unless contraindicated. The physician must document the clinical rationale for why any additional attempted dose reductions would likely impair the resident's function or increase distressed behavior.

Based on interview and document review the facility failed thoroughly investigate an allegation of staff to resident abuse for 1 of 3 residents (R2) when resident safety upon immediately at the time of the allegation and during the the investigation was not addressed, no additional residents or staff where interviewed and no staff education/training was provided following incidents. Findings include: R2's quarterly Minimum Data Set, dated dated dated [DATE], identified moderately impaired cognition with wandering behavior one to three days out of seven. During an interview on 2/14/24 at 10:00 a.m. NA-B stated came into work and arrived at 2:00 a.m. NA-B indicated around approximately 3:30 a.m. NA-A radioed for assistance on 2nd floor with R2. NA-B went up to 2nd floor to assist and saw NA-A held R2's door shut and R2 yelled let me out while she pulled on the door from inside her room. NA-B requested NA-A remove her hand from the closed door handle and asked R2 let go of door, go to middle of room so she could be assisted. NA-B entered R2's room, calmed her down, and assisted her to the bathroom. NA-B verified R2 was scared, shaking, and asked to not be left alone. NA-B stated R2's left arm long sleeve was pushed up a bit and noticed her left lower arm had a dark purple bruise that covered 75% of her arm. NA-B stated R2 said to her that bitch did that to me, grabbed my arm and squeezed it hard. NA-B stated after she assisted R2 back to bed reported to RN-A approximately 2:15 a.m. all details regarding the incident between R2 and NA-A when she arrived up to 2nd floor and the large bruise she had found on R2's left lower arm R2 asked NA-B not to leave and reassurance was given. During an interview on 2/14/24 at 12:30 p.m. licensed practical nurse (LPN)-B stated at shift change around 6:15 a.m. (4 hours later) she was informed by registered nurse (RN)-A R2 had a ruff night and NA-B had noticed an injury on R2's left forearm. LPN-B stated at approximately 6:30 a.m. along with RN-A went into R2's room and assessed her arm. LPN-B verified a large dark purple bruise with slight swelling was seen on R2's lower left arm. LPN-B completed measurements and immediately called the DON to report the bruise. LPN-B stated R2 was also taking aspirin at that time. LPN-B indicated R2 stated the witch squeezed my arm and this happened in the middle of the night but unable to identify a name. During an interview on 2/16/24 at 9:30 a.m. RN-A stated R2 was usually calm and her confusion had progressed in the past month or so. RN-A stated R2 required assist of two staff to toilet her or one depending on her condition that day. RN-A stated unsure what triggered R2's behaviors the night of the incident, and had never been combative or hard headed prior to this incident. RN-A stated at approximately 2:15 a.m. NA-B assisted NA-A with R2. NA-B returned to first floor and informed RN-A R2 had something on her left arm that needed to be looked at. RN-A stated she informed NA-B it would be checked later. RN-A stated she waited until 4:00 a.m. and R2 was sleeping, decided not to bother her, and waited until change of shift. RN-A stated around 6:30 a.m. (over 4 hours later) along with LPN-A went in and assessed R2's left arm and found a large purple bruise measured approximately to 10 to 14 centimeters (cm) and 4 cm across, bulging lump on top, and painful. RN-A verified only one call was made to the DON at 12:00 a.m. during the night shift regarding R2 and her change in behavior. RN-A failed to report the alleged abuse, interview R2 and remove potential staff from working with R2 to ensure R2's safety. Facility internal live event documentation dated 2/6/24, identified event type safety/security event and sub event type threatening behavior/verbal assault. R2 sustained bruise. Intervention: monitor to determine possible harm. R2 obtained a large dark purple bruise measuring 14.5 centimeters (cm) x 6.3 cm to left forearm as a result of incident. R2 did state that witch squeezed my arm. Director of nursing (DON) interviewed both registered nurse (RN) and nursing assistant (NA) on shift with NA noting resident became aggressive punching RN in buttock and stomach. NA reported she grabbed R2's arm to divert the situation but did not intend harm. R2 currently prescribed aspirin and prednisone (steroid) at risk for bruising and fragile skin. R2's progress notes from 2/6/24, through 2/7/24, identified: -2/6/24 at 12:30 a.m. (notes revised at 9:52 a.m.) R2 was found walking out of her room with rolling table unassisted. R2 stated loudly and insistently she want to go out and sit on that chair and pointed at the chair at nurse's station. Encouraged and assisted R2 back to her room to the wheelchair to be safe and allowed to roam around her room. R2 refused, got furious and punch nurse in right chest and right wide of stomach and tried to head bang nurse's face with hers. R2 roamed around the floor while RN-1 while NA-A toileted another resident, left the floor via elevator, and was found shortly afterwards on first floor. R2 was brought back up to second floor, secured doors by shutting them and kept her closely monitored. R2 was constantly furious and physical to NA-A when kept safe. Director of nursing (DON) notified. Maintenance will be notified in the morning to request for a wander guard, per DON. -2/6/24 at 6:40 a.m. (notes revised at 2:43 p.m.) Night nurse reported to writer there was an injury to R2's left arm from staff/resident altercation during the night. Writer checked arm with night nurse present. Bruise noted measuring 14.5 x 6.3 centimeters (cm), dark purple with slight swelling in the middle. Skin intact and tender to the touch. The resident reported that witch squeezed my arm. Monitor daily and take weekly measurements. Resident was on aspirin 81 milligram (mg) daily. DON (director of nursing) notified immediately. During an interview on 2/14/24 at 4:45 p.m. director of nursing (DON) stated a thorough internal investigation was completed on the incident date 2/6/24 with R2. DON indicated R2's memory would not have been reliable with her recent change in cognition. DON stated not a 100% guarantee the bruise on R2's arm was caused by grabbing her, she was an elderly [AGE] year old with cognitive impairments, dementia, and unable to directly make the assumption as to when it happened and/or what caused it. DON also stated the bruise had the potential to be caused by this event when staff utilized maximal physical effort to get R2 to sit down, and desolate the situation. DON stated education should have been provided and situation could have been handled a different way. DON indicated NA-A's personality/mentality was like she would not take any crap from anyone possibly due to lack of showing compassion and unaware of the encouragement that should have been given to the resident. During an interview on 2/14/24 at 5:56 p.m. administrator stated the 2/6/24, incident with R2 there was no intended neglect or intentional abuse. Administrator indicated no patterns had been identified with NA-A had displayed only generalized attitudes but not intentional harm or injury, therefore no additional interviews were completed with staff or residents. Administrator stated seemed as though another staff member tried to get back at another staff and filed a complaint. During a telephone interview on 2/20/24 at 1:00 p.m. NA-A stated worked the night shift on 2/5/24, on second floor. NA-A stated R2 had left second floor on her own via elevator around 12:00 a.m. NA-A stated later during the night R2 pushed bedside table with wheels to doorway of her room, RN-A intervened, and R2 swung at and punched her in the stomach. NA-A stated along with RN-A assisted R2 into her wheelchair, grabbed her left arm, and when R2 sat down into the chair stated you bitch, you bitch. NA-A indicated later during the night shift R2 was calm and pushed herself in wheelchair around the unit, bathroom was offered, and R2 accepted. NA-A stated while in hallway bathroom with R2 her behavior changed quickly, arms were flaring and unaware if she had lashed out. NA-A stated R2 was brought back to her room and started to hit and came at her with wheelchair. NA-A stated it was a little over whelming and very uncomfortable situation. NA-A indicated R2 was placed in her room alone, exited the room, radioed for help, stood outside of room and closed the door. NA-A stated R2 grabbed the door handle and attempted to open the door. NA-A stated she held onto the door handle and held door closed from the outside of R2's room, and unsure if any words were exchanged. NA-A stated was wrong to have held hand on door handle to hold door closed during that time and was not aware you pick and chose your battles. NA-A stated was the first time she had seen R2 respond that way and tried to avoid escalation of the situation NA-A stated felt uncomfortable working on second floor the rest of that night. NA-A indicated had met with human resources, was informed the residents have the right to leave their rooms if they wanted to. NA-A stated she understood she had made the wrong decision, placed her hand on the handle of the door to hold it closed, should have walked away, and allowed R2 to come out of her room. The facility lacked evidence a thorough investigating was completed which included residents and staff interviews about potential abuse or resident cares being provided by staff to prevent re-occurrence. Facility policy titled Investigation, Alleged VA (vulnerable adult) Incident dated 5/9/23, identified a consistent and thorough investigation should have been done as quickly as possible after a report to investigate while memories are fresh assures the most accurate, detailed accounts. Interview all staff on duty at the time of the alleged incident, family members, and other residents. Discreetly clarify statements that are different than reported by other observers. Be aware and alert for discrepancies, unusual behavior or performance or communication.

