Every finding on record at St Ottos Care Center

Based on interview and document review, the facility failed to ensure provider orders were processed for 1 of 1 resident (R76) reviewed for change in mental status. Findings include: R76's quarterly Minimum Data Set (MDS) dated [DATE], identified R76 had intact cognition and required assistance with all activities of daily living (ADL)'s. R76's diagnoses included hypertension, urinary tract infection, diabetes mellitus, hyperlipidemia, depression, chronic obstructive pulmonary disease (COPD), hypothyroidism, polyarthritis, and major depressive disorder. PHQ9 score was 13. MDS also indicated R76 hallucinated and delusions. R76's psychiatric provider visit note dated 9/12/24, indicated due to the symptoms reviewed in the HPI (history of present illness), current diagnose should include: major neural cognitive deficits secondary to Alzheimer's with behavioral disturbance, and severe episode of recurrent major depressive disorder with psychotic features. R76's psychiatric provider visit note dated 10/15/24, stated brexipiprazole for agitation and restlessness. R76 had hallucinations and delusions impacting her mental and physical well-being. The benefits of the medication far out weight the risks. Brexipiprazole 0.25 milligrams (mg) oral tablet for major neural cognitive deficits secondary to Alzheimer's with behavioral disturbance as well as severe episode of recurrent major depressive disorder with psychotic features. During record review, the following diagnoses were not listed in R76's medical record: major neural cognitive deficits secondary to Alzheimer's with behavioral disturbance as well as severe episode of recurrent major depressive disorder with psychotic features. R76's physician orders included orders for Rexulti (antipsychotic) 0.25 milligram (mg) by mouth at bedtime for major depressive disorder for seven days initiated on 10/15/24 and increased to 0.5 mg at bedtime on 10/22/24. During interview on 11/8/24 at 10:52 a.m., registered nurse (RN)-B stated the health unit coordinator (HUC) printed off new provider visit notes and the RN reviewed them for anything new or anything that might have been missed. RN-B stated whatever nurse that was on duty was the one who was responsible for reviewing orders/visit notes and making any changes needed. During interview on 11/8/24 at 11:57 a.m., director of nursing (DON) and assistant director of nursing (ADON) stated the HUC printed out provider visit notes/dictations when they were available, and the RN reviewed them for anything new or something that stood out. DON and ADON confirmed that neither diagnosis was processed. Neither was listed on R76's current diagnoses. DON and ADON stated it was important to ensure all diagnoses were listed so everyone knows how to care for the resident at the best of their ability for all of the residents conditions. Important to see the big picture. The facility Physician orders and Progress Notes policy, dated 11/15/21, indicated orders written by physician will be transcribed by nurse and inputted into EMAR (electronic medication administration record) by HUC and then verified for completeness by nurse. Completeness to include resident name, physician name, date, time of order, order compete with medication name, dosage/treatment and time, frequency, diagnosis for medication, legible to interpret, stop date if applicable and signature/credential of nurse. Physician progress notes will be printed off and placed in residents' chart when available.

Based on interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA)) for 1 of 1 resident (R76) with new onset mental illness. Findings include: R76's Census Record indicated admission on 4/17/24. R76's quarterly Minimum Data Set (MDS) dated [DATE], identified R76 had intact cognition and required assistance with all activities of daily living (ADL)'s. R76's diagnoses included hypertension, urinary tract infection, diabetes mellitus, hyperlipidemia, depression, chronic obstructive pulmonary disease (COPD), hypothyroidism, polyarthritis, and major depressive disorder. MDS also indicated R76 hallucinated and had delusions. R76's prior MDS's had no identification of a psychotic disorder. R76's psychiatric provider visit note dated 9/12/24, identified R76 was diagnosed with two new mental health diagnoses: Major neural cognitive deficits secondary to Alzheimer's with behavioral disturbance and Severe episode of recurrent major depressive disorder with psychotic features. R76's care plan printed 11/6/24, identified resident received psychotropic medication related to depression, recent major life events/lifestyle changes. R2 had a history of hallucinations and delusional/paranoid thinking such as; hearing voices of specific staff coming from R76's television, saying bad things about her, thinks two staff are out to get her, worrying excessively at times about what people will think of her. R76's Initial Pre-Admission Screening (PAS) Results,dated 4/16/24, did not identify a diagnosis of mental illness, nor the need for a Level II PASARR to be completed. During interview on 11/8/24 at 10:03 a.m., social worker (SW) stated she was not aware of R76's new mental health diagnoses. SW stated, had she been made aware, she would have contacted Senior Linkage Line (SLL) for guidance if a resident review was required. SW confirmed there were no new diagnoses entered into R76's health record. Therefore, she did not complete any follow up with the county. SW stated it was important for reassessment to occur to see what other services may be available for R76 to ensure the best possible care. During interview on 11/8/24 at 10:14 a.m., Senior Linkage Line representative (SLLR) stated R76 would need to have a resident review done due to her new mental health symptoms. SLLR stated facility should contact the county to have a resident review completed. SLLR referred to their policy regarding when a resident review should be completed which indicated if there is a change in the individual's situation that significantly changes the person's mental health symptoms or their need for mental health services. SLLR stated the intent of the resident review was to ensure the resident has been screened, they have access to services and to ensure where the resident was residing was appropriate. The facility Admission policy dated 2/4/21, indicated the social worker is responsible for ensuring proper preadmission screening was completed by the referring agency to the Senior Linkage Line for PASARR Level I and II screenings to provide appropriate services and rule out any mental health/MR/DD diagnosis that may require further follow up. The Social Worker will follow up on any MR/DD or mental health needs identified to ensure proper services remain in place and/or are documented in the chart.

Based on interview, and document review, the facility failed to implement interventions to prevent further development of decreased range of motion for 2 of 3 residents (R5 and R10) reviewed for positioning and mobility. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was admitted to the facility on [DATE] and had a moderate cognitive impairment and diagnoses of diabetes. R5's physical therapy (PT) discharge summary dated 7/14/21 through 8/13/21, indicated lower extremity (LE) exercises, LE ROM, and LE bike to maintain current level of performance, and prevent decline were recommended. R5's care plan dated 10/23/24, indicated pulley exercises/or upper extremity (UE) active range of motion program (AROM) to be completed 3-4 times a week and twice a day (BID) and a LE AROM program to be completed 3-4 times a week BID. The facility document titled Point of Care History dated 9/5/24 through 11/5/24, reviewed 60 days of AROM documentation and included staff documentation for the number of minutes, and frequency of completion of AROM programs each day. It indicated R5's AROM programs had only been completed BID on two of the sixty days reviewed, on the other days it was documented as being completed only once, not answered, or not preformed. R5's medical record lacked any documentation as to why the AROM programs were not completed or the rational for them not being performed. R10's quarterly MDS dated [DATE], indicated R10 was admitted on [DATE], cognitively intact, and diagnoses included: coronary artery disease (CAD) (hardening of the arteries of the heart), heart failure (HF) (heart does not pump appropriately), neurogenic bladder (bladder does not contract when stimulated by the brain, loss of control), dementia, cerebral vascular accident (CVA) (stroke), hemiplegia or hemiparesis (inability to move one side of the body), paraplegia (loss of ability to move body), and depression. R10's PT discharge summary dated 6/26/23 through 7/25/23, indicated a restorative program of ROM to the right UE, and right LE were recommended to prevent contractures and increase patient comfort. R10's care plan dated 10/2/24, indicated UE AROM to be completed 3-4 times a week BID and a LE PROM program to be completed 3-4 times a week BID. The facility document titled Point of Care History dated 9/5/24 through 11/5/24, reviewed 60 days of AROM and PROM documentation and included staff documentation for the number of minutes, and frequency of completion of these AROM/PROM programs each day. It indicated R10's AROM and PROM program's had been completed BID on two of the sixty days reviewed for PROM, and three of the sixty days reviewed for AROM. On the other days it was documented as being completed once, not answered, not preformed, or refused. R10's medical record lacked any documentation as to why the AROM/PROM programs were not completed other than refused on some occasions. On 11/7/24 at 1:27 p.m., nursing assistant (NA)-A stated the NA's completed the ROM programs or the restorative aide staff if they were available, and would document unknown if they did not get the resident up, or were unsure if it was completed or done by another staff member. If they knew it was not completed, they would chart no information or did not occur. NA-A stated they typically would not report it if not completed, if someone from restorative was working they would assume the other staff had completed it. On 11/7/24 at 3:51 p.m., the lead restorative licensed practical nurse (LPN)-A, stated six rehab team members and NA's were responsible for completing and documenting ROM programs in the point of care section of matrix. LPN-A stated they expected the ROM programs to be offered as ordered 3-4 times a week and BID. LPN-A stated if they documented not preformed, or not offered they simply did not have time to do it or did not complete the ROM programs. LPN-A stated it was important to complete ROM programs to prevent contractures, and not lose their ability to move. On 11/7/24 at 5:20 p.m., the director of nursing (DON) stated they expected ROM programs were completed 3-4 times a week and BID to prevent contractures and decreased abilities. The Restorative Nursing Policy last reviewed 10/24, indicated restorative programs are expected to be completed to maintain the resident at their highest level of functioning.

Based on observation, interview, and document review, the facility failed to implement and monitor orthostatic blood pressures and obtain a baseline AIMS (abnormal involuntary movement scale) with the initiation of an antipsychotic medication for 1 of 3 residents (R76) reviewed for antipsychotic medications. Findings include: R76's quarterly Minimum Data Set (MDS) dated [DATE], identified R76 had intact cognition and required assistance with all activities of daily living (ADL)'s. R76's diagnoses included hypertension, urinary tract infection, diabetes mellitus, hyperlipidemia, depression, chronic obstructive pulmonary disease (COPD), hypothyroidism, polyarthritis, and major depressive disorder. PHQ9 score was 13. MDS also indicated R76 hallucinated and delusions. MDS indicated R76 needed supervision or touching assistance with transfers and ambulation. R76's physician orders included orders for Rexulti (antipsychotic) 0.25 milligram (mg) by mouth at bedtime for major depressive disorder for seven days that started on 10/15/24 and was then increased to 0.5 mg at bedtime on 10/22/24. R76's medical record was reviewed and lacked any evidence orthostatic blood pressures and AIMS assessment were initiated and/or had been obtained for R76 with the initiation of an antipsychotic medication. During observation on 11/4/24 at 1:14 p.m., R76 was in her room and observed to self transferring to her wheelchair with no staff present. During interview on 11/5/24 at 10:32 a.m., consultant pharmacist (CP) stated any resident on an antipsychotic medication should have orthostatic blood pressures and a baseline AIMS assessment initiated upon start of an antipsychotic medication. Pharmacist stated orthostatic blood pressures and AIMS assessment were important to monitor for side effects as it helped evaluate the risks verses benefits of the medication and helped the facility see the big picture. CP also stated it was important to monitor side effects of antipsychotic medications due to postural hypotension (lowering of the blood pressure that can cause lightheadedness, dizziness, and blurred vision) being one of the major side effects and would put the resident at a higher risk for falls when taking these medications. During interview on 11/7/24 at 12:14 p.m., registered nurse (RN)-A stated orthostatic blood pressures and a baseline AIMS assessment were completed when antipsychotic medications were started and then every 6 months. RN-A stated AIMS assessment were important to complete so you can have early detection of side effects of the antipsychotic medications that may be irreversible. RN-A stated it was important to monitor orthostatic blood pressures for side effects that could affect the resident's mobility. RN-A stated R76's Rexulti was started on 10/15/24 and confirmed neither orthostatic blood pressures or a baseline AIMS assessment had not been initiated and/or completed for R76. RN-A confirmed R76 had a history of orthostatic hypertension so orthostatic blood pressures should have been initiated for R76. During interview on 11/8/24 at 11:57 a.m., director of nursing (DON) and assistant director of nursing (ADON) stated monitoring for antipsychotic medications consisted of orthostatic blood pressures and a baseline AIMS assessment. DON and ADON stated that both orthostatic blood pressures and a baseline AIMS assessment should have been initiated at the start of an antipsychotic medication to monitor for side effects of the antipsychotic medication. DON and ADON confirmed that there were no orders for orthostatic blood pressures in place and a baseline AIMS assessment were not obtained/completed for R76. The facility Orthostatic Hypotension policy, dated 8/15/22, indicated elderly have a natural incidence of postural hypotension and the possibility of post prandial hypotension. Orthostatic hypotension (OH) can be a consequence of normal aging, disease, and/or drug effect. Recommendations: OH blood pressures taken for initiation of antipsychotic medications. The facility Antipsychotic Drug Indication Criteria policy, dated 3/2024, indicated if a resident is admitted already using an antipsychotic or, if facility is considering starting an antipsychotic medication, then side effect monitoring procedure established BEFORE medication initiated. An AIMS should be completed every 6 months on resident's taking an antipsychotic medication. Monitor orthostatic blood pressures at baseline and every six months in conjunction with the AIMS.

Based on interview, and record review, the facility failed to complete a performance review every 12 months for 2 of 3 nurse aides (NA-D & NA-E) reviewed for performance reviews. Findings include: NA-D's Employee Evaluation revealed her last performance review was completed on 08/30/19. NA-E's Employee Evaluation revealed his last performance review was completed on 06/01/18. On 11/10/21, at 9:00 a.m. the Director of Nursing (DON) verified last performance review was completed 8/30/19 for NA-D and 6/01/18 for NA-E. DON stated she was aware the performance reviews were late prior to the start of survey. Review of the undated Employee Performance Evaluations policy revealed it is the facility's policy to complete performance evaluations annually.

Based on observation, interview and record review the facility failed to assess for restraints for 1 of 1 residents (R44) reviewed for use of a seatbelt. Findings include: R44's quarterly Minimum Data Set (MDS) dated [DATE], identified R44 was not able to understand others or communicate his needs. R44's skills for daily decision making were severely impaired. R44's MDS indicated no restraints. R44's face sheet dated 11/9/22, indicated R44's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R44's medical record lacked a physical assessment, progress notes indicating use and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 11/7/22, at 3:45 p.m. R44 was seated in his wheelchair in the facility day room. A seat belt, secured to the back of the wheelchair, was latched closed at R44's waist. R44 was not restless and his eyes were closed. No staff were in the day room. On 11/9/22, at 7:43 a.m. nursing assistant (NA)-D stated she frequently worked with R44 and was familiar with his care needs. NA-D stated she sometimes secured the seatbelt for R44, depending on his mood. NA-D was not aware if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NA-D acknowledged use of the seatbelt was considered a restraint, but felt he was grandfathered in because he used it at his previous facility. NA-D stated she used the seatbelt when R44 was upset, after getting direction from the nurse. On 11/9/22, at 7:47 a.m. licensed practical nurse (LPN)-C indicated use of a restraint required an assessment and orders. LPN-C confirmed R44 did not have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-C stated she had not given instruction for use of the seatbelt and had not seen it in use. On 11/9/22, at 9:55 a.m. registered nurse (RN)-A confirmed use of restraints required an assessment, care planning, and orders. RN-A stated she was not aware of residents in the facility currently assessed for or approved for use of restraints. On 11/9/22, at 10:07 a.m. director of nursing (DON) stated there were no restraints in use in the facility. DON was aware R44 had a seatbelt on his wheelchair, it was on the wheelchair when R44 admitted . DON indicated she did not feel R44's seatbelt was warranted at this time as his seizures are well controlled. Facility policy Restraint Use reviewed date 5/2019, indicated the need for restraint use is assessed on admission, at regularly scheduled interdisciplinary care plan conference reviews and as needed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation with restraint use include pre-restraining assessment, fall risk assessment, MD order, family consent and quarterly review/reduction and daily documentation of every two hours release.

