Every finding on record at Thief River Care Center

Based on interview and document review, the facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 4 of 7 residents (R22, R62, R29, R46) reviewed for MDS discrepancies. Findings include: R22 R22's significant change MDS dated [DATE], identified R22 had a diagnosis of hyperlipidemia. The MDS identified R22 was taking an anticoagulant, antibiotic, diuretic, and hypoglycemic medications. R22's MDS did not identify they received an antiplatelet medication. R22's March 2026, Medication Administration Record (MAR), identified R22 was receiving the following medications: Aspirin (an antiplatelet medication) 81 mg one a day for hyperlipidemia (high cholesterol or triglycerides). R22 was not receiving an anticoagulant medication during this time, as identified on the MDS. R62 R62's quarterly MDS dated [DATE], identified R62 had a diagnosis of hyperlipidemia. The MDS identified R62 was taking an antipsychotic, antidepressant, anticoagulant, and diuretic medications. R62's MDS did not identify they received an antiplatelet medication. R62's December 2025, MAR, identified R62 was receiving Aspirin (an antiplatelet medication) 81 mg one a day for hyperlipidemia. R62 was not receiving an anticoagulant during this time, as identified on the MDS. R29 R29's quarterly Minimum Data Set (MDS) dated [DATE], identified R29 had a diagnoses of a lower extremity artery aneurysm, diabetes type II, depression, hypertension and anxiety. R29 used antipsychotic, antianxiety, antidepressant, anticoagulant, opioid, hypoglycemic, and anticonvulsant medications. R29's March 2026 MAR failed to identify R29 received an anticoagulant medication during the observation period. R29's Medication Review Report dated 4/1/26, identified R29 received aspirin (an antiplatelet medication) (aspirin is used to treat mild to moderate pain, inflammation, and fever, and is frequently used at low doses to prevent heart attacks and strokes) 81 milligrams (mg) by mouth every day for prophylactic. R29 did not have a history of taking an anticoagulant. R46 R46's quarterly Minimum Data Set (MDS) dated [DATE], identified R46 had diagnoses that included Alzheimer's disease and diabetes type II. R46 used antipsychotic, antidepressant, anticoagulant, diuretic, and hypoglycemic medications. R46's March 2026 MAR failed to identify R46 received an anticoagulant medication during the observation period. R46's Medication Review Report dated 4/1/16, identified Aspirin EC Tablet 325 mg by mouth every day for ischemic cardiomyopathy (an issue with damaged heart muscle that can't pump blood well). R46 did not have a history of taking an anticoagulant. During an interview on 4/1/26 at 2:53 p.m., registered nurse (RN)-A stated he was the facility's MDS coordinator. RN-A had always coded aspirin as an anticoagulant medication and had never been told differently. During an interview on 4/1/26 at 3:57 p.m., the director of nursing (DON) stated the resident MDS assessments should be coded accurately to ensure the MDS reflected the resident's care needs. The facility policy MDS 3.0 Assessment reviewed/amended 8/20/24, identified the facility would conduct comprehensive, accurate and standardized assessments known as Minimum Data Set (MDS) for each resident, as specified in the Centers for Medicare and Medicaid and the State of Minnesota Resident Assessment Instrument (RAI) Manual. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2025, instructed to code all high-risk drug class medication according to their pharmacological classification, not how they were being used: N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days).

Based on observation, interview, and document review the facility failed to ensure staff maintained the proper positioning for gastrostomy tube care for 1 of 1 resident (R10) reviewed for tube feedings.Findings include: R10's annual Minimum Data Set (MDS) dated [DATE], identified R10 had severe cognitive impairment and included a diagnosis of cerebral palsy spastic quadriplegia (the most severe form of spastic cerebral palsy, resulting from brain injury before, during, or shortly after birth). R10 had an enteral feeding tube (delivers nutrition directly to the stomach or small intestine for individuals unable to take in adequate calories by mouth) and was dependent on staff for all care areas.R10's care plan revised 3/20/26, identified R10 had an ADL self-care performance deficit related to CP. Staff were directed to ensure R10's head of bed was elevated above 30 degrees when R10 was hooked up to her feeding. However, the care plan failed to identify to pause the feeding during turning and repositioning.R10's undated care sheet, directed staff that during transfers R10 needed nursing staff to stop R10's tube feeding before the transfer and restart it after transfer was complete. If nursing assistants were assisting with R10's transfer, they must notify a nurse to manage R10's feeding.During an observation on 4/1/26 at 9:58 a.m., nursing assistant (NA)-A and NA-D assisted R10 into bed using a fully body mechanical lift and performed turning and repositioning for R10. When R10 initially laid down, R10's head of bed was flat, and NA-A raised the bed to approximately 20 degrees. NA-A and NA-D rolled R10 left and right while R10's feeding continued running. A bright pink sign hung on the wall at the head of R10's bed stating Reminder: have nurses pause feeding when lying lower than 30 degrees during repositioning, transfers, or cares. Restart by nurse when above 30 degrees. At 10:05 a.m., NA-A raised R10's head of bed to 45 degrees.During an interview on 4/1/26 at 10:08 a.m., NA-A stated the nurses using came and took care of R10's feeding and stuff. However, neither NA-A or NA-D had asked the nurse to come and pause R10's feeding before laying R10 down. NA-A stated R10 was lying flat but NA-A had raised the head of the bed but could not say if it was greater than 30 degrees. NA-A then stated she did not know if the feeding needed to be paused if it was a split second thing. I'll have to get that clarified. During an interview on 4/1/26 at 10:15 a.m., NA-D stated she was only helping NA-A to lay R10 down and didn't think of the feeding at all. NA-D stated they should have asked the nurse to pause R10's feeding because R10 could have vomited. During an interview on 4/1/26 at 2:29 p.m., licensed practical nurse (LPN)-A stated whenever the aides were going to lie R10 down they were supposed to ask a nurse to come and pause the feeding, then when they're done, they're supposed to call the nurse to turn it back on. That is supposed to happen every time. During an interview on 4/1/26 at 2:36 p.m., registered nurse (RN)-B stated the nursing assistants were expected to ask nursing to pause R10's feeding before transfers and to restart once the transfers/cares were done. This was required every time to prevent complications such as vomiting and aspiration. During an interview on 4/1/26 at 3:58 p.m., the director of nursing (DON) stated R10 had been assessed for possible aspiration but lung sounds were clear and R10 had no signs or symptoms of distress. The DON stated staff were expected to follow R10's care plan and request to have R10's feeding paused prior to transfers because the care plan reflected the R10's needs as well as the assessed needs to prevent complications. The DON stated R10 had been assessed for possible aspiration but lung sounds were clear and R10 had no signs or symptoms of distress. The facility policy Enteral Feeding Tube Usage revised 4/1/19, identified the facility provided enteral feeding tube care and services. However, the policy failed to direct staff how to care for the feeding during turning and repositioning.Nursing Skills textbook ISBN-13: 9781734914122 (ebook) dated 2021, identified the head of the bed (HOB) should be elevated to a 30 to 45-degree angle (semi-Fowler's position) during enteral feeding and for at least 30-60 minutes afterward to prevent aspiration. This positioning is crucial for all patients receiving tube feeds to reduce the risk of formula entering the lungs.

Based on interview and document review, the facility failed to ensure staff were comprehensively assessing falls and implementing appropriate interventions for 1 of 3 (R50) residents reviewed for falls.Findings include:R50's quarterly Minimum Data Set (MDS) dated [DATE], identified R50 was cognitively intact and was dependent on two staff for activities of daily living (ADL's) including toileting and transfers in/out of wheelchair and on/off the toilet. R50 was non-ambulatory and had contractures of both lower extremities. R50's diagnoses included cerebral palsy, epilepsy, schizophrenia and mild intellectual disability.R50's care plan dated 11/25/24, identified R50 was totally dependent on two staff and required a total mechanical lift (hoyer) for transfers to/from the bed/wheelchair/toilet. R50 was at risk for seizures related to epilepsy. Interventions included monitoring for seizure activity and staying with and ensuring the resident was safe during a seizure. R50 was at risk for falls related to impaired mobility and psychoactive medication use. Interventions included ensuring resident's call light was within.R50's fall risk assessment dated [DATE], identified R50 was alert and oriented, chairbound, incontinent of bowel and bladder, and was at risk for falls. The facility incident investigation report dated 7/18/25, identified R50 was being transferred from toilet to the wheelchair with the hoyer lift and staff were following the resident's care plan. The top strap on the hoyer sling on the right side came off and R50 was lowered to the floor with the hoyer. R50 reported she didn't know what happened and had not touched the strap. Immediate interventions included the hoyer strap was rehooked and R50 was lifted from the floor to her wheelchair. Staff were educated to ensure a double check was performed on all straps before lifting residents. R50 was educated on the importance of not touching the straps. The staff present at the time of incident identified the straps were hooked when R50 was lifted from the wheelchair to the toilet. The investigation failed to identify if the resident could be left unattended with the hoyer in the bathroom and if the straps were double checked prior to transferring R50 from the toilet to the wheelchair.R50's progress note dated 7/18/26 at 9:49 a.m., identified R50 had a fall in R50's bathroom on 7/18/25. the root cause analysis identified it appears that resident had been messing with hoyer straps. The interventions identified staff were educated to ensure they double check all straps before lifting the resident. R50 was educated on the importance of not touching the straps. R50 preferred staff to stand outside of bathroom and be left alone for privacy. During observation on 3/31/26 at 9:57 a.m., NA-A and NA-B were assisting R50 onto the toilet using the hoyer lift. The NA's left the sling attached to the hoyer. NA-A secured the hoyer brakes and both NA's left R50 unattended in the bathroom.During interview on 3/30/26 at 3:51 p.m., R50 stated she fell out of the hoyer lift previously, the staff came and helped. R50 was unable to provide further details of when or how the fall happened.During interview on 3/31/26 at 10:00 a.m., NA-A stated staff usually left R50 unattended in the bathroom with the hoyer brakes locked, the lift sheet under her and fastened to the hoyer lift.During interview on 3/31/26 at 10:10 a.m., NA-B stated after R50 was transferred onto the toilet with the hoyer, staff would leave the lift sheet under the resident with the straps fastened to the lift. The hoyer locked in place in front of the resident and exited the bathroom to provide privacy.During interview on 4/1/26 at 2:30 p.m., registered nurse (RN)-C stated it was a safety concern and staff were not to leave a resident unattended in the bathroom with the hoyer lift sheet under them and fastened to the lift. Residents could potentially fall from the toilet and injure themselves.During interview on 4/1/26 at 4:24 p.m., the director of nursing (DON) stated staff were instructed and shown proper use of the hoyer lift upon hire. The DON stated a resident should not be left unattended in the bathroom while seated on the toilet with the lift sheet under them and attached to the hoyer lift. It was a safety concern because the residents could potentially use the remote control and end up dangling or falling from the lift.The facilities Mechanical Lift policy reviewed 5/28/25, identified care center staff were to use appropriate techniques and processes when utilizing mechanical lift devices to lift and move residents, to protect the safety and well-being of staff and residents, to promote quality care, and to follow applicable laws regarding use of power-driven mechanical lifts.The Volaro Series 4 Lift operator's manual dated 3/2019, identified staff were to ensure all four loops from the sling were properly nested in the bottom of the hooks before lifting or transferring a patient or resident, as well as ensuring all four retainer springs were functioning correctly.

Based on observation, interview and document review, the facility failed to ensure turning and repositioning was timely for 1 of 1 resident (R10) reviewed who was at risk for the development of pressure ulcers.Findings include:R10's annual Minimum Data Set (MDS) dated [DATE], identified R10 had severe cognitive impairment and included a diagnosis of cerebral palsy spastic quadriplegia (the most severe form of spastic cerebral palsy, resulting from brain injury before, during, or shortly after birth). R10 was dependent on staff in all care areas.R10's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 3/3/26, identified R10 was unable to reliably express needs or discomfort. Braden score indicated moderate risk for skin breakdown. R10's head of bed was typically elevated approximately 30 degrees for positioning and comfort. R10 required pressure-reducing devices for bed and chair and followed a turning/repositioning program. Foot deformity present. R10 had a history of recurrent redness under bilateral breasts and lateral trunk folds consistent with moisture/friction areas; No open areas noted at this time. Peripheral vascular disease/peripheral artery disease (poor circulation) symptoms, venous stasis signs, or neuropathy symptoms noted at this time. R10's skin remains intact. Ongoing monitoring and preventative interventions were in place to reduce risk of pressure injury and moisture associated skin disorder (MASD).R10's Comprehensive Skin Risk dated 2/24/26, identified R10 was at moderate risk for pressure ulcer/injury.R10's care plan revised 3/20/26, identified R10 had a potential/actual impairment to skin integrity related to fragile skin. Staff were directed that R10 was to be turned and repositioned every two hours to help prevent skin breakdown.During a continuous observation on 4/1/26 between 7:33 a.m. to 10:06 a.m., R10 attended breakfast in the dining room, attended large group activities and returned to the common area to watch television. Staff did not reposition R10. At 4/1/26 9:58 a.m., nursing assistant (NA)-A and NA-D assisted R10 to lie down in bed using the full body mechanical lift. R10 did not have any pressure ulcers.During an interview on 4/1/26 at 10:15 a.m., NA-D stated she was only helping NA-A to reposition R10 and did not know the last time R10 had been repositioned. During an interview on 4/1/26 at 10:48 a.m., NA-A stated she didn't have a care sheet and was not sure how often R10 needed to be repositioned. NA-A went to the nurses' desk and picked up a resident care sheet and stated R10 required repositioning every two hours. NA-A stated staff were expected to write down repositioning times on the care sheets, but NA-A could not find her care sheet. NA-A placed the care sheet on the stack at the nurse's desk. NA-A stated she did not know the last time R10 had been repositioned that morning because R10 had a bath and the bath aide assisted R10. During an interview on 4/1/26 at 11:14 a.m., NA-F stated R10 was the first resident to have a bath that morning and was done at approximately 6:30 a.m.During an interview on 4/1/26 at 2:29 p.m., licensed practical nurse (LPN)-A stated R10 should be provided repositioning every two hours to prevent skin breakdown as care planned.During an interview on 4/1/26 at 2:36 p.m., registered nurse (RN)-B stated staff were expected to follow the resident care plans. R10 should be repositioned every two hours to prevent skin breakdown as care planned. R10 had no ability to move on her own at all and R10 was at risk for skin breakdown due to moisture and pressure. That's a huge concern. During an interview on 4/1/26 at 3:58 p.m., the director of nursing (DON) stated staff were expected to follow the resident care plan because the care plan reflected the resident's needs as well as the assessed needs to prevent complications such as pressure ulcer/injury. A turning and repositioning policy was requested but not received.

Based on observation, interview, and document review, the facility failed to follow the care plan for check and change for 1 of 2 residents (R10) observed for activities of daily living (ADLs).Findings include:R10's annual Minimum Data Set (MDS) dated [DATE], identified R10 had severe cognitive impairment with a diagnosis that included cerebral palsy spastic quadriplegia (the most severe form of spastic cerebral palsy, resulting from brain injury before, during, or shortly after birth). R10 was dependent on staff for all care areas.R10's Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE], identified R10 had an indwelling urinary catheter in place for chronic urinary retention secondary to cerebral palsy. R10's catheter remained patent with clear yellow urine noted. No signs of obstruction, leakage, or malfunction observed. R10's peri care provided by protocol. R10 had bowel incontinence and was checked every 2 hours and as needed.R10's care plan revised 3/20/25, identified R10 had an ADL self-care performance deficit r/t cerebral palsy (CP). The care plan directed staff to do the following: TOILET USE: R10 was not toileted due to spastic movements, and it was not safe r/t CP. R10 wore a brief medium size. R10 needed to be checked and changed when R10 was repositioned, and barrier cream was to be applied. R10 was incontinent of bowel related to CP. R10 required check and change with repositioning every 2 hours and as needed. Staff to assist with changing R10's brief and provide peri care after each incontinent episode R10 had.During a continuous observation on 4/1/26 between 7:33 a.m. to 10:06 a.m., R10 was sitting in her wheelchair in the common area. During this time, R10 attended breakfast in the dining room, attended large group activities and returned to the common area to watch television. Staff did not provide incontinence care for R10. At 4/1/26 9:58 a.m., nursing assistant (NA)-A pushed R10's wheelchair to R10's room and stated she was just waiting for NA-D to come with the full body mechanical lift to reposition R10. NA-A and NA-D transferred R10 into bed, however, R10's incontinence brief was clean and dry.During an interview on 4/1/26 at 10:15 a.m., NA-D stated she was only helping NA-A to reposition R10 and did not know the last time R10 had been toileted. During an interview on 4/1/26 at 10:48 a.m., NA-A stated she didn't have a care sheet and was not sure how often R10 needed to be toileted. NA-A went to the nurses' desk and picked up a resident care sheet and stated R10 required toileting every two hours. NA-A stated staff were expected to write down toileting times on the care sheets, but NA-A could not find her care sheet. NA-A replaced the care sheet on the stack at the nurse's desk. NA-A stated she did not know the last time R10 had been toileted that morning because R10 had a bath and the bath aide assisted R10. During an interview on 4/1/26 at 11:14 a.m., NA-F stated R10 was the first resident to have a bath that morning and was done at approximately 6:30 a.m.During an interview on 4/1/26 at 2:29 p.m., licensed practical nurse (LPN)-A stated R10 should be provided toileting every 2 hours to prevent skin breakdown as care planned.During an interview on 4/1/26 at 2:36 p.m., registered nurse (RN)-B stated staff were expected to follow the resident care plans. R10 should be toileted every two hours as care planned to prevent skin breakdown. R10 had no ability to move on her own at all and R10 was at risk for skin breakdown due to moisture and pressure. That's a huge concern. During an interview on 4/1/26 at 3:58 p.m., the director of nursing (DON) stated staff were expected to follow the resident care plan because the care plan reflected the resident's needs as well as the assessed needs to prevent complications. The facility policy Urinary Incontinence Program revised 4/16/15, identified each resident who is incontinent will be identified, assessed, and provided appropriate care and services to achieve or maintain their greatest level of continence. Each resident will receive the appropriate care and services to prevent incontinence related complications to the extent possible. An indwelling catheter will not be used unless there is valid medical justification for use, and if there is no indication for use, it will be discontinued as soon as clinically warranted.

Based on observation, interview and document review the facility failed to provide adequate supervision for 1 of 1 resident (R1) had a history of exit seeking behavior, communicated a desire to leave the facility and was able to elope. This resulted in an immediate jeopardy (IJ) for R1 when R1 was found outside in a wheelchair during hazardous weather conditions. The IJ began on 12/18/25 at 10:25 a.m., a visitor reported to the director of social services a resident in a wheelchair was stuck in the snow outside by the sidewalk. R1 was last seen by staff at 9:30 a.m. The weather was blizzard-like conditions, temperature approximately 0 to 5 degrees with wind from 38 to 44 miles per hour. R1 wore light weight material sweatpants, long sleeved t-shirt (waffle like material), tan colored gripper socks on his feet, with no coat/gloves/hat. The administrator and assistant director of nursing (ADON), were notified of the IJ on 12/30/25 at 5:45 p.m. The facility implemented corrective action by 12/18/25 prior to the start of the survey and therefore is issued as past non-compliance. Findings include: R1's Face Sheet dated 12/30/25, identified diagnoses paranoid personality and insomnia. R1's significant change Minimum Data Set (MDS) dated [DATE], identified he was admitted to facility on 12/9/19. R1's cognition was severely impaired without behaviors. He required partial/moderate assistance with oral hygiene, upper body dressing, roll left and right, sit to lying, sit to stand, substantial/maximal assistance with toileting hygiene, shower/bath, lower body dressing, personal hygiene, chair/bed/chair transfers, unable to walk and used a manual wheelchair for mobility. R1 was frequently incontinent of bowel and bladder. Active diagnoses identified non-traumatic brain dysfunction, diabetes mellitus (DM), osteoarthritis (a disease making bones weak and brittle), Alzheimer's Disease, and dementia. He had one fall without injury since admission. R1 received insulin injections 7 out of 7 days during the look back period, antipsychotic, antidepressant, anticoagulant, and diuretic. Wander/elopement alarm was not identified as being used. R1's Elopement risk assessment dated [DATE] at 5:39 p.m., identified he was not physically immobile. He had long/short term memory loss, disoriented times three, impaired decision-making skills, and impulsive. He had conditions in which contribute to elopement risk: Alzheimer's and dementia. He had attempted elopement in the last 90 days, looking for his car, staff was with during attempt to leave. Distracted which was successful. He verbalized seeing things (pets, people). R1 has made attempts to elope from current or previous living situations monthly with no successful attempts. Wander guard was placed on wrist and wheelchair due to safety concerns related to Alzheimer's disease. Behaviors: Was Santa during Christmas, years ago. R1's Elopement risk assessment dated [DATE] at 5:06 p.m., he will have impulsive behavior (one time in the past 90 days) attempted to pull fire alarm stated, I just want to make noise. He did not pose a risk for wandering/eloping from facility, no elopement attempts documented in the last three months. No exit seeking behavior noted. No wander guard. R1's medical doctor (MD) visit dated 11/20/25, identified confused, cognition poor, ambulated with walker but now stands and pivots. Confusion most likely related to intermittent worsening of dementia related to altered mental function. R1's Elopement risk assessment dated [DATE] at 10:47 p.m., identified history, cognition remained the same as 9/24/25 assessment. Summary for overall risk of elopement and interventions implemented. R1 does not pose a risk for wandering/eloping from facility, at times will have impulsive behavior such as attempting to pull fire alarm, one attempt in the past 90 days. No specific exit seeking behavior noted or documented in the last three months. No wander guard. R1's Elopement risk assessments dated 9/24/25 and 12/16/25 failed to identify his history of elopement, conditions which continued to contribute to his elopement risks such as Alzheimer's and dementia and failed to address winter/Christmas being an especially difficult time of year for R1. R1's Elopement risk assessment dated [DATE] at 2:12 p.m., identified changes: R1 has made attempts to elope from current living situations, weekly, and was successful. He was noted to be wandering, anxious and exit seeking behaviors in recent documentation. Could be related to the Christmas season due to history of being Santa Clause for many years and he drove a car painted like a [NAME]. Additionally it was noted he had long/short term memory loss, intermittent confusion, impaired decision-making skills, and pain. R1 verbalized the desire to go home and was looking for his truck. Wander guard was placed to wheelchair due to safety concerns, Alzheimer's disease, and poor safety awareness. R1's care plan dated 11/21/24, indicated Focus: unable to leave facility independently initiated on 10/13/25. Directed staff to assist with dress appropriate for weather conditions, staff and family supervision for all outdoor activities, family will notify facility and sign him out when leaving facility. R1 was an elopement risk related to impaired safety awareness, dementia, and paranoid personality disorder. He had a self-care performance deficit related to Alzheimer's. Staff were directed to transfer R1 with extensive assistant of two and Sara Steady (mechanical lift) due to unaware of safety needs, occasionally exit seeks and had a history of attempts to leave the facility unattended. Staff were directed to distract R1 from wandering/exit seeking, change wander guard device per manufacturer recommendations or as needed, encourage R1 to attend activities during highest wandering times. R1's behavior will be de-escalated by 1:1, offer food or drink, distraction, provide me with a wander guard and perform checks per facility policy. R1's care plan dated 9/24/25, all exit seeking behavior, wandering and use of the wander guard device was removed from the care plan. On 12/18/25, the focus: elopement was added back into the care plan and read as; unable to leave facility independently initiated on 10/13/25. Directed staff to assist with dress appropriate for weather conditions, staff and family supervision for all outdoor activities, family will notify facility and sign him out when leaving facility. R1 was an elopement risk related to impaired safety awareness, dementia, and paranoid personality disorder. He had a self-care performance deficit related to Alzheimer's. Staff were directed to transfer R1 with extensive assistant of two and Sara Steady (mechanical lift) due to unaware of safety needs, occasionally exit seeks and had a history of attempts to leave the facility unattended. Staff were directed to distract R1 from wandering/exit seeking, change wander guard device per manufacturer recommendations or as needed, encourage R1 to attend activities during highest wandering times, noting triggers for wandering/eloping are Christmas season and little kids. R1's behavior will be de-escalated by 1:1, offer food or drink, distraction, provide me with a wander guard and perform checks per facility policy. Resident care sheet undated and received on 12/19/25, identified transfer assist of two via Sara Steady, toilet every two to three hours and as needed (PRN), reposition with assist of two every two to three hours, and diabetic diet easy to chew thin. R1's treatment administration record (TAR) 12/1/25 through 12/17/25, identified monitoring for target behaviors: accusing people of taking my car, feeling people are stealing from me, lying to me, picking at my skin. Elopement monitoring/risk for elopement was not identified on TAR. R1's progress notes dated 12/6/25 through 12/23/25, identified:-On 12/6/25 at 9:35 p.m., R1 became agitated during supper meal. Wheeled towards another table. NA brought him back to table and sat with him and waited for supper. R1 was calm afterwards and brought back to pod.-On 12/16/25 at 11:38 p.m., Monthly evaluation. Mental status: disoriented, disorganized thinking, confused, severe cognitive impairment affecting all areas of judgement, and no unwanted behaviors/does not wander at night. Functional status: gait unsteady, poor balance when standing, and able to move all four extremities.-On 12/17/25 at 6:58 p.m., R1 asked where the exit is to find his pickup. Wandering around halls. Interventions: 1:1 with explanations of wife driving pickup home. Explained to him wife wants him to stay the night. R1 stated he did not want to stay the night. Effectiveness of interventions/follow-up: No documentation.-On 12/18/25 documented at 10:11 a.m., monitor bruise on right pectoral/rib 3 inches by 1 inch. Bruise is healing, purple/yellow, and resident denies pain to the area. (Nurse unavailable for interview to verify time she completed assessment).-On 12/18/25 at 12:51 p.m., At 10:25 a.m. R1 was found outside the facility in his wheel chair looking for his truck. He was safely redirected back into the facility without incident. Vitals taken temperature and within normal limits: 98.1 degrees Fahrenheit (F). Skin intact, cool to the touch at extremities and ears, no signs of frostbite or injury and denies pain. Warming blankets applied and placed on 1:1 visual observation. Wander guard applied and initiated hourly skin checks for 24 hours, vital signs every four hours, and head to toe assessments every shift for the next three days. R1 was oriented to place and safety needs. Elopement risk reinforced with care team. Environment assessed and secured appropriately. R1 stable condition at this time. Provider notified at 12:00 p.m., case worker at 11:15 a.m. and DON, Administrator, assistant director of nursing (ADON) and all other appropriate parties notified per facility protocol. Continued monitoring ongoing.-On 12/18/25 at 1:41 p.m., 2:55 p.m., 3:26 p.m., 4:32 p.m., 6:07 p.m., 7:01 p.m., 8:23 p.m., and 10:02 p.m., Inspect skin hourly for color changes, temperature . R1 denies any pain, skin color/diameter/irregularity (C/D/I), no new wounds, skin color and temperature are within normal limits. No concerns. At 2:55 p.m. Temperature 97.1 degrees F. Facility internal incident report dated 12/18/25 at 10:25 a.m., incident description identified at 10:25 a.m. R1 was found outside the facility in his wheelchair looking for his truck. He was safely redirected back into the facility without incident. Incident was witnessed. Was not taken to hospital; warming blankets and heat applied, placed on 1:1 visual observation. Temperature 98.1 degrees Fahrenheit (F), extremities cold to the touch, no signs of frostbite or injury, able to feel everything, and denied pain. Wander guard applied, hourly skin checks initiated x24 hours, vital signs every four hours for the next three days, and head to toe assessments to be completed every shift for the next three days. All appropriate parties notified. No injuries observed. Predisposing environmental and situational factors: none checked. Predisposing Physiological factors: confused, able to answer questions appropriately, and demonstrated impaired judgement related to dementia. Redirectable with cueing. Facility 5-day report dated 12/23/25 at 4:18 p.m., identified on 12/17/25 at 7:00 p.m. R1 had asked staff where he could find his pickup. Staff provided 1:1, reassurance to divert behavior and no concerns noted during the night. On 12/18/25 at 10:25 a.m., a family member reported a resident was outside in a wheelchair on the sidewalk. Resident told family member he was going home. Social worker immediately went outside with administrator and asked him where he was going, and he stated I don't know. He was last observed on POD (resident rooms located along with a large open area with trees, tables, lounge, and small kitchen area) he lived on at 9:30 a.m. He had Alzheimer's disease, paranoid personality disorder, and severely impaired cognition. Wander guard had been removed on 8/31/25, due to no exit-seeking behaviors documented in the last six months. He had a history of being the community Santa in the city, car was painted like a [NAME] he drove year around. With the holiday it may be a trigger for him. Care plan was modified to prevent reoccurrence: elopement focus was added related to impaired safety awareness, dementia, and paranoid personality disorder to prevent reoccurrence. R1 triggers for exit seeking/eloping are Christmas season/little kids. Exit seeking intervention education was provided to staff. The allegation of neglect was not verified, care plan was followed, no injuries noted, and was an isolated incident. According to the Weather Channel the weather the morning of 12/18/25 was blizzard-like conditions outside, 0 to 5 degrees Fahrenheit with winds from 38 to 44 miles per hour. Observations of R1 from 12/29/25 through 12/30/25, identified:-On 12/29/25 at 3:20 p.m. R1 sat in a high back wheelchair at a large round table, awake in POD where he lived. His feet were located on the floor without foot rests, tennis shoes on, fully dressed in jogging pants, t-shirt with short sleeves, and well groomed. A white wander guard bracelet was located on a bar on the back side of the wheelchair. -On 12/29/25 at 4:34 p.m. R1 pushed himself away from the table located in the POD area with his feet on the floor. He moved himself in wheelchair to a smaller table approximately 10 feet away.-On 12/30/25 at 9:02 a.m. R1 sat in high back wheelchair awake in POD area dressed in long black pants, tennis shoes, and a long-sleeved black shirt. A white wander-guard bracelet was located on a bar on the back side of the wheelchair. During an interview and observation on 12/29/25 at 4:25 p.m., R1 sat in a wheelchair in the lounge area at a table. He stated he liked living at the facility, was treated well and was unsure how long he had lived there. R1 stated his wife and son came to visit him but was unsure how often. R1 was not able to provide time or day. During interview a white wander guard bracelet was observed to be located on the backside of the wheelchair bar and he appeared to become anxious and restless when asked questions so interview was ended. During an interview on 12/30/35 at 1:07 a.m., Registered nurse (RN)-C stated R1's cognition had been declining. He was unable to self-transfer and required assist of two with the [NAME] Study Mechanical lift do to his poor cognition. RN-C stated she monitored R1 continuously on the evening shift, kept him within eyesight so that he did not leave the floor or find an exit door. He made her nervous with a history of attempted elopements in the past, but had not done that in a long time. The day before he eloped (12/17/25) R1 asked where his pickup was and she told him his wife had taken it home. R1 asked where an exit door was and stated he wanted to leave. RN-C kept R1 within eyesight until he was placed in bed between 7:00 p.m. and 8:00 p.m. The next day she found out he had eloped. R1 used to have a wander guard on but it was removed a couple of months ago. R1 usually stayed on the unit and should have not been allowed to leave by himself, he required supervision due to lack of cognition and poor safety awareness. If R1 saw the exit doors he would be more likely to go out. RN-C indicated she was unsure what happened that morning. The weather was cold, blowing snow, not good conditions at all. RN-C stated she should have passed the information onto the next shift so that they would have been aware to keep a closer watch on him and she failed to let them know. During an interview on 12/30/25 at 9:34 a.m., NA-A stated R1 had dementia, cognition/memory was not the best, and he was frequently forgetful. She used resident care sheets to identify how to care for each resident. She was unaware if he was at risk for elopement until he went out to the parking lot in a snowstorm recently. Staff were expected to check on him at least every two to three hours. NA-A stated if R1 talked about leaving and/or looking for his pickup she would have kept a closer eye on him for wandering, exit seeking, talk to him, and redirect from leaving building. He was not allowed to go outside by himself and would not have been safe out in cold weather alone. During an interview on 12/30/25 at 11:46 a.m., NA-C stated R1 had a poor memory, seemed lost all the time and did not really know what was going on. R1 had a history of elopement and was not safe going outside alone. Staff were expected to check on him every two to three hours, but was usually more often. On 12/18/25, she had provided cares to R1 at 7:15 a.m. and no behaviors were noted. R1 ate breakfast in the dining room and at 9:15 a.m. sat in his wheel chair in the POD area by the nurse's station. Last time she saw him was at 9:30 a.m. where he was still sitting in his wheelchair in the POD area wearing Addidas jogging pants and a short or longed sleeved shirt (not sure), shoes and socks. When she returned from her break she became aware he had eloped outside. NA-C was unsure as to how long R1 was outside. The weather that day was a bad storm day, snowing, cold, and roads were closed. NA-C arrived at work at 6:00 a.m. and received report from the night shift. There was no mention of R1 expressing exit seeking behavior from the prior shift. If she would have been told that it would have made a difference, she would have kept a closer watch on him to keep him safe and help avoid him getting out that day. During an interview on 12/30/25 at 12:18 p.m., RN-B stated R1 had a short term memory loss, confused, and verbalized being frustrated and afraid when he cannot remember things. His cognition had slowly declined. R1 was able to push himself around the facility with his feet in the wheelchair, not one to go very far typically, but staff were expected to escort him to the dining room. He had poor safety awareness, cognition was not consistent verified by 12/18/25, when he eloped from the facility, and was very odd thing for him to do. RN-B had been told by staff R1 believed he was Santa Clause at one time, was more anxious around Christmas and wanted to be Santa Clause this year. RN-B added she was unsure why he was not this year during the facility's holiday events. This information was added to his care plan following the elopement due to behaviors associated with it, such as finding his truck. He was found outside in his wheel chair on 12/18/25, unsure how long he was out there, the weather was bad that day, snowing, cold, stormy weather with a wind chill. Due to his lack of memory and poor judgement he would have not been safe outside without supervision. Unknown how he got out there by himself. When R1 was brought back into the building he stated he thought he had found his truck and tried to get into it. RN-B stated she was present during the morning report given on 12/18/25, and she would have expected RN-C to have reported off to the next shift, concerns about R1 on the 12/17/25 evening shift such as R1 looking for an exit door, asking for his pickup and wanting to leave facility. The oncoming day shift could have monitored R1 closer, a management meeting would have been held right away, a plan put in place to help avoid an elopement, and a revision to his care plan. During a follow up interview on 12/30/25 at 2:10 p.m., RN-B stated R1's target behaviors did not include elopement risk, when a resident had a behavior such as exit seeking, that would be expected to documented in the progress notes and an alert on the 24 hour report would be activated. RN-B verified she had not seen the 24 hour report and was unsure where to find it. She would have expected RN-C to have provided better documentation and include interventions and R1's response to the interventions, would have been beneficial. The incident on 12/17/25, R1 expressed exit seeking behaviors which warranted a revaluation for elopement and he should have been reassessed to prevent the elopement. During an interview on 12/30/25 at 2:03 p.m., care coordinator/floor manager registered nurse (RN)-A stated she completed the resident elopement risk assessments upon admission, quarterly, and whenever there was a change in condition. The criteria used to determine if a resident was at risk for elopement would be target behaviors and the elopement assessment. She was unsure if there were different levels of risk for elopement and not every resident with a risk for elopement required a wander guard. RN-A stated she completed R1's elopement assessment on 12/16/25, for a quarterly assessment. He did not have a wander guard on at that time, was mobile, and had not made any attempts to elope. RN-A stated when a progress note was entered regarding exit seeking and elopement a 24-hour report should have popped up and she had not seen anything regarding a progress note entered 12/17/25. RN-A verified R1's care plan did not include a focus and/or intervention(s) regarding elopement/exit seeking prior to the 12/18/25 incident, most likely because he was not actively a risk, and no longer actively making attempts to elope to necessitate the wander guard. R1's cognition was severely impaired, and he remained at risk for elopement. When she resolved and removed the focus and interventions on R1's care plan on 9/24/25, she was unaware of his history and lacked knowledge training on how to assess the risk. This information should have remained on R1's care plan and would have been important for staff to be aware of his history to prevent an elopement. RN-A stated she was unaware that Christmas time would trigger R1's exit seeking behaviors and possible elopement so none of that history was included as part of the elopement assessment on 9/24/25 or 12/16/25, which was unfortunate. During an interview on 12/30/25 at 4:00 p.m., social service director (SS) stated on 12/18/25, between 10:00 a.m. and 10:30 a.m. a visitor informed her a resident was outside and they could not get him to come into the building. SS went outside and found R1 in a wheelchair stuck in a snowbank. He had gone off the side walk to the left of the front pillars of the building in the first handicap parking spot where there were snow drifts and could not get himself out. He was not dressed for the weather and wore light weight material sweatpants, long sleeved t-shirt (waffle like material), tan colored gripper socks on his feet, with no coat/gloves/hat. The weather was bitter cold, very windy. She had ran out there with a jacket on and was cold. R1 sat in his wheelchair faced away from the building. SS stated she was a pretty big person and it was hard for her to get him pulled out of the snow. There was an SUV parked next to where he was stuck. SS pushed R1 back into the facility and noted his left hand was blue, grabbed it, held it with both of her hands, and placed it next to her body to warm it up. R1's face and lips looked ok. R1 did not realize he was in danger. SS stated R1 used to play Santa Clause and believed this may have triggered the elopement. During an interview on 12/30/25 at 4:23 p.m., assistant director of nursing (ADON) stated R1 had a wander guard applied 2022 or before and was discontinued the end of August 2025. ADON verified on 12/17/25, the evening prior to his elopement R1 asked where the exit door was located, talked about looking for his pickup, and indicated he did not want to stay at the facility. ADON stated R1 was exit seeking at that time per the facility policy and she would have expected RN-C to have completed an elopement assessment right away, and place a wander guard on him to keep him safe. RN-C's documentation was not clear, lacked details such as interventions and outcome of the interventions. ADON stated she would have expected RN-C to inform the oncoming shift in the morning R1 had been exit seeking, so they could have been on alert, included him in the resident council meeting (he did not attend), kept a closer eye on him, and would have helped keep him safe and prevented the elopement. Staff statements identified R1 ate breakfast and was last seen at 9:28 a.m. inside the building. Staff were expected to check on R1 at least every two to three hours and he was usually in the POD area where he lived, supervised. ADON stated it was unknown how long he was outside, the facility did not have cameras. The weather on 12/18/25, was a bad day, stormy and cold. ADON stated she was there when he was brought back into the building and if he had been outside more than five more minutes would have had frost bite. R1's hands were cold and slightly red, no blue noted on hands. Two staff nurses assessed R1 and documented in his medical record. The provider was notified right away, did not want him seen/sent in, but monitored closely. Hourly checks were completed on R1 and no frost bite or injuries were identified. R1 was wearing slide on shoes, socks, nylon stretchy pants with a stripe down the side, a long-sleeved maroon colored shirt, and no hat/mittens or gloves were worn. ADON verified R1's care plan did not include an elopement focus area or interventions such as: looking for his truck, asking for the exit door, indicating he did not want to stay at facility, triggers such as Christmas and little children due to being Santa Clause in the community. ADON stated would have been important to have the elopement information in his care plan so that staff would have been aware he had displayed behaviors of elopement and would have helped prevent the elopement. The day before he went outside, another person dressed up as Santa Clause was in the building and that may have caused him to think he needed to get outside and be Santa Clause. R1 was assessed in August 2025, had not had any exit seeking behaviors in the last assessment period, and was then found no longer be at risk for elopement, wander guard was discontinued, elopement section of the care plan was resolved/removed, and should not have been. The elopement assessment process should have included the whole picture of R1's history and based on his mobility and cognition. Facility policy Elopement dated 5/21/25, identified definition of elopement is when a resident who is cognitively, physically, mentally, emotionally and/or chemically impaired wanders away, walks away, runs away, escapes or otherwise leaves a care center or environment, unsupervised and/or prior to their scheduled discharge. When a resident is determined at risk for determined at risk for elopement, an elopement risk assessment will be performed and a corresponding care plan developed. If a resident is suspected of leaving the building, staff will promptly report to the nurse in charge, and the Missing Resident Protocol will be initiated. If staff were unaware that the resident had exited the building and the resident was later discovered outside by the staff or a visitor, the situation would be considered an elopement and would need to be reported to the state agency. In the event of an elopement a care center wide audit will be completed including assessing residents at risk for elopement to ensure an appropriate care plan is in place, providing additional training to care center staff, as needed, to reinforce resident safety measures. The past noncompliance immediate jeopardy began on 12/18/25. The immediate jeopardy was removed and the deficient practice corrected by 12/18/25, after the facility implemented a systemic plan that included the following actions: -upon R1's return to facility a complete head to toe health assessment was completed -R1's provider was updated -An elopement assessment with his past and recent risk for elopement was included. A wander guard was placed on his wheelchair. - Reviewed and revised R1's care plan. Ensured CP included details related to his holiday challenges, how staff will communicate, behavioral tracking and interventions that will be used if R1 is exit seeking to ensure he is safe. - Elopement assessment practices were reviewed and revised as needed to best determine resident elopement risk. (i.e. ensure other factors such as history, mental health, seasonal challenges, med changes are considered) -Nursing staff completing elopement assessments were retrained on recognizing and responding to exit seeking behavior. -Trained all staff on R1's care plan changes and facility policy changes to include: Facility education document Critical Safety Alert: Elopement Prevention & Emergency Protocol dated 12/18/25, identified: this training is issued following a critical safety event where a resident with Alzheimer's successfully eloped from the facility during dangerous blizzard conditions. This lapse in clinical judgement and protocol adherence placed a vulnerable life at immediate risk:1. Zero Tolerance for Reasoning: Attempting to reason with a cognitively impaired resident regarding their safety is clinically insufficient and an unacceptable intervention. If a resident vocalizes a desire to leave and/or displays wandering behavior, you must take immediate physical action.2. MANDATORY Immediate Interventions: When exit-seeking behavior is identified, the following actions must be taken immediately: Elopement Assessment, interventions must be documented immediately, wander guard placement, increased Surveillance, environmental Safety. 3. Failed Communication - Endangerment: Communication breakdowns are the primary cause of elopement: Mandatory Handover- you are required to provide a detailed verbal or written report to the oncoming shift and the nurse in charge regarding any wandering or behavioral changes. Point Click Care (PCC) Entry - Documentation of elopement prevention protocols must be entered into PCC immediately and not at the end of the shift.4. Professional & Legal Consequences: State reporting and Disciplinary Action.

