Every finding on record at Stewartville Care Center

Based on observation, interview and document review, the facility failed to complete weekly wound assessment and documentation for 1 of 1 resident (R6) reviewed for pressure Ulcer/Injury who had 2 unhealed stage 4 pressure ulcers (full-thickness skin and tissue loss, exposed bone, ligament, cartilage, or muscle) on bilateral buttocks. This had the potential to delay identification of changes in wound status and impact timely interventions to promote healing. Findings Include:R6's quarterly Minimum Data Set (MDS) assessment, dated 6/3/26, identified R6 had intact cognition and was dependent on staff for activities of daily living and mobility. MDS identified two stage 4 pressure ulcers, pressure reducing device for bed, chair and application of nonsurgical dressing and ointment.R6's diagnoses included stage 4 pressure on right and left buttock, hereditary spastic paraplegia (inherited disorders that cause progressive stiffness and weakness in the legs, often leading to mobility challenges).R6's care plan dated 6/10/26, directed staff to assess the pressure ulcer location, stage, size (length, width and depth), presence/ absence of granulation (healing) tissues, conduct a systematic skin inspection weekly and report any signs of further skin breakdown.R 6's wound treatment order dated 4/14/26 included: dressing plan for the bilateral open stage 4 ischial pressure injuries, continue to use Vashe (wound cleanser) barely moistened kerlix covered with ABD (thick multi-layered medical dressing) pad held in place with silicone tape, 3 times daily.R6's Electronic Medical Record (EMR) review indicated R6 was hospitalized from [DATE] to 01/26/26 for progressive worsening of bilateral buttocks stage 4 pressure ulcers with concern for infection and a hospitalization from 05/14/26 to 5/18/26 for acute osteomyelitis (infection in a bone), both ischial (sit bones) wounds were open to bone and periosteum (connective tissues), with the left wound correlating with new osteomyelitis.Review of R6's EMR wound documentation identified 3 wound assessments and documentation in 90 days:On 3/31/26, wound documentation indicated: old dressing was removed; area was cleansed with dermal wound cleanser; kerlix saturated in half solution of Dakin's. bottom looked good overall with scant amount of maceration to peri wound. Left buttock wound measured; 4 cm(centimeters) L(length) x 7 cm W(width)x 7 cm D (depth),Right gluteal wound measuring 2 cm (L) x 3.5 cm (W) x 5.3 cm (D).On 04/2/26, wound documentation indicated: old dressing was removed; area was cleansed with dermal wound cleanser; kerlix saturated in half solution of Dakin's.Left buttock wound measured; 9.6 cm (L) x 5.2 cm (W) x 9.2 cm (D),Right gluteal wound measuring 3.5 cm (L) x 2.7 cm (W) x 5.0 cm (D).On 6/3/26, wound documentation current indicated: wound care completed this AM after resident had a shower. Left buttock wound measured 1.5cm x 2.0 cmx 4.0cmRight buttock wound measured 2.0 cm x 4.0 cm x 6.4.cm, no s/s of infection, no odor, no drainage, resident denies pain and tolerated treatment well.During an observation and interview on 6/17/2026 7:22 a.m., R6 stated, wounds dressing changes were completed by 7 a.m., between 12 p.m., and 2:00 p.m., and after 7:00 p.m., R6 said he spent most of the day in the facility apartment visiting his wife and returned to the facility for medications and treatments.During observation on 6/17/2026 1:40 p.m. R6 returned to the facility, took scheduled medications, declined wound treatment and assessment, and returned to the facility apartment to visit his wife.During an interview on 06/17/26 12:50 p.m., licensed practical nurse, (LPN)-A stated, weekly wound assessment and documentation was completed by the nurse manager.During an interview on 06/17/26 10:57 a.m., interim director of nursing (IDON) stated, the expectation was all wounds would be measured and documented on weekly basis.During an interview on 06/17/26 at 2:33 p.m., licensed nurse practitioner (NP)-B expected facility staff to complete weekly wound assessment and report any issues identified.Facility policy title Skin Integrity, Wound, Care and Pressure Injury Prevention reviewed on 6/18/26 on indicated, all wound, and pressure injuries shall be assessed upon identification and monitored routinely thereafter. Assessment shall include Location, size and measurement, stage (if applicable), appearance of wound bed, drainage characteristics, sign and symptoms of infections, pain, periwound condition and response to treatment. Residents with existing wounds or pressure injuries shall have treatment goals and interventions reflected in the care plan.

Based on interview and record review the facility failed to ensure medications were available for administration per physician order for 1 of 1 resident (R37) reviewed for pharmacy services. Findings include: R37 face sheet indicated R37 admitted to the facility on [DATE]. R37's admission Minimum Data Set (MDS) assessment, dated 6/9/26, indicated R37 was cognitively intact with no delirium and no behaviors. R37 had upper and lower body impairment and required assistance with all activities of daily living. The MDS also indicated R37 had diagnoses of anxiety and depression. R37's diagnoses list included heart disease, major depressive disorder, and generalized anxiety disorder. R37's care plan indicated R37 received an antianxiety medication related to anxiety disorder.R37's hospital discharge orders dated 6/3/26, indicated clonazepam (prescribed to treat anxiety)0.5 mg tablet give 1/2 tablet twice a dayR37's Medication Administration Record (MAR) indicated R37 had an order for clonazepam 0.5 mg tablet. Give 1/2 tablet twice a day scheduled. The MAR further indicated R37 did not receive the clonazepam from 6/3/26 evening shift through 6/15/26 due to drug not available. Additional notes on the MAR indicated on 6/3/26 drug unavailable, resident informed. Will call pharmacy in the AM. On 6/5/26 evening shift the MAR also indicated medication not found, also checked Ekit (emergency kit) not available. On 6/11/26 the MAR also indicated no written script from pharm(pharmacy).R37's progress notes indicated R37 was seen on 6/4/26 for a first post admission recertification with orders for labs placed. The progress notes also indicated R37 was seen at the facility by the nurse practitioner for an acute visit on 6/10/26. The progress notes lacked documentation a provider was updated of R37's clonazepam not being administered due to being unavailable. A hand written faxed document dated 6/4/26, to the medical director indicated FYI. [facility pharmacy] needs an updated script for [R37] clonazepam. Provider progress notes indicate the medical director was in the facility on 6/4/26 to sign R37's admission orders and R37 was seen for an acute visit on 6/10/26. Neither document mentioned needing a valid prescription for clonazepam. During an interview on 6/16/26 at 11:21 a.m., trained medication aide (TMA)-A stated if a medication was not found, she would look through all of the medication carts and call the pharmacy to order it. TMA-A stated staff are not supposed to document unavailable on the MAR. If a script is needed, she would tell the nurse on duty. When asked about R37's clonazepam, TMA-A stated I think they were trying to get her off of that, I'm not really sure. I know it wasn't a prior authorization thing. TMA-A looked through the medication cart and verified there was no card of clonazepam available. During an interview on 6/16/26 at 1:01 p.m., the pharmacy technician stated the pharmacy last filled 30 tablets of clonazepam for R37 on 11/6/25 and they do not have a current order for clonazepam for R37. During an interview on 6/16/26 at 1:08 p.m., licensed practical nurse (LPN)-A stated if a medication is not available the pharmacy is notified and a note is made in the progress notes. If the pharmacy states a new script is required, the provider is updated. LPN-A stated he does not work with R37 often but does recall one of the nurses stating messages were sent to the provider for the clonazepam order. LPN-A reviewed R37's progress notes and confirmed there is no documentation stating a provider was updated. LPN-A stated an SBAR (a note written to providers) is placed in the SBAR binder. LPN-A could not find documentation in the binder indicating a request for clonazepam was made. On 6/16/26 at 2:08 p.m., the administrator provided an SBAR that was written on 6/14/26 to the provider indicating discontinue orders for Clonazepam BID. No script, has not taken while here. During interview on 6/16/26 at 2:21 p.m., the nurse practitioner (NP) stated she is at the facility weekly. The NP confirmed R37 was discharged from the hospital with an order for clonazepam 0.5 mg tablet 1/2 tablet twice a day. The NP also confirmed R37 was seen by the medical director on 6/4/26 and by her on 6/10/26 for an acute visit. The NP stated she was unaware R37 had not been receiving clonazepam and did not see any documentation or fax indicating a request for a script for clonazepam. The NP stated she would expect to be notified immediately if a medication was unavailable. During an interview on 6/17/26 at 8:18 a.m., the assistant director of nursing (ADON) stated the facility has a binder with the procedure for obtaining medications that are controlled substances. The ADON stated if a medication is unavailable, staff are expected to check the emergency kit, reach out to the pharmacy, and reach out to the provider. The ADON stated she expects continued communication until the medication is available. The ADON confirmed the documentation the medication was not available. She stated she would expect the nursing staff to communicate with the providers at least every shift until the situation was rectified. The ADON confirmed the medical director was at the facility on 6/4/26 to certify R37's admission orders and the nurse practitioner saw R37 on 6/10/26 for an acute visit. The ADON confirmed there was no evidence a provider was notified of the clonazepam between the fax on 6/4/26 and the SBAR written 6/14/26. She stated the facility had ample opportunity to reach out to the providers to obtain the script for the clonazepam. A policy titled Procedure for Addressing Controlled Substance/Narcotic Supply shortage dated 11/5/25, indicated if it is a med we have in the emergency kit, first call the pharmacy (after hour pharmacy if that is appropriate) to see if you can access the emergency kit for the medication, if they say yes, do so and document/request replacement accordingly. But you will need to send a request for a refill if the pharmacy is not planning on sending more to the facility. If no, because there is not a valid Rx [prescription], then you will have to call the provider or the on-call provider for after hours. If they do it, ask them to be sure to send it to [pharmacy name]. It is then necessary to document what you have done and what the result is. If for some reason you are not able to get a medication, you need to monitor the resident, offer non-pharmacological interventions, and if that is not enough, call the family to notify and send the resident to the ED (emergency department). Notify facility DON by phone or email.

Based on observation, interview, and document review, the facility failed to ensure resident assessment to self-administer medications, was implemented and followed consistently in accordance with physician orders for 1 on 1 resident (R8) reviewed for self-administration of medications.Findings include: R8's comprehensive Minimum Data Set (MDS) assessment, dated 5/11/26, identified R8 had impaired cognition and required extensive assistance with activities of daily living(ADL) and maximal assistance with mobility. R8's care plan dated 05/04/26 indicated, resident would like to administer oral medications and be more independent with ADL's. Resident was unable to self-administer safely medications, may self-administer inhalers/nebs after set up only. R8's active medications list review included an order for R8 to self-administer inhalers and nebulizer treatments only after set up by staff and could not self-administer oral medications safely dated 11/09/23. R8's self-administration of medication assessment dated [DATE] indicated, R8 did not wish to self-administer any medications, had moderately impaired cognitive status, made poor decision, required cues/supervision and based on evaluation, it was not appropriate for R8 to self-administer any medications. During an observation on 06/16/26 4:09 p.m., R8 was found sitting in a wheelchair in the room, holding in the left hand a 1 oz medication cup containing 4 tablets and in the right hand, an 8 oz clear cup, containing water. When asked who provided the medications and water, R8 stated, the medications were from a while ago and was unable to recall who provided the medications. At 4:38 p.m., R8 was found in the same position, with no medication cup in the left hand and the water cup was placed on the nightstand. When R8 was asked what happened to the medications, R8 was unable to recall. Further inspection showed the medication cup and the 4 tablets of medication on the floor and a small amount of spilled water. R8 's call light was used and trained medication aid (TMA)-A and registered nurse (RN)-A at 4:40 p.m responded to the call light. During an interview on 06/16/26 at 4:41 p.m., (TMA)-A stated, R8 was not supposed to self-administer oral medications except inhalers and nebulizer treatments only after set up by staff and was unsure who provided the medications found on the floor. RN-A also confirmed, R8 was not to self-administer any oral medications except inhalers and nebulizer treatments only after set up by staff and would notify supervisor immediately. Medications found on the floor were identified as tramadol 50 mg tablet, 2 tablets of Tylenol 500mg and calcium citrate 200mg tablet. During an interview on 06/17/26 at 10:30 a.m., administrator indicated a near miss medication investigation report was completed and trained medication aid (TMA)-B was identified as staff member involved. During an interview on 6/17/26 at 1:43 p.m., TMA-B stated, they had provided R8 with an inhaler first, which R8 self-administered after set up, then the 4 tablets in a medication cup and water on 6/16/26 at 4:30 p.m., TMA-B confirmed was aware R8 was unable to self-administer oral medications except inhalers and nebulizer treatments only after set up by staff. TMA-B stated, was under the impression that R8 took the medications in her presence. During an interview on 06/18/2026 11:04 a.m., acting director of nursing (ADON), upon review of R8's self-administration of medication assessment dated [DATE] and confirmed, R8 was unable to self-administer any medications including inhalers and nebulizer treatments. Facility policy titled Self -Administration of Medication Policy revised on 6/16/26 indicated, nursing staff shall review self-administration documentation routinely and ensure appropriate entries are reflected on the Medication Administration Record (MAR).

Based on interview and document review, the facility failed to ensure the required Notice of Medicare Non-Coverage (NOMNC) was provided timely to 1 of 3 residents (R27) reviewed for beneficiary notices.Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had intact cognition. R27's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form dated 6/15/26, indicated R27's last covered day of Medicare Part A service was on 2/15/26. R27's NOMNC form dated 6/15/26, indicated R27's last covered day of Medicare Part A service was on 2/14/26. The form was signed by the resident dated 6/15/26. Additionally, R27's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form dated 6/15/26, indicated R27's last covered day of Medicare Part A service was on 5/23/26. R27's NOMNC form dated 6/15/26, indicated R27's last covered day of Medicare Part A service was on 5/23/26. The form was signed by the resident dated 6/15/26. During an interview on 7/1/25 at 1:34 p.m., R27 stated she did not recall anyone reviewing the form mentioned above with her but was okay with her therapy services ending. During an interview on 6/17/26 at 9:28 a.m., administrator confirmed she oversaw reviewing NOMNCs with residents and, after reviewing R27's medical record, could not find evidence that the notice had been given to R27 at least two days before the end of Medicare Part A coverage as required. The facility's NOMNC policy dated 6/18/26 indicated the NOMNC must be delivered at least two calendar days before Medicare-covered services end.

Based on interview, observation and record review, the facility failed to develop a person-centered care plan for 2 of 3 resident (R4, R1) reviewed for hospice care and smoking. Findings Include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was moderately cognitively impaired. R4's diagnosis included dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) with moderate agitation During record review on 6/16/26 at 10:01 a.m., noted R4 was admitted to hospice on 1/30/26. R4's comprehensive care plan failed to include a resident-specific hospice care plan, including hospice diagnosis, hospice provider information, and resident choices and preferences. During an interview on 6/16/26 at 1:24 p.m., registered nurse (RN)-A stated she is unsure why R4 was put on hospice, probably due to his infections or maybe his worsening dementia. RN-A stated she didn't know what end-of life preferences R4 had. During an interview on 6/16/26 at 1:27 p.m., Minimum Data Set (MDS)-A coordinator and RN-B stated after the resident chooses a hospice company, the hospice banner is added in the electronic medical record (EMR), hospice contact information is added to the resident care plan and is updated to include pertinent hospice information. The hospice care plan would include the hospice company information, hospice diagnosis, and any known resident choices and preferences. MDS-A confirmed R4 was admitted to hospice on 1/30/26. MDS-A confirmed R4's care plan did not have a hospice care plan. MDS-A and RN-B stated the hospice care plan is important, so all staff are aware of the resident status and how to care for him at the end-of-life stage. A facility policy titled Care Plans, Comprehensive Person-Centered dated 8/3/2018, the facility will provide a comprehensive person-centered interdisciplinary care plan. R1 R1's quarterly Minimum Data Set (MDS) assessmen, dated 5/11/26, indicated intact cognition, and R1 was independent with mobility. R1's ecord review indicated R1's had impaired vision related to macular degeneration and was legally blind. R1 was able to ambulate up and down the halls in the facility and outside of the facility only in the area of the railing safely. Smoking observation/assessment dated [DATE] indicated, R1's was able to smoke independently, requested staff assistance when ready to go out to smoke and smoked less than a cigarette a day. R1's record review lacked smoking care plan (problem, goals/outcomes, and interventions). During an interview on 06/17/26 08:15 a.m., administrator acknowledged, R1 was able to smoke safely with staff assistance and had no smoking care plan in place. A facility policy titled Care Plans, Comprehensive Person-Centered dated 8/3/2018, the facility will provide a comprehensive person-centered interdisciplinary care plan.

Based on observation, interview, and document review, the facility failed to provide supervision to 1of 1 resident (R8) reviewed for activities of daily living who was left unattended on the toilet for more than 1 hour. Findings Include: R8's comprehensive Minimum Data Set (MDS) assessment, dated 5/11/26, identified R8 had impaired cognition and required extensive assistance with activities of daily living and maximal assistance with mobility. R8 's care plan dated 5/4/26 indicated, resident had a history of falling related to impulsiveness and perceived abilities. Motion sensor alarm to monitor movements due to unattended / unassisted transfers resulting in falls, reminders to use call light for all transfers. Record review indicated R8's had an unwitnessed fall on 6/12/26 at 10:06 a.m., in the bathroom, right beside the toilet and the wheelchair. R8's head was found leaning against the corner of the doorway. During an observation on 6/16/26 9:03 AM, R8 was assisted onto the toilet by nursing assistant (NA)-A. At 9:40 a.m., R8 was observed sitting on the toilet, chin to chest, sleeping and snoring lightly. At 10:10 a.m., staff returned to R8's bathroom and assisted R8 off the toilet, then to bed. During an interview on 6/16/26 2:21 p.m., nursing assistant (NA)-A stated, R8 was able to use the call light when ready, R8 had requested more time on the toilet when staff had gone too early in the past. When asked to clarify the meaning of too early, NA-A stated, 10 to 15 minutes. When pointed out to NA-A, R8 had fallen asleep on the toilet, NA-A stated, yes, R8 liked to sleep on the toilet. NA-A stated, today was busy or I would have gone back in there sooner. During an interview 6/18/26 11:04 a.m., assistant director of nursing (ADON) stated, the expectation was for staff to check in with residents at least 15 minutes when left unattended on the toilet. Facility policy titled Activity of Daily Living (ADL) Assistance and Functional Maintenance reviewed on 6/18/26 indicated, provide supervision and support to residents with balance deficit or fall risks.

Based on observations, interviews, and document review, the facility failed to protect a resident's right to be free from verbal abuse for 1 of 3 residents (R4) when R1 who had a history of cognitive impairment, personality changes, impulsiveness, and making poor choices, repeatedly yelled at R4, made a threat to shoot him in the head, and entered his room on three different occasions.Findings include: R4's admission minimum data set (MDS) dated [DATE], he was cognitively intact, no depression or behaviors. He was occasionally incontinent with bowel movements and frequently incontinent with urination. His care areas triggered activities of daily living, urinary incontinence, falls, and pressure ulcers. R4's care plan dated 1/15/26, indicated he had polyneuropathy (nerves to the arms and legs are damaged causing numbness, tingling, pain, and weakness), repeated falls, heart issues, pain in the right hip and knees, weakness, and lower back pain. He needed assistance with the toilet, bathing, grooming, and dressing. R4's progress notes by LPN-A dated 3/26/26 at 4:19 p.m., indicated she was alerted to an incident that happened in R4's room. She found R4 visibly shaken and choked up stating R4 did not feel safe and wanted to change rooms. R1 came very close to R4's face and was waving his fingers acting like he was going to hit him. R1 threatened to shoot R4. R1 and R4 shared a bathroom. R4 indicated he always made sure R1's bathroom was unlocked when he finished toileting because he feared what R1 would do. R4's progress notes by RN-A dated 3/27/26 at 10:33 a.m., indicated R4's family came to the facility to discuss the incident that happened with R1. They were concerned R1 would come back to the facility, and the behavior would continue. R4 stated he did not want to share a bathroom or be located close to R1 if he returned. R1's hospital summary dated 1/21/26, indicated he was in a motor vehicle accident in 1974, where he was thrown through the windshield and suffered a basilar skull fracture and coma. The incident left him with personality changes and mild cognitive impairment. On 1/21/26, he was admitted to the hospital related to progressive weakness, falls, and an inability to care for himself. His mental status at that time included memory and attention deficit, impulsiveness, made poor choices leading to an inability to care for himself. In addition, he was severely malnourished. R1's admission Minimum Data Set (MDS) dated [DATE], indicated he had moderate cognitive impairment, minimal depression, and no behaviors during the seven days look back period. He triggered cognition abilities, inability to complete activities of daily living, urinary incontinence, falls, nutrition, and pressure ulcers. R1's care plan dated 2/6/26 indicated he needed limited assistance from staff to set up clothing, and help dress as needed, personal care, and shower. He was continent of bowel and bladder, and independent with toileting. R1's progress notes by LPN-B dated 2/16/26 at 10:42 a.m., indicated R1 was yelling about R4's commode stating it should not be left in the room. He brought the commode to the shower room and told staff to keep the damn thing out of his room. R1's progress notes by LPN-B dated 2/17/26 at 9:38 a.m., indicated R1 removed R4's commode from his room yelling He do not care! He knows the laws. R1 pushed the commode all the way to the shower room, slamming it into the wall. R1's progress notes by LPN-B dated 2/17/26 at 1:22 p.m., indicated R1 was frustrated with R4's commode (portable toilet placed over the facility toilet to function as a riser) and the shared bathroom situation. She informed him he was not allowed to go into other residence rooms and remove items. R1's provider note dated 3/20/26, indicated he suffered from depression, anxiety, impatience, and angry outburst since 1974. He was unable to live independently at home and manage his needs. Hospital weight was 107 lbs. and upon admission to the facility it increased to 118 lbs. R1's progress notes by LPN-A dated 3/26/26 at 4:42 p.m., indicated R1 was angry and told her he was frustrated when the bathroom door was locked when he needed to use it. He described the incident with R4 when he was unable to use the bathroom because the door was locked. He was angry when he went into R4's room, and he pointed his finger at R4's face and he told him I will shoot you in the face if this happens again. Staff observed R1 leave the room only to return and continue to threaten R4. Staff were concerned that he would physically harm R4 based on his threats and behavior. This was not the first time, and R1 was capable of hurting R4. The police were contacted. R1's progress notes by LPN-A dated 3/26/26 at 5:11 p.m., indicated R1 was transported to the hospital for evaluation. R1's hospital emergency encounter note dated 3/26/26, indicated R1 was brought to the facility for aggressive behavior towards another resident. He told them he was upset with the shared bathroom door being locked all the time and this had been occurring at least six times in the past two weeks. He was frustrated with the staff's lack of action. R1's progress notes by RN-B dated 3/26/26 at 10:22 p.m., indicated the hospital wanted to discharge R1 back to the facility. She told the hospital they were unable to accommodate his return because they had not been able to ensure the other patient would be safe and needed time to address the safety concerns. The facility administrator's investigation statement dated 3/26/26, indicated while she was talking with R4, R1 was standing in the hallway watching them. She tried to redirect R1 several times, but he refused to leave. R4 was visibly shaken up and stated R1 pointed his finger at him and said he was going to shoot him in the head while he was sleeping. She then accompanied R1 to her office. R1 was very agitated and the administrator worried about her own safety. She contacted the police to transport him along with EMS to the hospital. She stated they did not have the means to do one-to-one care or transfer him to another room in the facility. Initially he refused to go to the hospital but later agreed if he could go to his room and get something. They followed him to his room and found him yelling and punching things. Police report dated 3/27/26 at 8:02 a.m., indicated they responded to the 911 call at the facility to investigate the incident. The police officer spoke with R4 who stated he had encounters with R1 six or seven times prior regarding the shared bathroom door being locked. Staff indicated they did not have an open room for R1 to be transferred to, and they did not have the staff to provide continuous observation to make sure R4 would be safe. R1's progress notes by social worker (SW)-A dated 3/27/26 at 2:17 p.m., indicated she hoped R1 could return to the facility. She did talk with him about his behavior but at that time he was still unwilling to take responsibility for his actions. She added based on his medical history regarding the traumatic brain injury (TBI) he had a lack of impulse control, and it did not take much to make him angry. R4's progress notes by Administrator dated 3/30/26 at 9:28 a.m., indicated R4's family wanted to know if R1 would be returning to the facility. It was explained to them that he was not. They were concerned that he could still come back and harm their father and what the facility would do to prevent him from coming back. R4 became agitated during the conversation, and it was decided that they would no longer talk about the incident in front of the resident to prevent further agitation. R4's progress notes by Administrator dated 4/3/26 at 9:44 a.m., indicated R4 had returned to his baseline and did not mention the incident to staff while doing cares. During an interview on 4/6/26 at 10:00 a.m., family member (FM)-A stated R1 suffered from a traumatic brain injury 53 years ago. Since he became a loner and did not participate in any family activities. He stopped talking to her three years ago when she was trying to get him to follow up with doctor appointments. When he finally contacted her, she went to see him and found him in bad shape. He lost a lot of weight and told her all he wanted to do was lay in bed and die. She had spoken with him after the incident, and he did not take responsibility for his actions. During an interview on 4/6/26 at 2:30 p.m. the administrator stated R4's family was very upset about the incident that occurred and the possibility that R1 would be returning to the facility. Previously R1 had been upset because he shared a bathroom with R4 who required the assistance of a commode over the toilet to raise the seat high enough for him to be able to use it. R1 did not like the commode in the bathroom and voiced his concerns. In addition, he complained about the bathroom door was always locked when he needed to use it. When the subject first occurred, staff were reminded to make sure they unlocked that door before they left the bathroom. Then they removed the commode completely out of the bathroom when he was done using it. When R1 walked by his room and saw that he had a commode in his room he started to yell, and he took the commode out of his room twice. In response the staff covered the commode with a sheet. They also placed a sign on the bathroom door reminding staff to make sure they unlock the bathroom door when R4 was done. She added after the incident they did not accept R1 back to the facility because they did not have enough staff conduct constant supervision. In addition, they did not have a room with a private bath available. When the event occurred staff immediately separated both residents along with shutting all residence stores and the fire door to keep other staff out of the area. R4's family was very upset and threatened to remove their father from the facility if R1 returned. They also wanted police charges placed on R1 and a legal restraining order. During an interview on 4/7/26 at 11:02 a.m., R4 stated during the incident he wanted to smack him but R1 looked so frail he was afraid of hurting him. He was afraid of R1 and had been telling the staff for over a month that the patient was nuts. One time, R1 saw the commode in his room and dragged the chair out of the room down the hallway. He said if R1 returned to the facility he would move out. He wanted the nursing staff to call the police because he had made a death threat to him when he stated he wanted to shoot him in the head. At the time of the interview, he said he forgot about the incident and was okay to talk about it. He had been very concerned about the situation regarding the bathroom doors and always reminded the staff to unlock the door when they were done using it. During an interview on 4/7/26 at 1125 a.m., RN-C stated R1 had been upset about the bathroom door being locked when he needed to use it and later unhappy with the commode whether it was in the bathroom or in R4's room. At times he had been confrontational with staff and had difficulty redirecting him, the facility did not have a private room for him nor the ability to separate them. She said once R1 gained strength and mobility she was concerned about the residents' safety. During an interview on 4/7/26 at 12:00 p.m., R4 asked if R1 could come to the facility and harm him again. Explained to him several times the facility had discharged R1 from the facility, and R1 did not have the means to return to the facility. During an interview on 4/7/26 at 2:30 p.m., the administrator stated R1 Did not like sharing a bathroom with R4. Initially the problem revolved around the bathroom door continued to be locked when R1 was done with the toilet. R1 needed assistance from staff to toilet, and they placed a commode over the toilet to raise the seat. She stated R1 did not like the commode in the bathroom so after using it they returned it to R4's room. Later when R1 walked past his room and saw the commode he went inside and started yelling and removed the commode, bringing it to the shower room. In response to that incident staff made sure the commode was in the other patient's room and covered with a sheet but that did not stop him from going into the room again yelling at staff and bringing the commode back to the shower room. They placed a sign on the door to remind staff to unlock R1's bathroom door when they were done using it. On 3/26/26, when R1 became upset the door was locked, R4 was using the bathroom, and staff communicated with him they were almost finished. Staff were unable to deescalate the situation before R1 entered R4's room. During the incidents between R1 and R4 she looked to see if they could separate them into different rooms without sharing a bathroom, but they had no availability at the time. In addition, they did not have staff to sit with R1 continually. She added after every encounter between the two residents they addressed the situation, developed interventions, and updated the staff. None of the incidents prior ever became physical or threatening and no harm was done. Facility policy Abuse Prevention Plan dated 2/24/26, indicated Prevention included completing a vulnerable assessment upon admission, care plan identified risks, and monitoring the resident for worsening cognitive impairment, aggressive behavior, and communication deficit. Staff education included abuse prevention training at orientation and annually along with conflict resolution, and cultural awareness. Facility policy Abuse Prohibition & Zero-Tolerance Policy dated 2/24/26, indicated All residents have the right to be free from abuse from staff or other residents. All employees are mandatory reporters. The facility would complete an investigation and report abuse to state agencies. The facility prohibits retaliation against reporters. The administrator was responsible for enforcement of the policy to include reporting, investigating, and prevention.