Based on observation, interview and record review the facility failed to properly assess for self-administration of medications. This had the potential to affect 1 of 1 residents (R47) reviewed for self-administration of medications. Findings include: R47's quarterly Minimum Data Set (MDS) dated [DATE], indicated R47 was sometimes able to understand others and was sometimes able to make himself understood. R47's cognition was severely impaired. R47's cognition was unchanged from his baseline. R47's face sheet dated 11/10/22, indicated R47's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R47's signed physician's orders dated 9/1/22-9/30/22, indicated R47 had orders for [MEDICATION(S)]-[MEDICATION(S)] 0.5mg-3mg (medication to treat [CONDITION(S)]) inhaled by nebulizer every two hours as needed. R47's physician's orders did not include orders to self-administer medications, including nebulizers. R47's care plan lacked instructions for self-administration of medications. R47's medical record failed to include an assessment for self-administration of medications. On 11/8/22, at 12:50 p.m. licensed practical nurse (LPN)-B was observed setting up an unknown medication in R47's nebulizer, placed the face mask on R47, turned on the machine and left the room. On 11/8/22, 12:56 p.m. LPN-B returned to R47's room. LPN-B made no adjustments to the nebulizer machine or mask and left the room and area of R47's room. On 11/8/22, at 1:04 p.m. LPN-B returned to R47's room. LPN-B turned off the nebulizer machine and removed the face mask. On 11/9/22, at 7:16 a.m. LPN-B set up an unknown medication in R47's nebulizer, placed the face mask on R47's face, turned the machine on and left the room. On 11/9/22, at 7:26 a.m. LPN-B returned to R47's room, turned off the nebulizer machine and removed the face mask. On 11/9/22, at 12:14 p.m. LPN-B confirmed the medication administered via nebulizer was [MEDICATION(S)]-[MEDICATION(S)]. LPN-B stated for a resident to self-administer medications, including nebulizers, an assessment was completed. LPN-B stated, for R47, she was able to set up the medication, place the mask, turn on the machine and walk away if she continued to check on him. If LPN-B noted R47 having difficulty with the nebulizer, LPN-B would place her medication cart by R47's room while the nebulizer was running to keep a closer eye on him while continuing to pass medications to other residents. LPN-B confirmed R47 was not previously assessed for self-administration of medications and did not have order for self-administration of medications, including nebulizers. On 11/10/22, at 9:33 a.m. director of nursing (DON) confirmed self-administration of a nebulized medication occurred when the medication was set up, the mask placed, the machine turned on and staff left the immediate area of the resident. She expected staff to stay within eyesight of any resident receiving a nebulizer treatment unless they have been assessed and determined safe to self-administer medications. DON stated she expected a signed physician's order for self-administration, specific to the medication, as well as instructions in resident's care plan would be found in the resident's record. DON confirmed R47's medical record did not include an assessment for self-administration of medications and R47's physician's orders did not include orders for self-administration of medications. Facility policy, Self-Administration of Medications by Residents with revision date 7/28/14, directed the interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis.

Based on observations, interviews, and record review, the facility failed to ensure passive range of motion (PROM) was performed for 1 of 4 residents (R30) reviewed for positioning and mobility. This failure had the potential to affect any resident who needed assistance implementing restorative care interventions. Findings include: R30's face sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a document provided by the facility titled Restorative Nursing Program Therapy Recommendation, dated 01/25/22, indicated R30 was to receive PROM to the left upper extremity in all three planes. On the resident's right side, R30 was to use three-pound bar bells, upper extremity curls, and diagonal supination/pronation five to seven times per week. R30's quarterly Minimum Data Set (MDS) indicated the resident had intact cognition. The assessment indicated that R30 required extensive assistance of one staff member for bed mobility and transfers and was impaired on one side of his body, both upper and lower extremities. R30's care plan indicated alteration in mobility due to a past stroke with left sided [CONDITION(S)] (paralysis). The care plan intervention was to provide left side PROM to upper extremities for all planes of motion. The resident's right side was to use a three-pound bar bell, curls, diagonal, supination, and pronation. The range of motion was to happen 12 to 15 times per month. This care plan intervention contradicted the directions for PROM from skilled therapy. During an interview on 11/09/22, at 10:10 a.m. Certified Nursing Assistant (CNA)-A stated she did not provide restorative services to R30. During an interview on 11/09/22, at 10:15 a.m. CNA-B stated he did not provide restorative services to R30 since the facility utilized a restorative CNA. During an interview on 11/09/22, at 10:17 a.m. CNA-C stated she was the restorative aide but got pulled to the floor frequently. During an interview on 10/09/22, at 11:24 a.m. the Director of Rehabilitation (DOR)-A stated R30 was referred to restorative nursing after he had completed skilled services. DOR-A stated the benefit of a resident placed on restorative nursing services was to maintain mobility and function. During an interview on 11/09/22, at 12:22 p.m. Licensed Practical Nurse (LPN)-A confirmed she supervised the restorative nursing program. LPN-A stated there had been no decline identified with R30. During an interview on 11/09/22, at 1:14 p.m. the Director of Nursing (DON)-B stated goals were set on a care plan in an attempt to achieve them for a resident and the facility does their best to accomplish the goals. During an interview on 11/10/22, at 8:59 a.m. DON-B stated her expectation for the restorative program would be to meet the restorative goals as directed by a resident's care plan. During a subsequent interview on 11/10/22, at 9:13 a.m. DON-B provided several documents which identified R30's sessions for the restorative program. The documents were titled Nursing Rehab (Rehabilitation) Time Log. DON B stated for the month of 08/22 the resident received six restorative sessions. DON-B stated for the month of 09/22 the resident received 15 restorative sessions and for the month of 10/22 the resident received two restorative sessions. DON-B stated it was her expectation if the restorative aide was pulled to the floor, other CNAs were to complete the restorative sessions with the resident. DON-B stated the electronic medical record (EMR) prompted staff to identify the PROM ordered for the resident. During an interview on 11/10/22, at 9:50 a.m. R30 stated he completed his own PROM on his left arm. R30 stated no staff had worked with him with weights or on the left side which was affected by his stroke. Review of a document provided by the facility titled Restorative Nursing Policy, dated 06/15/22, indicated .To incorporate interventions that promote a resident's ability to adapt and adjust to living safely and as independently as possible. It includes rehabilitation, management of behavioral symptoms, cognitive performance, and physical function .

Based on interview and document review, the facility failed to ensure all staff received the COVID-19 vaccination or were granted an religious and/or medical exemption for 2 of 8 staff members (housekeeper (HSK)-A, volunteer (V-A) ) reviewed in the sample. This resulted in a 99.1% staff vaccination rate. Findings include: During entrance conference on [DATE], at 1:05 p.m. the facility owner and the director of nursing (DON) stated the facility had six residents currently positive with COVID-19; however, no residents were hospitalized or died due to COVID-19 in the past four weeks. An untitled undated facility form, tracked all direct hire, contracted staff and volunteer vaccination status'. The form identified the name, direct facility hire/contracted hire, title, position, assigned work area, partially vaccinated, completely vaccinated, booster dose, medical exemption, non-medical exemption, temporary delay per CDC (Centers for Disease Control) /new hire and not vaccinated without exemption. Each employee line had a X which indicated the appropriate status of each employee. The form identified HSK-A was partially vaccinated and exemptions were not applicable. The form identified V-A was completely vaccinated. HSK-A's undated immunization card identified they received one dose of the Moderna vaccine on [DATE]. No further doses were identified. HSK-A's payroll timecards dated [DATE] through [DATE], identified HSK-A worked in the facility without having a second dose of a COVID-19 vaccine and was not fully vaccinated. V-A's immunizations were requested, but were not provided. During interview on [DATE], at 3:06 p.m. DON stated she called and spoke with HSK-A earlier on [DATE], after his records were requested by the State Agency (SA) to inquire on his vaccine status and to let him know he was due for his second dose. The DON obtained HSK-A's payroll timecards and verified they worked at the facility without being fully vaccinated. V-A was incorrectly identified as fully vaccinated on the staff vaccination form. V-A had a health condition that may warrant an exemption; however, this was not requested. The facility policy COVID Vaccination/Testing Requirements - Staff revised [DATE], identified it was the goal and expectation of the facility to be in full compliance with all rules and regulations implemented by the Centers for Medicare and Medicaid Services (CMS). All staff were to be vaccinated and up to date against COVID-19 unless they had a medical or religious exemption. All team members hired on [DATE], or later would provide proof of vaccination before hire or before providing any care, treatment, or series to residents or an exemption was requested.

Based on interview and document review, the facility failed to thoroughly investigate an allegation of physical abuse for 1 of 1 resident (R1) who reported a staff member squeezed his hand resulting in bruising on hand. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS, indicated R1 required extensive assistance of two staff members for bed mobility, transfers, toileting. R1's care plan printed 10/22/21, indicated R1 was at risk for maltreatment related to confusion from dx [diagnosis] dementia, his orientation to place, time varies at times. [R1] is also at risk for maltreatment related to falls, has a past hx [history] of a frequent [NAME], will self-transfer at times. [R1] needs staff supervision at times. Review of facility report made to the State Agency (SA) dated 10/14/21, at 2:00 p.m. indicated Lane nurse reported on 10-14-21 at 12:00 p.m. to RN that resident's hand has a new bruise on top. Lane nurse reported that resident stated 'a black woman put on a pair of gloves and then rubbed my hand real hard.' Incident reported immediately to administration for further investigation. Charting and staff interviews reflect resident did not report the bruise or encounter with staff member prior to encounter with lane nurse at 12:00 p.m. on 10-14-21. Further, report indicated alleged perpetrator (AP) removed from schedule until remaining investigation is completed. Review of facility 5-day investigative report to the SA dated 10/19/21, at 3:04 p.m. indicated Conclusion: based on interview with staff, resident and AP there was no intentional harm done to resident and AP did not cause bruise. Bruise was noted to be there during LPN interaction with resident on 10/13 immediately after AP had asked for her assistance. Resident states he does not feel AP or any staff member caused bruise and denies being harmed. He states he is not afraid of anyone at the facility and was comfortable with AP working with him. However, reported lacked evidence that other residents were interviewed, who were under the direct care of the AP, to ensure no additional victims and no other concerns related to abuse were identified. On 10/22/21, at 1:08 p.m. R1 stated it was a piece of furniture she was going to take, and she wouldn't let me have it. She was jerking and jerking it. I kept pulling on it and tightening my grip on it and every time I tightened my grip she would pull more and harder. She had both hands holding my hand. That is how I got this bruise here and it got to the point where it was tight and hurt so bad, I let loose. On 10/22/21, at 2:34 p.m. director of nursing (DON) stated she was made aware of the allegation on 10/14/21, by the Administrator. Further, DON indicated staff were interviewed and we interviewed residents through the five day there were 5-7 residents we interviewed. I thought it was in some of these reports. I would have to look to see if we have anything else. DON confirmed there were no other residents interviewed, who were under the direct care of the AP, during the investigation but residents are interviewed related to abuse periodically and during care conferences. DON stated we spoke with all staff involved and looking at his change and overall status, his history and notes, he said it wasn't intentional and he was not afraid of her and that is what we looked at to make those decisions that we did. It was not substantiated for abuse. In addition, DON indicated interviewing other residents would be important to see if any residents have had issues with any kind of abuse and that is why we have a system. On 10/22/21, at 3:27 p.m. licensed social worker (LSW) indicated she was not apart of the 5- day investigation for the alleged abuse and was not sure who completed the full investigation it was during the interim when the administration was in a leadership training. Further, LSW indicated the facility's process for investigating allegations of abuse included starting interviews with the resident involved in the allegation and then staff involved, alleged perpetrator, and other potential witnesses. In addition, LSW stated I don't know if I would go to each resident. I would start with the resident and the AP and if I felt the need to expand as appropriate I would. LSW indicated interviewing other residents would be important because they see stuff too. On 10/22/21, at 3:37 p.m. when asked what the facility's process for investigation an allegation of abuse was, Administrator indicated upon reporting we assess the situation and determine if it's a reportable issue and determine who is involved. If there is abuse involved, they [AP] are suspended until a thorough investigation is completed upon talking with the first responders. Further, Administrator indicated DON completed the investigation and interviewed staff that interacted with [R1] and [R1] himself and spoke with [AP] to come to the conclusion. When asked if other residents on the unit were interviewed during the investigation, Administrator stated in previous cases we talk with other resident that are coherent to verify that they are safe and feel safe and haven't had anyone harm them. I would say it depends on the scenario if the investigation leads to serious concern about abuse it would expand further investigation if it's identifiable that there is no additional risk which there was not. Further, Administrator indicated there was an incident of misunderstanding that was reported involving another resident and the AP and there was no abuse concerns at that time maybe that is why we didn't interview other residents. That time there was no concerns on that level I am thinking because we had done it a week or two prior to that it was identified that there was not concern with the other residents in the past so that's the path we took. In addition, Administration indicated the importance of interviewing other residents who were under the care of the AP was to ensure they are safe and there is not an issue going on. On 10/22/21, at approximately 4:00 p.m. Administrator indicated staff go where the investigation leads them and R1 denied intention of harm by the AP when interviewed and stated the AP did not mean to do it. Further, Administrator indicated if R1 were still angry that would have precipitated it to go further. Review of facility policy titled Abuse Prohibition revised 6/7/21, indicated the intent of this policy is to provide protections for the health, welfare and rights of each resident residing at St Otto's Care Center. St Otto's will identify events that may constitute maltreatment such as abuse, neglect and misappropriation of resident property and determine the direction of the event. This will be accomplished by following the Abuse Prevention Plan, providing in-service education, completing a thorough assessment and investigation, and involving outside experts as needed, including, but not limited to, legal assistance and law enforcement. Further review of facility policy, indicated resident/daycare clients, the alleged perpetrator, and other team members will be protected from harm during an investigation.