Based on interview and document review the facility failed to ensure a dependent resident was toileted per request for 1 of 2 residents (R32) reviewed for accidents. This resulted in actual harm for R32 who fell when self transferring to the toilet and fractured their hip. Findings include: R32's significant change Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment. R32 was dependent on staff for toileting transfer and required maximal assistance with toileting hygiene. R32 had no falls prior to admission, however had two or more falls, without injury, since admission. Diagnoses included dementia, kidney failure, diabetes and history of urinary tract infections (UTI). R32's History and Physical dated 1/7/25, identified R32 was being seen for a left intertrochanteric hip fracture following a fall in the nursing home. R32 was forgetful and tried to go to the bathroom on her own which caused her to fall. R32 was to be admitted to the hospital for orthopedic surgery. A Nursing Home Incident Report-Investigative Summary dated 1/10/25, identified activities aide (AA)-C observed R32 wheeling out of the facility dining room and asked R32 where she was going. R32 stated she needed to use the bathroom. AA-C reported to nursing assistant (NA)-AA and NA-BB who stated R32 had been toileted thirty minutes prior to going to the dining room and was reminded that she had just gone to the bathroom. AA-C asked R32 if she had just been to the bathroom and R32 shrugged and stated she was full up. AA-C told R32 to stay in the dining room and wait for someone to assist her to the bathroom. AA-C notified NA-AA and NA-BB, R32 was adamant she needed to use the bathroom and was trying to leave the dining room. Neither NA-AA or NA-BB knew when R32 had left the dining room as they continued to pass trays in the dining room. R32 was found on the floor, in the public bathroom at 5:20 p.m., complained of severe pain to her left hip and transferred to the emergency room at 5:30 p.m. R32's care plan dated 12/4/24, identified a risk for falls and injury related to cognitive deficit with a goal to be free from falls and injury. Interventions included call don't fall sign in room, call light in reach and encourage to call for assistance, appropriate footwear, bed in low position with fall mats and non skid strips next to bed. R32 required assistance with activities of daily living (ADLs) and was dependent on staff to transfer. Staff were directed to anticipate and meet needs, ensure call light was within reach and to respond promptly to all requests for assistance. Staff were directed to provide extensive assist of one to two for toileting. R32 was frequently incontinent of bladder and occasionally of bowel and staff were directed to assist with toileting on awakening, before and after all meals and every two hours. During telephone interview on 1/13/25, at 6:11 p.m. family member (FM)-A stated R32 did not have the patience to wait to go to the bathroom. When she had to go to the bathroom, she would not wait for staff to help her. R32 had already fallen in November trying to go to the bathroom herself. R32 could not remember to use the call light. On 1/14/25, at 9:00 a.m. R32 was observed lying in bed with head of the bed elevated. The bed was in lowest position to the floor and a bedside mat was on the floor beside the bed. R32 was drowsy and difficult to arouse. Registered nurse (RN)-B entered room to administer medications. RN-B stated R32 had fallen in the public bathroom in the main entry area, had broken her hip and just returned from the hospital. The facility had put Velcro stop signs on the public bathroom doorways to prevent confused residents from entering the bathrooms to prevent future falls. R32's progress notes identified the following: - 12/4/24, When staff went to offer toileting, R32 was found in the bathroom transferring herself off of the toilet. - 12/16/24, R32 was found on floor in bathroom, after having toileted herself. R32 was to be care planned to toilet before and after meals and as needed. - 12/29/24, Staff noted resident room door was shut. On entering room, R32 was found to have self transferred to the toilet. - 1/6/25, R32 was found in public bathroom in common entry area. R32 had been trying to use the bathroom, urine was on the floor and R32's pants and brief were down. R32 was admitted to the hospital with left hip fracture. R32's current Urinary Continence Task flow sheet 1/11/25 to 1/15/25, identified the following: - 1/11/25, R32 was incontinent of urine at 1:30 a.m., 5:30 a.m., and 7:58 p.m. and did not void when toileted at 10:37 a.m. - 1/12/25, R32 was incontinent of urine at 3:10 a.m., 10:20 a.m. and 9:44 p.m. -1/13/25, R32 was incontinent of urine at 2:38 a.m., 6:30 a.m., 2:30 p.m., 4:30 p.m., 6:15 p.m., and 8:15 p.m. -1/14/25, R32 was incontinent of urine at 3:26 a.m., 10:33 a.m. 3:49 p.m., 5:30 p.m., 7:15 p.m., 8:45 p.m. -1/15/25, R32 was incontinent of urine at 5:59 a.m., 1:59 p.m. and 4:11 p.m., 6:09 p.m., and 9:09 p.m. The flow sheet lacked documentation that R32 had been checked and/or changed every 2 hours and before and after meals as directed on R32's care plan. The Urinary Continence Task Flow sheet for the day of the fall was requested and not received. During interview on 1/14/25, at 2:44 p.m. NA-A stated he thought R32 felt the need to urinate frequently was related to her up and down blood sugars. Staff toileted R32 every two hours. R32 was hoyer lift transfer and could not bear weight, but would still try to get up on her own and toilet herself as R32 had no patience. NA-A was not working when R32 had fractured her hip, but he could see R32 getting up and to toilet herself as R32 had been so confused. When interviewed on 1/15/24, at 7:50 a.m. NA-CC stated she would toilet R32 before and after meals and every two hours but R32 was one that would ask to go to the bathroom ten minutes after just being taken. R32 was continent of bladder prior to her fall with fracture and may have been nervous about having accidents. R32 was very anxious and when R32 felt the urge to go she would have to go right then and nothing would stop her. R32 liked to be in her room and if tried to have her out by the nurses station, she would just wheel away. When interviewed on 1/15/25, at 8:09 a.m. NA-C stated R32 was a handful. NA-C would leave R32's room door open, and continuously walk around the wing to keep an eye on her. If NA-C noticed R32 was getting slightly restless, she would immediately take her to the bathroom. R32 was continent prior to her fall and could have been nervous of having an accident in her pants. NA-C just checked on R32 all the time and took her to the bathroom. During joint interview with nurse consultant registered nurse (RN)-I and the director of nursing (DON) on 1/15/25, at 1:37 p.m. The DON stated she was present when R32 had her last fall and so had questioned all the staff involved immediately following the incident. NA-AA and NA-BB had been busy passing plates and getting supper going when R32 requested to go to the bathroom. The aides told R32 she had just been on the toilet and could hold on a little bit. AA-A notified the both NA-AA and NA-BB R32 needed to use the bathroom. The DON stated staff should have assisted R32 to the bathroom when she asked for help. The DON immediately educated the aides regarding providing assistance to residents and following resident's care plan. When interviewed on 1/16/25, at 9:37 a.m. the DON stated flow sheets for R32's turn and repositioning and toileting did not indicate R32 was checked or changed every two hours. Urinary Continence Task flow sheet was requested prior to her hospital return on 1/10/25, however, no flow sheets were available prior to her hospital return on 1/10/25, as the facility had started tracking when she returned from the hospital. The DON stated there had been no audits or documentation to ensure staff were following R32's care planned interventions, specifically toileting every two hours, and R32 had been falling regarding toileting. The facility Fall Prevention and Management dated 6/5/23, identified a fall analysis would be completed if a resident had two or more falls to review fall trends, identify individual and systemic causes of falls, evaluate current interventions for effectiveness and if needed to determine additional interventions. If identified as a high fall risk, a comprehensive assessment would be completed. The assessment would identify resident's history of falls, activity level, visual impairment, balance and gait, elimination status and diagnoses and medications, and other contributing factors related to fall. Assessment data would be analyzed with a summary completed identifying interventions to mitigate the resident's fall risk. All interventions identified through the assessment/review process would be documented in the resident's care plan using person centered language.

Based on observation, interview and document review, the facility failed to expand COVID-19 testing/ and or contact tracing of staff and residents on other units after residents tested positive for COVID19 per Centers for Disease Control (CDC) guidelines. In addition, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 3 residents (R53) reviewed for activities of daily living (ADLs). This had the potential to affect all 60 residents residing in the facility. Findings include: COVID-19 Testing: The current CDC guidance on COVID-19 in the Nursing Home dated June 2024 included : Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. On 1/13/25 at 1:25 p.m., R10 stated she was waiting for her shower because the NA that was supposed to help her was pulled to the other unit (Evergreen) to work. On 1/15/25 at 2:37 p.m., maintenance worker-A stated there was a potential that housekeeping staff would be pulled to work from one unit to the other during the same shift. Review of the facility covid outbreak document dated 1/7/25, identified the following: - NA-E worked the night shift (10:00 p.m. - 6:30 a.m.) on 1/6/25 and evening shift on 1/7/25 on Evergreen unit. Throughout the evening on 1/7/25, NA-E developed symptoms (not listed) and at 9:00 p.m. tested positive for COVID-19. NA-E immediately left the facility. The morning of 1/8/25, infection surveillance and tracking was initiated. The document identified NA-E had high risk contact with all 29 residents on Evergreen Unit and 16 staff (RN-C, RN-G, RN-H, LPN-C, TMA-A, NA-R, NA-S, NA-T, NA-U, NA-V, NA-W, NA-X, NA-Y, NA-Z, Hsk-C, Scheduler) that worked in the facility. - On 1/8/25, 4 residents (R3, R17, R36 and R43) tested positive for COVID-19 and were immediately placed on droplet precautions and were quarantined to their rooms. R3's symptoms included cough, congestion and sore throat. R17's symptoms included cough and congestion. R36 and R43 were asymptomatic. - On 1/10/25, all residents on Evergreen unit were tested for day 3 outbreak testing. One additional resident, R46, tested positive for COVID-19. R46 had symptoms including cough and runny nose and was immediately placed on droplet precautions and quarantined to the room. The previously identified high risk staff all tested negative for COVID-19. - On 1/12/25, all residents on Evergreen unit and previously identified high risk staff were tested and were negative for COVID-19. The facility staff schedules identified 19 staff, including 11 nursing staff (RN-B, RN-E, RN-F, LPN-A, LPN-B, NA-B, NA-H, NA-I, NA-J, NA-K, NA-L, NA-M, NA-O, NA-P, NA-Q), 5 dietary aides (DA-A, DA-B, DA-C, DA-D), 2 activity aides (AA-A, AA-B) and 1 housekeeping staff (HSK-A), worked on 1/8/25, and were not tested for COVID-19. The schedules did not identify if staff were pulled to the other unit during their shift. During joint interview on 1/15/25 at 1:02 p.m., registered nurse (RN)-C and RN-D identified the on 1/7/25, nursing assistant (NA)-E was working the evening shift (2:00 p.m.-10:30 p.m.). Throughout the shift NA-E developed body aches and congestion. At 9:00 p.m., NA-E tested positive for COVID-19 and was immediately sent home by the nurse. The morning of 1/8/25, RN-C and RN-D were notified of NA-E's positive COVID-19 result and started employee contact tracing. All high risk staff identified through, contact tracing, and all residents on Evergreen unit were tested for COVID-19. Of those tested , zero staff tested positive; however, four residents tested positive. The positive residents were immediately placed in droplet precautions and a mass text was sent to inform all other employees of the positive cases. - The facility continued to test the originally identified high risk staff and all residents on Evergreen unit on day 3 (1/10/25), day 5 (1/12/25), day 7 (1/14/25) and planned to test on 1/17/25. The facility failed to expand the contact tracing, to include staff/residents exposed to the positive residents; or complete broad-based testing of all staff and residents after continued positive cases of COVID-19 were identified. Staff continued to worked in close proximity with residents and other staff from both units throughout their workday. The facility tried to keep staff, (including nursing, dietary, and housekeeping staff) on one unit or the other during their shift, although there was a potential for staff to be pulled from one unit to the other during, as well as residents from either unit to co-mingle during times including meals and activities. The facility failed to complete additional employee contact tracing and failed to consider broad-based testing for all staff and residents even after the facility continued to have positive COVID-19 test results. On 1/16/25 at 10:33 a.m., RN-C stated she was monitoring the residents on Blueberry unit for symptoms of COVID-19 by reviewing their progress notes and receiving verbal report from nursing staff. She had not tested the residents on Blueberry because she thought symptom monitoring was sufficient. Additional staff were not tested because staff were monitoring their own symptoms. In addition, RN-C stated there was a potential for staff, including nursing, housekeeping, activities and dietary staff, to work on both units during the same shift, as well as residents from either unit to come into contact with each other during facility activities. On 1/16/25 at 10:53 a.m., the director of nursing (DON) stated the facility dropped the ball on testing staff and residents for COVID-19. Once there were additional cases of COVID-19 they should have tested the entire facility because staff work back/forth on both units and there was a risk that the staff were exposed and worked with other residents and/or staff when they had not been tested . The DON stated the risk of not testing appropriately is the risk of spreading the illness to other residents, staff or visitors. The facility Coronavirus Prevention, Screening, and Identification policy reviewed/revised 10//11/23, included the following: The facility will assess and identify the potential staff risk. Low risk includes when there is no direct exposure to a COVID-19 infected person. Contact risk is identified as close (within 6 feet for 15 minutes or more, or within same living space) contact of person(s) with COVID-19 within 48 hours. The facility will communicate the risk level and recommendations to staff. Care center wide testing includes: if the care center becomes aware of a COVID-19 positive case among staff who have worked within the past 2 days and/or residents, an assessment to determine exposure will begin immediately. Residents and staff with close contact with someone with COVID-19 will begin testing 24 hours after exposure. If unable to determine close exposure to the COVID-19 positive individual broad testing of all staff and residents (regardless of vaccination status) will occur. The facility Suspected (or Confirmed) Coronavirus (COVID-9) Outbreak policy reviewed/revised 7/25/23, identified the purpose was to provide guidance for care center staff on handling suspected or confirmed Cornona virus (COVID-19) disease. During an outbreak of COVID-19 disease the facility would begin testing all exposed staff and residents immediately day one, (two days after exposure) day three, and day five after exposure, and 5-7 days after testing until 14 days of no further positive results. 41575 Enhanced Barrier Precautions: R53's quarterly Minimum Data Set (MDS) dated [DATE], identified R53 had severely impaired cognition and was dependent on staff for all activities of daily living (ADLs). R53 was incontinent of bowel and had an indwelling catheter and a feeding tube. Diagnosis included spastic quadriplegic cerebral palsy. On 1/14/25, at 8:55 a.m. a personal protective equipment (PPE) cart was observed in the hall beside R53's room door. The PPE cart's drawers contained disposable hospital gowns, disposable gloves and masks. A sign was posted above the cart which identified enhanced barrier precautions were required when providing high contact care with resident residing in the room. The poster identified when and what staff were required to don prior to entering the room. During observation on 1/14/25, at 9:02 a.m. nursing assistant (NA)-Q entered R53's room to assist her with her morning care. NA-Q was wearing a surgical mask and put on gloves. NA-Q removed R53's brief and washed up R53's peri area with disposable wipes. NA-Q turned R53 away and then rolled her back toward her, leaning over R53 to perform the peri care. NA-Q changed her gloves after performing incontinence care and rolled R53 from side to side to secure the clean brief. R53's body would lean against NA-Q uniform at times, when rolling R53 toward her. NA-B entered the room wearing a face mask, gloves and disposable gown. NA-B and NA-Q placed a Hoyer (full lift) lift sheet underneath R53's body, again rolling her from side to side and at times leaning into NA-Q's uniform. Both aides utilized the Hoyer lift to transfer R53 into her wheelchair and secured her catheter bag to the side of the wheelchair and adjusted R53's feeding tube lines to ensure placement was appropriate. When interviewed on 1/14/25, at 9:14 a.m. NA-Q stated she wore a disposable gown in the [NAME] when she got R53 dressed. It was especially important to wear a gown and gloves when working with R53's indwelling catheter. NA-Q had not worn a gown when assisting with incontinent peri care, as she was just getting the resident up in her wheelchair and not emptying her catheter or anything like that. R53 had touched NA-Q's uniform when she was assisting her, and NA-Q had provided bowel incontinent peri care without a gown on. NA-Q should have worn a gown before assisting R53 with personal care. During interview on 1/14/25, at 9:18 a.m. NA-B stated staff were suppose to a wear gown and gloves with any residents who had a catheter or open wounds. Staff were to wear the PPE whenever providing care to those type of residents; however, were not required to wear the PPE when just passing water or going in room to speak with them. During joint interview with infection preventionist registered nurse (RN)-C and RN-D on 1/16/25, at 10:15 a.m. RN-C stated R53 was on enhanced barrier precautions and staff should wear the appropriate PPE of gown, mask and gloves to perform peri care. Staff were educated on the use of PPE with enhanced barrier precautions (EBP) in April 2024, and were to wear PPE whenever providing care, transfers, or toileting. The resident's that required EBP had PPE carts outside of their room doors and EBP posters on their doors to direct staff. The facility policy Enhanced Barrier Precautions dated 8/20/24, identified EBP were to be used when providing high contact care to residents who were colonized or infected with a multi-drug-resistant organism. EBP would also be used for residents with chronic wounds and/or indwelling medical devices. EBP was to be employed when performing high contact resident care activities such as dressing, bathing, changing linen, transferring, hygiene care, toileting, peri care, emptying catheter bag, wound care, indwelling medical device care and therapy treatment. The CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multi-drug-resistant Organisms (MDROs) manual, dated 7/2022, identified MDRO transmission within a nursing home was common and contributed to substantial resident morbidity and mortality. The feature outlined EBP were defined as, . expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The feature identified several examples of high-contact resident care activities including dressing, bathing, providing hygiene, transferring, changing linens or briefs, and wound care.

Based on observation, interview and document review, the facility failed to ensure the final rinse on the dishwasher reached 180 degrees Fahrenheit (F) to sanitize dishes. This had the potential to affect 61 of 62 residents who consumed food from the main production kitchen. Findings include: On 1/13/25, at 11:58 a.m., an initial kitchen tour was completed with dietary aide (DA)-A. A single commercial dishwasher was observed along the wall with several hard plastic racks on the conveyor belt in front of machine. DA-A loaded several plate covers onto a hard plastic rack and placed them into the dishwasher. Two gauges were located on the top front of the dishwasher. One gauge was labeled wash and on the gauge next to the 150 F degrees there was black marker identifying the temperature. A second gauge was labeled rinse, and the black marker was marked at 180 F next to the gauge. DA-A identified the temperatures were the minimum required for the dishwasher to reach when monitoring the temperatures. DA-A ran the rack with plate covers through the dishwasher machine three times. On the first run, the rinse temperature registered 160 F., on the second run the rinse temperature registered 172 F, and on the third run, the rinse temperature registered 180 F just after the dish tray exited the dishwasher and the cycle was completed. DA-A stated the third tray had not reached the rinse temperature of 180 when in the dishwasher. The Dishwashing Machine Temp Sheet for the month of January 2025, identified from January 25 through January 29, 2025, the dishwasher rinse temperature was recorded between 150 degrees and 160 degrees for the am shift/meal. The Dishwashing Machine Temp Sheet for the month of December 2024, identified 12 of 49 recorded dishwasher rinse temperatures were recorded below 180 degrees when monitored for the three meals. During interview on 1/13/25, at 12:00 p.m. cook (CK)-B stated the dishwasher repair person had told dietary staff to shut off and drain the washer every shift to help it to reach adequate temperatures and she was not sure that was being done. The dishes would not be rinsed properly if the rinse temperature did not reach the required 180 degrees. When it was identified the dishwasher was not reaching adequate temperatures, staff were to call the dishwasher repair person. Staff were to keep running the dishes through the dishwasher until it reached the adequate rinsing temperature to ensure the dishes were sanitized and she would let maintenance know they were having problems with the dishwasher. During interview on 1/13/25, at 12:32 p.m. maintenance (MAINT)-A observed the dishwasher cycle with rinse temperature at 160 degrees. MAINT-A stated he had never been notified the dishwasher was not working properly. He did not work on the dishwasher but would call the repair person to come. A joint interview was completed with DA-A and CK-B on 1/13/25, at 12:40 p.m. CK-B stated they never manually sanitized dishes in the sink. CK-B could only remember hand washing dishes one time when the dishwasher was being replaced. CK-B stated currently the dishwasher was not working properly if the rinse did not reach 180 degrees. DA-A stated maybe they should be hand washing the dishes to sanitize them. During a second tour of the kitchen on 1/13/25, at 1:05 p.m. DA-A was observed hand washing cooking equipment, pots and utensils in a sink with soapy water. DA-A put the hand washed equipment into a hard plastic rack and ran three racks of hand washed pots, equipment and utensils through the dishwasher. The dishwasher rinse gauge registered 175 degrees. DA-A stated she ran the dishes through the dishwasher after hand washing them in order to sanitize the dishes. DA-A stated the dishes were not getting properly sanitized since the rinse temperature did not reach 180 degrees, but she did not know what else she could do. At 1:24 p.m. DA-A completed washing all the lunch dishes through the dishwasher and the rinse temperature reached 180 degrees and greater. DA-A stated it was just the first few trays that were run through that the rinse was below 180 degrees. DA-A was watching all the trays going through now to make sure the rinse reached 180 degrees or more. During interview on 1/14/25, at 10:30 a.m. MAINT-A stated the dishwasher repair person checked the dishwasher, and it was working properly. The repair person indicated the surface temperature needed to be 160 degrees and was reaching 168 degrees. The staff needed to run a holding thermometer or test strip or plate through the machine to get the most accurate readings. During observation of dishwasher on 1/14/25, at 4:29 p.m. DA-B ran a rack of plastic glasses through the dishwasher. The rinse temperature registered 160 degrees. DA-B stated she always ran resident glasses through two times. DA-B ran the glasses through the dishwasher a second time. The rinse temperature registered 178 degrees. DA-B stated she did not know where to locate or how to run a thermometer or temperature plate through the dishwasher, as she had never been taught. DA-B stated she only looked at the front gauges to record the dishwasher temperatures and had never been told or taught to do it any other way. During interview on 1/14/25, at 5:35 p.m. MAINT-A stated the dishwasher took a while to heat up to the 180 degree rinse. MAINT-A was not aware the dietary staff were not trained on how to check dishwasher temperatures other than to read the front gauges. The dishwasher repair technician who checked the machine earlier that day had not trained the dietary staff on alternative methods to check dishwasher temperatures. During interview on 1/15/25, at 1:11 p.m. CK-A stated he thought he had figured out the problem with the facility's dishwasher. The dishwasher took a while to heat up to the required 180-degree rinse temperature. CK-A instructed all the dietary staff to run a tray through the dishwasher several times until the rinse temperature reached 180 degrees before washing any dishes with the dishwasher. Staff had not been getting the dishwasher up to the required temperature before washing dishes. The staff would just run the dishes through right away in order to get done for the day quickly. The staff have been instructed now to get the dishwasher up to required temperature prior to starting to wash any dishes. When interviewed on 1/15/25, at 1:28 p.m. the director of nursing (DON) stated if dietary staff were not running dishes through a properly working dishwasher, they ran the risk of the dishes not being sanitized properly. The DON would expect the dietary staff to try to problem solve and find out the reason the dishwasher was not reaching the required temperature and to reach to the dietary manager or maintence when equipment was not working properly. During telephone interview on 1/15/25, at 2:16 p.m. the director of dietary services (DODS) stated running dishes through the dishwasher at low rinse temperatures meant the dishes were not being sanitized, which was not appropriate. DODS stated it was an area staff would need training on. The facility policy Cleaning Dishes/Dish Machine dated 4/20/22, identified the facility used a high temperature dishwasher which used heat for sanitization. Minimum wash temperatures were 150 degrees and minimum rinse temperature was 180 degrees. If minimum temperatures were not obtained, staff were to utilize sanitation process and indicate on the temperature log the corrective action used to ensure dishes were sanitized.

Based on observation, interview and document review, the facility failed to ensure food was served at warm, palatable temperatures for 5 of 5 residents (R30, R4, R32, R11,R18) who received meal trays out of temperature range. Findings include: R30's significant change MDS dated [DATE], identified R30 had intact cognition and was independent with eating. On 1/14/25, at 2:00 p.m. R30 stated he ate his meals in his room and the meal trays served were almost always cold. R30 stated this occurred with all the meals served in his room and it did not matter if was breakfast, lunch or supper. On 1/14/25, at 4:56 p.m. the supper meal services were observed on the Blueberry unit where several residents were seated in the dining area waiting for the supper meal. Residents were served a meal of hot dogs and tater tots in the dining room. The supper trays were on an open metal cart with three shelves. Each tray was covered with a dish cover over the plate of food. At 5:18 p.m. nursing assistant (NA)-O began delivering supper trays to the residents in their rooms. At 5:19 p.m. NA-O delivered a supper tray to R30's room. At 5:20 p.m. NA-O delivered a supper tray to R4's room. At 5:20 p.m. NA-O delivered a supper tray to R32's room. At 5:21 p.m. NA-O delivered a supper tray to R11's room. At 5:23 p.m. NA-O delivered a supper tray to R18's room. At 5:25 p.m. a test tray was removed from the resident cart and cook (CK)-A tested the hotdog and tater tots for temperature. The hot dog measured 99.5 degrees, and the tater tots measured 94 degrees. CK-A stated the food was cold and should temp around 145 degrees. On 1/14/25, at 5:40 p.m. CK-A stated the food had been hot when leaving the kitchen area and he thought the problem with the food cooling off so quickly was the dietary aide had not allowed the steam table to warm up adequately prior to meal service. The dietary aide had also not been trained on using the plate warmer function of the steamer table and that may have contributed to the cold food as well. When interviewed on 1/15/25, at 1:28 p.m. the director of nursing (DON) stated the food temperatures at supper service was not acceptable and should have been warmer. The cold food did not taste very palatable and was unappetizing. During interview on 1/15/25, at 2:16 p.m. the director of dietary services (DODS) stated she observed food service at the facility in the past and could recall the facility used an open tray cart, which could contribute to the food cooling off quickly. Food was not safe if the temperature was dropped below 135 degrees and cold food was just not palatable. The facility policy General Food Preparation and Handling dated 10/23, identified all meats were to be heated to a safe minimum internal temperature. Staff were to refer to the charts Minimum Cooking Food Temperatures and Holding Times and Suggested Food Cooking Temperatures and Holding Times, which identified hot holding temperature of 135 degrees.

Based on observation, interview and document review, the facility failed to provide timely repositioning for 1 of 2 residents (R8) reviewed for pressure ulcers. Findings include: R8's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. R8 required substantial/maximal assistance with turning and repositioning and toileting. R8 was at risk for pressure ulcers, currently did not have any skin issues. Diagnoses included Alzheimer's disease and non-Alzheimer's dementia. R8's Braden Risk Assessment (a tool used to assess a patient's risk of developing pressure ulcers) dated 11/1/24, identified R8 was at moderate risk of developing a pressure ulcer. R8's care plan dated 11/12/24, identified R8 should be repositioned every three hours as R8 had a potential for skin impairment. R8's Tissue Tolerance-Repositioning Observation dated 1/6/25, identified after R8 was in sitting or lying in same position after two hours redness was observed in areas of pressure. It identified R8 was to be repositioned every two hours. R8's progress note dated 1/6/25 identified a new skin issue located on the inside of R8's right buttock. The area was 1.5 centimeters (cm) x 1.5 cm with 100% granulation tissue (a new, pink or red, moist tissue that forms at the site of a wound as it heals.). Primary care provider notified. Tissue tolerance identified to turn every 2 hours. Continuous observations were completed on 1/15/25 at 7:18 a.m. through 11:13 a.m. and identfied the following - At 7:18 a.m. R8 was seated in her wheelchair and wheeling herself down the hall heading to the common area - At 8:08 a.m. R8 was in dining room for breakfast. She was seated in her wheel chair and had not been repositioned or offered respositioning. - At 9:24 a.m. R8 was taken by unidentified activity staff to an activity in the common area of the nursing home. R8 remained seated in her wheelchair and had not been repositioned or offered respositioning. - At 9:40 a.m. R8 was brought to the common area when activity was completed and was watching TV. R8 remained in common area seated in the wheelchair and had not been repositioned or offered repositioning. - At 10:40 a.m. R8 remained in the common area and participated a bible study that finished at 10:50 a.m. R8 had not been repositioned or offered to be repositioned. - At 11:00 a.m. R8 remained in her wheelchair seated in the same position. R8 had not been repositioned or offered to be repositioned. During an interview on 1/15/25 at 11:06 a.m. nursing assistant (NA)-G stated they were assigned to care for R8 today. NA-G stated R8's care plan was recently updated and R8 was supposed to be repositioned every two hours, because R8 had a new area of impaired skin integrity on the identified R8's buttocks. NA-G was not sure when the last time R8 was repositioned. The aids usually repositioned R8 right after breakfast, but NA-G did not do it today and was unsure if it was done. The last time NA-G knew R8 was repositioned was when she got R8 up this morning. NA-G then went to bring R8 to the bathroom and reposition her. During observation on 1/15/25 at 11:13 a.m., nursing assistant (NA)-G assisted R8 to the bathroom. When R8's incontinent brief was removed there was a small amount of feces in the brief and smeared on her buttocks and the brief had a small amount of urine. There was a scabbed area on R8's inner right buttocks that looked one cm in size, the skin around the area was intact. During an interview on 1/15/25 at 3:00 p.m., registered nurse (RN)-C stated R8 had developed a new area on her inner right buttocks and were doing dressing changes every three days and as needed. R8 was also to be repositioned every two hours to keep pressure off the wound. The updates with repositioning R8 had been communicated with nursing staff and the nursing assistants. R8 should not have gone more than two hours without repositioning as her ulcer could worsen. During an interview on 1/16/25 at 9:55 a.m., the director of nursing (DON) stated it is the expectation staff followed the care plan related to resident with impaired skin integrity and/or pressure sores. Which included timely repositioning of R8. A policy for pressure ulcers was request, but not received. The facility's Tissue Tolerance Repositioning Observation policy dated 11/26/24, identified it was to establish and adjust individualized repositioning schedules based on skin assessments. To provide guidelines to staff on the ability of the resident's skin and its supporting structures to endure the effects of pressure without adverse effects.