Based on interview and document review, the facility failed to immediately report to the administrator and failed to immediately report, no later than 2 hours, to the State Agency (SA) an allegation of staff to resident abuse for 1 of 3 residents (R2) who were reviewed for staff to resident abuse. Findings included: R2's quarterly Minimum Data Set, dated dated dated [DATE], identified moderately impaired cognition. Facility internal live event documentation dated [DATE] at 12:03 a.m. identified event type safety/security event and threatening behavior/verbal assault. R2 displayed exit seeking behaviors via second floor door, unsuccessful. Cares provided to another resident by registered nurse (RN)-A and nursing assistant (NA)-A, when finished R2 was no where to be found. First floor staff informed second floor staff R2 had used the elevator to access first floor. R2 brought back to second floor and constantly monitored. R2 was constantly furious and physical to NA-A when kept safe. Director of nursing (DON) notified at 12:31 a.m R2 sustained a large dark purple bruise measuring 14.5 centimeters (cm) x 6.3 cm tender to touch to left forearm as a result of incident. R2 stated that witch squeezed my arm. Intervention identified: monitor to determine possible harm. DON was notified of bruise at 6:40 a.m. DON interviewed both RN-A and NA-A. NA-A noted resident became aggressive punching RN-A in buttock and stomach. NA-A reported she grabbed R2's arm to divert the situation but did not intend harm. R2 currently prescribed aspirin and prednisone (steroid) at risk for bruising and fragile skin. R2's progress notes from [DATE], through [DATE], identified: -[DATE] at 12:30 a.m. (notes revised at 9:52 a.m.) R2 was found walking out of her room with rolling table unassisted. R2 stated loudly and insistently I want to go out and sit on that chair and pointed at the chair at nurse's station. Encouraged and assisted R2 back to her room to the wheelchair to be safe and allowed to roam around her room. R2 refused, got furious and punch nurse in right chest and right wide of stomach and tried to head bang nurse's face with hers. R2 roamed around the floor while RN-1 and NA-A toileted another resident, left the floor via elevator, and was found shortly afterwards on first floor. R2 was brought back up to second floor, secured doors by shutting them and kept her closely monitored. R2 was constantly furious and physical to NA-A when kept safe. DON notified. Maintenance will be notified in the morning to request for a wander guard, per DON. -[DATE] at 6:40 a.m. (notes revised at 2:43 p.m.) Night nurse reported to writer there was an injury to R2's left arm from staff/resident altercation during the night. Writer checked arm with night nurse present. Bruise noted measuring 14.5 x 6.3 centimeters (cm), dark purple with slight swelling in the middle. Skin intact and tender to the touch. The resident reported that witch squeezed my arm. Monitor daily and take weekly measurements. Resident was on aspirin 81 milligram (mg) daily. DON notified immediately. Progress notes did not identify when night nurse was notified of interactions between NA-A and R2's bruise. During an interview on [DATE] at 10:00 a.m. NA-B stated came into work and arrived at 2:00 a.m. NA-B indicated around approximately 3:30 a.m. NA-A radioed for assistance on 2nd floor with R2. NA-B went up to 2nd floor to assist and saw NA-A held R2's door shut and R2 yelled let me out while she pulled on the door from inside her room. NA-B requested NA-A remove her hand from the closed door handle and asked R2 let go of door, go to middle of room so she could be assisted. NA-B entered R2's room, calmed her down, and assisted her to the bathroom. NA-B verified R2 was scared, shaking, and asked to not be left alone. NA-B stated R2's left arm long sleeve was pushed up a bit and noticed her left lower arm had a dark purple bruise that covered 75% of her arm. NA-B stated R2 said to her that bitch did that to me, grabbed my arm and squeezed it hard. NA-B stated after she assisted R2 back to bed reported to RN-A approximately 2:15 a.m. all details regarding the incident between R2 and NA-A when she arrived up to 2nd floor and the large bruise she had found on R2's left lower arm R2 asked NA-B not to leave and reassurance was given. During an interview on [DATE] at 9:30 a.m. RN-A stated R2 was usually calm and her confusion had progressed in the past month or so. RN-A stated R2 required assist of two staff to toilet her or one depending on her condition that day. RN-A stated unsure what triggered R2's behaviors the night of the incident, and had never been combative or hard headed prior to this incident. RN-A stated at approximately 2:15 a.m. NA-B assisted NA-A with R2. NA-B returned to first floor and informed RN-A R2 had something on her left arm that needed to be looked at. RN-A stated she informed NA-B it would be checked later. RN-A stated she waited until 4:00 a.m. and R2 was sleeping, decided not to bother her, and waited until change of shift. RN-A stated around 6:30 a.m. (over 4 hours later) along with LPN-A went in and assessed R2's left arm and found a large purple bruise measured approximately to 10 to 14 centimeters (cm) and 4 cm across, bulging lump on top, and painful. RN-A verified only one call was made to the DON at 12:00 a.m. during the night shift regarding R2 and her change in behavior. RN-A failed to report the alleged abuse, interview R2 and remove potential staff from working with R2 to ensure R2's safety. During an interview on [DATE] at 4:45 p.m. DON stated RN-A notified her at 12:31 a.m. of R2's elopement, at 1:33 a.m. reported a resident death on first floor and then again at 1:43 a.m. regarding death questions. DON indicated she was not notified of R2's bruise to her arm until 6:49 a.m. R2's bruise had the potential to be caused by this event and the physical aggression and the staff to use to provide maximal physical effort to deescalate R2's situation. DON stated staff were expected to notify her as soon as the incident happened however was informed the bruise was not seen earlier. During an interview on [DATE] at 5:56 p.m. administrator stated was notified by DON of R2's incident/bruise on arm on [DATE] at 6:56 a.m. Administrator stated he believed the bruise to R2's arm occurred when staff assisted R2 to a seated position. Administrator indicated the incident with R2 was not filed with the state because there was no intended neglect or intentional abuse. Administrator indicated NA-A had displayed generalized attitudes but not intentional harm or injury and DON and myself decided together it was not reportable. Facility policy titled Vulnerable Adults, Reporting Maltreatment, LTC (long term care), AL (assisted living), Swing bed - [NAME] dated [DATE], identified the facility was expected to have provided a safe environment to patients, residents, and clients of [NAME] Medical Center (SCMC), and consistent guidelines for preventing, identifying, investigating and reporting suspected maltreatment ensure compliance with the Minnesota Statute 626.557, the Vulnerable Adults Act and amendments; Minnesota Statue 245A.65, and federal nursing home regulation 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. Facility internal reporting of a suspected maltreatment of a vulnerable adult including all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source that may constitute reasonable suspicion of a crime are reported immediately but not later than two hours after the allegation was made, if the event that cause the allegation involve abuse or result in serious bodily injury. The facility must submit the electronically report of the incident to the Minnesota Department of Health (MDH) or South Dakota Department of Human Services (SD DHS), immediately, but no later than 24 hours after the incident's discovery. Definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain or mental anguish or exploitation. Physical abuse includes hitting, slapping, pinching, kicking, and also includes controlling behavior through corporal punishment (any act causing deliberate physical pain or discomfort in response to some undesired behavior).

Based on observation, interview and document review the facility failed to ensure 1 of 1 staff (housekeeper (H)-A followed transmission-based precautions (TBP) for appropriate use of personal protective equipment (PPE). This had the potential to affect 17 of 43 residents who resided on that unit. The facility also failed to ensure policies were reviewed and/or revised annually. Findings include: Observation beginning on 8/2/21 at 12:45 p.m., upon entrance to the facility, identified R143's room had a blue PPE holder on the door. A bright orange sign indicating Contact Precautions were required was tucked into a center pocket with only the top 2 inches visible. PPE required for any persons entering the room included a gown, gloves, mask, and eye protection. R143's current, undated face sheet identified R143 was admitted on [DATE] from the local acute care facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R143 was placed in a private room in quarantine for 14 days following admission, to be discontinued on 8/6/21. Observation on 8/5/21 at 12:37 p.m. with housekeeper (H)-A as she cleaned R143's room identified she wore a mask, gloves and eye protection. H-A retrieved cleaning supplies from the housekeeping cart and entered R143's room and proceeded to the bathroom to clean. H-A wore no gown when entering R143's room. Interview on 8/5/21 at 12:40 p.m., with H-A identified she had received training on Infection control, and precautions and stated she would be aware of a resident on precautions by signage placed on the door. H-A agreed she should have been wearing a gown when she entered R143's room, but hadn't thought about it. Interview 8/05/21 at 1:02 p.m., with the administrator identified all staff had received training on working with residents on transmission based precautions (TBP) and use of appropriate PPE. The administrator identified H-A usually worked in the adjacent hospital and had been brought over to the facility to assist with routine cleaning. The administrator's expectation was all staff were to follow appropriate use of PPE and TBP. Review of the 2/5/20, Standard and Transmission Based Precautions (Isolation) policy identified the use of PPE for Contact Precautions included wearing a gown, gloves, mask, and eye protection prior to entering a resident' room.