Based on observation, interview, and document review, the facility failed to identify alternatives prior to installing or using grab bars (bars installed at the head of the bed for a resident to hold onto for bed mobility or transfers), ensure grab bars were comprehensively assessed to determine if they were appropriate and safe, discuss the risks and benefits, and obtain informed consent prior to use of grab bars for 2 of 3 residents (R3, R4) who were observed to have grab bars on their bedsR3's quarterly minimum data set (MDS) dated [DATE] indicated intact cognition with diagnoses included Type 2 diabetes and chronic heart failure.R3's care plan dated 6/16/25 indicated R3 was independent with bed mobility and utilized bilateral grab bars.R3's Informed Choice Consent for Assistive Devices dated and signed 11/17/23 indicated risks and benefits were discussed and consent obtained from R3 for bilateral grab bars. R3's electronic health record (EHR) lacked evidence a grab bar assessment had been completed to determine necessity, and whether R3 could safely use grab bars.On 10/2/2025 at 2:00 p.m., R3 was observed sitting in her recliner. The bed next to the recliner was observed with bilateral grab bars. R3 confirmed she slept in the bed at night. R3 stated she requested the grab bars and utilized them when getting in and out of bed. R3 thought she had signed a paper about the grab bars but could not remember what it was about.R4's significant change MDS dated [DATE] indicated severely impaired cognition with diagnoses included dementia and stroke. R4's care plan dated 8/12/25 indicated R4 required the assistance of 2 staff members for bed mobility and transfers. R4's care plan lacked information about grab bars.R4's EHR lacked evidence a grab bar assessment had been completed to determine necessity, and whether R4 could safely use grab bars. Additionally, R4's EHR lacked evidence the resident or representative was educated on the risk of having grab bars on the bed, and/or a consent form was completed.On 10/2/25 at 12:59 p.m., bilateral grab bars were observed on R4's bed. R4's wife stated R4 used the grab bars sometimes to hold onto when staff are rolling him in bed. R4's wife could not recall whether anyone spoke to her about the risks of using the grab bars or if she signed any paperwork about the grab bars.During an interview on 10/2/25 at 2:46 p.m., registered nurse (RN)-A stated the nurse manager completed a grab bar assessment before grab bars could be placed on a resident's bed. RN-A was unable to find a grab bar assessment in the electronic health record (EHR) for R3 or R4. During an interview on 10/2/25 at 6:15 p.m., licensed practical nurse (LPN)-A stated when a resident requested grab bars the nurse manager was notified. The nurse manager completed the grab bar paperwork.During an interview on 10/3/25 at 10:33 p.m., RN-B stated she was the nurse manager who completed grab bar assessments. All residents should be assessed for safety prior to grab bar placement. The grab bar assessment was completed by hand on paper then placed in the resident's paper chart. During an interview on 10/3/25 at 2:11 p.m., the director of nursing (DON) stated the nurse manager would complete an assessment of the resident then risks and benefits of grab bars would be explained to a resident/resident representative and a consent signed prior to grab bar placement. DON did not know where the grab bar assessment was documented. DON confirmed R3 should have a grab bar assessment but one could not be located and R4 should have an grab bar assessment and signed consent, but they could not be located.The Use of Grab Bars Evaluation policy dated 6/2018 instructed to assess a resident to identify appropriate alternative and risk of entrapment from grab bars prior to installation. Staff also must review risk and benefits with resident and resident representative and obtain an informed consent. Based upon individual comprehensive assessment if it is determined that Grab Bars will be indicated to assist resident in maintaining or improving functional ability and do not constitute a restriction as defined as a restraint, Grab Bars may be utilized and care planned with consent of the resident/resident representative/Therapy to meet the individual needs.

Based on observation, interview and document review the facility failed to ensure proper personal protective equipment (PPE) was utilized for 5 of 5 residents (R23, R6, R15, R21, R36) reviewed for enhanced barrier precautions (EBP). Findings include: R23's face sheet printed 4/2/25, included diagnoses of chronic pain, artificial hip joint, weakness, and fistula of intestine. R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, no rejection of care, upper and lower extremity impairment, use of a wheelchair, substantial/maximal assistance with toileting hygiene, upper and lower body dressing. R23's care plan revised 1/5/24, indicated extensive assist with bathing, grooming, and dressing. R23's care plan further indicated incontinence of bowel and presence of nephrostomy (opening between kidney and the skin) for urination. R6's face sheet, included diagnoses of history of traumatic brain injury, benign prostatic hypertrophy (enlargement of prostate gland causing difficult urination), weakness, and pain. R6's significant change MDS dated [DATE], indicated moderately impaired cognition, no behaviors or rejection of care, use of a wheelchair, substantial/maximal assistance with toileting hygiene, bathing, dressing, and personal hygiene. R6's care plan revised 1/31/25, indicated urinary catheter for benign prostatic hypertrophy, urinary retention, and frequent urinary tract infections. R6's care plan further indicated R6 had all personal bowel and bladder cares provided by nursing staff. R15's face sheet printed 4/2/25, indicated diagnoses of congestive heart failure, obesity, chronic pain, open wound of scalp, and open wound of left lower leg. R15's quarterly MDS dated [DATE], indicated intact cognition, no rejection of care, impairment of left lower extremity, dependent on staff for toileting hygiene, and substantial/maximal assistance for bathing and dressing. R15's physician's orders printed 4/2/25, indicated wound to left lower leg with orders to cleanse with wound cleanser, apply dressing, cover with absorbent pad, wrap from foot to knee. Physician's orders further instructed to soak wound with acetic acid for 15 minutes daily. In addition, physician's orders directed to soak scalp wound gently with soap and water, pat wound dry, and bandage. Before applying bandage, wipe away any crusting that formed. R21's face sheet printed 4/2/25, indicated diagnoses of congestive heart failure, paraplegia (loss of muscle use in the lower half of the body), obesity, presence of urinary catheter, and open wound of the left thigh. R21's annual MDS dated [DATE], indicated intact cognition, no rejection of care, upper and lower extremity impairment, use of a wheelchair, dependent on staff for toileting hygiene, and substantial/maximal assistance with dressing, bathing, and personal hygiene. R21's care plan date 2/27/25, indicated presence of chronic pressure injury stage II due to lack of repositioning while out of the facility. R21's care plan further indicated urinary incontinence and the presence of a suprapubic catheter (tube inserted into the bladder through incision in lower abdomen) and need for staff assistance with toileting and incontinence care. During interview and observation on 4/1/25 at 8:42 a.m., nursing assistant (NA)-C and NA-B assisted R23 with toilet use, transfer, and hygiene. R23 had an Enhanced Barrier Precautions (EBP) sign her room entrance door. NA-C and NA-B were not wearing gowns when providing cares to R23. NA-C stated she did not wear a gown to assist R23. NA-C further stated she was educated on EBP and should have worn a gown when providing cares to R23. NA-B state she did not wear a gown to assist R23, she knew the sign for EBP was on R23's door, but staff did not usually wear gowns because everything changes all the time, and she was not sure what she was supposed to do. During interview and observation on 4/1/25 at 12:57 p.m., NA-B assisted R6 with hygiene and emptying of urinary catheter bag. R6 had a sign on his room entrance door indicating the need for EBP. NA-B did not wear a gown to assist R6. NA-B stated she knew there was an EBP sign on R6's door, knew she should wear a gown to assist R6, but did not wear a gown. During interview and observation on 4/1/25 at 1:21 p.m., NA-B and NA-C assisted R15 with personal hygiene and brief change. R15 had an EBP sign on her room entrance door. NA-B and NA-C did not wear gowns while assisting R15. NA-B and NA-C stated they knew they should have worn gowns to assist R15 due to her wounds, but did not wear gowns. During interview and observation on 4/2/25 at 8:46 a.m., NA-D assisted R21 with emptying his urinary catheter. R21 had an EBP sign on his room entrance door. NA-D did not wear a gown while assisting R21. NA-D stated she was unaware she was supposed to wear a gown while assisting R21 and did not know what the EBP sign meant. NA-D stated she would go find some gowns to use. During interview and observation on 4/2/25 at 8:49 a.m., NA-E assisted R15 with personal hygiene and brief change. R15 had an EBP sign on her room entrance door. NA-E did not wear a gown while assisting R15. NA-E stated she did not know she needed to wear a gown, was unsure which resident in the room required use of EBP and would have to go ask someone for answers. During interview on 4/2/25 at 9:04 a.m., licensed practical nurse (LPN)-A stated she would expect the nursing assistants to wear gowns when providing cares in EBP rooms. LPN-A further stated she was unsure why they were not wearing proper PPE for EBP because they had all had training on EBP. During interview on 4/3/25 at 9:43 a.m., director of nursing (DON) stated staff had been educated on EBP and she expected staff to use EBP when required. During interview on 4/2/25 at 10:11 a.m., infection preventionist (IP) and administrator stated they were not aware proper PPE was not being used for EBP resident rooms and would expect staff to wear gowns in EBP rooms to prevent spread of infection. 49893 R36 significant change Minimum Data Set (MDS) assessment dated [DATE] indicated, R36 was moderately impaired with no behaviors, dependent on staff for all activities of daily living (ADLs), incontinent of bowel and bladder, received nutrition and fluid intake through feeding tube (tube surgically inserted in the stomach to provide artificial nutrition and fluids. R36's diagnoses list included encephalopathy [a disorder involving altered brain function related to underlying disease/condition], transient ischemic attack (TIA) [temporary loss of blood flow to the brain], cerebral infarction [death of brain tissue due to loss of blood flow], gastrostomy [feeding tube surgically inserted into the stomach], moderate protein-calorie malnutrition, and nontraumatic intracranial hemorrhage [bleeding in the brain not caused by external force]. R36's provider orders included NPO [nothing by mouth] total tube nutrition, Nutren 1.5 cal ( brand of liquid nutrition) 500 ml three times a day, and water flushes 120 ml before and after each feeding. Provider orders also indicated route of administration for medications as gastric tube. A careplan dated 3/14/25 indicated R36 2 staff to assist [R36] to reposition in bed and chair every 2 hours, 2 staff to assist [R36] to transfer to and from chair and bed using Hoyer lift (machine used to lift a resident completely from one surface to another), and extensive assist with dressing, bathing, and personal cares. It also indicated R36 was NPO total tube feed due to inability to swallow. The careplan lacked indication of EBP. During interview on 3/31/25 at 5:54 p.m., R36's family member (FM)-A stated R36 requires tube feeding due to recent stroke and hospitalization for COVID. FM-A has not noticed staff wearing gowns when providing cares. During observation on 4/1/25 at 9:25 a.m., R36 was laying in bed with the head of his bed elevated. Bag dated 4/1/25 containing tube feeding solution was hanging from pole in the room. Enhanced barrier precautions sign was taped to the door. No PPE noted in or around R36's room. During observation and interview on 4/1/25 at 10:40 a.m., nursing assistant (NA)-A entered R36's room, applied gloves, and boosted R36 in bed by standing at the HOB and using soaker pad to boost resident in bed. NA-A then provided oral cares to resident using moistened sponges. During interview, NA-A stated staff are only required to wear gloves with EBP. NA-A stated carts with PPE are in the shower room in the middle of each hall. NA-A reiterated staff are required to wear gloves only for residents with EBP. NA-A and surveyor walked to shower room and observed a cart with drawers containing yellow gowns, gloves and other PPE. During observation and interview on 4/1/25 at 12:58 p.m., LPN-A arrived at R36's room and applied gloves. Without wearing a gown, LPN-A checked R36's residual volume [the volume of liquid remaining in the stomach]. LPN-A then administered water in R36's tube to flush tube and add fluid volume. After flushing the tube with water, LPN-A then hooked the liquid nutrition up to the feeding tube. LPN-A then removed the gloves. When asked about the EBP sign of R36's door, LPN-A stated she forgot to put a gown on. LPN-A stated resident's who have wounds, catheters, and feeding tubes are required to be placed on EBP. LPN-A stated nursing assistants are also required to wear a gown. When asked where the gowns are located, LPN-A looked up and down the hall stating gowns are normally located outside the resident's rooms however, In this one [hall] I think they are located in the shower room. LPN-A stated staff receive infection training yearly. The facility EBP sign posted on R23, R6, R15, R21, and R36's room entrance doors indicated the following: Enhanced Barrier Precautions- Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care. A facility policy titled Infection Control printed 4/3/25, indicated it was the policy of the facility that each resident and staff member be provided with a safe, sanitary and comfortable environment in which to live and work in by adapting processes to prevent development and transmission of disease and infection. An EBP policy was requested but not received.

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition. This had potential to affect all 40 residents, staff and visitors who consumed meals from the main production kitchen. Findings include: During interview on 4/2/25 9:11 a.m., cook (C)-A stated the left side of the plate warmer does not work, only plates on the right side get warm. C-A stated the left side had not functioned for some time. C-A stated she told the dietary manager (DM) a while ago, but the left side of plate warmer is still broken. C-A stated the broken plate warmer was a concern because the warmed plates help the food stay warmer longer. Food that is placed on the cold plates from the left side of the plate warmer cools faster and residents become unhappy when they eat cold food. During interview on 4/2/25 1:47 p.m., administrator stated the facility does not have or keep maintenance logs for the kitchen plate warmer. Administrator stated if dietary had a problem with the plate warmer, they should call maintenance and if maintenance can't fix it then they would have to call the manufacturing company. She stated she didn't think any of the equipment in the kitchen needed maintenance. During interview on 4/2/25 at 2:01 p.m., dietary district manager (DDM) stated the facility does not use a maintenance tracking system; they communicate by word of mouth. He stated he was unsure when the facility was aware the plate warmer was not working. Verified the plate warmer did not have a maintenance log associated with it. During interview on 4/2/25 at 2:13 p.m., DDM stated the dietary manager, and the maintenance team discussed the broken plate warmer approximately one month prior. DDM confirmed the plate warmer was not working earlier today. A facility equipment maintenance policy was asked for, none was provided.

Based on observation, interview, and document review, the facility failed to ensure meals were served warm/hot and palatable to promote quality of life and nutritional intake for 2 of 2 residents (R16 and R29) reviewed for dining. This had the potential to affect all residents who received food from the kitchen. Findings include: During an observation on 4/02/25 at 7:07 a.m., the cook (C)-A was preparing breakfast, food observed on the heat table included oatmeal, malt-o-meal, ham, and western style eggs. Toast was sitting above the steam table on a metal baking sheet. 4/02/25 at 7:34 a.m., plating begins for the residents seated in the dining room, C-A stated meals are served to dining room first then resident who prefer a tray in their rooms. 4/2/25 at 8:15 a.m., plating begins for East wing, trays put inside transport cart and delivered, last tray delivered to R16 in the East wing 4/2/25 at 8:22 a.m. 4/2/25 at 8:36 a.m., plating begins for North wing, trays put inside transport cart and delivered. 4/2/25 at 8:47 a.m., plating begins for [NAME] wing; extra tray added to transport cart for tasting. Last tray delivered to R29 on 4/2/25 at 9:03 a.m. 4/2/25 9:05 a.m., extra tray taken back to kitchen, C-A and dietary aide (DA)-A tasted meal on extra tray. C-A and DA-A confirmed eggs, and ham were cold and the toast was cold and soggy. C-A confirmed the toast was cooked at 7:07 a.m. was the same batch served to the last resident at 9:03 a.m. During interview on 4/2/25 at 9:33 a.m., R29 was observed to be the last resident to get her meal tray delivered to her room, she stated her eggs were cold, the toast was soggy, and the ham was a little chewy and cold. She stated she did not eat much of it; observed resident tray to be approximately 1/4 of portion was eaten. During interview on 4/2/25 at 10:38 a.m., R16 was observed to be the last resident to get his tray in the east wing. He stated his breakfast delivered this morning on 4/2/25 at approximately 8:20 a.m., the toast was so soggy he couldn't even eat it. The ham and eggs were both cold, so he did not eat any of it; observed resident tray to be uneaten. During interview on 4/3/25 at 11:45 a.m., C-A confirmed the breakfast foods can be difficult to keep warm or hot. C-A confirmed toast left sitting for over two hours would be expected to be soggy and cold; should have been redone. During interview on 4/3/25 at 11:45 a.m., dietary manager (DM) confirmed toast left out for 2 hours should not have been served to residents. Facility policy dated 2/2023 stated safe food handling procedures for time and temperature control will be practiced in the transportation and delivery of all food items.

Based on observation, interview, and record review, the facility failed to ensure discontinued medications were returned to the pharmacy or destroyed in a timely manner to decrease the potential for drug diversion for 1 of 1 medication rooms. Findings include: During an observation and interview with Licensed Practical Nurse (LPN)-A on 4/2/25 at 11:00 a.m., the shelf in the medication room had 108 cards of varying oral medications including blood pressure medications, supplements, antidepressants, etc. There were also two plastic bins with varying creams, bulk powdered medications, bottled liquid medications, boxes of insulin pens, and IV (intravenous) antibiotic medications. These medications included: -One unopened box of 5 glargine insulin pens dated 12/8/24 and an unopened box of 5 aspart insulin pens dated 1/2/24 for R39. -Ten medicine balls of intravenous cefazolin (antibiotic) dated 1/13/25 for R92, two unopened bottles of liquid Haldol (antipsychotic medication used to treat mental health disorders) containing 15 ml (milliliters) and 30 ml's liquid medication dated 3/4/25 for R93. -an undated, unlabeled bottle of Haldol containing 12 ml's liquid medication. -Two full boxes of sodium polystyrene (liquid medication used to treat elevated potassium) dated 2/15/25 for R7. LPN-A stated the medications on the shelf either needed to be sent back to the pharmacy or destroyed. Medications that need to be sent back to the pharmacy are placed in brown paper bags and sent with the pharmacy delivery driver who comes daily. LPN-A stated all shifts are responsible for helping destroy or prepare medications that need to be sent back. LPN-A confirmed the amounts of medications. R39's record read passed away on 1/29/2025. R93's record read passed away on 3/5/2025. R92's provider orders indicated cefazolin was ordered every 12 hours x 6 days with an end date of 1/21/2025. R92's face sheet indicated an admitted [DATE] and a discharge date of [DATE]. R7's provider order indicated sodium polystyrene was discontinued 2/26/2025. During interview on 4/2/25 at 11:33 a.m., the infection preventionist/assistant director of nursing (IP) confirmed the medications on the counter are due to be sent back or destroyed and are from residents who have been discharged , passed away, or had orders changed. The IP confirmed R93 passed away, R92 discharged , R7's orders changed to a different form of the medication, R39 passed away. During interview on 4/3/25 at 10:46 a.m., the consultant pharmacist (CP) stated residents receiving Medicare-A benefits get reimbursed and should have their medications returned to the pharmacy. Others should be returned for destructions or can be destroyed at the facility. Medications due to be credited should be returned to the pharmacy within 30 days, the remaining medications should be destroyed as soon as possible. CP indicated the monthly bubble pack medications are usually returned to the pharmacy, however, the staff could destroy them at the facility. During an observation and interview on 4/3/25 at 10:52 a.m., the administrator stated medications no longer needed are pulled from the medication cart and placed in the med room waiting to be sent to the pharmacy or destroyed. The administrator stated very little medications get sent back and nurses destroy them when they have time. The administrator stated she would expect medications to be destroyed or sent back biweekly and all nurses are expected to make sure medications get destroyed timely. Administrator observed the medications stored on the counter and confirmed the medications should have been taken care of to decrease the risk of diversion. During an interview on 4/3/25 at 11:52 a.m., the director of nursing stated destruction of medications is time dependent, however would hopefully be done within a month. Staff education provided to nursing staff January 2025 indicated Returns are all nurses jobs on all shifts!!!. If you have downtime do them! It should not take hours for one person to do them after they get ignored and piled up!! It continues, These are just some things that have been seen while doing cart audits that will help keep our medication carts/med storage at state regulations.' A policy dated 12/01/2016 titled Discontinued Medications indicated, discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. Complete 'Destruction of non-control substances' form and dispose of medications

Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators and dry storage were labeled, dated and discarded properly. This deficient practice had the potential to affect all 40 residents, staff and visitors who received food from facility kitchen. Findings include: During the initial kitchen tour on [DATE] at 11:35 a.m., dietary manager (DM) stated the dates listed on the food was the date of opening or when it was prepped and should be tossed after one week. The following items were observed in the fridge or dry storage with expired or undated food: -Hot dogs dated [DATE] -Bratwurst dated [DATE] -Tuna Salad dated [DATE] -Clam chowder dated [DATE] -Cranberry preparation date [DATE] -Celery preparation date ,d+[DATE] -Corn preparation undated -Ground all spice, manufacturer expiration date [DATE] -Ground Cloves, manufacturer expiration date [DATE] During interview on [DATE] at 9:11 a.m., cook (C)-A and dietary aide (DA)-A stated the date on foods in the fridge are the dates they were open or prepped on. C-A and DA-A both stated the foods should be thrown one week after the date on the food. C-A and DA-A both stated everyone is responsible for throwing out expired foods. During interview on [DATE] 2:45 p.m., dietary district manager (DDM) confirmed the facility policy is to date the food with the date it was opened or prepared; items should be thrown 7 days later. DDM verified the opened date on the hot dogs was [DATE] and should have been thrown by [DATE]. DDM verified the opened date on the celery was [DATE] and should have been thrown by [DATE]. DDM verified the manufacturers expiration date on the ground all spice was [DATE] and should have been thrown. Verified the manufacturers expiration date on the ground cloves was [DATE] and should have been thrown. Per facility Food Storage policy dated ,d+[DATE], storage areas will be neat, arranged for easy identification, and date marked as appropriate.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R6) reviewed for nutrition and weight loss had received a supplement to increase calorie intake and weight per provider order. Findings include: R6's face sheet included diagnoses of history of traumatic brain injury, weakness, pain, surgery of the digestive system, vascular disorder of the intestine, ischemic colitis (reduced blood flow to the colon), intestinal obstruction, and dysphagia (difficulty swallowing foods and liquids). R6's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, no behaviors or rejection of care, use of a wheelchair, substantial/maximal assistance with toileting hygiene, bathing, dressing, and personal hygiene. R6's care plan revised 1/31/25, indicated history and risk of dehydration, thickened liquids, risk for aspiration related to traumatic brain injury and postural positioning, poor safety awareness related to eating, pureed diet, and approaches of encouraging R6 to follow diet orders, eat small bites, chew well, eat smaller meals frequently throughout the day, and monitor for signs and symptoms of aspiration. R6's care plan further indicated R6 was able to feed himself after setup assistance, had a history of difficulty swallowing, and refused assistance with tasks beyond setup. R6's care plan category: nutritional assessment updated 1/31/25, indicated R6 was hospitalized from 12/11/24-12/20/24, due to intestinal obstruction and aspiration pneumonia. Diet was ordered for puree texture foods and thickened liquids. Video swallow completed 12/26/24, R6 and family chose to have no enteral feeding. Supervision and aspiration precautions to be observed. R6 height 72 inches and weight 145.6 pounds. Weight one month ago 161.8 pounds, weight 6 months ago 163.4 pounds. Weight loss of 9.7% in one month and 10.8% in 6 months. Weight loss related to swallow problem and due to need for hospitalization with surgical procedure. Will continue to provide food/fluid for comfort. Review of R6's record on 4/1/25, indicated the following weights: 10/1/24- 160.3 pounds 11/1/24- 156.4 pounds 12/1/24- 161.4 pounds 1/2/25- 145.8 pounds 2/2/25- 139.6 pounds 3/1/25- 134.6 pounds 4/1/25- 135 pounds Review of R6's nutritional assessment dated [DATE] indicated registered dietician (RD) documented weight loss of 11% in six months. RD requested nutritional supplement eight ounces three times per day with meals, staff assist as needed. R6's physician's orders printed 4/1/25, indicated dysphagia diet, pureed texture. R6's physician's orders did not include an order for a nutritional supplement due to weight loss. Review of a facility provided document titled Physician's Telephone Order dated 3/1/25, indicated a physician's order for Ensure/Boost supplement eight ounces three times per day with meals due to weight loss was ordered on 3/1/25. During interview on 4/2/25 at 11:39 a.m., RD stated she reviewed R6's record on 2/20/25, and recommended a supplement three times per day due to weight loss. RD stated R6's height was 72 inches tall and she would expect him to increase his weight to 178 pounds. RD further stated extra calories were needed to increase his weight back to baseline. RD stated she was not aware the supplement had not been started and would have expected it to be put in within one week of her recommendation. During interview on 4/2/25 at 11:58 a.m., director of nursing (DON) stated she was not aware R6's order for nutritional supplement had not been entered. DON stated any nurse could put orders in, but they didn't have a good system, and this order had been placed on her desk and lost in a stack of papers. DON further stated she would expect this order to be entered within one to two days of being signed by the provider. A policy on order entry of nutritional supplements was requested but not received.