Based on observation, interview, and document review, the facility failed to identify a significant increase in weight with dependent edema in the lower extremeties and conducted a comprehensive assessment and implement interventions for 1 of 1 residents (R55) reviewed for edema. Findings include: R55's admission Minimal Data Set (MDS) dated [DATE], identified R55 had intact cognition and required moderate to maximal assist with activities of daily living (ADLs). R55's admission weight was recorded as 203 pounds (lbs). Diagnoses included acute embolism and thrombosis of deep veins of superior vena cava, kidney failure, hypertension and pulmonary hypertension. R55's undated care plan identified R55 required assistance with ADL's and staff were directed to assist R55 with dressing, grooming, toileting, bed mobility and transfers. The plan of care failed to identify issues with intact skin, weight or edema. R55's medical record identified the following weights: - 10/30/24, R55 weighted 203 lbs. - 11/26/24, R55 weighted 219 lbs. - 12/03/24, R55 weighted 231 lbs. (28 lb weight gain from admission, 13.79% gain) - 12/10/24, R55 weighted 229 lbs. - 12/17/24, R55 weighted 232 lbs. - 12/24/24, R55 weighted 231 lbs. - 1/14/25, R55 weighted 225 lbs(22 lb weight gain from admission, 10.84% gain) R55's medical record lacked evidence the significant weight gains were assessed and interventions implemented. R55's progress note dated 12/23/24, identified family member (FM)-A requested a nurse to look at R55's left foot. FM-A requested the facility obtain an order for ace wrap to R55's left leg. A fax was sent to R55's primary provider to update on R55's skin and request ACE wrap for R55's left leg. On 1/13/25, at 5:53 p.m. R55 was observed seated in a wheelchair in his room. R55's legs were in a dependent position and feet were placed on the wheelchair foot rests. There was significant swelling in both of R55's lower extremities from his knees to his toes with greater swelling noted on his left leg. On 1/14/25, at 3:22 p.m. R55 was observed seated in wheelchair in his room watching television. R55 was observed with his legs in a dependent position with feet resting on wheelchair footrests. R55 had significant swelling in both feet and lower legs bilaterally. On 1/15/25, at 9:30 a.m. registered nurse (RN)-B entered R55's room to check R55's feet. RN-B removed R55's socks, both lower extremities had significant swelling from knees to toes. RN-B wrapped R55's left lower leg and foot with ace wrap after covering both legs with a soft sleeve. On 1/15/25, at 9:45 a.m. FM-A stated the facility staff never made attempts to have R55 lie down in bed or elevate his legs. If FM-A chased down the staff and begged them, they would come in and assist him to lie down. R55 needed to lie down to help with the swelling in his legs. When R55 was at home for three weeks in October, he did not have any swelling in his legs at all, because he had remained in bed a majority of the time. On 1/15/25, at 9:47 a.m., RN-B stated the facility had notified the provider about R55's edema, but they never get any response. Staff try to ask R55 to lie down or sit in recliner but he frequently refuses. The facility did not schedule for R55 to elevate his feet or document when he refused their attempts. RN-B stated the facility was not monitoring R55's weights or edema on R55's treatment record. There was no one tasked to assess edema or look at resident weights. Further, if a large weight gain was noted from week to week, the facility should print off the weights and see if the provider wanted to address them. RN-B would check with the charge nurse to see if anyone had addressed R55's weight gain. During interview on 1/15/25, at 10:46 a.m. RN-B stated the facility had been requesting compression wraps for R55's left leg and his provider was faxed with that request on 12/23/24, however, the facility had never received a response back from R55's provider. During interview on 1/15/25, at 10: 26 a.m. RN-A stated the facility conducted weekly weight meetings which they discussed resident weight gain or losses and reviewed everything with dietary. RN-A did not document any notes related to the meetings, but they discussed resident weights, reviewed if they were felt to be accurate, if supplements were needed and such. RN-A knew R55's provider had been notified of his edema but the provider had not gotten back to them. No new interventions had been attempted to try to reduce R55's edema and RN-A had not reviewed R55's diet or spoken to him about the need to lie down or elevate his feet in the afternoons. During interview on 1/16/25, at 9:47 a.m. the director of nursing (DON) stated facility staff should be reviewing resident's weights when they documented them in the resident's medical record. R55 should have had orders for ACE wraps or compression hose. Residents with weight gain should be evaluated and staff should be assessing residents weights regularly. The facility policy Weight Monitoring Program dated 1/18/21, identified a medically significant weight gain was a weight gain of five or more pounds in one week which could indicate a change in health status. Weight data would be assessed, tracked, and entered into the residents medical record weekly. The attending practitioner would be contacted for any resident with a medically significant weight gain of five pounds or more.

Based on observation, interview, and document review, the facility failed to provide timely assistance with toileting/incontinence care for 1 of 3 residents (R8) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R8's significant change Minimum Data Set (MDS) dated [DATE], identified R8 had severe cognitive impairment and was dependent on staff for her ADLs. R8 was incontinent of bowel and bladder. The MDS included diagnoses of Alzheimer's disease, and non-Alzheimer's dementia. R8's Bowel and Bladder Risk assessment dated [DATE], identified R8 was incontinent of bowel and bladder. R8's care plan dated 11/12/24, identified R8 required extensive assist of one for toileting and incontinence care every three hours and as needed. Continuous observations were completed on 1/15/25 at 7:18 a.m. through 11:13 a.m. and identfied the following: - At 7:18 a.m. R8 was seated in her wheelchair and wheeling herself down the hall heading to the common area. - At 8:08 a.m. R8 was in dining room for breakfast. She was seated in her wheel chair and had not been toileted or offered toileting. - At 9:24 a.m. R8 was taken by an unidentified activity staff to an activity in the common area of the nursing home. R8 had not been toileted or offered toileting. - At 9:40 a.m. R8 was brought to the common area when activity was completed and was watching TV. R8 remained in common area seated in the wheelchair and had not been toileted or offered toileting. - At 10:40 a.m. R8 remained in the common area and participated in a bible study that finished at 10:50 a.m. - At 11:00 a.m. R8 continued in her wheelchair and had not been toileted or offered toileting. During an interview on 1/15/25 at 11:06 a.m. nursing assistant (NA)-G stated they were assigned to care for R8 today. NA-G was not sure when the last time R8 was toileted. NA-G then went to bring R8 to the bathroom. During observation on 1/15/25 at 11:13 a.m., nursing assistant (NA)-G assisted R8 to the bathroom. When R8's incontinent brief was removed there was a small amount of feces in the brief and smeared on her buttocks and the brief had a small amount of urine. There was a scabbed area on R8's inner right buttocks that looked one cm in size, the skin around the area was intact. During an interview on 1/15/25 at 11:04 a.m., NA-F stated staff reviewed the communication board or it would be passed on in report when a resident was to be assisted with toileting and/or have their brief checked. The facility recently updated their electronic charting system and staff could also see the care planned interventions in the Kardex . NA-F stated she had not worked with R8 and did not know when she needed to be checked. During an interview on 1/15/2 at 11:07 a.m., NA-G stated they were assigned care of R8. R8's care plan was recently updated and was supposed to be offered toileting and check and change every 2 hours because an area of impaired skin integrity was identified on her buttocks. NA-G was not sure of when the last time R8 was checked or offered toileting assistance. NA-G stated they usually checked her right after breakfast, but did not do it today and was unsure if it was done. The last time NA-G knew R8 was checked was when she got up this morning and NA-G brought R8 to the bathroom. During an interview on 1/15/25 at 3:00 p.m., registered nurse (RN)-C stated R8 was to be checked and changed every 2 hours, which was changed from check and change every 3 hours due to a new area of impaired skin integrity. Residents who sat in soiled incontinent briefs had an increased chance of skin breakdown and should be checked and changed frequently. During an interview on 1/16/25 at 9:55 a.m., the director of nursing (DON) stated it was the expectation staff would have followed resident care plan related to check and change of incontinent briefs to ensure R8's care was done. The facility's Urinary Incontinence Program policy dated 4/6/15, identified each resident will receive the appropriate care and services to prevent incontinence related complications to the extent possible.

Based on interview and document review, the facility failed to update the care plan with a new transfer status for 1 of 2 residents (R32) reviewed for falls; and the facility failed to update the care plan with a new turning and repositioning schedule for 1 of 2 residents (R8) reviewed for pressure ulcers. Findings include: R32's significant change Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment. R32 was dependent on staff for toileting transfer. R32's History and Physical dated 1/7/25, identified R32 was seen for a left intertrochanteric hip fracture following a fall in the nursing home. R32 was to be admitted to the hospital for orthopedic surgery. R32's care plan dated 1/14/25, identified R32 required assistance with activities of daily living (ADLs) and was weight bearing as tolerated. Staff were to assist R32 with assist of one and gait belt to transfer. R32 had a recent left hip fracture related to a fall with surgical intervention. Staff were directed to anticipate and meet needs, make sure call light was with in reach and to respond promptly to all requests for assistance. R32 was able to be weight bear as tolerated with physical and occupational therapy evaluations ordered. During observation on 1/14/25, at 5:34 p.m. R32 was lying in bed with bed low to the floor and head of the bed elevated to sitting position. Nursing assistant (NA)-B sat at R32's bedside and stated they did not get R32 up to the toilet or commode or in her wheel chair because the Hoyer lift (full lift) transfers were to painful for R32. A joint interview was conducted with registered nurse consultant (RN)-I and director of nursing (DON) on 1/15/25, at 1:37 p.m. The DON stated after R32 fell on [DATE], she was non weight bearing and needed a Hoyer lift to transfer, as the family opted not to have surgical repair to R32's right hip. RN-I stated when a resident returned from the hospital, licensed staff completed a skilled progress note daily, bowel and bladder, fall, skin, and pain assessments were completed. Changes were then made to the resident's care plan and changes would go directly to the resident's Kardex where the aides could see what care needs and changes the resident had. Therapy was also seeing R32 and went by their recommendations as well for care plan items. When interviewed on 1/16/25, at 10:52 a.m. the DON stated therapy was seeing R32 since her hospital return and R32 was to be a Hoyer lift transfer. The DON had questioned several nursing assistants and they reported they were using a Hoyer lift when transferring R32; however, R32's care plan was not accurate and did not match her transfer status to reflect her needs. Updating the plan of care to accurately reflect what residents needed was an issue the DON had been aware of and was working on. 40948 R8's significant change MDS dated [DATE], identified severe cognitive impairment. R8 required substantial/maximal assistance with turning and repositioning and toileting. R8 was at risk for pressure ulcers, currently did not have any skin issues. Diagnoses included Alzheimer's disease and non-Alzheimer's dementia. R8's care plan dated 11/12/24, identified R8 should be repositioned every three hours as R8 had a potential for skin impairment. R8's progress note dated 1/6/25 identified a new skin issue located on the inside of R8's right buttock. The area was 1.5 centimeters (cm) x 1.5 cm with 100% granulation tissue (a new, pink or red, moist tissue that forms at the site of a wound as it heals.). Primary care provider notified. Tissue tolerance identified to turn every 2 hours. During an interview on 1/15/25 at 11:06 a.m. NA-G stated they were assigned to care for R8 today. NA-G stated R8's care plan was recently updated and R8 was supposed to be repositioned every two hours, because R8 had a new area of impaired skin integrity on the identified R8's buttocks. NA-G was not sure when the last time R8 was repositioned. During an interview on 1/15/25 at 3:00 p.m., RN-C stated R8 had developed a new area on her inner right buttocks and were doing dressing changes every three days and as needed. R8 was also to be repositioned every two hours to keep pressure off the wound. The updates with repositioning R8 had been communicated with nursing staff and the nursing assistants, but not updated on the care plan. The facility policy Person Centered Care Planning revised 4/20/23, identified the resident's baseline care plan would be developed based on admission orders, information available from the transferring provider and discussion with the resident and resident representative. Information would be included necessary to properly care for the resident, including immediate health and safety concerns to prevent decline or injury and activities of daily living (ADL)s.

Based on observation, interview and document review, the facility failed to ensure an assessment was completed for an electric scooter to increase mobility for 1 of 1 residents (R57) reviewed for accomadation of needs. Findings include: R57's significant change Minimum Data Set (MDS) dated [DATE], identified R57 was cognitively intact, was independent with bed mobility, no functional limitation in range of motion of upper or lower extremities, and used a walker and wheelchair for mobility. R57 participated in physical and occupational therapy during the assessment period. R57's care plan revised on 11/14/24, identified R57 was independent with bed mobility, required assistance of one staff and gait belt to transfer between surfaces, and required stand-by assistance while walking with a walker. The plan failed to identify use of an electric scooter. On 1/13/25 at 6:20 p.m., R57 stated she had an electric scooter at home and talked to staff about it. R57's son brought the scooter to the facility; however, R57 stated she had not received any follow-up from staff. R57 stated she received therapy every day and had not had any discussion or assessments related to use of the scooter. R57's care conference notes from 11/27/24 were reviewed; however, the notes did not identify any discussion regarding the electric scooter use. R57's medical record lacked any assessment or referral for the use of the electric scooter. On 1/16/25 at 9:13 a.m., social services (SS)-A stated R57's electric scooter was in the building by the front entrance and was under the impression R57 was assessed by occupational therapy but was not strong enough to drive the scooter independently. SS-A stated she was uncertain what R57 had been told regarding using the scooter. On 1/16/25 at 12:13 p.m., physical therapy assistant (PTA)-A stated therapy had not received a referral to assess R57 for use of the electric scooter. On 1/16/25 at 12:13 p.m., SS-A provided an undated and untitled document with R57's name and written notes that identified scooter eval. - key in top drawer. SS-A stated the document was notes she made to herself, although she failed to pass the information onto nursing staff. A policy regarding following up on resident's requests was requested but not provided.

Based on document review and interview, the facility failed to ensure physician orders for an anticonvulsant medication (used to reduce/eliminate seizures) were administered without error for 1 of 3 residents (R1) reviewed. This resulted in harm for R1 when partial doses of his anticonvulsant medication were omitted during administration for 3 days and subsequently, R1 had a seizure, was transported to the emergency department (ED) by ambulance and required medical intervention. The facility implemented corrective action, so the deficient practice was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition without behaviors. R1 was independent with personal hygiene, toileting, transfers, and used motorized wheelchair for mobility. R1 had a seizure disorder/epilepsy. R1's last visit with the nurse practitioner neurology dated 1/9/24, identified last known seizure was 10/16/17. Since that time frame he had been taking Lamictal, Keppra, and Zonisamide. No concerns with how he tolerated the doses, no missed doses, and no new neurological changes. R1's physician signed orders dated 7/16/24, identified: -Lamotrigine (Lamictal) (anticonvulsant drug used in treatment of epilepsy to prevent or control seizures) Oral Tablet 100 mg (milligram) 4.5 tablets by mouth one time a day every day in morning 7 a.m. to 10 a.m. for epilepsy. Special instructions: there were three packets for this medication. Order start date 5/31/22. -Lamotrigine oral tablet 100 mg 5 tablets by mouth daily at bedtime 6:30 p.m. to 10:00 p.m. for epilepsy. Special instructions: there were three packets for this medication. Order start date 5/31/22. -Levetiracetam (Keppra) (anticonvulsant drug used in treatment of epilepsy to prevent or control seizures) oral tablet 1000 mg 2 tablets by mouth two times per day every day at morning 7 a.m. to 10 a.m. and bedtime 6:30 p.m. to 10:00 p.m. for epilepsy. Order start date 5/31/22. -Zonisamide (anticonvulsant drug used to decrease abnormal electrical activity in the brain to prevent seizures) oral capsule 100 mg 2 capsules by mouth one time a day every morning 7 a.m. to 10 a.m. for epilepsy. Order start date 5/31/22. -Zonisamide oral capsule 100 mg 3 capsules by mouth one time every day at bedtime 6:30 p.m. to 10:00 p.m. for epilepsy. Order start date 5/31/22. R1's care plan dated 8/1/24, identified R1 took anticonvulsant medication and would not experience drug reactions. Staff were directed to administer R1's anticonvulsant medications as ordered. R1 was to be reminded to wear helmet in case of a seizure but may refuse. A safe environment was to be provided when R1 had a seizure. Monitor R1's eye movement, muscle clenching or jerking, and duration of seizure activity. Any seizure lasted more than 15 minutes should be sent to ED via 911 emergency ambulance with vitals and description of seizure activity and duration of seizure. A facility reported incident (FRI) report submitted to the State Agency (SA) filed on 7/15/24, at 9:11 a.m. identified R1 had a known seizure disorder and had a seizure on the evening of 7/14/24, in his bed. R1 was sent to ED for evaluation, lab work done, with Lamictal level pending. No medication changes at ED visit. R1 reported he felt fine on 7/15/24. R1 takes Lamotrigine oral tablet 100 mg medication order 100 mg oral tablet take 4 1/2 tablets in morning. On 7/25/24, license practical nurse (LPN) found that she had missed two pills of the 4.5 of Lamotrigine on 7/8/24, and 7/9/24. Upon investigation, found additional 2 missed pills from 4.5 on 7/14/24. R1's EMAR dated August 2024, identified: -Lamotrigine oral tablet 100 mg 4.5 tablets by mouth one time every day at morning 7:00 a.m. - 10 :00 a.m. Special instructions: there were three packets for these medications. Dose is 450 mg. All scheduled day doses were signed off as administered from 8/1/24, through 8/30/24. -Lamotrigine oral tablet 100 mg 5 tablets by mouth daily at bedtime 6:30 p.m. to 10:00 p.m. Special instructions: there were 3 packets for this medication. Dose 500 mg. All scheduled bedtime doses were signed off as administered from 8/1/24, through 8/30/24. R1's progress notes from 7/14/24, through 7/15/24, revealed: -7/14/24, at 8:27 p.m. registered nurse (RN) entered R1's room as he headed for bathroom. R1 told writer he would be a few minutes. LPN notified RN to come back into R1's room. R1 laid on his back, did not respond to verbal stimuli, and right eye did not constrict with pen light. R1's head rolled back and forth and BLE's (bilateral lower extremities) kicked out in jerking movements. VS (vital signs) taken: T (temperature) 98.1 F (Fahrenheit), BP (blood pressure) 127/84, O2 sats (oxygen saturation levels) 88% (normal range 90 to 100%) on RA (room air), RR (respirations) 24, P (pulse) 110. Writer asked LPN to call 911 as R1 was a full code and did not respond. Emergency contact notified and reported and would meet R1 at ED. R1 left with paramedics via ambulance on stretcher. Notified RN on call of R1's status via phone call. -7/15/24, at 12:24 a.m. R1 returned from ED via ambulance on stretcher, his emergency contact was with him. R1 seemed tired. R1 was to follow up with primary care provider (PCP) in three days. R1 was seen in ED for seizures had CT (cat scan) of head with contrast, EKG, and chest x-ray completed. Added appointment to book and scheduled with care provider in the morning. The above added to 24-hour report sheet. -7/15/24, at 8:09 a.m. incident follow-up: R1 reported felt fine no change from baseline after seizure on 7/14/24. R1 was alert and oriented, neurologically intact. Primary care provider scheduled to see R1 on 7/16 at care center and will reach out to neurologist. -7/15/24, at 4:21 p.m. R1 rested in bed, speech clear, alert, and oriented. -7/15/24, at 4:52 p.m. when nurse passed a.m. shift medications noted R1's Lamictal had doses left in the card that should have been punched out. R1's a.m. order for Lamictal 100 mg tablet, give 4 and 1/2 tabs (450 mg) by mouth in the morning. It appeared 200 mg of Lamictal had not been given on 7/7/24, 7/9/24, and 7/10/24. -Telephone encounter dated 7/15/24, with R1's Neurologist (N) and R1's family member (FM)/legal guardian. R1 had a seizure last night but had been stable for quite some time now. R1 was found unresponsive and unsure of duration. R1 had received only half dose of medication for two full days per FM after she had talked with nursing staff. N indicated since there were missed doses, no changes needed. -7/16/24, at 5:07 p.m. PCP rounded on R1. Order received to check blood pressure times one week and sent results to provider. -Follow up visit dated 7/16/24, primary provider/medical doctor (MD) identified R1 was seen during nursing home rounds. R1 accidentally received a lower dose of Lamictal 7/7/24, through 7/10/24. R1 had break through seizure 7/14/24, and seen in ED. R1's ED visit dated 7/14/24, identified [AGE] year-old male with past medical history significant for seizures with a breakthrough seizure. R1's was found slumped over with a jerking behavior and postictal (altered state of consciousness after an epileptic seizure) on arrival to ED. R1 started to answer question but clearly sedated and afebrile (without a fever). R1 was mildly hypoxic (body is deprived of adequate oxygen at the tissue level and can cause confusion and difficulty breathing) secondary to his somnolence (state of drowsiness) but once R1 woke up improvement was noted. EKG (electrocardiogram) (a recording of the hearts activity) showed sinus tachycardia (fast heart rate over 100 beats per minute) without signs of ischemia (reduction of blood flow) or dysrhythmia (irregular heartbeat). Labs were reassuring and Keppra (medication given for seizures) level was pending. CT (cat scan) of head was negative and chest x-ray were both negative. At 9:45 p.m. R1 was treated with levetiracetam (medication used to treat epilepsy seizures) in NaCl (normal saline in intravenous fluid), then at 10:14 p.m. discharged from ED and sent back to nursing home. Recommended R1 follow up with primary provider in three days on 7/17/24. R1's CT scan without contrast completed on 7/14/24, results compared with 12/25/13, revealed senescent (biological process of aging and deterioration) changes, global atrophy (loss of brain cells or number of connections between brain cells), and evidence for remote microvascular (tiny blood vessels) ischemic insults (blood vessels located in the brain that are blocked or narrowed that leads to reduced blood supply to the brain tissue) involving deep white matter (tissue located in the brain that connects nerve cells and spinal cord) for both cerebral hemispheres. There was not acute intracranial (within the skull) pathology (study of a disease and injury) suggested, no edema (swelling) or hemorrhage (bleeding). R1's lab results from 7/15/24, through 7/17/24, identified: -7/14/24, Levetiracetam 1 mcg/ml (normal range 6.0 - 46.0 mcg/ml). -7/17/14, Lamotrigine 12.7 mcg/ml (micrograms/milliliters) (normal range 3.0 - 150 mcg/ml). -7/17/24, Zonisamide 14 mcg/ml (normal range 10 - 40 mcg/ml). Facility internal incident report dated 7/15/24, identified staff nursed noted when medications were passed on morning shift (a.m.) R1's Lamictal (lamotrigine) had doses left in the medication card that should have been punched out. R1's order for a.m. was Lamictal 100 mg tablet, give 4 and 1/2 tabs (450 mg) by mouth daily in the morning. It had appeared that 200 mg of the Lamictal had not been given on 7/7/24, 7/9/24, and 7/10/24. Medication sent from pharmacy in three different cards. Two cards contained 2 tabs (200 mg per card), and one card contained 1/2 tab (50 mg). It appeared that one care equaling 200 mg was not given for three days. Type of medication error: Omitted medication. R1 had a seizure on the evening of 7/14/24 and was sent to ED. Seizure possibility related to missed doses of Lamictal on 7/7/24, 7/9/24, and 7/10/24. Facility five-day report submitted to SA on 7/18/24, at 3:22 p.m. identified care plan was not followed regarding medication administration. R1 was care planned to have been provided anti-seizure medication as directed by provider. Both LPNs were interviewed and identified the process of medication administration had confused nursing staff, not all staff removed the first pill on the same side of the punch card and therefore medications were removed from the bubble packs on different days than intended. It was identified as R1's bubble pack for anti-seizure medication was messed up and not administered in sequence as should have been. R1's lab levels came back in therapeutic range, imagining of head was negative for changes, and follow up appointment scheduled with neurologist. Reviewed notes form ED visit and identified both medications were in therapeutic range and could not be determined if omission brought on seizure activity. Education was provided to staff: reviewed the process for removal of medications from bubble packs starting at same place every time and if removed from a different bubble pack staff would be expected to initial the medication card indicating that and the step-by-step process during medication administration. A laminated picture of the removal of medication sequence from punch card was placed at each nurse cart and in each nursing bible resource on each pod. Audits on all staff passing medications will be completed. During and observation/interview on 7/31/24 at 12:00 p.m., LPN-A removed R1's Lamotrigine (Lamictal) medication cards from the medication cart. LPN-A stated the cards were set up by the pharmacy to hold two weeks of medications for each dose and showed surveyor R1's morning dose of Lamotrigine (total of three cards) were empty. LPN-A indicated all R1's doses were administered as ordered for the past two weeks. LPN-A indicated some doses have more than one card such as R1's seizure medication, Lamotrigine, morning dose was provided in three separate cards: card one had Lamotrigine 100 mg tablets two in each bubble pack, card two had Lamotrigine 100 mg tablets two in each bubble pack, and card three had Lamotrigine one-half of a 100 mg in each bubble pack for a total ordered a.m. dose of 450 mg. LPN-A replaced the empty cards with the full ones and stated R1's Lamotrigine cards were labeled 1 of 3, 2 of 3, 3 of 3, to avoid future medication errors. During an observation on 7/31/24 at 1:00 p.m., a laminated document titled Easy Pak Medication System undated was seen on the medication cart. Instructions on the document included: It is important to start in the correct position on the card and to proceed correctly across the card, so that medications that are not given every day are in the correct place. At the beginning of each new cycle, start punching the card with Wednesday, on the left sift of the card, through Saturday on the bottom right, then go back to Sunday on the upper left of the card and finish out the two-week cycle. A picture of the medication punch card was included on this document to show staff a visual of where to start punching out the first dose of medication. During an observation/interview on 7/30/24 at 4:00 p.m., R1 laid in bed. R1 stated was brought to ED last Sunday due to a seizure. R1 verified had not had a seizure in years prior to that day. R1 stated the staff messed up, had not received the right dose of seizure medication, not sure how that could have happened. R1 stated had a seizure, not sure why, unaware it was going to happen, and was found lying sideways on the bed by staff. During an interview on 7/31/24 at 10:35 a.m., RN-A stated R1 had not had a seizure at this facility prior 7/14/24. RN-A stated they had not worked the day R1 had missed some medications and had a seizure. RN-A stated according to facility protocol staff were expected to have notified the provider regarding any medication error especially when a wrong dose was administered or discovered. RN-A indicated was a big deal when a wrong dose of seizure medication (Lamictal) was given especially when it was less than what was ordered for three days. RN-A confirmed R1's seizure could have been caused by that medication error. During an interview on 7/31/24 at 10:57 a.m., floor manager RN-B stated R1 had a history of seizures. RN-B indicated R1 had received only partial doses of Lamictal, 250 mg rather than the full dose ordered 450 mg in the morning on 7/7/24, 7/9/24, and 7/10/24 adding, there were three medication punch cards for R1's morning dose of Lamictal. RN-B indicated staff were expected to look at the EMAR and follow the rights of medication administration to ensure R1 received the correct dose. RN-B stated on 7/14/24, R1 laid on his bed and had a seizure. RN-B stated staff were expected to closely follow the dosing recommendations for R1's seizure medications. RN-B indicated without the correct dose administered staff caused injury and R1 had a seizure. RN-B stated the incident was reviewed in IDT (interdisciplinary team) meeting and all nursing staff attended a mandatory education meeting. RN-B stated we reviewed the rights of medication administration, the medication punch cards, where the first medication should have been removed, and medication errors. During an interview on 7/31/24 at 12:15 p.m., LPN-A stated she had missed administration of R1's Lamictal partial dose 200 mg on 7/10/24, and therefore R1 only received 250 mg of the 450 mg dose ordered that morning. LPN-A stated she had signed off on the EMAR the full dose was given but then the following Monday 7/15/24, after R1 had already had a seizure, she noticed a partial dose of 200 mg (2/100 mg tablets) remained in the bubble on the punch card for 7/10/24. Additionally, LPN-A stated there were two other dates 7/7/24, and 7/9/24, two 100 mg Lamictal pills remained inside the bubble pack on the medication card. LPN-A stated unsure how no one else noticed three of R1's Lamictal pills partial doses remained on the medication card. LPN-A verified she had reported her findings to the director of nursing (DON) on 7/15/24 right away. LPN-A verified she had received mandatory education on 7/16/24, along with most of the other staff nurses on how to best utilize the medication punch cards, medication errors and how medications were to be administered safely. LPN-A indicated the Easy Pack Medication System guide instructions were printed, laminated, and placed on the medication carts as a reference. LPN-A stated dosing recommendations should have been closely followed, especially for seizure medication because when the level of medication dropped R1 would most likely have a seizure and was required to maintain a therapeutic level. During a telephone interview on 7/31/24 at 1:35 p.m., pharmacy consultant (PC) stated R1's Lamictal had a daylong 1/2 life, and the level would slowly decrease over time if not well maintained and could certainly have contributed to a seizure. PC indicated R1 was on a therapeutic dose of Lamictal, had no seizure in years, then received a lower than ordered dose for at least three days, and had a seizure. That would have to be a pretty big coincidence, adding the decreased dose of Lamictal over three days could have contributed to a seizure especially when R1 had not had a seizure in a long time. PC stated facility staff were expected to closely follow the order, this was the final wall that avoided the seizure and when removed a seizure appeared. During a telephone interview on 7/31/24 at 2:32 p.m., medical director (MD) verified there were safety concerns when R1 only received a partial dose (250 mg rather than what was ordered 450 mg) of Lamictal which resulted in a seizure most likely due to inadequate dosing. MD stated in his opinion he was unable to rely on lab value results within the normal range, R1 still could have had a seizure due to levels that may have not been within a therapeutic range for him. MD stated the harm identified was the omission of the medication for the three days R1 received less seizure medication than what was ordered which resulted in a seizure. MD stated there was a negative outcome that compromised R1's wellbeing but no side effects such as physical injury. MD indicated this type of situation was very concerning, cannot continue to happen, and obviously a system failure. During an interview on 7/31/24 at 3:40 p.m., director of nursing (DON) confirmed R1 had a known diagnosis of epilepsy and received anticonvulsant medication. R1 had a seizure at the facility on 7/14/24 and was sent to ED via ambulance. DON verified on 7/15/24, LPN-A worked the day shift and realized there had been a medication error and the facility reported the error to the state agency since they failed to follow the resident's physician's order and care plan. DON indicted the medication card had three days on one of the three cards where 200 mg of Lamictal tablets remained in the bubble packs and therefore R1 received 250 mg instead of the ordered 450 mg for the morning dose on 7/7/24, 7/9/24, and 7/10/24. DON stated two out of the three nurses were unable to identify how the medication error occurred. DON stated all nursing staff have received education and they changed the system on the cards to identify how many cards there were (1 of 2, 2 of 3, 3 of 3). DON stated there were safety concerns for this type of medication to have been administered as a partial dose three times because of the seizure threshold could have been lowered and a seizure could have occurred. DON stated we were unable to determine the cause of the seizure and therefore determined this incident inconclusive. DON indicated the therapeutic level for anticonvulsant medication was not the same for everyone and resulted in a different threshold. DON stated each resident when initially started was required to have been regularly titrated to determine their threshold. During a telephone interview on 8/1/24 at 9:45 a.m., RN-C indicated they worked the evening shift on 7/14/24, and around 8:15 p.m. an LPN informed her R1 laid across the bed and was unresponsive. RN-C indicated when they entered R1's room he was unresponsive to verbal stimuli, head rolled back and forth, lower extremities made jerking movements, was breathing but oxygen level was slightly low at 88% so the applied oxygen, but R1 removed it. RN-C indicated they immediately called 911 as R1 had not had a seizure at this facility prior to this date, which seemed unusual, and received a lot of antiseizure medications. RN-C indicated it was important to ensure they administered the correct dose of seizure medication at the same time each day according to what was ordered to ensure R1's therapeutic levels were maintained and avoid a seizure. During a telephone interview on 8/1/24, at 10:30 a.m. primary physician (PP) stated she had seen R1 on 7/16/24, was made aware he had a seizure on 7/14/24. PP stated R1's last seizure was 2013. PP indicated additional lab work was completed but not necessarily helpful in this case unless R1 was found to be toxic from the Lamictal. PP stated R1 had received the correct dose after the seizure occurred and the level could have been lower prior to that and caused the seizure. PP also indicated R1's seizure could have been prevented and most likely resulted from receiving less that Lamictal than was ordered for those three days. During a telephone interview on 8/1/24 at 11:00 a.m., LPN-B verified she had worked the day shift on 7/9/24. LPN-B stated R1's Lamictal medication card was inappropriately started, a big mess, and attempted to straighten it out to get back into order. LPN-B stated should have pulled R1's medication card sleeve from the medication cart, contacted pharmacy, and requested a new punch card. LPN-B stated R1 had missed three days of a partial dose, was not administered as ordered, R1 most likely fell below his threshold when medication level dropped, then had a seizure due to the lowered threshold. LPN-B stated harm was caused when R1 had a seizure, transferred, and treated in the ER. LPN-B indicated they received mandatory education on 7/16/24, regarding the use of the punch medication card, starting at the same place every time, and the importance of completion of all rights of medication administration. Review of staff education documents and medication administration audits identified the facility implemented corrective action and was determined to be in compliance prior to survey entrance. Facility policy Medication Errors dated 7/1/24, identified administration of medication would be completed in the safest way possible and according to the physician orders, to keep residents free of any significant medication errors. A significant medication error was one which caused the resident discomfort or jeopardizes his/her health safety. Any drug that altered a resident's blood level and caused negative symptoms or toxicity would be a significant medication error such as anticonvulsants. Facility policy Medication Administration dated 8/7/23, identified all medications were expected to be administered safely according to current standards of practice and regulatory requirements. Staff were directed to check the EMAR (electronic medication administration record) verify resident, medication, dose, time, and route. Remove blister pack from bin, label must be checked again the EMAR for accuracy. Appropriate dosage should be placed into souffle cup. Re-read the label against the EMAR and return blister pack to bin. Medication errors must be reported immediately to the charge nurse and/or the DON, and Physician. If significant medication error occurred physician would be notified immediately for further treatment orders.