Based on observation, interview, and document review, the facility failed identify potential interventions to prevent resident-to-resident altercations between 4 of 4 residents (R1, R2, R3, and R4) with known physical behaviors. Findings include: Review of the 3/10/21, report to the State Agency (SA) identified R1 and R4 were having a conversation when R4 became angry and slapped R1 on the left side of her face. Staff immediately intervened. No injuries were noted and staff continued to monitor. R1's 1/7/21, Minimum Data Set assessment (MDS) dated identified severe cognitive impairment, Alzheimer's disease with behavioral disturbance, depression, anxiety, and history of chronic pain. R1 was independent with activities of daily living (ADLs) for all but dressing which required limited assistance. R1 wandered on a daily basis and was exit-seeking at times. Observation and interview on 3/16/21 at 2:15 p.m., with R1 in her room identified she was seated in her recliner. R1 denied any abuse concerns or problems with staff or residents and stated every one was really nice. R1 then leaned back in her chair, closed her eyes and went to sleep. There were no observable signs of abuse noted. R1's current, undated care plan identified behaviors of dementia and a tendency to develop crushes on males, both residents and staff. Staff were to provide redirection to divert R1's attention from focusing her conversations primarily toward male staff or residents. R1 was to be monitored due to issues with sun-downing (behavioral problems that occur in the evening or while the sun is setting), agitation, and anger. R1 identified herself as a caregiver, due to a history of working as a nursing assistant (NA). R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When staff would attempt to redirect R1 from the room she became vocal and argumentative. There were no interventions to identify how staff were to prevent behaviors that would affect other residents. Interview on 3/16/21 at 2:30 p.m., with LPN-A identified R1 was confused most of time, but usually responded to attempts of redirection but R1 was not able to determine herself, when other residents did not want to be bothered. R1 was bossy toward other residents due to wanting to direct their activity or provide care and answer call lights. R1 was difficult to redirect from her attempts of assistance and didn't accept staff telling her no and would become argumentative. LPN-A was not aware of any previous incidents between R1 and R4 but both residents were kept safe by staff monitoring and providing intervention to prevent close contact. Interview on 3/16/21 at 2:51 p.m., with nursing assistant (NA)-D identified he had noticed R1 had previously irritated other residents by attempting to provide cares, such as attempts to help them transfer, push their wheelchairs, or making comments to them about what they could or could not do. R1 had also become upset with staff for their attempts at redirection or speaking with other residents about something she had over-heard and didn't agree with. R1 wandered through out the unit and had attempted to enter other resident spaces and would attempt to answer call lights and provide assistance to them. R4's 2/25/21, quarterly, MDS identified he had severe cognitive impairment with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He required limited assist with personal hygiene, extensive assistance for dressing and toileting, and was independent in other areas. R4 displayed behaviors of wandering on a daily basis with frequent exit-seeking attempts and agitation at staff attempts of redirection. R4's current, undated care plan identified he had behaviors of wandering into private spaces, rummaging in other's belongings, exit-seeking, refusal of care and medication, and lack of safety awareness. He was know to hit at staff, swear, grumble under his breath and had resistance to attempts at redirection. Staff were to redirect as able and provide a calm environment. There were no interventions to identify how staff were to prevent behaviors that would affect other residents. Interview on 3/16/21 at 2:30 p.m., with LPN-A identified she was notified of the incident by NA-E and attempted to interview R4 who replied, he was tired of R1's [expletive]. I slapped her. R4 continued to wander in the hall and no further incidents were noted. R4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-A was not aware of any incidents directed toward other residents. R4 wandered and would attempt to exit facility outer doors or get on the elevator. He would become agitated when the alarm sounded and the door didn't open. She described R4 as having an angry facial expression, and leaning his upper body toward staff in a threatening manner when they attempted to redirect him. Interview on 3/16/21 at 2:51 p.m. with NA-D identified R4 was upset and more irritable at times, and R1 was not able to differentiate between R4's moods or recognize when he does not want to be bothered. R4 was exit-seeking and wandered. He would be looking for family members or believed he needed to care for farm animals. R4's behaviors included wandering into resident rooms and rummaging through belongings, becoming angry with staff who attempted redirection, and refusal of care and medications. NA-D identified the frequency of his behavior can vary, but he was frequently exit seeking and became angry when the door wouldn't open and the alarm sounded Interview on 3/17/21 at 3:26 p.m. with NA- E identified she was walking with R1 on 3/10/21 at 9:47 p.m. when R4 asked what they were doing. R1 responded and R4 became angry and began swearing. R1 became upset that R4 was swearing at her. R4 came closer, leaned toward R1, grabbed her arms and shook them, then raised his hand and slapped her on her left cheek. NA-E immediately stepped between R1 and R4 and was able to redirect R1 and R4. R1 did not have any redness or injury to her cheek. NA-E ensured R1 was safe and reported the incident to LPN-A. Later that same evening R1 and R4 were attempting to converse and had no recollection of the earlier incident. Staff remained in attendance to ensure neither resident was within arms length of the other. NA-E was not aware of any previous incidents between R1 and R4. R4 had behaviors toward staff persons at times, but she was not aware of any physical behavior directed at other residents prior to the incident. Review of the 10/16/20, report filed to the SA report identified R3 was seated in his wheelchair in front of the nursing desk laughing and joking with staff. R2 was standing next to him when R3 suddenly yelled move .move!. R3 struck R2 2 times in the stomach with a closed fist, causing her to bend forward and grab her stomach. LPN-B immediately separated R2 and R3 and assessed R2 for injury. R2 had a 2 centimeter (cm) reddened area located above her belly button area. R2 denied discomfort or distress and continued to wander in the halls while being monitored. R3 returned to his room without further incident R2's 10/12/20, MDS identified R2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had severe cognitive impairment but was independent with all ADL's except personal hygiene and dressing which required the limited assistance of 1 staff. R2's current, undated care plan identified a bright an orange sign with R2's name was posted by her room door to assist her in finding her room. Staff were to redirect R2 when she was found in another resident's room. R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 would at times strike out at staff when they attempted redirection. There were no interventions to identify how staff were to prevent behaviors that would affect other residents. Interview on 3/16/21 at 3:10 p.m., with NA-D identified R2 wandered in and out of her room frequently down both halls and would wander into other resident rooms. R2 became upset easily and at times would throw objects at staff when they attempted redirection. R3's 10/22/20, quarterly MDS identified R3 had severe cognitive impairment with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 exhibited behaviors of hitting and kicking at staff with cares and yelling out. R3 required extensive assistance with all ADLs including eating. R3's current, undated care plan identified staff were to monitor R3 to promote safety and prevent behavior directed toward other residents. He was to receive hourly checks from staff for safety and his room was across from nursing station. R3's would be easily frustrated, refused care or to get out of bed, and was combative at times toward staff. Following the 10/16/20 incident an additional entry was added to include R3 was to maintain a safe distance from R2. There were no interventions to identify how staff were to prevent behaviors that would affect other residents. R3's 10/16/20 at 3:55 p.m., progress note identified after the incident on 10/16/20, R3 showed no reaction and wheeled himself to his room. Staff noted R3's cognition had continued to decline following admission to the facility and he had exhibited inappropriate anger and impulsivity demonstrated by striking out at staff. Interview on 3/16/21 at 3:10 p.m., with NA-D described R3 as easy going. He he had not displayed aggressive behavior toward other residents, only toward staff when they attempted to provide care or transfer him into his chair. Interview on 3/16/21, at 3:46 p.m., with LPN-D identified R2 and R3 did have occasional issues due to R2 wanting to touch other residents. R2 had limited vision and liked to walk with her hand on the hand rail. This practice would have caused her to pass the area in which R3 liked to sit. LPN-D thought R2 had possibly touched R3 as she attempted to move past. Following the incident, staff were to keep R2 and R3 out of touching distance, but the two liked to visit at times and it wasn't not always easy to keep them apart. Staff were aware R3 was more irritable and likely to strike out following visits from his significant other. Interview on 3/17/21 at 4:30 p.m., with the director of nursing (DON) identified the above mentioned incident between R2 and R3 occurred following a visit from R3's significant other. The DON was informed R3 was heading back to his room, and R2 was in his way. He became impatient and struck out. The DON identified R2 and R3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had decreased vision and cognition which could have been the reason she did not move out of R3's path as he began moving away from the area. The DON identified there was not adequate identification into potential interventions that should have been in place knowing R3 displaying irritability following visits from his significant other. Review of the 1/7/21,Vulnerable Adults Reporting Maltreatment policy identified the facility was to provide a physically and emotionally safe environment for all residents residing in the facility. Residents receiving services from the facility were to be protected from abuse from anyone, including but not limited to staff and other residents, family members, friends, or other individuals.

Based on observation, interview and document review, the facility failed to ensure staff were actively screened at the point of entry in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for COVID-19. This had the potential to affect all 47 residents in the facility. Additionally, the facility failed to maintain appropriate infection control practices for mechanical lift slings between multi-resident-use for 1 of 6 residents (R1) and hand hygiene after personal cares for 1 of 1 resident (R1). Findings include: SCREENING Observation on 4/8/20 at 9:00 a.m., identified the entrance to the facility was located on the north side of the building. The entrance was composed of a glass exterior entry door, a small entrance area, and an interior door opening into the facility. The exterior door was locked and signs were posted at the entrance restricting visitors and directed people to enter through the adjacent clinic entrance. A thermometer and binder sat on a table placed in the entryway. Interview on 4/8/20 at 10:00 a.m., licensed practical nurse (LPN)-A identified staff enter the building at the front entrance on the north side of the building and self- screen for signs and symptoms of COVID-19 before entering the facility. Staff were to take their own temperatures and complete the questionnaire. If they had symptoms or a temperature, staff were to notify the nurse inside the facility. Interview on 4/8/20 at 10:05 a.m., with housekeeper (H)-A identified staff were to enter the facility through the north entrance take their own temperature and record it in the log located in the front entrance. If they had symptoms, they were to notify the nurse in the facility and refrain from work. Interview on 4/8/20, at 10:05 a.m., with nursing assistant (NA)-A identified staff enter through the front entrance of the facility and screen themselves for COVID-19 symptoms prior to entering the building. A thermometer and sign-in sheet were on a table at the front entrance. Interview on 4/9/20 at 8:42 a.m., with the director of nursing (DON) identified The DON was unaware staff needed to be actively screened at the point of entry by another staff person prior to being allowed into the facility to prevent potential exposure of COVID-19 to all residents. Review of the 3/16/20, Temperature Checks for Staff COVID-19 Symptom Screening policy identified staff were to take their temperature at the beginning and end of their shift and record the information in the binder in the facilty's designated entry. All staff were to self-monitor for symptoms on an ongoing basis and notify their manager for further direction if symptoms were identified. INFECTION CONTROL Observation on 4/8/20, at 10:10 a.m., identified a total lift with a (mesh fabric) sling hanging hanging on the hand grips. NA-A brought the left into R1's room. NA-A placed the sling under R1. NA-B hooked the sling onto the lift and transferred R1 onto the commode. Once R1 finished toileting, R1 was assisted off the commode. NA-A donned gloves and assisted R1 with personal hygiene care. R1 was lowered into her wheelchair. Without removing the gloves, and performing hand hygiene, NA-A positioned the wheelchair under R1 using the wheelchair handles. R1 was lowered into the wheelchair. While wearing the same contaminated gloves, NA-A detached the sling loops from the lift and placed the contaminated sling onto the lift. While wearing the same gloves used to perform peri cares, NA-A moved R1's personal belongings and placed them on R1's table tray. NA-A removed her gloves and without performing hand hygiene, donned a new pair of gloves, emptied the commode, and disinfected the commode. NA-B used a disinfectant wipe to disinfect the lift's hand grips and control panel. NA-B removed the lift and mesh sling from the room and placed the lift into the storage area with the contaminated mesh sling. Interview on 4/8/20 at 10:20 a.m., with NA-B identified sling was used for 4 other residents and was not laundered after transferring R1 between use. Interview on 4/8/20 at 10:35 a.m., with NA-A identified staff were to perform hand hygiene before and after resident cares and after removing gloves. She had not removed her gloves after performing R1's personal care because R1 had no bowel movement. 4 residents used the sit to stand lift for transfers. Residents did not have dedicated lift slings. The sling was used multiple times during the day for the 4 residents. The same sling had been used for all 4 residents. The slings were only laundered washed when they became visibly soiled. NA-A had asked management about having dedicated slings to use for the residents and was told there was not enough slings for each resident. Interview on 4/9/20 at 9:28 a.m., with the infection control preventionist (ICP) identified she expected staff to follow appropriate hand hygiene after removing gloves. Gloves should be removed and hand hygiene performed after provision of person care and before touching high contact areas and equipment shared between residents. The ICP agreed slings needed to be appropriately laundered between multi-resident use. Interview on 4/9/20 at 8:42 a.m., with the director of nursing (DON) identified she expected staff to follow infection prevention policies and procedures during the above observations. Staff were to remove gloves and perform hand hygiene after performing personal care and touching high touch areas and equipment used between residents. The slings were not dedicated equipment to each resident. There was no policy or procedure in place for routine laundering of mesh slings. Review of the 7/11/18, Hand Hygiene Policy and Procedure identified hand hygiene was to be performed after contact with a patient's intact skin, body fluids or excretions, and mucous membranes if hands were not visibly soiled. Hand hygiene was to be performed after contact with contaminated surfaces, objects, medical equipment in the immediate vicinity of the patient. Hand hygiene was to be performed after removing gloves. There was no policy or procedure related to laundering mesh slings between resident use.