Based on observation, interview, and record review the facility failed to revise the comprehensive care plan for diabetic management that included goals and individualized interventions for 2 of 3 residents (R1, R2) reviewed for diabetic management. Findings incude: R1's face sheet identified R1 had diagnoses that included type 1 diabetes mellitus (autoimmune disease where the pancreas fails to produce insulin) with hyperglycemia (high blood sugar), unspecified diabetic retinopathy (diabetic complication that leads to vision loss) without macular degeneration, other diabetes complications unspecified, hypoglycemia (low blood sugar) without coma. R1's quarterly minimum data set (MDS) dated [DATE], identified R1 had verbal behaviors directed at others that occurred 1 to 3 days, did not reject cares, and had insulin injections daily. R1's lab report dated 4/9/24, identified a hemoglobin A1C (blood test that measures the average amount of sugar in the blood for over the past few months) result was 8.6 which indicated high with a reference range to be 4.0-5.6. R1's care plan dated 4/12/24, identified R1 is medication-diet controlled diabetic and receives insulin every day. R1's goal was to have stabilization of diabetes as evidenced by all blood sugars below 150. Review at each physician visit and care conference. Interventions included: administer medications as ordered, provide labs as ordered, staff to do chemstrips as ordered and report any changes to physician, staff to monitor food intake and remind R1 of diabetic diet. R1's physician orders included orders for insulin and included the order dated 5/17/24, that directed R1 to have blood sugar checks before every meal and at hour of sleep (HS) via Dexcom monitor (continuous glucose monitoring device). Review of R1's care plan did not address a communication plan between R1 and staff for the Dexcom smart phone application installed on R1's personal cell phone that would log the blood sugars and alert R1 when blood sugars were too low or too high. Further did not specify a goal range for R1's blood sugars. R1's medication administration record (MAR) for November 2024, identified blood sugar checks via Dexcom monitor were scheduled at 7:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. Record review identified R1 had a wide range blood sugars; being as low as 47 and as high as 600. Although the MAR identified blood sugars as low as 47 and as high as 600, and R1 had documented refusals to take his prescribed insulin, R1's care plan did not address R1's symptomology of hypo/hyperglycemia nor individualized interventions to prevent/mitigate the risk of hypo/hyperglycemia and management of. Additionally the care plan did address behavioral management of R1's rejections of insulin medication to control blood sugars. During an interview on 12/10/24 at 3:41 p.m., licensed practical nurse (LPN)-A stated she would use her nursing judgement for low blood sugar and get something to eat/drink and hold insulin until resident would reach a healthy number. For hyperglycemia LPN-A would give insulin and recheck the blood sugar later barring the resident was asymptomatic. LPN-A stated R1 was very difficult to manage his blood sugars. R2's face sheet identified R2 had diagnoses of type 2 diabetes with diabetic chronic kidney disease, hyperglycemia. R2's quarterly MDS dated [DATE], identified R2 was poor at making decisions, and needed cues/supervision. R2 had insulin injections daily. R2's lab report dated 11/7/24, identified A1C of 8.2, which indicated high with a note from the medical provider that stated over the past 3 months the hemoglobin has greatly improved and to continue with current orders for blood sugar control. R2's physician orders included insulin and an order dated 9/26/24, identified blood sugar four times a day. R2 had a Dexcom sensor. Notify provider if blood sugar <70 or >550 via note or if outside parameters and symptomatic notify provider same day. R2's MAR dated November 2024, identified blood sugar checks via Dexcom monitor were scheduled at 7:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. Record review identified R2 had blood sugars above 200 very frequently R2's care plan did not include diabetic management focus that included R2's blood sugar range goals, management of the Dexcom sensor, R2's symptomology of hypo/hyperglycemia nor individualized interventions to prevent/mitigate the risk of hypo/hyperglycemia and management of. During and observation and interview on 12/12/24 at 8:14 a.m., registered nurse (RN)-A went to R2's room and went to the receiver and pushed the button that lit the screen up and read 205 as the blood sugar. RN-A verified that R2 did not have diabetic management in the care plan. During an interview on 12/11/24 at 1:06 p.m., Director of Nursing (DON) reviewed the care plan of R1 and that it did not address diabetic management clearly. Reviewed R2's care plan and verified that the care plan did not address diabetic management. DON would expect the care plans to have diabetic management in them, and moving forward they definitely will. During an interview on 12/12/24 at 2:26 p.m., Administrator stated the facility wanted the standard things to watch for hyper and hypoglycemic issues, watch their feet, wounds that are not healing, should be everyone with diabetes. Each care plan should be individualized. Administrator would expect the care plan to be updated and have each residents diabetic issues addressed within it. The facility Comprehensive Care Plan policy and procedure revised 8/18, identified the care plan as a personalized plan of daily care based on the nature of the illness, treatment prescribed, long and short range goals including how they can best be accomplished, types of care and consultation needed, what methods are most successful, modification to ensure best results.

Based on observation, interview and document review, the facility failed to implement care planned fall interventions for 1 of 2 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who had an unwitnessed fall while self-transferring when the motion sensor alarm did not sound and failed to alert staff that R1 was self-transferring as intended per care plan. Additionally, the facility failed to determine why the motion sensor alarm did not alert staff following the fall and added a second alarm. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, anxiety, and depression with severe cognitive deficits. R1 used a wheelchair and walker, was frequently incontinent of bladder and occasional incontinent of bowel. R1's care plan dated 2/20/23, indicated R1 had delusional disorders, neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) and was at risk for falls due to history of falls, poor decision making and dementia and was on antipsychotic medication. Staff were directed to initiate fall prevention program to include using call light for assistance, bed low and locked, per occupational therapy and physical therapy; all transfers & ambulation-SBA (stand by assist) with four wheeled walker, due to cognitive decline and poor safety with increased fall risk. Additionally, call light always within reach, position as needed for safety at nursing station am, pm and night shift. The care plan also indicated a motion sensor alarm (that sounds at the nurse's station making staff aware that R1 was self-transferring). R1's nursing assistant care sheet (which directs care staff for cares) indicated R1 used assist of one with walker for am and pm cares, used reading glasses, and was incontinent of bowel and bladder. (The care sheet did not indicate R1 was at risk for falls nor that an alarm system was in place to notify staff R1 was attempting to get out of bed). Review of Observation Detail List Report for R1 revealed a Fall Risk (Acuity) completed on 5/2/24, indicated R1 was disorientated, had poor visual impairment, and had a fall risk score of 20 (10 or higher represented a high risk for falls). Review of R1's Falls indicated the following: -11/09/23 R1 fell at 9:56 a.m. while trying to pull back curtain to talk to roommate and bumped head. Intervention included: educated R1 to use call light and wait for staff to assist. -12/19/13 at 4:443 p.m., R1 found on floor unwitnessed fall, trying to get up, staff heard R1 yelling. Intervention included: Reminders to use call light, bed low and locked, restorative therapy, motion sensor alarm. -12/22/23 at 4:01 p.m. R1 fell attempting to reach for walker from bed (to self-transfer) to use the bathroom, unwitnessed fall. Intervention included: Reminder to use call light for assistance, bed low and locked, restorative therapy, and motion sensor alarm. -12/31/23 at 5:38 p.m. R1 was found on floor next to roommates' bed with wheelchair next to her. R1 bumped head. Intervention included: Reminders to use call light for assistance, bed low and locked, restorative therapy, motion sensor alarm, position as needed for safety at nursing station a.m., p.m. and night. -6/04/24 at 6:20 a.m. (progress note indicated) R1 was found on floor in front of her bedroom. Fall was unwitnessed and resulted in a large hematoma above the left eye and upper lip. Resident kept on the floor in the upper seated position. Lying caused greater discomfort. At 7:00 a.m. Gold Cross (Emergency Medical Transport) arrived and left with resident, daughter was notified and will meet resident at St Mary's Emergency Department (ED). A follow up note indicated at 7:41 p.m. by the director of nursing (DON), received call from ED, R1 was admitted with diagnosis (Dx) of rib fx (fracture) and UTI (urinary tract infection). ED Provider Notes dated 6/04/24 at 3:04 p.m., indicated R1 was a [AGE] year-old female with a history of dementia from nursing home coming to the ED after a fall. She has two anterior rib fractures and right-sided chest wall pain. She also has contusion to her left eye and face. The prior team was worried of her having delirium, with altered mental status alternating between somnolence (sleepy) and agitation. Sources of delirium could be pain, in the setting of fall and rib fractures, or a urinary tract infection. During interview on 6/10/24 at 6:20 p.m., family member (FM)-A stated R1 has Lewy's bodies dementia, and she forgets she can no longer walk anymore. FM-A stated the staff informed her R1 was found on 6/04/24 in front of the doorway on the floor and there was blood on her nightstand, which was odd because she had a window bed. FM-A stated her window bed was at least 10 feet from the doorway. In addition, she was told there was no alarm sounding which was concerning to her since R1 has had several falls and she was wondering why they would not be using the alarm when it was working to reduce her falls. During interview on 6/11/24 at 9:30 a.m., registered nurse (RN)-A stated R1 was found sitting on the floor in front of the door the morning of 6/04/24, and there was no sensor alarm sounding. R1 was bleeding on her upper lip and leg and RN-A could see she was rubbing it all over. RN-A indicated the overnight staff are supposed to make sure the alarms were working and are on so we are alerted if she was up, the fall occurred at the beginning of her shift, R1 was still in her pajamas and had no shoes on. RN-A stated due to the emergency and because she was in so much pain, they did not change her or move her before the paramedics arrived. During observation and interview on 6/11/24 at 10:36 a.m., R1 was sitting with nursing assistant (NA)-A with motion sensor receiver next to NA-A. NA-A stated she was not working the day R1 fell . NA-A stated R1 used to have a motion sensor alarm but thinks they stopped it a while back and does not know why, but now she has a new pressure sensor alarm on her bed. During observation, R1 was looking at a bird magazine and commented at how beautiful the hummingbirds were. R1 had some bruising noted from the top of the left side of her face down to her chin, bruising was noted to be dark purple in color. Across the hall, the housekeeper made a noise with her mop bucket (moderate noise you would expect when mopping) and R1 was observed to get startled by the noise (jumped) and stated, I had one of those, but it never made noise like that! During observation on 6/11/24 at 10:40 a.m., R1's room had a motion sensor alarm on the dresser facing her bed (which would alarm to the nurse's station), along with a pressure sensor bed alarm (which would alarm in R1's room) attached to her bedside rail. NAR-A pushed R1's bed to demonstrate how the alarm sounded on bed. During interview on 6/11/24 at 10:54 a.m., with the director of nursing (DON) stated the fall R1 had was not reported to the state agency since she felt the care plan was followed, the sensor alarm was in R1's room and felt the staff were following it and her bed was low and in the locked position. The DON added she did not know why the motion sensor alarm did not go off the morning of R1's fall. The DON also indicated she was planning to have a nursing meeting today to go over the falls policy and to make sure they are completing the forms. Lastly, the DON stated she added a new alarm to R1's bed which was a pressure sensor alarm, which would alarm in R1's room. This was additional the motion sensory alarm. During interview on 6/11/24 at 3:24 p.m., LPN-B indicated she didn't hear the alarm go off the morning of R1's fall, we heard her yell. LPN-B stated she knows there were batteries in the motion sensor because she checks that all the time, adding the motion alarm assist staff to know when R1 was getting up so we can keep her from falling. During interview on 6/12/24 at 10:41 a.m., nursing assistant (NA)-C stated R1 has a motion alarm in her room, and that was the only alarm she had. In addition, we keep her bed in the low position due to her falls history and that keeps her from being able to get up. NA-C also indicated R1 can be easily startled. Adding, if R1 was in the hallway eating a snack, and someone spoke to her she would jump up or if you knocked on the door to her room, you would startle her. During interview on 6/12/24 at 10:55 a.m., NA-E stated she found R1 on the floor on 6/04/24, when she had her recent fall. NA-E stated she had her [NAME] stocking (compression stockings) on which should have been taken off when she went to bed, and her motion sensor alarm was not going off. NA-E stated she heard R1 yelling for help and when she got in the room R1 had blood coming down her face so she yelled for the nurse to come help. During interview on 6/12/24 at 11:25 a.m., NA-D stated she checks the alarms when she starts her shift in the morning to make sure they are on. NA-D indicated she was on the North Hall the morning R1 fell and never heard an alarm sound which she added she had mentioned to the DON, social worker, and the nurses. NA-D also stated she mentioned that R1 should be closer to the nurse's station since she was a fall risk but was told there was no open beds. Additionally, when speaking directly about the new intervention of the pressure sensor alarm, NA-D stated R1 can easily be startled, even when you speak to her, or you knock on her door. Startling her can also make her more likely to fall. During interview on 6/12/24 at 11:40 a.m., with assistant director of nursing (ADON) stated he is on the falls committee and helped with interventions. ADON added, R1 had a motion sensor alarm and no other alarms. Lastly, R1 was to be reminded to use her call light and ask for assistance with transfers and the bed has is to be in a low and locked position (the bed has to be low so the wheels go up so they don't move). The facility failed to determine why the motion sensor alarm failed, which had assisted to reduce falls since December 2023. Instead, the facility added a second pressure sensor alarm, without assessing the potential disruption this sounding alarm may cause the resident (with a diagnosis of Lewy bodies) and failed to update care planning/direct care staff sheets and nursing staff to the fall prevention and changes for R1 to prevent future falls. Falls Prevention and Management revised 3/03/2023, indicated to ensure residents live in an environment that is free from hazards over which the facility has control, and provide appropriate intervention to each resident to prevent avoidable accidents and injuries.

Based on observation, interview and document review the facility failed to report an unwitnessed fall with injury to the state agency (SA) for 1 of 2 residents (R1) reviewed for falls. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, anxiety and depression with severely cognitive deficits, used a wheelchair and walker, frequently incontinent of bladder and occasional incontinent of bowel. R1's care plan dated 2/20/23, indicated R1 had delusional disorders, neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function) and was at risk for falls due to history of falls, poor decision making and dementia and was on antipsychotic medication. Staff were directed to initiate fall prevention program to include using call light for assistance, bed low and locked, per occupational therapy and physical therapy; all transfers & ambulation-SBA (stand by assist) with four wheeled walker, due to cognitive decline & poor safety with increased fall risk. In addition, call light always with in reach, position as need for safety at nursing station am, pm and at night and motion sensor alarm. Review of R1's Progress Note: -6/04/24 at 6:20 a.m., R1 was found on floor in front of her bedroom. Fall was unwitnessed and resulted in a large hematoma above the left eye and upper lip. Resident kept on the floor in the upper seated position. Lying caused greater discomfort. At 7:00 a.m. Gold Cross (Emergency Medical Transport) arrived and left with resident, daughter was notified and will meet resident at St Mary's Emergency Department (ED). A follow up note indicated at 7:41 p.m. by the director of nursing (DON), received call from ED, R1 was admitted with diagnosis (Dx) of rib fx (fracture) and UTI (urinary tract infection). ED Provider Notes dated 6/04/24 at 3:04 p.m., indicated R1 was a [AGE] year-old female with a history of dementia from nursing home coming to the ED after a fall. She has two anterior rib fractures and right-sided chest wall pain. She also has contusion to her left eye and face. The prior team was worried of her having delirium, with altered mental status alternating between somnolence (sleepy) and agitation. Sources of delirium could be pain, in the setting of fall and rib fractures, or a urinary tract infection. During interview on 6/12/24 at 10:55 a.m., NA-E stated she found R1 on the floor on 6/04/24, when she had her recent fall. NA-E stated she had her [NAME] stocking (compression stockings) on which should have been taken off when she went to bed, and her motion sensor alarm was not going off. NA-E stated she heard R1 yelling for help and when she got in the room R1 had blood coming down her face so she yelled for the nurse to come help. During interview on 6/12/24 at 11:25 a.m., NA-D stated she checks the alarms when she starts her shift in the morning to make sure they are on. NA-D indicated she was on the North Hall the morning R1 fell and never heard an alarm sound which she added she had mentioned to the DON, social worker, and the nurses. During interview on 6/11/24 at 10:54 a.m., with the director of nursing (DON) stated the fall R1 had was not reported to the state agency since she felt the care plan was followed, the sensor alarm was in R1's room and felt the staff were following it and her bed was low and in the locked position. The DON added she did not know why the motion sensor alarm did not go off the morning of R1's fall. Vulnerable Adult Procedure revised 11/17/20, indicated all cases of known or suspected maltreatment of vulnerable adults to the MN Department of Health Office Of health facility complaints. If the incident involving the vulnerable adult requires immediate emergency services to protect the individual, call MAARC.

Based on interview and document review the facility failed to thoroughly investigate an unwitnessed fall with a serious injury for 1 of 2 residents (R1) whose motion sensory alarm did not sound/alert staff of movement and R1 fell . This resulted in rib fractures and contusions to R1's face. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, anxiety and depression with severely cognitive deficits, used a wheelchair and walker, frequently incontinent of bladder and occasional incontinent of bowel. R1's care plan dated 2/20/23, indicated R1 had delusional disorders, neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function) and was at risk for falls due to history of falls, poor decision making and dementia and was on antipsychotic medication. Staff were directed to initiate fall prevention program to include using call light for assistance, bed low and locked, per occupational therapy and physical therapy; all transfers & ambulation-SBA (stand by assist) with four wheeled walker, due to cognitive decline & poor safety with increased fall risk. In addition, call light always with in reach, position as need for safety at nursing station am, pm and at night and motion sensor alarm. Review of R1's Progress Note: -6/04/24 at 6:20 a.m., R1 was found on floor in front of her bedroom. Fall was unwitnessed and resulted in a large hematoma above the left eye and upper lip. Resident kept on the floor in the upper seated position. Lying caused greater discomfort. At 7:00 a.m. Gold Cross (Emergency Medical Transport) arrived and left with resident, daughter was notified and will meet resident at St Mary's Emergency Department (ED). A follow up note indicated at 7:41 p.m. by the director of nursing (DON), received call from ED, R1 was admitted with diagnosis (Dx) of rib fx (fracture) and UTI (urinary tract infection). ED Provider Notes dated 6/04/24 at 3:04 p.m., indicated R1 was a [AGE] year-old female with a history of dementia from nursing home coming to the ED after a fall. She has two anterior rib fractures and right-sided chest wall pain. She also has contusion to her left eye and face. The prior team was worried of her having delirium, with altered mental status alternating between somnolence (sleepy) and agitation. Sources of delirium could be pain, in the setting of fall and rib fractures, or a urinary tract infection. During interview on 6/12/24 at 10:55 a.m., NA-E stated she found R1 on the floor on 6/04/24, when she had her recent fall. NA-E stated she had her [NAME] stocking (compression stockings) on which should have been taken off when she went to bed, and her motion sensor alarm was not going off. NA-E stated she heard R1 yelling for help and when she got in the room R1 had blood coming down her face so she yelled for the nurse to come help. During interview on 6/12/24 at 11:25 a.m., NA-D stated she checks the alarms when she starts her shift in the morning to make sure they are on. NA-D indicated she was on the North Hall the morning R1 fell and never heard an alarm sound which she added she had mentioned to the DON, social worker, and the nurses. During interview on 6/11/24 at 10:54 a.m., with the director of nursing (DON) stated the fall R1 had was not reported to the state agency since she felt the care plan was followed, the sensor alarm was in R1's room and felt the staff were following it and her bed was low and in the locked position. The DON added she did not know why the motion sensor alarm did not go off the morning of R1's fall. The DON also indicated she was planning to have a nursing meeting today to go over the falls policy and to make sure they are completing the forms. Lastly, the DON stated she added a new alarm to R1's bed which was a pressure sensor alarm, which would alarm in R1's room. This was additional the motion sensory alarm. Vulnerable Adult Procedure revised 11/17/20, indicated an internal investigation will be started by the staff making the initial report along with with social services and licensed nurses. Staff initiating internal investigation should collect written statements from all staff members involved in incident. if there are any staff involved in the incident or abuse, they should be removed from the floor pending completion of the investigation.

Based on observation, interview and document review, the facility failed to assess, develop and implement a person centered dementia care treatment plan for 1 of 2 residents (R1) reviewed who had Lewy body dementia, was startled easily, at risk for falls, and the facility added a pressure sensor alarm to R1's bed, which sounded in her room. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had dementia, anxiety and depression with severely cognitive deficits, used a wheelchair and walker, frequently incontinent of bladder and occasional incontinent of bowel and had no falls since admission. R1's care plan dated 2/20/23, indicated R1 had delusional disorders, neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function) and was at risk for falls due to history of falls, poor decision making and dementia and was on antipsychotic medication. Staff were directed to initiate fall prevention program to include using call light for assistance, bed low and locked, per occupational therapy and physical therapy all transfers & ambulation-SBA (stand by assist) with four wheeled walker, due to cognitive decline & poor safety with increased fall risk. In addition, call light always with in reach, position as needed for safety at nursing station am, pm and at night shift, and motion sensor alarm. R1's Falls Observation dated 5/02/24, indicated R1 was disorientated had poor visual impairment and had a fall risk score of 20 (10 or higher represented a high risk for falls). During observation and interview on 6/11/24 at 10:36 a.m., R1 was sitting with nursing assistant (NA)-A with motion sensor receiver next to NA-A. NA-A stated she was not working the day R1 fell . NA-A stated R1 used to have a motion sensor alarm but thinks they stopped it a while back and does not know why, but now she has a new pressure sensor alarm on her bed. During observation, R1 was looking at a bird magazine and commented at how beautiful the hummingbirds were. Across the hall, the housekeeper made a noise with her mop bucket (moderate noise you would expect when mopping) and R1 was observed to get startled by the noise (jumped) and stated, I had one of those, but it never made noise like that! During interview on 6/12/24 at 10:41 a.m., nursing assistant (NA)-C stated R1 has a motion alarm in her room, and that was the only alarm she had. In addition, we keep her bed in the low position due to her falls history and that keeps her from being able to get up. NA-C also indicated R1 can be easily startled. Adding, if R1 was in the hallway eating a snack, and someone spoke to her she would jump up or if you knocked on the door to her room, you would startle her. During interview on 6/12/24 at 11:25 a.m., when speaking directly about the new intervention of the pressure sensor alarm, NA-D stated R1 can easily be startled, even when you speak to her, or you knock on her door. NA-D added, startling her can also make her more likely to fall. During interview on 6/11/24 at 10:54 a.m., the director of nursing (DON) stated she added a new alarm to R1's bed which was a pressure sensor alarm which would alarm in R1's room. This was additional to the motion sensor alarm. The facility was unable to provide evidence of an assessment process that determined a sounding pressure alarm was a person centered intervention to reduce falls for R1 based on her diagnosis and response environment/sounds around her, potentially putting her a greater risk of falls.