Based on observation, interview and document review the facility failed to ensure resident rights for 1 of 3 residents (R1) when the facility took shoes away from R1 to slow his movement in the facility. Findings include: R1's Resident Face Sheet identified diagnosis that included Alzheimer's, dementia, anxiety and depression. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he required assistance with transfer and self-propelled in his wheelchair. R1's Service Plan Detail report modified 5/3/24, indicated he could wheel himself short distances independently. A facility report log dated 4/26/24, indicated R1 was to wear gripper socks only and indicated his shoes were in the tub room. During observation and interview on 5/2/24 at 1:09 p.m., R1 was escorted to the common area of the facility by his family member (FM)-A. FM-A stated the facility had taken R1's shoes away from him and he was upset about it. FM-A said R1's shoes were taken away so he couldn't move as fast but said she did not think it made a difference. FM-A said R1 had brought up the shoes about three times. R1, who was very hard of hearing and required a white board to communiate said, Where do you think those shoes are? They're in one of these rooms. FM-A stated she had to take R1 to the dentist that morning and when she asked for his shoes registered nurse (RN)-A said could not give FM-A R1's shoes, even though it was raining outside. FM-A confirmed she had to take R1 to his appointment with only his socks on, and also had to transfer him in and out of the car in his socks while it was raining. During interview on 5/2/24 at 1:22 p.m., RN-B stated the facility took R1's shoes because he had gripper socks. RN-B said the reason the shoes were taken away was to slow him down since R1 was able to self propel and wandered in the facility. During observation and interview on 5/2/24 at 1:27 p.m., nursing assistant (NA)-A was in the tub room. On the floor inside the room were two pairs of black men's shoes. NA-A stated she did not know whose shoes they were. A few minutes later, NA-A approached surveyor and said the shoes belonged to R1. NA-A said she was told R1 was supposed to wear gripper socks so he could not move as fast. During interview on 5/2/24 at 1:47 p.m., the director of nursing stated R1's shoes were removed because he had behaviors that included kicking staff when he was agitated and said they were not trying to take away his ability to be mobile. The DON said she was not aware FM-A was told R1 could not have his shoes to go out of the facility. R1's medical record lacked evidence he displayed behaviors of kicking staff. During interview on 5/2/24 at 2:10 p.m., RN-A stated she didn't know much about R1's shoes but had been told he was supposed to wear socks only. RN-A said she had not been told R1 was allowed to have his shoes when he went out to appointments. RN-A stated when FM-A asked for them she had been following the direction she had been given. Facility Policy Resident [NAME] of Rights dated August 2002, indicated staff were to offer opportunities for the residents to make their own decisions and indicated residents are allowed to keep reasonable amounts of clothing and possessions for their use. Combined Federal and State [NAME] of Rights dated 2/1/17, indicated residents had the right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

Based on observation, interview and document review, the facility failed to ensure adequate supervision to prevent resident to resident sexual abuse when 1 of 2 resident (R1) who had a recent incident of resident-to-resident sexual abuse was found in the dining room rubbing a second female resident's (R2) genitals. This was an immediate jeopardy for R2 because this type of inappropriate and unwanted sexual contact would reasonably cause anyone to have psychosocial harm. It can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm including dehumanization and humiliation as a result of the sexual abuse. The immediate jeopardy (IJ) began on 4/13/24, at approximately 1:15 p.m. when R1 was left in the dining room unsupervised and found rubbing the genitals of a female resident (R2) who was unable to leave the area on her own. The IJ was identified on 4/19/24, and the director of nursing (DON) was notified of the IJ on 4/19/24, at 2:00 p.m. The immediate jeopardy was removed on 4/15/24, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's Resident Face Sheet, print date of 4/23/24, identified diagnosis that included Alzheimer's, dementia, anxiety and depression. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he required assistance with transfer and self-propelled in his wheelchair. R1's Service Plan Modification Report, undated, identified inappropriate actions and touching female residents. R1's service plan identified non-pharmacological interventions added 4/3/24, that included document whereabouts for patterns of behavior, redirection, engage in reading books and watch movies. 4/17/24, service plan was updated to include the addition of antipsychotic medications. R1's nursing assistant care sheet undated, included monitor when out of room due to touchy with ladies, hourly checks, seat at dining table with other males and back toward crowd and not left alone in the dining room, when done eating move by nurse until all residents are out of the dining room. The care sheet further indicated during activities R1 would be placed by male residents and with staff. During observation on 4/17/24, at 4:37 p.m. R1 was escorted to the dining room by staff. R1 was seated facing the back wall of the dining room with another male resident. R1 remained in the dining room supervised by staff until 6:16 p.m. when all other residents had left the dining room. R1's Progress Notes indicated the following: 3/29/24, Nursing assistant (NA) reported that she was going around getting residents from the unit down to the dining room before supper when she noted a call light and responded to the light. The NA went in to check the resident in that room and found R1 at the female resident's bedside in his wheel chair with his hands underneath the covers. R1 had his hands underneath her clothed buttocks. The NA assisted him in removing his hands from underneath the resident and brought him down to the dining room and reported to writer. The female resident in was in no distress and everything else in her room appeared untouched. R1 stated a few times as he was assisted to the dining room I didn't hurt her. R1 was assisted to his meal, then stated I just wanted to push my penis up against it to feel it. 4/7/24, R1 was seated in the chair in the corner of the room with only a shirt on. R1 stated he could get his penis up to belly button for writer. Writer assisted resident with putting brief, pants and socks on. While writer had resident standing, resident stated he could turn a little bit and slip it right in. 4/9/24 on 4/5/24 at a care conference, the administrator, DON, assistant director of nursing (ADON), social worker & nurse manager reviewed the 3/29/24, incident and interventions with R1's family member (FM)-A. Reviewed all the non-pharmacological interventions in place, reviewed the incident, investigation findings, and new interventions in place. Provided education about medication recommendations, specifically to address sexual urges, and explained side effect monitoring protocols. FM-A was able to provide additional items for redirection. Activities staff have modified their invitation request language and R1 had responded well with increased participation. 4/13/24, NA reported to staff that R1 was rubbing the genital area of a female resident (R2). NA-A stated R1 had his left hand on R2's upper thigh and his right hand was rubbing back and forth on her genitalia. No nursing staff were in the dining room at the time of the incident. R2 later reported it made her feel uncomfortable. R1 was placed on 15 minute checks until further notice. During observation on 4/17/24 at 4:43 p.m. R1 was seated in the dining room in his wheelchair facing the back wall of the dining room. R1 was seated with another male resident at the table. Outside the dining room a staff member was supervising from a large window. R2's Resident Face Sheet print date of 4/23/24, identified diagnosis that included Hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), schizoaffective disorder, depression, anxiety and aphasia (disorder that results from damage to portions of the brain that are responsible for language). R2's annual MDS dated [DATE], indicated a Brief Interview for Mental Status (BIMS) of 6 (severe cognitive impairment) and indicated she did not display behaviors. R2's Service Plan Modification Report indicated she preferred a stop sign to keep wanderers out of her room, added 4/4/24. R2's Resident Progress Notes indicated the following: -4/13/24, Call made to R2's FM (family member) to update her on the incident that occurred. -4/15/24, R2 was asked about the events on 4/13/24, and stated I was scared but I don't let him bother me. I'll yell again. An untitled, undated facility investigation indicated 4/13/24, vulnerable adult report. The investigation indicated on call registered nurse (RN) notified DON that R1 was rubbing the clothed groin of R2 in the dining room just prior to the noon meal time. Staff report that they were following the care plan for R1 by having him in the dining room first and out last. Staff were transporting residents into the Blueberry dining room. When nursing assistant (NA) entered the dining room with another resident, NA saw R1 with his hand on R2's knee and the other hand on R2's groin, rubbing back and forth. The NA separated the two residents and transferred R2 to her room. The licensed practical nurse (LPN) on duty reported she implemented interventions of 15 minute checks on R1 and R1 would wait outside of dining room before and after meals until staff were able to sit with him in the dining room and take him back to the unit. Staff verified that care plan was being followed for R1 and that all stop signs were in place during the shift. Staff reported that they were transferring residents back to unit area after meal and that no staff members were present in the dining room at the time of the incident. R1 was interviewed and could not recall event. R2 was interviewed and stated I was scared but I don't let him [R1] bother me. I'll yell again. R2 was offered counseling. Review of resident to resident Incident on 4/13/24 lacked evidence R1 was adequately supervised to protect other vulnerable residents in the dining room. The Facility investigation outlined interventions that included: Hourly checks ongoing. R1 was moved to a table in the dining room with only males and not within sight of female residents. R1 will be placed outside the dining room by the nurse prior to start of meal and at the end of the meal while staff are transporting other residents back and forth to unit. During activities R1 will be stationed next to a staff member. Behavioral health physician met with care team to discuss R1. Medication management included the addition of antipsychotic medication. Protection for R2 included keeping her out of R1's sight line at meals and activities. Keep reasonable distance between R1 and R2. Ongoing use of mesh stop sign at room door. Protection for general population included changing dining room seating, R1 seated at table with other men and staff member in dining room when R1 was present in dining room. During interview on 4/17/24 at 1:47 p.m., registered nurse (RN)-B stated prior to the incident on 4/13/24, stop signs had been placed on the doors of the more vulnerable residents. RN-B stated immediately following the incident on 4/13/24, R1 had been placed on 15 minute checks but had since transitioned to hourly checks ongoing. During interview on 4/17/24 at 1:52 p.m., NA-B stated since the incident on 4/13/24, R1 had been placed on hourly checks. NA-B said R1 had to be the first one in the dining room and the last one out and could not be left alone and said if the NA's were busy he had to remain next to the nurse. During interview on 4/17/24 at 2:02 p.m., licensed practical nurse (LPN)-A stated when R1 was in the dining room he had to sit facing away from other residents and had to be in sight of staff of all times. LPN-A said R1 had to be the first one in the dining room and the last out for supervision. During interview on 4/17/24 at 2:08 p.m., NA-C stated when in the dining room, R1 sat with other males. NA-C said she had received communication both written and verbal. NA-C said R1's location in the dining room had been changed and staff were to sit with him. During observation and interview on 4/17/24 at 7:27 p.m., R2 was in her wheelchair in her room watching television. R2 stated she remembered the incident from 4/13/24. When asked if she was afraid, R2 said well, not afraid, I was trying to get away. R2 further stated no staff were in the dining room and that the incident had made her uncomfortable. Lastly, R2 indicated, I just don't want to have him [R1] here. During interview on 4/17/24 at 7:39 p.m., RN-C stated R1 has supposed to be the first one in the dining room and the last out and said some of the residents had stop signs on their doors to keep him from wandering in. RN-C said since the incident on 4/13/24, R1 had a new spot in the dining room and had to be the first one to go in and the last one to leave. RN-C stated they were completing hourly checks on R1 had and to keep him in sight at all times. RN-C stated she had received the updates on a form for staff to read and sign during report. During an interview with the Corporate Nurse Consultant for the facility on 4/18/24 at 10:35 a.m., it was indicated that the intention of the intervention for R1 to be the first and last resident in and out of the dining room was to provide supervision by staff. During interview on 4/18/24 at approximately 10:40 a.m., The ADON stated since the incident occurred on 4/13/24, R1 was now seated at a table in the dining room with a male resident and his back to the rest of the residents. The administrator stated they had consulted with the psychiatrist and discussed and received consent for the addition of an anti-psychotic medication. Regarding supervision during non dining hours, the ADON stated when R1 was in common areas, staff had to keep eyes on him. During interview on 4/19/24 at 10:43 a.m., the DON stated the facility had not implemented a plan for 24-hour supervision of R1 because they did not think R1 would display inappropriate touching of female residents in the public areas of the facility. She further indicated that the intention of the intervention to have R1 to be the first and last resident in and out of the dining room was to ensure supervision while in dining room, which was not effective in preventing abuse on 4/13/24 because staff left him unsupervised. DON stated new intervention were introduced and staff had been immediately trained. Facility abuse prevention policy was requested but not received. The past noncompliance immediate jeopardy began on 4/13/23. The immediate jeopardy was removed, and the deficient practice corrected by 4/15/23, after the facility implemented a systemic plan that included the following actions: - The facility implemented a plan to ensure R1 was supervised while in common areas of the facility and without access to vulnerable residents. - Audits have been initiated to ensure R1 was not left unsupervised in dining room. - Facility updated R1's care sheet and care plan and provided education to staff on changes and updates.

Based on interview and document review the facility failed to ensure resident to resident abuse was reported to law enforcement for 2 of 2 residents (R1, R2) reviewed for sexual assault. Findings include: R1's Resident Face Sheet identified diagnosis that included Alzheimer's, dementia, anxiety and depression. R1's quarterly Minimum Data Set (MDS) identified severe cognitive impairment and indicated he required assistance with transfer and self-propelled in his wheelchair. R1's Service Plan Modification Report identified inappropriate actions and touching female residents. R1's Progress Note dated 4/13/24, indicated nursing assistant (NA) reported to staff that R1 was rubbing the genital area of a female resident (R2). NA stated R1 had his left hand on R2's upper thigh and his right hand was rubbing back and forth on her genitalia. No nursing staff were in the dining room at the time of the incident. R2's Resident Face Sheet identified diagnosis that included Hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), schizoaffective disorder, depression, anxiety and aphasia (disorder that results from damage to portions of the brain that are responsible for language). R2's annual MDS indicated severe cognitive impairment and indicated she did not display behaviors. R2's Service Plan Modification Report indicated she preferred a stop sign to keep wanderers out of her room, added 4/4/24. R2's Resident Progress Note dated 4/15/24, indicated R2 was asked about the events on 4/13/24, and stated I was scared but I don't let him bother me. I'll yell again. During observation and interview on 4/17/24 at 7:27 p.m. R2 was in her wheelchair in her room watching television. R2 stated she remembered the incident from 4/13/24. When asked if she was afraid, R2 said well, not afraid, I was trying to get away. R2 further stated it had made her uncomfortable. During interview on 4/19/24 at 11:40 a.m. the director of nursing stated the incident had not been reported to law enforcement and said she was not aware of the requirement to report. Facility policy Reporting Reasonable Suspicion of a Crime dated 10/3/16, indicated the facility must report a reasonable suspicion of a crime against a vulnerable adult to the Minnesota Adult Abuse Reporting Center (law enforcement) and the state agency.

Based on interview and document review the facility failed to report an allegation of sexual assault to the state agency (SA) for 1 of 3 residents reviewed who alleged she had been raped at the facility. Findings include: R4's Resident Face Sheet identified diagnosis that included Parkinsonism, Alzheimer's disease and dementia. R4's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated physical and verbal behaviors. The MDS further indicated R4 displayed hallucinations and delusions. R4's care plan updated 4/9/24 identified auditory hallucinations exhibited by seeing people in room, yelling, hitting and refusal to take medications. The care plan indicated R4 voiced false accusations about staff. The care plan directed staff to provide one to one, offer food/drink, call spouse, turn on television and re-approach. R4's facility Progress Note dated 2/28/24 at 4:46 p.m., indicated R4 was upset and yelling and sated the guy with the square head, ended up raping me. 2/28/24 at 10:40 p.m. R4 was noted at the hallway screaming and yelling that he wants to rape me. 3/11/24, R4 had two episodes of delusional behavior with hallucinations. R4 accused male nursing assistant (NA) of raping her. R4 had accused male NA of rape before which was not substantiated. During interview on 4/10/24 at 2:42 p.m., the social services designee (SSD) indicated R4 was not cognitively strong and said she knew who she was and where she was and on a good day could tell you what day it was. The SSD stated, I know she has accused people of raping her but was not sure where it came from. The SSD stated she was not involved in the reporting process. During interview on 4/11/24 at 3:10 p.m. the director of nursing (DON) stated R4 had made accusations that staff were trying to practice voodoo on her and staff had smashed her head, and that staff had tried to beat her up. The DON stated R4 did say she had been raped and said staff had talked to her but R4 tended to be vague and did not provide a lot of detail. The DON stated registered nurse (RN)-A sat and talked with R4 and determined it was not a thing. During interview on 4/11/24 at 3:42 p.m. RN-B stated R4 had good times and tough times and said she had behaviors. RN-B stated when R4 tried to explain things she was unclear. RN-B stated she was aware R4 had made an allegation of rape and said she heard it during report in the past. During interview on 4/11/24 at 4:58 p.m., the administrator stated R4's allegations of rape had not been reported to the SA and said she had not been aware of the rape allegations. Facility policy Maltreatment Reporting Guidelines dated 10/8/21, indicated the facility must report to the SA any suspected maltreatment (all alleged violations involving abuse, neglect, exploitation or maltreatment, including injuries of unknown source and misappropriation of resident property) immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.

Based on observation, interview and document review the facility failed to ensure safe transfer using a mechanical lift during provision of care for 3 of 3 residents (R1, R2, R3) and failed to ensure staff competency following two separate falls from a mechanical lift (R1, R2). This resulted in an Immediate Jeopardy (IJ) for R1, R2, R3. The IJ began on 12/22/23, when R1 fell from the Hoyer lift during provision of care and the facility failed to thoroughly investigate and identify if staff were correctly using the lift per manufacturer's guidelines when the incident occurred. Then, a second fall from a lift occurred on 12/25/23, involving R2 with the same failed response from the facility. The IJ was identified on 1/2/24. The director of nursing (DON) was notified of the immediate jeopardy at 5:55 p.m. on 1/2/24. The IJ was removed on 1/3/24, but non-compliance remained at the lower scope and severity level 2, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy (level D). Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and indicated she required substantial/maximal assistance with transfers. R1's care plan dated 11/21/23, identified left sided hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body). The care plan directed staff to transfer R1 using a mechanical lift, two staff and a medium sized sling. The care plan further identified a risk for bleeding related to use of an anticoagulant (blood-thinning medication). R1's progress note dated 12/22/23, indicated nursing assistant (NA) was independently transferring R1 with the mechanical lift. While R1 was in the sling, NA accidentally bumped the bed with the wheel of the lift. R1 tipped over backwards, hitting the back of her head on the floor. Staff called the ambulance and made responders aware that resident received Coumadin (anticoagulant). R1's progress note dated 12/28/23, indicated follow up to fall on 12/22/23, Root cause : Transferred with the mechanical lift with only one NA. Immediate intervention was to educate NA on policy. Interdisciplinary team (IDT) review: clinical staff meeting scheduled for 1/8, 1/9 & 1/11/24, to go over transfer policy. R1's Facility Investigation identified the following: An untitled document indicated on 12/22/23, R1 fell from the mechanical lift on the evening shift. R1 hit the back of her head and was sent to the emergency department due to the use of blood thinner. NA-A reported the lift was knicked on the side of the bed and R1 fell backward onto the floor from three feet in the air. 12/26/23, NA-A reported R1 had a toileting (split leg) sling under her and said the sling was not appropriate for R1. NA-A reported she only used a shower or full body sling to transfer R1. NA-A reported she was bringing R1 around in the sling and the lift caught on the edge of the bed. NA-A said she moved the left leg back and then moved the lift forward. NA-A reported the whole lift pitched forward and R1 slid forward with the lift and landed on the ground. An Incident Form dated 12/22/23, indicated R1 sustained a hematoma (an injury causes blood to collect and pool under the skin) to the back of her head. The Incident form identified the root cause of the fall as a one person transfer with the mechanical lift. During observation on 1/2/24 at 11:49 a.m., NA-B and NA-E assisted R1 into the mechanical lift transfer sling. While in the air, R1 stated, I'm going to fall out again. R1 was in a split leg sling and her buttocks was hanging far out of the bottom of the sling. During interview and observation on 1/2/24 at 12:07 p.m., R1 stated she remembered falling from the lift. R1 stated it hurt on top of her head and the back of her head. The sling used during the transfer was on a chair in R1's room. The sling was observed to be size large. During observation on 1/2/24 at 12:13 p.m., NA-B stated the sling size used was based on the residents weight. NA-B confirmed the sling used during the transfer observed was a large and said R1 required the use of a medium sling. NA-B said she was aware R1 had fallen from the lift but had not received any education following the incident. During interview on 1/2/24 at 12:49 p.m., NA-C stated she had gotten R1 out of bed in the morning. NA-C stated the sling was in R1's room and she had not confirmed to see if it was the correct size before using it for R1's transfer. R2's quarterly MDS dated [DATE], identified moderate cognitive impairment and indicated she was dependent on staff for transfers. R2's care plan dated 3/5/23, indicated she required the use of a mechanical lift for transfers and used and extra large sling. R2's facility Progress Note dated 12/25/23, indicated NA reported the mechanical lift tipped over while R2 was being transferred from her bed to wheelchair causing R2 to fall to the floor. Legs were in widest position. R2 was noted to be on the floor directly in front of her wheelchair, did not hit her head and was not injured. Progress Note dated 12/27/23, follow up to fall on 12/25/23. The root cause was identified as mechanical lift unbalanced. IDT review indicated the lift was inspected and determined nothing was determined to be wrong with lift. Progress Note indicated, lift used was smaller, with a smaller extension of the legs than the heavier model. Staff to use heavier model when transferring R2. Vulnerable Adult Investigation Statement dated 12/27/23, indicated staff reported that lift was positioned with legs spread out at maximum. Staff stated correct sling size and two staff transferring R2. Staff reported R2 began turning in the air so staff used handles on sling to position R2 over the wheel chair. The lift then tipped to the right side and R2 landed on the floor. Investigation showed the lift had a base of 39 inches when legs spread apart. Other lift had a base of 44.5 inches. Suspect result of lift tipping in two cases. Maintenance inspected the lift and determined lift was in working condition per manufacturers recommendations. Will have staff training on lifts. An Incident Form dated 12/25/23, indicated R2's weight caused the machine to lose balance. During interview on 1/2/24 at 12:56 p.m., the DON stated following R1's fall from the lift, NA-A was put on administrative leave. The DON said NA-A reported R1 had a toileting sling under her and R1 did not use the toilet. The DON stated, we contributed that to the fall. The DON stated NA-A said she did not wait to get help before transferring R1. The DON said NA-A demonstrated how the incident had occurred and said the feet were apart and the leg got caught on the bed and kind of swung so NA-A used her foot to kick the wheel to get it unstuck and when she brought the lift forward, the momentum of it caused R1 to slide forward and onto the floor. The DON stated over the holiday weekend there was another incident using the same mechanical lift involving R2. The DON said R2 reported staff were using the lift correctly. The DON said the base on the lift used in both incidents was not as wide as the other lifts. The DON stated maintenance looked at the lift and said nothing was wrong with it. The DON stated a training was scheduled for 1/8, 1/9 and 1/11/24, for competency with the lifts. During interview on 1/2/24 at 1:10 p.m., R2 stated she was okay using the lift after the incident but said, it was scary. During interview on 1/2/24 at 1:19 p.m., NA-D stated she was involved in the transfer that resulted in R2's fall from the lift. NA-D stated she had been holding on to R2 and she was not lined up with the wheel chair. R2 said she went to adjust R2 and the lift just went over. During interview on 1/2/24 at 2:52 p.m., NA-C stated she had been involved in the transfer when R2 fell . NA-C stated she pulled the lift back and got R2 in front of the chair. NA-C said she did not recall the lift getting stuck on anything and said the legs were wide open. NA-C said NA-D used the sling to maneuver R2 and the lift tipped sideways. On 1/2/24, at 2:30 p.m. the maintenance aide and Environmental Service Director were interviewed. The maintenance aide said the lifts were inspected quarterly using the manufacturers checklist. The maintenance aide said the lift used when both residents fell was newer and the facility had just got it in August of 2023. The maintenance aide said he had spoken to the representative for the manufacturer who said the lift should not have tipped unless it was faulty. The maintenance aide said when the lift was inspected they noticed when the legs were spread they did not open as wide as the other lifts in the facility. He stated the lift used when R1 and R2 fell was rated for 450 pounds and the heavy duty lift was rated for 700 pounds. The maintenance aide said he called the representative who said the lift was narrower because it was not a heavy duty lift. The maintenance aide stated both R1 and R2's weights were within the parameters of the lift. R3's quarterly MDS dated [DATE], identified intact cognition and indicated she required substantial/maximal assistance for transfers. R3's care plan dated 3/27/23, directed staff to transfer her on and off the toilet using a mechanical lift and large sling. During observation and interview on 1/2/24, at 3:50 p.m., NA-F and NA-G assisted R3 from the toilet using a mechanical lift. R3 was lifted off the toilet and hung in the sling while staff adjusted her pants. The NA's then closed the legs of the lift and brought R3 backwards through the doorway of the bathroom to the entry of the room. With the legs of the sling still closed the NA's turned the lift around and began to push the lift toward the wheelchair which was approximately eight feet across the room. Both NA-F and NA-G stated they were not aware the lift should not be used for transport. SMT Health Systems Volaro series 4 lift, PC450/HD450 operators manual 3/2019, included the following safety tips: - The Volaro lift is designed for patient transfer only. Using the lift for transport can create an unsafe patient handling situation. - Lift legs must be fully extended into the wide position when lifting a patient or resident. - Do not push or pull on the beam or resident. This will jeopardize the lift's stability. Specification Sheet indicated - 450 LBS Lifting Capacity-PC450 - 700 LBS Lifting Capacity-HD450 Facility Transferring Policy revised 1/2023, indicated mechanical lift transfers must be performed by a minimum of two nursing staff. The IJ that began on 12/22/23, was removed on 1/3/24, when it was verified through observation, interview and document review the facility identified and assessed all residents who utilized a mechanical lift for safety, completed competency training with staff, utilizing a return demonstration of safe lift operation,implemented a plan to educate all staff who utilized mechanical lifts prior to working with the lifts.

Based on interview, and document review, the facility failed to ensure resident advance directives were accurately documented in the clinical record to reflect the residents' current wishes which affected 3 of 28 residents (R57, R32, R25) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R57, R32, and R25 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R57's, R32's, and R25's electronic health record (EHR) main screen banner identified they were Full Code (administer CPR) however, their updated Physician Orders For Life Sustaining Treatment (POLST) all identified wishes of do not resuscitate (DNR). The administrator, director of nursing (DON), and nurse consultant (NC)-A were notified of the IJ on [DATE], at 4:54 p.m. The IJ was removed on [DATE], at 3:41 p.m. when the facility had implemented corrective action, however non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R57 R57's admission Minimum Data Set (MDS) dated [DATE], identified R20 had moderate cognitive impairment and diagnoses which included: chronic kidney disease, transient ischemic attach (TIA) (temporary period of symptoms similar to a stroke) and aphasia (disorder that affects how someone communicates). R57's care plan revised [DATE], identified R57's advanced directives had the potential for significant change in medical condition, and R57's code status would be reviewed quarterly and as needed (PRN). R57's EHR banner identified R57's code status: full code. R57's EHR Health Care Directive, undated, indicated full code, would change to DNR/ DNI (do not intubate) insertion of a tube to aid in breathing) when POLST completed- waiting on signatures. R57's POLST was not yet signed by the physician but signed by DON on [DATE], which identified DNR. R57's Resident Care Conference Signature form dated [DATE], identified R57's code level remained DNR/DNI. The facility untitled report form dated [DATE], identified R57's code status was Full Code. During an interview on [DATE] at 1:12 p.m., licensed practical nurse (LPN)-A stated if a resident was not breathing or heart stopped, she would check to see if they were DNR, and if not she would begin cardiopulmonary resuscitation (CPR). LPN-A reviewed R57's EHR's banner and identified R57 was full code so she would perform CPR. LPN-A indicated she would check resident's EHR banner first, then check the facility's twenty four hour report form to identify their code status. LPN-A confirmed the untitled report form identified R57 as full code. During an interview on [DATE] at 1:18 p.m., registered nurse (RN)-A stated a resident's code status was determined when they were admitted . RN-A confirmed R57's banner identified full code. RN-A indicated in the absence of a pulse or respirations if a resident was full code she would immediately start CPR and call 911. RN-A stated her usual process was to enter full code into a resident's EHR banner until the facility received the POLST signed by the physician, even if their wishes were DNR. RN-A indicated the nurse manager who received the POLST signed by the physician then would change the banner to DNR. During an interview on [DATE] at 2:30 p.m., DON confirmed R57's POLST was not in her medical record yet as they were waiting for the provider to send a signed copy back. DON confirmed she had documented R57's EHR health care directive as full code, made a note will be DNR/ DNI when POLST was completed, and changed R57's EHR banner to read Full Code on [DATE]. DON confirmed R57's code status was DNR and had confirmed this with family member (FM)-A. DON indicated her understanding was a resident's wish to be DNR could not be honored until the physician had signed the POLST. As a result, she had recently completed an audit to assure all resident's POLSTs were signed before they would follow the resident's wish to be DNR. During an interview on [DATE] at 3:53 p.m., FM-A confirmed R57's wishes were DNR. FM-A stated he had discussed this when R57 was first admitted and also at a meeting on [DATE]. FM-A stated he had informed RN-A and DON he would not want them to perform CPR on R57. 45844 R32 R 32's quarterly MDS dated [DATE], indicated R32 had intact cognition and had diagnosis which included: cancer of the endometrium, depression, and kidney failure. Identified R32 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R32's care plan revised [DATE], identified R32's advance directives had the potential for significant change in medical condition, and identified R32 's code status was DNR and code status would be reviewed quarterly and as needed. During an interview on [DATE] at 9:12 a.m., R32 stated the facility had spoke to her about her wishes a while back and she indicated she wanted to be DNR. R32's EHR banner on [DATE] at 5:02 p.m., indicated full code. R32's EHR Health Care Directive, on [DATE] at 5:02 p.m., indicated full code, would be DNR/DNI when POLST completed; waiting on signatures. R32's POLST signed by the provider on [DATE], identified DNR. R32's Resident Care Conference Signature form dated [DATE], [DATE], [DATE], and [DATE], identified R32's code status was a DNR. Facility untitled report dated [DATE], identified R32's code status as DNR. During an interview on [DATE] at 1:19 p.m., licensed practical nurse (LPN)-D stated in the event a resident did not have a pulse or respirations she would review the paper daily report sheet for code status and proceed accordingly. During an interview on [DATE] at 1:24 p.m., registered nurse (RN)-D stated in the event a resident did not have a pulse or respirations, she would look at the banner which was located in the EHR for code status and proceed accordingly. 48583 R25 R25's quarterly MDS dated [DATE], indicated R25 had intact cognition and had diagnosis which included: heart failure, depression, and kidney failure. Identified R25 required minimal assistance with ADL's which included dressing and toileting. R25's quarterly MDS further indicated R25 was independent with transfers and ambulation. R25's care plan revised [DATE], identified R25's advance directives had the potential for significant change in medical condition, and identified R25's code status was DNR and code status would be reviewed quarterly and as needed. R25's EHR Banner, on [DATE] at 5:10 p.m., identified full code. R25's EHR Health Care Directive indicated, would be DNR/DNI when POLST completed; waiting on provider signature. R25's Progress Notes dated [DATE], revealed Dr. Helia sent signed POLST back: DNR with selective treatment options. Will add to hard copy chart. During an interview on [DATE] at 9:11 a.m., R25 indicated she could not think right now and stated It is too early in the morning. R25 declined any further discussion. During an interview on [DATE] at 1:23 p.m., RN-B stated in the event a resident did not have a pulse or respirations, she would review the main banner in the EHR and proceed accordingly. RN-B confirmed R25's EHR banner identified Full-Code and R25's code status would be changed to DNR/DNI when a signed POLST was received from the provider. During an interview on [DATE] at 1:44 p.m., RN-G stated in the event a resident did not have a pulse or respirations, she would review the main banner in the EHR and proceed accordingly. During an interview on [DATE] at 1:51 p.m., RN-H stated in the event a resident did not have a pulse or respirations she would review the main banner in the EHR and proceed accordingly. During an interview on [DATE] at 1:54 p.m., RN-E stated in the event a resident did not have a pulse or respirations, she would look at the banner in the EHR for code status and proceed accordingly. RN-E verified discrepancies existed in R25's and R32's advance directive records. R25's and R32's banner in the EHR indicated both residents were a full code status and R25's and R32's POLSTs identified both residents were a DNR. In addition, RN-E verified the advance directive tab in R25's and R32's EHR indicated R25 and R32 were both full code until the POLST was signed. RN-E stated they had been waiting for the MD to sign R25's and R32 's POLST and once the POLST was signed the banners would have been changed to DNR. RN-E was unsure why the banner had not been updated once the POLST had been signed on [DATE]. During an interview on [DATE] at 2:16 p.m., DON confirmed R25 and R32 had a POLST in the hard chart which indicated R25's and R32 's wishes were to be a DNR code status. DON confirmed she had changed R25's and R32's EHR banners and health care directives to full code, and noted will be DNR/DNI when POLST was completed on [DATE]. DON indicated her understanding was a resident's code status wish to be DNR could not be honored until the physician had signed the POLST. As a result, she had completed an audit to assure all resident's POLST were signed before they would follow the resident's wish to be DNR. DON stated her expectation was that the banner in the EHR would have matched the POLST and would have accurately reflected the wishes of R25 and R32. Facility policy titled Cardiopulmonary Resuscitation (CPR) revised [DATE], identified St. [NAME] Health Services of [NAME], INC (SFHS) would facilitate the appropriate nursing response according to the residents' wishes, when a resident unexpectedly had an absence of a pulse an/or respirations. Upon admission, the admissions nurse would document the resident's code status (CPR status) on a Physician's Order for Life Sustaining Treatment (POLST) according to the resident and/or their legal representative's wishes and place it on the resident's hard chart. The resident's elected code stats would also be documented in the electronic medical record (EMR). All residents would be presumed to have an order for CPR unless an order for Do Not Resuscitate (DNR) was entered in their POLST, or other advance directive document and their EHR. The IJ was removed on [DATE], at 3:41 p.m. when the facility developed and implemented a systemic removal plan which was verified by interview and document review: -All residents' records were reviewed to ensure the POLST form and EHR's were updated to ensure resident's wishes for advance directive were accurate on [DATE]. -The Advanced Care Planning policy and CPR policy was reviewed on [DATE]. -Licensed Staff were educated on each policy as evidenced by the Education Sign in Sheet and interview. -A process was implemented to assure all other nurses completed mandatory education prior to the start of their next shift on [DATE], by notification of required mandatory education via phone/text. -During interviews on [DATE], LPN-B, RN-C, RN-A, LPN-C, RN-F, RN-G, RN-H, RN-B, RN-E, LPN-E verified they received education regarding policies and honoring resident's code status wishes.