Based on observation, interview, and document review, failed to ensure food was free from potential physical contamination ( aluminum foil) and failed to ensure proper glove use was performed by 2 of 2 dietary assistants (DA) and 1 of 1 cook (C)-B, during food service. This had the potential to affect all 40 residents whom received meal service from the kitchen. Findings include On 5/14/19, at 5:43 p.m., during the evening meal service, DA-A was observed preparing for the evening meal on the Willow and Maple dining areas. DA-A proceeded to take temperatures before serving food. DA-A punctured the foil with the thermometer rather than appropriately pull back the foil and stick the thermometer directly into the food. An interview with DA-A on 5/14/19 at 5:47 p.m., identified temperatures were obtained by puncturing foil with the thermometer. DA-A was unaware particles of foil could mix with the food when the aluminum foil was punctured and was a risk of physical contamination. On 5/14/19 at 5:53 p.m., DA-A put on gloves. After putting on gloves, he proceeded to touch various kitchen drawer handles on the steam table, refrigerator handles, cupboard handles, and serving utensils. At 5:56 p.m., DA-A then opened the refrigerator and removed beverage containers from the refrigerator. DA-A then opened plastic bags containing cold sandwiches. With those same gloves, DA-A touched the sandwiches in the bag to arrange them for service. At 6:02 p.m., he removed a sandwich from the bag, and placed it on a plate and handed it to staff to be served. At no time did DA-A remove his gloves after touching contaminated surfaces and prior to handling food. An interview with DA-A on 5/14/19 at 6:49 p.m., identified staff were expected to remove contaminated gloves, perform hand hygiene, and put on new gloves before handling food On 5/15/19 at 8:00 a.m., during the morning meal service, DA-B checked temperatures performing the same actions by piercing the foil and not pulling back the foil to expose the food. On 5/15/19 at 10:52 a.m., C-B removed baked potatoes from the oven. She the put on gloves and touched handles of the oven to close the door. With those same gloves, DA-B then touched the potatoes with her contaminated gloves, and placed them into the steam table. On 5/15/19 at 11:44 a.m., DA-B was on the Maple and Willow dining area with the steam table. DA-B continued to obtain temperatures by puncturing the foil with the thermometer. On 5/15/19 at 12:40 p.m., the dietary manager (DM) and the Dietitian expectation was staff were not to touch handles in the kitchen or any other high touch surfaces without removing gloves, performing hand hygiene, and putting on new gloves. The dietitian agreed the foil was not to be punctured with the thermometers to check temperatures to ensure food was free from physical contaminants. Review of the facility's Nutrition Infection Control policy dated 12/19/18, identified it was the responsibility of every employee to know how to use sanitary techniques for food handling and environmental controls. Employees were required to wash their hands before starting work, after handling soiled dishes, and discard gloves if become contaminated or soiled, followed by hand hygiene. There was no mention how staff to ensure food was free from potential physical contaminant particles. Review of the 3/9/18, Food Code, US Public Health Service, FDA US Food and Drug Administration (YEAR) guidelines, page 144, identified temperature measuring devices were to be maintained in contact with food.

Based on observation, interview, and document review, the facility failed to appropriately assess and monitor 1 of 1 resident (R14) for safety before and during use of mechanical lift to prevent potential injury. Furthermore, the facility failed to perform preventative maintenance on all 6 facility mechanical lifts used for resident transfers on a routine basis as identified by the manufacture guidelines, which has the potential to affect 11 of 11 residents whom used the mechanical lift. Findings include: R14's [DIAGNOSES REDACTED]. R14's Fall Assessment, dated 2/26/19, indicated R14 had impaired mobility, required assistive devices for balance and gait, and was at high risk for falls. R14's record lacked evidence of a comprehensive safe mechanical lift assessment. R14's care plan, revised on 3/11/19, indicated R14 required full body lift and two staff with medium sling. Review of a facility reported incident report, incident date 4/25/19, indicated R14 fell out of the mechanical EZ Way total Smart lift while being transferred from the bed to the wheelchair with the assist of two staff members. Review of the facility reported incident investigation report, submission dated 5/1/19, indicated R14 is unable to participate in transfers, does not follow commands, and has contractures and rigidity. The report further indicated R14 was positioned slightly to his right side, the right leg strap came unhooked, and R14 slid out of the sling. Review of the facilities Multi-Cause Analysis investigation notes indicated the following: (1) Both staff members indicated the straps were properly in place prior to beginning the transfer. (2) Staff were completing multiple steps at one time and not using the remote control on the mechanical lift which resulted in the staff not having both hands on the resident. (3) Staff indicated R14 may have been placed slightly to the side of the sling. (4) The mechanical lift was immediately inspected and found to be in working condition. (5) The sling was in good condition and the appropriate size was being used. During observation on 5/15/19 at 8:20 a.m., NA-A and NA-B transferred R14 from bed to wheelchair with use of mechanical lift. Leg straps were crossed appropriately, and loops were placed in lift hooks appropriately. As R14 was being lifted into the air, NA-A noted one of the loops came unhooked from the lift hook. R14 was immediately lowered back onto the bed and loops were replaced. During observation on 5/16/19 at 11:16 a.m., R14 was transferred with use of the total mechanical lift and two staff assist. R14 was positioned on the lift sling, four loops were appropriately placed on the lift hooks and placement was double checked. R14 chanted out during transfer and staff continued to cue him to keep his hands on his chest during the transfer. During interview on 5/15/19 at 8:20 a.m., NA-A and NA-B indicated nurse assistants are trained annually on use of mechanical lifts and they have one scheduled for (MONTH) 22, 2019. During interview on 5/16/19, NA-B indicated the lift R14 slipped out of was taken out of service and sent down to maintenance to determine if it had malfuncioned on 5/15/19. During interview on 5/16/19 at 11:00 a.m., NA-A indicated there is a list of residents and sling sizes posted on the mechanical lift and staff completing the transfer are able to determine the size of sling to be used according to the residents weight. NA-A further indicated on 5/15/19, R14 fell out of the mechanical lift during morning cares, a medium sling was used, leg straps were crossed, and loops were placed in hooks appropriately. NA-A was running the mechanical lift control, R14 reached up to bar and NA-A reached up to assist R14 to move his arms to his chest at the same time NA-A lifted his legs from the bed. At this time one of the loops came unhooked and R14 slid out of the bottom edge of the sling but was uninjured. NA-A also indicated R14 was not centered on the sling and was off to the left, which may have caused the left leg sling loop to come unhooked, causing the fall out of the sling. NA-A indicated she had completed additional training since the incident which included: videos, scenarios with the mechanical lift, and competencies. NA-A also stated the mechanical lift was found in proper working order and the sling was in good shape. During interview on 5/16/19 at 11:16 a.m., NA-A and NA-B indicated the mechanical lift usually used on the floor does not lift appropriately at times and had been removed 5/15/19 related to that. The process to fix improper equipment is to complete a work order on the computer and remove the equipment from use. During observation on 5/16/19 at 11:38 a.m., the mechanical lift remained in the basement hall outside of the maintenance mangers office. During interview on 5/16/19 at 12:48 p.m., maintenance manager (MM) indicated they only track maintenance on equipment by the floor they are sent from, there was no tracking of specific equipment by model number or serial number. MM indicated a work order was completed for the mechanical lift from first floor (also the lift involved in the fall) last night by the administrator (ADM) because the lift stopped during a transfer. During interview on 5/16/19 at 12:51 p.m., ADM provided a Performance Indicator Worksheet audit form that will be implemented following a mandatory lift training, which is scheduled on (MONTH) 22, 2019. During a phone interview on 5/16/19 at 1:10 p.m., EzWay representative indicated the rubber covers on the hooks are only to prevent cutting of people or fraying of loops on sling, they are not required for use. During interview on 5/16/19 at 1:29 p.m., Director of Nursing (DON) indicated anyone can look at the grid from the manufacture to determine the size of sling to be used during transfer with mechanical lifts, but most are advised by therapy. Once a sling size is determined, it is indicated on the individual care plan and reviewed at minimum of quarterly. DON indicated lift training is completed during new hire training and offered every summer from the manufacture, it is also taped so those not able to attend must watch every summer and tape it to show. Competencies are completed with every new hire before they start on the floor, the facility has annual skills fairs, and will be adding mandatory annual mechanical lift training. DON expects staff to follow the protocol and have two staff member present during all mechanical lift transfers, pay attention to what they are doing, have one person taking the lead, be slow and safe, and to notify if her with concerns. During interview on 5/16/19 at 2:20 p.m., ADM indicated staff will have a mandatory training on (MONTH) 22, 2019, they will be requiring annual mechanical lift training, and believes the event itself has added awareness which created caution. On 5/16/19 at 2:49 p.m., a phone call was attempted to NA-C, the other NA involved in the incident, with no answer. Routine Maintenance During interview on 5/16/19 at 12:58 p.m., MM indicated there were 6 mechanical lifts in the facility. Bio Medical performed annual inspections on each lift, but there was no additional routine maintenance done by the facility. MM further indicated all mechanical lifts were inspected on (MONTH) 3, 2019, and plan to inspect them every six months going forward. During interview on 5/16/19 at 1:29 p.m., DON expects a monthly observation of each mechanical stands to be completed and provide a report to her. DON indicated they will be doing mechanical lift audits following an upcoming mandatory training. During interview on 5/16/19 at 2:20 p.m., ADM indicated BioMed does annual maintenance checks on all mechanical lifts in the facility; the facility was not aware of the 6 month interval manufacturer's guidelines of safety check requirements every 6 months. According to the current EZ Way Operator's Instruction Guide, all EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist. The guide further indicates inspection should be completed at intervals of not greater than six months.