Based on interview and record review, the facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutritional service. This had the potential to affect 45 of 45 residents who resided in the facility. Findings include: During an interview on 5/24/24 at 9:12 a.m., [NAME] (C)-A, indicated the previous DM walked out earlier this month and the regional manager quit in April (2024). C-A had been doing the orders and the schedule for the past week. During a clarifying interview on 5/24/24 at 12:30 p.m., C-A stated she has not had any formal training for DM position and there was [NAME] currently in training for that position. C-A further stated the facility's registered dietician (RD), does not come into the kitchen when the RD is at the facility and has not been providing any support since the DM walked out. C-A could not articulate when RD was last at the facility. During an interview on 5/23/24 at 7:00 p.m., the administrator indicated the facility's dietary staff were contracted staff under an agreement with an outside company. Administrator verified there had not been a dietary manager since 5/10/24. There had been a lack of communication from the company on exactly when they would be sending a replacement but thought it would be soon. Administer further stated the registered dietician position was also a contracted position and was last at the facility in April 2024. During an interview on 5/24/24 at 1:59 p.m., dietary company regional director of operations (RDO-A) stated an awareness there was not DM at the facility and a new DM was hired but was not able to start because of delayed results from a pending back ground study. RDO-A indicated if dietary staff needed support they could call for guidance. Review of the facility contracted dietary company's policy dated 10/2022, titled, Professional staffing, HCSG policy 001, indicated there should be a qualified dietician or other clinically qualified nutrition professional, either full or part time. If the qualified dietician or other clinically qualified nutrition professional is not employed full time, a director of food and nutrition services who meets the necessary qualifications will be employed. Under Procedures: 1.) the qualified dietician, or other clinically qualified nutrition professional, will provide guidance and oversight to the Dining Services department for the consistent preparation and service of all regular and therapeutic diets, the training and supervision of all department staff, the purchase of food and supplies for the department and ensuring all practices are in full compliance with current standards of practice and all applicable regulatory requirements.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure ulcer interventions for 1 of 3 residents (R1) who was admitted to the facility without pressure ulcers. The facility failed to provide ongoing comprehensive skin assessments, monitor for signs of infection/deterioration and ensure R1 was seen at the wound clinic per physician orders. As a result, R1 had a life threatening infection that required an above the knee amputation resulting in an immediate jeopardy. The IJ began on 12/20/22, when R1 was transferred to hospital-B for left above knee amputation related to diagnoses of osteomyelitis (bone infection) and calcaneus sepsis (life threatening bone infection that has spread through the body) from R1's pressure ulcer. The director of nursing (DON), assistant director of nursing (ADON), and social worker (SW)-A were notified of the IJ on 1/30/23, at 3:55 p.m. The IJ was removed on 2/2/23, at 1:51 p.m. Noncompliance remained at the lower scope and severity level of D-isolated indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Pressure Ulcer/Injury (PU/PI); localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin or open ulcer. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Ulcer: partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Unstageable Pressure Ulcer: full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar should only be removed after careful clinical consideration and consultation with the resident's physician. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Debridement: the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. Eschar: is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. R1's Face sheet printed 1/30/23, identified a diagnoses of Diabetes and morbid obesity. R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 did not have cognitive impairment. R1 required limited assistance from one staff for hygiene, dressing, and toileting and required extensive assist from one staff for bed mobility and transfers. In addition, R1 was at risk for pressure ulcers, did not have skin concerns, and utilized a pressure reducing device for his bed. R1's skin care plan 8/18/22, indicated R1 was at risk for delayed healing and additional skin break down due to immobility and diabetes. Corresponding interventions included treat skin issues/wounds per MD orders. Record location, size (length, width, depth), color, surrounding skin, presence/absence of drainage/pain/signs of healing. Avoid shearing resident's skin during positioning, transferring, and turning. R1's East Nurse Aide Shift Report document, dated 8/19/22, evening shift, identified that R1's left heel has a pressure ulcer-the nurse knows. R1's record lacked a comprehensive assessment that included description, measurements, interventions to improve and/or prevent further deterioration. Further, it was not evident the physician was notified upon identification. R1's care plan 8/1/22 did not include interventions to treat R1's pressure ulcers once they developed. Additionally, review of physician orders identified delay in treatment and intervention. Physician order dated 8/21/22, directed staff not to put R1's shoes on and physician order dated 8/23/22 directed staff to change left heel dressing every 3 days and as needed: cleanse with wound cleanser, foam heel dressing and secure with Kerlix (roll gauze). Check twice a day for placement, keep dry and intact. This order remained until 10/6/22 even though there had been physician ordered treatment change on 9/7/22. R1's progress note dated 8/23/22, indicated R1's Mepilex (absorbent antimicrobial foam dressing) dressing was changed to his left heel with a moderate amount of serosanguinous drainage (composed of red blood cells and blood serum, typically thin and watery with light red or pink hue). Area measured 8 centimeters (cm) x 8.5 cm. Wound appeared to be a drained open blister, top skin is intact, pink, and whitish overall. New dry foam heel dressing applied with Kerlix, blue boots on and left heel floated while in bed. The note did not identify the stage of the ulcer, and the care plan was not revised to identify the aforementioned interventions. R1's progress note dated 8/24/23, indicated R1's left heel large blister is now open, Xerofoam (medicated dressing) applied, Vaseline gauze, ABD pad (an absorbent pad) and wrapped with ace bandage. R1's physician orders did not identify a signed order to change/add the medicated gauze wound treatment from the ordered treatment on 8/23/22, that directed to clean wound with wound cleanser, apply heel dressing, and secure with Kerlix every three days. In review of R1's record it could not be determined the duration of how long Xeroform was used. R1's significant change MDS dated [DATE], identified R1 had one stage 2 pressure ulcer. However, R1's skin assessment dated [DATE], i identified a stage 2 pressure ulcer on his left heel and had wounds to left buttock. No further assessment was identified, however R1 would be referred to the wound clinic. R1's Nurse Practitioner visit, dated 9/7/2022, indicated R1 has developed a pressure ulcer to the plantar (sole) of his left heel that had been found a few days ago. The ulcer was fairly large, reddened area that encompassed most of the plantar aspect of his heel, two inch diameter eschar in the center of the wound. Nurses think it might be slightly improving. New treatment included, cleanse the wound with wound cleanser, apply Medi honey (an antibacterial wound gel), foam heel dressing, and secure with Kerlix, change dressing every 3 days and as needed. Further indicated a provider from wound clinic would be coming to visit R1 for wound care yet this week. We will continue to monitor R1 on a routine and as needed basis. Diagnosis of pressure injury of skin of left heel, unspecified injury stage. R1's wound assessment dated [DATE], indicated R1's medical record identified R1 developed a pressure ulcer to his left heel that measured 5 centimeters (cm) x 6.5 cm with a heavy amount of serosanguinous drainage. The record lacked staging of the pressure ulcer. R1's skin care plan was revised on 9/21/22, identified the left heel pressure area and had pressure areas on the tops of his right toes. Additional interventions included; air mattress on bed, followed by podiatry, determine if R1's feet are desensitized to pain/pressure, discourage R1 from using anything sharp/abrasive /drying to feet or nails. R1's progress note dated 9/26/23, indicated R1's wound changed in appearance; wound bed about 98% necrotic tissue. R1's wound note dated 9/28/22, left heel measured 5 cm x 5.7 cm, necrotic, declining. R1's Nurse Practitioner visit, dated 9/28/2022, indicated R1 was being seen today for his left heel, this started out as a blister approximately 8/23/22. The nursing staff have been trying to keep pressure off of it and have been treating it, but it has progressed. R1 has a very large black spot on the bottom/back of his left heel, with slight foul odor. Diagnosis: pressure injury of skin of left heel, unspecified injury stage. Referral to the wound clinic was completed. R1's Wound Care Clinic After Visit Summary (AVS) dated 10/6/22, indicated a new order placed for an ultrasound of the lower left extremities. Culture taken of unstageable left heel pressure ulcer. Will need wound care follow-up on 10/20/22. Included orders to start antibiotic medications. Wound dressing orders included: carefully remove all prior wraps and dressings and rinse all open areas with saline. Soak gauze in Dakin's 1/4 solution (a strong topical antiseptic to clean infected ulcers) and apply to heel for 15 minutes with dressing change daily, apply Iodosorb (wound gel that cleanse the wound by absorbing fluids and removing exudate) to the left posterior heel, place absorbent pad. If dressing becomes soiled, saturated, displaced, please remove, and replace. 100% non-weightbearing to the left lower extremity-PRAFO boot provided for wound offloading of left posterior heel, toe touch as needed for transfers. Use a tubigrip or stockinette to his left lower extremity. R1's culture results dated 10/11/23, identified methicillin resistant staphylococcus aureus (MRSA) was found in left heel wound and antibiotics were changed. R1's Medication Administration Record (MAR) identified the Iodosorb was not transcribed or implemented until 10/26/26. 20 days after the order was to be initiated. Further, R1's MAR identified on 10/8/22, 10/9/22, and 10/10/22, dressing was not changed with Dakin's solution, due to item unavailable. On 10/20/22 not completed as R1 was unavailable. R1's wound note dated 10/18/22, indicated left heel measured 5.0 cm x 6.5 cm, necrotic, declining. R1's Doctor of Podiatric Medicine (DPM) wound clinic visit, dated 10/20/22, indicated R1 was last seen on 8/19/22. The nursing facility applied the foam dressing to the left heel without removing the plastic covering, this was applied incorrectly so this caused maceration of the pressure injury. Post debridement measurements were 7.6 cm x 6.9 cm x 0.2 cm. New orders to apply Iodosorb, calmoseptime (an ointment that forms a barrier on the skin to protect it from irritants) and ABD pad applied to left heel ulceration. R1's vascular ultrasound scheduled for 11/7/22. Physician orders dated 10/21/22 identified the aforementioned order from the podiatrist, however, did not include the directive to apply the calmoseptime. Corresponding MAR identified the dressing was completed without the calmoseptime from 10/21/22 to 10/26/22. R1's Wound Clinic AVS dated 10/27/22, indicated R1 has an appointment on 11/7/22 at 9:00 am to have an ultrasound completed of his lower extremities, and wound care follow up on 11/10/22. According to R1's record, R1 was not seen for vascular ultrasound as ordered. R1's Physician assistant (PA) advanced wound healing visit and orders, dated 10/27/22, indicated R1's wound was very macerated and has worsened since his last visit. Radiographs of his left heel unstageable pressure ulcer, revealed no osteomyelitis. Wound was debrided; post debridement measurements were 5.5 cm x 9.1 cm x 0.4 cm. Advised R1 to increase protein intake via diet supplementation to accelerate wound healing. Return in 2 weeks for re-evaluation. New orders included, discontinue previous order. start daily dressing changes; cleanse wound with saline and gauze, soak the wound using gauze soaked in Dakin's 1/4 strength for 10 -15 minutes. Apply Santyl (an ointment used to remove dead tissue from a wound) to the left posterior wound bed (nickel thick), cover with ABD pad. R1's PA advanced wound healing visit, dated 11/10/22, indicated that R1 stated during his visit that his dressing does not get changed every day. R1 further stated he has significant pain in the region of the ulcer edges, failed to complete his vascular ultrasound appointment and R1 reported the transportation never arrived, and was rescheduled today. R1 left heel unstageable pressure ulcer was debrided, post debridement measurements were 4.2 cm x 8.1 cm x 0.6 cm. Return to clinic in 1 week. According to R1's record it was not evident R1 returned to the wound clinic within one week as ordered. R1's NP Visit note, dated 11/30/22, indicated R1 was seen due to concerns with right heel, identified right heel as an unstageable pressure injury, referral in place for the wound clinic for his right heel. The visit note did not include further description of the left and right heel pressure ulcers. R1's quarterly MDS, dated [DATE], identified R1 had 2 unstageable pressure ulcers, however R1's record (aside from MDS) did not identify the presence of a second unstageable ulcer. R1's progress note, dated 12/6/22, indicated that social worker (SW)-A escorted R1 to his wound clinic appointment. R1 was sent to the emergency department from the wound clinic for further evaluation due to R1's elevated INR (a blood test that measures the time for blood to clot), pale complexion, lethargy and possible cellulitis of wound and was admitted to the hospital. In review of R1's medical record, it was not evident an assessment was completed to determine the tissue tolerance over bony areas to pressure in accordance with facility policy. Not evident on-going monitoring was completed. Further not evident weekly comprehensive assessments were completed for all of R1's pressure ulcers that included risk factors, size, depth, stage, wound bed characteristics, drainage, and pain. There was no indication the facility reassessed PU prevention modalities and treatment strategies for effectiveness every 14 days or sooner to ensure appropriateness for healing and/or prevent infection and further deterioration. During a continuous observation on 1/26/23, from 9:35 a.m. to 10:51 a.m. R1 was observed to be lying on his back in bed. R1 was observed to have an above the knee amputation on his left leg and had a wound vac that was attached to the stump that was running. R1's right lower extremity had a blue PRAFO boot (a device worn on the calf and foot that is used to prevent pressure ulcers to the back of the heel) on. R1 stated he had not eaten breakfast yet. During an interview on 1/26/23, at 10:38 a.m. nursing assistant (NA)-A stated she had been the one who had first identified the pressure ulcer on R1's left heel that had resulted in left leg amputation because of infection. R1 was hospitalized for about a month. NA-A explained NAs did not document toileting/reposition in the electronic health record (EHR); they would use paper care sheets with time slots of 6 am, 8 am, 10 am, 12 pm. We just put a check mark if we toileted or repositioned them. If the care plan changed the sheets would be updated by the nurse so that the NA's knew what to do. Most of the sheets don't direct us to offload heels for for people who need it, NA-A did not think that staff would offload heels if it was not on the care sheet. NA-A stated she could not get residents toileted and repositioned on time per their care plan because there was not enough staff. NA-A stated she had not had time to reposition R1 yet, because she had been busy with other residents. At 10:56 a.m. R1 was transferred via full body lift to his wheelchair. During an interview on 1/26/23, at 2:01 p.m. registered nurse (RN)-A changed R1's right heel dressing; reported the scabbed area measured 2.4 cm x 1.0 cm which would not be stageable. RN-A indicated the ulcer looked like it was getting better. During an observation and interview on 1/26/23, at 2:15 p.m. unit clinical manager (CM)-A stated, the floor nurses should be doing weekly wound assessments, this is typically done on Saturdays and should be documented in the nursing notes. CM-A stated R1 had pressure ulcers to his buttocks and was not sure how long they have been there. At 2:27 p.m. RN-A removed the sacral Mepilex dressing from R1's coccyx area; dressing had pinkish drainage on it. RN-A stated there was a moderate amount of serosanguinous drainage on the dressing. Four open areas were observed on R1's coccyx area. RN-A stated they were all stage 2 pressure ulcers. RN-A measured the areas and started to cleanse the areas with wound cleanser. R1 clenched his buttocks during the cleansing and stated, Ow! Ow! Ow! Wound beds all were red. Measurements were as follows: middle coccyx area measured 3.1 cm x 1.0 cm, ulcer directly below measured 0.5 cm x 0.5 cm. Right middle buttock ulcer was 1.5 cm x 0.5 cm and right lateral area was 0.7 cm x 0.7 cm. RN-A cut pieces of Aquacel and placed in each wound bed. RN-A stated they did not have any sacral Mepilex so instead she used a square 4 x 4 Mepilex and placed it in the middle of R1's coccyx area. R1 was then repositioned to his left side. During an interview on 1/26/23, at 3:04 p.m. CM-A stated the facility did not have a designated nurse to oversee wound care right now; the wound care system that had been in place just kind of fell apart. After a wound was identified a comprehensive assessment should be completed that included measurements, staging (if pressure ulcer), wound bed appearance, drainage and surrounding skin area. Assessments were to be completed weekly because if it started to worsen, the provider would be notified for possible change in treatments. The dressing should be changed per the MD order. During an interview on 1/26/23, at 5:17 p.m. CM-A thought R1's left heel wound started as a stage 2 pressure ulcer. CM-A was not sure when the ulcer became unstageable because the weekly wound assessments were not done. CM-A reported she was responsible for tracking the wound clinic appointments and communicating with SW-A to set up transport services; R1's follow-up appointment after the 11/10/22 was missed. On 11/30/22, R1 had developed a blister on his right heel. We obtained a referral to wound clinic, the appointment was made for 12/6/22, when he was transferred to the emergency room . He was admitted to hospital with osteomyelitis (bone infection) that resulted in a left above the knee amputation. During an interview on 1/26/23 at 4:49 p.m. SW-A, stated she was the one who set up transportation for outside appointments. R1 did not go to his vascular ultrasound appointment. The follow-up wound clinic appointment from the 11/10/22 visit was missed because nursing had not informed her of R1's need for appointment or transportation. R1 did not have another wound clinic appointment until 12/6/22, that she escorted him to. When we got to the clinic, R1 looked very white and pale looking. Clinic staff took him back for examination and came back out and told her they were sending him to the emergency room because he had an elevated INR, he was pale, and had possible cellulitis (skin infection). During an interview on 1/26/23, at 3:24 p.m. assistant director of nursing (ADON) stated the facility did not have anyone in charge of wounds currently. Anyone with a wound should be comprehensively assessed at least weekly. With any worsening the provider would need to be called to ensure appropriate treatment was in place. The resident's wound clinic physicians have been the ones doing the measurements. During an interview on 1/30/23 at 12:59 a.m. director of nursing (DON) stated, when R1 was admitted he had no pressure ulcers. DON stated R1 did not have weekly skin assessments performed as he should have to include pressure ulcer staging, measurement of ulcer, wound bed characteristics, surrounding skin area. Assessment needed to be done weekly to ensure the current treatment was working. DON stated on 11/10/22, R1 was supposed to have a follow-up appointment with the wound specialist within a week and the MD orders were not followed. R1 did not get to the wound specialist until 12/6/22. At the appointment R1 was immediately hospitalized with sepsis and ultimate left leg above the knee leg amputation. DON stated the floor nurses should be doing weekly bath audits which would be where the comprehensive skin assessments should go. During a phone interview on 1/30/23, at 1:57 p.m. NP-A explained she had seen R1 in September (2022) for his left heel unstageable ulcer so depth could not be determined. NP-A referred R1 to the wound clinic. Then on 11/30/22, NP-A wrote another referral for R1's right heel unstageable ulcer. The missed appointments and lack of assessments resulted in an unstageable pressure ulcer, sepsis, and ultimate loss of his left leg. NP-A stated she had recently seen R1 for his pressure ulcers on his buttocks, she had cultured the wounds, results were MRSA. We will be starting antibiotics. During a phone interview on 1/31/23, at 4:34 p.m. physician assistant wound specialist (PAWS)-A stated R1's left heel unstageable pressure ulcer was being managed by the wound clinic. We saw R1 on 10/20/22, at that time the left heel was just a big eschar cap. On 11/10/22, the eschar cap had softened and was macerated because the facility had applied the dressing incorrectly by not taking the plastic off. R1 was supposed to come back in a week for follow-up however, did not come back until 12/6/22. When he presented on 12/6/22 for that appointment he was really sick, pale, weak, cognition was blunted, his INR was high, he was just way off from his baseline. and that they sent him right over to the ER. He further stated he, the podiatrist, and ortho looked at his left heel, it was all open and wet, eschar stringy tissue, it looked terrible. R1 was diagnosed at the hospital with osteomyelitis and calcaneus sepsis. On 12/20/22, R1 transferred to another hospital where he had an above the knee amputation as a direct result from the infection in the pressure ulcer. Had R1 came back for his follow-up visit as ordered, could have prevented amputation of his leg. Facility policy entitled, Pressure Sores Protocol, revised 8/3/18, indicated a purpose to identify residents at risk for developing pressure sores. To assure residents are receiving necessary treatment and services to prompt healing, prevent infection and prevent new sores from developing. 1. Identifying at-risk individuals needing prevention and specific factors placing them at risk will be done in the initial comprehensive nursing assessment and in on-going assessments by the nursing staff. 5. Protection of residents from external mechanical forces such as friction, pressure, and shearing will be done as follows: a. positioning devices, such as pillows or foam wedges, should be used to keep boy prominence's from direct contact with one another, according to a written plan of care. B. individuals in bed who are completely immobile should have a care plan that includes the use of devices that totally relieves pressure on heels. The heels should be raised off the bed. F. Any individual assessed to be at risk for developing pressure areas should be placed on a pressure reducing device such as an air mattress, RoHo or gel cushions. The resident should be repositioned, shifting the points of pressure at least every hour. Resident capable of being taught should be instructed to shift weight every 15 minutes while sitting. Facility policy, entitled, Tissue Tolerance Audit Policy and Procedure, revised 8/3/18, included: 1. Tissue tolerance is the skin and its supporting structures ability to endure the effects of pressure without adverse effects. Each resident who is dependent on bed and/or chair mobility, will be monitored for tissue tolerance while lying and sitting: a. upon admission, readmission; and b. with a change in condition 2. Once an individualized turning and repositioning schedule is determined a daily skin inspection by the nursing assistant and a weekly skin inspection by the licensed nurse will be done to ensure that there are no adverse effects to the skin and its supporting structures, ensuring that the determined intervals are still appropriate. Facility policy entitled, Pressure Sore Monitoring, revised 8/3/18, identified a purpose to assure assessment and reassessment completion of all open area and appropriateness of treatment. 1. Staff nurse will assess all open areas on each resident on his/her wing weekly. 2. Staff will document on the skin and wound assessment and record sheet the stage of each area and present treatment. 3. Report of open areas and treatment will be given to the Quality Assurance Nurse. 4. Quality Assurance Nurse will do random assessments of open areas on each unit on an ongoing basis. %. Copies of weekly assessments of open areas will be available to the dietician for her review at her next visit. Residents with significant open areas will be reviewed by the dietician and recommendations made. Scheduled reviews with dietician will be coordinated by the dietary manager. 6. Assessment information will be utilized to assure on-going individual care plan approaches are current and specific for each resident. The immediate Jeopardy that began on 12/20/22, was removed on 2/2/23 at 1:51 p.m. when it was verified through interview and document review the facility implemented the following: -immediately review/revise/develop their pressure ulcer program policies and protocols. -Provided education to licensed staff on completing comprehensive pressure ulcer assessments and care plan interventions for pressure ulcers. -Comprehensively assess all residents who have any stage pressure ulcers. Evaluated and review/revise care plan for appropriateness of treatment and services to reduce the risk of pressure ulcer development and/or further deterioration of pressure ulcers and infection with notification to the physician as appropriate. -Provided education to direct care staff on pressure ulcer prevention modalities in accordance with the care plan.