Based on observation, interview and document review the facility failed to ensure 5 of 5 employees, (licensed practical nurse (LPN)-A, dietary aide (DA)-D, activity aide (AA)-C, nursing assistant (NA)-D and LPN-B) were appropriately cleared to return to work following reports of potential symptoms of COVID-19; failed to initate contact tracing or facility wide testing for COVID-19 following potential exposure from a staff who tested positive for COVID-19; failed to ensure 3 of 53 residents (R108, R29, R41) were isolated while presenting with symptoms of COVID-19; and failed to utilize appropriate protective equipment for 2 of 3 residents (R41, R50) when they were placed in isolation. In addition, the facility failed to ensure twelve employees (cook (CK)-A, activity director (AD)-A, DA-B, the director of nursing (DON), DA-C, assistant dietary manager (ADM)-A, DA-B, registered nurse (RN)-D, DA-D, NA-C, NA-A,NA-B) who were out ill with potentially communicable illness' were cleared to return to work: failed to to track resident symptoms of infection and implement an ongoing analysis of collected data to ensure patterns and trends were identified and acted upon to reduce the risk of disease spread within the facility as recommended by the Centers for Disease Control (CDC) guidance to prevent/or minimize the transmission of COVID-19. This resulted in a system wide failure in infection control procedures to prevent the spread of illness within the facility to vulnerable residents and the staff of the facility and resulted in an immediate jeopardy (IJ) which placed all 54 residents at a high likelihood to for serious illness and/or death by contracting a communicable disease, including but not limited to COVID-19. The IJ began on 12/20/22, when NA-D returned to work following COVID-19 symptoms on 12/19/22 and subsequently became positive on 12/21/22. Following the positive COVID-19 test result, the facility failed to conduct contact tracing or initate facility wide testing for COVID-19. The facility failed to isolate and implement transmission based precautions for R108, R29 and R41 when they displayed signs and symptoms of COVID-19. In addition, after the facility placed residents in isolation, staff were observed to not use the appropriate PPE. The administrator and DON were notified of the IJ on 1/11/23, at 2:00 p.m. The IJ was removed on 1/12/23, at 3:00 p.m. when the facility implemented actions to reduce/prevent the spread of illness, including COVID-19. However, noncompliance remained at the lower scope and severity, F, widespread, which indicated no actual harm with potential for more than minimal harm that was not IJ. Findings include: The Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 23, 2022, identified anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for COVID-19 as soon as possible. Mild illness is defined as any various signs and symptoms of COVID-19 such as fever, cough, sore throat, malaise, headache, muscle pain, without shortness of breath, dyspnea or abnormal chest imaging. Moderate illness is defined as evidence of lower respiratory disease, by clinical assessment or imaging, and a saturation of oxygen of <94% on room air. CDC further indicated HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. Further, patients with symptoms of COVID-19 (even before results or diagnostic testing) should be placed in Transmission-Based Precautions. The decision to discontinue empiric transmission based precautions by excluding the diagnosis of a current COVID-19 infection for a patient with symptoms can be made based upon having negative results from at least one viral test. If using an antigen test, a negative result should be confirmed by either a negative molecular test or a second negative antigen test taken 48 hours after the first negative test. Patients with suspected or confirmed COVID-19 should be placed in a single person room and the door should be kept closed, if safe to do so. Healthcare workers who enter the patients rooms should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The CDC Symptoms of COVID-19, updated October 26, 2022, identified people with COVID-19 have had a wide range of symptoms reported-ranging from mild symptoms to severe illness. Symptoms may appear 2 to 14 days after exposure to the virus. Possible symptoms include: fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea. Employee Illness Tracking The facility employee infection control logs for the month of December 2022, identified the following: Respiratory Illness - On 11/24/22, dietary aide (DA)-A tested positive for RSV. DA-A was not tested for COVID-19 illness. DA-A returned to work on 11/28/22. -On 12/4/22, licensed practical nurse (LPN)-A reported aching, sore throat, and headache. LPN-A was not tested for COVID-19 illness. LPN-A returned to work on 12/5/22. LPN-A was not tested for COVID-19 illness. LPN-A worked 12/5/22, 12/6/22 and 12/7/22. On 12/8/22, LPN-A tested positive for influenza B and was still not tested to rule out COVID-19. An analysis of potential contacts who may have been exposed or resolution of symptoms was not documented. -On 12/6/22, DA-D reported increase respiratory symptoms. DA-D was not tested for COVID-19 illness. DA-D returned to work on 12/21/22. -On 12/7/22, AA-C reported symptoms of aching and cough. AA-C was not tested for COVID-19 illness. AA-C returned to work on 12/12/22. -On 12/19/22, NA-D reported respiratory symptoms. NA-D was not tested for COVID-19 illness. NA-D returned to work on 12/20/22. On 12/21/22, NA-D reported illness and tested positive for COVID-19. Contact tracing and testing for COVID-19 to evaluate staff and residents potential exposure and limit the spread of the illness within the facility was not initiated, despite NA-D having worked providing direct care to residents the day prior to her positive test result. -On 12/24/22, LPN-B reported illness of headache and aching while working her shift. LPN-B tested positive for COVID-19 on 12/27/22. LPN-B returned to work on 12/29/22. Contact tracing and testing for COVID-19 to evaluate staff and residents potential exposure and limit the spread of the illness within the facility was not initiated, despite LPN-B having worked providing direct care to residents the day she began exhibiting symptoms of illness. Gastrointestinal Illness (GI) -On 12/8/22, cook (CK)-A reported diarrhea illness and went home. CK-A was not tested for COVID-19 illness. CK-A returned to work on 12/9/22. -On 12/8/22, activity director (AD)-A reported nausea and went home. AD-A was not tested for COVID-19 illness. AD-A returned to work on 12/9/22. -On 12/8/22, dietary aide (DA)-B reported nausea, vomiting and diarrhea and went home. DA-B was not tested for COVID-19 illness. DA-B returned to work on 12/9/22 -On 12/9/22, the director of nursing (DON) reported diarrhea and headache. The DON was not tested for COVID-19 illness. The DON returned to work on 12/12/22. -On 12/9/22, DA-C reported GI symptoms. DA-C was not tested for COVID-19 illness. DA-C returned to work on 12/19/22. -On 12/9/22, assistant dietary manager (ADM)-A reported GI symptoms. ADM-A was not tested for COVID-19 illness. -On 12/12/22, DA-B reported GI symptoms. DA-B was not tested for COVID-19 illness. DA-B returned to work on 12/13/22. -On 12/14/22, registered nurse (RN)-D reported body aches, nausea and vomiting. RN-D did not test for COVID-19 illness. RN-D returned to work on 12/16/22 -On 12/21/22, DA-D reported GI symptoms. DA-D was not tested for COVID-19 illness. DA-D returned to work on 12/30/22 -On 12/27/22, nursing assistant (NA)-C reported vomiting and diarrhea. NA-C was not tested for COVID-19 illness. NA-C returned to work on 12/29/22 -On 12/28/22, NA-A reported nausea and dizziness. NA-A was not tested for COVID-19 illness. NA-A returned to work on 1/9/23. -On 12/29/22, NA-B reported nausea, vomiting and diarrhea. NA-B was not tested for COVID-19 illness. NA-B returned to work on 12/31/22. There was no evidence assessments were conducted to determine if employee illness could potentially be COVID-19 symptoms and require testing prior to return to work or if there were potential resident and staff exposures and a need to conduct contact or outbreak testing. The infection control logs lacked evidence the facility conducted a comprehensive analysis of the collected outcome surveillance data to determine if any of the infections identified were potentially related or corresponded with resident illness for the same month period. There was no evidence the facility had investigated the infections identified for potential causes and/or subsequent actions to reduce the risk of recurrence. When interviewed on 1/10/23, at 2:15 p.m. LPN-A stated if an employee came to her with complaints of feeling sick she would ask them about their symptoms. If it was just sniffles or a little under the weather, she would not send them home. If they were really sick and they had coverage, she would send them home. During interview on 1/10/23 at 2:35 p.m. NA-C stated she would not come to work if she felt sick. If NA-C was already working and started to feel sick, she would try to get someone to come in and replace her but if could not find anyone, she couldn't just go home. It depended on what her symptoms were and which of the nurses was working. If she was throwing up she would probably go home, but if was just feeling run down she would have to work out her shift. When interviewed on 1/10/23, at 3:40 p.m. NA-D stated she was ill with COVID in December of 2022, and tested positive for COVID-19 on 12/21/22. The symptoms NA-D experienced during that illness were GI upset of nausea, vomiting and diarrhea. During interview on 1/11/23, at 10:30 a.m. LPN-B stated she was sick the day she worked on 12/24/22. LPN-B called the administrator that evening to let her know and did not work on 12/25/22 or 12/26/22. LPN-B tested positive on 12/27/22, as she knew she would as a family member in her home was ill with COVID-19 the week before. LPN-B returned to work on 12/29/22, when she was no longer feeling ill and it was five days since her symptoms first appeared. During interview on 1/10/23, at 10:20 a.m. RN-D, who was the infection preventionist, stated she saw the employees when they returned to work after having called in and none appeared ill. RN-D did not test the employees on their return to work. RN-D had known LPN-B had a family member who was ill with COVID-19 living in her home and reported not feeling well on 12/24/23; however, continued to work her entire shift. LPN-B did test positive on 12/27/22. The facility had not initiated any testing of potentially exposed residents or staff, as RN-D felt the doctors in the area believed people tested for COVID too often. RN-D was aware of the facility's policies for staff who had signs and symptoms of COVID-19 like illness (based on screening) and/or a temperature (100 degrees or higher) should not report to work until testing could be completed as well as contact tracing for potential exposures; however, the policies were written by the corporate office and did not necessarily reflect current practice. RN-D stated she visualized all the staff members LPN-B worked with when LPN-B was presenting with symptoms at work. The unidentified staff did not display any symptoms of illness, so RN-D did not feel any COVID-19 testing was necessary, despite COVID-19 having asymptomatic transmission. RN-D saw DA-A on her return to work on 11/28/22, after testing positive for RSV on 11/24/22, and DA-A had no obvious symptoms of illness, and there were no other cases of RSV in the facility. The employees who reported symptoms of GI illness during the month of December were not tested for COVID-19 as their symptoms did not act like a COVID-19 illness. It depended on staff symptoms if they would need to test before returning to work after an illness. An interview was conducted with the DON and administrator on 11/10/22, at 3:30 p.m. The administrator stated if staff or residents displayed illness that could indicate a COVID-19 infection, the ill resident or staff were to isolate and COVID-19 testing would be done on day one, day three and day five of symptom onset. If the results were negative and the resident or staff was asymptomatic isolation was lifted. For contact tracing, the facility did outbreak testing with COVID-19 antigen tests. The facility had not completed an assessment to see if outbreak testing would be needed when LPN-B had tested positive as her positive test was more than 48 hours since she had last worked, despite having displayed symptoms of COVID-19 while at work on 12/24/22. The facility allowed staff to return to work in five to ten days of a positive COVID test, five days if emergency staffing, if they had improved symptoms and were fever free. They allowed LPN-B to return to work on 12/29/22, because they had used onset of symptoms 12/24/22, for the start of her illness. RESIDENT OBSERVATIONS: During observation of R41 on 1/11/23, at 8:40 a.m. there was a sign on R41's door which directed staff/visitors to stop at nurses station prior to going into the room. An isolation cart was outside of the room. During observation of R41 on 1/11/23, at 8:51 a.m. R41's door was wide open and R41 was not in the room. During observation of R41 on 1/11/23, at 8:56 a.m. R41 was in the dining room and seated at a table in the far corner of the room approximately 10-12 feet (ft) from other residents. Nursing assistant (NA)-C was wearing a face mask and was seated next to R41 to assist R41 with eating. During observation of R41 on 1/11/23, at 8:58 a.m. activity aide (AA)-C wheeled R41 out of the dining room and into the hallway near the waterfall. R41 was not wearing a face mask. During observation on 1/11/23, at 9:06 a.m. R41 was seated in her wheelchair, was not wearing a face mask and was seated next to two unidentified residents in the hallway near the waterfall. During observation of R41 on 1/11/23, at 9:06 a.m. R41 was observed unmasked and seated in her wheelchair in the activity area. R41 stated she didn't feel well. R41 coughed several times. Licensed practical nurse (LPN)-C stated R41 could eat in the dining room as long as the resident wore a face mask and sat at the table in the far corner. LPN-C needed to give R41 a breathing treatment and started to wheel R41 out of the activity area. While LPN-C was wheeling R41 down the hallway, LPN-C was interrupted and left R41 in the hallway. R41 was still unmasked. During observation of R41 on 1/11/23, at 9:17 a.m. LPN-C returned to R41 and started wheeling R41 towards her room. LPN-C stated R41 should be wearing a face mask since she was in the hallway. During observation on 1/11/23, at 9:21 a.m. LPN-C was standing next to R41, nurse prepped nebulizer equipment near R41 and then exited residents room. LPN-C did not put on personal protective equipment (PPE) prior to entering R41's room, and did not perform hand hygiene prior to entering or upon exiting the room. LPN-C re-entered R41's room wearing a face mask and carried gloves balled up in her left hand. LPN-C did not put on PPE or use hand sanitizer prior to entered R41's room. With bare hands, LPN-C prepped R41's nebulizer medication (inhaled medication used to reduce inflammation in the lungs or to open airways to improve breathing ability), and placed the face mask over R41's face, secured the elastic straps around R41's head and turned the machine on. LPN-C proceeded to clean and walk around the area near R41 while the nebulizer machine was bubbling and running. LPN-C maintained a distance between 2 feet and 8 feet from R41 during the entire time. During observation at 9:28 a.m. NA-F entered R41's room, talked with LPN-C and then exited the room. Upon entering R41's room NA-F did not use hand sanitizer or put PPE on prior to entering room, use hand sanitizer upon exiting the room or to change face mask after exiting the room. During observation at 9:30 a.m. LPN-C continued to walk around R41's room. LPN-C leaned over R41 and stand face-to-face with R41 while R41's nebulizer was still running. LPN-C was wearing a face mask . LPN-C then removed R41's nebulizer mask, walked behind resident and turned nebulizer machine off. With bare hands, LPN-C carried the nebulizer mask into the bathroom. LPN-C exited the bathroom and walked to R41's side. LPN-C arranged R41's oxygen tubing, placed the nasal cannula on the resident's face and listened to her chest with a stethoscope. LPN-C was within one to two feet of R41 the entire time. Then LPN-C walked into the bathroom, washed hands, removed the face mask, exited R41's room and put on a clean face mask. LPN-C was in R41's room for a total of 8 minutes while in close proximity of R41 and only wearing a face mask. During interview on 1/11/23, at 9:28 a.m. NA-F stated despite there being a sign on the door and a cart outside R41's room she completely forgot to put on PPE prior to entering R41's room. During interview on 1/11/23, at 9:35 a.m. LPN-C stated R41 had a cough and tested negative for COVID-19 on 1/10/23. LPN-C stated R41 was on contact and droplet precautions due to R41's cough and R41 should wear a face mask when out of the room. Staff were supposed to wear on a gown, gloves and face mask when entering R41's room and the sign on the door identified that information. LPN-C did not wear a gown and gloves upon entering R41's room but should have. COVID-19 testing recommendations were to test on day 1, day 3 and day 5 before residents were considered negative. Yesterday was R41's first test. LPN-C stated she did not think R41 would be considered free from COVID-19 after one negative test. When interviewed on 1/11/23, at 9:57 a.m. NA-G stated when she came to work that morning R41 had transmission based precautions (TBP) cart with PPE and a sign on the door directing staff to wear a gown, gloves, eye goggles and face mask when entering the room. Wearing PPE was used to help reduce the risk of spreading infections to other staff and residents. NA-G was initially told R41 had to stay in her room but then later was told the resident could go to the dining room for breakfast as long as she sat at the table furthest in the corner and away from other people. When NA-G wheeled R41 through the dining room R41 did not wear a face mask. During interview on 1/12/23, at 3:48 p.m. the director of nursing (DON) stated when a resident was on TBP the staff were expected to wear a gown, gloves, mask, and depending on the precaution would also expect staff to wear eye goggles, face shield or N95 mask. The staff would also be expected to use hand sanitizer prior to and upon exiting the residents room. That was the policy and staff knew and were expected to follow the policy. When interviewed on 1/11/23, at 10:34 a.m. LPN-B stated R50 started to complain of a sore throat and headache that morning. R50's first COVID-19 test that morning was negative; however, R50 was placed on isolation until confirmatory COVID-19 testing could be completed and her symptoms evaluated. During observation of R50 on 1/11/23, at 10:50 a.m. housekeeper (HK)-A was cleaning R50's room while wearing a surgical face mask and gloves. R50's room had an isolation cart outside of her door and the door way to her room was clearly marked with a sign that indicated anyone who entered needed to observe transmission based precautions and put on a disposable gown, gloves, eye protection and face mask before entering the room. R50 was lying on her bed reading a magazine. The DON approached the room and asked HK-A to leave the room to talk with her. HK-A was instructed on contact precautions. HK-A removed and discarded her gloves in the garbage; however, continued to wear the same surgical mask. HK-A stated they were not told residents were placed in transmission based precautions. HK-A did not see the signs indicating the TBP on R50's door, as R50's door was open when she approached it. During observation odf R50 on 1/11/23, at 10:53 a.m. HK-B entered R50's room to deliver laundry. R50 was lying on her bed reading a magazine. HK-B wore a surgical face mask under her chin, that did not cover her mouth or nose. HK-B did not put on a gown, gloves or eye protection, and entered the room with clean laundry. HK-B delivered the resident's laundry, putting the clean clothes in the residents closet and exited the room; however, did not perform hand hygiene. HK-B stated the transmission based precaution sign hanging on R50's door and the isolation cart outside her door was set up just for visitors, if they were staying in the room for a long time. If the resident was being quarantined for COVID infection there would have been a large COVID sign on her door and in that case, she would not have entered the resident's room and just hung the clean laundry outside her door for nursing staff to put away. HK-B knew her mask was to cover her nose and mouth. It kept sliding down and so she adjusted it back in place. Resident Illness Tracking Resident illness tracking logs for the month of November 2022, identified the following: Respiratory illness -On 11/4/22, R15 developed symptoms of lethargy, decrease oxygen saturation, cough and increase confusion. R15 received two antibiotics for treatment of pneumonia; however, sensitivities were not identified and COVID-19 testing was not conducted. -On 11/19/22, R34 developed symptoms of nasal drainage, cough, loss of taste and smell. R34 tested positive for COVID-19 on 11/22/22 and placed in isolation. -On 11/28/22, R38 was identified as positive for COVID-19 and placed in isolation. Urinary Tract Infections (UTI) -On 11/21/22, R3 developed a UTI. R3 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified. -On 11/28/22, R38 developed a UTI. R38 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified. Resident illness tracking logs for the month of December 2022, identified the following: Urinary Tract Infections (UTI) The December 2022 Infection Surveillance Log (ISL) identified : -On 11/30/22, R23 developed a UTI -On 11/24/22, R3 developed a UTI. R3 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified. -On 12/2/22, R35 developed a UTI. -On 12/6/22, R23 developed a UTI. R23 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified. -On 12/8/22, R33 developed a UTI. R38 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified. -On 12/8/22, R41 developed a UTI. R41 received antibiotic treatment; however, sensitivities to see if the organism was sensitive to the antibiotic ordered, were not identified -On 12/27/22, R23 developed a UTI. R23 received two different antibiotics for treatment; however, sensitivities to see if the organism was sensitive to the antibiotics ordered, were not identified The summary of December 2022 infection control log identified eight resident UTI's, 7 consisted of bacterial infections and 1 was contaminated but treated anyway. The infection control logs lacked evidence the facility conducted a comprehensive analysis of the collected outcome surveillance data to determine if any of the infections identified were potentially related or corresponded with staff illness for the same month period to initiate appropriate corrective action. There was no evidence the facility investigated the infections identified for potential causes and/or subsequent actions to reduce the risk of reoccurrence. The following resident medical records in conjunction with the facility infection control logs identified the following: - Progress note (PN) dated 12/16/22, identified R108 developed decrease lung sounds and oxygen saturations of 70 to 80% with oxygen in place. R108 required hospitalization and returned with diagnosis of pneumonia with unknown origin. R108 was not identified on resident illness logs for surveillance when he presented with initial illness, or throughout his illness. R108 was not evaluated or tested for COVID-19 during the initial course of illness and was not isolated from other residents until COVID-19 testing could be completed to rule out the infectious illness. -PN dated 1/9/23, identified R29 developed symptoms of nausea and vomiting. A rapid COVID-19 test was performed and was negative. R29 was not listed on the resident illness tracking log for surveillance, nor placed on isolation pending a confirmatory test. -PN dated 1/4/23, identified R41 developed low grade temperature of 99. 5, oxygen saturation of 93% with supplemental oxygen at 2L/min, and complaints of not feeling well. A rapid COVID-19 test was performed and was negative. However, R41 was not listed on the resident illness tracking log. R41 remained symptomatic with cough and general malaise, no further COVID-19 test were performed and R41 was not placed into transmission based precautions as recommended by the Centers for Disease Control (CDC) until facility was notified of surveyor concerns on 1/11/23. During interview on 1/10/23, at 10:20 a.m. RN-D stated the nursing staff were supposed to fill out a sick log form when residents had symptoms of illness and she would update her surveillance logs from those forms weekly. RN-D was notified R41 was tested for COVID-19 on 1/4/23, and was negative. R41 had nasal drainage and a cough when she had assisted her in the dining room on 1/6/23. RN-D then notified the charge nurse after wheeling R41 out of the dining room. Testing was usually done on day one, day three and day five for symptomatic staff and residents because of the potential incubation period of the illness. RN-D usually did the COVID-19 testing for residents but did not fill out the sheets for R41's follow up tests, so the required follow up testing was not completed. RN-D was not sure why R108 was not on the resident infection December 2022 logs, as R108 should have been, especially because of his emergency room visit and diagnosis of pneumonia. RN-D indicated it was important to be sure to include all ill resident and employees on the surveillance logs so you could track where they were, how the illness was going and if it was spreading. During interview on 1/10/23, at 4:00 p.m. registered nurse (RN)-A stated if a resident showed signs of COVID-19, they would isolate the resident and test with a rapid antigen test. If still showing symptoms they would retest the resident. They always notified RN-D when they tested a resident for COVID-19. R41 displayed a cough and low grade fever. R41 was tested on [DATE] and was negative for COVID-19. R41 still exhibited symptoms of cough and her oxygen saturation was 95% at rest with supplemental oxygen. R41's cough was loose and in her chest, not in her lungs. RN-A had not personally done a repeat COVID test and would have to check with the nurses working on the floor if another test was needed. No second confirmatory testing was completed after the initial test was done on 1/4/23, despite her continued symptoms. R41 had not been isolated, although continued to exhibit symptoms of cough and shortness of breath. When interviewed on 1/11/23, at 8:30 a.m. RN-D stated some of the resident UTI infections should not have had an antibiotic ordered because no specific bacteria was cultured. RN-D looked for patterns and trends with the resident infections but could only find incontinence of urine and resisting staff assist with peri care after an incontinent episode as a common factor. There did not seem to be a common bacteria with the infections or in the same areas of the facility or she would have suspected staff as the source. RN-D did not document sensitivities to cultures or follow up to make sure the antibiotic ordered was effective against the identified organism. Some times the facility would get sensitivity results on cultures and sometimes they would not. In some instances the lab would not even do a sensitivity on a culture. RN-D stated she watched some staff complete peri care to ensure proper technique; however, had not documented audits formally. She had tried to start audit forms but staff had become angry with the audits and so they were not completed. RN-D did not identify if any concerns or training with peri care had been completed while performing audits. The facility's Coronavirus Prevention, Screening and Identification policy dated 10/9/22, indicated If a resident exhibited any symptoms of respiratory infection, or other COVID-19 related symptoms the resident's provider would be notified immediately. Quarantine interventions and testing would be initiated. If initial test was negative, the resident would be encouraged to use mask and social distance. For residents with suspected or confirmed COVID; monitoring of vital signs and respiratory symptoms would be at least twice a day. and any vital sign changes would be identified and further licensed nurse assessment would occur. During an outbreak, any breach of Personal Protective Equipment (PPE) would be reported immediately to the supervisor or designee. Staff who had signs and symptoms of COVID-19 like illness (based on screening) and/or a temperature (100 degrees or higher) would not report to work until testing could be completed. Staff who had mild to moderate illness, who were not moderately to severely Immunocompromised, could return to work if at least 7 days if a negative antigen or PCR was obtained within 48 hours prior to returning to work or 10 days have passed since symptoms had first appeared, and at least 24 hours had passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) had improved. Staff who were asymptomatic throughout their infection and were not moderately to severely Immunocompromised could return to work if at least 7 days if a negative antigen or PCR was obtained within 48 hours prior to returning to work or after 10 days if testing was not performed. Staff who had a high risk exposure would have three viral tests for SARS-CoV-2 infection. testing would occur (as able) on day one (where day of exposure is day 0), day three, and day five. Care center would keep a list of any staff unprotected exposure to COVID-19. The list would include all staff that interacted with the positive person from two days before symptoms started. For potential staff exposure, the facility would complete Assessment for Health Care Workers (HCW) Assessment for Health Care Workers Potentially Exposed to COVID-19 in Minnesota. Identify the risk level using assessment. Contact tracing may indicate low risk when there was no direct exposure to a COVID-19 infected person. Contact risk was identified as close (within 6 feet for 15 minutes or more, or within same living [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure all staff were tested for COVID-19 during outbreak testing; and failed to test and/or implement confirmatory testing for symptomatic residents and staff, licensed practical nurse (LPN)-A, LPN-B, dietary aide (DA)-D, activity aide (AA)-C, nursing assistant (NA)-D, R108, R29 and R41, who were not tested or had an initial negative rapid antigen testing for COVID-19, per the Centers for Disease Control (CDC) guidance on testing protocols. This system wide breakdown resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death to all 54 residents residing in the facility, along with staff and visitors. The IJ began on 11/23/22, when the facility identified an outbreak of COVID-19 in November and failed to ensure all staff were tested according to CDC outbreak testing requirements. The facility failed to provide evidence 34 staff who worked during outbreak were tested . In addition, the facility failed to initially test or provide a confirmatory test for residents and/or staff who exhibited or reported symptoms of COVID-19 and were tested with antigen tests. The administrator and the director of nursing (DON) were notified of the IJ on 1/10/23, at 2:00 p.m. The immediate jeopardy was removed on 1/11/23, at 3:00 p.m. when the facility implemented interventions to ensure all staff would be tested according to CDC guidelines; however, noncompliance remained at the lower scope and severity level of F, widespread, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: The CDC guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Diseases 2019 (COVID-19) Pandemic updated 9/23/22, indicated for nursing homes, a single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts could not be identified or managed with contact tracing or if contact tracing failed to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. The CDC guidance Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 (COVID-19) Infection or Exposure to SARS-CoV-2 updated 9/23/22 indicated when testing a person with symptoms of COVID-19, negative results from at least one viral test indicate that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. HCP who are not symptomatic could return to work after results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT. STAFF OUTBREAK TESTING: The facility's undated staff line testing forms identified outbreak testing began on 11/23/22, and the facility was testing three times weekly through 12/5/22. The staff line testing form and corresponding working schedules for November 23, 2022 through 12/9/22, identified the following: - On 11/23/22, the facility began their first week of outbreak testing for all staff and residents in the facility following two residents who tested positive for COVID-19. The facility scheduled the first week of testing for staff on 11/23/22, 11/25/22, and 11/28/22. Of the 76 staff listed on the testing logs, 21 staff tested negative on 11/23/22, two staff were not eligible to be tested and the remaining 53 staff did not have test results recorded. On 11/25/22, 10 staff tested negative for COVID-19, two staff were ineligible for testing and 64 staff did not have test results recorded. On 11/28/22, 18 staff tested negative for COVID-19, two staff were ineligible to test and 56 staff did not have test results recorded. - On 11/29/22, the facility began their second week of outbreak testing for COVID-19. The facility scheduled the second week of testing staff on 11/29/22, 12/1/22, and 12/5/22. On 11/29/22, of the 82 staff listed on the testing logs, 14 staff tested negative on 11/29/22, two were ineligible to test, and 64 staff did not have test results recorded. On 12/1/22, 22 staff tested negative, two were ineligible to test and 58 staff did not have test results recorded. On 12/5/22, 25 staff tested negative for COVID-19, two staff were ineligible to test and 55 staff did not have test results recorded. The facility time sheets during the entire outbreak period identified 34 of the facility staff worked in the facility during the outbreak period 11/23/22, through 12/5/22, without having completed any of the required outbreak testing. During interview on 1/10/22, at 10:15 a.m. registered nurse (RN)-D, who was also the infection prevention (IP) nurse, stated the facility conducted outbreak testing 11/23/22 through 12/5/22, after two residents tested positive for COVID-19 in the facility. Staff were notified of the facility test dates and were expected to test prior to working. RN-D went on the nursing floor and reminded staff who had not tested to do so, but they refused to test. The facility policy to send the staff home if they refused to test was not enforced because the facility would not have enough staff to care for their residents. Some staff who did not test during the outbreak testing were still permitted to work. RN-D stated she notified the administrator of staff non-compliance with testing; however, felt she would not have the back up to enforce staff to not work if do not test. - LPN-B had a family member who was ill with COVID-19 living in her home and reported not feeling well on 12/24/22; however, continued to work her entire shift and tested positive on 12/27/22. The facility did not initiate any testing of potentially exposed residents or staff, as RN-D thought the doctors in the area felt people tested for COVID to often. RN-D was aware of the facility's policy's regarding COVID-19 testing; however, the policies were written by the corporate office and did not necessarily reflect current practice. RN-D had observed the staff LPN-B worked with and they did not display any symptoms of illness, and didn't feel testing them was necessary. When interviewed on 1/10/22, at 3:30 p.m. the administrator stated when outbreak testing, the facility would conduct antigen testing three times a week for two weeks. If any COVID positive tests were obtained the start cycle of testing would start over, until no new positive tests were obtained. The facility would stop testing and consider the outbreak resolved when no new positive tests were documented for two weeks. The administrator was not sure how the facility determined the outbreak had resolved when all the employees had not tested as required. All staff were notified by mass text to comply with outbreak testing and assumed they were compliant. If staff did not work on the scheduled test dates, they could test prior to their next scheduled shift. The administrator was not aware any staff were refusing to test. The facility expected all staff to test prior to working with residents when in outbreak status. The administrator did not think this was enforced but it was the expectation. If staff displayed illness that could indicate a COVID-19 infection, the ill staff was to isolate and COVID-19 testing would be done on day one, day three and day five of symptom onset. If results of the testing was negative and the staff was asymptomatic, isolation was lifted. The facility had not initiated outbreak testing when LPN-B had tested positive as her positive test was more than 48 hours since she had last worked, despite having displayed symptoms of COVID-19 while at work on 12/24/22. During interview on 1/11/23, at 8:51 a.m. LPN-C stated outbreak testing was done two times per week. LPN-C may have forgotten to get tested during the outbreak as required. No one ever stated a test was needed to be done before the start of the shift. Sometimes RN-D would remind staff to come and test but LPN-C was already working on the floor by then. If LPN-C remembered to test she did so. LPN-C was not aware of any consequences if staff did not test as required. When interviewed on 1/11/23, at 9:15 a.m. NA-G stated facility outbreak testing was done sometimes two times per week and sometimes three times per week. NA-G tested when she was told to test. NA-G did not think the last round of facility testing was for everyone to test, just some of the staff, as not all of the staff were exposed to the COVID positive resident. On 1/11/23, at 10:30 a.m. LPN-B stated the staff did have to test for COVID-19 during the outbreak starting 11/23/22. The testing was done one or two times per week or if you lived a distance from the facility, staff just had to test prior to start of their shift. When interviewed on 1/11/23, at 10:50 a.m. NA-H stated facility outbreak testing was conducted two times per week. NA-H did not come in for the testing but did a rapid antigen test prior to starting her shift. The nurse on the duty did the test and gave the results to RN-D. RN-D did not always document all the staff COVID antigen tests, but NA-H knew she tested when required. During interview on 1/11/23, at 9:55 a.m. the administrator stated she was not aware so many of the facility staff had not tested during the outbreak testing that was conducted 11/23/22 through 12/5/22, and thought the facility compliance had improved. The administrator did not know why the untested staff were allowed to work and felt the facility needed to do a better job with their COVID-19 testing. The expectation was a list would be made of all the staff who had not tested and a plan to see who had not been tested and how it would get done prior to their next scheduled shifts. TESTING WITH SYMPTOMS: Staff: The facility staff infection control logs for the month of December 2022, identified the following: -On 12/4/22, licensed practical nurse (LPN)-A reported aching, sore throat, and headache. LPN-A was not tested for COVID-19 illness. LPN-A returned to work on 12/5/22. LPN-A worked 12/5/22, 12/6/22 and 12/7/22. On 12/8/22, LPN-A tested positive for influenza B. LPN-A was not tested for COVID-19. LPN-A returned to work on 12/10/22. -On 12/6/22, DA-D reported increase respiratory symptoms. DA-D returned to work on 12/21/22. A COVID-19 test was not documented prior to return to work. -On 12/7/22, AA-C reported symptoms of aching and cough. AA-C was not tested for COVID-19. AA-C returned to work on 12/12/22. -On 12/19/22, NA-D reported respiratory symptoms. NA-D was not tested for COVID-19. NA-D returned to work on 12/20/22. On 12/21/22, NA-D reported illness and tested positive for COVID-19. -On 12/24/22, LPN-B reported illness of headache and aching while working her shift. LPN-B tested positive for COVID-19 on 12/27/22. LPN-B returned to work on 12/29/22. There was no evidence an assessment was conducted to determine potential resident and staff exposures or if there were a need to conduct contact or outbreak testing based on the positive staff results. Residents: -Progress note (PN) on 12/16/22, identified R108 developed decrease lung sounds and oxygen saturations of 70 to 80% with oxygen in place. R108 required hospitalization and returned with a diagnosis of pneumonia with unknown origin. R108 was not evaluated or tested for COVID-19 during the initial course of illness to rule out COVID-19. -PN on 1/9/23, identified R29 developed symptoms of nausea and vomiting. A rapid antigen COVID-19 test was performed and was negative. The medical record lacked documentation of a secondary test performed to confirm the negative finding. -PN on 1/4/23, identified R41 developed a low grade temperature of 99. 5 F, oxygen saturation of 93% with supplemental oxygen at 2L/min, and had complaints of not feeling well. A rapid antigen COVID-19 test was performed and was negative. On 1/10/23, R41 was observed symptomatic with cough and general malaise and out with other residents; however, no further COVID-19 tests had been conducted. During interview on 1/10/22, at 10:15 a.m. registered nurse RN-D, the IP nurse, was notified R41 was tested for COVID-19 on 1/4/23, and was negative. RN-D was not sure why further follow up testing for COVID-19 was not done for R41. RN-D assisted R41 in the dining room on 1/6/23, and observed R41 with nasal drainage and was coughing, so she wheeled her out of the dining room and notified the charge nurse. Testing was usually done on day one, day three and day five for symptomatic staff and residents because of the potential incubation period of the illness. RN-D usually did the COVID testing for residents but had not filled out the sheets for R41's follow up tests .The sheets were completed so the required follow up testing can be completed. When interviewed on 1/10/22, at 3:30 p.m. the administrator stated if residents displayed illness that could indicate a COVID-19 infection, the ill resident was to isolate and COVID-19 testing would be done on day one, day three and day five of symptom onset. If results of the testing was negative and the resident was asymptomatic isolation was lifted. During interview on 1/10/23, at 4:00 p.m. registered nurse (RN)-A stated if a resident showed signs of COVID-19, they would isolate the resident and test with a rapid antigen test. If still showing symptoms they would retest the resident. They always notified RN-D when they tested a resident for COVID-19. R41 displayed a cough and low grade fever. R41 was tested on [DATE], and was negative for COVID-19. R41 still exhibited symptoms of cough and her oxygen saturation was 95% at rest with supplemental oxygen, but the cough was loose and in the chest, not in the lungs. RN-A had not personally done a repeat COVID test and would have to check with the nurses working on the floor if another test was needed. No second confirmatory testing was completed after the initial test was done on 1/4/23, despite R41's continued symptoms. The facility's Coronavirus Prevention, Screening and Identification policy dated 10/9/22, indicated If a resident exhibited any symptoms of respiratory infection, or other COVID-19 related symptoms the resident's provider would be notified immediately. Quarantine interventions and testing would be initiated. If initial test was negative, the resident would be encouraged to use mask and social distance. Staff who had signs and symptoms of COVID-19 like illness (based on screening) and/or a temperature (100 degrees or higher) would not report to work until testing can be completed. Staff who had mild to moderate illness who were not moderately to severely Immunocompromised, could return to work if at least 7 days if a negative antigen or reverse transcription polymerase chain reaction (PCR) was obtained within 48 hours prior to returning to work or 10 days have passed since symptoms had first appeared, and at least 24 hours had passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) had improved. Staff who were asymptomatic throughout their infection and were not moderately to severely Immunocompromised could return to work if at least 7 days if a negative antigen or PCR was obtained within 48 hours prior to returning to work or after 10 days if testing was not performed. Staff who had a high risk exposure would have three viral tests for SARS-CoV-2 infection. testing would occur (as able) on day one (where day of exposure is day 0), day three, and day five. Care center would keep a list of any staff unprotected exposure to COVID-19. The list would include all staff that interacted with the positive person from two days before symptoms started. For potential staff exposure, the facility would complete Assessment for Health Care Workers (HCW) Assessment for Health Care Workers Potentially Exposed to COVID-19 in Minnesota. Identify the risk level using assessment. Contact tracing may indicate low risk when there was no direct exposure to a COVID-19 infected person. Contact risk was identified as close (within 6 feet for 15 minutes or more, or within same living space) contact of person(s) with COVID-19 within 48 hours. Communicate the risk level to the staff with work-related recommendations. Recommendations would be followed for staff who had high-risk workplace exposure to COVID-19 and staff with household or intimate contacts who had confirmed or suspected COVID-19. The facility's policy COVID-19 Testing, dated 9/29/22, indicated COVID-19 testing strategies would be implemented to assist with identification and mitigation of spread of COVID-19 illness. The care center would test residents and staff based on parameters defined by the Center for Medicare and Medicaid Services (CMS), the Minnesota Department of Health (MDH) and the CDC. Symptomatic residents or staff would be tested . If newly identified COVID-19 positive staff or resident were identified all staff and residents would be tested , regardless of vaccination status. Any care center staff who refused to test would not be allowed to work within the care center. An employee must be tested prior to returning to work. Positive results from antigen tests are highly accurate, but there would be a chance of false negatives. A negative rapid antigen test may need to be confirmed using a RT-PCR test, especially if the result of the antigen test was inconsistent with the clinical symptoms. Individuals who have signs and symptoms must be tested on days one, three and five for COVID-19. If positive results the employee must be removed from the care center and may remain out for up to ten days from the beginning of symptoms. Residents with signs and symptoms must be tested and if positive test, quarantine for ten days. All residents and staff with exposure should be tested immediately and all staff and residents that tested negative should be retested every five to seven days until testing identified no new cases of COVID-19 infection among staff or residents. Care centers will complete testing according to MDH, CDC and CMS guidelines. For symptomatic residents and staff, the date and time of identification of symptoms, when testing was conducted and the results and the actions the care center took based on the results would be documented. The facility would document the actions taken for residents and staff who refuse testing. The IJ which began on 11/23/22, was removed on 1/11/23, at 3:00 p.m. when it could be verified through interview and document review the facility implemented housewide COVID-19 testing in accordance with CDC guidance, including performing confirmatory testing on symptomatic antigen negative residents and staff. Education was provided to all employees on current and updated COVID-19 protocols for testing.