Based on interviews, and document review the faciltiy failed to ensure an injury of unknown source was reported or thoroughly investigated for 1 of 1 resident (R23) with injury of unknown source. Findings include: R23's significant change Minimum Data Set (MDS) on 3/28/19, identified [DIAGNOSES REDACTED]. She had moderate cognitive impairment. R23 required extensive assistance of 2 staff for transfers, bed mobility, dressing, toileting, and extensive assistance of 1 staff for personal hygiene. R23's incident report on 3/15/19, identified a large 16 centimeter (cm) by 16 cm bruise on R23's left inner thigh and a 3.2 cm x 2.5 cm bruise on her right ankle. R23 did not recall the event and was oblivious to bruises. There was no indication an investigation was completed to determine injury of unknown source, nor was the state agency notified of this suspicious bruise. R23's incident report on 3/24/19, at 7:00 a.m., a 2 cm by 1.4 cm bluish/red bruise above by the right elbow and a 6 cm by 3.5 cm bruise towards her elbow and a 1 cm by 1 cm reddish blue bruise on her inner elbow. On R23's left arm had 2 reddish-purple bruises. A 3 cm by 1.5 cm bruise was by her left elbow, and a 2 cm x 2 cm bruise by her wrist. R23 was unable to recall how the bruises occurred. She used a walker to walk independently. The director of nursing's (DON) noted R23 had a long history of bruising and bumped herself a lot. There was no indication an investigation was completed to determine injury of unknown source, nor was the state agency notified of this suspicious bruise. R23's incident report on 4/30/19 identified a dark purple 6.5 cm by 4.5 cm bruise on R23's lower inner forearm. She was not aware it was there. R23 was described as forgetful, and had a history of [REDACTED]. R23 was offered arm sleeves. There was no indication an investigation was completed to determine injury of unknown source, nor was the state agency notified of this suspicious bruise. There was no indication an investigation was completed to determine injury of unknown source, nor was the state agency notified of this suspicious bruise. An interview with nursing assistant (NA)-A on 5/16/19 at 1:02 p.m., identified R23 as independent prior to a fall when she fractured her pelvis on 3/24/19. When a injury including bruising of unknown source was discovered, the nurse was notified immediately. The nurse was responsible to notify the director of nursing (DON). An interview with registered nurse (RN)-D on 5/16/19 at 1:41 p.m., identified R23 was independent with cares prior to a fall. She recently [MEDICATION NAME] pain control, and had increased bruising related to the medication. When a bruise of unknown source was discovered, the charge nurse measured the and the bruise, completed an incident report, and immediately notified the DON, administrator, and family. Additionally any bruise greater than 10 cm was reported if it was of an unknown source. The DON or administrator were responsible to complete investigations and submit reports to the state agency (SA). An interview on 5/16/19 a 3:43 p.m., with the DON identified R23 walked independently at the time of the bruising. She had a history of [REDACTED]. R23 requested to [MEDICATION NAME] improved pain control on 3/11/19, and her provider restarted her on the medication. She was observed bumping into things and sat down hard in the chairs frequently. The DON spoke with RN-B before the interview. RN-A assisted with follow up of incident reports. The DON expected RN-A thoroughly investigate and document findings to identify potential causes R23's bruises. The DON agreed R23's bruising was large, and located in a suspicious area. The injury was unwitnessed, and R23 was unable to recall how the bruise occurred. The DON felt the bruise was not a result of abuse because R23 [MEDICATION NAME] was prone to bruising. The DON was unable to provide documentation that an investigation occurred. There was no documentation included on the incident report or progress notes to indicate why the bruising was not reported or staff were interviewed for potential causes of bruising for R23. The facility's Vulnerable Adults (VA), Reporting, Abuse, Neglect and Exploitation policy revised on 9/26/18, indicated the definition of an injury of unknown origin was (1) not observed or could not be explained by the resident, and (2) was suspicious because of the extent or location of the injury. The facility's Investigation, Alleged VA Incident policy revised on 3/22/19, indicated timely investigation assured the most accurate, detailed accounts of an incident. Upon receipt of an incident, the investigation process was initiated. The supervisor immediately contacted the administrator or contact designee. The supervisor or manager determines if additional help was needed with investigations. The investigator was to thoroughly document, note and sketch investigation information. The investigation included asking open-ended questions and follow-up questions. The investigator was to interview the alleged victim when physical/medical issues were identified. Interviews were to be conducted separately and individually. The investigator was to record or ask the individuals to record their observations in their own words using facts, without inclusion of emotion or speculation. All staff on duty at the time of the alleged incident, alleged victim's roommate, family members, visitors, and other residents were required to be interviewed. In cases where an incident had an eye witnesses, interviews were required to confirm events. Clarifications were required when statements differed form other reports. Patterns of previous incidents including involving the same victim, location, perpetrator were to be reviewed. Findings and conclusions were to be reported to the faciltiy directors, state agency (SA), and affected parties within 5 working days. When indicated, staff education and audits were to be completed. All documentation, statements, and information gathered during the investigation were required to be retained by the facility along with the original report.

Based on observation, interview and document review the facility failed to implement intervention timely to ensure proper supervision for 1 of 1 residents (R5) reviewed for elopement. Findings include: R5's Face Sheet, dated 7/25/18, indicated current [DIAGNOSES REDACTED]. R5's quarterly Minimum Data Set (MDS), dated [DATE], indicated moderately impaired cognition, used a wheelchair, and needed extensive assistance with most activities of daily living (ADL's). R5 was occasionally incontinent of bladder, received scheduled pain medication, takes a daily antidepressant and was working with physical therapy. The facility Progress notes dated 6/1/18, indicated R5 was attempting to exit facility when staff intervened and asked her where she was going R5 states I'm going out to jump off a ledge. I'm done. Progress note dated 6/3/18, indicated call placed to oncall health care provider with orders to follow up with primary Monday in regards to statement made on 6/1/18, and daughter notified. During interview on 7/25/18, at 10:53 a.m., registered nurse (RN)-A indicated R5 has attempted to leave facility in past. RN-A reviewed facility progress notes for 6/1/18 through 6/3/18, and verifies R5 had elepememt attempt on 6/1/18, interventions were not put into place following attempted elopement with statement of wanting to jump off of ledge until 6/3/18. RN-A acknowledges facility progress notes indicated two days after attempted elopement before doctor or daughter notified. RN-A spoke to the director of nursing (DON) and verified DON had not been informed of attempted elopement with statement of wanting to jump off ledge until 6/3/18. RN-A further indicated that DON relayed to RN-A if she had been notified on 6/1/18, she would of have directed staff to implement interventions immediately. During interview on 7/25/18, at 11:10 a.m., R5 indicated she did not remember ever making statement of wanting to jump off a ledge and states I would never do that R5 also did not remember attempting to leave building. R5 further denies feeling down in the dumps or sad at this time. R5's Elopement Risk assessment dated [DATE], showing R5 needed extensive assistance, had past unsuccessful elopement attempts, and has wander guard indicating risk for elopement. No other elopement risk assessments were provided. The care plan dated 7/10/18, indicated R5 problem start date 6/1/18, at risk for Elopement , goal will be safe. 6/3/18, wander guard put on for increased elopement risk. Wander guard placed to wheelchair. Encourage resident to express self as able if upset. R5 also has other care plan area's for falls has hourly checks, for mood and psychosocial well-being social service visits one to one as needed, outreach Ministry Team from her church provides visits and activities completes one to one visits twice a week. The Facility Event Form dated 6/3/18, indicated R5 had a witnessed elopement attempt when staff asked resident where R5 was going R5 I'm going to jump off a ledge, I'm done. the form indicated the event happened on 6/1/18 at 1430, medical provider was notified on 6/3/18, family was notified on 6/3/18, and DON notified on 6/3/18, at 17:27. The facility policy dated 6/20/17, Canby Long Term Care Elopement Assessment. Policy indicates facility will protect and maintain resident safety, assess for elopement risk and continued need for monitoring for ongoing elopement risk. Policy further indicates each resident will be assessed for risk of elopement at admission, annually, and as needed for any significant change in condition.