Based on observation and interview the facility failed to ensure proper eye protection was worn during direct cares and medication administration. This had the potential to effect six residents (R20, R70, R57, R56, R67, R25) who received medications or personal cares during observation of medication administration. Findings include: R20's quarterly Minimum Data Set (MDS) dated [DATE], indicated R20's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R70's quarterly MDS dated [DATE], indicated R70's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57's quarterly MDS dated [DATE], indicated R57's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R56's annual MDS dated [DATE], indicated R56's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R67's admission MDS dated [DATE], indicated R67's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R25's admission MDS dated [DATE], indicated R25's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/22/21, at 7:16 a.m. licensed practical nurse (LPN)-B was observed not wearing eye protection (goggles) when standing at the medication cart. Goggles were observed on LPN-B's medication cart at this time. LPN-B approached R20 to administer medications. LPN-B was standing within two feet of R20. LPN-B then returned to the medication cart to prepare R70's medications. LPN-B removed her eyeglasses, then entered R70's room and stood within two feet of R70 to administer medications. LPN-B then transferred her eyeglasses and goggles to a different medication cart. R57 was requesting help. LPN-B approached R57, stood within one foot of R57 while assisting him to drink water through a stray. LPN-B returned to the medication cart, prepared medications for R56, then donned goggles before entering R56's room to administer medications. Upon returning to the medication cart, LPN-B doffed her goggles and placed them on the medication cart. LPN-B entered R67's room, without wearing goggles, to assist with R67's shoes and to the bathroom with a mechanical lift. LPN-B then entered R25's room, stood within two feet of R25 to ask if she needed pain medication. Upon return to the medication cart, LPN-B donned her goggles. On 9/22/21, at 7:54 a.m. LPN-B confirmed she was in and out of several resident rooms to administer medications and assist with personal cares, without wearing goggles. LPN-B stated she was aware she was supposed to wear goggles when in close contact with all residents such as during cares and medication administration. LPN-B indicated she was not aware of the reason for the goggles or the importance of wearing them to protect herself and the residents. On 9/23/21, at 10:36 a.m. registered nurse (RN)-A confirmed the facility possessed enough personal protective equipment for all staff to wear goggles. RN-A expected goggles to be worn when providing direct care to residents, anything within six feet for care of residents. On 9/23/21, at 4:27 p.m. the director of nursing (DON) stated she expected all staff to wear goggles when coming within six feet of a resident such as when doing cares and medication administration. The DON stated, We are in a time when infection is all around us. We need to protect ourselves and the residents. The DON indicated goggles were importance because of the risk of infection, hospitalization and possibly death. A copy of the facility's eye protection policy was requested but was not provided.

Based on observation, interview and record review, the facility failed to ensure dental services were provided for 1 of 2 residents (R58) reviewed for routine and emergency dental services. Findings include: R58's quarterly Minimum Data Set (MDS) dated [DATE], indicated R58's hearing was adequate, and speech was clear; R58 was usually able to make himself understood and was usually able to understand others. R58's cognition was moderately impaired. R58 did not have difficulty chewing or swallowing food. R58's Face Sheet dated 9/23/21, indicated R58's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R58's care plan dated 2/23/21, failed to address R58's dental care needs. R58's Care Conference Notes reviewed for 7/13/21, and 9/15/21, failed to address R58's dental status and did not note if dental services were offered. R58's Oral Cavity Observation dated 8/26/21, had a question about the condition of teeth which included option for, obvious or likely cavity or broken natural teeth. Option chosen was, None of the above were present. On 9/20/21, at 1:27 p.m. R58 stated he had not been offered to see a dentist since admitting to the facility on [DATE]. R58 indicated he had a rotted out, tooth that needed to be fixed on the right side of his upper jaw. R58 stated he had not told anyone about the tooth, and no one had asked about his teeth since admission. R58 pulled his cheek back and pointed to the tooth he was concerned with. R58's tooth was observed to broken and black in color. R58 denied oral pain or discomfort and denied difficulty chewing his food. On 9/23/21, at 9:06 a.m. R58 was observed drinking a cup of coffee. R58 offered no complaints of pain or discomfort. R58 stated no one had looked in his mouth since admission. If he had been offered to see a dentist, he would have accepted. Althought R58 stated no one had looked in his mouth, someone had, but did not note the condition of R58's tooth. On 9/23/21, at 4:27 p.m. the director of nursing (DON) indicated she expected oral assessments to be completed by visual inspection. Teeth problems should be indicated on the assessment. If a resident had a likely cavity or decay, even if it wasn't causing the resident pain, discomfort or difficulty with chewing, the resident should still be offered to see a dentist. The risk for the resident included pain, discomfort, lack of sleep, emesis, infection and possibly death caused by possible infection. The facility Dental Care and Services policy revised 1/2021, indicated all residents are assessed on admission and annually for dental services needs. Residents would be asked if they wished to see a dentist at each care conference.

Based on interview and document review, the facility failed to thoroughly assess and follow up after a reported fall for 1 of 1 residents (R45) reviewed for accidents. Findings include: R45's quarterly Minimum Data Set, dated dated dated [DATE], indicated R45's speech was clear, vision was adequate and was usually able to make himself understood. R45's cognition was moderately impaired. R45 required supervision for transfers and walking in his room. R45's balance was not steady, but he was able to stabilize himself when standing without physical assistance from staff. R45's Face Sheet dated 9/23/21, indicated R45's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's care plan edited 9/7/21, instructed staff to provide frequent reminders for R45, observe for impulsive behaviors and keep items within resident's reach when in his room. R45's care plan failed to identify the fall R45 stated he reported to staff, or interventions put in place following that fall. R45's progress note dated 8/10/21, noted a bruise on R45's left knee. R45 indicated he got the bruise when he fell , but no fall had been reported. R45 stated he got up by himself, after the fall. States he fell by his bed but unable to say when or what time of day. Facility fall assessments for 2021, were requested but were not received. On 9/20/21, at 3:38 p.m. R45 reported he fell about a month ago. R45 stated he got off the floor by himself, then told a staff member who was in the hallway. On 9/23/21, at 10:48 a.m. nursing assistant (NA)-B stated she had not heard of R45 falling recently. NA-B also stated R45 had not previously made false statements to staff or others about falling. On 9/23/21, at 11:13 a.m. licensed practical nurse (LPN)-A indicated an unwitnessed fall or fall reported by a resident was still considered a fall. The nurse would still need to go through the process of a skin check, vital signs, notifying a registered nurse, completing a fall incident report, and doing the post fall huddle. LPN-A stated she would have believed R45 if he told her he fell and got off the floor by himself. On 9/23/21, at 4:27 p.m. the director of nursing (DON) confirmed an unwitnessed fall or fall reported by a resident was still considered a fall. She expected staff to follow the facility procedure for falls which included completing a fall report, documenting in progress notes, completing a skin check and monitoring for injury. Interventions to prevent future falls should be updated as appropriate. The DON stated there were no incident reports regarding a fall for R45 for the year 2021. The DON stated it was important to follow the facility procedures regarding falls to prevent future falls and to be able to track for possible patterns. The facility Fall Prevention policy revised 3/20/19, directed to complete the following post fall: routine vital signs, blood sugar check one time immediately after the fall, and incident report.

Based on interview and document review, the facility failed to ensure accusations of potential abuse were thoroughly investigated for 1 of 1 residents (R48) who reported allegation of verbal abuse by a staff member. In addition, the faciliyt failed to investigate a report of a missing wedding ring for 1 of 1 residents (R26) reviewed for misappropriation of property. Findings include: R48's admission Minimum Data Set (MDS) dated [DATE], indicated R48 did not have deficits in hearing or speech but R48's vision was moderately impaired. R48 had difficulty seeing reading material and used a magnifying glass. R48 was usually understood and usually able to understand others. R48 had no cognitive impairment. R48's Face Sheet dated 9/23/21, indicated R48's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R48's care plan dated 9/23/21, directed staff to assist with visual tasks per R48's request and to follow facility abuse policy and procedure for abuse prevention. On 9/20/21, at 3:53 p.m. R48 stated approximately two weeks ago she requested assistance from an unidentified staff member to see the numbers on her television remote and on her phone. The unidentified staff member told her she was being lazy and refused to assist her. R48 reported the allegation of verbal abuse to another unidentified staff member the morning following the incident. R48's progress notes were reviewed for 8/6/21, - 9/23/21. No progress notes regarding the alleged incident were found. R48's abuse and neglect risk assessment dated [DATE], indicated R48 was at risk for maltreatment related to care needs, has weakness and chronic numbness. R48 relies on staff assistance. On 9/23/21, at 4:27 p.m. the director of nursing (DON) and administrator stated they expected allegations of abuse were investigated and action taken to prevent the potential of it happening again. Both the DON and administrator confirmed they were not made aware of the incident so it was not investigated. R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 had severe cognitive impairment and required assist of one staff for dressing, personal hygiene, and toilet use. R26's Face Sheet printed 9/23/21, indicated R26's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/20/21, at 4:20 p.m. R26's son stated R26's wedding ring had been missing for approximately three months, and he had been told by the facility that he could have reported it to the police. R26's son further stated, I do not believe it was lost and I'm really pissed off about it. During an interview on 9/23/21, at 1:14 p.m. RN-D stated she was made aware R26's wedding ring was missing from a copy of the INterdepartmental Communication (IC) posted in the nurse office. During an interview on 9/23/21, at 3:05 p.m. the assistant administrator stated the investigation included the documented conversation with R26's son and education was provided to RN-B. The assistant administrator further stated interviews with staff and/or other residents were not conducted. During an interview on 9/23/21, at 4:19 p.m. the director of nursing (DON) stated the allegation was not investigated, staff/family searched R26's room right away, felt maybe it fell off, and facility continued to look for it. Further, the DON stated the facility should have questioned other residents and staff. Additionally, the DON stated the facility could not have determined the wedding ring was not stolen, because an investigation had not been done. An IC dated 7/26/21, signed by registered nurse (RN)-B indicated R26's wedding ring was missing, and R26's daughter and RN-B looked through R26's room. The IC indicated it had been given to social services, laundry/environmental services, and the DON. The follow-up section of the IC indicated the assistant administrator spoke with R26's son on 7/27/21, and documented the conversation, he did not feel a report was necessary. 'mom is always hiding things - probably misplaced' not concerned. Further documentation on the IC by the AA, educated staff to offer report immediately if suspect stolen, family does not suspect stolen. No other documentation related to the investigation of this allegation was provided by the facility. The facility Abuse Prohibition policy dated 6/3/21, indicated the facility would follow the written policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property and establish policies and procedures to investigate any such allegations. Additionally, the policy indicated once the initial report to the SA was made, a full investigative report would be provided to the SA within five working days of the incident. The policy further indicated the investigation would be initiated by the RN supervisor on duty/designee, and the DON/Social Worker (SW) completed the SA investigative report. The facility Missing Item policy dated 7/5/21, indicated missing items would be investigated promptly, and if exploitation was suspected the facility would follow the Vulnerable Adult reporting process and reporting a crime process.

Based on interview and record review the facility failed to ensure allegations of potential verbal abuse were immediately reported to the administrator and the state agency (SA) for 1 of 1 residents (R48) who alleged verbal abuse from staff. In addition, the facility failed to report a missing wedding ring to the SA for 1 of 1 residents (R26) who reported a missing wedding ring. Findings include: R48's admission Minimum Data Set (MDS) dated [DATE], indicated R48's did not have deficits in hearing or speech but R48's vision was moderately impaired. R48 had difficulty seeing reading material and used a magnifying glass. R48 was usually understood and usually able to understand others. R48 had no cognitive impairment. R48's Face Sheet dated 9/23/21, indicated R48's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R48's care plan dated 9/23/21, directed staff to assist with visual tasks per R48's request and to follow facility abuse policy and procedure for abuse prevention. On 9/20/21, at 3:53 p.m. R48 stated approximately two weeks ago she requested assistance from an unidentified staff member to see the numbers on her television remote and on her phone. The unidentified staff member told her she was being lazy and refused to assist her. R48 reported the allegation of verbal abuse to another unidentified staff member the morning following the incident. R48's progress notes were reviewed for 8/6/21, - 9/23/21. No progress notes regarding the alleged incident were found. R48's abuse and neglect risk assessment dated [DATE], indicated R48 was at risk for maltreatment related to care needs, had weakness and chronic numbness. R48 relied on staff assistance. Reports made to the SA by the facility revealed no reports were made regarding allegation of verbal abuse made by R48. On 9/23/21, at 10:24 a.m. nursing assistant (NA)-A stated she frequently would assist R48 in the morning with cares. R48 was able to communicate, and NA-A was able to understand R48 without difficulty. NA-A stated R48 did not report allegations of verbal abuse from a staff member to her. If R48 did report it, NA-A had no reason to not believe her. On 9/23/21, at 11:10 a.m. licensed practical nurse (LPN)-A confirmed R48 was able to communicate her needs and LPN-A understood her without difficulty. R48 had not made false accusations against staff in the past. LPN-A stated she was not made aware of R48's allegation of verbal abuse. If a resident reported an allegation of verbal abuse to an unlicensed staff member, she expected it would be reported to a nurse. On 9/23/21, at 4:27 p.m. the director of nurse (DON) stated she expected allegations of abuse to be reported immediately to a nurse. The report would then be given to the DON, administrator or social worker so a report could be made to the SA, if appropriate. The DON confirmed she was not made aware of this incident by the unidentified staff member so it was not reported to the SA. The facility Abuse Prohibition policy dated 6/3/21, indicated suspicions of abuse would be reported immediately but not later than two hours after forming the suspicion of abuse. R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 had severe cognitive impairment and required assist of one staff for dressing, personal hygiene, and toilet use. R26's Face Sheet printed 9/23/21, indicated R26's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/20/21, at 4:20 p.m. R26's son stated R26's wedding ring had been missing for approximately three months, and he had been told by the facility that he could have reported it to the police. R26's son further stated, I do not believe it was lost and I'm really pissed off about it. During an interview on 9/23/21, at 3:05 p.m. the assistant administrator stated misappropriation of property occurred when property was misappropriated or stolen, and that misappropriation of property was reportable to the State Agency (SA). The assistant administrator further stated family felt R26 had misplaced the ring, so the facility thought it did not need to be reported to the SA. Additionally, the assistant administrator stated she was comfortable not having reported the missing ring to the SA, and R26's son was not angry when she spoke with him about the missing wedding ring. During an interview on 9/23/21, at 4:19 p.m. the director of nursing (DON) stated the administrator, assistant administrator, and DON jointly determine when a report to SA would have been made. Additionally, the DON stated any misappropriation of property should have been reported to the SA. The DON further stated, In this case, I think since it was valuable, we should have reported it and then done our investigation process and a wedding ring had meaning, and the allegation should have been reported to the SA. An Interdepartmental Communication (IC) dated 7/26/21, signed by registered nurse (RN)-B indicated R26's wedding ring was missing, and R26's daughter and RN-B looked through R26's room. The IC indicated it had been given to social services, laundry/environmental services, and the DON. The follow-up section of the IC indicated the assistant administrator spoke with R26's son on 7/27/21, and documented the conversation, he did not feel a report was necessary. 'Mom is always hiding things - probably misplaced' not concerned. Further documentation on the IC by the AA, educated staff to offer report immediately if suspect stolen, family does not suspect stolen. No other documentation related to the investigation or reporting of this allegation was provided by the facility. The facility Abuse Prohibition policy dated 6/3/21, indicated a 9/10 clarification of the CMS definition of Misappropriation of Resident Property, If a missing item potential for being a theft a VA report is to be made. The policy further indicated the facility would report to the SA not later than 24 hours if the events that caused the suspicion did not include abuse and did not result in serious bodily injury. The facility Missing Item policy dated 7/5/21, indicated missing items would be investigated promptly, and if exploitation was suspected the facility would follow the Vulnerable Adult reporting process and reporting a crime process.