Based on interview and document review, the facility failed to ensure residents were free from neglect when they allowed two nursing assistants (NA)-A, NA-B, who were suspected of chemical impairment to work in the facility. NA-A and NA-B both tested positive for illicit drugs. 3 of 3 residents (R2, R3, R4) sustained falls that resulted in injuries when NA-A and NA-B did not follow the care plan. This resulted in an immediate jeopardy (IJ) for resident health and safety when NA-A and NA-B provided care. The IJ began on 1/18/23, when the facility failed to ensure residents were free from neglect when they allowed two nursing assistants who tested positive of chemical impairment to work in the facility. The administrator and the director of nursing (DON) were notified of the IJ on 1/25/23, at 5:28 p.m. The IJ was removed on 1/27/23, at 5:30 p.m. but scope and severity remained at a level D, no actual harm with potential for more than minimal harm. Findings include: NA-A's employee file dated 1/31/22, included a self-reported history of alcoholism. On 2/1/22, the facility implemented a plan to breathalyzer NA-A at beginning and middle of her shift while employed. On 2/20/22, NA-A reported to work at 6:30 a.m. and had a breathalyzer test (A breath alcohol test determines how much alcohol is in your blood) of 0.13 (0.08 is considered legally intoxicated in the state on Minnesota.) NA-A was sent home before starting her shift. The facility did not complete any breathalyzer testing after 5/10/22. NA-A's employee file contained NA-A's Escreen (an online portal that enables individuals to schedule and pay for drug screening and testing services and receive the online results.) Specimen Result Certificate dated 1/18/23, at 9:31 a.m., showed positive presence of amphetamines (a synthetic, addictive, mood-altering drug, used illegally as a stimulant). The report indicated the laboratory confirmation cutoff for a positive test of amphetamines as being 500 (nanograms/milliliter) ng/ml and this specimen indicated NA-A's result of over 1000 ng/ml. The result disposition of this specimen indicated NA-A's specimen as being positive for amphetamines. NA-B's employee file contained NA-B's Escreen Specimen Results Certificate dated 4/11/22, at 8:36 a.m. Employee file identified on her pre-employment drug screen sent to Escreen on 4/5/22, at 2:00 p.m. showed a positive presence of marijuana. The report indicated the laboratory confirmation cutoff for a positive test of marijuana as being 15ng/ml and this specimen indicated NA-B's result of over 50ng/ml. The result disposition of this specimen indicated NA-B's specimen as being positive for marijuana. On 1/19/23, at 1:09 p.m. an interview was conducted with NA-C. NA-C stated she had reported concerns to registered nurse (RN)-A about NA-A smelling of alcohol and sneaking out the window to drink in NA-A's truck during a shift. NA-C also stated on a shift in November (unknown date), NA-A had ran into a parked car in the parking lot and come into work smelling of alcohol. NA-C stated she did not feel NA-A was safe to continue to work at the facility as residents continued to fall on NA-A's shifts. NA-C stated she felt management was aware of her concerns because NA-C had told management she refused to work at the same time as NA-A, because N-A came to work impaired, and NA-C didn't want to work with someone you could not rely on. On 1/19/23, at 1:48 p.m. an interview was conducted with RN-A. RN-A stated she was aware that both NA-A and NA-B were supposed to be in recovery. RN-A stated she had heard about NA-A and NA-B coming to work chemically impaired in the past, and had heard about NA-A drinking at work last week. RN-A stated she had gotten calls from staff with concerns of NA-A and NA-B being at work impaired, and she told the staff to send them home. RN-A stated the last time she had told someone to send one of them home was a few months ago. RN-A stated she has had to do some coaching and re-education with NA-A when she had completed a transfer wrong and nearly dropped a resident when she wasn't using a gait belt during the transfer. RN-A stated she was unable to recall date of the coachings but stated it had been more than once On 1/19/23, at 2:23 p.m. an interview was conducted with director of nursing (DON) who stated she had heard allegations of NA-A drinking on the facility premises and sneaking out the window to avoid facility camaras on the weekend of the January 1st, 2023. The DON did not come to the facility but reviewed the camera footage on January 2nd, 2023, and stated she had not found anything concerning. The DON stated NA-A and NA-B did not have any substance abuse concerns in their employee files (despite NA-A self-reporting concerns and being breathalyzed previously at the facility). The DON stated she had NA-A and NA-B drug tested on [DATE]rd, 2023, to rule out staff suspicions of intoxication at work. The DON stated NA-A had never tested positive for alcohol at work during her breathalyzer testing contract. The DON stated NA-A's drug screen from 1/3/23, had come back positive for amphetamines (a synthetic, addictive, mood-altering drug, used illegally as a stimulant and legally as a prescription drug to treat children with ADD and adults with narcolepsy) on 1/18/23. NA-A had admitted to taking Vyvanse (a stimulant medication that is mainly used to treat attention deficit hyperactivity disorder in people over the age of five.) and continued to stay on the schedule and work pending the DON getting direction from the Escreen doctor on how to proceed on 1/23/23 when the doctor would be available for consultation. The DON stated she was not concerned about diversion related to the positive amphetamine test with NA-A, because no current residents had orders for amphetamines. The DON stated the facility was aware that NA-B had a prescription for medical marijuana and the DON had no concerns for NA-B's work performance with residents. The DON stated they had no monitoring of NA-A and NA-B's work performance related to their known chemical abuse history. On 1/19/23, at 5:13 p.m. an interview was conducted with the administrator who stated the DON had informed him on the day of the survey 1/19/23, she had a copy of NA-B's medical marijuana card in NA-B's employment file. The administrator stated he had reviewed NA-B's employment file and was unable to locate a medical marijuana card and had found a pre-employment drug test that was positive for marijuana. The administrator was unsure if staff would be able to work when using medical marijuana and would have to review the facility policy. The administrator stated nothing had been or was currently in place for monitoring impairment in NA-A or NA-B. The administrator stated he had thought both NA-A and NA-B had been removed from the schedule on 1/3/2023 pending further investigation, he was unaware NA-A and NA-B continued to be on the schedule. On 1/23/23 at 9:04 a.m. an interview was conducted with assistant director of nursing (ADON). The ADON stated he had been the person who tested NA-A with the portable breathalyzer on 2/10/22, and had sent her home. The ADON stated he was instructed by the DON to breathalyze NA-A at the beginning of her shifts back in February of 2022, but he was not sure who was supposed to breathalyzer her in the middle of her shifts. The ADON stated he had called the DON and informed her he had sent NA-A home on 2/10/22, related to the positive breathalyzer test. The ADON stated the DON informed him he had done the right thing, and she would have to meet with NA-A and have a conversation with her before NA-A's next work shift. The ADON stated staff had reported concerns of NA-A and NA-B coming to their shifts smelling of drugs and alcohol, but he had not observed this himself. The ADON stated he had usually been informed of the concerns a day or more after these occurred, so he was unable to determine the accuracy of these allegations. On 1/23/23, at 1:30 p.m. an interview was conducted with NA-D. NA-D stated she had worked with both NA-A and NA-B, and had reported her concerns to nurses on the floor as well, as the DON and administrator. NA-D stated she had reported seeing NA-A drinking in her truck at work, and being intoxicated, to her charge nurse. NA-D stated she was told by licensed practical nurse (LPN)-B, Yeah, she (NA-A) probably is. NA-D stated she personally witnessed NA-B transferring patients without her gait belt, and the residents falling and getting injured. NA-B stated she was present during at least five residents falls related to NA-B. NA-D stated she asked NA-B if she was impaired at work during one of her shifts, and NA-B had admitted she was. NA-D stated she observed NA-B transferring a resident with no gait belt, and the resident fell and hit her head on the floor causing a large goose egg on the resident's (R6) forehead. NA-D stated, Four of the residents are no longer with us. (R6) passed away last Tuesday, and I feel real bad. NA-D stated she witnessed NA-B transferring another resident without her gait belt, and NA-B let go of the resident and she fell , and NA-B put the gait belt on after the fall. NA-D stated she reported the incident to the floor nurse (LPN-A.) NA-D stated she had witnessed NA-A and NA-B always on break, and she could see them smoking out on the corner of the building. NA-D stated NA-B smoked her pen thing that smelled of marijuana, out on the corner for hours. NA-D stated NA-B had sat in NA-D's car at work one day and she witnessed NA-B rolling a white substance in white paper in NA-D's car and smoking it. NA-D stated she became upset, and had another co-worker assist her to get NA-B out of NA-D's car. NA-D stated she was so upset she went to the DON and threatened to quit after the incident, and the DON stated she couldn't do anything because the DON wasn't present when the incident happened. NA-D stated she asked NA-B directly if she used chemicals at work and NA-B told NA-D she used alcohol, and meth only on her breaks and at home. NA-D stated she had gone to the administrator with her concerns, and he stated, he would look into it but he never got back to her. NA-D stated she felt her concerns were not being addressed. On 1/24/23, at 11:11 a.m. an interview was conducted with trained medication assistant (TMA)-A. TMA-A stated she had been told by NA-D of concerns of NA-A drinking at work the previous week. TMA-A stated NA-D had told the nurse on duty about NA-A appearing drunk and was told, She probably is. TMA-A stated NA-A and her schedules did not overlap because NA-A came to work late most shifts. TMA-A stated management had to be aware of NA-B's substance addictions, because NA-B talked openly about it, and the DON had to work around NA-B's treatment schedule. TMA-A reported she was aware of NA-B having frequent falls with the residents related to NA-B not using her gait belt. TMA-A stated she witnessed NA-B with R2 on the floor and putting on the gait belt after the fall. TMA-A stated R2 ended up going to the hospital and having hip problems. TMA-A stated NA-B had multiple falls with residents and had been reported under the influence to management. On 1/24/23, at 12:11 p.m., an interview was conducted with DON stated she was aware of NA-B completing her treatment. The DON stated she had never asked NA-B if she had ever used chemical substances at work or come to work impaired. The DON stated she had not received results of NA-B's Escreen. The DON stated she had not put any monitoring in place for NA-B, and was aware of NA-B had chemical dependency issues. The DON reported after being asked to call the lab for results, NA-B had texted the DON's phone and informed the DON that her Escreen was positive for cocaine and marijuana. On 1/24/23, at 2:21 p.m. an interview was conducted with LPN-A. LPN-A stated she had been present during falls with NA-A and NA-B, and had to provide education on using gait belts and transferring residents properly. LPN-A also reported an incident when a resident had fallen and had sustained a hip injury. LPN-A stated she had specifically asked NA-A and NA-B to not walk the resident, only to return later in the shift and find NA-A and NA-B were walking the same resident she had specifically asked them not to walk. LPN-A stated NA-A's appearance at work has been questionable at times, with her coming to work with red, blood shot eyes and a disheveled appearance. LPN-A stated NA-A and NA-B were known to take numerous breaks. LPN-A stated she was present when RN-A had told NA-A and NA-B they couldn't take a break yet as they had just gotten to work. LPN-A stated she could remember this had happened with in the last month but was unable to determine exact date. On 1/24/23, at 2:55 p.m. an interview was conducted with NA-E who stated she had heard of people jumping out the windows at the facility to avoid being seen by the facilities cameras. NA-E reported NA-A was aware of her breaks being tracked by the DON. NA-E stated NA-A was going out the window to make it harder for the DON to track her breaks. NA-E stated when she worked with NA-A and or NA-B, she frequently would not get her breaks because the two would be on break so much, and things needed to get done so she wouldn't take her breaks. On 1/24/23, at 4:12 p.m. an interview was conducted with RN-C who stated she had a shift that occurred in December 2022, when NA-C had come to her with concerns related to NA-A acting odd and drinking alcohol. NA-A had told RN-C she had reported her concerns to RN-D, and nothing had been done. RN-C stated she had RN-D handle the situation before the end of RN-D's shift. RN-C stated NA-A had been tested with the breathalyzer and it had been zeros indicating no alcohol, and NA-A was still sent home because she was upset and seemed out of sorts. RN-C stated one other time, two NA's had been working with NA-A, and observed her in her truck drinking and charting while she was on the clock. RN-C stated she had not been at the facility when she received the phone call and the NA's were reporting the incident had happened at work on the previous day. RN-C stated she had directed the reporting NA to write up a statement, make a copy of it, and put it under the DON's door as proof of the report. RN-C stated she herself had texted the DON on the day she received the report from the NA's. RN-C stated she may have even shoved the papers under the DON's office door herself on the Monday after the incident happened, but was not positive if she did or not. RN-C stated she later reported the text on her phone to the DON was on September 5th, 2022. On 1/25/23, at 12:14 p.m. an interview was conducted with drug testing company certified medical reviewer (CMR, who was a medical doctor). CMR reported the testing completed for NA-A and NA-B were regulated tests, and there were very strict procedures that were followed for these tests to ensure accuracy. CMR reported that NA-A's test was a confirmatory positive test for amphetamines, and that 500 was considered confirmatory, and NA-A's test was 1900. CMR stated he would consider this a positive test with no legitimate explanation for the result of four times the confirmatory sample. CMR stated he would consider her impaired if she was to work at this level of intoxication. CMR reported NA-B had informed the tester she had a medical marijuana card, but was unable to produce it for the test, and declined to provide a prescription list or medical diagnoses for the test. MD-A stated NA-B's test for cocaine was twice the cut off, and she had tested positive for marijuana with 400 being the mean of what is considered a high-test, NA-B's test was at 1373. The CMR stated he felt both would be considered impaired and not safe to work with the vulnerable population on the day they were tested . On 1/25/23, at 2:57 p.m. an interview was conducted with NA-F who stated she had smelled alcohol on NA-A and reported it to RN-C after the Labor Day weekend. NA-F stated she had gone to the DON's office after that weekend and told the DON she was quitting because she was tired of dealing with NA's being impaired at work. NA-F reported that she had reported her concerns to RN-C, they had written out the letter together, and she then had gone into to the DON's office to talk to her face to face. NA-F stated she told the DON she was not going to do it anymore, that NA-A and NA-B were always outside, and work was not being done because you couldn't find them. NA-F stated nothing had changed, and the DON never got back to her after her report. On 1/25/23, at 4:19 p.m. an interview was conducted with the administrator. the administrator stated he was not aware of a history of impairment with NA-A or NA-B. The administrator stated he was not aware of the breathalyzer contract between NA-A and the DON in February of 2022. Administrator stated he did receive one call at home from RN-D one evening, and was told by RN-D the DON told her to inform him of NA-A being sent home, but her breathalyzer test had been negative. The administrator stated when it came to staff coming to work impaired or suspicion of being impaired, he would follow the facility policy. The administrator stated he would depend on his nurses to determine if a staff could work or not. The administrator stated, I did not know (NA-A) or (NA-B) worked on the day of the testing on [DATE]rd, and was not aware they had returned to work before we had received the test results. The administrator stated he would increased monitoring if there were concerns of staff using chemicals. A review of resident's incident reports indicated: -R1's fall event report dated 5/8/22, at 12:47 p.m. indicated NA-A transferred resident with one person transfer having R1 stand and ambulate to transfer causing a fall. R1's care plan dated 9/30/2021 identified R1 required a full body lift and two staff for transfers. -R2's Fall Scene Investigation Report (FSI) dated 11/18/22, at 8:00 a.m., indicated R2 fell in the bathroom during a transfer with NA-B. 5 whys completed by LPN-A indicated, Gait belt not in use. Interventions included gait belt or consider stand for all transfers. -R2's progress note dated 11/18/22, at 1:13 p.m., identified R2 had a fall earlier and had landed on her left hip. R2 reported hip was painful. physician assistant ordered R2 sent to emergency department for evaluation of left hip. -R2's progress note dated 11/18/22, at 11:29 p.m., stated R2 admitted to the hospital for bleeding into the hip. -R3 Progress note dated 12/28/22, at 4:22 p.m., stated R3 let go of white stand and had a fall while being toileted resulted in large bruising to her hand, small skin tear on right mid forearm.-R3's Care Plan approach dated 11/3/22, stated R3 was to have two staff assist her to transfer to and from chair and bed using sit to stand lift. Assess residents strength when using white stand and be aware she becomes weak, not able to maintain grip. -R3 progress note dated 12/28/22, at 7:03 p.m. stated new bruises and skin tear. -In an email received from DON dated 1/25/23, at 1:32 p.m., stated the facility had not created a fall event for R3's fall on 12/28/22, so no investigation had been completed. DON indicated NA-A had been assigned to the hall of R3 on the date and time of the fall. -R4 FSI dated 12/26/22 at 6:50 p.m., indicated R4 was rushing in bathroom with NA-B when resident lost balance and fell . FSI indicated NA-B had not used a gait belt during the transfer. Recommendations on the FSI stated,Do not rush, use transfer belt, gripper socks and use assistive device if resident appears weak. -R6 fall on 1/7/23 states resident had a fall from a wheelchair hit her head causing large goose egg. -On 1/23/23, 1:30 p.m. interview with NA-D stated she witnessed NA-B, drop R6 causing R6 to hit her head on the ground. NA-D stated NA-B doesn't follow resident care plans. NA-D stated she has observed NA-B put gait belts on after the falls. The facility policy The 3 I's Policy Intoxication, Impairment & Under the Influence dated 1/27/23, directed the facility is committed to health and safety of the facility and will work together to control impairment-related risks in the workplace. The facility's Vulnerable Adult Policy dated 11/17/20, directed each resident has a right to be free from abuse and defined abuse including Neglect as the failure of the facility, its employees or service provider to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The immediate jeopardy that began on 1/25/23, at 5:28 p.m. was removed on 1/27/23, at 5:30 p.m. when it was verified through interview and document review the facility implemented the following: -immediately reviewed/revised policy/procedures for protecting residents from impaired staff. Including investigation on any impact of impairment to residents. -Identified and determined if any staff members were impaired and didn't allow them to work with residents. -Educated all staff on signs and symptoms of alcohol and illicit drug intoxication, and protocols for reporting to administration. -Educated the DON how to respond to concerns brought forward by staff, monitoring and supervision of staff with known chemical dependency issues, education on protecting residents when reasonable suspicion of impairment is determined and/or staff are drug tested .

Based on interview and document review, the facility failed to ensure interventions were implemented as recommended to reduce the risk for falls for 1 of 3 residents (R32) reviewed for falls in the facility. Although R32 sustained actual harm, a displaced intertrochanteric fracture of left femur as a result of a fall when a staff person failed to implement the plan of care, the facility has already implemented corrective action so this is being issued as past non compliance. Findings include: R32's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R32 was cognitively intact, required extensive assist of two persons for transfers, and two persons to walk in room. Mobility device used walker. [DIAGNOSES REDACTED]. History of falls in last month prior to admission and last two to six months prior to admission and fracture related to fall in last six months prior to admission. R32's admission orders [REDACTED]. R32's care area assessment (CAA) dated 4/16/19, included an analysis of Falls: Triggered due to (R32) needing limited to extensive assist with all activities of daily living (ADL's) and mobility related to arm fracture and [MEDICAL CONDITION]. Has history of falls at home with fractures, has weakness and pain. (R32) is unsteady with transfers.(R32) receives narcotic pain medication, antianxiety as needed (PRN) and antidepressant daily. (R32) is receiving physical therapy (PT) and occupational therapy (OT). (R32) has had pain and stated it is frequent and rates at a 4 (pain scale 0-10). (R32) may be at risk for further decline in ADL's, mobility, for falls with injury, for increased pain and for increased incontinence. R32's care plan last reviewed/revised 4/24/19, included a problem area related to Mobility, needs limited to extensive assist with mobility related to recent decline in function and increased weakness at home and falls after discharging from SNF (skilled nursing facility). History of ORIF (open reduction internal fixation) of left radius/wears a brace and has a [DIAGNOSES REDACTED]. She can walk with assist. Receiving PT (physical therapy) and OT (occupational therapy). Has complaints of pain frequently related to fracture that she rates at 10. Receives PRN (as neeed) pain medications. fell while walking with therapy, X-ray done, sent to emergency room (ER). Approaches included: one staff to assist to transfer to and from chair and bed using hemi walker, provide PT and OT and follow their recommendations. Problem: [DIAGNOSES REDACTED]. History of fracture left radius after a fall, wears a brace. During interview on 6/10/19 at 9:39 a.m., R32 stated, I had a fall. Physical therapist assistant (PTA)-I was walking me to my doorway. I was standing with the platform walker. PTA-I walked away from me to put the Kleenex box back and when she did I let go with one hand to wipe my nose because it was running. I started to fall and yelled her name and down I went with the platform walker. I was supposed to have someone standing by me and holding onto me with the gait belt. I broke my left hip, which set me back. R32's physical therapy communication note dated 2/20/19, indicated R32 required assist of one with a platform walker to transfer and ambulate in her room, to and from the bathroom. An Event Report dated 3/6/19, identified R32 had a fall in her room while walking with the therapist. Complaints of pain pelvis and left thigh/groin. Rated at 9 (pain scale 1-10). Range of motion painful/limited in lower extremity. Attending physician notified. The Event Report indicated orders had been received to apply ice to affected area of injury post fall for 20 minutes four times a day PRN. Monitor for significant injury. Notify physician of severe swelling/bruising/pain. Monitor status for 72 hours for bruising, change in mental status, condition, pain, or other injuries related to fall. O.K. to send resident to hospital for evaluation of left hip/pelvic pain post fall. Nursing ProgressNotes included 3/6/19, at 16:35 (4:35 p.m.) resident was working with PT and walking with platform walker when resident asked therapist for a Kleenex. The therapist grabbed resident a Kleenex and at that time resident fell backwards onto buttocks. Resident was unsure whether she lost balance of if the walker started to tip and caused her to fall. The note indicated the resident had reported, It happened so fast, I don't know. Resident also stated that she has told therapy her walker tips easily. Resident unable to bear weight without pain. Nursing had obtained a telephone order to have x-ray of pelvis and left thigh/femur. 3/6/19, at 21:57 (9:57 p.m.) PPX (professional portable x-ray) completed x-ray of pelvis and left femur. Results to follow. 3/8/19, at 12:05 a.m., during repositioning resident very hesitant to move. Resident was unable to move left extremity on her own, but able to wiggle toes. Evaluation of left extremity remains the same size as right extremity. No deformity or rotation of left extremity. A slight extension of left extremity caused discomfort. Due to pain level and discomfort resident stated had not improved, raised concern for and the need for possible further evaluation. Results of x-ray on 3/6/19, had not been received by mid morning. Provider and PPX were contacted twice to receive results of x-ray and obtain order for resident to be sent in to be evaluated. Results of x-ray were sent to facility at 13:16 (1:16 p.m.) Ambulance contacted at 13:30 to transport to ER (emergency room ) for evaluation. 3/8/19, at radiology impression: mild grade 2 Kellgren and Lawrence [MEDICAL CONDITION] changes of the hips bilaterally and subtle non-displaced left intertrochanteric fracture is seen. R32's hospital dismissal summary dated 3/7/19-3/11/19, identified [DIAGNOSES REDACTED]. The patient underwent DHS placement for left intertrochanteric fracture. Patient tolerated procedure well. During interview on 6/13/19, at 9:14 a.m., PTA-I verified she was the person walking R32 when R32 had a fall on 3/6/19. PTA-I stated I helped R32 stand with a platform walker and I was going to walk R32 out into the hallway. R32 was two to three feet away from her doorway leading into the hallway. R32 sneezed and said she wanted a tissue. I asked R32 to wait until I could have her be seated in a chair, but R32 was yelling she needed a tissue. I turned to see how far away the tissue box was and the box was about four feet away on R32's tray table. I was hanging onto the gait belt around R32 waist, but I could not reach the tissue box without letting go. I let go of the gait belt to get the tissue box and after grabbing the tissue box I placed my hand back onto the gait belt and handed R32 the box for her to pull a tissue out. R32 was still standing at that time. R32 grabbed a tissue, wiped her nose. I told R32 to stay there (in standing position) and I let go of the gait belt to set the tissue box back on the tray table. When I turned around from setting the tissue box on the tray table R32 had turned to follow me with her head and was trying to blow her nose again. I am assuming that is what threw R32 off balance. When I was walking back towards R32, R32 was yelling where are you and that is when she started going down butt first, straight back with the platform walker. R32 did not bend her knees. R32 fell straight back with straight legs with her butt back. I could have only stopped R32 from hitting the floor if I directly put myself in the way. I did not want to do that, because I thought this would throw R32 more off balance and R32 could hit the door or something else and I would have been knocked off balance. I thought it would be better for R32 to fall straight down on the her butt, which is the cushiest. R32's mobility status at the time was one staff assist to walk with the platform walker in and out of the bathroom and to hang onto the gait belt. PTA-I stated absolutely the gait belt should always be held onto when walking R32. PTA-I the reason she had let go of R32 gait belt was she had been working with R32 and R32 had been able to stand by herself by a chair. PTA-I stated quite honestly I could not believe R32's balance was that off, as she was doing standing exercises. PTA-I stated R32 had a limitation on left leg from years ago, but she could stand and maintain balance at platform walker with someone next to her and your hand did not always have to be on the belt standing next to R32 when working with R32 for therapy. When (R32) fell , I had briefly turned my back and was 2 ½-3 feet away from her and could not reach her prior to her fall. PTA-I also stated that on the same day as the fall, an interdisciplinary team discussion had occurred between nursing and therapy, and she and other staff had been re-educated about remaining close to R32, and not turning away even if she was expressing anxiety. During interview on 6/13/19, at 9:47 a.m., licensed practical nurse (LPN)-C stated had been working the day R32 had fallen. LPN-C stated, All I remember was (PTA-I) was walking (R32) and (R32) asked for a Kleenex and the therapy assistant turned to grab a Kleenex and (R32) fell directly on her butt and (PTA-I) could not catch her. During interview on 6/13/19, at 10:18 a.m., the interim director of nursing (IDON) stated although she had not been working at the facility in (MONTH) when R32 fell , she would have expected the resident's care plan to have been followed. The facility held an interdisciplinary conference on 3/6/19 and implemented corrective action including re-education and direction for PTA-I and reminders for nursing staff. The resident's plan of care was updated immediately to reflect the need for staff to stand by her at all times while walking.