Based on observation, interview and document review, the facility failed to ensure access to the call light for 1 of 1 residents (R37) that was reviewed for reasonable accommodation of needs. Findings include: R37's quarterly Minimum Data Set (MDS), dated [DATE], indicated moderately impaired cognition, total assistance with activities of daily living, scheduled pain medication, [MEDICAL TREATMENT], therapeutic diet, daily antidepressant and continuous oxygen. R37's care plan dated 5/10/18, indicated right hand [MEDICAL CONDITION] glove, history of [MEDICAL CONDITION] disease affecting left side R37 unable to use left side of body requires total assist with full body lift for transfers, total assist with dressing, toileting, personal hygiene and eating. During observation on 7/25/18, at 7:12 a.m., R37 attempted to push call light button on with right hand that had [MEDICAL CONDITION] glove on without success, stated it's not the easiest R37 with instructions tries again to push the call light on and is unsuccessful. Writer left room to alert staff of residents need for assistance and inability to place call light on. During interview on 7/25/18, at 2:25 p.m., licensed practical nurse (LPN)-A indicated sometimes R37 uses call light but not often. Surveyor along with LPN-A asked R37 to place call light on with right hand (good hand) and R37 was unable to use call light successfully. R37 stated It would be nice to have a different one that I could use. LPN-A agreed that R37 could not use call light. On 7/25/18, at 2:35 p.m., director of nursing (DON) was notified of R37 being unable to use regular style call light and DON thanked surveyor for bringing it to her attention. DON addressed and had soft touch call light placed in R37 room and care plan was updated. Review of R37 medical record R37 had recent hospital stay following a new fistula being placed in left upper arm with sutures, steri strips, gauze in place, covered by bandage. To remain in place until reviewed by Vascular Surgeon on 7/25/18. Left arm to be elevated and left hand splint but not secure tightly. The facility Canby Call light use policy dated 6/14/18, was reviewed and did not address assessing a residents ability to use call light.

Based on observation, interview, and document review, the facility failed to ensure nail care was provided for 1 of 2 residents (R7) reviewed for activities of daily living, who was dependent upon staff for assistance with grooming. Findings include: R7's face sheet inlude's the following Diagnoses: [REDACTED]. R7's significant change in status Minimum Data Set ((MDS) dated [DATE], identified R7 as being severely cognitively impaired as evidenced by inability to do a Brief Interview for Mental Status and being mostly non verbal. The MDS further indicates needs extensive assist of two staff with bed mobility and transfers, extensive assist of one with personal hygiene and dressing, being totally dependent with locomotion on and off the unit and bathing, and required supervision with eating. R7's care plan reviewed 7/10/18, indicated the resident needed assist of one with personal hygiene and able to eat independently after set up but would try to eat food with his fingers. On 7/23/18, at 4:53 p.m. R7 was observed at the dining room table with brown substance under fingernails of left hand, dirty cushioned arm protector on right arm. Observation on 7/24/18, at 9:05 a.m. revealed R7's fingernails on the left hand had a brown substance under the nail and around the nail bed and cuticles. During observation on 7/24/18, at 11:55 a.m. R7 was observed at the dining room table with a brown substance under fingernails on his left hand. On 7/25/18, at 8:05 a.m. R7 cares were observed with nursing assistant (NA)-A and NA-B assisting. NA-B stated that R7 was washed up earlier in the morning and they were going to get him out of bed and out to breakfast. Further stated that showers were on Tuesdays and confirmed that shower was given previous evening. Left hand was noted to have brown substance under fingernails on the left hand. No offer of cleaning fingernails was noted. R7 was brought to the dining room. 7/25/18, at 8:42 a.m. R7 observed in dining room using his left fingers and thumb to scoop up his applesauce, scrambled eggs, and pureed meat and bring it to his mouth for the duration of the breakfast meal. 7/25/18, 11:33 a.m. sitting at dining room table with brown substance under fingernails. Interview with licensed practical nurse (LPN)-A on 7/25/18, at 2:25 p.m. confirmed that R7's fingernails did have a a brown substance underneath them and further stated that he doesn't use his eating utensils but likes to use his fingers to eat so further stated, I am assuming it is food. LPN-A stated, his fingernails are checked daily because they get jagged and he scratches himself. Expectation is to clean after and before meals if there is stuff underneath them. Interview with DON on 7/25/18, at 2:37 p.m. stated the expectation would be that the fingernails would be done weekly unless there is an issue or need to be cleaned. Treatment sheet printed on 7/25/18, includes a treatment order that began on 4/9/18, to check fingernails and file smooth every other day due to history of resident scratching self. Documentation indicated fingernails were checked last on 7/24/18 by LPN-A as smooth. Sanford Policy titled Nails, Care of (Finger and Toe) last reviewed 11/2/16, indicates the purpose of nail care is to provide cleanliness, prevent spread of infection, comfort, and prevent skin problems. Sanford Policy titled Standards of Care and Standards of Practice last reviewed 11/2/16, indicates that fingernails and toenails are to be kept clean and trimmed.

Based on observation, interview and document review, the facility failed to monitor bruising for 1 of 1 residents (R47)reviewed who received a routine dose of anti-coagulation medication. Findings include: R47's admission Minimum Data Set ((MDS) dated [DATE], identified R47 had [DIAGNOSES REDACTED]. The MDS identified R47 was cognitively intact, required extensive assistance with all activities of daily living (ADLs). Further, the MDS identified R47 had received an antibiotic, and diuretics in the last 7 days. However, the MDS did not identify R47 had received anticoagulant(blood thinning) medication. Review of R47's care area assessment (CAA) dated 11/15/16, identified R47 required extensive assistance with her ADLs due to weakness, right thigh pain and inability to stand independently. The CAA further identified R47 had [MEDICAL CONDITION] and staff were to refer to the Treatment Flow sheets for any skin issues and the Medication Record for medication orders. R47's PPS 14 day MDS dated [DATE], identified R47 had [DIAGNOSES REDACTED]. The MDS identified R47 had intact cognition, and required extensive assistance with all ADLs. The MDS further identified R47 received a daily dose of anti-coagulant medication. R47's care plan, dated 3/28/17, identified R47 had a [DIAGNOSES REDACTED]. Further, R47's care plan listed the problem of skin and identified R47 took Eliquis (anti-coagulant medication) and may bruise and bleed easily. The care plan listed various interventions which included to monitor skin issues and monitor for bleeding /bruising. Review of the untitled facility form, dated 4/13/17, identified as the nursing assistant worksheet, listed various directions for R47's care which included assist of staff for bed mobility, toileting, dressing and grooming. However, the form lacked direction to monitor or report any bruising or bleeding for R47. On 5/8/17, at 5:11 p.m. R47 was observed seated in her recliner in her room. R47 had a large round dark purple bruise on her left forearm and several large purple bruises on her left shin. R47 stated she did not know how she got the bruises, they just appeared. On 5/10/17, at 8:52 a.m. R47 was seated in her recliner in her room and ate her breakfast from a tray on a bedside table. R47 had a white pillow behind her head and appeared fatigued and coughed frequently. R47 stated she had bumps and bruises all over because she had such thin skin, took anti-coagulant medication and caused her to bruise so easy. R47 stated she didn't know how she got the bruise on her left arm and stated, You should see my legs. R47 pulled up her pant legs and both of her shins/calf area had several bruised areas. R47's shin/calf areas had bruises which varied in size and shades of purple/blackish. R47 stated she was not sure how the bruises on her legs had happened. On 5/11/17, at 9:35 a.m. NA-C stated she was not aware R47 had any current bruises. She stated if she noticed a bruise she reported it to the nurse and they would monitor the bruise. On 5/11/17, at 9:40 a.m. NA-D stated she had been aware R47 had bruises on her shins for 2 weeks. She stated she was not sure what caused R47's bruises. On 5/11/17, at 9:49 a.m. registered nurse (RN)-A stated R47 bruised easily because she received Eliquis medication. She stated she was aware R47 had bruising at her right eye in the past, but was unaware R47 had any current bruises. She stated she expected all staff to report any bruising to the nurse so they could assess, notify the physician, set up treatments and monitoring and notify the director of nursing (DON). RN-A confirmed R47's Treatment Flowsheet and confirmed the flowsheet lacked documentation of current bruising for R47. On 5/11/17, at 10:08 a.m. RN-A entered R47's room with surveyor to visualize her skin. R47 sat in a chair with both feet out in front of her, elevated on the seat of her rolling walker. R47 had large bruised areas on both the right and left shin and calf area to her knees. R47 also had a large purple bruise on her left forearm. RN-A measured R47's bruises; left forearm bruise measured 3.0 centimeters (cm) x 1.0 cm, left upper shin bruise measured 2.0 cm x 1.4 cm, outer left calf bruise measured 1.0 cm x 0.5 cm, right upper shin bruise measured 1.5 cm x 1.5 cm, lower right shin bruise measured 1.5 cm x 1.5 cm. RN-A stated she felt the bruises were various shades of purple and in different stages of healing and stated she had been unaware of R47's bruises to her left arm or her shins/calf. She stated she was not sure what had caused R47's bruises or how long the bruises had been present. She stated she felt some of the bruises could be caused from R47 resting her legs on the seat of her walker. RN-A stated she expected the nursing assistants (NAs) to observe R47's bruises when they assisted her with cares and would expect R47's bruising to have been reported to the nurse for evaluation and monitoring. After RN-A completed the measurements for the various bruises, R47 stated she had never bruised like this when she had taken [MEDICATION NAME] (another type of anti-coagulant medication) in the past. She stated she felt she bruised more now since she started taking the Eliquis medication. Review of R47's physician progress notes [REDACTED]. Review of R47's Hospital Discharge Summary note dated 3/13/17, identified R47 was discharged to the nursing home with [DIAGNOSES REDACTED]. The summary identified R47 received a renal adjusted twice daily dosing of Eliquis for chronic anticoagulation therapy. Review of R47's Hospital Discharge Summary note dated 3/20/17, identified R47 was discharged to the nursing home with [DIAGNOSES REDACTED]. The summary identified R47 was to continue with the twice daily dosing of Eliquis for chronic anticoagulation therapy. Review of R47's Physician Order Report signed 4/27/17, identified R47 had chronic [MEDICAL CONDITION] (irregular heart rate which caused poor blood flow and could lead to blood clots ), [MEDICAL CONDITION] and long term use of anticoagulant medication. The report further identified R47 received a 2.5 milligram (mg) of Eliquis by mouth twice a day for chronic [MEDICAL CONDITION]. Review of R47's Treatment Flowsheet, dated May 2017, 5/1/17 to 5/11/17, revealed direction check for any adverse effects of Eliquis. Notify doctor if any of the following are present. A: new bruises/bleeding noted, B: nose bleed, C:current bruises increasing in size or skin injuries starting to bleed or ooze blood. Zero means non of the following are present. The [DIAGNOSES REDACTED]. However, the flowsheet lacked documentation of bruises present on lower legs or forearm and did not identify any bruising for R47. Review of R47's progress notes from 4/11/17 to 5/11/17 revealed the following: - 4/24/17 bruising under right eye resolved and continue to check under left eye. - 4/13/17, skin intact - 4/12/17, skin intact - 4/11/17, skin intact No further documentation of monitoring for adverse effects of Eliquis and bruising was found in the progress notes. Review of the Treatment with Eliquis package insert dated 8/16, identified Eliquis was a blood thinner medicine that reduces blood clotting and could cause bleeding, which could be serious, and rarely may lead to death. Further, the insert identified that while taking Eliquis, you may bruise more easily and it may take longer than usual for any bleeding to stop. On 5/11/17, at 10:28 a.m. DON stated R47 received a blood thinner and aspirin medications and bruised easily. She stated she would expect staff to have seen and reported R47's bruises when they assisted her get dressed. She stated she expected the NA's to report any bruises to the charge nurse. She stated she expected the nurse to make a progress note, measure weekly, complete an incident report, and inform her and the administrator of the bruise. She stated she expected staff to pay special attention to bruising for signs of bleeding in residents who took anti-coagulant medications. She confirmed R47's care pan and stated R47 received a routine dose of Eliquis medication. DON stated she would expect staff to follow R47's care plan and the process for reporting and monitoring bruising for R47. Review of the facility policy Accident and Incident Investigation dated 11/10/16, identified the facility was to identify and investigate the cause of all marks, discolorations and injuries to residents that had not been witnessed. The policy further identified the facility would document the size and color of injures, treatments and any preventative measures to be taken to prevent further injuries.