Based on interview and document review, the facility failed to ensure 1 of 7 residents (R62) reviewed for advance directives had an accurate Provider Orders for Life-Sustaining Treatment (POLST). Findings include: R62's face sheet printed [DATE], indicated Full Code directive, and R62's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R62's admission Minimum Data Set (MDS) dated [DATE], indicated R62's cognition was severely impaired. R62's MDS further indicated R62's speech was clear, hearing was adequate, and R62 was usually able to understand others and usually able to make herself understood. R62's POLST signed was by the physician on [DATE]. Section A, if patient had no pulse and was not breathing, Attempt Resuscitation/CPR was checked, indicating R62 wished to have cardiopulmonary resuscitation (CPR). Further, R62's POLST Section B indicated if R62 had a pulse and/or was breathing, Selective Treatment was checked. Selective Treatment on the POLST indicated basic, comfort-focused medical treatments aimed at treating new or reversible illness, and no intubation, advanced airway interventions or mechanical ventilation would be done. The POLST indicated R62's daughter/POA (power of attorney), provided verbal ok for CPR and Selective Treatment. Additionally, the POLST indicated registered nurse (RN)-B was the health care provider who prepared document and signed [DATE]. However, the POLST had written instructions for Attempt Resuscitation/CPR indicating Note: selecting this requires selecting Full Treatment in Section B). During interview on [DATE], at 12:17 p.m. registered nurse (RN)-C stated a POLST cannot indicate full code/CPR with selective treatment or comfort care; a resident with a full code/CPR status should have Full Treatment indicated. RN-C further stated the POLST was completed incorrectly, she contacted the responsible party, provided additional education, and completed a corrected POLST. After looking at R62's POLST, RN-C stated, CPR with selective treatment; I would correct this one. During interview on [DATE], at 4:19 p.m. the director of nursing (DON) stated Selective Treatment or Comfort Care should not have been selected with full code/CPR. The DON further stated, I did have to recently educate one of my nurses on the need to follow the form guidelines. The DON agreed a POLST should not have indicated CPR and selective treatment stating, it's in black and white; the form is very straight-forward. Additionally, the DON stated she expected staff reviewed the POLST quarterly with residents/family members, and made sure the POLST was accurate, completed correctly, and signed. R62's care plan printed [DATE], did not include R62's code status. The facility's POLST/Advance Directives policy reviewed [DATE], indicated, For the POLST decision, discussion and education will be held with the primary decision maker and care planning team member/s, including the attending MD/NP, if possible. The policy further indicated if the primary decision maker could not meet in person, the decision could be reached by telephone conference with the primary decision maker and social service, nursing, or MD/NP; and the social worker or nursing staff would document the discussion. The policy did not provide guidelines on how a POLST should have been filled out.

Based on observation, interview and document review, the facility failed to operationalize their abuse prohibition policy to report and protect a resident immediately following an allegation of staff to resident abuse for 1 of 3 residents (R1) reviewed for staff to resident abuse allegations. This resulted in an immediate jeopardy situation (IJ) and had the potential to affect all 37 residents who resided on the second floor at the time of the incident. The IJ began on 9/4/20, when R1 reported to licensed nursing staff that nursing assistant (NA)-A was rough with him and twisted his arm. The allegation of physical abuse was not reported until 9/5/20, when staff identified a significant bruise(s) to R1's right arm which measured 6.5 centimeters (cm) x 7 cm and 2 cm x 1 cm. The bruise on the left forearm measured 2 cm x 1 cm. NA-A continued to work the entire shift on 9/4/20, and immediate protection from further abuse was not provided to R1 nor the other residents who resided on the second floor, because the allegation was not reported to administration on 9/4/20. The administrator, director of nursing (DON) and licensed social worker (LSW) were notified of the IJ on 9/15/20, at 2:02 p.m. The IJ was removed on 9/16/20, at 8:33 a.m. when the facility successfully implemented a removal plan; however, non-compliance remained at a pattern scope with potential for more than minimal harm which is not immediate jeopardy (Level E). Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 was cognitively intact and usually made themselves understood; however, had some difficulty communicating some words or finish thoughts but was able to, when prompted. The MDS did not identify any behaviors including rejection of care. The MDS further identified that R1 required extensive assistance from staff to complete toileting, transferring and bed mobility tasks. A [DIAGNOSES REDACTED]. R1's care plan revised 7/28/20, identified R1 was at risk for maltreatment related to confusion from dementia, an intervention identified the facility would follow their abuse policy and procedures and there was known history of maltreatment or exploitation for R1. On 9/14/20, at 2:36 p.m. R1 was observed seated in his recliner with his feet elevated and had on a long sleeved shirt. R1 stated NA-A had purposely given him bruises on his arms when he refused to take a bath. R1 pulled up his right sleeve and there was a significant bruise to his right forearm about the size of a baseball with three smaller bruises protruding from the larger bruise, this bruise was purple/ maroon in color. R1 then pulled up his left sleeve and identified a small thumb print sized bruise to his left forearm, the bruise was also purple/ maroon in color; however, was more faded than the larger bruise on the right. R1 stated the incident took place in the bathroom. R1 further stated NA-A had a bunch of gowns in a ball and threw them at his chest, and NA-A told R1 to put the gown on and told him he was going to take a bath. R1 told NA-A he was not going to take a bath because he was not feeling well that evening and had the chills. R1 went on to state that NA-A kept arguing with R1 about putting the gown on. NA-A was grabbing and holding onto R1's arms. At one point NA-A placed something around his arms. NA-A grabbed his arms again and was holding R1's arms. R1 told NA-A keep your goddamn hands off of me. NA-A was very mean like and rough. NA-A then pulled his right arm away and twisted it, trying to make him put on the gown. R1 demonstrated with his hands a twisting motion with his hands moving in an opposite direction creating a friction motion. R1 stated NA-A then grabbed both of R1's arms and pushed them towards R1's chest knocking him from a standing position back onto the toilet to a seated position. R1 stated what NA-A did hurt him, and was acting like Hitler. NA-A then threw the gown or robe into the bathroom corner and left the room. R1 stated other staff were aware the evening of the incident because someone came in to assist him and there was a lot of yelling going on. Further, R1 told the staff that came to his room NA-A grabbed and twisted his arm. R1 stated that was the first time NA-A had ever become physical with him and had no concerns with other staff. He had not seen NA-A since that evening. An untitled incident report was submitted to the state agency (SA) on 9/5/20, at 8:41 p.m. by the facility administrator. The incident report identified an allegation of physical abuse resulting in a bruise of unknown origin. The date and time of the incident was identified on 9/4/20, at 9:00 p.m. The description of the incident was identified as Bruise on right forearm identified during weekly skin assessment of resident by LPN (licensed practical nurse). Resident states his arm was grabbed by a CNA (nursing assistant) the previous evening while in the restroom prior to bed. Alleged perpetrator is not in facility or on the schedule until afternoon of 9/8/2020. Resident in normal mindset and mood. Not worried about safety at this time. Further investigation to be completed. The untitled completed investigation was submitted to the SA on 9/10/20, at 3:34 p.m. and identified NA-A was suspended during the investigation and subsequently terminated for causing bruising to R1's arms. The facility investigation concluded based on interviews with staff, R1 and NA-A an altercation did occur on 9/4/20, on the evening shift in R1's bathroom. R1 had clearly identified NA-A by name with interviewers and other staff. R1's story remained consistent. R1 had bruising to his bilateral arms. NA-A confessed to an altercation with resident on 9/4/20, and identified they probably gave the resident three of the four bruises while trying to assist with putting on a gown for bed. NA-A stated they were trying to calm R1 down. NA-A stated should not have grabbed R1's arms and raise voice. Several employees and residents were interviewed as part of the investigation. The undated untitled internal staff interviews form included the following staff interviews: -9/8/20, at 1:16 p.m. trained medication assistant (TMA)- A reported R1 had a rough night on 9/4/20. NA-A came and got LPN-A for help because R1 would not get off the toilet. TMA-A and LPN-A went in R1's room to assist. When entering the room R1 was agitated and did not want his gown on. TMA-A and LPN-A had to redirect R1 and calm him down and assist him to bed. R1 was put to bed without a gown, because he would not allow the staff to put one on. R1 reported NA-A was getting rough with him . (NA-A) pushed me and grabbed me because I would not get off the toilet. The interview identified TMA-A did not continue to probe the resident and at this time the charge nurse and co-owner were investigating the incident. R1 was very adamant and did not change his story. Further TMA-A stated NA-A was pretty stern with the residents. -9/8/20, at 2:00 p.m. NA-A stated on 9/4/20, R1 was wandering down to other residents rooms and NA-A had to drag R1 out. R1 was confused that evening and stated he was looking for dead bodies and was saying other strange things. NA-A was helping get R1 ready for bed that evening. R1 was seated on the toilet and NA-A was trying to put a gown on over R1's head. R1 did not want to put on the gown because it was wet and he was cold. R1 became really upset and whipped the gown off. NA-A stated he then went to grab three more gowns but R1 did not want them and stated to NA-A you don't control me, don't tell me what to do. NA-A stated he then grabbed R1's arms as R1 was trying to whip the gown off his head and the gown got caught on R1's ear. NA-A then demonstrated to the administrator his actions. R1 had his arms above his head trying to untie the gown to remove it and NA-A stated, I looked him in the eyes and grabbed his arms adn (sic) said (R1) listen to me? NA-A grabbed his arms and tapped him on the head. Then NA-A left the room to get help from another staff member. The other staff member entered the room and told NA-A they would handle it. NA-A reported to the other staff member (R1) is trying to accuse me of giving him those bruises on his arms. NA-A stated there was a large bruise on his right arm already and was present all week. However, after NA-A changed his story multiple times regarding if the bruising was present or not, NA-A stated the other three bruises were from NA-A. NA-A denied giving R1 the larger bruise on R1's right forearm. - 9/8/20, at 3:45 p.m. licensed practical nurse (LPN)-A reported on 9/4/20, NA-A asked LPN-A to assist with escorting NA-A out of the bathroom as NA-A was not able to. When LPN-A entered the room R1 was in the bathroom sitting on the toilet and appeared to be agitated. LPN-A assured R1 everything was ok and LPN-A would help R1 to their bed. R1 told LPN-A that NA-A wanted R1 to take a bath and was trying to put a gown on him. LPN-A clarified R1 was attempting to be toileted and get ready for bed and no bath was involved that night. R1 proceeded to tell LPN-A that NA-A was trying to get a towel away from him, but there was no towel; however, there was a gown. R1 then stated, while pointing at his arms, that (NA-A) had grabbed on to my arm and made a twisting motion. LPN-A stated the area on R1's arm was slightly red. LPN-A was able to calm R1 down and encourage R1 into bed. On 9/5/20, LPN-A was asked to obtain a skin assessment following R1's bath. While completing the skin assessment LPN-A observed bruising on R1's bilateral forearms. LPN-A asked R1 what happened to his arms. R1 stated, Exactly the same thing as he did the night prior. LPN-A was not sure if any documentation had been completed regarding the bruising. LPN-A checked R1's record and identified the bruising had not been previously documented and alerted the charge nurse. LPN-A let the charge nurse know the bruising was new and could possibly be from the evening before. The charge nurse contacted the co-owner and registered nurse (RN)-B of the facility. R1 was able to explain to the charge nurse and RN-B the exact same story. RN-B then contacted the administrator of the facility. R1 's Physician order [REDACTED]. R1 's progress note(s) identified the following: - There were no progress notes documented on 9/4/20. - 9/5/20, at 9:58 p.m. a skin assessment was completed and bruises were noted on the right and left forearms. The bruises on right forearm measured 6.5 cm x 7 cm , 2 cm x 1.4 cm. The bruise on the left forearm measured 2 cm x 1 cm. R1's weekly Bath Skin Assessment identified the following: - 8/22/20, R1's skin was intact and without any identified bruising. - 9/5/20, R1 had bruises to the right and left forearm and the registered nurse was notified per facility policy. -9/12/20, R1 had bruising to the right and left forearm. NA-A's Employee Discipline Report signed 9/10/20, identified NA-A was discharged from employment at the facility. The report identified the following: NA-A had completed annual training on vulnerable adult/abuse/suspicion of a crime training on 4/27/20. Based on interviews with staff, resident and team members, (NA-A) admits that he grabbed resident's arms during an interaction in the resident's restroom the evening of 9/4/2020 forcefully holding resident creating significant bruising on forearms of resident. Resident consistently identified (NA-A) created the bruises. Resident has bruising to bilateral arms. Interaction between (NA-A) and resident caused physical harm, and emotional distress to the resident. During interview on 9/14/20, at 3:05 p.m. R3 stated most of the staff were good but (NA-A), kinda pushy, we didn't like each other. R3 stated NA-A had never abused or harmed him in anyway and felt safe at the facility. R3 's significant change MDS dated [DATE], identified R3 had moderate cognitive impairment. On 9/14/20, at 3:07 p.m. the administrator was in the hallway on second floor and identified NA-A was always scheduled on the second floor, on the Canary Lane, however, helped with transferring and answering call lights of all the residents on the second floor. The facility provided untitled resident listing dated 9/14/20, identified 37 residents resided on the second floor. On 9/15/20, at 9:26 a.m. a message was left for NA-A. A phone call was not returned. During interview on 9/15/20, at 10:44 a.m. LPN-A stated on the evening of 9/4/20, NA-A had requested her help with R1 because they were refusing to put a gown on to go to bed. LPN-A stated R1 was agitated and was not making much sense as 9/4/20, was not R1's bath day. She assisted R1 from the bathroom to bed. R1 made a comment that NA-A had twisted his arm. LPN-A stated she then observed R1's arm and it was slightly red. R1 demonstrated a twisting motion with his hands identifying how NA-A had twisted his arm. LPN-A stated she did not report the incident on 9/4/20, to the charge nurse or administrator at that time because she did not see an injury and did not think NA-A would be physical with a resident. She thought maybe they just got into an argument. She did complete the skin check on 9/5/20, and observed the bruising on R1's forearms. She then reported the incident immediately to the charge nurse who then reported the incident to administration. LPN-A stated she should have reported the incident on 9/4/20, when R1 stated NA-A had twisted his arm. LPN-A had not received any recent education on behavior management or identifying and reporting abuse. During interview on 9/15/20, at 10:53 a.m. RN-A stated they received abuse training in multiple forms annually. If she is made aware of any potential abuse concern they report immediately to the administrator. She was made aware of R1's bruising, however, it had already been reported and was in the process of being investigated. She had not received any recent education on behavior management or identifying and reporting abuse. No other residents had alleged abuse to her knowledge. During interview on 9/15/20, at 11:05 a.m. LPN-B stated she was aware R1 alleged abuse against NA-A because she went to give R1 his pills the morning of 9/6/20 and he told her NA-A was mean to him. R1 pulled up his sleeves and showed her the bruises. R1 stated NA-A had twisted his arm. LPN-B was not aware of the situation prior to starting her shift so she reported the incident immediately to RN-A, however, they found out the administrator was already aware and it was being investigated. LPN-B had not been provided any recent training on behavior management or identifying and reporting abuse. On 9/15/20, at 11:34 a.m. the administrator, DON and LSW were interviewed regarding the allegation of abuse. The administrator stated he was called on 9/5/20, because R1 had bruising not previously observed and R1 reported NA-A had caused the bruises. Upon talking with LPN-A on 9/5/20, she stated in hindsight she should have reported the incident on 9/4/20; however, R1 was flustered and mumbling and there was not a lot of discernable information from R1. LPN-A did identify R1's right forearm was a little red on 9/4/20. I don't think at the time she thought NA-A did anything wrong to R1 until 9/5/20, when the bruising was observed. The administrator stated he would expect to be notified immediately of potential abuse on any suspicion level. There did not need to be bruising to identify if someone was abused. NA-A had worked on 9/4/20, until 10:30 p.m. and then did not work again in the facility until he was terminated on 9/10/20, following the facility investigation. During the facility interview with NA-A he altered his story about the bruises a few different times. When they pointed out the fingerprint sized bruises NA-A admitted to causing at least three of the bruises when trying to calm him down. The facility identified NA-A had infringed upon the residents rights by restraining inappropriately. That is not how the facility expected the staff to treat residents. The facility trains on abuse annually and as needed. There were no previous concerns with NA-A. If LPN-A had reported the allegation immediately on 9/4/20, NA-A would have been removed from the shift immediately and not allowed to continue working. The DON stated R1 was not receiving any medication that could increase his bleeding potential. They had not reeducated any of the staff on behavior management or identifying or reporting abuse. The DON further stated they had a virtual nursing staff meeting set up for later that week on 9/17/20, and that R1 did not have any residual effects. The undated Virtual Staff Meeting Agenda, identified a staff meeting was being held on 9/17/20, and included vulnerable adult reporting. However, the meeting agenda did not include how to identify potential abuse and how to handle resident behaviors when refusing cares. On 9/16/20, at 7:35 a.m. the administrator stated while interviewing all interviewable residents, R2 reported an allegation of abuse by NA-A. The incident was reported immediately to the SA and was being investigated. On 9/16/20, at 7:50 a.m. R2 stated NA-A was very acidic and NA-A had physically hurt him. NA-A poked him in the chest, face and forehead with his finger. NA-A was a Mr. know it all. R2 further stated he never reported NA-A had poked him as he thought NA-A was just singling R2 out. R2 stated he felt safe and would try and think about more details and report them to the LSW. R2 could not provide any dates or frequency of the alleged physical abuse. There were no marks or bruising to R2's face. R2's annual MDS dated [DATE], identified R2 had moderate cognitive impairment and had a [DIAGNOSES REDACTED]. During interview on 9/16/20, at 8:59 a.m. RN-B stated she had been assisting with resident cares since March 2020, when the COVID-19 restrictions were implemented. R1 had been having some increase behaviors and needed more cues with toileting in the recent months. RN-B did not feel LPN-A could have known R1 was alleging abuse against NA-A on 9/4/20, as his confusion was not abnormal. RN-B was not aware LPN-A had stated she was aware on 9/4/20, that R1 was agitated that evening and required intervention of LPN-A to assist him to bed that evening. She was also not aware R1 stated on 9/4/20, to LPN-A, that NA-A had twisted his arm. RN-B was also not aware LPN-A assessed his arm and identified it was slightly red. The facility had never suspected NA-A of any abuse prior to this incident. The facility Abuse Prohibition policy revised 7/15/20, identified each resident had the right to be free from abuse and residents should not be subjected to abuse by anyone including facility team members. Abuse included hitting, slapping, kicking, biting, scratching, pushing or any other corporal punishment. Further, the policy identified an allegation of abuse would be reported immediately, to the administrator and SA (state agency), but not later than two hours after forming the suspicion of abuse. Residents would be protected from harm during the investigation. The facility would accomplish this by removing the alleged perpetrator from the facility, if necessary; moving the resident to a more easily observed area if necessary; involving law enforcement if necessary; increasing direct eyes on monitoring if necessary. Further the policy identified any person with the knowledge or suspicion of suspected violations shall report immediately, without fear of reprisal if the report is made in good faith. The facility Behavior Management and Monitoring policy revised 9/16/20, identified staff education on behaviors would be provided annually for those providing direct care. Staff would manage behaviors with the goal of maintaining and or improving quality of life. The IJ was removed on 9/16/20, at 8:33 a.m. when it could be verified through interview and document review the facility had educated staff in how to identify potential abuse, immediately report abuse along with resident behavior education. In addition, the facility interviewed all interviewable residents and completed skin assessments on all non-interviewable residents to identify potential scope of abuse.