Based on observation, interview, and document review the facility to comprehensively assess, develop interventions and ensure consistent clinical monitoring was completed for 3 of 3 residents (R53, R36, R4) who had experienced a change in condition. his resulted in actual harm for R53, who was hospitalized with sepsis and expired. Findings include: R53's quarterly Minimum Data Set (MDS) dated [DATE], identified R53 was cognitively intact, diagnosis included diabetes mellitus type 2, and required assist with activities of daily living (ADL's). R53's undated face sheet, identified diagnoses including history of clostridium difficile (C.diff - an infection in the colon which symptoms including diarrhea, belly pain and fever), diarrhea and nausea with vomiting. R53's care plan dated [DATE], directed staff to monitor R53 for changes in abilities, report loose foul-smelling stools and to monitor stool consistency. R53's Medication Administration Record (MAR) dated [DATE] through [DATE], identified the following: - Staff monitored R53's daily fluid restriction of ,d+[DATE] cc although the total daily fluid intake was not documented. - R53's daily weight was documented all but four days and ranged from 203 lbs on [DATE], to 207.5 lbs on [DATE]. On [DATE] through [DATE], and on [DATE], R53's vital signs (blood pressure, pulse, oxygen saturation (O2 sats), respirations and temperature) was documented at least once daily. Staff had not documented vital signs from [DATE], [DATE], or [DATE] through [DATE]. [DATE] evening shift: ,d+[DATE], R20, O2 sats 97% RA, P88, T 97.7F [DATE] evening shift: ,d+[DATE], R20, 99% RA, P88, T 98.6F [DATE] evening shift: ,d+[DATE], morning shift: ,d+[DATE], R20, 99% RA, P 97, T 97.5F, [DATE] evening shift: ,d+[DATE], R20,99% RA, P 92, T 97.2F, [DATE] evening shift: ,d+[DATE]. R20, 99% RA, P113, T 97.8F, [DATE] evening shift ,d+[DATE]. R20, 93% RA, P93, T 98.2F, [DATE] evening shift ,d+[DATE], R18, 91% RA, P 100, T 97.7F, [DATE] evening shift ,d+[DATE], R20, 97% RA, P84, T 97.9F, [DATE] morning shift: ,d+[DATE], other VS not documented - R53's blood pressure was not documented on [DATE], [DATE] or [DATE] through [DATE]. - R53's Respirations were not documented from [DATE] through [DATE]. - R53's O2 sats were not documented from [DATE] through [DATE] - R53's pulse or temperature were not documented from [DATE] through [DATE]. - Medication(s) including Loperamide (medication used to decrease the frequency of diarrhea) as needed four times daily was administered and documented as not effective on [DATE] and [DATE]; administered with no effectiveness documented on [DATE]; and administered and documented as effective on [DATE], [DATE], [DATE]. - Gastrointestinal (GI) distress including nausea, vomiting or abdominal pain was documented on [DATE], [DATE], and [DATE]. Specific symptom(s), severity or frequency were not documented. - Body aches or headaches on [DATE], [DATE], [DATE], and [DATE] were documented but specific symptom(s) were not. R53's pain rating was documented on [DATE] as #,d+[DATE], and on [DATE] was #,d+[DATE]. R53 had received Acetaminophen 650 mg on [DATE] and [DATE]. R53's Progress Notes dated [DATE] through [DATE], included the following: - On [DATE], R53 requested imodium for loose stools. Effectiveness was not documented. - On [DATE], R53 complained of sore throat, feeling tired and not able to smell very good. R53 was afebrile and had a negative rapid COVID test. - On [DATE], at 5:00 a.m. R53 had a low blood sugar of 31. Snacks were provided, and blood sugar recheck at 5:45 a.m. was 145. - On [DATE], at 2:05 p.m. note stating res is being transferred to hospital with diagnosis of sepsis. - On [DATE], at 2:06 p.m. change of condition note documented stating R53 was in the dining room for breakfast, then went back to room and resident started complaining of not feeling well. Vitals sign's were completed showing a BP: ,d+[DATE]. R53 was having a difficult time with formulating words and sentences and had complaints of chest pain. Ambulance was called and R53 sent to the emergency department (ED). R53's emergency department (ED) record dated [DATE], identified R53 presented to the ED for evaluation of increased fatigue and lethargy. The ED medical doctor (ED MD) identified R53 was ill-appearing, toxic appearing, was tachycardic with heart rate of ,d+[DATE], and shallow respirations at 30. Treatments included intravenous (IV) fluids, Levophed (IV medication used to treat life-threatening low blood pressure), panculture (testing of the blood, urine, sputum, or stool to identify infection), and IV antibiotics. The final diagnoses included sepsis due to unspecified organism, unspecified whether acute organ dysfunction present and the plan had been to transfer R53 to another facility for critical care management. R53's hospital progress notes identified the following: - [DATE], R53 presented to the ED due to feeling weak, lethargic, and decreased blood pressure. R53 had diarrhea for about a week, dysuria (painful urination), and abdominal pain. There was abnormal lab work and CT (medical imaging tests that take pictures of selected areas inside the body) scans. Diagnoses included septic shock due to a combination of UTI and colitis as well as acute kidney injury, anemia, low potassium, and low magnesium. At 6:25 p.m. the provider addend the progress note and included an additional diagnosis of acute respiratory failure with treatment including 12 liters of oxygen, additional antibiotic for potential atypical pneumonia and one dose of Lasix (medication used to prevent the body from absorbing too much salt and allows the salt to be passed out of the body through the urine). - [DATE], continue Levophed (medication used to treat life-threatening low blood pressure that can occur with certain medical conditions), continue IV antibiotics and continue oral antibiotics. - [DATE], continue Levophed and antibiotics. At 5:34 p.m. the provider addend the progress note and identified throughout the day R53 had not produced any urine and required increased oxygen resulting in multiorgan system failure. - [DATE], R53 was non-responsive, on bipap (a type of ventilator that helps with breathing), not producing urine, was acidotic (a medical condition in which too much acid is produced in the body and/or the kidneys cannot remove enough acid through the urine. The medical condition may lead to confusion, shock or even death), had fluid overload and prognosis was very poor. The provider discussed with family and decided on comfort cares and no further escalation of treatment. R53's hospital discharge summary dated [DATE], identified R53 continued to decline and expired at 12:53 a.m. During interview on [DATE], at 7:43 p.m. registered nurse (RN)-A stated she was not familiar with R53. On [DATE], at 7:45 p.m. during joint interview with RN-C and RN-D, who is also the infection preventionist, RN-D stated R53 was sickly, was a drug seeker and always had something going on. RN-C stated R53 tested negative for COVID-19 on [DATE] and was monitored for GI issues on [DATE], [DATE], and [DATE]. RN-C and RN-D stated staff should have further monitored and assessed R53 prior to going to the hospital. During interview on [DATE], at 8:02 p.m. nursing assistant (NA)-E stated R53 had always been sick, had always complained of not feeling well and had diarrhea all the time. NA-E stated R53 had been confused the week before she went to the hospital. A few days prior to R53's transfer to the ED R53 became pale, yellowish in color, became weak and her ability declined from a 2-person stand-by-assist to a total mechanical lift. NA-E stated she reported R53's changes to the nurse. On [DATE], at 8:21 p.m. left a message requesting MD-A return call. During interview on [DATE], at 3:06 p.m. medical doctor (MD)-A stated R53 was a very complicated resident and had diagnoses including anemia, diabetes, thyroid disorder, and atrial fibrillation; all of which were stable at the time of R53's evaluation on [DATE]. R53's exam had been non-specific (normal) and residents only symptoms were fatigue and feeling tired. When R53 was at baseline, R53 had been able to communicate her needs. MD-A stated she expected staff to assess R53, respond appropriately, and notify MD-A of any changes. MD-A stated she had been unable to find any communication (via fax, computer messages or phone calls) from the facility beginning after the [DATE] evaluation through the ED admitted [DATE]. MD-A stated she would expect the facility to notify herself or her nurse of any change in condition. - MD-A stated upon review of R53's emergency department (ED) note dated [DATE], R53 was hypertensive, tachycardic and was admitted to the hospital. The final diagnoses were Clostridioides difficile (C-diff) colitis (an infection in the colon which symptoms including diarrhea, belly pain and fever) and septic shock (a life-threatening condition caused by an infection. Symptoms include low blood pressure, pale and cool arms and legs, chills, difficulty breathing, decreased urine output, mental confusion, and disorientation). MD-A stated R53 was admitted to the hospital and according to the hospital notes had declined quickly. Signs and symptoms of septic shock included any signs of infection, diarrhea, cellulitis, fever, tachycardia, an increase in blood pressure and then a drop in blood pressure. Further, MD-A stated the nurses should have assessed R53 and should have been able to tell something was wrong. R53's medical record did not identify comprehensive assessment(s) were completed after identification of R53's confusion, weakness, diarrhea and change in color, nor identify interventions implemented to stabilize R53's mental and physical status, or evidence of ongoing monitoring. Further, it was not evident the MD-A had been notified of the change in R53's cognition, mental status, or GI status. 41575 R36's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment, required supervision or setup for most activities of daily living (ADLs) and used a walker for mobility. R36's care plan dated [DATE], identified R36 had shortness of breath related to chronic obstructive pulmonary disease (COPD) and asthma and directed staff to monitor her shortness of breath and oxygen levels. R36 had short term memory problem and/or periods of confusion. During observation and interview with R36 and family member (FM)-A on [DATE], at 12:10 p.m. R36 was sleeping soundly and did not respond to the knock on her door or her name being called. FM-A stated R36 had frequent periods where she was unresponsive and was unable to be aroused from sleep. R36 had frequent low oxygen saturations and was requiring oxygen more and more frequently. R36's Physician Orders dated [DATE], identified R36 received Ipratropium bromide nasal solution, xopenex inhaler, and Trelegy Ellipta for respiratory failure and COPD. R36 also received Xarelto (a medication to prevent blood clots). The physician orders did not identify the use of oxygen. R36's progress notes identified the following: -[DATE], R36 felt weak and complained of no strength. She fell on to her left arm. Was alert and orientated and assisted up with assist of two staff. The doctor was notified of the fall. -[DATE], R36 was confused and wandered into another resident's room. -[DATE], R36 reported she had fallen off her toilet the day before and hit her head. R36 stated she had gotten herself up and did not notify anyone at the time of her fall. -[DATE], R36's physician was notified of her reported fall. Orders were received to monitor her mental status. -[DATE], R36 was very sleepy during the evening shift. Staff will continue to monitor for COVID-19 symptoms. Oxygen saturation was 92% on room air. -[DATE], R36 was very sleepy through out the evening shift. FM-A requested staff assess her vital signs. R36 oxygen saturation was 92% on room air. -[DATE], R36 was on leave of absence (LOA) with FM-A. FM-A called the facility at 12:00 p.m. and again 2:30 p.m. to report he was unable to awaken R36. He was told to take R36 to her physician to be evaluated. -[DATE], R36 went by ambulance while on LOA with family. Returned to the facility at 7:00 p.m. Direction to follow up with primary physician with no new orders. Will continue to monitor. -[DATE], FM-A requested staff to assess R36 vital signs. Vital signs were taken and oxygen saturation was 80%. Oxygen was applied and oxygen saturation was rechecked 45 minutes later. Oxygen saturation was 89%. The medical record lacked evidence of further assessment for R36's unusual lethargy, confusion, abnormal oxygen saturations, and new utilization of PRN oxygen. During interview on [DATE], at 3:30 p.m. the director of nursing (DON) stated more assessment would be needed when R36 was difficult to arouse or when exhibits low oxygen saturations. The DON would expect further assessment and vital signs as well as report to next shift for ongoing assessments. R4's significant change MDS dated [DATE], identified R4 had moderate cognitive impairment, received antipsychotic, antianxiety and antidepressant medications on a daily basis, and required extensive assistance to complete activities of daily living (ADLs). The MDS outlined a section to record R4's mood. R4 was unable to be interviewed, however, staff assessment of R4's mood severity scored 3, as minimal. No hallucinations, rejection of care or behaviors were recorded and no change in R4's mood and behavior had occurred since her last assessment. During interview on [DATE], at 2:40 p.m. R4 stated her feet were really swollen and she was concerned about it. She was not taking diuretic medications. The staff did have her elevate her feet in the afternoons. The swelling bothered her and her daughter had ordered some elastic stockings for her to try but they had not been delivered yet. R4's progress notes identified the following: -[DATE], hospice note. Noted 3+ edema (swelling) to right lower leg and foot and 2+ to the left. Orders received to try Lasix (a diuretic medication to decrease fluid retention) 20 milligrams (mg) daily for seven days. Will reevaluate in seven days. -[DATE], hospice note. Gradual weight gain in past months. is back to her baseline weight of 190 to 200 pounds. R4 has significant edema to her feet. Encourage to elevate her legs. -[DATE], hospice note. R4 has ,d+[DATE]+ edema to both feet. Encouraged to elevate during the day. She does have compression wraps on at this time. R4's Physician Order Review, dated [DATE], identified R4's current signed orders. These included medications: Lasix (a diuretic medication) 20 mg every day for 5 days with start date [DATE] and end date [DATE], for localized edema. R4's most recent Physician Progress Note, dated [DATE], identified the current visit was for medication recheck. The progress note lacked evidence R4's diuretic medication and edema had been addressed, or if the physician was aware the medication ordered for five days ended [DATE], with need for further evaluation. R4's weights were reviewed [DATE] through [DATE] and indicated the following: -[DATE], R4's weight was 200 pounds. -[DATE], R4's weight was 186 pounds. -[DATE], R4's weight was 181.8 pounds. -[DATE], R4's weight was 192 pounds. -[DATE], R4's weight was 198 pounds -[DATE], R4's weight was 182 pounds. ' The recorded weights identified R4 had a significant weight gain of 5% in less than a two week period between [DATE] and [DATE]. R4's diuretic medication was ordered [DATE], with end date of [DATE], however, the medical record lacked evidence R4's weight gain was assessed after the discontinuation of the medication. When interviewed on [DATE], at 11:50 a.m. registered nurse (RN)-G stated the physician came to the facility to see patients. Medications were discussed verbally on rounds. R4 did have Lasix ordered for 5 days as recommended by hospice, as R4 had developed ,d+[DATE]+ pedal edema in her lower extremities. The medication was for a limited time and then would be reevaluated. Staff did try to have R4 lie in a recliner with her feet elevated in the afternoon as an intervention for her edema. She was not aware R4 had a weight gain after the diuretic was stopped. The staff obtained the resident weights on their bath days but had difficulty with putting the information in the electronic medical record, so RN-G had to rely on staff verbal reports if they noticed resident weight gains or losses. The unit has been actively weighing all the residents this week to obtain current weights and getting them documented in to the each residents medical records. RN-G had not done any type of assessment for R4 when her diuretic was discontinued because R4 was a hospice patient and she felt the hospice nurse should have assessed R4. R4's ten pound weight gain was not reported by the nursing assistants who did the weights and because they had not tracked resident weights in the computer the significant weight gain was missed. RN-G was not aware R4 had gained ten pounds in the two weeks after discontinuing her diuretic, but thought it could have been due to her increased appetite. When interviewed on [DATE], at 3:15 p.m. the DON stated when a resident was prescribed a diuretic medication she would like to see their weight come down and watch their fluid intake. The DON remembered R4 had been pretty fluffy and hospice was trying to get some of the fluid off for comfort. Staff would need to assess weights to find out if the diuretic ordered was effective and weights should be done weekly. The DON did not feel a ten pound weight gain in a two week period could be attributed to appetite alone. Assessments were expected to be conducted when needed, regardless if the resident was under hospice care. A policy on assessing for a change of condition was requested and not provided. The facility's Weight Monitoring Program policy dated [DATE], identified the purpose was to provide guidance to staff for monitoring weights to maintain or improve the overall health of residents. The policy defined a medically significant weight gain as a weight gain of 5 or more pounds within one week could indicate a change in health status per the plan of care (i.e. diuretics, cortcosteroids, etc). Staff were directed to weigh residents weekly, as needed, or as ordered by the physician. Weight data would be assessed, tracked and entered into the electronic health record weekly. The physician would be contacted for any resident with a medically significant weight gain of 5 pounds or more.

Based on interview and document review, the facility failed to ensure resident identified as elopement risk had a functioning WanderGuard unit or other interventions were implemented to prevent elopements for 1 of 3 residents (R1) reviewed for elopements. This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 12/1/21 when R1's WanderGuard was tested and determined to not be functioning but was not replaced, nor was additional interventions put in to place to keep R1 safe until the WanderGuard could be replaced. Then on 12/8/21 R1 eloped out of the building and was found by a visitor/contractor lying in a snowbank unharmed. The facility failed to place immediate interventions to prevent a future elopement when it was again determined R1's WanderGuard was not functioning, which resulted in R1 eloping out of the building again an hour later (on 12/8/21), and was found by another visitor outside (on campus) unharmed. In addition, there were no immediate interventions placed after the second elopement. On 12/15/21, at 3:30 p.m. administrator, director of nursing (DON), and consultant were notified of the IJ. The IJ was removed on 12/16/21, at 1:46 p.m. but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of facility report number 9 to the State Agency (SA) dated 12/8/21, indicated R1 went outside wearing 2 tee-shirts and sweatpants. He subsequently fell on the ice as he tried to stand and into the snow bank. Staff was notified that the resident was outside in the snow bank by a pharmacy tech that was delivering medications to the facility. Review of the 5-day investigation to the SA dated 12/9/21, indicated replaced wanderguard bracelet as his was not in working condition as the action taken to prevent reoccurrence to resident. R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses included Alzheimer's, dementia and had severe cognitive impairment. R1 required extensive assistance from one staff for activities of daily living, however, was able to utilize wheelchair independently for mobility. Further review of MDS, indicated R1 had delusions but did not exhibit any wandering behaviors. R1's Elopement Risk assessment dated [DATE], identified R1 as an elopement risk related to decreased motivation and cognitive status, has attempted to leave in the past. However, assessment lacked information related to interventions in place to prevent a future elopement. R1's care plan dated 12/8/21, indicated R1 displayed paranoid behaviors and would accuse people of stealing his car and that staff were lying to him. R1's care plan directed staff to provide one on one attention, distractions, and offer food and beverages. R1's care plan lacked information on R1 being an elopement risk and interventions for staff when resident was displaying wandering or exit seeking behavior. However, on 12/14/21, after survey entrance, R1's care plan was revised to include R1 had a history of elopement and directed staff to observe for wandering behaviors, offer activity when restless, redirect as able, replace WanderGuard every 85 days, and check WanderGuard for placement and functioning located on R1's left wrist. Review of R1's progress notes lacked evidence of the two elopements occurring on 12/8/21. Further review of R1's progress notes dated 12/10/21, indicated R1 was seen by the nurse practitioner who observed and spoke with resident. The following order was received: Collect UA [urinary analysis] for increased confusion. However, R1's progress notes lacked evidence that a UA was attempted or obtained with the results. R1's Incident Details report dated 12/8/21, indicated, Resident has been fixated on his glasses getting fixed. He did come to the dining room but was too fixated on his glasses to eat any supper. He wheeled himself out of the dining room. At [6:05 p.m.] this writer went to the door for medication delivery. The delivery person said something about a man in a wheelchair outside. The delivery man assisted with resident getting into the wheelchair and back into the facility. I did bring him down to his room so he could use the bathroom. He is sitting at the nursing station with me now. He has no bruises or scratches from falling sideways into snowbank. Further review of incident report, lacked evidence of immediate interventions placed to prevent future elopements for R1. Review of a second incident report dated 12/8/21, at 7:15 p.m. indicated R1 was fixated on his car when he self- propelled in his wheelchair down the hallway. It was noted by a nursing assistant another visitor had seen him outside and helped him back in through the front doors. This incident report indicated staff reoriented R1, offered food and R1 went to his room. Review of licensed nurses' 24-hour report sheet dated 12/1/21, indicated R1's WG [WanderGuard] not working. In addition, review of the 24-hour report sheets lacked evidence of R1's WanderGuard being addressed. On 12/14/21, at 1:50 p.m. R1 was observed to be sitting at the edge of his bed and a WanderGuard bracelet was on his left wrist. R1 stated he had just woken up from a nap and appeared to be mildly confused when responding to surveyors questions. On 12/14/21, at 3:18 p.m. licensed practical nurse (LPN)-A indicated R1 was known to get agitated and concerned about things and he won't forget about it. Further, LPN-A indicated prior to R1's two elopements on 12/8/21, R1 required a WanderGuard bracelet, however, it hasn't been working for a week if not more. Everybody knew it wasn't working so we were watching him closely. In addition, LPN-A indicated R1 was noted to wander nearly every day and has attempted to exit the building in the past. On 12/14/21, at 3:51 p.m. registered nurse (RN)-A indicated R1 had no short-term memory and will often get fixated on something and there is only so much you can do. On 12/8/21, R1 was noted to be fixated on his glasses and would not eat the supper meal. R1 left the dining room and ended up outside in a matter of minutes. R1 fell out of the wheelchair and into a snowbank with no injuries noted. RN-A brought R1 back into the facility and assessed R1 for injuries. RN-A indicated she re-orientated R1 and notified the DON. RN-A then noted R1 fixated on finding his car and wheeling past the nursing station in the hallway and called for a CNA to get R1. By the time the CNA reached R1, R1 was being brought back into the facility by a visitor. RN-A then indicated she re-orientated R1 once again and the staff got him ready for bed. RN-A indicated R1 had a WanderGuard on, however, after the first and second incident RN-A did not check the WanderGuard, but it did not sound the alarm for both incidents. RN-A stated, I didn't put any extra monitoring in place. I just passed it on in the 24-hour report, so everyone knew what was going on with him [R1]. On 12/15/21, at 8:16 a.m. LPN-B indicated R1 will persistently ask where he should be or what he should be doing and we [staff] use a lot of reassurance but its very difficult to redirect and reorient due to poor short-term memory. Further, LPN-B indicated she checked R1's WanderGuard for functioning a week or week and a half ago and it was not functioning, so I passed it through report, and I believe we didn't have it [new WanderGuard] in the building. I believe we ordered some. On 12/15/21, at 8:43 a.m. nursing assistant (NA)-A indicated R1 was not identified as an elopement risk and did not wear a WanderGuard. NA-A indicated staff are made aware of elopement risk and interventions through report, however some aids are not good at communicating and NAs are also able to look at the nursing care guide sheets. On 12/15/21, at 9:47 a.m. RN-B indicated R1is not orientated and getting worse. RN-B indicated R1 was identified as an elopement risk with interventions that included 1-1, offer food, drink, and distractions. RN-B indicated all of the interventions are in R1's care plan, however, they were just added to the care plan on 12/14/21. RN-B indicated, Staff know by word of mouth and interventions are placed on the care guide sheets, however, as of 12/15/21, the care guide sheets did not identify R1 as an elopement risk nor provide staff with interventions. RN-B indicated she was aware that R1's WanderGuard was not working but was unable to give a date when she was made aware. RN-B indicated she updated maintenance to order some when she found out R1's was not working and stated, I didn't put anything in place because he wasn't exit seeking to be honest with you. RN-B was unsure what was implemented following R1's incidents on 12/8/21, as well. When asked what the process is once staff identify the WanderGuard is not working, RN-B stated, I can't answer what the process is. On 12/15/21, at 10:15 a.m. environmental services director (ESD) indicated he was not aware of R1's WanderGuard not functioning properly prior to his two elopements on 12/8/21. Further, ESD stated, Prior to that we didn't have any extras because that is when they told me they were out. I think it's a lack of communication. I should check to make sure they don't run out. In addition, ESD stated, She [RN-B] said one was outdated and I think that was [R1]'s. On 12/15/21, at 10:48 a.m. director of nursing (DON) indicated WanderGuards were being monitored on the overnight shift but after R1's incidents was changed to be checked on days and evenings due to they were either not being done or not being communicated that they were no longer working. When asked what the process is when the WanderGuards are identified as not working and no extras are found, DON stated, communicate to the am staff so that they can get more. There is nothing in place at this time to be frank with you. DON indicated staff know who an elopement risk is by knowing who has a WanderGuard on and the licensed nursing staff are able to look in the care plans to identify and what interventions are in place. However, DON confirmed R1's care plan was updated on 12/14/21, with elopement risk and interventions. DON indicated on 12/8/21, R1 eloped outside looking for his glasses and he tried to stand and fell on the ice. There was no injury noted. DON indicated she was aware R1's WanderGuard was not working that night, so DON directed staff to keep eyes on him until he went to bed. DON left for the evening and was not aware of the second incident until the following morning on 12/9/21. DON was unsure what was put into place after the second incident. Once DON was aware of the second incident on 12/9/21, DON stated, I asked [Maintenance] for a WanderGuard to replace it and we found out we didn't have any so then they were ordered. When asked what was put into place until the new WanderGuard arrived, DON stated, check on him more frequently and to know where R1 is at every hour. DON indicated she verbally updated staff but, I didn't document it anywhere looking back I should have done a one-hour safety check. Further, DON indicated she was not aware that the WanderGuard was not working on 12/1/21, and you can assume that it was not working from 12/1/21 through 12/8/21. On 12/15/21, at 11:14 a.m. administrator was not aware that there were no WanderGuard's available for R1 nor was she aware the WanderGuard was not working on 12/1/21. In addition, administrator indicated when staff identify a WanderGuard is not functioning they were expected to change it and if there were no WanderGuards available they should call maintenance. He has back ups in his office. Further, administrator indicated if there were no WanderGuard's available in the building at that point they would need to do safety checks. On 12/15/21, at 1:14 p.m. RN-C indicated staff were to check on the overnight shift for Wanderguard functioning. RN-C indicated if a WanderGuard is identified as not working, I will report it to the next shift. I don't know where to find the new ones. I just report it to the next shift and let them know. RN-C confirmed prior to R1's incident she knew his WanderGuard was not functioning and I heard it wasn't working probably weeks before that. I can't tell you the exact date but I had known it wasn't working. RN-C stated, The night before he got out I was working and I don't believe it was working. I don't know if it was reported. It was reported so many times I think I just gave up on it. Review of facility policy titled, Elopement revised 10/23/17, indicated all residents will be assessed for risk of wandering or elopement and if the resident is identified to be at risk for elopement interventions will be in place to prevent an elopement, and the nurse will enter these into the resident's care plan. Further review of policy indicated nursing will test the notification bracelet (WanderGuard) daily for proper signaling and damage to the bracelet. However, the policy lacked direction for staff if the WanderGuard bracelet is checked and is not functioning correctly and what they are supposed to implement to protect the resident from an elopement. The IJ which began on 12/1/21, was removed on 12/16/21, at 1:46 p.m. after the facility successfully implemented a removal plan which included the following: - All resident's requiring a WanderGuard were reviewed and checked for functioning - Audits on WanderGuard supply - Modified charting procedure to include the functional status in the resident's treatment record - Updated elopement policy - Updated maltreatment policy to include steps to take when a WanderGuard is not functioning and - All staff/ nurses were to review both policies prior to working next shift; but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on interview and document review, the facility failed to notify the primary physician regarding the development of a newly formed wound and obtain treatment of [REDACTED]. This resulted in actual harm when R1's wound had deteriorated to a necrotic (dead tissue) state, required emergency intervention and hospitalization . In addition, the facility failed to assess, provide and document treatment of [REDACTED]. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated he had intact cognition and required extensive assistance from staff for bed mobility, transfers and toileting. The MDS indicated R1 was frequently incontinent of bowel and bladder. R1's MDS identified he was at high risk for pressure ulcer development, however, did not have an active pressure ulcer present. The MDS indicated R1's [DIAGNOSES REDACTED]. R1's care plan dated 4/17/20, identified R1 as cognitively intact and able to express his needs. R1 required assistance with bed mobility, transfers, dressing, grooming, and toileting, was unable to ambulate, was occasionally incontinent of bladder and used incontinence briefs or pads to manage with assistance. The care plan indicated an ulcer was identified on his buttock and directed staff to encourage fluid intake, keep clean and dry, observe skin for signs of redness, blistering, shearing, blanching and skin tears, use pressure reducing cushion in wheelchair and on bed and to reposition every two hours and as needed (prn). On 5/15/20, the care plan identified an open area to R1's left heel, with a goal to be healed within next 90 days. The care plan directed staff to observe weekly and prn, turn and reposition every two hours and prn, treatment as indicated and to float heels when in bed. Buttocks wound A progress note (PN) dated 3/31/20, indicated R1 had an open area on his right gluteal cleft with orders to wash with soap and water, to apply a sacral [MEDICATION NAME] dressing and to change every three days. Review of R1's April and May 2020 treatment record lacked staff direction to care for R1's open area to his right gluteal cleft. Review of R1's PN's for the month of April 2020 lacked documentation related to R1's open area to his right gluteal cleft, that was identified in progress note dated 3/31/20. A nurses's observation note dated 4/6/20, indicated R1's Braden Scale for Predicting Pressure Sore Risk indicated R1 was at risk for skin breakdown. Observations of the area on buttock were described as a cyst like area that was present on admission. R1's medical record lacked documentation of a skin assessment. Heel wound -R1's PN dated 5/9/20, with an entered date of 5/11/20, indicated R1 had a blister that popped on his heel, leaving an open area the size of a silver dollar. Skin prep was applied and the wound was covered with a dressing. -Wound progression noted dated 5/15/20, indicated a new, first recording, of a pressure ulcer to R1's left heel. The note indicated R1 frequently rested pressure on his heel and had been educated to keep the heel elevated and to not rest on it. Documented wound measurements: 2.0 centimeters (cm) x 3.0 cm with eschar (dead or necrotic tissue) present. -PN dated 5/17/20, indicated skin breakdown noted to R1's left heel. Area was cleansed and covered with a dressing. A pillow was placed under his heel to float and keep off the mattress. The note indicated R1 complained his tailbone was sore. The nurse assessed area and applied a dressing to the area per R1's request, however, no open area was identified. -PN dated 5/20/20, indicated R1 complained of pain in his heel and rated it a three on a scale of one to 10 (10 worst pain). -Wound progression note dated 5/22/20, indicated frequently rested pressure on his heel and had been educated to keep it elevated and to not rest on it. R1 was encouraged not to wear shoes. The wound measured 2.0 cm x 2.0 cm and contained slough (dead skin tissue that may have a yellow or white appearance) and [MEDICATION NAME] tissue (tissue regeneration) with slight drainage. -PN dated 5/23/20, indicated R1 complained of pain in his heel and rated it a three on a scale of one to ten. -PN dated 5/25/20, indicated a fax was sent to R1's physician regarding R1's wounds to his coccyx and left heel, 16 days after identification. The physician responded to schedule an appointment with a wound specialist. -PN dated 5/26/20, indicated when R1's dressing was changed on his left heel he complained of pain with light touch along the back of his left lower leg. R1 voiced concerns about his open areas and was asking to see a wound doctor. -PN dated 5/27/20, referred to a call from R1's family member asking if R1 had an appointment to have his heel and coccyx checked. The family member had been informed R1 would be seeing a physician that day. -Wound progression noted dated 5/27/20, indicated the wound bed was dark red in color and moist with a 0.4 cm white circle of skin encircling the wound. The dressing was moderately saturated and exudate (drainage) on the dressing when removed, was almost black and malodorous. A small amount of thick white exudate was removed from the wound bed. -PN dated 5/27/20, referred to a call from the emergency room . The emergency room nurse informed the facility that R1 would be transferring to another hospital for his left heel due to his [DIAGNOSES REDACTED]. Although R1's 3/31/20, PN identified a right gluteal cleft open area with subsequent orders to wash with soap and water, apply a sacral [MEDICATION NAME] dressing and to change the dressing every three days, R1's wound progression notes lacked documented evidence of R1 having a buttock wound, monitoring and treatment. Review of R1's medication record for May 2020, revealed there were no treatment orders for R1's wounds on his heel or his buttocks. Review of R1's treatment record for May 2020, directed staff to check R1's blood sugars four times per day, check vital signs daily, draw lab one time per day for [MEDICATION NAME] (blood clotting) time on indicated ordered dates, administer R1's insulin, administer R1's nebulizer treatments, bladder scan when indicated, change nebulizer tubing, and run control for blood sugar machine one day monthly. However, the treatment record lacked any direction or indication to monitor or treat R1's wounds on his heel or his buttock. Review of R1's physicians orders lacked any indication of physician involvement related to R1's wounds, as well as any treatment orders for R1's wounds even though a wound of R1's buttocks was identified on the care plan on 4/17/20, and a wound on R1's heel was identified on 5/9/20. Review of R1's physician office visit progress note, dated 5/27/20, indicated R1 had a necrotic wound on his left heel. R1's wound was documented as a large necrotic area along the medial calcaneus (back of heel) that was malodorous (unpleaseant smelling), non-tender to palpation. The wound measured four by five cm. Because of his comorbidities and the need for [MEDICAL TREATMENT], possibly vascular consultation and wound debridement, the emergency room accepted the patient with the goal of transferring him to a higher level of care. Review of R1's emergency room note dated 5/27/20, indicated R1's [DIAGNOSES REDACTED]. R1 was stabilized and transferred to another facility. On 6/4/20 at 9:00 a.m. certified nursing assistant(CNA)-A stated she had seen R1's ulcer on his left heel. She stated she thought it had started out as real small spot and then grew. CNA-A stated when she saw R1's heel it was black in color. On 6/4/20 at 9:15 a.m. registered nurse (RN)-A stated R1 had gotten a blister on his heel. She stated the top layer had peeled off but the area was dry. RN-A stated she looked at it the next week and then over the weekend it fell apart and he was needing to be seen, so they sent him in. She stated R1 went to urgent care after his [MEDICAL TREATMENT] because they felt he could not wait for a wound specialist appointment. RN-A stated the facility had a policy that the physician was to be contacted regarding wounds and decubiti but did not specify who was to contact the physician. RN-A verified R1's primary physician should have been contacted when the wound was first discovered. On 6/4/20 at 9:52 a.m. the director of nursing (DON) stated there had been a break in communication. R1 had a blister and it had not been communicated to everybody, and in fact, she had been unaware of it. DON stated the physician should have been notified with the first assessment of the open area. The DON verified there was no treatment ordered for the care of R1's wound and R1's treatment record lacked any information related to R1's skin care, treatment or interventions. The facility's Skin Ulcer Protocol policy, dated 11-1-15, indicated residents would receive appropriate care and services to prevent, treat, and monitor progress of all healing ulcers. The policy directed staff to report all open skin areas to the facility wound nurse. The staff were to provide wound cares as indicated by facility wound care guidelines, wound care nurse recommendations and physician orders. The policy further indicated wound care protocol was the physician must be notified of all stage two to stage four wounds, significant changes and non healing wounds. The policy directed staff when considering implementation of the wound care protocols, ensure an appropriate assessment and individualized interventions are in place. Update resident/family and obtain appropriate physician orders. The facility's Significant Change policy, with a revised date 1/7/19, directs staff to immediately inform the resident, consult with the physician and notify the resident's representative, when the resident has a significant change. The policy defined a significant change as a change in a residents status, a need to alter treatment, an accident that results in injury, or a decision to transfer or discharge an individual.

Based on observation, interview and document review, the facility failed to ensure pain medication was available to be administered as prescribed for 1 of 1 resident (R50) with chronic pain and whose narcotic pain medication was not refilled timely resulting in nine consecutive missed doses. This failure resulted in actual harm due to R50 experiencing increased pain, anxiety, and [MEDICAL CONDITION]. Findings include: R50's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R50's [DIAGNOSES REDACTED]. The MDS also indicated R50 had intact cognition, experienced frequent pain which made it hard to sleep and limited day to day activities. R50 required scheduled and as needed (PRN) medication. R50 rated the pain as a 7 out of 10 (with 10 being the most severe) pain level. R50's Physician orders [REDACTED]. [MEDICATION NAME] HCL (a narcotic used to relieve severe pain) 5 milligrams (mg) by mouth TID (three times a day) at 8 a.m., 2 p.m., and 8 p.m. [MEDICATION NAME] extended release 650 mg - 1 tablet two times per day (BID) at 6 a.m. and 8 p.m. [MEDICATION NAME] 650 mg every four hours PRN. The Sanford Telephone Encounter form dated 10/27/18, at 9:51 a.m. revealed a nurse from the facility had attempted to obtain a refill of R50's [MEDICATION NAME]. The telephone encounter indicated the nurse had contacted MD-2, the on-call provider for the nursing home this weekend and he was not willing to write a prescription for R50's [MEDICATION NAME] refill and advised that R50 be seen in the emergency room in order to obtain the prescription. However, the facility nurse stated she did not have a way to get R50 to the emergency room . R50's Progress Note written on 10/27/18, at 11:06 p.m. indicated when the author of the note had started her shift at 6:30 a.m., it was passed on to her in report that R50 was out of his scheduled pain medication: [MEDICATION NAME]. The treatment nurse called the pharmacy in which the pharmacist stated they did not have a current prescription for the medication refill. The treatment nurse had then called the on-call MD-2 who stated he could not help due to R50 not being his patient. MD-1 (resident's MD) was unavailable for the weekend. MD-2 stated R50 would have to go to the emergency room /urgent care in order to obtain/receive the medication. Resident refused. Nothing can be done until Monday. On 10/29/18, at 4:10 p.m. licensed practical nurse (LPN)-A verified R50's [MEDICATION NAME] 5 mg TID order per the electronic Medication Administration Record [REDACTED]. He had missed nine doses total up to this time. On 10/29/18, at 4:12 p.m. R50 stated he was not good as the facility had run out of his pain medication and he had not slept for 48 hours straight, and could not complete his physical therapy because of pain. R50 stated the staff told him he could have gone to the emergency room /urgent care on Saturday in order to get pain medicaiton however, he did not go because the staff told him they'd been working on getting his medication. R50 stated he had seen MD-1 at 9:30 a.m. this morning, and MD-1 had stated he had not been notified by either the facility, or the pharmacy, that a new prescription for the [MEDICATION NAME] was needed in order to refill it. R50 stated this same thing had happened 2-3 months ago with his [MEDICATION NAME] medication (antianxiety). On 10/29/18, at 4:30 p.m. registered nurse (RN)-A stated it was her understanding the pharmacy and the facility staff had been trying to contact MD-1 in order to obtain an updated prescription. RN-A confirmed R50 had been taken to see MD-1 this morning and verified it had taken until now (4:30 p.m.), to get the [MEDICATION NAME] prescription to the facility. RN-A stated R50 had been offered [MEDICATION NAME] over the weekend and was not aware of any cold turkey (abruptly stopping medication) effects regarding [MEDICATION NAME] use therefore the staff were not monitoring for any of these concerns, other than pain. On 10/29/18, at 4:45 p.m. LPN-A stated the [MEDICATION NAME] medication card, which held R50's individual tablets, had a peel off label which was to be peeled off and faxed to the pharmacy for refill seven days prior to the medication running out. A fax confirmation of nursing home re-order received on 10/30/18, confirmed the [MEDICATION NAME] refill for R50 had been sent to the pharmacy on 10/18/18. On 10/29/18, at 4:45 p.m. the director of nursing (DON) verified she was not aware of any side effects related to the abrupt discontinuation of [MEDICATION NAME]. On 10/29/18, at 4:55 p.m. R50 stated the staff had not made it clear to him that if he chose not to go to the ER he wouldn't have the [MEDICATION NAME] available until Monday. R50 stated the staff assured him they were working on getting the medication filled which was why he did not go to the emergency room /urgent care. On 10/30/18, at 8:09 a.m. the DON stated R50 was on the lowest dose of [MEDICATION NAME] and he would have let the staff know if he was experiencing any withdrawal symptoms. The DON could not provide any documentation/evidence that potential withdrawal symptoms for monitoring had been communicated to staff or R50. On 10/30/18, at 8:30 a.m. the pharmacist was interviewed by telephone. The Thrifty White pharmacist stated he had originally received a request from the nursing home to refill R50's [MEDICATION NAME] on 10/18/18, and a fax had been sent to the prescribing MD on 10/18/18, 10/26/18, & 10/29/18, requesting a prescription to refill the medication. The pharmacist stated he would be very concerned with withdrawal symptoms for a person who abruptly stopped taking [MEDICATION NAME] because the symptoms could be very serious and harmful to the person. When asked, the pharmacist confirmed R50's increased anxiety, uncontrolled pain, and [MEDICAL CONDITION] could have been caused and exacerbated by the abrupt withdrawal of the [MEDICATION NAME]. On 10/30/18, at 9:05 a.m. R50 stated he had lower back pain and the [MEDICATION NAME] helped relieve the pain. R50 stated on the weekend he did not think he was going to make it because the pain was so bad. R50 said he had not slept Saturday or Sunday and was awake for 48 hours straight. R50 stated the staff kept telling him they were calling about getting his [MEDICATION NAME] filled and acknowledged they had given him Tylenol but stated that did not help with the pain. R50 stated even though he had asked many, many times, the staff did not attempt to get him anything else for the pain because they said they could not get anything. R50 said, What if I was dying, do I just die in pain? It made me feel sad and angry. R50 stated he had asked for an extra [MEDICATION NAME] to help him sleep and the staff informed him they did not have an order to give him an extra dose. Again R50 verfied the staff had not told him that if he didn't go to the emergency room , he wouldn't have the [MEDICATION NAME] until Monday. When asked, R50 stated the staff had not informed him of the potential [MEDICATION NAME] withdrawal symptoms to watch for but he thought his increased anxiety and inability to sleep for 48 hours could have been due to the abrupt discontinuation of the medication. R50 stated he had received two doses of [MEDICATION NAME] yesterday (10/29/18) and was able to sleep last night. He said when he'd asked for his third dose at 3 a.m. today he was told he could not have it until 7:00 a.m R50 then stated he had asked for his [MEDICATION NAME] at 7:30 a.m. today but did not get it until 9 a.m. At this time, R50 rated his pain at a 7 out of 10 on the pain scale. On 10/30/18, at 9:25 a.m. LPN-B confirmed R50 had received his [MEDICATION NAME] at 8:47 a.m. that morning, and verified she had not asked him to rate his pain at that time. LPN-B stated the staff only asked/assessed for the resident pain rate when administering PRN medications. Review of the E-Mar indicated R50 received [MEDICATION NAME] 650 mg as follows: - 10/27/18 at 1:22 p.m. for pain due to being out of [MEDICATION NAME] - 10/27/18 at 5:22 p.m. for pain 7/10 - 10/28/18 at 12:56 a.m. for pain 7/10 affecting sleep - 10/28/18 at 8:32 a.m. for pain 5/10 - 10/29/18 at 12 midnight for pain 7/10 affecting sleep R50's Physician's Progress note dated 10/29/18, indicated patient here for follow-up on chronic pain - back pain. Has been on [MEDICATION NAME] for the last few months. Patient has been out of his [MEDICATION NAME] and requested the medication be restarted. [MEDICATION NAME] refilled for the patient. An Appointment Transfer Sheet note dated 10/30/18, with pain management MD-3, indicated: increased pain without [MEDICATION NAME], could not function or sleep. Will resume [MEDICATION NAME], narcotic contract. Ordered [MEDICATION NAME] 5 mg TID and [MEDICATION NAME] 50 mg one tablet every 12 hours PRN for breakthrough pain. On 10/30/18, at 8:45 a.m. a call was made to MD-1, and a message was left. Progress notes for R50 reviewed from 10/18/18, to present were absent of any notations (except above on 10/27/18) regarding R50 being without [MEDICATION NAME] and what the facility did to obtain pain medication/relief. No evidence was available to indicate whether the facility had made a request for additional medications that could have been helpful during the time R50 was without his [MEDICATION NAME], or to identify whether R50 had been educated on withdrawal symptoms that could occur that he should report to staff. Review of the facility's Medication Policy reviewed/amended 1/2016, indicated the night nurse was to go through the medication carts and reorder as needed for Narcotics. This is scheduled every Sunday and Thursday. Review of the facility's undated Pain Management Policy indicated: .residents receiving pain management interventions would be monitored for pain levels on a scheduled basis, and/or PRN, using the appropriate scale. - any residents routinely receiving a scheduled or PRN [MEDICATION NAME] would be reassessed for appropriateness and effectiveness at periodic intervals. Potential adverse consequences associated with medications would be monitored and addressed. - the physician would be notified when pain persists or reoccurs despite treatment or if suspected adverse consequences are noted. Attempts to reach MD-1 during the survey were unsuccessful. Upon completion of the survey on 11/1/18, at 1:15 p.m. MD-1 returned a phone call. When asked, MD-1 verified absolutely that R50 could have experienced withdrawal symptoms by not being provided his ordered [MEDICATION NAME] for nine doses. MD-1 stated that R50's uncontrolled pain, increased anxiety and [MEDICAL CONDITION] could all have been withdrawal symptoms. Further, MD-1 also stated in the past 17 days, his office had not been contacted by either the nursing home facility or the pharmacy requesting a re-fill of R50's [MEDICATION NAME]. MD-1 stated his personal policy for re-filling medications was within 24-48 hours of being contacted. MD-1 stated this was an unfortunate incident that should not have happened to R50. .