Based on observation, interview and document review the facility failed to implement care plan interventions for skin monitoring related to bruises for 1 of 1 resident (R47) who currently received anticoagulant therapy. Findings include: R47's care plan, dated 3/28/17, identified R47 had a [DIAGNOSES REDACTED]. Further, R47's care plan listed the problem of skin and identified R47 took Eliquis (anti-coagulant medication) and may bruise and bleed easily. The care plan listed various interventions which included to monitor skin issues and monitor for bleeding /bruising. Review of the untitled facility form, dated 4/13/17, identified as the nursing assistant worksheet, listed various directions for R47's care which included assist of staff for bed mobility, toileting, dressing and grooming. However, the form lacked direction to monitor or report any bruising or bleeding for R47. On 5/8/17, at 5:11 p.m. R47 was observed seated in her recliner in her room. R47 had a large round dark purple bruise on her left forearm and several large purple bruises on her left shin. R47 stated she did not know how she got the bruises, they just appeared. On 5/10/17, at 8:52 a.m. R47 was seated in her recliner in her room and ate her breakfast from a tray on a bedside table. R47 had a white pillow behind her head and appeared fatigued and coughed frequently. R47 stated she had bumps and bruises all over because she had such thin skin, took anti-coagulant medication and caused her to bruise so easy. R47 stated she didn't know how she got the bruise on her left arm and stated, You should see my legs. R47 pulled up her pant legs and both of her shins/calf area had several bruised areas. R47's shin/calf areas had bruises which varied in size and shades of purple/blackish. R47 stated she was not sure how the bruises on her legs had happened. On 5/11/17, at 9:35 a.m. NA-C stated she was not aware R47 had any current bruises. She stated if she noticed a bruise she reported it to the nurse and they would monitor the bruise. On 5/11/17, at 9:40 a.m. NA-D stated she had been aware R47 had bruises on her shins for 2 weeks. She stated she was not sure what caused R47's bruises. On 5/11/17, at 9:49 a.m. registered nurse (RN)-A stated R47 bruised easily because she received Eliquis medication. She stated she was aware R47 had bruising at her right eye in the past, but was unaware R47 had any current bruises. She stated she expected all staff to report any bruising to the nurse so they could assess, notify the physician, set up treatments and monitoring and notify the director of nursing (DON). RN-A confirmed R47's Treatment Flowsheet and confirmed the flowsheet lacked documentation of current bruising for R47. On 5/11/17, at 10:08 a.m. RN-A entered R47's room with surveyor to visualize her skin. R47 sat in a chair with both feet out in front of her, elevated on the seat of her rolling walker. R47 had large bruised areas on both the right and left shin and calf area to her knees. R47 also had a large purple bruise on her left forearm. RN-A measured R47's bruises; left forearm bruise measured 3.0 centimeters (cm) x 1.0 cm, left upper shin bruise measured 2.0 cm x 1.4 cm, outer left calf bruise measured 1.0 cm x 0.5 cm, right upper shin bruise measured 1.5 cm x 1.5 cm, lower right shin bruise measured 1.5 cm x 1.5 cm. RN-A stated she felt the bruises were various shades of purple and in different stages of healing and stated she had been unaware of R47's bruises to her left arm or her shins/calf. She stated she was not sure what had caused R47's bruises or how long the bruises had been present. She stated she felt some of the bruises could be caused from R47 resting her legs on the seat of her walker. RN-A stated she expected the nursing assistants (NAs) to observe R47's bruises when they assisted her with cares and would expect R47's bruising to have been reported to the nurse for evaluation and monitoring. After RN-A completed the measurements for the various bruises, R47 stated she had never bruised like this when she had taken [MEDICATION NAME] (another type of anti-coagulant medication) in the past. She stated she felt she bruised more now since she started taking the Eliquis medication. On 5/11/17, at 10:28 a.m. DON stated R47 received a blood thinner and aspirin medications and bruised easily. She stated she would expect staff to have seen and reported R47's bruises when they assisted her get dressed. She stated she expected the NA's to report any bruises to the charge nurse. She stated she expected the nurse to make a progress note, measure weekly, complete an incident report, and inform her and the administrator of the bruise. She stated she expected staff to pay special attention to bruising for signs of bleeding in residents who took anti-coagulant medications. She confirmed R47's care pan and stated R47 received a routine dose of Eliquis medication. DON stated she would expect staff to follow R47's care plan and the process for reporting and monitoring bruising for R47. Review of the facility policy, Assessment of Residents and Interdisciplinary Plan of Care dated 12/1/16, identified the facility would meet the individualized needs of the residents to help each resident attain or maintain their highest practicable level of well-being.

Based on observation, interview and document review, the facility failed to assess smoking safety for 1 of 1 resident reviewed (R 14) observed smoking on the facility grounds. Findings include: R14's Resident Face Sheet identified R47 had [DIAGNOSES REDACTED]. Review of R14's quarterly Minimum Data Set ((MDS) dated [DATE], identified R14 was cognitively intact and required extensive assistance to transfer and ambulation. Further the MDS revealed R14 was independent with locomotion and used a wheelchair. Review of R14's activities of daily living (ADL) Functional Status/Rehabilitation Potential Care Area Assessment (CAA) dated 11/28/16, identified R14 would have his ADL needs met and would work with therapy towards higher level of independence. R14's CAAs lacked reference to a routine smoking safety assessment and lacked smoking practices. Review of R14's current care plan revised on 3/3/17, revealed R14 had chronic obstructive pulmonary disease (COPD), (inflammation of the airways leading to the lungs (bronchi). Characterized by a cough, mucus production, shortness of breath, and wheezing) and chronic bronchitis (a form of COPD). R14's care plan listed R14 had smoked for [AGE] years and did not intend to quit. R14's care plan indicated he would go outside of facility on non facility property to smoke when his family took him. Staff were to monitor if using the e-cig (electronic cigarette) and to ask for it or chart if he refused. On 5/9/17, at 4:45 p.m. R14 was observed seated in his red electric scooter between the corner of the building and the elevated front entrance concrete ramp. He was wore a black jacket, and navy blue pocketed sweat pants which had three pencil eraser sized holes with skin exposed on the right thigh area. R14 had a cigarette in his right hand, and used his right hand to repeatedly bring cigarette to his mouth to smoke. R14's hand was steady while he smoked. He had a covered grey handled mug and straw sitting on the edge of the ramp next to him. R14 remained seated in the scooter, next to the elevated ramp, smoking his cigarette until 5 p.m. At 5:00 p.m., after he extinguished his cigarette, R14 placed the remaining used cigarette in his pants pocket. He utilized the scooter to move to the garbage can by the sidewalk outside of the facility. R14 removed several cigarette butts from his right pants pocket and placed them in the garbage can. R14 immediately exited the area with the garbage can and drove his scooter to the front door of the facility. On 5/10/17, at 6:55 a.m. R14 was observed seated in his red electric scooter on the street, near the curb, in front of the facility. R14 wore a white shirt, black slacks and a black jacket. No burn holes were noted on his clothing at that time. R14 had a cigarette in his right hand and repeatedly brought cigarette to his mouth to smoke. On 5/10/17, at 8:22 a.m. R14 was observed seated on his red electric scooter at a dining room table in the front lounge of the facility. R14 independently fed himself his breakfast meal which consisted of pancakes and coffee. Review of R14's clinical record revealed various assessments, however, lacked documentation of a smoking assessment for R14. During interview on 5/10/17, at 2:56 p.m. nursing assistant (NA)-A indicated he had seen R14 smoke on the campus several times. NA-A indicated he would direct him to smoke in the alley across from the front entrance and he had gone to the alley with R14 at times. NA-A indicated he was aware R14 routinely smoked alone outside of the facility. NA-A indicated he felt R14 held the cigarette normally, had seen him not ashing the cigarette appropriately but had not seen burn holes in his clothing. NA-A indicated he would notify the nurse if he had. NA-A indicated he was aware R14 kept cigarette butts in his pocket and brought them into the facility and threw the used cigarettes in his garbage can in his room or at times in his toilet. On 5/10/17, at 3:12 p.m. NA-B indicated she had not witnessed R14 smoke, but worried about it because she had seen he was shaky at times. NA-B stated she noted a burn hole in his clothing one time and had notified the nurse. NA-A indicated she was told by the nurse that R14 had also notified her about the burn in his clothing. On 5/10/17, at 3:14 p.m. licensed practical nurse (LPN)-A indicated she was aware R14 routinely smoked alone. LPN-A indicated the facility had a no smoking policy for the entire campus and felt it was not necessary to do an assessment since R14 smoked off facility grounds and he was cognitively intact. On 5/11/17, at 8:24 a.m. registered nurse (RN)-A confirmed she was aware R14 smoked alone and indicated she had seen R14 smoke independently on and off facility grounds in the past. RN-A confirmed R14 had not been assessed for safety with smoking and indicated because R14 made his own decisions and he smoked while outside the facility it the assessment was not needed. On 5/11/17, at 8:37 a.m. director of nursing (DON) confirmed R14 was going out on his own to smoke since the weather had changed. DON confirmed R14 had not been assessed for safe smoking. She indicated the facility had not had a smoking resident in years. DON stated she would expect a smoking assessment to be completed for R14 and reassessed at least quarterly. Review of R14's incident event documentation from 11/22/16 to 5/11/17, revealed R14 had not sustained any burns to his skin. Review of R14's resident progress notes from 11/22/16 to 5/11/17, revealed documentation on 3/7/17, indicated during care conference R14 was going outside to smoke now and staff to remind him to go off facility property. No further documentation of R14's safety with smoking was found. A facility policy titled Tobacco Free Campus-Enterprise revised 10/26/16, specified the entire geographic area compromising the entire campus was tobacco free. The policy lacked information regarding smoking safety assessments for those residents who smoked.