Based on interview and document review, the facility failed to ensure an allegation of physical abuse was reported to the State Agency (SA) within two hours of the allegation for 1 or 2 residents (R1) who had alleged physical abuse by a staff member. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 was cognitively intact and usually made themselves understood; however, had some difficulty communicating some words or finish their thoughts but was able when prompted. R1 required extensive assistance from staff to complete toileting, transferring and bed mobility tasks. The MDS identified a [DIAGNOSES REDACTED]. An incident report was submitted to the SA on 9/5/20, at 8:41 p.m. by the facility administrator. The incident report identified an allegation of physical abuse resulting in a bruise of unknown origin. The date and time of the incident was identified on 9/4/20, at 9:00 p.m. The description of the incident was identified as Bruise on right forearm identified during weekly skin assessment of resident by LPN (licensed practical nurse). Resident states his arm was grabbed by a CNA (nursing assistant) the previous evening while in the restroom prior to bed. Alleged perpetrator is not in facility or on the schedule until afternoon of 9/8/2020. Resident in normal mindset and mood. Not worried about safety at this time. Further investigation to be completed. On 9/14/20, at 2:36 p.m. R1 was observed seated in his recliner with his feet elevated and had on a long sleeved shirt. R1 stated nursing assistant (NA)-A had purposely gave him bruises on his arms when he refused to take a bath. R1 pulled up his sleeve and there was a significant bruise to his right forearm about the size of a baseball with three smaller bruises protruding from the larger bruise, this bruise was purple/ maroon in color. R1 then pulled up his left sleeve and identified a small thumb print sized bruise to his left forearm, the bruise was also purple/ maroon in color. R1 stated other staff were aware the evening of the incident because someone came in to assist him and there was a lot of yelling going on. During interview on 9/15/20, at 10:44 a.m. LPN-A stated on the evening of 9/4/20, NA-A had requested her help with R1 because they were refusing to put a gown on to go to bed. LPN-A stated R1 was agitated and was not making much sense as 9/4/20, was not R1's bath day. She assisted R1 from the bathroom to bed. R1 made a comment that NA-A had twisted his arm. LPN-A stated she then observed R1's arm and it was slightly red. R1 demonstrated a twisting motion with their hands identifying how NA-A had twisted his arm. LPN-A stated she did not report the incident on 9/4/20, to the charge nurse or administrator at that time because she did not see an injury and did not think NA-A would be physical with a resident. She did complete the skin check on 9/5/20, and observed the bruising on R1's forearms. She then reported the incident immediately to the charge nurse who then reported the incident to administration. LPN-A stated she should have reported the incident on 9/4/20, when R1 stated NA-A had twisted his arm. During interview on 9/15/20, at 11:34 a.m. the administrator stated he was called on 9/5/20, because R1 had bruising not previously observed and R1 reported NA-A had caused the bruises. Upon talking with LPN-A on 9/5/20, she stated in hindsight she should have reported the incident on 9/4/20; however, R1 was flustered and mumbling and there was not a lot of discernable information from R1. LPN-A did identify R1's right forearm was a little red on 9/4/20. I don't think at the time she thought NA-A did anything wrong to R1 until 9/5/20, when the bruising was observed. The administrator stated he would expect to be notified immediately of potential abuse on any suspicion level. There did not need to be bruising to identify if someone was abused. The facility policy Abuse Prohibition revised 7/15/20, identified each resident had the right to be free from abuse and residents should not be subjected to abuse by anyone including facility team members. Abuse included hitting, slapping, kicking, biting, scratching, pushing or any other corporal punishment. Further, the policy identified an allegation of abuse would be reported immediately, to the administrator and SA, but not later than two hours after forming the suspicion of abuse.

Based on observation, interview and record review the facility failed to develop a comprehensive infection control program that provided education to family and friends that were in contact with residents on contact precautions, that utilized a consistent process for tracking and documenting infections for accurate data analysis of resident infections to reduce the risk of spread of infections to other residents in the facility. This had the potential to affect all 81 residents who resided in the facility. Findings include: R1's Minimum Data Set (MDS) indicated R1 was cognitively intact and needed extensive assistance with activities of daily living (ADL'S). Additionally, R1 was always incontinent of bowel and bladder and was on antibiotics for [MEDICAL CONDITION] (C. Diff.) is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Additionally. R1 had a [DIAGNOSES REDACTED]. It may be caused by various infections, with bacteria, viruses, fungi, parasites, or other causes due to [DIAGNOSES REDACTED]. During observation on 1/22/2020, at 9:00 a.m. R1's room had a yellow caddy hanging over the outside of R1's room. A contact precaution sign was noted to be in one of the compartments with a box of bleach wipes covering the lower half of the sign which was 8 by 11.5 inches. Further the contact precautions sign was tilted forward making it difficult to read in that position. During observation on 1/22/2020, at 1:20 p.m. a family friend (FF)-A was observed to be in R1's room wearing street clothes and bare hands rubbing R1's upper right shoulder and leaning in towards R1 in conversation. R1 was covered with a blanket. During interview on 1/22/2020, at 1:25 p.m. FF-A stated the facility staff did not ask her to wear gloves or wash FF-A's hands before leaving R1's room. FF-A stated she visited R1 every few days. Further, FF-A was observed to leave R1's room without washing her hands and proceeded to take an elevator with three other residents and touched the door of a public restroom. During interview on 1/22/2020, at 2:08 p.m. nursing assistant (NA)-A stated in order to see that R1 was on contact precautions the sign needed to be removed entirely from the caddy to be able to read outside of R1's door. The contact precautions sign outside R1's door indicated visitor report to nurses station before entering. The contact precaution sign outside R1's room has all black text with a light green background. During interview on 1/22/2020, at 2:10 p.m. registered nurse (RN)-A stated the only interaction with visitors or notification of visitors of a resident who is on contact precautions is the precaution signs posted on R1's room. Further, RN-A stated if visitors did not know what to do she would expect the visitors to ask the facility staff what they needed to do. Additionally, RN-A stated the precautions sign outside R1's door is behind a box of bleach wipes and is not easy to read. RN-A also stated if R1 has regular visitors RN-A would assume the visitors know what to do for contact precautions. During interview on 1/22/2020, at 2:58 p.m. family member (FM)-B stated she visits R1 and had not been told to wash her hands before leaving R1's room. Further, FM-B stated she helped change R1's brief and did not wear a gown or gloves. Additionally, FM-B stated R1 constantly leaks urine and stool and it's impossible to keep R1 clean all the time. FM-B stated she has never worn gloves and washed FM-B hands frequently when R1 is in isolation. During interview on 1/23/2020, at 8:55 a.m. licensed practical nurse (LPN)-A stated if a visitor asked about the sign outside R1's door LPN-A would direct the visitor to gown and glove before entering R1's room. Further LPN-A stated when the visitor leaves the room the gown and gloves would need to be removed in R1's room and the visitor should wash their hands with soap and water so the visitor did not spread anything to anyone else. During interview on 1/23/2020, at 9:00 a.m. RN-A stated the registered nurses would complete the 2020 [DIAGNOSES REDACTED] Tracking log in the infection control tracking book located at the nurse station. The tracking log lists the following information: the lane, room, resident name, symptom onset date, date isolation precautions started, date medical doctor (MD) notified, [DIAGNOSES REDACTED] test results positive/negative and the date isolation precautions were discontinued. Further, RN-A stated the nurses would complete an event in the electronic medical record (EMR) which includes details about the infection; was a culture was obtained, was the MD contacted, was the resident put on antibiotics and if the resident was placed in isolation. RN-A stated the event form in the EMR has a list of questions that need to be answered based on the type of infection. Upon review of R1's EMR, RN-A stated R1 did not have an event completed for [DIAGNOSES REDACTED]. Further, RN-A stated once an event is filed in R1's EMR the event would be listed on the dashboard report which is the first place that launches when RN-A logs into the EMR. During record review R1 was not on the 2020 [DIAGNOSES REDACTED] Tracking form for (MONTH) 2020. Additionally, R1 was diagnosed with [REDACTED]. Diff Tracking form did not have R1 listed. R4's medical record indicated R4 was diagnosed with [REDACTED]. on 1/6/2020. R4 and was no longer in isolation for [DIAGNOSES REDACTED]. as of 1/19/2020. R4's medical record indicated an event was completed for R4 on 1/6/2020. During interview on 1/23/2020, at 10:46 a.m. with the Director of Nursing (DON) and the Infection Preventionist (IP)-B stated the facility nursing supervisor completed the infection control logs located on each floor. The logs are used for tracking infections and are used by both the nursing staff and infection control. Infection control logs are reviewed routinely by infection control. Additionally, IP-B stated the nursing staff need to document an event in the EMR, which displayed on the dashboard screen. Further, IP-B stated the event in the EMR is primarily used for the antibiotic stewardship program. Both the DON and IP-B stated neither R1 and R4 were listed on the infection control logs and that R1 did not have an event completed. In addition, the DON and IP-B observed the posted signage at R1's room to review the contact precaution sign in the caddy sleeve, both stated the information for visitors would be easily missed and the information is not highlighted. The DON and IP-B stated the contact precaution sign should have a red stop sign so visitors would know to go ask the nursing staff what they needed to do. A policy titled [MEDICAL CONDITION] dated 3/1/2010 with a revision on 8/7/2019, indicated [DIAGNOSES REDACTED] spores can remain in the environment for months if contaminated surface and/or items are not properly cleaned and disinfected. Further the policy indicated gloves and gowns will be worn prior to entering the resident's room and removed prior to exiting the room. The policy also indicated perform hand hygiene before putting on gloves, after removing gloves, and any time hands are visibly soiled. A document titled Contact Precautions For [DIAGNOSES REDACTED]. undated indicated family members need to be provided education to them and offer a gown and gloves (especially gloves!) before entering the resident's room. Please give them a copy of the [DIAGNOSES REDACTED] fact sheet and answer any questions they may have. Emphasize the importance of hand washing. Encourage them to not visit multiple residents. A policy titled Categories of Isolation Precautions dated 3/1/2010, with a revision date of 8/16/2017, indicated gloves should be worn when providing direct care (changing clothing, toileting, bathing, etc.) to residents with multi-drug resistant organisms (MDRO's). Gloves should also be worn when handling items potentially contaminated by MDRO's (bed linens, nightstand, bedside tables etc.). A policy titled Guideline for management of Antimicrobial Resistant Microbes (ARMS) dated 3/1/2010, with a revision date of 4/10/2019, indicated gloves should also be worn when handling potentially contaminated by ARM's. Potentially contaminated items include bedside tables, over bed tables, bed rails, bathroom fixtures, television and bed controls, intravenous poles, suction and oxygen tubing and electronic equipment, especially control knobs.