Based on observation, interview and document review, the facility failed to ensure the physician was notified timely of a change in condition related to increased verbal and non-verbal expressions of severe pain and behaviors for 1 of 1 resident (R5) who sustained a [MEDICAL CONDITION]. This failure resulted in actual harm for R5 whose treatment of [REDACTED]. Findings include: R5's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R5 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS indicated R5 required extensive assistance with activities of daily living (ADL), was non-ambulatory, and had no functional limitations in range of motion of her upper or lower extremities. The MDS further indicated [REDACTED]. R5's Pain Care Area Assessment (CAA) dated 8/21/18, indicated R5 had no noticeable signs of pain noted no facial grimacing, moaning, calling out or restlessness. R5 denied pain upon interview. The CAA indicated R5 had been diagnosed with [REDACTED]. Staff stated R5 sometimes complained of pain when repositioned or during dressing changes to her right heel. Staff also indicated R5 had no complaints of pain when seated in a Geri chair (large padded chair with wheeled base). Non-pharmacological interventions for pain included: warm/cool pack and repositioning. Goal for pain management was not to have pain which had been met and R5 was able to enjoy activities. R5's Care Plan reviewed 6/13/18, indicated R5 was able to express her needs and occasionally expressed pain. The Care Plan directed staff to provide medications as ordered and observe for signs and symptoms of discomfort and treat and update provider as necessary. The Care Plan also indicated R5 was at risk for fall or injury related to cognitive deficits and directed staff to provide pain assessment and monitoring. The Care Plan further indicated R5 had behaviors which included calling out/disruptive noises, spitting out medications and refusing cares. The Care Plan directed staff to implement interventions which included: --ask if there was anything needed/reason for calling out/disruptive noises --attempt to meet R5's needs when calling out/disruptive noises --monitor frequency of calling out/disruptive noises --report all behaviors to the nurse to chart --update physician as needed for behavior changes. The Care Plan was updated 8/10/18, to indicate R5 had decreased mobility related to a non-surgical [MEDICAL CONDITION] femur head and directed staff to assist as needed with mobility. On 8/29/18, at 8:34 a.m. R5 was observed dressed and seated in a Geri chair in the dining room for breakfast. Staff observed to ask preferences for breakfast meal. R5 exhibited no verbal or non-verbal indicators of pain. --At 12:11 p.m. R5 was seated in a Geri chair in dining room eating the noon meal with assistance from nursing assistant (NA)-L. R5 exhibited no verbal or non-verbal indicators of pain. --At 2:23 p.m. R5 was observed resting in bed with the lights off. R5 was positioned on her right side. No verbal or non-verbal indicators of pain observed. On 8/30/18, at 7:11 a.m. R5 was observed resting quietly in bed, positioned on her left side. --At 7:13 a.m. NA-M entered R5's room and greeted R5. NA-M checked R5's incontinent brief, then assisted R5 to roll onto her back and NA-M lowered her pants and removed the brief. NA-M provided perineal care and provided cues and assistance for R5 to roll back again after assisting R5 to don a clean brief. Registered Nurse (RN)-A entered the room with mechanical lift and RN-A and NA-M transferred R5 to the Geri chair with the use of the lift. NA-M wheeled R5 into the bathroom, set up and provided cues for R5 to brush her teeth, comb her hair and wash her hands. R5 tolerated the cares and transfer well and did not express verbal or non-verbal signs of pain. Review of R5's medical record revealed the following events and progression of verbal and non-verbal expressions of pain exhibited by R5: --7/16/18, progress note (PN): R5 transferred to emergency room (ER) at 10:30 p.m. for evaluation. --7/16/18, -7/17/18, ED (emergency department) note: diagnosed with [REDACTED]. Lab order identified urine collection was via straight catheter. --7/17/18, PN at 2:37 a.m. returned from ER at 1:10 a.m --7/17/18, PN at 7:52 a.m. Fax communication sent to primary care physician (PCP) updating that R5 was sent to ER last evening returned [DIAGNOSES REDACTED]. --7/17/18, PN at 2:15 p.m. transferred to urgent care at approximately 12:30 p.m --7/17/18, Urgent Care Note: transferred to urgent care at 12:30 p.m. for fatigue, somnolence and elevated blood sugar. --7/17/18, PN at 3:37 p.m. returned to facility from ER visit. New orders [MEDICATION NAME](antibiotic) 500 mg twice daily for 7 days. [MEDICATION NAME] (insulin) subcutaneous sliding scale, BMP (basic metabolic panel) (laboratory testing) and CBC (complete blood count) (laboratory testing) (MONTH) (sic) 20th, (YEAR). Will update primary healthcare provider. --7/17/18, PN at 6:46 p.m. Resident has been complaining of left leg pain. R5 also had a fever of 100.8 and was given Tylenol. --7/19/18, at 2:03 p.m. PN: R5 complained of continuous right hip pain with gradual onset which has affected mobility. R5 hollered and moaned with movement and was given two Tylenol. --7/19/18, PN at 8:59 p.m. pain control unrelieved by medication. --7/19/18, PN at 9:00 p.m. resident verbalized knee pain. --7/20/18, at 12:19 p.m. PN: verbalized hip pain. --7/21/18, PN at 7:54 a.m. R5 developed a fluid filled blister to the right heel and the physician (MD) was notified via fax. --7/21/18, PN at 1:50 p.m. MD in to the facility to see R5's right heel blister and recommended referral to Podiatry. MD was not notified of new onset of pain and right hip pain was not addressed. --7/22/18, PN at 4:25 p.m. verbalized hip pain, repositioned for comfort. --7/24/18, PN at 1:18 p.m. hip pain rated 9/10 (0 being no pain at all and 10 being the worst pain), screaming, moaning. --7/25/18, PN at 1:23 p.m. hip pain rated 6/10, screaming, grimacing, and moaning. --7/25/18, PN at 9:39 p.m. verbalized acute hip/leg pain rated 8/10. --7/26/18, PN at 3:53 p.m. received orders from Podiatrist for right heel ulcer. --7/27/18, PN at 6:49 p.m. back pain rated 5/10, unrelieved at 9:43 p.m --7/30/18, PN at 12:43 p.m. verbalized acute back pain/ache rated 6/10. --7/30/18, Nursing Home Note: R5 seen by MD for routine visit. (However, MD was not notified of right hip pain and pain was not addressed). --8/1/18, Nurse Communication to Physician Order: Situation/Background: R5 has been having right hip pain on and off for approximately 2 weeks. No injury. Unable to schedule appointment with you for 2 weeks. Would you like her to be seen in urgent care or can you fit her in? Physician/Provider Response: MD-A indicated: Please remind staff that this should be mentioned when I round. I saw her twice during the last couple weeks and this was not mentioned. I have openings next week or she can be seen in same day care. --8/1/18, PN at 8:34 a.m. R5 continued to complain of right hip pain with no injury. Appointment scheduled for 8/3/18 with PCP. Notified daughter, she is unable to attend appointment. --8/2/18, PN at 2:40 p.m. hip pain rated 6/10, moaning. --8/3/18, PN at 10:52 p.m. leg pain rated 5/10. --8/6/18, PN at 2:34 p.m. hip pain. --8/6/18, PN at 10:52 p.m. hip and foot pain rated 7/10, restless, agitation, anxiety, screaming, grimacing, guarding or protecting body parts. Interventions included: worked with relaxation techniques, heat application given, repositioned for comfort. Pain unrelieved at 2:14 a.m. --8/7/18, PN at 7:31 a.m. hip pain, grimacing. --8/7/18, PN at 2:50 p.m. hip pain, restlessness, anxiety, withdrawal, screaming. --8/8/18, PN at 11:15 a.m. She has been having right hip pain and has been receiving PRN Tylenol for pain control. Spoke with daughter about keeping her scheduled appointment for 8/14/18 or being seen sooner. She agreed she could be seen in Same Day Care on 8/10/18 and she will meet at the clinic. --8/8/18, PN at 12:57 p.m. hip pain rated 7/10. --8/8/18, PN at 5:55 p.m. hip pain rated 8/10. --8/9/18, PN at 12:19 a.m. continuous hip, foot, and leg pain, limits mobility, change in mood, change in behavior, [MEDICAL CONDITION]. Restlessness, anxiety, screaming and moaning. Two Tylenol given for complaint of pain in left hip and legs/feet. Resident was repositioned in bed and legs/feet were elevated due to increased [MEDICAL CONDITION]. Music is turned on in room for distraction. Lights reduced to a minimum to promote sleep. --8/9/18, PN at 6:57 a.m. hip pain rated 7/10. --8/9/18, PN at 1:44 p.m. hip pain rated 6/10. --8/10/18, PN at 7:52 a.m. hip pain rated 7/10, screaming, moaning. --8/10/18, PN at 8:00 a.m. transported to urgent care for intermittent right hip pain at this time. R5's Office Visit note dated 8/10/18, indicated R5 had been having problems with pain in her hip. Nobody was quite sure when it had begun. R5 complained of pain to right hip with movement but had no pain when not moved. X-rays were reviewed and R5 was noted to have osteopenia (condition in which bone mineral density is lower than normal) present and was noted to have a subcapital displaced femoral neck (extending through the junction of the head and neck of femur) fracture. The fracture margins were rounded and [MEDICATION NAME], suggestive that several weeks had passed since R5's fracture occurred. The physician's impression was subacute to possible chronic femoral neck fracture of right hip. The recommendation was non-surgical treatment. R5's electronic Medication Administration Record [REDACTED]. No other orders for pain medication were available until 8/10/18, when the [MEDICATION NAME] order was changed to 1000 mg 3 times daily for fracture of neck of right femur and a new order for [MEDICATION NAME] 50 mg PRN 3 times daily for fracture of part of neck of right femur was added. R5's medical record revealed the following trend in R5's use of PRN [MEDICATION NAME]. 7/1/18 to 7/15/18: 1 time 7/16/18 to 7/31/18: 13 times 8/1/18 to 8/10/18: 12 times R5's Mood & Behavior - Incident Based report dated 7/1/18 to 8/31/18, indicated R5 exhibited such behaviors as verbal and physical aggression, yelling, [MEDICAL CONDITION], anxious complaints, repetitive verbalizations, and unpleasant mood. The report revealed the following trend in R5's behaviors: --7/1 to 7/15: 11 instances of behaviors --7/16 to 7/31: 11 instances of behaviors --8/1 to 8/15: 24 instances of behaviors --8/16 to 8/31: 9 instances of behaviors R5's record lacked a comprehensive assessment of R5's increased pain and behaviors to triage the immediacy of need for intervention and treatment. On 8/30/18, at 1:51 p.m. licensed practical nurse (LPN)-A stated R5 went through phases of being extremely tired, to hollering out, to periods of contentment. LPN-A indicated she was not aware of R5's [MEDICAL CONDITION]. LPN-A stated they had increased R5's Tylenol lately and she seemed better. LPN-A indicated R5 used to be awake at night and more restless during the day but she seemed to be better with pain. LPN-A also stated R5 was not really able to express her pain so they looked for pain indicators such as restlessness, yelling out, grimacing and not sleeping at night. --At 1:57 p.m. nursing assistant (NA)-M stated R5 had been about the same as before before they identified her [MEDICAL CONDITION]. NA-M stated R5 seemed content and happy now. NA-M indicated she could not speak to how R5 was right before the [MEDICAL CONDITION] was identified and stated she had not noticed any major differences. --At 2:01 p.m. NA-N and NA-L stated R5 did more hollering in the evening and sometimes in the early morning. NA-L indicated she also worked as a trained medication assistant (TMA) and stated R5 had complained of hip pain and could tell them the hip was hurting before the fracture was identified. NA-L indicated they tried non-pharmacological interventions for pain and she had been receiving Tylenol, which seemed to help. NA-L stated the hip pain had been something new R5 had not complained of before. --At 2:06 p.m. registered nurse (RN)-A confirmed R5 had an emergency room (ER) visit on 7/17/18 for a urinary tract infection and also had been seen in urgent care for high blood pressure on that date. RN-A confirmed R5 had complained of leg pain on 7/17/18, and had first complained of right hip pain on 7/19/18. RN-A verified R5 then developed a blister on her right heel on 7/21/18 and had been seen by MD-A on that date. RN-A confirmed MD-A had not addressed R5's right hip pain at that time. RN-A verified MD-A had again seen R5 on 7/30 but had not addressed the hip pain. RN-A stated they had made an appointment for R5 to be seen on 8/3/18, however the daughter was unable to attend and the appointment was rescheduled for 8/13/18. RN-A indicated they had been able to get an earlier appointment and R5 was seen on 8/10/18. RN-A indicated there was no documentation of an injury or accident for R5. --at 2:51 p.m. the director of nursing (DON) clarified R5's 8/3/18 appointment had been canceled by MD-A. DON verified R5 had experienced no accidents or injuries. DON stated R5's pain had been intermittent and the only time she had expressed pain was when she had been laying in bed. DON stated they would give R5 Tylenol and get her up and she would be content. DON stated as the pain had not been consistent, she could understand why the nurses on duty had not informed MD-A of R5's pain when MD-A had been at the facility. DON indicated they had been trying to get R5 an appointment due to the change in her condition however, verified there was no documentation of a nursing assessment of the change. DON stated they had been allowing MD-A to make the assessment as that was what MD-A preferred. DON stated they notified MD-A of the change and waited for her to make the assessment. DON verified they notified MD-A of the change on 8/1/18 and R5 was seen on 8/10/18. On 8/31/18, at 10:28 a.m. MD-A stated she had been a little annoyed R5's right hip pain had not been brought to her attention as she had been in the facility to see R5 twice prior to having been notified. MD-A stated it was a strange response to defer the assessment to her and indicated she would not have expected an orthopedic assessment but an RN assessment would have been helpful. MD-A stated she would have like to have known about R5's pain sooner. MD-A stated even though it would not have necessarily have changed her care, as R5 was not a surgical candidate, pain medication may have been needed. MD-A stated the communication should have been better. --At 10:39 a.m. NA-E stated if a resident had a change she would communicate to the nurse and fill out a Stop and Watch form. NA-E indicated these forms were for communicating issues to staff so they would be aware. NA-E indicated the forms were given to the nurses who included the identified concern in report. NA-E provided a Stop and Watch Early Warning Tool which indicated: identified changes while caring for or observing a resident should be circled and the nurse should be notified as soon as possible. The form included areas to document resident name, staff name, reported to with date and time, nurse response with date and time and nurse name. Areas of concern included: -S: Seems different than usual -T: Talks or communicates less -O: Overall needs more help -P: Pain: new or worsening; participated less in activities -a: Ate less -n: No bowel movement in 2 days; or diarrhea -d: Drank less -W: Weight change -A: Agitated -T: Tired, weak, confused or drowsy -C: Change in skin color or condition -H: Help with walking, transferring, toileting more than usual --At 11:51 a.m. RN-B stated NAs would fill out Stop and Watch forms or communicate any new concerns directly with nurses and indicated the goal was the forms ultimately went to the RN for follow up. RN-B stated if he received information about new pain he would do a head to toe assessment of the resident and then ultimately see if they needed to be seen by a physician. --At 3:41 p.m. RN-C stated if she was notified of a change in a resident, she would assess the resident to see if further action was needed such as notify the physician or implement a nursing order. RN-C indicated most likely there should be something the nurse should be watching and let the MD know it is not clearing up and ask if there is something they would like done. The undated Pain Management Policy directed a comprehensive pain assessment would be completed by a registered nurse on admission, with each MDS assessment thereafter, and when any new pain is identified. The policy indicated pain would be considered the 5th vital sign, checked along with the other 4 standard vital signs (temperature, pulse, respirations and blood pressure). The policy also indicated the physician would be notified of pain levels indicated on the pain evaluation as appropriate. The physician would also be notified when pain persisted or reoccurred despite treatment if suspected adverse consequences were noted. The Notification of Physician/Family on a Condition Change policy dated 9/2017, directed to notify the physician and resident's responsible party in the event of a status change. The policy directed the physician was to be contacted immediately for any significant change in condition as assessed by a licensed nurse.

Based on observation, interview and document review, the facility failed to comprehensively assess a change in condition related to increased verbal and non-verbal expressions of severe pain and behaviors in order to determine the need for timely intervention and treatment for 1 of 1 resident (R5) who sustained an unexplained [MEDICAL CONDITION]. This resulted in actual harm for R5 whose treatment of [REDACTED]. Findings include: R5's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R5 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS indicated R5 required extensive assistance with activities of daily living (ADL), was non-ambulatory, and had no functional limitations in range of motion of her upper or lower extremities. The MDS further indicated [REDACTED]. R5's Pain Care Area Assessment (CAA) dated 8/21/18, indicated R5 had no noticeable signs of pain noted no facial grimacing, moaning, calling out or restlessness. R5 denied pain upon interview. The CAA indicated R5 had been diagnosed with [REDACTED]. Staff stated R5 sometimes complained of pain when repositioned or during dressing changes to her right heel. Staff also indicated R5 had no complaints of pain when seated in a Geri chair (large padded chair with wheeled base). Non-pharmacological interventions for pain included: warm/cool pack and repositioning. Goal for pain management was not to have pain which had been met and R5 was able to enjoy activities. R5's Care Plan reviewed 6/13/18, indicated R5 was able to express her needs and occasionally expressed pain. The Care Plan directed staff to provide medications as ordered and observe for signs and symptoms of discomfort and treat and update provider as necessary. The Care Plan also indicated R5 was at risk for fall or injury related to cognitive deficits and directed staff to provide pain assessment and monitoring. The Care Plan further indicated R5 had behaviors which included calling out/disruptive noises, spitting out medications and refusing cares. The Care Plan directed staff to implement interventions which included: --ask if there was anything needed/reason for calling out/disruptive noises --attempt to meet R5's needs when calling out/disruptive noises --monitor frequency of calling out/disruptive noises --report all behaviors to the nurse to chart --update physician as needed for behavior changes. The Care Plan was updated 8/10/18, to indicate R5 had decreased mobility related to a non-surgical [MEDICAL CONDITION] femur head and directed staff to assist as needed with mobility. On 8/29/18, at 8:34 a.m. R5 was observed dressed and seated in a Geri chair in the dining room for breakfast. Staff observed to ask preferences for breakfast meal. R5 exhibited no verbal or non-verbal indicators of pain. --At 12:11 p.m. R5 was seated in a Geri chair in dining room eating the noon meal with assistance from nursing assistant (NA)-L. R5 exhibited no verbal or non-verbal indicators of pain. --At 2:23 p.m. R5 was observed resting in bed with the lights off. R5 was positioned on her right side. No verbal or non-verbal indicators of pain observed. On 8/30/18, at 7:11 a.m. R5 was observed resting quietly in bed, positioned on her left side. --At 7:13 a.m. NA-M entered R5's room and greeted R5. NA-M checked R5's incontinent brief, then assisted R5 to roll onto her back and NA-M lowered her pants and removed the brief. NA-M provided perineal care and provided cues and assistance for R5 to roll back again after assisting R5 to don a clean brief. Registered Nurse (RN)-A entered the room with mechanical lift and RN-A and NA-M transferred R5 to the Geri chair with the use of the lift. NA-M wheeled R5 into the bathroom, set up and provided cues for R5 to brush her teeth, comb her hair and wash her hands. R5 tolerated the cares and transfer well and did not express verbal or non-verbal signs of pain. Review of R5's medical record revealed the following events and progression of verbal and non-verbal expressions of pain exhibited by R5: --7/16/18, progress note (PN): R5 transferred to emergency room (ER) at 10:30 p.m. for evaluation. --7/16/18, -7/17/18, ED (emergency department) note: diagnosed with [REDACTED]. Lab order identified urine collection was via straight catheter. --7/17/18, PN at 2:37 a.m. returned from ER at 1:10 a.m --7/17/18, PN at 7:52 a.m. Fax communication sent to primary care physician (PCP) updating that R5 was sent to ER last evening returned [DIAGNOSES REDACTED]. --7/17/18, PN at 2:15 p.m. transferred to urgent care at approximately 12:30 p.m --7/17/18, Urgent Care Note: transferred to urgent care at 12:30 p.m. for fatigue, somnolence and elevated blood sugar. --7/17/18, PN at 3:37 p.m. returned to facility from ER visit. New orders [MEDICATION NAME](antibiotic) 500 mg twice daily for 7 days. [MEDICATION NAME] (insulin) subcutaneous sliding scale, BMP (basic metabolic panel) (laboratory testing) and CBC (complete blood count) (laboratory testing) (MONTH) (sic) 20th, (YEAR). Will update primary healthcare provider. --7/17/18, PN at 6:46 p.m. Resident has been complaining of left leg pain. R5 also had a fever of 100.8 and was given Tylenol. --7/19/18, at 2:03 p.m. PN: R5 complained of continuous right hip pain with gradual onset which has affected mobility. R5 hollered and moaned with movement and was given two Tylenol. --7/19/18, PN at 8:59 p.m. pain control unrelieved by medication. --7/19/18, PN at 9:00 p.m. resident verbalized knee pain. --7/20/18, at 12:19 p.m. PN: verbalized hip pain. --7/21/18, PN at 7:54 a.m. R5 developed a fluid filled blister to the right heel and the physician (MD) was notified via fax. --7/21/18, PN at 1:50 p.m. MD in to the facility to see R5's right heel blister and recommended referral to Podiatry. MD was not notified of new onset of pain and right hip pain was not addressed. --7/22/18, PN at 4:25 p.m. verbalized hip pain, repositioned for comfort. --7/24/18, PN at 1:18 p.m. hip pain rated 9/10 (0 being no pain at all and 10 being the worst pain), screaming, moaning. --7/25/18, PN at 1:23 p.m. hip pain rated 6/10, screaming, grimacing, and moaning. --7/25/18, PN at 9:39 p.m. verbalized acute hip/leg pain rated 8/10. --7/26/18, PN at 3:53 p.m. received orders from Podiatrist for right heel ulcer. --7/27/18, PN at 6:49 p.m. back pain rated 5/10, unrelieved at 9:43 p.m --7/30/18, PN at 12:43 p.m. verbalized acute back pain/ache rated 6/10. --7/30/18, Nursing Home Note: R5 seen by MD for routine visit. (However, MD was not notified of right hip pain and pain was not addressed). --8/1/18, Nurse Communication to Physician Order: Situation/Background: R5 has been having right hip pain on and off for approximately 2 weeks. No injury. Unable to schedule appointment with you for 2 weeks. Would you like her to be seen in urgent care or can you fit her in? Physician/Provider Response: MD-A indicated: Please remind staff that this should be mentioned when I round. I saw her twice during the last couple weeks and this was not mentioned. I have openings next week or she can be seen in same day care. --8/1/18, PN at 8:34 a.m. R5 continued to complain of right hip pain with no injury. Appointment scheduled for 8/3/18 with PCP. Notified daughter, she is unable to attend appointment. --8/2/18, PN at 2:40 p.m. hip pain rated 6/10, moaning. --8/3/18, PN at 10:52 p.m. leg pain rated 5/10. --8/6/18, PN at 2:34 p.m. hip pain. --8/6/18, PN at 10:52 p.m. hip and foot pain rated 7/10, restless, agitation, anxiety, screaming, grimacing, guarding or protecting body parts. Interventions included: worked with relaxation techniques, heat application given, repositioned for comfort. Pain unrelieved at 2:14 a.m. --8/7/18, PN at 7:31 a.m. hip pain, grimacing. --8/7/18, PN at 2:50 p.m. hip pain, restlessness, anxiety, withdrawal, screaming. --8/8/18, PN at 11:15 a.m. She has been having right hip pain and has been receiving PRN Tylenol for pain control. Spoke with daughter about keeping her scheduled appointment for 8/14/18 or being seen sooner. She agreed she could be seen in Same Day Care on 8/10/18 and she will meet at the clinic. --8/8/18, PN at 12:57 p.m. hip pain rated 7/10. --8/8/18, PN at 5:55 p.m. hip pain rated 8/10. --8/9/18, PN at 12:19 a.m. continuous hip, foot, and leg pain, limits mobility, change in mood, change in behavior, [MEDICAL CONDITION]. Restlessness, anxiety, screaming and moaning. Two Tylenol given for complaint of pain in left hip and legs/feet. Resident was repositioned in bed and legs/feet were elevated due to increased [MEDICAL CONDITION]. Music is turned on in room for distraction. Lights reduced to a minimum to promote sleep. --8/9/18, PN at 6:57 a.m. hip pain rated 7/10. --8/9/18, PN at 1:44 p.m. hip pain rated 6/10. --8/10/18, PN at 7:52 a.m. hip pain rated 7/10, screaming, moaning. --8/10/18, PN at 8:00 a.m. transported to urgent care for intermittent right hip pain at this time. R5's Office Visit note dated 8/10/18, indicated R5 had been having problems with pain in her hip. Nobody was quite sure when it had begun. R5 complained of pain to right hip with movement but had no pain when not moved. X-rays were reviewed and R5 was noted to have osteopenia (condition in which bone mineral density is lower than normal) present and was noted to have a subcapital displaced femoral neck (extending through the junction of the head and neck of femur) fracture. The fracture margins were rounded and [MEDICATION NAME], suggestive that several weeks had passed since R5's fracture occurred. The physician's impression was subacute to possible chronic femoral neck fracture of right hip. The recommendation was non-surgical treatment. R5's electronic Medication Administration Record [REDACTED]. No other orders for pain medication were available until 8/10/18, when the [MEDICATION NAME] order was changed to 1000 mg 3 times daily for fracture of neck of right femur and a new order for [MEDICATION NAME] 50 mg PRN 3 times daily for fracture of part of neck of right femur was added. R5's medical record revealed the following trend in R5's use of PRN [MEDICATION NAME]. Documentation indicated the resident did not always obtain relief from the [MEDICATION NAME]. 7/1/18 to 7/15/18: 1 time 7/16/18 to 7/31/18: 13 times 8/1/18 to 8/10/18: 12 times R5's Mood & Behavior - Incident Based report dated 7/1/18 to 8/31/18, indicated R5 exhibited such behaviors as verbal and physical aggression, yelling, [MEDICAL CONDITION], anxious complaints, repetitive verbalizations, and unpleasant mood. The report revealed the following trend in R5's behaviors: --7/1 to 7/15: 11 instances of behaviors --7/16 to 7/31: 11 instances of behaviors --8/1 to 8/15: 24 instances of behaviors --8/16 to 8/31: 9 instances of behaviors R5's record lacked a comprehensive assessment of R5's increased pain and behaviors to triage the immediacy of need for intervention and treatment. On 8/30/18, at 1:51 p.m. licensed practical nurse (LPN)-A stated R5 went through phases of being extremely tired, to hollering out, to periods of contentment. LPN-A indicated she was not aware of R5's [MEDICAL CONDITION]. LPN-A stated they had increased R5's Tylenol lately and she seemed better. LPN-A indicated R5 used to be awake at night and more restless during the day but she seemed to be better with pain. LPN-A also stated R5 was not really able to express her pain so they looked for pain indicators such as restlessness, yelling out, grimacing and not sleeping at night. --At 1:57 p.m. nursing assistant (NA)-M stated R5 had been about the same as before before they identified her [MEDICAL CONDITION]. NA-M stated R5 seemed content and happy now. NA-M indicated she could not speak to how R5 was right before the [MEDICAL CONDITION] was identified and stated she had not noticed any major differences. --At 2:01 p.m. NA-N and NA-L stated R5 did more hollering in the evening and sometimes in the early morning. NA-L indicated she also worked as a trained medication assistant (TMA) and stated R5 had complained of hip pain and could tell them the hip was hurting before the fracture was identified. NA-L indicated they tried non-pharmacological interventions for pain and she had been receiving Tylenol, which seemed to help. NA-L stated the hip pain had been something new R5 had not complained of before. --At 2:06 p.m. registered nurse (RN)-A confirmed R5 had an emergency room (ER) visit on 7/17/18, for a urinary tract infection and also had been seen in urgent care for high blood pressure on that date. RN-A confirmed R5 had complained of leg pain on 7/17/18, and had first complained of right hip pain on 7/19/18. RN-A verified R5 then developed a blister on her right heel on 7/21/18, and had been seen by MD-A on that date. RN-A confirmed MD-A had not addressed R5's right hip pain at that time. RN-A verified MD-A had again seen R5 on 7/30/18, but had not addressed the hip pain. RN-A stated they had made an appointment for R5 to be seen on 8/3/18, however, the daughter was unable to attend and the appointment was rescheduled for 8/13/18. RN-A indicated they had been able to get an earlier appointment and R5 was seen on 8/10/18. RN-A indicated there was no documentation of an injury or accident for R5. --at 2:51 p.m. the director of nursing (DON) clarified R5's 8/3/18, appointment had been canceled by MD-A. DON verified R5 had experienced no accidents or injuries. DON stated R5's pain had been intermittent and the only time she had expressed pain was when she had been laying in bed. DON stated they would give R5 Tylenol and get her up and she would be content. DON stated as the pain had not been consistent, she could understand why the nurses on duty had not informed MD-A of R5's pain when MD-A had been at the facility. DON indicated they had been trying to get R5 an appointment due to the change in her condition, however, verified there was no documentation of a nursing assessment of the change. DON stated they had been allowing MD-A to make the assessment as that was what MD-A preferred. DON stated they notified MD-A of the change and waited for her to make the assessment. DON verified they notified MD-A of the change on 8/1/18 and R5 was seen on 8/10/18. On 8/31/18, at 10:28 a.m. MD-D stated she had been a little annoyed R5's right hip pain had not been brought to her attention as she had been in the facility to see R5 twice prior to having been notified. MD-A stated it was a strange response to defer the assessment to her and indicated she would not have expected an orthopedic assessment but an RN assessment would have been helpful. MD-A stated she would have like to have known about R5's pain sooner. MD-A stated even though it would not have necessarily have changed her care, as R5 was not a surgical candidate, pain medication may have been needed. MD-A stated the communication should have been better. --At 11:51 a.m. RN-B stated NAs would fill out Stop and Watch forms or communicate any new concerns directly with nurses and indicated the goal was the forms ultimately went to the RN for follow up. RN-B stated if he received information about new pain he would do a head to toe assessment of the resident and then ultimately see if they needed to be seen by a physician. --At 3:41 p.m. RN-C stated if she was notified of a change in a resident, she would assess the resident to see if further action was needed such as notify the physician or implement a nursing order. RN-C indicated most likely there should be something the nurse should be watching and let the MD know it is not clearing up and ask if there is something they would like done. The undated Pain Management Policy directed a comprehensive pain assessment would be completed by a registered nurse on admission, with each MDS assessment thereafter, and when any new pain is identified. The policy indicated pain would be considered the 5th vital sign, checked along with the other 4 standard vital signs (temperature, pulse, respirations and blood pressure). The policy also indicated the physician would be notified of pain levels indicated on the pain evaluation as appropriate. The physician would also be notified when pain persisted or reoccurred despite treatment if suspected adverse consequences were noted. The Notification of Physician/Family on a Condition Change policy dated 9/2017, directed to notify the physician and resident's responsible party in the event of a status change. The policy directed the physician was to be contacted immediately for any significant change in condition as assessed by a licensed nurse.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident reviewed for pain (R50) received a prescribed pain medication in order to ensure pain relief. This failure resulted in actual harm to R50 who due to an abrupt discontinuation of routinely scheduled pain medication, suffered increased pain, increased anxiety, and [MEDICAL CONDITION]. Findings include: R50's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R50's [DIAGNOSES REDACTED]. The MDS also indicated R50 had intact cognition, experienced frequent pain which made it hard to sleep and limited day to day activities. R50 required scheduled and as needed (PRN) medication. R50 rated the pain as a 7 out of 10 (with 10 being the most severe) pain level. R50's Pain Care Area Assessment (CAA) dated 2/13/18, indicated R50 stated he had always had chronic pain in his back which he rated a 7 out of 10. R50 stated the pain had kept him from sleeping at night and it also made it difficult to get out of bed and move around. R50 received [MEDICATION NAME] 10 milligrams (mg) three times per day (TID) and Tylenol PRN which he had used almost daily within the MDS reference period. R50's general nursing observation started on 7/31/18, and completed on 8/1/18, indicated R50 stated he always had chronic pain in his back and rated his pain within the last week at a 7 out of 10 on a 0-10 scale, with 10 being the worst. R50 stated the pain kept him from sleeping at night and it also made it difficult to get out of bed and move around. R50 received [MEDICATION NAME] 5 mg (TID), BioFreeze ointment and Tylenol PRN. He had Tylenol three times during the observation reference period. R50 stated the pain medications helped relieve his pain. R50's care plan provided on 10/30/18, indicated R50 had chronic pain related to disc degeneration, lumbar region. Goal: resident would remain comfortable from pain, daily. Approaches included: administer [MEDICATION NAME] per medical doctor (MD) orders, observe signs and symptoms of pain (grimacing, moaning, guarding) and report to MD as needed, use 0-10 pain scale to determine pain level and effectiveness of medication. R50's Physician orders [REDACTED]. [MEDICATION NAME] HCL (a narcotic used to relieve severe pain) 5 milligrams (mg) by mouth TID (three times a day) at 8 a.m., 2 p.m., and 8 p.m. [MEDICATION NAME] extended release 650 mg - 1 tablet two times per day (BID) at 6 a.m. and 8 p.m. [MEDICATION NAME] 650 mg every four hours PRN. The Sanford Telephone Encounter form dated 10/27/18, at 9:51 a.m. revealed a nurse from the facility had attempted to obtain a refill of R50's [MEDICATION NAME]. The telephone encounter indicated the nurse had contacted MD-2, the on-call provider for the nursing home this weekend and he was not willing to write a prescription for R50's [MEDICATION NAME] refill and advised that R50 be seen in the emergency room in order to obtain the prescription. However, the facility nurse stated she did not have a way to get R50 to the emergency room . R50's Progress Note written on 10/27/18, at 11:06 p.m. indicated when the author of the note had started her shift at 6:30 a.m., it was passed on to her in report that R50 was out of his scheduled pain medication: [MEDICATION NAME]. The treatment nurse called the pharmacy in which the pharmacist stated they did not have a current prescription for the medication refill. The treatment nurse had then called the on-call MD-2 who stated he could not help due to R50 not being his patient. MD-1 (resident's MD) was unavailable for the weekend. MD-2 stated R50 would have to go to the emergency room /urgent care in order to obtain/receive the medication. Resident refused. Nothing can be done until Monday. On 10/29/18, at 4:10 p.m. licensed practical nurse (LPN)-A verified R50's [MEDICATION NAME] 5 mg TID order per the electronic Medication Administration Record [REDACTED]. He had missed nine doses total up to this time. During interview with R50 at 4:12 p.m. on 10/29/18, R50 stated he was not good as the facility had run out of his pain medication and he had not slept for 48 hours straight, and could not complete his physical therapy because of pain. R50 also stated he had [MEDICAL CONDITIONS] from the Vietnam War. R50 stated the staff told him he could have gone to the emergency room /urgent care on Saturday in order to get pain medication however, he did not go because the staff had told him they had been working on getting his medication. R50 stated he had seen MD-1 at 9:30 a.m. this morning, and MD-1 had stated he had not been notified by either the facility, or the pharmacy, that a new prescription for the [MEDICATION NAME] was needed in order to refill it. During interview with registered nurse (RN)-A at 4:30 p.m. on 10/29/18, RN-A stated it was her understanding the pharmacy and the facility staff had been trying to contact MD-1 in order to obtain an updated prescription. RN-A confirmed R50 had been taken to see MD-1 this morning and verified it had taken until now (4:30 p.m.), to get the [MEDICATION NAME] prescription to the facility. RN-A stated R50 had been offered [MEDICATION NAME] over the weekend. LPN-A was interviewed at 4:45 p.m. on 10/29/18 and stated the [MEDICATION NAME] medication card, which held R50's individual tablets, had a peel off label which was to be peeled off and faxed to the pharmacy for refill seven days prior to the medication running out. A fax confirmation of nursing home re-order received on 10/30/18, confirmed the [MEDICATION NAME] refill for R50 had been sent to the pharmacy on 10/18/18. On 10/29/18, at 4:55 p.m. R50 stated the staff had not made it clear to him that if he chose not to go to the ER he wouldn't have the [MEDICATION NAME] available until Monday. R50 stated the staff assured him they were working on getting the medication filled which was why he did not go to the emergency room /urgent care. On 10/30/18, at 8:30 a.m. the pharmacist was interviewed by telephone. The Thrifty White pharmacist stated he had originally received a request from the nursing home to refill R50's [MEDICATION NAME] on 10/18/18, and a fax had been sent to the prescribing MD on 10/18/18, 10/26/18, & 10/29/18, requesting a prescription to refill the medication. On 10/30/18, at 9:05 a.m. R50 stated he had lower back pain and the [MEDICATION NAME] had helped relieve the pain. R50 stated on the weekend he did not think he was going to make it because the pain was so bad. R50 said he had not slept Saturday or Sunday and was awake for 48 hours straight. R50 stated the staff kept telling him they were calling about getting his [MEDICATION NAME] filled and acknowledged they had given him Tylenol but stated that did not help with the pain. R50 stated even though he had asked many, many times, the staff did not attempt to get him anything else for the pain because they said they could not get anything. R50 said, What if I was dying, do I just die in pain? It made me feel sad and angry. R50 stated he had asked for an extra [MEDICATION NAME] to help him sleep and the staff informed him they did not have an order to give him an extra dose. Again R50 verfied the staff had not told him that if he did not go to the emergency room , he would not have the [MEDICATION NAME] until Monday. R50 stated he had received two doses of [MEDICATION NAME] yesterday (10/29/18) and was able to sleep last night. He said when he had asked for his third dose at 3 a.m. today he was told he could not have it until 7:00 a.m R50 then stated he had asked for his [MEDICATION NAME] at 7:30 a.m. today but did not get it until 9 a.m. At this time, R50 rated his pain at a 7 out of 10 on the pain scale. On 10/30/18, at 9:25 a.m. LPN-B confirmed R50 had received his [MEDICATION NAME] at 8:47 a.m. that morning, and verified she had not asked him to rate his pain at that time. LPN-B stated the staff only asked/assessed for the resident pain rate when administering PRN medications. Review of the E-Mar indicated R50 received [MEDICATION NAME] 650 mg as follows: - 10/27/18 at 1:22 p.m. for pain due to being out of [MEDICATION NAME] - 10/27/18 at 5:22 p.m. for pain 7/10 - 10/28/18 at 12:56 a.m. for pain 7/10 affecting sleep - 10/28/18 at 8:32 a.m. for pain 5/10 - 10/29/18 at 12 midnight for pain 7/10 affecting sleep R50's Physician's Progress note dated 10/29/18, indicated patient here for follow-up on chronic pain - back pain. Has been on [MEDICATION NAME] for the last few months. Patient has been out of his [MEDICATION NAME] and requested the medication be restarted. [MEDICATION NAME] refilled for the patient. An Appointment Transfer Sheet note dated 10/30/18, with pain management MD-3, indicated: increased pain without [MEDICATION NAME], could not function or sleep. Will resume [MEDICATION NAME], narcotic contract. Ordered [MEDICATION NAME] 5 mg TID and [MEDICATION NAME] 50 mg one tablet every 12 hours PRN for breakthrough pain. On 10/30/18, at 8:45 a.m. a call was made to MD-1, and a message was left. Progress notes for R50 reviewed from 10/18/18, to present were absent of any notations (except above on 10/27/18) regarding R50 being without [MEDICATION NAME] and what the facility did to obtain pain medication/relief. No evidence was available to indicate whether the facility had made a request for additional medications that could have been helpful during the time R50 was without his [MEDICATION NAME] Review of the facility's Medication Policy reviewed/amended 1/2016, indicated the night nurse was to go through the medication carts and reorder as needed for Narcotics. This is scheduled every Sunday and Thursday. Review of the facility's undated Pain Management Policy indicated: .residents receiving pain management interventions would be monitored for pain levels on a scheduled basis, and/or PRN, using the appropriate scale. - any residents routinely receiving a scheduled or PRN [MEDICATION NAME] would be reassessed for appropriateness and effectiveness at periodic intervals. Potential adverse consequences associated with medications would be monitored and addressed. - the physician would be notified when pain persists or reoccurs despite treatment or if suspected adverse consequences are noted. Attempts to reach MD-1 during the survey were unsuccessful. Upon completion of the survey on 11/1/18, at 1:15 p.m. MD-1 returned a phone call. MD-1 stated in the past 17 days, his office had not been contacted by either the nursing home facility or the pharmacy requesting a re-fill of R50's [MEDICATION NAME]. MD-1 stated his personal policy for re-filling medications was within 24-48 hours of being contacted. MD-1 stated this was an unfortunate incident that should not have happened to R50.