Based on observation, interview and document review, the facility failed to ensure fluid restrictions were implemented and monitored per physican orders for 3 of 4 residents (R41, R47 and R19 ) reviewed for fluid restriction. R41 experienced harm when she required hospitalization s due to shortness of breath, a cough, [MEDICAL CONDITION] and weight gain requiring diuresis (removal of fluid) when her fluid intake was not adequately monitored. Findings include: R41's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R41 was cognitively intact, required supervision for eating, had prior surgery, required a therapeutic diet, received diuretic medications, and had [DIAGNOSES REDACTED]. During interview with R41 on 6/10/19 at 8:53 a.m., R41 stated she would like to have some fresh water to drink. the surveyor informed licensed practical nurse (LPN)-B of the resident's request. LPN-B brought a pitcher of ice water to R41's room and poured water into a plastic container (almost full) which was set on R41's tray table. During observation and interview on 6/10/19 at 9:15 a.m., R41 was observed to be short of breath (SOB) when speaking, and she was utilizing oxygen (O2) at 2 liters via nasal cannula. During observation on on 6/11/19 at 10:39 a.m., R41 was observed in her room. There was a 240 cc (cubic centimeter) glass of water in the resident's room, and R41 was drinking from it. In addition, a glass with 60 cc water and ice, a mayo clinic plastic mug with 450 cc of water (the mug had marking of amounts of cc's on the cup) were observed on R41's overbed table. During the observation, R41 reported the staff had weighed her that day and added, I want to know if I am keeping my fluid down. R41 then stated, Sometimes I become SOB when I lean. The resident was observed to puff slightly when breathing in and out of her mouth. During observation on 6/11/19 at 12:05 p.m., the water containers previously observed, remained in R41's room. Immediately following a review of her room, R41 was observed in the dining room eating lunch. At that time, she had a 240 cc glass of water by her plate. During observation of R41's room on 6/11/19 at 1:26 p.m., a 240 cc glass of water (slightly over half full glass) was observed on R41's tray table. During an observation on 6/11/19 at 3:17 p.m., R41 was in her room visiting with a family member (FM)-H. A half full 240 cc glass of water, and a mayo mug of water (also half full), were noted on R41's tray table. R41's care plan last revised 6/6/19, included: Diet: (R41) receives NAS (no added salt) diet with regular textures and thin liquids. 2L (liter) fluid restriction daily: 1440 cc fluids with meals, 360 cc fluids with medications, 200 cc free fluids daily. Monitor and record weight as ordered. Record intake related to fluid restriction. R41's hospital discharge summary dated 4/5/19 - 5/6/19, included [DIAGNOSES REDACTED]. The hospital dismissal weight was recorded as 84.1 kilograms (kg) (185 pounds). The Dismissal Orders included: daily weight monitoring, call provider if weight gain of 2-3 pounds or more per day over a 2 day period, or 5 pounds in one week. Common heart failure symptoms include: chest pain, fatigue and weakness, rapid or irregular heart beat, shortness of breath when you exert yourself or when you lie down, reduced ability to exercise, persistent cough or wheezing with white or pink blood-tinged phlegm, swelling in abdomen/legs/ankles and feet, and difficulty concentrating or decreased alertness. If any of these symptoms suddenly become worse or you develop a new symptom, it may mean that existing heart failure is getting worse or not responding to treatment. Contact your doctor promptly. Documentation from the physical exam at dismissal from the hospital identified R41 had one plus [MEDICAL CONDITION] noted to bilateral extremities. R41's weight record indicated a weight of 191 pounds at the facility on 5/6/19. Although the hospital dismissal orders identified a discharge weight of 185 pounds that same day, there was no documentation of a reweigh at the time of admission to the facility to determine if the 191 pound weight was accurate. R41's physician orders, resident progress notes, chest x-ray results and physician progress notes [REDACTED]. 5/6/19, physician order for [REDACTED].>5/6/19, bilateral lower extremity 2 to 3 plus [MEDICAL CONDITION]. 5/13/19, admission weight 191 pounds. 5/14/19, has been up in wheelchair most of the night, states cannot get comfortable in bed. Complained of pain in left foot. Removed sock and found it (the sock) had left an indentation on her foot under a seam in her sock. 5/14/19, physician order weigh weekly and today also. 5/15/19, at 11:48 a.m., seen by physician post admit, ordered O2 via nasal cannula (NC) at 1-2 liters as needed (PRN) for shortness of breath and if up and moving around. 5/15/19, physician progress notes [REDACTED]. They are asking if O2 can be increased to 2 liters. Patient has been advised to stay on [MEDICATION NAME] (diuretic) for 1 week, but she still does have difficulty with dependent [MEDICAL CONDITION]. Patient reports fatigue, does become SOB when exerts self. Physical examination: lungs do sound clear presentation. Examination of extremities, has 2 plus dependent [MEDICAL CONDITION]. An order was written to have O2 increased to 2 liters as needed. Continue with present dose of [MEDICATION NAME] in view of the dependent [MEDICAL CONDITION]. 5/16/19, at 10:18 a.m., low grade temperature of 99.6. Tylenol given, encouraged to use spirometer (a device that measures how deeply someone can inhale) and increase activity, continues to remain in bed. 5/16/19, at 14:03 (2:03 p.m.) nurse practitioner called regarding resident desaturation during physical and occupational therapies while on O2 at 2.5 liters, unwillingness to follow through with incentive spirometer and spending most of day in bed sleeping. O2 SAT's at 92-93 percent. Bilateral breath sounds slightly diminished in the bases with slight wheezing noted in right lower quadrant. 5/16/19, physician orders included to have a chest x-ray, [MEDICATION NAME] 80 milligrams daily and potassium chloride 20 miliequivalents daily. 5/16/19, at 14:31 (2:31 p.m.) O2 at 2.5 liters. Minimally working with physical and occupational therapy staff and has been desaturating into 85-86 range. 5/17/19, at 17:46 (5:46 p.m.) chest x-ray results received, no [MEDICAL CONDITION] congestion shown, patchy opacity seen in right lower lobe, no pneumothorax seen, large pleural effusion shown left lobe. 5/17/19, x-ray results identified left pleural effusion seen. Impression right lower lobe infiltrate seen, follow up recommended and large loculated left pleural effusion. 5/18/19 (a Saturday) at 2:04 a.m., uses 2.5 liters of O2, may titrate up to 4 liters. 5/18/19 at 17:35 (5:35 p.m.), O2 at 3 liters per minute via NC with O2 SAT's 95 percent. Did have some issues with O2 SAT's dropping into the mid 80's with activities. O2 SAT's increased back into the 90's with rest. SBAR (Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) submitted for nurse practitioner to see on Tuesday. 5/18/19, at 22:58 (10:58 p.m.) resident stating short of breath and got up to sit on the side of the bed. Checked vital signs and temperature was 100, blood pressure (B/P) 184/90. Given 650 milligrams of Tylenol, remains sitting on edge of bed. Room is very warm. Will continue to monitor. 5/19/19 at 3:48 a.m., Temperature has gone down to 97.1 and B/P down to 154/65. 5/19/19 at 18:54 (6:54 p.m.), O2 at 3 liters with O2 SAT's 95 percent. 5/21/19 at 4:52 a.m., O2 at 3 liters with O2 SAT's of 98 percent. 5/21/19 at 14:13 (2:13 p.m.), family member alerted nurse informing R41 could not breathe well and had turned up the O2. 5/21/19 at 15:28 (3:28 p.m.), Nurse practioner here. Order for chest x-ray for dyspnea and exertion. 5/21/19, physician orders identified chest x-ray for dyspnea on exertion. 5/22/19 at 3:45 a.m., has nonproductive cough. Sitting up in bed then laying down in bed. O2 at 1.5 liters and O2 SAT's remained at 95 percent. Respiratory easy at 18. 5/22/19, x-ray results identified the lungs show mild [MEDICAL CONDITION] venous congestion and probable bilateral interstitial [MEDICAL CONDITIONS]. Large amount left pleural fluid. 5/23/19 at 4:04 a.m., R41 spent half the night up in wheelchair. Complained of being uncomfortable in bed. O2 SAT's have been 94-96 percent with O2 at 2 liters. 5/23/19 at 14:43 (2:43 p.m.), resident awoke this morning with excessive dry cough, weakness, trembling, fever and chills. Vital signs: temperature 100.8, B/P 109/67, respirations 22, heart rate 71. O2 SAT's 95 percent with O2 at 2 liters. Lung sounds clear in right lobular region, mild crackles in the right region. Resident states feels tired. Tylenol given and temperature reassessed at 99.5. Physician ordered to send to emergency department non-urgent for evaluation. 5/23/19, physician orders identified send to emergency room for evaluation and treatment R41's record lacked documentation of continued monitoring of [MEDICAL CONDITION] from 5/6 through 5/23/19. In addition, the record lacked documentation of daily weight monitoring from 5/7 through 5/14/19 per physician orders. There was no documentation of a comprehensive nursing assessment during times when R41 was experiencing SOB, low grade fever, when her O2 saturations dropped, or when R41 experienced a cough and complaints of not feeling comfortable. R41's hospital discharge summary dated 5/23-5/28/19, identified principle [DIAGNOSES REDACTED]. The discharge summary indicated R41 had presented to the hospital with increasing shortness of breath, cough accompanied by lower extremity [MEDICAL CONDITION], and weight gain. In the emergency room a chest x-ray revealed pleural effusion and cardiomegaly. R41 was treated with 40 milligrams (mg) of intravenous (IV) [MEDICATION NAME] (diuretic). The documenation indicated at time of discharge, R41 would need close management of daily weights, and intake and output monitoring to avoid fluid volume overload. The hospital admission weight was recorded as 84 kg (185 pounds) with a dismissal weight of 76.9 kg (170 pounds). Orders included daily weights for heart failure, if weight increases by five pounds over baseline consider increasing diuretic therapy for three days, and diet included 2 liter (8 cups) fluid restriction. R41's facility weight record indicated the dietary manager had documented her weight as 169 pounds upon readmit from the hospital 5/28/19. R41's Medication Administration Record [REDACTED]. However, the documentation did not indicate fluid R41 had taken in. R41's progress notes indicated R41 had been readmitted on [DATE] at 1645 (4:45 p.m.). The notes indicated, Upon admission SOB from exertion observed. Lung sounds diminished and mild crackles heard all regions. General [MEDICAL CONDITION] noted to both lower extremities. On 5/29/19 at 16:33 (4:33 p.m.) the notes indicated, Complained of not being able to breathe through nose and not feeling well this a.m. As the day progresses resident seemed to become more SOB with exertion and unable to transfer or walk without getting really fatigued. O2 SAT's dropped to 85 percent on 2 liters of oxygen during therapy and therapist reported resident weaker. Temperature 100.8. Family member present, physician called and ordered to send to emergency department for evaluation. R41's hospital discharge summary from a stay 5/29-5/31/19, indicated she had a fever of unknown origin, acute on chronic diastolic (congestive) heart failure and pleural effusion. Further, the summary included: Presented to emergency department with complaints of low grade fever of 100.8 F. (fahrenheit) and had been discharged approximately 24 hours previously from the same service after being [MEDICATION NAME] aggressively with IV diuretics. (R41) has not had any weight change in the day (R41) has been gone. The note indicated with regard to the low-grade fever, R41 was afebrile while hospitalized . Weight 5/31/19 at the hospital was recorded as been 76. 9 kg. (169.18 pounds). Diet at discharge included: no more than 1.5 to 2 liters (6-8 cups of total) fluid restriction each day. Other orders included: call your provider with any weight gain greater than three pounds in one day, or more than five pounds over your baseline weight. In addition, R41's physician orders from 5/31/19 included: O2 at 1-2 liters PRN SOB and if up moving around. A follow up physician order from 6/7/19 included: Daily weight, notify provider if weight up 2-3 pounds in one day or 5 pounds over baseline weight. R41's record revealed the following weights: 6/6/19, 169.18 documented in the dietary manager's progress note. 6/11/19 164 6/12/19 163 6/13/19 163 6/14/19 160 Although R41's MARs and TARs for 5/31-6/11/19, included the fluid restriction of 2 liters daily, documentation of fluid intake was missing for 5/31, 6/1, 6/2, 6/3, 6/4, 6/5 and 6/6/19. On 6/7/19 fluid intake was recorded as 480 milliliters (ml) AM, 240 ml AM, and again 240 ml AM. On 6/8/19 fluid intake was recorded as 480 ml AM and another 240 ml AM. On 6/9/19 fluid intake was recorded as 500 ml AM, 240 ml AM and 0 ml AM. On 6/10/19 fluid intake was documented as 580 ml AM, 520 ml AM, and 200 ml AM. On 6/11/19, fluid intake was recorded as 480 ml AM, 150 ml AM, and 90 ml AM. Vitals Report sheet identified the documented fluid intake by nursing assistants (NA) on 6/7/19 as 480 ml and on 6/12/19 as 90 ml. R41's record lacked documentation of the total daily 24 hour fluid intake amounts R41 took in. R41's progress notes from 5/31-6/11/19, included: 5/31/19, 17:34 (5:34 p.m.) returned to facility. Lung sounds clear and diminished in all regions. O2 SATS 97 percent with O2 at 2 liters. 6/1/19, 4:10 a.m. Has slept little, states cannot breathe when in bed. Sat in recliner and wheelchair and stated cannot get comfortable. 6/1/19, at 17:36 p.m. (5:36 p.m.) On O2 at 2 liters and O2 SAT's at 97 percent. SOB upon exertion. 6/4/19, at 5:07 a.m., Resident complained of SOB, noted to be breathing from mouth, respirations 26. O2 at 2 liters and O2 SAT'S at 96 percent. Lung sounds diminished, clear. 6/7/19 at 18:05 (6:05 p.m. ) reported feeling dizzy during physical therapy. Vitals within normal limits when checked, O2 at 2 liters. 6/8/19 at 19:05 (6:05 p.m.) Does exhibit some dyspnea with exertion. O2 SAT's 99 percent on O2 at 2 liters. through out shift resident had a look of distress on face, and you could see visibly breathing through nose and out through mouth. Her facial expressions (furrowed brow) and body language (tense, leaning forward) to this writer indicated she was having some sort of distress. Resident offered complaints at times of not getting enough air. O2 SAT's 99 percent on O2 at 2 liters. O2 titrated down to 1.5 liters and O2 SAT's at 98 percent. Based on the inability to find a reason for SOB this writer is concerned that potentially could be retaining CO2 (carbon [MEDICATION NAME]). With resident symptoms this writer asked family member if would like the physician called. Family member said to just wait and would like to try Tylenol throughout the day and given before bed to see if could sleep better. Although an SBAR was written to address concerns, there was no assessment of lung sounds documented. A physican progress note dated 6/11/19, indicated: Has 2 liter per 24 hours fluid restriction. Breath normal and effort normal. No respiratory distress, no wheezes or rales. Exhibits [MEDICAL CONDITION] of 1-2 plus [MEDICAL CONDITION]. Nursing concerns, not recording intake and output correctly and family not following fluid restriction. Continue current plan of care. R41's record lacked documentation of continued monitoring of [MEDICAL CONDITION], documentation of daily weight monitoring and fluid restriction per physician orders. R41's record lacked documentation of a comprehensive nursing assessment during times when R41 was experiencing SOB, feeling dizzy and had complaints of not feeling comfortable. During interview on 6/11/19 at 10:55 a.m., nursing assistant (NA)-D stated R41 was not on a fluid restriction. NA-D stated there should be a sign of a faucet with dripping water on the doorway to R41's room if R41 was on a fluid restriction. At that time, the surveyor and NA-D observed R41's doorway, and there was no sign of a faucet with dripping water posted. During interview and observation on 6/11/19 at 11:01 a.m., licensed practical nurse (LPN)-B stated R41 was on a fluid restriction, but did not know how much free water R41 could have in her room. LPN-B stated, We track how much (R41) drinks at meals, and track the jug in (R41's) room and any other glasses of water. LPN-B also stated, There should be a sign with a faucet with dripping water on (R41's) doorway to alert for fluid restriction. LPN-B observed R41's doorway at the time and confirmed there was no such sign on R41's doorway to alert staff of her fluid restriction. LPN-B stated the nutrition person was the one who would figure out fluid restriction amounts. LPN-B added, Sometimes we cannot document the amount of fluid on the MAR, so we have the NA's document the amount. During interview on 6/11/19 at 11:47 a.m., trained medication aide (TMA)-B stated nursing assistants write resident weights down on a piece of paper, and the nurse records the weights in the computer system. During interview on 6/11/19 at 2:17 p.m., LPN-B stated he was unable to locate a form that showed the break down of fluids for R41's fluid restriction. LPN-B stated R41 was to be restricted with the amount of fluids in room, but R41 and FM-H would consistently bring fluids to R41's room when she wanted them. R41's record lacked any documented evidence R41 had been educated regarding the risks and benefits of following the fluid restriction. During interview on 6/11/19 at 2:39 p.m., LPN-B stated R41's urine output was not being monitored. During interview on 6/11/19, at 4:05 p.m., the interim director of nursing (IDON) stated for fluid restrictions, dietary determined how to divide out the fluids throughout the day using a sheet of fluids prepared by dietary to follow for any resident on 2000 cc fluid restriction. The sheet provided for a 2000 cc Fluid Restriction included: Breakfast 480 cc, lunch 480 cc, supper 480 cc, with total daily fluids 1440 cc at meals, nursing fluids with medication 360 cc and free fluids 200 cc, for a total fluid intake of 2000 cc daily. The IDON also stated there should have been a sign of a faucet with dripping water posted on R41's doorway, that R41 should not have a pitcher of water in her room, and if R41 was refusing to follow the fluid restriction, the physician should be notified. The IDON stated fluids should be recorded with actual amounts of fluid taken in throughout the day, to identify the daily total the resident took in. The IDON acknowledged R41 does not follow her fluid restriction, but stated a risk and benefits conversation for not following the fluid restriction had not been discussed with R41. Further, the IDON verified weights had not been recorded daily as per physician orders and stated she expected the weights to be completed daily as ordered, and for staff to notify the nurse practioner regarding parameters. IDON stated she would expect physician orders for the fluid restriction to be followed and staff should be recording all fluids R41 was receiving. IDON reviewed R41's physician progress notes [REDACTED]. R47's Face Sheet indicated the resident was admitted [DATE], with [DIAGNOSES REDACTED]. R47's admission minimum data set (MDS) assessment dated [DATE], indicated R47 had intact cognition, required supervision in eating, and received a mechanically altered therapeutic diet. R47's nutritional assessment dated [DATE], included: .Fluid restriction as follows: 6 cups (1440 cc) to 8 cups (1920 cc) fluid q (every) day. Nursing staff and dietary to provide fluids. Resident is able to feed self .Resident [MEDICATION NAME] in hospital with IV [MEDICATION NAME] and wt (weight) on 4/17/19 = 180.62 # (pounds) and 151.15# on 4/24/19 reflecting a weight loss of 29.5# . R47's Initial Nutritional Review dated 5/1/19 included, 2L (liters) fluid restriction daily. 1400 cc fluids with meals, 360 cc fluids with meds (medications), 200cc free fluids daily . R47's physician order dated 4/27/19 included: 2 Liter Fluid Restriction. Twice a day; 07:00 (7 a.m.), 18:00 (6 p.m.). R47's nutritional status care plan last reviewed/revised 6/6/19 included .2L (liters) fluid restriction daily: 1400cc fluids with meals, 360 cc fluids with medications. 200 cc free fluids daily . Interventions included: Monitor and record weights as ordered. 2L (liters) fluid restriction daily. 1440 cc fluids with meals, 360 cc with meds, 200 cc free fluids daily. Record fluid intake per Rx (medical prescription) fluid restriction. R47'S MARs were reviewed from 4/27 to 6/13/19. The MAR indicated [REDACTED]. R47's (MONTH) 2019 MAR indicated [REDACTED]., R47's (MONTH) 2019 MAR indicated [REDACTED]. In addition, there was no fluid intake documented for 6 p.m. on 5/14/19, and no fluid intake documentation for 7:00 a.m. on 5/25/19. The total month of (MONTH) 2019 lacked daily totals of fluid intake. Review of R47's MAR from 6/1-6/12/19, included no fluid intake documentation for 7:00 a.m. on 6/3/19 and 6/9/19. There was no daily totals of fluid intake completed from 6/1/19 to 6/12/19. On 6/13/19, at 12:37 p.m. LPN-C stated, We monitor (R47's) fluid restriction at meals and we do not put a watcher pitcher in her room. LPN-C stated she kept track of the fluids R47 had during each meal and would enter it (fluid total from meal) into the MAR indicated [REDACTED]. LPN-C stated the aides also have sheets at their work station that track fluid intake. LPN-C said she also added the intake of fluids from the aides into the MAR. LPN-C stated, It is my responsibility as the day goes on to make sure (R47) does not go over (her fluid intake). LPN-C verified there was no documentation in the medical record of daily fluid intake totals being monitored for R47. On 6/13/19 at 1:25 p.m., the interim director of nursing (IDON) stated dietary has a form kept at the nurse stations and it lays out how many cc's they can have with meals, meds (medications) and free water in the room. The IDON stated it was also on the diet card what specifically residents could have at each meal. The IDON stated the nurses do twelve-hour shifts and are suppose to chart the fluid intake total for their shift. The IDON stated right now there was not a daily total being added up for fluid restrictions. R19's Face Sheet, identified an admitted [DATE], and [DIAGNOSES REDACTED]. of stroke, [MEDICAL CONDITIONS] and other heart-related complications). R19's significant change MDS dated [DATE], identified R19 suffered from severe cognitive impairment and required 1 person assist with most activities of daily living (ADL)'s. R19's Physician Order Sheet, signed by the physician on 4/30/19, indicated R19 was to be weighed twice a week. R19's Physician Order Report, signed by physician on 5/15/19, identified the following orders: please weigh twice a week every Tuesday and Saturday, and cardiac diet with fluid restriction of 1200 ml (milliliter) daily. R19's care plan identified a problem: R19 receives no added salt (NAS) diet with regular textures and thin liquids, 1200 ml fluid restriction daily (720 ml of fluids with meals, 360 ml fluids with medications and 120 ml of free fluids daily). Goal: will maintain adequate nutritional status confirmed by intake of 75% of food and fluids offered. Approach: monitor and record weight as ordered, provide NAS diet with 1200 ml fluid restriction daily as ordered, record fluid intake per fluid restriction. The care plan did not include direction for weighing the resident twice weekly. Review of R19's weights since admission: 3/1/19: 211.8 # 3/10/19: 209.8 # 4/1/19: 209 # 5/1/19: 201.8 # 5/4/19: 201.12 # 6/1/19: 198.8 # 6/11/19: 194.12 # Review of R19's Vitals Report for fluid intake for June, 2019 included: 6/8/19: 360 ml 6/10/19: 360 ml 6/12/19: 120ml Vitals Report lacked any fluid documentation for any other days in June. Review of R19's MAR for June, 2019 identified the following fluid intake totals: 6/3/19: 1440 ml 6/5/19: 1320 ml 6/10/19: 1380 ml During observation and interview on 6/13/19, at 12:42 p.m. R19 was observed sitting in a recliner in her room wrapped in a blanket. R19 stated, I am tired, but I am going to go out later today with my husband. R19 appeared comfortable with no signs of shortness of breath. During interview on 6/12/19, at 2:14 p.m. TMA-B verified R19 was on a 1200 ml fluid restriction and stated, We chart fluid intakes at meals. We do not give her the pink water pitchers. (R19) does not always follow her fluid restriction, sometimes her husband brings her in Coke (cola). We do ask how much (R19) has had to drink when her husband takes her out. We should have a fluid sheet we fill out each shift on each wing. TMA-B checked for the fluid sheet and verified there wasn't one for R19. TMA-B further verified several days were missing documented fluid intake and stated, We have a lot of pool staff so that could be a reason, they might not know we have to do that. During interview on 6/12/19, at 2:28 p.m. LPN-A-A verified R19 was admitted on [DATE] with an exacerbation of her [MEDICAL CONDITION], and that she has been on a 1200 ml fluid restriction since admit. LPN-A verified there were several days of fluid documentation missing from the medical record and stated, It would be hard for a doctor to review her fluids to see whether she has been in compliance. LPN-A further stated they had not notified the doctor they had not been monitoring her fluids as ordered. LPN-A stated, (R19) does not always follow her restrictions and her husband does not always comply, and brings in big bottles of soda. LPN-A stated there had not been a risk and benefit form signed by R19 related to not following the fluid restriction. LPN-A stated, We could do better with documenting the fluids, [MEDICAL CONDITION], oxygen saturations, weights as ordered, and the lung sounds for a person with [MEDICAL CONDITION] and a fluid restriction. During interview on 6/13/19, at 1:52 p.m. the interim director of nursing (IDON) verified R19 has a [DIAGNOSES REDACTED]. The IDON verified there were several intakes and weights missing from R19's record. She stated, Each resident with [MEDICAL CONDITION] and orders for a fluid restriction should be assessed and monitored for [MEDICAL CONDITION] exacerbation including checking lung sounds, oxygen saturations, shortness of breath, [MEDICAL CONDITION], and weights per the doctor's order, and should record accurate intakes and outputs. The facility's 11/2018 policy, Heart Failure-Clinical Protocol, included: Assessment and Recognition: 1. As a part of the initial assessment, the physician will help identify individuals with a history of heart failure and will clarify, as much as possible, its severity and underlying causes. Treatment/Management: 1. the physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, etc .) to monitor, when to report findings to the physician. Monitoring and follow up: 1. the physician will help monitor the progress of individuals with heart failure, including ongoing evaluation and documentation of signs, symptoms, and condition changes. The facility 7/2015 Weight Policy, included: Procedure: i. Nursing staff will record height and wight on admission and readmission records. Baseline weight will be recorded if available. ii. Nursing staff will record weights monthly, an as ordered by physician . ix. Nursing will monitor intake of residents with significant weight change until weight stable greater than 90 days . xi. Dietary manager/nursing will follow recommendations from nurse practitioner/medical doctor. Undated, facility policy, Fluid Restriction Measurement, identified a purpose to maintain an adequate record of the resident's daily restricted fluid intake. A. verify fluid restriction with doctors' orders. B. Notify dietary department of resident's fluid restriction. C. Dietary department will make up a schedule of kinds and amount of fluid that the resident is to receive during meal times. D. Schedule of fluid intake to be posted on the resident nursing unit. E. Intake sheets will be put in the med book on yellow paper sheets so that the amount of fluids drank with meals can be recorded. F. Sheets will be totaled at the end of each shift and will be recorded in the fluid intake summary in the resident's record. G. Evaluate the need for continued monitoring monthly by the dietician. The facility 10/2010 Encouraging and Restricting Fluids policy, included: Purpose: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan and/or your daily assignment sheet to assess for any special needs of the resident. General Guidelines 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake . 5. Encourage the resident's family and visitors to stay within the limits of his or her intake . 7. When a resident has been placed on restricted fluids, remove the water pitcher and cup from room. If the resident refuses to have the water pitcher removed, notify the supervisor and in turn, the physician. 8. Be sure intake and output record is maintained in the resident's room. The facility's 10/2010 policy Intake, Measuring and Recording, included: Purpose: The purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24 hour period. General Guidelines: 1. Inform the resident and his or her family and visitors that the resident is on intake and output. 2. If the resident is medically capable of understanding the procedure, ask him or her to assist you in telling you when he or she drank some fluid and how much he or she drank .4. Record the fluid intake as soon as possible after the resident has consumed the fluids. 5. At the end of your shift, total the amounts of all liquids the resident consumed. 6. Record all fluid intake on the intake and output record in cubic centimeters (mls) 7. Post an intake and output record form in the resident's room. Documentation: The following should be recorded in the resident's medical record, per facility guidelines: 5. If the resident refused treatment, the reason(s) why and the intervention taken. Reporting 1.