Based on observation, interview and record review the facility failed to develop a comprehensive infection control program which provided consistent information on the various Infection control forms that were utilized to allow for accurate data analysis of resident infections and trending to reduce the risk of spread of infections to other residents in the facility. This had the potential to affect all 84 residents who resided in the facility. Findings include: A cumulative listing of the facility's infection control information was provided from 3/1/19 through 7/30/19. This untitled document had columns to identify room number, name, indicator for either resident or staff illness, admitted , acquired status of illness (identified as either hospital or community acquired), date of onset, infection category, organism/x-ray, medication, and resolution status. Although there was an identified column to identify resident room number, this information was completed only 14 times in relation to 84 identified resident infections. The document lacked identification of symptoms related to illness. Additionally, this document lacked identification if isolation precautions were indicated. Although the document indicated receipt of antibiotic therapy, it did not identify dosing or length of treatment. A review of tracking sheets which were used on each floor, titled 2019 Infection Control Tracking, indicated for (MONTH) of 2019 was completed which identified there were four infections. The tracking sheets on the floor included columns for the onset date, resident, room number and lane, symptoms presented with option of marking new or ongoing, infection source, culture completed, organism type, antibiotic ordered/antibiotic time out, notification of physician, if isolation was indicated and if so what date was this implemented, infection acquired (Indicating if present on admit, hospital or nursing home acquired) and resolution. Of these four infections listing on the unit tracking from, three were skin related and one was respiratory in nature. Although not indicated on the tracking form, one of the residents identified had been placed on isolation precautions for a skin infection. The (MONTH) tracking information did not consistently identify resident name and room number, or identify if the infection was acquired on admit, hospitalization or while in nursing home. On 8/22/19, at 12:58 p.m. executive director (ED) reviewed the graphs provided as compiled with the program, My Ability- Infection Watch, which indicated a spike in (MONTH) related to norovirus presence. ED stated infection control interventions were put into place during this episode and was effective to mitigate spread of the illness. ED stated following the outbreak, the leadership team met, reviewed the policy, evaluated the effectiveness of the interventions and developed an after action report (AAR) for this event. A policy, A Guidance for Management of GI (Gastrointestinal) Illness was developed. ED reviewed the information on the document titled 2019-Summary of Infection Surveillance by the Month. The (MONTH) entry identified there were a number of respiratory infections increased from January, however, previous analysis for (MONTH) did not address any illnesses aside from influenza. The documentation indicated staff continue to monitor for signs and symptoms of influenza, with an ongoing emphasis on respiratory etiquette and hand hygiene. A review of the cumulative log provided by the facility identified two respiratory infections and one UTI. The entry for (MONTH) surveillance identified there was a Norovirus (An illness with symptoms including nausea, vomiting, and diarrhea) outbreak which affected both staff and residents. The note indicated three residents were diagnosed with [REDACTED]. A review of the infection control monitoring log for (MONTH) identified 35 cases identified as gastrointestinal for residents. Additionally, it was identified there were two residents identified with respiratory infections and one resident with a UTI. The infection control log did not indicate any [DIAGNOSES REDACTED]. The entry for (MONTH) indicated there was an increase in respiratory infections for the month, similar to (MONTH) and indicated facility mapping was completed by location. The note identified one resident was admitted with an acute exacerbation of [MEDICAL CONDITION] ([MEDICAL CONDITION]-a disease which affects the respiratory status) and identified one resident was provided with antibiotics for a lower respiratory infection when they did not meet the criteria. A review was completed of the cumulative log provided by the facility indicated seven incidents in respiratory infections (compared to two residents documented on log in February). Additionally, the record review identified three incidents of UTI, one incident of GI, and three resident with skin infections. The entry of surveillance in (MONTH) identified there were increased incidents of UTI and identified a skills fair coverage of urinary catheter insertion, care of catheter bags and pericare was provided. Additionally, the document indicated there was also an infection control station at the skills fair which included hand hygiene, donning, doffing, meaning of Contact time for disinfectants. Aside from UTI's, no other documentation was completed about infections in the facility. A review of the facility tracking form indicated the occurrences of UTI's in three residents (consistent with March), and also included one incident each with GI and skin infections. The entry for (MONTH) surveillance indicated there was a discussion with the medical director regarding the increase in UTI's, use of antibiotics and the need was identified for additional education to be completed with providers which was identified as the responsibility of the medical director. The note identified there was ongoing discussions in the IDT meetings with the the criteria for UTI's before notifying the provider and criteria was available in the IC manuals at the the desk. A note indicated the UTI infection rate was trending down from May. A review of the facility infection control log identified two incidents related to UTI' and one incident each of URI and GI infections. The entry for (MONTH) surveillance indicated a scripted time out form was developed for antibiotic usage. The note also indicated an increase in skin infections this month, as well as a slight increase in UTI's from June. Although the note did identify one resident had underlying health condition who presented with skin infections, it lacked any potential of relation in regards to lane, staff, or other features to identify possible patterns or need for education. A review of the facility cumulative log identified three incidents of UTI's, two incidents of respiratory infections, one incident of GI, and seven skin related infections. The surveillance note of (MONTH) identified that there was a time out form completed for use with the identified need to follow up with concerns with the medical director. The entry lacked any information for resident presented cases of infections. The cumulative log also lacked entry for August. A review of the floor tracking logs indicated the presence of four infections on the units. A review of the cumulative infections control data from 3/1/19 indicated the following residents were identified as being treated for [REDACTED]. R55 was treated for [REDACTED]. R11 was treated for [REDACTED]. R11 has been cultured positive for [DIAGNOSES REDACTED] (A bacteria which can be transmitted person to person) on 2/25/19. R72 was documented as being treated for [REDACTED]. R17 was documented as being treated for [REDACTED]. R20 was documented as being treated for [REDACTED]. R67 was documented as being treated for [REDACTED]. R287 was documented as being treated for [REDACTED]. R62 was documented as being treated for [REDACTED]. The log reflected R62 was initially cultured on 3/18/19 and treated with antibiotics, however, the subsequent u/a did not reflect a u/c. R75 was documented as being treated for [REDACTED]. ED stated a urine culture was indicated when residents exhibited symptoms meeting the criteria of a UTI. ED stated absence of u/c with a u/a would be considered an unsubstantiated infection without a positive culture supporting the use of antibiotic therapy. ED did go into the computer system following initial discussion and identified out the 16 infections where cultures were not completed, 11 of the samples did have cultures completed, with 9 of the cultures being positive for growth, and 2 of the cultures being negative. ED reported cultures were not completed on five of the urine specimens. ED stated the information of the culture results was necessary to treat the infections with the appropriate antibiotic. On 8/22/19 at 3:15 p.m. the director of nursing stated the purpose of completing infection control logs is to allow the facility to identify if there are areas of concerns with the process of infection control, to identify any trends, and implement precautions to prevent spread of infections. The DON stated the logs should reflect what is currently being addressed with the residents and should be monitored so interventions can be implemented. The facility policy titled Antibiotic Stewardship, revised 4/10/19, identified there was to be assessment of those considered to have an infection which would be completed with the use of Loeb's criteria. The policy identified the infection preventionist directly monitored this process and identified any trends to the DON for follow through. A policy for Infection Control was requested and was not received.