Based on observation, interview and document review the facility failed to implment the plan of care for bathing preferences for 1 or 2 residents (R52) reviewed for choices and for 1 of 3 residents (R54) reviewed for activities of daily living (ADLs) who were dependent on staff. Findings Include: Review of R52's care plan dated 9/24/15, revealed R52 desired a bath and required extensive assist of two to transfer and assist of one to bathe. R52's care also listed it was very important to her to choose a TUB BATH !!! On 4/11/16, at 6:44 p.m. R52 stated she had not been given the choice on what type of bathing she preferred. R52 stated she had received a shower, though preferred a tub bath. On 4/13/16, at 8:17 a.m. during a follow up interview, R52 stated she had received a shower that morning and would have preferred a bath. R52 stated she had thought she was asked by staff after she was admitted about what type of bathing she preferred. R52 stated she had told the staff she would prefer a bath and not a shower. R52 stated she did not recall having had a bath since her admission. On 4/13/16, at 1:36 p.m. nursing assistant (NA)-A stated R52 was showered twice a week on Wednesday and Sundays. NA-A stated R52 had received a shower that morning and was unaware R52 preferred a bath. NA-A stated residents preference for bathing would be listed on the residents care grid. NA-A stated she would follow resident care grids to determine what type of cares and assistance the resident needed. NA-A was unaware R52's care grid had identified she preferred a tub bath. On 4/13/16, at 1:37 p.m. NA-B stated R52 received a shower twice a week and was unaware R52 preferred a bath and not a shower. On 4/13/16, at 2:44 p.m. registered nurse (RN)-A stated she was under the impression R52 had preferred showers. RN-A confirmed R52's care plan had indicated it was very important for R52 to have a tub bath. RN-A stated residents were asked quarterly with care conferences about bathing preference and was unaware R52 did not want a shower. R54's care plan, dated 3/21/16 identified R54 had weakness and decreased functional status. R54's care plan goal was to receive the assistance she needed to perform ADLs. The care plan listed various interventions which included R54 needed assistance of staff with personal hygiene, trim file nails as needed and to trim R54's facial whiskers with scissors as needed. R54's nursing care grid dated 4/12/16 listed various grooming interventions which included to assist with hair, and nail care. However, the grid lacked direction for trim of facial whiskers with scissors as needed. On 4/11/16, at 6:12 p.m. R54 was observed seated in a chair, with several other residents present, in the community dining room during the evening meal. R54 had thick gray facial hair which extended from both sides of her lip line all the way down to below her chin to her throat/neck. R54 had many gray hairs on her upper lip with several long, black, coarse straight hairs that protruded from both corners of her mouth. R54 also had 2 very long black, course straight hairs that stuck out from her right lower cheek. R54's finger nails were painted neatly, her clothes were in new-condition and stylish, and her hair was styled. On 4/12/16, at 3:30 p.m. R54 was seated in a chair in her room having her finger nails painted by staff, her clothes were in new-condition and stylish, and her hair was styled. The long, coarse facial hair remained on R54's upper lip, cheek and throat area. On 4/13/16, at 12:13 p.m. R54 was seated in the community dining room with many other residents, during the noon meal, and again was observed to have thick gray facial hair extending from both sides of her lip line all the way down to her chin to her throat/neck. R54 had many gray hairs on her upper lip with several long, black, coarse straight hairs that protruded from each corner of her mouth. R54 also had 2 very long black, course straight hairs which stuck out from her right lower cheek. On 4/13/16, at 1:07 p.m. licensed practical nurse (LPN-A) stated the nursing assistant's (NAs) were responsible to check female residents for facial hair every morning, and any facial hair was to be removed before residents came out of their room for breakfast. She stated she would expect residents to be offered facial hair removal every morning, and as they needed it. She confirmed R54's care plan and nursing care grid and confirmed the nursing care grid did not include shaving for R54. On 4/13/16, at 2:49 p.m. NA-C stated she had never removed facial hair from any female resident in the facility. She confirmed facial hair should be removed every morning and as needed and stated the usual facility practice if facial hair on a woman was present, to offer to remove it as part of their morning cares. On 4/13/16, 2:52 p.m. NA-D stated the usual facility practice was if nursing assistants noticed facial hair on any resident, was to remove it during morning or night-time cares. She indicated she was not aware if R54 required facial hair removal. On 4/14/16, at 8:22 a.m. Clinical Manager, (CM-A) stated the NAs were responsible to check residents for facial hair everyday with morning cares. CM-A confirmed R54's care plan, and nursing care grid. She confirmed R54's facial hair, and stated she knew R54 had some wild, crazy hairs before and R54 had wanted the facial hair removed. She confirmed R54 liked being well groomed, got her nails painted routinely, and went to the beauty shop every week.

Based on interview and document review the facility failed to provide bathing based on resident preference for 1 of 2 residents (R52) reviewed for choices. Findings Include: Review of R52's quarterly Minimum Data Set ((MDS) dated [DATE], identified R52 had [DIAGNOSES REDACTED]. The MDS identified R52 was cognitively intact, required extensive assistance with all activities of daily living (ADL's) including bathing and preferred a tub bath. Review of R52's admission MDS dated [DATE], identified R52 had been interviewed on her personal preferences and identified it was very important to R52 to choose what type of bath she had preferred. Review of R52's care plan dated 9/24/15, revealed R52 desired a bath and required extensive assist of two to transfer and assist of one to bathe. R52's care also listed it was very important to her to choose a TUB BATH !!! Review of R52's care grid printed 4/12/16, revealed R52 required assistance of one staff on Wednesdays and Sunday am's for a bath. Review of R52's care conference review forms dated 10/14/15, and 1/12/16, both lacked documentation regarding personal preferences for type of bath R54 preferred. On 4/11/16, at 6:44 p.m. R52 stated she had not been given the choice on what type of bathing she preferred. R52 stated she had received a shower, though preferred a tub bath. On 4/13/16, at 8:17 a.m. during a follow up interview, R52 stated she had received a shower that morning and would have preferred a bath. R52 stated she had thought she was asked by staff after she was admitted about what type of bathing she preferred. R52 stated she had told the staff she would prefer a bath and not a shower. R52 stated she did not recall having had a bath since her admission. On 4/13/16, at 1:36 p.m. nursing assistant (NA)-A stated R52 was showered twice a week on Wednesday and Sundays. NA-A stated R52 had received a shower that morning and was unaware R52 preferred a bath. NA-A stated residents preference for bathing would be listed on the residents care grid. NA-A stated she would follow resident care grids to determine what type of cares and assistance the resident needed. NA-A was unaware R52's care grid had identified she preferred a tub bath. On 4/13/16, at 1:37 p.m. NA-B stated R52 received a shower twice a week and was unaware R52 preferred a bath and not a shower. On 4/13/16, at 2:44 p.m. registered nurse (RN)-A stated she was under the impression R52 had preferred showers. RN-A confirmed R52's care plan had indicated it was very important for R52 to have a tub bath. RN-A stated residents were asked quarterly with care conferences about bathing preference and was unaware R52 did not want a shower. RN-A confirmed R52's care conference review forms dated 10/14/15, and 1/12/16, both lacked R52's bathing preference. On 4/3/16, at 3:09 p.m. the director of nursing (DON) verified R52's care grid sheet and care plan. The DON stated the facility's usual process to determine resident bathing preference was the activity director would ask the resident at the time of admission and care planned per resident preference. The DON stated she expected residents bathing preferences to be honored. The DON stated she expected residents to be asked quarterly with care conferences regarding their bathing preferences, as well as to ask if any changes needed to be made. Review of a facility policy titled Assessment of Residents and Interdisciplinary Plan of Care, revised 11/15, revealed a facility purpose for an interdisciplinary process to meet individualized needs of the residents for necessary care and services to attain or maintain their highest practicable level of well being. The policy directed facility staff to assess each residents personal preferences and to incorporate resident preferences into their plan of care. The policy directed staff to communicate residents plan of care to all persons involved in that residents care.