Based on observation, interview and document review, to provide pain management including a comprehensive reassessment and ongoing monitoring for uncontrolled pain and timely interventions to relieve severe pain for 1 of 1 resident (R36) reviewed for pain. Although the facility has since implemented corrective action, R36 experienced actual harm when staff failed to collaborate with other health professionals and address ongoing severe pain for several days. Therefore this is being cited as past noncompliance. Findings include: R36's face sheet indicated R36 had been admitted to facility on 3/19/18, with primary [DIAGNOSES REDACTED]. R36's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R36 had moderate cognitive impairment, required one staff assist for bed mobility, transfers, dressing, toileting, and personal hygiene needs, and had pain described as frequent which was present during the time of the assessment. The MDS further indicated R36 required as needed (PRN) medications in addition to scheduled pain medications. R36's care plan dated 5/8/18, indicated R36 had moderately impaired decision-making and required assistance of one staff for activities of daily living (ADL)s, and transfers. The care plan included a problem area initiated 6/6/18 regarding pain due to acute onset of back pain compression fractures. Interventions included: staff to administrator pain medication as ordered, monitor effectiveness and report to medical doctor (MD)/nurse practitioner (NP). The care plan goal included: R36 will have no increased complaints of pain and will have relief after receiving pain medications. physician's orders [REDACTED]. 1) Decrease [MEDICATION NAME] to 2.5 mg (milligrams) four times daily and 2.5 mg PRN every four hours. 2) Inform NP if R36 has increased verbal report or nonverbal display of pain with dose reduction. A physician's progress note date 5/14/18, assessment plan show [DIAGNOSES REDACTED]. In addition, indicated that pain and depression concerns were reviewed with staff and all agree no changes to current mediations. NP-A's progress note date 5/18/18 (Friday), indicated she had been called by facility staff regarding R36 having increased severity of pain located in low [MEDICATION NAME] spine since the previous day. The note indicated the resident had increased yelling out behaviors that had started the prior evening and continued today. The NP indicated R36 was quite uncomfortable and the current pain management regimen was not effective. New orders for increased pain medications given. To re-evaluate (R36's) back pain on 5/22/18, when back in facility. Nursing progress notes dated 5/19/18 (Saturday) at 5:05 a.m. included: Resident called out loudly most of night. Administered PRN [MEDICATION NAME] 5 mg with no or little relief in an hour. Difficult to administer medications due to non-compliance, didn't understand what was going on, biting medicine cup and moving it so that pills fell out and had to search through bedding until found. After administration, resident continued to scream various things repeatedly such as Water! (When she was offered she wouldn't drink but continued to scream out water!) Also screaming for help even though she is in no acute distress. She was unable to verbalize anything that made sense except random words she was hollering out. Behaviors present even after 3 staff tried to calm resident. Attempted massage, 1:1 time, turning, repositioning (in which she screamed the entire time she was being moved), toileted 3 times, transferred out of bed to chair, food and drink offered etc. Resident is currently still crying out but she did voice to staff she didn't know she was calling out. Nursing progress notes dated 5/20/18 (Sunday) at 12:00 a.m. included: Resident slept for a short time this evening, then woke around 2300 (11:00 p.m.), yelling for help. UA (unable) to verbalize her needs. When asked about her level of pain, she said Yes. [MEDICATION NAME] 2.5 mg given along with ice pack. At 2:00 a.m. Resident sleeping off and on, and is now in her recliner yelling for help. She states that the pain in her back is worse. Another 2.5 mg Oxy ([MEDICATION NAME]) was given. At 4:30 a.m. Resident moved to bed and has been yelling for help since that time. Redirection, repositioning, reassurance seem to have no effect. When she does get words out, she reports terrible pain in her back and reaches for her mid to lower back. [MEDICATION NAME] (topical [MEDICATION NAME]) was used earlier and ice pack was just placed. Oxy 5 mg given. Nursing progress notes dated 5/21/18 (Monday) at 1:30 a.m. included: Resident has been yelling for help since she went to bed at 2100 (9:00 p.m.). She is unable to say what she needs or what is wrong. Both arms are behind her back. Redirection, repositioning, reassurance, toileting have had no effect. [MEDICATION NAME] applied and ice pack was placed. Oxy 5 mg given at 2100 and 0130 (1:30 a.m.). She falls asleep easily but awakens and yells help very loudly. Nursing progress notes dated 5/22/18 (Tuesday) included: (R36) was seen at the facility by NP-A. NP-A's progress note dated 5/22/18 included, over the past several days had significant exacerbation of [MEDICATION NAME] back pain and is very uncomfortable. Nursing staff reports that (R36) has been sleeping very poorly at night and is frequently yelling out Help me! Help me! At this point, she has had very little sleep over the past two days. (R36) appears very anxious and restless with facial grimacing and pain behaviors that are evident. (R36) having significant pain with any movement, current pain management is not effective. Recommendation to send (R36) to Emergency Department (ED) for further evaluation. On 5/22/18 at 8:39 p. m., the facility received a call from St. [NAME]'s ED (emergency department) that R36 was being admitted to the hospital for control of back pain, and reported R36 had been identified as having new compression fractures. The hospital Discharge Summary dated 6/5/18, included on page 3, indicated: computed tomography (CT) scan of the thoracolumbar spine displayed a new compression fracture to L1 with mild posterior retropulsion, (vertebral fracture fragment that is displaced into the spinal canal, thereby potentially causing spinal cord injury) along with the T11, T12 fractures noted prior. Spine surgery was consulted and recommended vertebroplasty (procedure for stabilizing compression fractures in the spine) which was completed successfully on 5/31/18, with much improved back pain. A pain interview for the MDS 3.0 section J, Health Conditions, with an assessment reference date of 4/24/18, indicated: pain present- Yes with a hand written note, Better today! The resident's pain frequency was identified as a frequent with a hand written note, New medications helping, Ice helps. The resident's pain intensity was identified as a 10 (scale of 0=no pain, to 10=worst pain you can imagine). A subsequent pain interview for the MDS 3.0 assessment reference date of 6/11/18, indicated pain was present, and the frequency was documented as occasionally and the pain intensity was identified as a 7. Although the provider was asked about a reassessment of R36's pain management, for the dates of 5/18 through 5/22/18, none was provided. On 7/18/18 at 12:30 p.m., trained medication aide (TMA)-B stated (R36's) pain seemed to be increasing about a week or two week after her last fall (fall on 5/5/18). At that time they called the doctor to get an increase in pain medication. When she was not able to get any relief from the pain, it seemed the scheduled dose would not hold her for very long and the PRN medications were not helping either. The NP saw her on 5/22/18 and sent her to the hospital for pain control. On 7/18/18, at 1:24 p.m., during interview with licensed practical nurse (LPN)-B regarding pain management for R36 LPN-B stated, I would do an assessment and find out where they are having pain and the severity of the pain. Depending on the location and severity, I would reposition, try ice, etc. If that did not work, I would see if PRN medications could be given, and would verify when the scheduled pain medications had last been given. If there was no improvement in pain control then I would take their vitals and update the doctor or nurse practioner (NP) regarding pain symptoms, background, assessments done, and recommendations, by communicate note or calling them. On 7/18/18 at 01:34 p.m., registered nurse (RN)-A stated review of progress notes included notification of the NP regarding R36's increased pain on 5/18/18. On 5/18/18, the NP ordered an increase in narcotics. When questioned about whether the NP had been notified of the resident's uncontrolled pain even with the increase of narcotics, RN-A verified the NP was notified about the resident's continued pain until she visited the patient again on 5/22/18. On 7/19/18 at 9:14 a.m., the assistant director of nursing (ADON) stated during interview, she had reviewed nursing notes. The ADON verified neither the NP or medical doctor (MD) had been notified of R36's uncontrolled pain which developed following the NPs assessment 5/18/18, to 5/22/18 when the NP was back at the facility to assess the resident. When questioned about when staff were expected to call the NP/MD, the ADON stated, I would expect staff to call the NP/MD or on-call provider to update them on increase pain, in order to get further recommendations. During observations on 7/16/18 at 3:30 p.m., staff were observed to remind the resident to wait for help to transfer into recliner chair, the resident had no signs of discomfort. On 7/17/18 at 2:00 p.m., R36 was observed to be sitting in a recliner chair in the lobby watching TV. The resident exhibited no signs of pain or discomfort at that time. On 7/18/18 at 7:19 a.m., R36 was observed in the dining room sitting eating breakfast. The resident exhibited no signs of pain or discomfort. On 7/18/18 at 10:23 a.m., R36 was observed sitting in a recliner in her room. The resident's eyes were closed and she had no signs of pain or discomfort. Breathing is regular and relaxed. The facility's undated policy, Resident Pain Evaluation Protocol, indicated staff were to plan interventions conferring with the resident's medical provider as necessary.

Based on observation, interview and document review, the facility failed to immediately report allegations of verbal and physical abuse to the administrator and State agency, failed to thoroughly investigate allegations of staff abuse, neglect, and/or mistreatment for 2 of 5 residents (R75, R65) reviewed for abuse, and failed to ensure residents were protected from further abuse. The facility's failure to operationalize their abuse/neglect/maltreatment policy/procedures following identification of abuse to R75 and R65, resulted in an immediate jeopardy (IJ) situation for R75 and R65 as well as for other residents who resided on the main and lower floor living units where the alleged perpetrator worked, presenting a risk of additional staff abuse, neglect, and/or mistreatment. In addition the facility failed to operationalize their abuse/neglect policy that clearly identified reporting, investigation, and protection of residents if allegation/s of staff abuse, neglect, and mistreatment for 3 of 6 other allegations reviewed (R64, R99, and R98). The immediate jeopardy began on 4/24/15 when facility staff witnessed licensed practical nurse (LPN)-E verbally abuse R75 and then physically abuse R65. The director of nursing (DON) and administrator were notified of the immediate jeopardy at 3:00 p.m. on 6/12/15. The immediate jeopardy was removed on 6/16/15 but noncompliance remained at the lower scope and severity level of an E, a pattern scope, with severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Although R75 was observed by staff to be yelled at by licensed practical nurse (LPN)-E on 4/24/15 following the supper meal, and LPN-E was subsequently observed to be verbally and physically abusive to R65 that same evening, however, the incidents were not immediately reported to the administrator or the State agency, nor were interventions initiated to prevent further abuse. A facility COMPLAINT/CONCERN FORM REGARDING an EMPLOYEE had been completed by nursing assistant (NA)-C dated 4/25/15. The concern included: EMPLOYEE NAME: (LPN-E's first name) . COMPLAINT OR CONCERN: Upon returning from bringing residents from supper co-worker (NA-E) and I heard a lot of commotion/screaming. We noticed that the nurse (LPN-E) was yelling and screaming at resident (R75). We tried to take her (R75) to her room, she (R75) asked (LPN-E) another question and he started yelling at her again. That's when we removed her (R75) from the situation . R75's quarterly minimum data set ((MDS) dated [DATE] indicated R75 had a brief interview for mental status (BIMS) score of 4 which indicated R75 was severely cognitively impaired. The MDS also indicated R4 could hear with minimal difficulty. During an interview and observations on 6/9/15 at 9:51 a.m., R75 was observed during an interview with family (F)-A. R75 conversed with F-A and the surveyor without hearing difficulty and surveyor did not have to speak loudly for resident to hear. R75's care plan directed staff to provide, Clear, careful, explanations to facilitate her comprehension .repeat/rephrase words as needed to facilitate hearing and comprehension. Information provided by the DON related to the investigation of these incidents, included a typed interview conducted 4/25/15 at 10:00 a.m., by the DON with NA-L. The interview documentation included, Spoke to (NA-L) concerning incident Friday 4-24-15 p.m. shift. She stated he (LPN-E) was talking to (R75). (R75) was repeating questions and as (LPN-E) was answering questions he was becoming more upset and yelling, and was probably yelling more than he should. (R65) was standing nearby with her walker but did not say anything. Stated she (NA-L) heard a little later from another CNA (certified nursing assistant) that (R65) was hitting at staff, kicking and attempting to hit them with her walker. Another typed account of these incidents had been documented by LPN-J on 4/25/15. LPN-J's account included, On Friday 4/24/15 I was here for staff potluck, overheard loud voice of a staff member (LPN-E) addressing a resident. I did not see who it was but another staff stated it was (R75). Went out for a smoke break after eating, when a staff member came out and said (LPN-E) had stated 'could just kill them all'. When I came back in I asked (LPN-E) if he was ok, he stated 'we had a call in for night shift', (he also said his grandson was back in the hospital.) I offered to call to see if I could get someone to come in for night shift, he said that would be great. Received page from another staff (registered nurse (RN)-H), had me come down to the breakroom and talk with (assistant director of nursing (ADON) RN-A). Discussed issue regarding (LPN-E) and it was decided (LPN-E) would be asked to go home. According to interviews and written witness statements, following the verbal altercation with R75, LPN-E was instructed to go home. However, LPN-E continued to remain in the facility without continuous supervision or immediate removal from resident access. LPN-E verbally and physically abused R65 after the altercation with R76. During that altercation R65 sustained an injury to her left hand. The facility's time clock records indicated LPN-E had punched out from his shift at 7:37 p.m., approximately one hour after the incident of verbal abuse with R75 had occurred. RN- H had documented a late entry progress note in R75's medical record on 4/27/15 at 19:38 (7:38 p.m.) which included, Late entry from 4/24/15. Several staff members were in the south conference room when a staff nurse was heard raising his (LPN-E) voice towards resident. This writer came out in attempts to ascertain what the resident (R75) needed. Asked if she wanted to go to her room. The notes indicated LPN-E had stated, she can drive herself wherever she wants to go, and had then made some comments about arguing with her. RN-H further documented, Able to redirect the resident and diffuse the situation. DON, ADON and social services all notified of incident. LPN-E was observed on 6/9/15 at 3:45 p.m. to be conducting a medication pass on a unit in the lower level of the facility. LPN-E's personnel record was reviewed. LPN-E had an active Minnesota Nursing License and had been employed at the facility since January 2015. Review of LPN-E's in-service training record indicated that LPN-E had received initial Abuse Protocol training during orientation, but had not received training on dealing with cognitively impaired residents since hire until after the incidents of alleged abuse on 4/24/15. LPN-E had completed online education related to Abuse Prohibition/Resident rights/Caring for the Alzheimer's client on 4/28/15. During an interview with NA-C on 6/11/15 at 5:41 p.m., NA-C recalled the incident form 4/24/15 and stated, I was sitting in the back nursing area, we heard (LPN-E) yelling and screaming at (R75). NA-C then explained she had walked up the hallway near the nurse's station and was able to re-direct R75, We started walking away with her but then she (R75) asked him (LPN-E) another question and he started yelling and screaming at her again. We were finally able to remove her from the situation. NA-C stated she could not remember what LPN-E was yelling and screaming about. During an interview on 6/11/15 at 6:00 p.m., NA-E indicated she could not recall all of the events that had taken place the evening of 4/24/15. However, she stated she could remember she'd heard LPN-E yelling at R75. NA-E could not remember what had been said during the confrontation but stated the yelling had lasted at least 10 minutes. NA-E also stated she had never been interviewed about the incident and was not aware she could report abuse to the State agency. During an interview on 6/12/15, at 9:30 a.m., the DON was asked to provide all information regarding the immediate reporting of the allegations of abuse between LPN-E and the residents to the administrator or State agency, and any interventions taken to protect R75 or other residents, or any investigation of the abuse incident. The DON confirmed he had not reported the allegation involving R75 to the State agency because he had been more focused on the physical abuse allegation between LPN-E and R65. During a follow-up interview with NA-C on 6/12/15 at 2:34 p.m., NA-C stated the yelling had started after dinner which was around 6:30 p.m. NA-C stated, (LPN-E) was really loud, we could hear him down the hallway. We went to see what the yelling was all about, when we went up there, he was in her face yelling at her, she was sitting in the wheelchair, and I think (R75) was more confused than usual. NA-C further explained that after the incident R75 had kept repeating, That man was yelling at me, why was he yelling at me? until she went to bed. NA-C stated that besides the repeated question, R75 had been anxious and quiet the rest of the night until she went to bed. NA-C stated she could not recall who she'd told about the incident. The facility COMPLAINT/CONCERN FORM REGARDING an EMPLOYEE completed by NA-C on 4/25/15 also included: .Around 7:40 (p.m.) I went to go ask nurse (LPN-J) a question and noticed resident (R65) standing by the med cart arguing with (LPN-E). She (R65) attempted to grab the water pitcher and he (LPN-E) grabbed her from behind like a choke hold. I attempted to go over but (LPN-J) went over and intervened. I tried to calm resident (R65) down afterwards but she was too worked up. A typed witness account of the physical abuse that occurred on 4/24/15, as part of the investigation for R65, had been documented on 4/25/15 by LPN-J and included: Discussed issue regarding (LPN-E) and it was decided (LPN-E) would be asked to go home. He was finishing up a medication admin at cart when (R65) came up, grabbed the water pitcher, and tried to hit him with it. He grabbed it out of her hands and set it back on cart. She then raised up her walker, as if to hit him with it, not sure if he knocked it down or she dropped it but it fell on the floor. (LPN-E) picked it up and (R65) went as if to hit him with a closed fist at which time I got between them and asked (R65) to leave the area which she did. (LPN-E) left shortly after that. Another witness statement regarding the alleged physical abuse of R65 had been documented by RN-H on 4/25/15 and included: I did not witness the interaction between (LPN-E) and (R65) on 4/24/15 as I was on phone (symbol for with) (RN-A). I was informed by (LPN-J) that (R65) had gotten in (LPN-E's) face but was unaware of the fact that (LPN-E) had put his arm and hand around (R65) until 11 p.m. on 4/24/15. CNA (NA-C) is filling out an incident report stating it was reported to myself and (LPN-H). I was made aware of this situation 4 hours (symbol for after) it had occurred by (LPN-B). I reported incident as soon as able. R65's quarterly MDS dated [DATE], indicated R65 had a BIMS score of 4 indicating severe cognitive impairment. R65's care plan verified the resident demonstrated behavioral problems and interventions included: She is much more receptive when she has familiar staff working with her using calm, direct approach. Review of R65's medical record indicated a certified nurse practitioner (CNP)-D had been requested to conduct an assessment of R65 on 4/28/15. The CNP's assessment was documented as an Evaluation of patient after physical assault. The documented assessment included: Charge nurse has informed me that patient was physically assaulted by a staff nurse on April 24, 2015. According to the charge nurse, the patient had been placed in a chokehold per another eyewitness. No bruising was noted after the event. Patient had no difficulty breathing, no laryngeal [MEDICAL CONDITION], stridor, or tracheal deviation. Director of nursing and Social Services were notified. A vulnerable adult form was filled with Olmsted County. Nursing is requesting that patient be evaluated for any potential injury from assault. Patient has no evidence of any trauma to her neck. There is no bruising, abrasions, evidence of finger prints on her neck or shoulder area. She has some resolving bruising noted on her left hand and nurse reported that she has some mild soft tissue swelling of her left thumb after the incident which has now resolved . An additional entry written by CNP-D on 4/28/15 at 6:18 p.m. included, . Charge nurse has informed me that patient (R65) had an altercation with a staff nurse on April 24, 2015. The patient was agitated and attempted to throw her water pitcher at the nurse. The nurse reached and grabbed the patient's wrist with one hand and the water pitcher with the other hand. There was some mild swelling noted on the patient's left thumb web space with a bruise occurring after the incident. Today she has some resolving bruising noted on her left hand and no further swelling of her left thumb after the incident which has now resolved. Director of Nursing and Social Services were notified. A vulnerable adult form was filled with Olmsted County. Nursing is requesting that patient be evaluated for any potential injury from the altercation. She (R65) denies all complaints of pain today. Patient has no evidence of any trauma to her body with no bruising or abrasions, or change in her functional status . During an interview on 6/11/15, at 9:34 a.m. in regards to when he was notified of the abuse incident with R65 which occurred on 4/24/15 after evening meal, DON stated staff had placed a phone message on his home phone following the incident but he did not listen to it until the next morning (Saturday 4/25/15) at which time he had come to the facility to follow-up on the incident. The DON stated it was the responsibility of the director of nursing, assistant director of nursing, administrator, or social worker to submit any internal investigative reports to the State designated agency. The facility provided the incident report, a submission report to the State agency (Office of Health Facility Complaints-OHFC), and all investigative notes regarding these allegations. According to the report submitted to OHFC, the allegations were not immediately reported. The allegation of physical abuse against R65 had been reported the day after it had occurred, 4/25/15. There had been no report of the allegation of verbal abuse against R75. The documentation indicated an investigative report had been submitted to the OHFC on 4/29/15. The report included LPN-E's account of the physical abuse of R65 however, it lacked other eye witness accounts of the physical abuse testimony and accounts from all of the witnesses. Despite the CNP's assessment, the investigative report indicated R65 had suffered no harm or injury. However, nurses reported swelling in the hand area that was grabbed by LPN-E during abuse altercation and CNP-D's physical and functional assessment completed on 4/28/15 verified there had been swelling and bruising of R65's left wrist. The investigative report also documented a personal improvement plan for LPN-E that included education re., vulnerable adult and dementia training, follow up with social worker, report to the board of nursing, and reassignment to another unit. During an interview with the DON on 6/12/15 at 9:45 a.m., the DON stated LPN-E receiving counseling, education on dealing with difficult behaviors especially residents with dementia who might become agitated and combative. However, the DON stated the social worker who had followed-up with LPN-E after the alleged abuse incidents for R75 and R65 was no longer employed by the facility and there was no documentation as to what improvements LPN-E was working on in regards to his performance improvement, competence of handling agitated dementia related behaviors, or dealing with personal stress in a healthy manner to prevent abuse situations from redeveloping. RN-A was interviewed on 6/12/15, at 11:57 a.m. she verified that LPN-E had received initial Abuse Protocol training during orientation, but had not received training on dealing with cognitively impaired residents since hire until after the incidents of alleged abuse on 4/24/15. RN-A versified that following the incidents, LPN-E had been required to complete online education related to Abuse Prohibition/Resident rights/Caring for the Alzheimer's client on 4/28/15. Following the surveyor's inquiry about the reporting of these alleged incidents of verbal/physical abuse, the DON made a report to the State agency (OHFC) regarding the verbal abuse R75 had sustained on 4/24/15. The report was made on 6/12/15, as part of the immediate plan of correction following the facility having been informed that an immediate jeopardy situation existed. The incident description sent to the State agency included: During routine MDH (Minnesota Department of Health), it was brought to this writer's attention that on 4/24/15, staff LPN (LPN-E) was yelling at resident (R75). An incident was initially reported on 4/25/15 regarding another demented resident (however, R65 was the main focus of that OHFC report and information in regards to R75 was to support the investigation of R65. During this incident (R75) was also agitated and following the nurse and not responding to re-direction. Nurse (LPN-E) did yell at resident due to his frustration with resident (R75) and her continued agitation. This writer initially combined both of these actions by the nurse (LPN-E) into one investigation and I am now reporting this particular situation as a separate incident . On 6/16/15 all staff received a copy of the facility's abuse protocol packet (forms undated) from the assistant director of nursing as they reported for work. The staff were requested to read the packet of information in regards to abuse protocol. The packet included specific policies entitled: Background Screening Investigations, In-Service Training, Preventing Resident Abuse, Recognizing Signs and Symptoms of Abuse/Neglect, Reporting/Investigating Resident Accidents/Incidents. Abuse and/or Neglect Investigation, Protection of Residents During Abuse Investigation, Report Abuse to State Agencies and Other Entities/Individuals, Reporting Suspected Cases and/or Incidents of Rape, Vulnerable Adult Reporting of Alleged Misappropriation of Residents Personal Property, Investigating Unexplained Injuries, Resident-to-Resident Abuse, and reporting forms. In addition the packet of information included undated facility policies for Visitation, Quality of Life-Dignity, Employee In-Service Program, Six Keys to Resident Loyalty, Indicators of Abuse, and Indicators of Neglect. Interviews were conducted by survey staff with direct care staff, activities staff, pool nursing staff, and supervisory nursing from day and evening shifts on 6/16/15 between 2:20 p.m. and 2:40 p.m. to verify receipt of education prior to starting their shifts. Each staff person interviewed verified they had received a packet of information and were in the process of reading it as detailed in the facility's IJ removal plan. RN-A was interviewed on 6/16/17 at 2:45 p.m RN-A stated all staff were provided training as described as they reported to work. Facility policies related to Abuse Prohibition were reviewed. An undated policy entitled Reporting/Investigating Resident Accidents/Incidents included: All accidents/incidents involving residents must be reported to the director of nursing services and immediately to the administrator .All accidents/incidents involving residents will be thoroughly investigated by management and the findings of such investigation will be kept on file by the Director of Nursing. An undated policy entitled Abuse and/or Neglect Investigation included: All reports of resident abuse or neglect shall be promptly and thoroughly investigated. The undated policy entitled Reporting Abuse to State Agencies and Other Entities/Individuals included, All alleged/suspected violations and all substantiated incidents of abuse will be reported immediately to the Administrator and promptly reported to appropriate State agencies. The immediate jeopardy that began on 4/24/15, was removed on 6/16/15 when it could be determined the facility had operationalized their plan for removal in regards to educating all staff as they reported to work regarding the facility's policies related to abuse, neglect, maltreatment and reporting prior to allowing staff to work with residents. In addition, montioring systems had been developed and initiated to ensure continued complaince with facility protocols. However, non-compliance remained. Additional incidents of failure to follow facility policies for reporting/investigating: The facility had submitted a report to the state agency on 4/16/15, indicating a nurse had witnessed R64 being hit on the forearm by family (F)-B on 4/15/15, around 4:40 p.m. The report indicated, (R64) was sitting in a reclining chair next to (F-B) .As he was attempting to get up and out of the chair, (F-B) struck him on the forearm . R64's diagnosis, according to the resident admission record dated 1/21/15, included debility with functional decline and dementia. The quarterly Minimum Data Set ((MDS) dated [DATE], identified R64 had severe cognitive impairment and required extensive assistance from one person for all activities of daily living (ADL)'s. A review of the nursing progress notes dated 4/15/15, included a note from 4:30 p.m., Nurse observed resident attempting to get out of a recliner chair. (F-B) attempted to tell resident to sit back down. Nurse noted agitation in the (F-B ' s) voice. Nurse then observed resident's (F-B) pull the chair control out of resident's hand and hit him on the right forearm .Nurse immediately called social services to evaluate the situation. Administrator notified as well. Although the facility was aware of the family member striking R64 on 4/15/15, the incident was not reported to the State agency until the next day, 4/16/15. Although R99 sustained an injury of unknown origin on 8/19/14, the facility failed to ensure the administrator and state agency were notified immediately. An incident report for R99 had been submitted to the State agency on 8/20/14 for an incident that had occurred the previous day, Res (resident) was found in her room by a CNA (certified nursing assistant). Another resident was lying on the floor .(R99) was standing in the room guarding her left arm. She did complain of pain. Res was sent to the emergency room for xray and preliminary results indicate resident sustained [REDACTED]. R99's record was reviewed. The resident admission record dated 2/26/10, identified [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], identified R99 as having severe cognitive impairment and requiring limited assistance from one person for transferring and walking. A review of the nursing progress notes dated 8/19/14 at 10:30 a.m. included, CNA entered this resident's room and noted that this resident's friend was laying on the floor and this resident was standing guarding her left arm .She guards her left arm and said owe-owe when any attempt was made to do ROM (range of motion). A review of the facility's Alleged Resident Abuse Investigation Report Form, signed by the administrator and director of nursing on 8/20/14, indicated the incident had been reported to the administrator on 8/20/14, AM, and had been reported to the State licensing agency on 8/20/14, PM. Although the facility was aware R98 had bruising of unknown origin on 8/10/14, the facility failed to ensure the administrator and state agency were notified immediately. The facility had submitted a report to the State agency on 8/12/14, which included: During AM cares (8/10/14) resident was discovered to have a large, purple-black bruise on the left medial forearm extending along the left thumb and index finger. Has no history of recent trauma, or falls. Resident is not able to say what happened due to [MEDICAL CONDITION]. R98's record was reviewed and the resident admission record dated 12/5/08 indicated the resident had [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE], identified R98 had severe cognitive impairment and was totally dependent on staff for all activities of daily living. A review of the nursing progress notes dated 8/10/14 at 12:40 p.m., indicated while morning cares were being provided, a large, purple-black bruise was noted on R98's left medial forearm, extending along the left thumb and index finger, measuring 23.5 cm (centimeters) in length, and 4.5 cm in width. The progress notes also indicated R98's left hand and fingers were [MEDICAL CONDITION], and the area appeared to be tender, as R98 cried out when arm was moved. A Skin Integrity Events Report dated 8/10/14, indicated the purplish-black bruise on R98's left medial forearm extending to the side of the thumb and index finger, was mildly painful and was swollen. A review of the facility's Alleged Resident Abuse Investigation Report Form, signed as reviewed by the administrator and director of nursing on 8/15/14, included: Unexplained bruise noted on resident's L (left) medial forearm. No history of trauma to area. Discomfort noted with gentle ROM. Seen by NP (nurse practitioner) on 8-12-14, and x-ray ordered. Results show a comminuted impacted fracture distal radius with intra-articular extension and [MEDICAL CONDITION] . The investigative report also indicated the administrator had not been notified of the 8/10/14 incident until 8/12/14. During interview on 6/11/15 at 9:34 a.m., the DON stated administrative staff were to submit reports to the State agency, Other staff can, but I want them to call me. The DON stated he carried a cell phone and staff knew they could always reach him, and he would then report incidents to the administrator. The DON verified the reports that were submitted for R64, R99, and R98, had not all been submitted immediately to the administrator or State agency as required. The DON confirmed he was aware the reports needed to be submitted immediately and stated, We have a system problem. Review of the facility's undated policy Reporting Abuse to State Agencies and Other Entities/Individuals included: Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse be suspected, it must be immediately reported to the administrator and to proper State agencies.