Based on interview and document review, the facility failed to ensure 1 of 1 resident (R1) was free from physical abuse. R1 suffered actual harm, trauma to the mouth and teeth while alone in his room with a family member (F-A). Findings include: R1's Resident Face Sheet dated 3/12/19, indicated R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R1's discharge Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had short term memory problems and severely impaired cognitive skills for daily decision making. The MDS also indicated R1 had no physical or verbal behavioral symptoms, was totally dependent on staff for assistance with transfers and personal hygiene, and required extensive assistance with dressing, toilet use, and eating. R1's care plan updated 3/25/19, indicated R1 exhibited behaviors of yelling at others, hitting, kicking, and pushing away with cares, had complaints of chronic pain, had impaired skin integrity, and was at risk for maltreatment related to impaired physical ability and cognitive impairment. R1's care plan indicated strong family involvement and F-A was Health Power of Attorney. R1's nutritional assessment, dated 3/19/19, indicated R1 had current diet order including regular mechanical soft, regular fluids, lactose intolerant, but was able to have pudding, ice cream and yogurt, and was offered 4 ounces of juice nutritional supplement four times a day. R1's current weight was 178 pounds on 3/13/19. R1's usual body weight range was 176-184 for the past 6 months. R1 had his own teeth, and there was no documentation of any dental concerns. The assessment also included R1 required total assistance with eating and required nutritional supplement for skin/wounds. R1's resident progress notes between 9/19/18 and 3/15/19, included several entries describing interactions between R1 and F-A, while F-A attempted to feed R1. The notes indicated F-A persistently attempted to get R1 to eat even when R1 was non-cooperative. More recent notes included: A progress note dated 1/5/19, indicated R1 was extremely combative and called F-A names when she attempted to feed him. The notes further indicated R1 called F-A and staff names including [***] , and was heard yelling at F-A get away from me, leave me the hell alone, and don't touch me you son of a [***] . The notes indicated R1's behaviors continued throughout the day with short lapses of no yelling. The notes further indicated a staff had observed R1 punching F-A in the face. F-A was subsequently observed to go to the day room crying, but then went back to R1's room a few minutes later to encourage R1 to drink. A progress note from 1/18/19, indicated RN-B had heard R1 yelling Ouch and had gone to the resident's room to investigate. The note indicated RN-B had observed F-A force feeding R1 his breakfast, and R1 was observed physically fighting with F-A. R1 was trying to push F-A away while F-A was fighting back to get the sippy cup closer to R1's mouth so R1 would drink. The notes indicated R1 was heard to yell, Get this damn woman out of here. I said I don't want that damn[***]Leave me alone! The note indicated F-A was witnessed to stumble backwards three times due to R1 pushing F-A. A progress note from R1's 1/23/19 care conference, indicated the director of nursing (DON) had informed F-A that it was upsetting to nursing staff when R1 became physically combative, agitated, and began yelling and swearing during F-A's visits. The notes indicated the DON had informed F-A if R1 exhibited these types of behaviors during F-A's visits, staff would approach F-A to assist with attempting to calm R1. A progress note from 3/10/19, at 8:32 p.m. indicated a nursing assistant (NA) reported to the nurse she'd observed F-A feeding R1 liquids with a large sized syringe. The note indicated a nurse had immediately gone to R1's room, but was not able to verify F-A's use of a syringe. A progress note from 3/16/19, at 10:32 p.m. indicated licensed practical nurse (LPN)-B had observed F-A tug on R1's hair at the back his neck to get R1 to open his mouth so F-A could put food in R1's mouth. The note indicated LPN-B had asked R1 if he was okay, and F-A had responded R1 was okay. The progress note also indicated the facility's assistant director of nursing (ADON) and RN/co-owner were notified of observation. A progress note from 3/17/19, at 9:30 a.m. included: (F-A) here going to try to feed resident, resident yelling 'get that away from me.' According to a nursing home report submitted to the state agency (SA) on 3/18/19, at 5:36 p.m., the provider submitted a report of the incident from 3/16/19 including: (F-A) has been educated multiple times regarding appropriate feeding methods, reapproaching when refusing meals. (F-A) was instructed to give some time and reapproach. A progress note from 3/18/19, at 10:43 p.m. indicated LPN-A had received a report from NA-A at approximately 8:00 p.m., that when she'd heard R1 yelling, she'd gone in to see what was going on and had witnessed F-A pulling the hair on the back of R1's neck with her left hand to get him to open his mouth. The notes indicated NA-A had reported when R1 opened his mouth to yell 'ouch you stupid [***] get that away from me', F-A had shoved mashed potatoes into his mouth with the utensil she was holding in right hand. The progress note indicated RN-A was updated, and RN-A had notified the DON. On 3/19/19, at 12:19 p.m. a progress notes included, (F-A) stated, 'I am going to have (R1) put to bed now, (R1) is not going to eat and just so you know that at about 11:00 he did eat some breakfast, oatmeal, yogurt and some strawberry drink'. On 3/21/19, at 10:31 a.m. the progress notes indicated R1 was sitting in Hearthside room (dining area on 1st floor), facing the doors with F-A standing beside him. The progress note indicated RN-C had observed F-A trying to get R1 to drink what appeared to be orange juice, with the cup pressed against R1's face with the lower part in his mouth, and tipped up so the juice was covering his mouth fully. Further the note indicated R1 had been observed trying to shake his head but F-A had continued to hold the cup tight against his face. On 3/22/19, at 12:20 p.m. a progress note indicated RN-C had assisted R1 with lunch with F-A present and R1 had eaten approximately 1/2 of his meal, salmon cake and potatoes. When R1 refused to eat any more, RN-C had left the room with the tray of remaining food. An entry from 12:40 p.m. indicated the RN/co-owner had responded to R1's call light at which time F-A had requested assistance with R1 getting help into bed for a nap. According to the progress note, RN/co-owner went around to the front of R1's wheelchair at which time the co-owner noticed blood and redness on R1's right lower lip, blood across R1's teeth, and that R1 had a reddened tongue. When the RN/co-owner asked F-A what was going on with R1's mouth, F-A stated, Well, I have my thoughts, this facility is not giving him the proper care. The note further indicated while NAs transferred R1 into bed, the RN/co-owner had convened a meeting with R1's primary LPN, the DON, and the LSW in the day room. As a result, the local police were notified and asked to come to the facility to help ask F-A to leave the premises while R1 was transported to the local emergency department for evaluation. The notes from the emergency department (ED) dated 3/22/19, indicated R1 had arrived to the hospital ED at 2:20 p.m. for evaluation of possible abuse. The ED notes indicated a physical exam of R1 was significant for dried blood on the resident's upper and lower lips, and dried blood was noted on his tongue. There was bleeding from upper jaw gum-line, a chipped front incisor, and several teeth were missing on the right side of upper jaw. Fresh blood was noted in the dental sockets. The report further indicated, Serious dental trauma was identified, which appeared acute in nature. The police were called and possible abuse was reported. R1 was given [MEDICATION NAME] (antianxiety) intravenously (IV), and R1's pain appeared to be well controlled. R1 was discharged back to the facility at 5:42 p.m. Document review revealed a VA report had been submitted to the Minnesota Adult Abuse Reporting Center (MAARC) on 3/22/19, at 4:10 p.m. and sent the report to the SA on 3/23/19, at 2:21 p.m. When interviewed on 3/27/19, at 2:05 p.m. the licensed social worker (LSW), stated she had heard from staff about R1's hollering and disruptive behaviors when F-A would attempt to feed him and that they had been working with F-A by including her in the development of R1's care plan, pain management, and meetings with the Ombudsman. LSW stated they had provided F-A at least 10 educational sessions on coping, Lewy bodies dementia, how to approach and reapproach R1, and had provided F-A with caregiver's support. The LSW stated she had learned about the 3/16/19 incident, from the administrator on 3/18/19, and had initiated an investigation. The LSW stated she had interviewed 25 staff and one resident between 3/19/19 and 3/21/19, to discern fact versus hearsay. In addition, the LSW stated she had communicated the information she'd learned during the staff interviews to the administrator and a decision had been made not to allow F-A to feed R1 until further notice. The LSW stated she had attempted to meet with F-A on 3/21/19, at about 10:30 a.m. however, F-A had refused to meet with her. The LSW stated she had still been able to inform F-A of the allegation and had explained to F-A she would not be allowed to feed R1 which had caused F-A to be angry, and F-A had replied: We'll see how it all plays out when (R1) starves to death. The LSW also stated she had accompanied R1 to the ED on 3/22/19, and while in the ED was directed to report the incident to MAARC (Minnesota Adult Abuse Reporting Center). The LSW also stated she'd tried to get emergency protection however, there was nothing she could do because it was late on a Friday afternoon. The LSW added that once she had submitted the report to MAARC, social services from the county got involved and ultimately did initiate emergency protection. The facility was able to obtain a no trespass order against F-A, and staff were educated, memos were sent out regarding security and safety, and the doors were locked. The LSW stated local police initiated extra patrols in the area and the LSW accompanied R1 back to the facility from the ED. The LSW stated speech therapy and emergency dental services had assessed R1 on 3/23/19, and stated she'd submitted a VA (Vulnerable Adult) report to the SA on 3/23/19, at 2:21 p.m. Review of the emergency dental assessment from 3/23/19 included, Oral evaluation done. Teeth #4-6 (upper right towards front) mild swelling noted. Teeth broken/decayed. Trauma also noted, lingual gingival tissues (gum tissue covering the teeth on the surfaces facing the tongue) teeth #3-5 (upper right towards front). Mild abrasion noted in area not extending to hard palate. No sutures required. Recommend antibiotic treatment .Will evaluate in 10 days, noting #4-6 might need extractions. Review of the Speech Therapy (ST) Plan Of Care dated 3/23/19 included, Based on the following assessment, patient presents significant changes in his oral phase of the swallow due to changes in his oral mucosa, dental status, probable oral pain from damaged tissue, probable oral trauma and at risk for malnutrition, weight loss and dehydration. He is also at risk for side effects to not being able to take oral medications due to changes in probable oral pain. He is also at risk for problems with pain management due to inabilities to take oral medications. Medications should be reviewed for altered administration if unable to take orally due to change in condition. ST recommended use of soft sponge toothette versus toothbrush during period of oral healing, avoid alcohol based mouthwashes that may add to dry mouth or accidentally swallowed by resident, offer saline based mouth moisturizer to lips to decrease cracking and additional discomfort. Also included, R1 will consume pureed food (not too hot, not too cold, room temperature items, avoiding spices) and thin liquids. Offer small frequent meals and if not eating, offer Ensure as a meal replacement as directed by dietician, trials of different feeding equipment such as nosey cup, Styrofoam cups, or plastic spoons. ST planned to see R1 three times a week for two weeks. During an interview on 3/27/19, at 5:14 p.m. NA-B stated F-A had previously been at the facility all day most days, and would remain in the resident's room all the time, watching everything staff did with R1. NA-B stated F-A fed him in the day room or in his room, and always shut the door. NA-B stated R1 could be heard yelling in his room, and that she would go to the RN to report concerns. However, NA-B added, We're used to it. You mind your own business. It's been going on for months. I can't imagine, I know she wants him to eat. I used to report it. During an interview on 3/27/19, at 5:29 p.m. LPN-A stated she documented everything, and stated, I do hear from other staff there has been times that (F-A) is more stern with him (R1) with feeding. With his progression, I know there are times that (R1) doesn't want to eat. She wants him to eat and drink fluids. I see her concerns, but there's too much, she encourages way too much. LPN-A stated she has heard R1 hollering and swearing at F-A several times. LPN-A stated she reports concerns to the RN charge, and discusses concerns about R1 with other staff members. LPN-A stated, I have attempted to calm (F-A). I have tried. I know she cares about him. I think she's in denial. It's a little too much and for his safety, (F-A) and family shouldn't force him. During an interview on 3/27/19, at 5:45 p.m. RN-A stated back in (MONTH) (YEAR), there had been times when she'd heard R1 hollering and would go down to where R1 and F-A were. RN-A stated she never witnessed F-A doing anything inappropriate but had reported her concerns to the administrator sometime in July, to let him know about F-A trying so hard to get R1 to eat. RN-A stated that she knew that there were other staff that were concerned about the interactions between R1 and F-A. RN-A stated, We were to educate (F-A). Management was trying to educate her. It was concerning to me because I know that I am a mandated reporter. I felt like it was possibly abuse. There was a fine line because they have been married a long time. I felt it was going too far for my comfort. RN-A stated she did make the phone call to the DON when NA-A reported on 3/18/19, at 8:20 p.m. that F-A had tried to feed him at 5:30 p.m. but R1 wouldn't eat, so F-A asked NA-A for another tray and wanted to feed R1 in his room. NA-A was across the hall, and could hear R1 hollering more than usual. NA-A stated the door was open about 6 inches and she observed F-A, pulling his hair in her fist. When R1 hollered, F-A shoved potatoes into his mouth, and the potatoes would fall out of his mouth. RN-A stated she called the DON, and the DON asked to speak to NA-A. After talking with the DON, NA-A had reported to RN-A DON planned to discuss the incident with the administrator in the morning. RN-A stated, When physical harm is done to the resident, it needs to be reported in a two hour window. As staff, we have said something several times. Others had talked about their concerns repeatedly. When interviewed on 3/27/19, at 6:22 p.m. NA-D stated F-A was always in the facility and R1 was often heard screaming. NA-C stated F-A always fed R1 in the day room and tries to shove it in his mouth and makes him try to drink. NA-C stated, It's been going on for months. When asked if she ever reported the interactions, NA-C stated, It should be reported immediately. I would guess they've reported it. When interviewed on 3/28/19, at 11:57 a.m. RN-C stated feeding and administering medications to R1 was challenging and sometimes staff needed to reapproach several times. RN-C stated she had recently observed R1 and F-A in the Hearthside room and F-A had a cup pressed up tight to R1's mouth and held it there, so he would drink. RN-C stated, What they've (staff) told me is, (F-A) will pinch the back of his neck and when he yells, she shovels the food in. RN-C stated, I have told them to chart it and they've said 'we have been.' RN-C stated, Most of the time when (staff) told me, it was after the fact. They were complaining because they have seen this happen and they couldn't do anything about it. I told them to chart it and make sure they told (administrator, RN/co-owner, DON). RN-C stated it was difficult because she'd never witnessed the incidents, and was just hearing it through the grapevine, and sometimes staff would report things to her two days after an alleged incident. RN-C stated, This is the situation, I feel it's a VA. What do you want me to do if they tell me it happened two days ago and I didn't see it? They come to me complaining because something happened and they don't see anything being done about it. If it was happening at the moment, I would report it. During an interview on 3/28/19, at 12:50 p.m. RN-B stated she had observed F-A approaching R1, and R1 pushing F-A away, but she still comes at him. RN-B stated F-A gets exhausted and breathes heavily, and has seen F-A stumble backwards because R1 pushed her. RN-B stated she would intervene and encourage F-A to reapproach R1 at another time, but that was never successful. RN-B stated these types of interactions happened every day, and added, I can't even tell you how many times this has happened. RN-B stated R1 hollers and swears so loudly that he can be heard throughout the unit. RN-B indicated while F-A was feeding R1, he would spit when the spoon was brought to his mouth, and R1 would purse his lips when the sippy cup was brought to his mouth. RN-B stated, I either charted it or reported to administration. I was always told they were handling it internally .I was never told what was being done. RN-B stated she has been taught, If you see it, report it. When interviewed on 3/28/19, at 1:35 p.m. the ADON reported on 3/16/19, she and the co-owner (an RN) were doing some troubleshooting with the computer system at the nurse's station, and LPN-B had reported F-A was observed pulling R1's hair. The ADON said LPN-B had said she would put a note in R1's progress notes. The ADON stated, We didn't do much about it because it's been going on for a long time and (administrator) was trying to handle it internally. We've discussed reporting it (to the SA) in the past but (administrator) wanted to work with (F-A). I think (administrator) realized we're not going to change it. But it's gotten worse so the decision was made to report it. During an interview on 3/28/19, at 1:53 p.m. the DON stated, We've had many conversations and education with (F-A) and recurrent conversations about reapproaching (R1) and trying to support (F-A) because she's concerned about (R1's) nutritional status. The DON stated at times, F-A would be more persistent which caused R1 to holler and swear, and that was emotionally unsettling for the staff. The DON stated she was not aware of any incidents between R1 and F-A prior to this, and stated I'm not up there (on the unit). During an interview on 3/28/19, at 4:25 p.m. the LSW stated, after interviewing staff during the investigation of the 3/16/19 incident, the decision was made on 3/20/19 to not allow F-A to feed R1, however F-A was not in the facility that day, so LSW informed her on 3/21/19 that staff would be feeding R1. When interviewed on 3/28/19, at 4:45 p.m. the administrator stated R1 and F-A had been married for more than [AGE] years, and he felt F-A could benefit from education on dementia and support from the staff. During a follow up interview on 3/29/19, at 11:10 a.m. the DON stated she was notified of the incident that occurred on 3/18/19 during the supper meal, by telephone by RN-A, and had then spoken to NA-A. The DON stated, I felt this instance mirrored the action that had occurred on Saturday (3/16/19). We needed to continue on course with our plan. During the investigation, the plan was to intervene if we felt uncomfortable, if we felt (F-A) was being forceful or if we felt that (R1) was being threatened by her behavior, verbally intervening, offering her reassurance that we can offer (R1) food and drink, monitoring the whole situation and observing them. The DON stated after talking to RN-A and NA-A, If I felt that something needed to be done immediately, I would have consulted with (administrator). However, I did not call and talk with him immediately after that phone call.The DON stated she talked with the administrator the next morning (3/19/19). Further the DON stated, Yes, (F-A) did feed him (R1) again on Tuesday (3/19/19). She wasn't here on Wednesday (3/20/19). On Thursday (3/21/19) the determination was made to not let (F-A) feed (R1) any longer. Staff were assigned to feed. I spoke with the LSW on Thursday and we put out an email to all of the RN's to disseminate to staff that (F-A) was to no longer feed (R1). When interviewed on 4/2/19, at 9:00 a.m. the administrator stated R1's primary attending physician was also the facility's medical director and he was aware of the situation with R1. When asked about the incident that occurred on 3/18/19, the administrator stated the DON had spoken to him on the morning of 3/19/19 however, he thought she was talking about the incident that occurred on 3/16/19. Review of the facility's policy Abuse Prohibition dated 5/19/17, included: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident must not be subjected to abuse by anyone, including but not limited to, facility team members, other residents, consultants or volunteers, team members of other agencies serving the residents, family members or legal guardians, friends, or other individuals. The policy also included, Training: 1. St. Otto's team members will be trained during orientation, and on an ongoing basis (at least annually) on the following issues related to abuse prohibition practices. The policy further included: Reporting of abuse procedures included: The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are reported to the administrator of the facility immediately and to other officials in accordance with State law through established procedures .Protection: Resident/Daycare Clients, the alleged perpetrator, and other team members will be protected from harm during an investigation. St Ottos will accomplish this by removing the alleged perpetrator from the facility if necessary; moving the resident to a more easily observed area if necessary; involving law enforcement if necessary; increasing direct eyes on monitoring if necessary.

Based on observation, interview and record review, the facility failed to ensure residents received appropriate pain management interventions for 2 of 2 residents reviewed (R16 and R108) with pain, which resulted in actual harm for R16. In addition, the facility did not adequately monitor [MEDICAL TREATMENT] sites, evaluate fluid intake or coordinate services with an outside [MEDICAL TREATMENT] provider for 1 of 1 residents (R150) reviewed who received [MEDICAL TREATMENT] at an outside provider. Findings include: Resident 16 (R16) was identified as having ongoing pain when her left hand was washed and with passive range of motion exercises. The facility failed to assess and develop a pain management program for R16's pain which caused actual harm. R16 [DIAGNOSES REDACTED]. Her quarterly MDS (Minimum Data Set) dated 7/19/11 indicated she had short and long term memory deficits, and required extensive assistance for all ADL's (activities of daily living). Further, it identified R16 had functional limitations of range of motion (ROM) in her upper extremity and lower extremity, and had a scheduled pain medication with vocal complaints of pain. R16 was observed 9/14/11 at 8:42a.m., receiving passive ROM to her left hand by nursing assistant (NA)-A. R16's left hand was clenched. NA-A rotated R16 left thumb in a circular motion and moved the left wrist up and down. R16 did not resist or have any facial expression while this was performed. NA-A then gently started to open up R16 fingers which were clenched. While NA-A attempted to do this, R16 grimaced, moaned, groaned and was pulled her left hand away while NA-A attempted to open her fingers. The certified occupational therapist (COTA)-A who was in the room during this time, attempted to open R16 fingers. R16 again grimaced, stated, "no" and pulled her left hand away while she pushed backward in her wheelchair away from the COTA-A. COTA-A stated R16 had too much pain and stopped passive range of motion because it was too painful for R16. During an interview on 9/14/11 at 12:16p.m., Licensed Practical Nurse (LPN)-E stated R16 would not let her left hand be cleansed. R16 had pain in her left hand, used to wear a splint but would just cry when they would use it, so they stopped using it. LPN-E stated R16 only had pain when they attempted to clean her left hand. They no longer give R16 hand soaks or massages from the activity department because her left hand hurts when they attempted to do them. During an interview on 9/14/11 at 1:32p.m., activities assistant (AA)-A stated she used to be able to massage R16's hand but R16 started to pull her hand away, with grimacing and moaning. She thought it was too painful for her so they stopped that activity a few months ago. During an interview 9/15/11 at 11:40a.m., NA-E stated she also noticed in the past few months that R16 had pain when they attempted to wash her left hand. When they washed this hand R16 cried, was combative and struck out. She stated R16 did not get combative or strike out during other cares but only does when they tried to open her left hand. During an interview on 9/15/11 at 11:50a.m., NA-C stated she had provided PROM to R16 but stopped the past few months. R16 would get teary eyed, upset and combative when they attempt to open her left hand. R16 used to tolerate 3-4 repetitions of PROM to her left hand but in the past two months R16 was unable to tolerate this. NA-C also stated it seemed to hurt R16 a lot, and it just seemed to get worse. Review of the physician orders [REDACTED]. The orders also identified that on 7-30-10 R16 received [MEDICATION NAME] ([MEDICATION NAME]) 25mg twice a day at 8:00 a.m. and 8:00 p.m. and as needed (PRN). Review of the Medication Administration Record (MAR) indicated R16 did not receive any as needed [MEDICATION NAME] for June, July, August or September 2011. The facility Pain Care Area Assessment completed on 4-26-11 indicated R16 had non-verbal indicators of pain which include facial expressions frowning, grimacing and vocal behaviors of sighing, moaning, groaning and crying. The assessment also identified a frequency and intensity of pain "with cares/transfers." The facilities "analysis of finding" indicated, "Has DJD and [MEDICAL CONDITION] with pain potential.... has swelling and pain in left hand, refuses to wear splint receives [MEDICATION NAME] and [MEDICATION NAME] for pain effective." Even though the assessment identified "non-verbal indicators of pain" with "cares/transfers" the assessment did not identify location, intensity, description of pain, frequency, care and treatment that precipitated and exacerbated the pain, in order to develop an effective pain management program. Record review identified R16's plan of care updated on 7-18-11 identified a problem with "[MEDICAL CONDITION] with pain potential...monitored for general pain related [MEDICAL CONDITION] arthritis. Is having swelling and pain in her left hand..." The approaches were to "Assess for pain every shift yes/no, non-verbal observation. Avoid being judgmental/accept pain as resident sees it." The June, July, August and September 2011 medication administration record (MAR) for R16 indicated "check for any kind of pain every shift weekly on Wednesdays...yes, no." The June, July, August and September 2011 MAR indicated on each Wednesday R16 did not have any pain. The back of the July 2011 MAR sheet had a summary on 8-25-11 indicated, R16 used scheduled [MEDICATION NAME] and [MEDICATION NAME] for pain, with one use of Tylenol 650mg. "Pain assess indicates no pain, no changes at this time." The September MAR indicated on 9-8-11 "Does not appear to be in pain, but will continue to monitor monthly." There were no other summaries for the months June and August 2011. Although the MAR had weekly documentation of pain, there was no indication that a pain scale was used for verbal or nonverbal residents as part of this weekly monitoring. During an interview on 9/15/11 at 12:50p.m., registered nurse (RN)-C, stated nurses are not marking any pain for R16 on the MAR because R16 only has pain when they work with her left hand. Even though the MAR directed the nurse to "check for any kind of pain every shift weekly on Wednesdays," this was not completed. The Occupational Screening form dated 9/14/11 completed by COTA-A indicated that R16 would not allow COTA-A to slowly stretch her fingers. The COTA-A consulted with the nurse practitioner and nurse who both reported that R16 became combative and struck out at others when the splint was used because of discomfort. During interview with the COTA-A and NA-F on 9/15/11 at 12:00 p.m., NA-F stated she attempted to do R16's PROM today and lifted her left hand but R16 started crying because she was having so much pain in her left hand. They have not been able to do the PROM or clean her hand very well for the past two months because R16 would pull away. The COTA-A then stated that she was unable to complete PROM on R16's during her screening yesterday (9-14-11) because R16 was having so much pain. Additional information was provided via fax on 9/16/11 at 1:30pm, included an interdisciplinary progress notes dated 9-15-11 (no time), "Resident refused ROM to hand- cries will continue to attempt at this time." Even though the 4-26-11 pain assessment identified R16 had pain with movement, the facility did not implement effective pain management interventions. The facility identified R16 cried, became combative, and pulled her left hand away routinely while R16 left hand was cleansed or when PROM was attempted. The facility did not implement any non-pharmacological or other interventions to help decrease or eliminate R16's pain in her left hand while PROM or cares were performed. The most recent pain medication regime was last changed on 7/30/2010, over one year ago. The [MEDICATION NAME] was increased from PRN to scheduled twice a day and PRN. Review of the MAR's indicated R16 did not received any as needed [MEDICATION NAME] in June, July, August or September 2011. Although the facility was aware that R16 had pain when her left hand was manipulated they did not comprehensively assess or develop a pain management program, which resulted in actual harm. The facilities Pain Management policy dated 3/1/10 indicated all residents reporting pain will be assessed, evaluated and treated for [REDACTED]." The policy also identifies a "Pain Scale, verbal/non-verbal 1-10." Resident 108 (R108) pain was not comprehensively assessed nor was an effective pain management program implemented. R108 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] identified R108 had no cognitive problems, was on a scheduled pain regimen and no complaints of current pain. During interview on 9-12-11 at 7:05 p.m. R108 stated she had a wound on her ankle and foot which she has been wearing a boot to promote healing. She stated the wound was starting to get better, but was still painful and had this wound for several months. During interview on 9-15-11 at 12:05 p.m. R108 stated the pain in her legs had gotten much worse in the "past few months." There were times when she almost could not get out of bed because of the pain which started a few months ago, but this "comes and goes." She stated the nurses were aware of it because they have been doing dressing changes on the wound and at times the pain was so bad it took two persons to get her out of bed. She further stated, she does not like a take a lot of medications. During interview on 9-15-11 at 1:50 p.m. Nursing Assistant (NA)-A stated R108's pain had gotten "pretty bad" in the last several weeks and the last few days had been "very bad, she can hardly get out of bed." Review of R108's current scheduled pain medications indicated Tylenol 1000 mg twice a day which was started on 10-13-10. Review of R108's June, July, August and September 2011 medication administration record (MAR) directed the nurse to "check for any kind of pain every shift weekly on Wednesdays...yes, no." The June, July, and August MAR did not indicate any pain. The September 2011 MAR identified pain on in the morning and evening on 9-7-11 and on 9-14-11. The MAR did not indicate where the pain was, interventions used to relieve the pain, or the intensity of the pain, but only marked a "Y" for yes. Review of R108's "Physicians Orders and Progress notes" dated 8-4-11 indicated resident "...states she still has some discomfort over the area on her heel that she had a blister on the right foot. This looks like it has healed but still has some tenderness." A "Interdisciplinary Progress note" dated 8-15-11 indicated "Past 3 days did not wear stockings- states they hurt her right heel." A "Physician Communication" form dated 8-22-11 indicated, "Increase pain in right foot- refusing to wear sock- makes it worse." A "Interdisciplinary Progress note" dated 8-27-11 indicated, "Right ankle/ foot less red, less swelling- painful to touch and movement." A "Interdisciplinary Progress note" dated 8-29-11 indicated, "Difficulty transferring- Right foot, heel, ankle tenderness, painful. Two staff to transfer." A "Physician Communication" form dated 8-29-11 indicated, "Right foot/ ankle- 1 week hot packs done- initial improvement- painful, difficulty transferring, crusted area on ankle." The most recent "Pain Evaluation" dated 7-12-10 identified R108 had pain with movement, when extremities were touched but was unable to describe the pain. The conclusion on the pain assessment indicated, "Hard to evaluate, as not able to express herself; reason: pain and drifts in and out of sleeping." Although R108 complained of pain in her legs for the "past few months," there was no indication her pain had been comprehensively assessed. Also, the 7-12-10 pain assessment identified R108 was unable to describe the pain, but currently had no cognitive impairments. During interview on 9-15-11 at 12:30 p.m. Registered Nurse (RN)-B stated the registered nurse was responsible for the monthly notes regarding R108 pain but only does a comprehensive assessment if there is an increase in pain noted. She verified the last comprehensive pain assessment was done on 7-12-10, approximately 14 months ago even though R108 has been complaining of pain in her legs for the "past few months." RN-B was aware that R108 was having increased pain and stated R108 needed to have a comprehensive pain assessment completed. Although the facility was aware that R108 had pain, they did not complete a comprehensive pain assessment nor implement an effective pain management program for R108. Resident 150 (R150) received hemo [MEDICAL TREATMENT] services through an outside agency. The facility did not adequately monitor and evaluate R150 [MEDICAL TREATMENT] site along with evaluating his fluid intake; also the facility did not coordinate services with the outside [MEDICAL TREATMENT] provider. R150 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] identified R150 had severe cognitive impairment, needed extensive assistance with all activities of daily living, and received [MEDICAL TREATMENT]. The "Dehydration/ fluid maintenance care area assessment (CAA)" dated 8-17-11 identified R150 was at risk for dehydration due to [MEDICAL TREATMENT], fluid restriction, and difficulty understanding. During observation on 9-14-11 at approximately 10:00 a.m. R150 had a [MEDICAL TREATMENT] access (a fistula) under his skin on his right upper arm. A Discharge note from the residents last hospital stay written on 8-4-11 from "CentraCare Health Systems" identified R150 had been receiving [MEDICAL TREATMENT] on Monday, Wednesday, and Fridays and used a right upper arm fistula for a [MEDICAL TREATMENT] access. During chart review on 9-13-11 R150's "Short term care plan" last updated on 9-12-11 did not identify R150 received any [MEDICAL TREATMENT] or had a [MEDICAL TREATMENT] access but identified a 1500 ml fluid restriction. Also the care plan did not identify how to care for the [MEDICAL TREATMENT] shut, how to identify infection or emergency procedures. During interview on 9-14-11 at 1:40 p.m. Licensed Practical Nurse (LPN)-B (R150's nurse that evening, when R150 returned from [MEDICAL TREATMENT]) stated she was unsure of what kind of [MEDICAL TREATMENT] access R150 had but identified this was on the Medication Administration Sheets (MAR) and/or care plan. LPN-B looked in both areas but was unable to find this information. She stated she was unsure where the access was but would "try to find out." LPN-B stated they do not do any monitoring of R150 [MEDICAL TREATMENT] access when he returns from [MEDICAL TREATMENT]. During interview on 9-14-11 at 1:45 p.m. LPN-A stated the [MEDICAL TREATMENT] information was listed on the MAR and the care plan. She verified the information was not in either area and was unable to identify what type of access R150 had or if there was any special care regarding the [MEDICAL TREATMENT] access. She stated when R150 goes to [MEDICAL TREATMENT] they send a folder with to transport any information back and forth to the unit. She indicated they do not get information about the residents run unless there were problems. The [MEDICAL TREATMENT] unit does not inform the facility how much fluid was removed on the [MEDICAL TREATMENT] run or what the vital signs were after the run was completed. A facility policy "Kidney [MEDICAL TREATMENT]" dated 2-09 identified to "See attached care plan templates." The templates instructed, "Monitor blood pressure post [MEDICAL TREATMENT] when has been hypertensive at [MEDICAL TREATMENT]; Potential for bleeding at access site after [MEDICAL TREATMENT]; check access site every shift for pulse bruit, color and temperature; observe access site for bleeding after [MEDICAL TREATMENT] run." Although the facility policy indicated to check blood pressure after [MEDICAL TREATMENT] if hypertensive, there was no indication blood pressures were reported to staff from the [MEDICAL TREATMENT] unit. In addition, the facility was not monitoring R150's [MEDICAL TREATMENT] access daily or after [MEDICAL TREATMENT] as instructed by the policy. Review of the facility intake monitoring sheet form for R150 indicated dietary staff were to record the fluid intake in the dining room for all meals. Nursing staff were to record the fluid during med pass and between meals. Directions on the bottom of the form indicate, "Dietary to start the form, lane nurse to tally up total at the end of the day. Nursing aide responsible for resident needs to report total fluids drank on their shift to lane nurse. Lane nurse is responsible for keeping sheets copied and up to date." Review of R150 fluid monitoring sheet from 8-4-11 to 9-4-11 indicated there were only three days the total fluid intake was actually monitored for R150, even though he was on a 1500 ml fluid restriction. During interview on 9-14-11 at 12:30 p.m. Registered Nurse (RN)-B stated the night nurse was responsible for tallying and tracking the fluid totals R150 drank throughout the day. During interview on 9-14-11 at 1:00 p.m. with the Dietary Manager stated nursing was responsible for tallying the daily fluid intake and report to dietary if there was a concern about the intake. The facility policy "Memo: Guidelines for new fluid restriction monitoring form" dated 8-28-09 instructed..."P.M. lane nurse to total intake at the end of the day for nursing/ dietary...Nursing and Dietary will monitor fluid restriction amounts." Although the facility was suppose to be monitoring R150 intake of fluids, this was not completed on a consistent basis. During interview on 9-13-11 at 2:05 p.m. Registered Nurse (RN)-A stated the floor nurses should know where R150 [MEDICAL TREATMENT] access was located. They should know how to monitor, care for the site along with tracking R150 fluid intake and getting report from the outpatient [MEDICAL TREATMENT] facility . RN-A stated R150 permanent care plan was in the medical record department waiting to be typed. She verified the temporary care plan did not contain any information regarding R150 [MEDICAL TREATMENT] access, what to monitor nor did the care plan identify any emergency procedures even though R150 had been residing in the facility over a month. No further information was provided.