Based on observation, interview and document review, the facility failed to ensure 2 of 2 residents (R75 and R65) reviewed for abuse, were free from verbal and physical abuse by staff. Although facility staff were aware of the abuse, the staff did not immediately report/intervene to prevent further abuse from occurring. The facility's failure to implement interventions to prevent continued abuse resulted in an immediate jeopardy (IJ) for R75, R65 and other residents residing on the main and lower floor levels where the alleged perpetrator worked The IJ began on 4/24/15, when facility staff had observed the abuse but failed to implement preventative interventions, failed to provide initial and ongoing education to staff for use of therapeutic interventions when dealing with residents with cognitive deficits, and failed to immediately report the abuse as efforts to prevent abuse from reoccurring. The director of nursing (DON) and administrator were notified of the immediate jeopardy at 3:00 p.m. on 6/12/15. The immediate jeopardy was removed on 6/16/15, but noncompliance remained at a lower scope and severity level of G, isolated scope and severity level, actual harm (bruising and swelling of R65's hand) that is not immediate jeopardy. Findings include: Although R75 was observed by staff to be yelled at by licensed practical nurse (LPN)-E on 4/24/15 following the supper meal, and LPN-E was subsequently observed to be verbally and physically abusive to R65 that same evening, the incidents were not immediately reported to the administrator or the State agency, nor were interventions initiated to prevent further abuse. A facility COMPLAINT/CONCERN FORM REGARDING an EMPLOYEE had been completed by nursing assistant (NA)-C dated 4/25/15. The concern read, EMPLOYEE NAME: (LPN-E's first name) . COMPLAINT OR CONCERN: Upon returning from bringing residents from supper co-worker (NA-E) and I heard a lot of commotion/screaming. We noticed that the nurse (LPN-E) was yelling and screaming at resident (R75). We tried to take her (R75) to her room, she (R75) asked (LPN-E) another question and he started yelling at her again. That's when we removed her (R75) from the situation . R75's quarterly minimum data set ((MDS) dated [DATE] indicated R75 had a brief interview for mental status (BIMS) score of 4 which indicated R75 was severely cognitively impaired. The MDS also indicated R4 could hear with minimal difficulty. During an interview and observations on 6/9/15 at 9:51 a.m., R75 was observed during an interview with family (F)-A. R75 conversed with F-A and the surveyor without hearing difficulty. R75's care plan directed staff to provide, Clear, careful, explanations to facilitate her comprehension .repeat/rephrase words as needed to facilitate hearing and comprehension. Information provided by the DON related to the investigation of these incidents, included a typed interview conducted 4/25/15 at 10:00 a.m., by the DON with NA-L. The interview documentation included, Spoke to (NA-L) concerning incident Friday 4-24-15 p.m. shift. She stated he (LPN-E) was talking to (R75). (R75) was repeating questions and as (LPN-E) was answering questions he was becoming more upset and yelling, and was probably yelling more than he should. (R65) was standing nearby with her walker but did not say anything. Stated she (NA-L) heard a little later from another CNA (certified nursing assistant) that (R65) was hitting at staff, kicking and attempting to hit them with her walker. Another typed account of these incidents had been documented by LPN-J on 4/25/15. LPN-J's account included, On Friday 4/24/15 I was here for staff potluck, overheard loud voice of a staff member (LPN-E) addressing a resident. I did not see who it was but another staff stated it was (R75). Went out for a smoke break after eating, when a staff member came out and said (LPN-E) had stated 'could just kill them all'. When I came back in I asked (LPN-E) if he was ok, he stated 'we had a call in for night shift', (he also said his grandson was back in the hospital.) I offered to call to see if I could get someone to come in for night shift, he said that would be great. Received page from another staff (registered nurse (RN)-H), had me come down to the breakroom and talk with (assistant director of nursing (ADON) RN-A). Discussed issue regarding (LPN-E) and it was decided (LPN-E) would be asked to go home. According to interviews and written witness statements, following the verbal altercation with R75, LPN-E was instructed to go home. However, LPN-E continued to remain in the facility without continuous supervision or immediate removal from resident access. LPN-E verbally and physically abused R65 after the altercation with R76. During that altercation R65 sustained an injury to her left hand. The facility's time clock records indicated LPN-E had punched out from his shift at 7:37 p.m., approximately one hour after the incident of verbal abuse with R75 had occurred. RN- H had documented a late entry progress note in R75's medical record on 4/27/15 at 19:38 (7:38 p.m.) which included, Late entry from 4/24/15. Several staff members were in the south conference room when a staff nurse was heard raising his (LPN-E) voice towards resident. This writer came out in attempts to ascertain what the resident (R75) needed. Asked if she wanted to go to her room. The notes indicated LPN-E had stated, she can drive herself wherever she wants to go, and had then made some comments about arguing with her. RN-H further documented, Able to redirect the resident and diffuse the situation. DON, ADON and social services all notified of incident. LPN-E was observed on 6/9/15 at 3:45 p.m. to be conducting a medication pass on a unit in the lower level of the facility. LPN-E's personnel record was reviewed. LPN-E had an active Minnesota Nursing License and had been employed at the facility since January 2015. Review of LPN-E's in-service training record indicated that LPN-E had received initial Abuse Protocol training during orientation, but had not received training on dealing with cognitively impaired residents since hire until after the incidents of alleged abuse on 4/24/15. LPN-E had completed online education related to Abuse Prohibition/Resident rights/Caring for the Alzheimer's client on 4/28/15. During an interview with NA-C on 6/11/15 at 5:41 p.m., NA-C recalled the incident form 4/24/15 and stated, I was sitting in the back nursing area, we heard (LPN-E) yelling and screaming at (R75). NA-C then explained she had walked up the hallway near the nurse's station and was able to re-direct R75, We started walking away with her but then she (R75) asked him (LPN-E) another question and he started yelling and screaming at her again. We were finally able to remove her from the situation. NA-C stated she could not remember what LPN-E was yelling and screaming about. During an interview on 6/11/15 at 6:00 p.m., NA-E indicated she could not recall all of the events that had taken place the evening of 4/24/15. However, she stated she could remember she'd heard LPN-E yelling at R75. NA-E could not remember what had been said during the confrontation but stated the yelling had lasted at least 10 minutes. NA-E also stated she had never been interviewed about the incident and was not aware she could report abuse to the State agency. During an interview on 6/12/15, at 9:30 a.m., the DON was asked to provide all information regarding the immediate reporting of the allegations of abuse between LPN-E and the residents to the administrator or State agency, and any interventions taken to protect R75 or other residents, or any investigation of the abuse incident. The DON confirmed he had not reported the allegation involving R75 to the State agency because he had been more focused on the physical abuse allegation between LPN-E and R65. During a follow-up interview with NA-C on 6/12/15 at 2:34 p.m., NA-C stated the yelling had started after dinner which was around 6:30 p.m. NA-C stated, (LPN-E) was really loud, we could hear him down the hallway. We went to see what the yelling was all about, when we went up there, he was in her face yelling at her, she was sitting in the wheelchair, and I think (R75) was more confused than usual. NA-C further explained that after the incident R75 had kept repeating, That man was yelling at me, why was he yelling at me? until she went to bed. NA-C stated that besides the repeated question, R75 had been anxious and quiet the rest of the night until she went to bed. NA-C stated she could not recall who she'd told about the incident. The facility COMPLAINT/CONCERN FORM REGARDING an EMPLOYEE completed by NA-C on 4/25/15 also included: .Around 7:40 (p.m.) I went to go ask nurse (LPN-J) a question and noticed resident (R65) standing by the med cart arguing with (LPN-E). She (R65) attempted to grab the water pitcher and he (LPN-E) grabbed her from behind like a choke hold. I attempted to go over but (LPN-J) went over and intervened. I tried to calm resident (R65) down afterwards but she was too worked up. A typed witness account of the physical abuse that occurred on 4/24/15, as part of the investigation for R65, had been documented on 4/25/15 by LPN-J and included: Discussed issue regarding (LPN-E) and it was decided (LPN-E) would be asked to go home. He was finishing up a medication admin at cart when (R65) came up, grabbed the water pitcher, and tried to hit him with it. He grabbed it out of her hands and set it back on cart. She then raised up her walker, as if to hit him with it, not sure if he knocked it down or she dropped it but it fell on the floor. (LPN-E) picked it up and (R65) went as if to hit him with a closed fist at which time I got between them and asked (R65) to leave the area which she did. (LPN-E) left shortly after that. Another witness statement regarding the alleged physical abuse of R65 had been documented by RN-H on 4/25/15 and included: I did not witness the interaction between (LPN-E) and (R65) on 4/24/15 as I was on phone (symbol for with) (RN-A). I was informed by (LPN-J) that (R65) had gotten in (LPN-E's) face but was unaware of the fact that (LPN-E) had put his arm and hand around (R65) until 11 p.m. on 4/24/15. CNA (NA-C) is filling out an incident report stating it was reported to myself and (LPN-H). I was made aware of this situation 4 hours (symbol for after) it had occurred by (LPN-B). I reported incident as soon as able. R65's quarterly MDS dated [DATE], indicated R65 had a BIMS score of 4 indicating severe cognitive impairment. R65's care plan verified the resident demonstrated behavioral problems and interventions included: She is much more receptive when she has familiar staff working with her using calm, direct approach. Review of R65's medical record indicated a certified nurse practitioner (CNP)-D had been requested to conduct an assessment of R65 on 4/28/15. The CNP's assessment was documented as an Evaluation of patient after physical assault. The documented assessment included: Charge nurse has informed me that patient was physically assaulted by a staff nurse on April 24, 2015. According to the charge nurse, the patient had been placed in a chokehold per another eyewitness. No bruising was noted after the event. Patient had no difficulty breathing, no laryngeal [MEDICAL CONDITION], stridor, or tracheal deviation. Director of nursing and Social Services were notified. A vulnerable adult form was filled with Olmsted County. Nursing is requesting that patient be evaluated for any potential injury from assault. Patient has no evidence of any trauma to her neck. There is no bruising, abrasions, evidence of finger prints on her neck or shoulder area. She has some resolving bruising noted on her left hand and nurse reported that she has some mild soft tissue swelling of her left thumb after the incident which has now resolved . An additional entry written by CNP-D on 4/28/15 at 6:18 p.m. included, . Charge nurse has informed me that patient (R65) had an altercation with a staff nurse on April 24, 2015. The patient was agitated and attempted to throw her water pitcher at the nurse. The nurse reached and grabbed the patient's wrist with one hand and the water pitcher with the other hand. There was some mild swelling noted on the patient's left thumb web space with a bruise occurring after the incident. Today she has some resolving bruising noted on her left hand and no further swelling of her left thumb after the incident which has now resolved. Director of Nursing and Social Services were notified. A vulnerable adult form was filled with Olmsted County. Nursing is requesting that patient be evaluated for any potential injury from the altercation. She (R65) denies all complaints of pain today. Patient has no evidence of any trauma to her body with no bruising or abrasions, or change in her functional status . During an interview on 6/11/15, at 9:34 a.m. in regards to when he was notified of the abuse incident with R65 which occurred on 4/24/15 after evening meal, DON stated staff had placed a phone message on his home phone following the incident but he did not listen to it until the next morning (Saturday 4/25/15) at which time he had come to the facility to follow-up on the incident. The DON stated it was the responsibility of the director of nursing, assistant director of nursing, administrator, or social worker to submit any internal investigative reports to the State designated agency. The facility provided the incident report, a submission report to the State agency (Office of Health Facility Complaints-OHFC), and all investigative notes regarding these allegations. According to the report submitted to OHFC, the allegations were not immediately reported. The allegation of physical abuse against R65 had been reported the day after it had occurred, 4/25/15. There had been no report of the allegation of verbal abuse against R75. The documentation indicated an investigative report had been submitted to the OHFC on 4/29/15. The report included LPN-E's account of the physical abuse of R65 however, it lacked other eye witness accounts of the physical abuse testimony and accounts from all of the witnesses. Despite the CNP's assessment, the investigative report indicated R65 had suffered no harm or injury. However, nurses reported swelling in the hand area that was grabbed by LPN-E during abuse altercation and CNP-D's physical and functional assessment completed on 4/28/15 verified there had been swelling and bruising of R65's left wrist. The investigative report also documented a personal improvement plan for LPN-E that included education re., vulnerable adult and dementia training, follow up with social worker, report to the board of nursing, and reassignment to another unit. During an interview with the DON on 6/12/15 at 9:45 a.m., the DON stated LPN-E receiving counseling, education on dealing with difficult behaviors especially residents with dementia who might become agitated and combative. However, the DON stated the social worker who had followed-up with LPN-E after the alleged abuse incidents for R75 and R65 was no longer employed by the facility and there was no documentation as to what improvements LPN-E was working on in regards to his performance improvement, competence of handling agitated dementia related behaviors, or dealing with personal stress in a healthy manner to prevent abuse situations from redeveloping. RN-A was interviewed on 6/12/15, at 11:57 a.m. she verified that LPN-E had received initial Abuse Protocol training during orientation, but had not received training on dealing with cognitively impaired residents since hire until after the incidents of alleged abuse on 4/24/15. RN-A verified that following the incidents, LPN-E had been required to complete online education related to Abuse Prohibition/Resident rights/Caring for the Alzheimer's client on 4/28/15. Following the surveyor's inquiry about the reporting of these alleged incidents of verbal/physical abuse, the DON made a report to the State agency (OHFC) regarding the verbal abuse R75 had sustained on 4/24/15. The report was made on 6/12/15, as part of the immediate plan of correction following the facility having been informed that an immediate jeopardy situation existed. The incident description sent to the State agency included: During routine MDH (Minnesota Department of Health), it was brought to this writer's attention that on 4/24/15, staff LPN (LPN-E) was yelling at resident (R75). An incident was initially reported on 4/25/15 regarding another demented resident (however, R65 was the main focus of that OHFC report and information in regards to R75 was to support the investigation of R65. During this incident (R75) was also agitated and following the nurse and not responding to re-direction. Nurse (LPN-E) did yell at resident due to his frustration with resident (R75) and her continued agitation. This writer initially combined both of these actions by the nurse (LPN-E) into one investigation and I am now reporting this particular situation as a separate incident . On 6/16/15 all staff received a copy of the facility's abuse protocol packet (forms undated) from the assistant director of nursing as they reported for work. The staff were requested to read the packet of information in regards to abuse protocol. The packet included specific policies entitled: Background Screening Investigations, In-Service Training, Preventing Resident Abuse, Recognizing Signs and Symptoms of Abuse/Neglect, Reporting/Investigating Resident Accidents/Incidents. Abuse and/or Neglect Investigation, Protection of Residents During Abuse Investigation, Report Abuse to State Agencies and Other Entities/Individuals, Reporting Suspected Cases and/or Incidents of Rape, Vulnerable Adult Reporting of Alleged Misappropriation of Residents Personal Property, Investigating Unexplained Injuries, Resident-to-Resident Abuse, and reporting forms. In addition the packet of information included undated facility policies for Visitation, Quality of Life-Dignity, Employee In-Service Program, Six Keys to Resident Loyalty, Indicators of Abuse, and Indicators of Neglect. Interviews were conducted by survey staff with direct care staff, activities staff, pool nursing staff, and supervisory nursing from day and evening shifts on 6/16/15 between 2:20 p.m. and 2:40 p.m. to verify receipt of education prior to starting their shifts. Each staff person interviewed verified they had received a packet of information and were in the process of reading it as detailed in the facility's IJ removal plan. RN-A was interviewed on 6/16/17 at 2:45 p.m RN-A stated all staff were provided training as described as they reported to work. Facility policies related to Abuse Prohibition were reviewed. An undated policy entitled Reporting/Investigating Resident Accidents/Incidents included: All accidents/incidents involving residents must be reported to the director of nursing services and immediately to the administrator .All accidents/incidents involving residents will be thoroughly investigated by management and the findings of such investigation will be kept on file by the Director of Nursing. An undated policy entitled Abuse and/or Neglect Investigation included: All reports of resident abuse or neglect shall be promptly and thoroughly investigated. The undated policy entitled Reporting Abuse to State Agencies and Other Entities/Individuals included, All alleged/suspected violations and all substantiated incidents of abuse will be reported immediately to the Administrator and promptly reported to appropriate State agencies. The immediate jeopardy that began on 4/24/15, was removed on 6/16/15 when it could be determined the facility had operationalized their plan for removal in regards to educating all staff as they reported to work regarding the facility's policies related to abuse, neglect, maltreatment and reporting prior to allowing staff to work with residents. In addition, montioring systems had been developed and initiated to ensure continued complaince with facility protocols. However, non-compliance remained.

Based on record review and interview, the facility failed to administer a pain medication as ordered for 1 of 1 residents (resident #1) reviewed for leg ulcers. This resulted in a significant medication error. Findings include: Resident #1 was prescribed an order on 10/28/2010 for [MEDICATION NAME] (an [MEDICATION NAME] medication used for moderate to moderately severe pain). Facility nursing staff did not administer the [MEDICATION NAME] for 20 of the 22 days in the order period. Record review for Resident #1 revealed a [DIAGNOSES REDACTED]." Further record review showed a clinician Nursing Home Visit dated 09/02/2010 that indicated resident #1 had "venous stasis ulcers" bilaterally to lower extremities. Review of the physician's orders [REDACTED]. Additional record review revealed a clinician Nursing Home Visit dated 09/30/2010 for review of the leg ulcers and this note indicated "It is extremely uncomfortable for the patient to have these dressing changes." The clinician Nursing Home Visit Note dated 10/21/2010 reported "The patient does have momentary pain with treatment to (resident #1's) legs." A weekly nursing summary dated 10/22/2010 indicated resident #1 had leg pain daily. Nurse's Notes dated 10/27/2010 indicated it was "very painful" for resident #1 during the leg ulcer treatments. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation for four of these days showed "no supply" with no reason documented for the other dates. (Resident #1 was hosptalized on [DATE]). Review of the monthly pharmacy review dated 11/11/2010 contained a "Comments" section that stated "tylenol dose reduced" and "[MEDICATION NAME] for dressing changes." There was no documentation regarding the missed doses of [MEDICATION NAME]. Nurse's Notes dated 11/02/2010 contained documentation of "continues to be painful with touch" regarding leg ulcers (the Skin And Wound Assessment and Record dated 11/02/2010 indicated this was "very painful"). Nurse's Notes dated 11/03/2010 showed resident #1 attended a care conference with the interdisciplinary team and there were "(no) issues except pain when doing leg (dressings)." Nurse's Notes dated 11/08/2010 contained documentation for the leg ulcer treatments and resident #1 had "slight discomfort when old (dressing) removed." Employee E/Director of Nursing (DON) was interviewed on 12/21/2010 at 11:37 a.m. and was not aware of the missed doses of [MEDICATION NAME] or the reason for the omitted doses.

Based on observation, record review and interview, the facility failed to administer pain medication as ordered for 1 of 1 residents (resident #1) reviewed for ulcers and failed to provide the necessary care and treatment when they failed to obtain an immediate medical evaluation for 1 of 3 residents reviewed for falls (resident #1). Findings include: Resident #1 had a physician's orders [REDACTED].#1. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review for Resident #1 revealed a [DIAGNOSES REDACTED]." Further record review showed a clinician Nursing Home Visit dated 09/02/2010 that indicated resident #1 had "venous stasis ulcers" bilaterally to lower extremities. This Nursing Home Visit note contained documentation that read "(resident #1) is gradually declining mentally and does not complain of pain in her lower extremities." Additional record review revealed a clinician Nursing Home Visit dated 09/30/2010 for review of the leg ulcers and this note indicated "It is extremely uncomfortable for the patient to have these dressing changes." The clinician Nursing Home Visit Note dated 10/21/2010 reported "The patient does have momentary pain with treatment to (resident #1's) legs." A weekly nursing summary dated 10/22/2010 indicated resident #1 had leg pain daily. Nurse's Notes dated 10/27/2010 indicated it was "very painful" for resident #1 during the leg ulcer treatments; resident #1 was being "pre-medicated" with tylenol and [MEDICATION NAME]. Review of the physician's orders [REDACTED]. Review of the MAR for October 2010 and November 2010 for resident #1 indicated the [MEDICATION NAME] was not given for the period of 10/28/2010 through 11/18/2010, with the exception of 11/10/2010 and 11/11/2010 being shown as given. Documentation for four of these days showed "no supply" with no reason documented for the other dates. (Resident #1 was hosptalized on [DATE]). Additional review of the MAR for the period of 10/28/2010 through 11/18/2010 showed four of these days resident #1 was administered as needed [MEDICATION NAME] (medication used to treat moderate to moderately severe pain) for pain related to the dressing changes; two of these days (10/28/2010 and 11/03/2010) showed resident #1 continued to have pain two hours after the [MEDICATION NAME] was given and the other two days (11/02/2010 and 11/08/2010) showed resident #1 exhibited pain during the treatment as further detailed in review of the nurse's notes below. Nurse's Notes dated 11/02/2010 contained documentation of "continues to be painful with touch" regarding leg ulcers (the Skin And Wound Assessment and Record dated 11/02/2010 indicated this was "very painful"). Nurse's Notes dated 11/03/2010 showed resident #1 attended a care conference with the interdisciplinary team and there were "(no) issues except pain when doing leg (dressings)." Nurse's Notes dated 11/08/2010 contained documentation for the leg ulcer treatments and resident #1 had "slight discomfort when old (dressing) removed." An observation on 12/07/2010 at 8:00 a.m. showed Employee I/LPN changed the leg ulcer dressings for Resident #1. Resident #1 denied pain when the surveyor asked about this and replied "It's been pretty good." At 8:12 a.m. Employee I applied ace wraps to resident #1's lower extremities and resident #1 stated "that's getting sore." Employee I reported resident #1 "usually screams in pain but (resident #1) is doing good today." Employee I further reported that resident #1 was given [MEDICATION NAME] (a medication used to treat moderate to severe pain) prior to the leg ulcer treatment. The hospital Dismissal Summary dated 11/23/2010 showed resident #1 returned to the facility with an order for [REDACTED]. Employee E/Director of Nursing (DON) was interviewed on 12/21/2010 at 11:37 a.m. and verbalized uncertainty as to the reason resident #1 did not receive [MEDICATION NAME] as ordered. At 3:45 p.m. Employee E did not have any further information pertaining to the reason for the missed doses of [MEDICATION NAME]. Resident #1 sustained an unwitnessed fall on 11/19/2010 and immediately after the fall exhibited signs of a possible [MEDICAL CONDITION]. Emergency personnel were contacted approximately 3 hours after the incident and resident #1 was hospitalized for [REDACTED]. Record review for resident #1 revealed a [DIAGNOSES REDACTED]." Further record review showed a significant change Minimum Data Set (MDS) (a resident assessment and screening tool) dated 8/03/2010 that indicated resident #1 had short and long term memory problems, was moderately impaired with cognitive skills for daily decision making and required extensive assistance of at least two staff for transfers, ambulation, bed mobility and toileting use. This MDS also indicated resident #1 used assistive devices for ambulation and transfers, walked independently with one staff one time in the corridor during this review period and fell in the past 30 days. The Interdisciplinary Notes for ADL function and falls dated 8/03/2010 contained documentation of "(resident #1) may walk with a walker in room and in hallway and receives Restorative Care for exercises. It is expected that (resident #1) will return to previous level of function." Further record review revealed a Nurse's Note dated 11/19/2010 and entered at 2:30 a.m. by Employee D/Licensed Practical Nurse (LPN) that indicated facility staff responded to alarms and found resident #1 "sitting on floor by walker on lower end of bed." This entry contained further documentation of "Took 4 staff to put in bed-(complained of right) thigh hurting-didn't want to move it when in bed-(right) foot is rotated out (and) shorter. (Resident #1) laying still and stated ok (with) this. Will observe for a while to see if pain better." An additional Nurse's Note dated 11/19/2010 and entered at 5 a.m. by Employee D contained documentation of "still will not move (right) leg...(resident #1) hollered out loudly about (right) thigh hurting." A physician's orders [REDACTED].#1 was transferred by ambulance to the emergency room at 5:30 a.m. An entry at 8 a.m. indicated resident #1 was diagnosed with [REDACTED]. Review of the undated "Patient Transfer Form-Nursing Home To Hospital" completed by Employee D contained documentation of "(resident) fell -(complained of right) thigh pain right away but (then) went to sleep (until 5 a.m.)." Employee D was interviewed on 12/9/2010 at 4:24 p.m. and verified the above incident. Employee D stated a "4 man lift" was used to assist resident #1 back to bed and this lift was completed by four nursing assistants (NA's) and not witnessed by Employee D (Employee D reported leaving the area to obtain a bath blanket to use to lift resident #1 back to bed and noted upon returning to the area that the NA's had already "lifted" resident #1 to bed). Employee D further indicated that because resident #1 fell asleep while in bed that she made the determination to continue observations and not have resident #1 referred for an immediate medical evaluation. Employee D further stated "I was surprised that (resident #1) had the fracture (because resident #1) didn't have pain in (the) groin or hip." Employee E/Director of Nursing (DON) was interviewed on 12/21/2010 at 11:37 a.m. and indicated the LPN's have access to Registered Nurses (RN's) 24 hours per day, 7 days per week and "can call anytime and they do when they have questions." The DON further reported "given the note I read in (resident #1's) chart I would have sent (resident #1) in." The DON agreed the signs and symptoms exhibited by resident #1 at the time of the incident were suggestive of a possible [MEDICAL CONDITION]. Review of information regarding [MEDICAL CONDITION] published in 2009 by the American Academy of Orthopaedic Surgeons (AAOS) (http://orthoinfo.aaos.org/topic.cfm?topic=A ) contained the following documentation: "[MEDICAL CONDITION] most commonly occur from a fall or from a direct blow to the side of the hip. The patient with a [MEDICAL CONDITION] will have pain over the outer upper thigh or in the groin. If the bone is completely broken, the leg may appear to be shorter than the noninjured leg. The patient will often hold the injured leg in a still position with the foot and the knee turned outward (external rotation). Most surgeons agree that patients do better if they are operated on fairly quickly."