Based on observation, interview and document review, the facility failed to ensure pain medication was available to be administered as prescribed for 1 of 1 resident (R50) with chronic pain and whose narcotic pain medication was not refilled timely resulting in nine consecutive missed doses. This failure resulted in actual harm due to R50 experiencing increased pain, anxiety, and [MEDICAL CONDITION]. Findings include: R50's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R50's [DIAGNOSES REDACTED]. The MDS also indicated R50 had intact cognition, experienced frequent pain which made it hard to sleep and limited day to day activities. R50 required scheduled and as needed (PRN) medication. R50 rated the pain as a 7 out of 10 (with 10 being the most severe) pain level. R50's Physician orders [REDACTED]. [MEDICATION NAME] HCL (a narcotic used to relieve severe pain) 5 milligrams (mg) by mouth TID (three times a day) at 8 a.m., 2 p.m., and 8 p.m. [MEDICATION NAME] extended release 650 mg - 1 tablet two times per day (BID) at 6 a.m. and 8 p.m. [MEDICATION NAME] 650 mg every four hours PRN. The Sanford Telephone Encounter form dated 10/27/18, at 9:51 a.m. revealed a nurse from the facility had attempted to obtain a refill of R50's [MEDICATION NAME]. The telephone encounter indicated the nurse had contacted MD-2, the on-call provider for the nursing home this weekend and he was not willing to write a prescription for R50's [MEDICATION NAME] refill and advised that R50 be seen in the emergency room in order to obtain the prescription. However, the facility nurse stated she did not have a way to get R50 to the emergency room . R50's Progress Note written on 10/27/18, at 11:06 p.m. indicated when the author of the note had started her shift at 6:30 a.m., it was passed on to her in report that R50 was out of his scheduled pain medication: [MEDICATION NAME]. The treatment nurse called the pharmacy in which the pharmacist stated they did not have a current prescription for the medication refill. The treatment nurse had then called the on-call MD-2 who stated he could not help due to R50 not being his patient. MD-1 (resident's MD) was unavailable for the weekend. MD-2 stated R50 would have to go to the emergency room /urgent care in order to obtain/receive the medication. Resident refused. Nothing can be done until Monday. On 10/29/18, at 4:10 p.m. licensed practical nurse (LPN)-A verified R50's [MEDICATION NAME] 5 mg TID order per the electronic Medication Administration Record [REDACTED]. He had missed nine doses total up to this time. On 10/29/18, at 4:12 p.m. R50 stated he was not good as the facility had run out of his pain medication and he had not slept for 48 hours straight, and could not complete his physical therapy because of pain. R50 stated the staff told him he could have gone to the emergency room /urgent care on Saturday in order to get pain medicaiton however, he did not go because the staff told him they'd been working on getting his medication. R50 stated he had seen MD-1 at 9:30 a.m. this morning, and MD-1 had stated he had not been notified by either the facility, or the pharmacy, that a new prescription for the [MEDICATION NAME] was needed in order to refill it. R50 stated this same thing had happened 2-3 months ago with his [MEDICATION NAME] medication (antianxiety). On 10/29/18, at 4:30 p.m. registered nurse (RN)-A stated it was her understanding the pharmacy and the facility staff had been trying to contact MD-1 in order to obtain an updated prescription. RN-A confirmed R50 had been taken to see MD-1 this morning and verified it had taken until now (4:30 p.m.), to get the [MEDICATION NAME] prescription to the facility. RN-A stated R50 had been offered [MEDICATION NAME] over the weekend and was not aware of any cold turkey (abruptly stopping medication) effects regarding [MEDICATION NAME] use therefore the staff were not monitoring for any of these concerns, other than pain. On 10/29/18, at 4:45 p.m. LPN-A stated the [MEDICATION NAME] medication card, which held R50's individual tablets, had a peel off label which was to be peeled off and faxed to the pharmacy for refill seven days prior to the medication running out. A fax confirmation of nursing home re-order received on 10/30/18, confirmed the [MEDICATION NAME] refill for R50 had been sent to the pharmacy on 10/18/18. On 10/29/18, at 4:45 p.m. the director of nursing (DON) verified she was not aware of any side effects related to the abrupt discontinuation of [MEDICATION NAME]. On 10/29/18, at 4:55 p.m. R50 stated the staff had not made it clear to him that if he chose not to go to the ER he wouldn't have the [MEDICATION NAME] available until Monday. R50 stated the staff assured him they were working on getting the medication filled which was why he did not go to the emergency room /urgent care. On 10/30/18, at 8:09 a.m. the DON stated R50 was on the lowest dose of [MEDICATION NAME] and he would have let the staff know if he was experiencing any withdrawal symptoms. The DON could not provide any documentation/evidence that potential withdrawal symptoms for monitoring had been communicated to staff or R50. On 10/30/18, at 8:30 a.m. the pharmacist was interviewed by telephone. The Thrifty [NAME] pharmacist stated he had originally received a request from the nursing home to refill R50's [MEDICATION NAME] on 10/18/18, and a fax had been sent to the prescribing MD on 10/18/18, 10/26/18, & 10/29/18, requesting a prescription to refill the medication. The pharmacist stated he would be very concerned with withdrawal symptoms for a person who abruptly stopped taking [MEDICATION NAME] because the symptoms could be very serious and harmful to the person. When asked, the pharmacist confirmed R50's increased anxiety, uncontrolled pain, and [MEDICAL CONDITION] could have been caused and exacerbated by the abrupt withdrawal of the [MEDICATION NAME]. On 10/30/18, at 9:05 a.m. R50 stated he had lower back pain and the [MEDICATION NAME] helped relieve the pain. R50 stated on the weekend he did not think he was going to make it because the pain was so bad. R50 said he had not slept Saturday or Sunday and was awake for 48 hours straight. R50 stated the staff kept telling him they were calling about getting his [MEDICATION NAME] filled and acknowledged they had given him Tylenol but stated that did not help with the pain. R50 stated even though he had asked many, many times, the staff did not attempt to get him anything else for the pain because they said they could not get anything. R50 said, What if I was dying, do I just die in pain? It made me feel sad and angry. R50 stated he had asked for an extra [MEDICATION NAME] to help him sleep and the staff informed him they did not have an order to give him an extra dose. Again R50 verfied the staff had not told him that if he didn't go to the emergency room , he wouldn't have the [MEDICATION NAME] until Monday. When asked, R50 stated the staff had not informed him of the potential [MEDICATION NAME] withdrawal symptoms to watch for but he thought his increased anxiety and inability to sleep for 48 hours could have been due to the abrupt discontinuation of the medication. R50 stated he had received two doses of [MEDICATION NAME] yesterday (10/29/18) and was able to sleep last night. He said when he'd asked for his third dose at 3 a.m. today he was told he could not have it until 7:00 a.m R50 then stated he had asked for his [MEDICATION NAME] at 7:30 a.m. today but did not get it until 9 a.m. At this time, R50 rated his pain at a 7 out of 10 on the pain scale. On 10/30/18, at 9:25 a.m. LPN-B confirmed R50 had received his [MEDICATION NAME] at 8:47 a.m. that morning, and verified she had not asked him to rate his pain at that time. LPN-B stated the staff only asked/assessed for the resident pain rate when administering PRN medications. Review of the E-Mar indicated R50 received [MEDICATION NAME] 650 mg as follows: - 10/27/18 at 1:22 p.m. for pain due to being out of [MEDICATION NAME] - 10/27/18 at 5:22 p.m. for pain 7/10 - 10/28/18 at 12:56 a.m. for pain 7/10 affecting sleep - 10/28/18 at 8:32 a.m. for pain 5/10 - 10/29/18 at 12 midnight for pain 7/10 affecting sleep R50's Physician's Progress note dated 10/29/18, indicated patient here for follow-up on chronic pain - back pain. Has been on [MEDICATION NAME] for the last few months. Patient has been out of his [MEDICATION NAME] and requested the medication be restarted. [MEDICATION NAME] refilled for the patient. An Appointment Transfer Sheet note dated 10/30/18, with pain management MD-3, indicated: increased pain without [MEDICATION NAME], could not function or sleep. Will resume [MEDICATION NAME], narcotic contract. Ordered [MEDICATION NAME] 5 mg TID and [MEDICATION NAME] 50 mg one tablet every 12 hours PRN for breakthrough pain. On 10/30/18, at 8:45 a.m. a call was made to MD-1, and a message was left. Progress notes for R50 reviewed from 10/18/18, to present were absent of any notations (except above on 10/27/18) regarding R50 being without [MEDICATION NAME] and what the facility did to obtain pain medication/relief. No evidence was available to indicate whether the facility had made a request for additional medications that could have been helpful during the time R50 was without his [MEDICATION NAME], or to identify whether R50 had been educated on withdrawal symptoms that could occur that he should report to staff. Review of the facility's Medication Policy reviewed/amended 1/2016, indicated the night nurse was to go through the medication carts and reorder as needed for Narcotics. This is scheduled every Sunday and Thursday. Review of the facility's undated Pain Management Policy indicated: .residents receiving pain management interventions would be monitored for pain levels on a scheduled basis, and/or PRN, using the appropriate scale. - any residents routinely receiving a scheduled or PRN [MEDICATION NAME] would be reassessed for appropriateness and effectiveness at periodic intervals. Potential adverse consequences associated with medications would be monitored and addressed. - the physician would be notified when pain persists or reoccurs despite treatment or if suspected adverse consequences are noted. Attempts to reach MD-1 during the survey were unsuccessful. Upon completion of the survey on 11/1/18, at 1:15 p.m. MD-1 returned a phone call. When asked, MD-1 verified absolutely that R50 could have experienced withdrawal symptoms by not being provided his ordered [MEDICATION NAME] for nine doses. MD-1 stated that R50's uncontrolled pain, increased anxiety and [MEDICAL CONDITION] could all have been withdrawal symptoms. Further, MD-1 also stated in the past 17 days, his office had not been contacted by either the nursing home facility or the pharmacy requesting a re-fill of R50's [MEDICATION NAME]. MD-1 stated his personal policy for re-filling medications was within 24-48 hours of being contacted. MD-1 stated this was an unfortunate incident that should not have happened to R50. .

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident reviewed for pain (R50) received a prescribed pain medication in order to ensure pain relief. This failure resulted in actual harm to R50 who due to an abrupt discontinuation of routinely scheduled pain medication, suffered increased pain, increased anxiety, and [MEDICAL CONDITION]. Findings include: R50's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R50's [DIAGNOSES REDACTED]. The MDS also indicated R50 had intact cognition, experienced frequent pain which made it hard to sleep and limited day to day activities. R50 required scheduled and as needed (PRN) medication. R50 rated the pain as a 7 out of 10 (with 10 being the most severe) pain level. R50's Pain Care Area Assessment (CAA) dated 2/13/18, indicated R50 stated he had always had chronic pain in his back which he rated a 7 out of 10. R50 stated the pain had kept him from sleeping at night and it also made it difficult to get out of bed and move around. R50 received [MEDICATION NAME] 10 milligrams (mg) three times per day (TID) and Tylenol PRN which he had used almost daily within the MDS reference period. R50's general nursing observation started on 7/31/18, and completed on 8/1/18, indicated R50 stated he always had chronic pain in his back and rated his pain within the last week at a 7 out of 10 on a 0-10 scale, with 10 being the worst. R50 stated the pain kept him from sleeping at night and it also made it difficult to get out of bed and move around. R50 received [MEDICATION NAME] 5 mg (TID), BioFreeze ointment and Tylenol PRN. He had Tylenol three times during the observation reference period. R50 stated the pain medications helped relieve his pain. R50's care plan provided on 10/30/18, indicated R50 had chronic pain related to disc degeneration, lumbar region. Goal: resident would remain comfortable from pain, daily. Approaches included: administer [MEDICATION NAME] per medical doctor (MD) orders, observe signs and symptoms of pain (grimacing, moaning, guarding) and report to MD as needed, use 0-10 pain scale to determine pain level and effectiveness of medication. R50's Physician orders [REDACTED]. [MEDICATION NAME] HCL (a narcotic used to relieve severe pain) 5 milligrams (mg) by mouth TID (three times a day) at 8 a.m., 2 p.m., and 8 p.m. [MEDICATION NAME] extended release 650 mg - 1 tablet two times per day (BID) at 6 a.m. and 8 p.m. [MEDICATION NAME] 650 mg every four hours PRN. The Sanford Telephone Encounter form dated 10/27/18, at 9:51 a.m. revealed a nurse from the facility had attempted to obtain a refill of R50's [MEDICATION NAME]. The telephone encounter indicated the nurse had contacted MD-2, the on-call provider for the nursing home this weekend and he was not willing to write a prescription for R50's [MEDICATION NAME] refill and advised that R50 be seen in the emergency room in order to obtain the prescription. However, the facility nurse stated she did not have a way to get R50 to the emergency room . R50's Progress Note written on 10/27/18, at 11:06 p.m. indicated when the author of the note had started her shift at 6:30 a.m., it was passed on to her in report that R50 was out of his scheduled pain medication: [MEDICATION NAME]. The treatment nurse called the pharmacy in which the pharmacist stated they did not have a current prescription for the medication refill. The treatment nurse had then called the on-call MD-2 who stated he could not help due to R50 not being his patient. MD-1 (resident's MD) was unavailable for the weekend. MD-2 stated R50 would have to go to the emergency room /urgent care in order to obtain/receive the medication. Resident refused. Nothing can be done until Monday. On 10/29/18, at 4:10 p.m. licensed practical nurse (LPN)-A verified R50's [MEDICATION NAME] 5 mg TID order per the electronic Medication Administration Record [REDACTED]. He had missed nine doses total up to this time. During interview with R50 at 4:12 p.m. on 10/29/18, R50 stated he was not good as the facility had run out of his pain medication and he had not slept for 48 hours straight, and could not complete his physical therapy because of pain. R50 also stated he had [MEDICAL CONDITIONS] from the Vietnam War. R50 stated the staff told him he could have gone to the emergency room /urgent care on Saturday in order to get pain medication however, he did not go because the staff had told him they had been working on getting his medication. R50 stated he had seen MD-1 at 9:30 a.m. this morning, and MD-1 had stated he had not been notified by either the facility, or the pharmacy, that a new prescription for the [MEDICATION NAME] was needed in order to refill it. During interview with registered nurse (RN)-A at 4:30 p.m. on 10/29/18, RN-A stated it was her understanding the pharmacy and the facility staff had been trying to contact MD-1 in order to obtain an updated prescription. RN-A confirmed R50 had been taken to see MD-1 this morning and verified it had taken until now (4:30 p.m.), to get the [MEDICATION NAME] prescription to the facility. RN-A stated R50 had been offered [MEDICATION NAME] over the weekend. LPN-A was interviewed at 4:45 p.m. on 10/29/18 and stated the [MEDICATION NAME] medication card, which held R50's individual tablets, had a peel off label which was to be peeled off and faxed to the pharmacy for refill seven days prior to the medication running out. A fax confirmation of nursing home re-order received on 10/30/18, confirmed the [MEDICATION NAME] refill for R50 had been sent to the pharmacy on 10/18/18. On 10/29/18, at 4:55 p.m. R50 stated the staff had not made it clear to him that if he chose not to go to the ER he wouldn't have the [MEDICATION NAME] available until Monday. R50 stated the staff assured him they were working on getting the medication filled which was why he did not go to the emergency room /urgent care. On 10/30/18, at 8:30 a.m. the pharmacist was interviewed by telephone. The Thrifty [NAME] pharmacist stated he had originally received a request from the nursing home to refill R50's [MEDICATION NAME] on 10/18/18, and a fax had been sent to the prescribing MD on 10/18/18, 10/26/18, & 10/29/18, requesting a prescription to refill the medication. On 10/30/18, at 9:05 a.m. R50 stated he had lower back pain and the [MEDICATION NAME] had helped relieve the pain. R50 stated on the weekend he did not think he was going to make it because the pain was so bad. R50 said he had not slept Saturday or Sunday and was awake for 48 hours straight. R50 stated the staff kept telling him they were calling about getting his [MEDICATION NAME] filled and acknowledged they had given him Tylenol but stated that did not help with the pain. R50 stated even though he had asked many, many times, the staff did not attempt to get him anything else for the pain because they said they could not get anything. R50 said, What if I was dying, do I just die in pain? It made me feel sad and angry. R50 stated he had asked for an extra [MEDICATION NAME] to help him sleep and the staff informed him they did not have an order to give him an extra dose. Again R50 verfied the staff had not told him that if he did not go to the emergency room , he would not have the [MEDICATION NAME] until Monday. R50 stated he had received two doses of [MEDICATION NAME] yesterday (10/29/18) and was able to sleep last night. He said when he had asked for his third dose at 3 a.m. today he was told he could not have it until 7:00 a.m R50 then stated he had asked for his [MEDICATION NAME] at 7:30 a.m. today but did not get it until 9 a.m. At this time, R50 rated his pain at a 7 out of 10 on the pain scale. On 10/30/18, at 9:25 a.m. LPN-B confirmed R50 had received his [MEDICATION NAME] at 8:47 a.m. that morning, and verified she had not asked him to rate his pain at that time. LPN-B stated the staff only asked/assessed for the resident pain rate when administering PRN medications. Review of the E-Mar indicated R50 received [MEDICATION NAME] 650 mg as follows: - 10/27/18 at 1:22 p.m. for pain due to being out of [MEDICATION NAME] - 10/27/18 at 5:22 p.m. for pain 7/10 - 10/28/18 at 12:56 a.m. for pain 7/10 affecting sleep - 10/28/18 at 8:32 a.m. for pain 5/10 - 10/29/18 at 12 midnight for pain 7/10 affecting sleep R50's Physician's Progress note dated 10/29/18, indicated patient here for follow-up on chronic pain - back pain. Has been on [MEDICATION NAME] for the last few months. Patient has been out of his [MEDICATION NAME] and requested the medication be restarted. [MEDICATION NAME] refilled for the patient. An Appointment Transfer Sheet note dated 10/30/18, with pain management MD-3, indicated: increased pain without [MEDICATION NAME], could not function or sleep. Will resume [MEDICATION NAME], narcotic contract. Ordered [MEDICATION NAME] 5 mg TID and [MEDICATION NAME] 50 mg one tablet every 12 hours PRN for breakthrough pain. On 10/30/18, at 8:45 a.m. a call was made to MD-1, and a message was left. Progress notes for R50 reviewed from 10/18/18, to present were absent of any notations (except above on 10/27/18) regarding R50 being without [MEDICATION NAME] and what the facility did to obtain pain medication/relief. No evidence was available to indicate whether the facility had made a request for additional medications that could have been helpful during the time R50 was without his [MEDICATION NAME] Review of the facility's Medication Policy reviewed/amended 1/2016, indicated the night nurse was to go through the medication carts and reorder as needed for Narcotics. This is scheduled every Sunday and Thursday. Review of the facility's undated Pain Management Policy indicated: .residents receiving pain management interventions would be monitored for pain levels on a scheduled basis, and/or PRN, using the appropriate scale. - any residents routinely receiving a scheduled or PRN [MEDICATION NAME] would be reassessed for appropriateness and effectiveness at periodic intervals. Potential adverse consequences associated with medications would be monitored and addressed. - the physician would be notified when pain persists or reoccurs despite treatment or if suspected adverse consequences are noted. Attempts to reach MD-1 during the survey were unsuccessful. Upon completion of the survey on 11/1/18, at 1:15 p.m. MD-1 returned a phone call. MD-1 stated in the past 17 days, his office had not been contacted by either the nursing home facility or the pharmacy requesting a re-fill of R50's [MEDICATION NAME]. MD-1 stated his personal policy for re-filling medications was within 24-48 hours of being contacted. MD-1 stated this was an unfortunate incident that should not have happened to R50.

Based on observation, interview and document review, the facility failed to adequately assess residents who developed pressure ulcers and implement additional interventions to minimize the risk of additional pressure ulcer development for 2 of 2 residents (R1, R2) reviewed who developed pressure ulcers. R2 developed a right ear pressure ulcer. The failure of the facility to consistently implement a repositioning program, resulted in harm, when R1 acquired an unstageable pressure ulcer on the left leg which required an above the knee amputation. In addition, R1 developed a pressure ulcer on her right leg, a stage 2 pressure ulcer on her right buttocks, a pressure ulcer on her coccyx, and a pressure ulcer on the right side of her head. Findings include: R1's medical record was reviewed. R1's face sheet indicated R1 was diagnosed with [REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 was cognitively intact, and required extensive assistance with bed mobility and was dependent on staff for transfers. R3 was identified at risk for development of pressure ulcers with no pressure ulcers noted. Interventions identified were a turning program and a pressure reducing mattress for the bed and chair. On 5/25/17, registered nurse (RN)-B documented on an appointment transfer sheet that R1 had not been feeling well, did not have much of an appetite the last couple of days, and had an open area on the lower left leg that required a diagnosis. The physician documented R1 had noticed a sore on her left leg. The physician described the area as eschar (black) associated with redness around it and diagnosed the area as a wound infection with surrounding [MEDICAL CONDITION] (an infection of the tissue just below the skin). The physician ordered [MEDICATION NAME] (an antibiotic) 250 milligrams three times a day for seven days. R1's dietary documentation by the dietitian dated 5/30/17, indicated R1 had an overall decline in eating and had lost nine pounds in the last 30 days. Nutritional supplements had been ordered in the past and R1 refused them. Continue to offer her favorite foods and provide encouragement at meals and snack time. R1's weight loss was not desirable and she was at higher nutritional risk. No new nutrition interventions recommended at this time. The documentation did not address the acquired left leg pressure ulcer. R1 lacked any further documentation from the dietitian when additional pressure ulcers developed. R1's care plan dated 6/1/17, indicated R1 was at risk for skin breakdown related to immobility. R1 was to be assisted with repositioning every three hours and as needed. On 6/2/17, registered nurse (RN)-N documented on a nurse communication form that was faxed to R1's primary physician. R1 had a wound on lateral left calf with eschar surrounded by [MEDICAL CONDITION] that was worsening. R1 was seen in urgent care by a physician on 5/25/17, and started on [MEDICATION NAME] for infection. Today the wound was 3 centimeters (cm) by 2 cm, black surrounded by black tissue that was not yet open for a size of 12 cm. Around this was redness extending 2 cm. It was painful. The physician sent the fax back to the facility on [DATE], and requested R1 be seen at the clinic. On 6/2/17, RN-N documented on R1's skin and wound log at 3:43 p.m. RN-N indicated the left middle calf was a new ulcer with [MEDICAL CONDITION] that was unable to be accurately staged due to slough and/or eschar 3 cm by 2 cm. The facility lacked any documentation that R1's left calf pressure ulcer wound had been comprehensively assessed. On 6/5/17, documentation from R1's physician indicated R1 was brought to the emergency department from the clinic for a left calf ulcer. Onset of the ulcer was unknown. R1 was noticed to have decreased vascular flow to the extremities and an arterial duplex ultrasound of the lower extremities as well as venous studies were completed. R1 had an approximate 6 cm by 2 cm ulceration to her left calf. R1 was transferred to a hospital for a vascular surgeon consult. R1's hospital admission history and physical dated 6/5/17, indicated R1 had a left calf ulcer with unknown onset. R1 stated the wound started a few weeks ago. R1's vascular surgery consult documentation dated 6/5/17, indicated R1 had a left leg pressure ulcer and the left foot showed no sores or ulcers. R1 was diagnosed with [REDACTED]. R1's wound consult documentation dated 6/6/17, identified a lower left leg ulcer measuring 12 centimeters (cm) by 3 cm wound bed with black eschar and white non viable tissue, edges with deep maroon and dark purplish discoloration and tan-serosanguineous drainage. R1 had a pressure ulcer to the coccyx area measuring 1.2 centimeters (cm) by .2 cm by .1 cm partial thickness wound with a pink moist wound bed. The facility lacked any documentation that R1's coccyx pressure ulcer had been comprehensively assessed. R1's physician documentation dated 6/13/17, indicated R1 was diagnosed with [REDACTED]. R1's hospital discharge summary dated 6/15/17, indicated R1's left calf wound had probably been present for a few weeks. R1's nursing progress notes dated 6/15/17, documented by registered nurse (RN)-A indicated R1 returned from the hospital. R1 had a left above the knee amputation (AKA) due to circulatory issues. R1 had a dressing over the coccyx area that was removed and the area was clear. Will continue with good turning and repositioning. R1's Braden Scale (a tool for predicting pressure ulcer risk) dated 6/21/17, indicated R1 was at moderate risk for pressure ulcer development. R1's significant change MDS dated [DATE], indicated R1 had severe cognitive impairment, required extensive assistance with bed mobility and was dependent on staff for transfers. R1's nursing progress notes dated 6/22/17, documented by RN-A, indicated R1 was to be repositioned every two to three hours with positioning pillows. However, R1's care plan still directed staff to reposition R1 every three hours.R1's consent for hospice admission was dated 6/27/17. R1's skin condition/wound progression documentation dated 6/30/17, was documented by licensed practical nurse (LPN)-J. New, first recording present on the right lower buttocks were superficial open areas. Skin was blanchable, no odor was apparent, no drainage was apparent. Multiple superficial open areas noted to buttocks. Applied Allevyn dressing times two for protection. The facility lacked documentation that a RN was notified of the new open areas. The facility policy was not followed and a comprehensive assessment of the areas was not completed. R1's care plan dated 7/1/17, indicated R1 was at risk for skin breakdown related to immobility. R1 was to be assisted with repositioning every three hours and as needed. R1's skin condition/wound progression documentation dated 7/4/17, was documented by licensed practical nurse (LPN)-J. New, first recording, present on the upper back of the head was a reddened area. Skin was blanchable, no odor was apparent, no drainage was apparent. This wound was not present on admission. The facility lacked documentation that a RN was notified of the new area. The facility policy was not followed and a comprehensive assessment of the area was not completed. R1 was seen in the clinic on 7/7/17, by her primary physician. R1's family was concerned about a sore on her right lower leg that she had for the last week. R1's family was also concerned about a sore on her buttocks for the last couple of weeks and an area on her head for four days. R1's family was concerned R1 was not repositioned regularly. The physician documented the buttock ulcer and the right lower leg pressure ulcer measuring approximately 15 cm by 3 cm with a shallow abrasion on R1's scalp. The physician ordered R1 to be repositioned every two hours, [MEDICATION NAME] dressing to buttocks pressure ulcer change daily and when soiled, [MEDICATION NAME] dressing to right calf pressure ulcer, change every five days, triple antibiotic ointment to scalp wound, and off load pressure from all wounds. The facility lacked documentation that a RN was notified of the new area. The facility policy was not followed and a comprehensive assessment of the area was not completed. R1's care plan was never updated to reflect the physican order to reposition every two hours. R1's skin condition/wound progression documentation dated 7/9/17, was documented by licensed practical nurse (LPN)-J. Present on the right buttocks were superficial open areas. Three open areas noted to resident's buttocks. Largest open area was on the coccyx. One small area to each buttock. The facility lacked any documentation that R1's coccyx pressure ulcer had been comprehensively assessed. R1's skin condition/wound progression documentation dated 7/10/17, was documented by RN-G. Present on the right lower buttocks was superficial open areas. Stage 2, skin was not blanchable, no odor was apparent, drainage consistency was thin, scan drainage was present, color was yellow. The wound was not present on admission. This site had a round open area in the middle. It was a stage 2, base was red with some scant amount of yellow slough. The dressing applied was foam. It was placed over the coccyx to protect the site. Resident had very poor circulation, abnormal labs including [MEDICATION NAME] level, and was currently a hospice patient. She had orders to reposition every two hours and had repositioning pillows, and a soft neck pillow. She did report pain with repositioning. R1's death certificate dated 7/16/17, indicated R1's cause of death was chronic [MEDICAL CONDITION], heart valve disease, and [MEDICAL CONDITION]. An interview was conducted with NA-D on 11/1/17, at 12:35 p.m. NA-D stated she observed R1's left calf area to be black, dry, and deep purple in color. NA-D stated after a couple of days the left calf was open and NA-D would place a pillow under the left calf and heel. NA-D stated after the left leg amputation, R1 developed a sore on her right calf that was purple, black, and then doubled in size. NA-D stated R1 then developed a red area on the side of her head that was open and bleeding. NA-D stated the area on R1's head was touching the pillow, so she would roll up a towel to prop under R1's head. NA-D stated they reported the area on R1's head to the nurses and it took a few days before that information was documented on the 24 hour report. NA-D stated when R1 developed the open area on her left calf, she had told the nurses for a week before the nurses were talking about the area. NA-D also stated the report between the nurses and the NA's needed to improve. NA-D stated repositioning was not getting done timely and it could be 30-45 minutes later due to staffing needs. NA-D stated the NAs receive a sheet of information about the residents, however; NA-D stated it was not the resident's full care plan. NA-D stated the resident's care plan was to be posted in their closet and that was not happening. NA-D stated the NA's can't improve the situation without the proper staffing and more education. An interview was conducted with registered nurse (RN)-B on 11/1/17, at 2:28 p.m. RN-B stated on bath day, the NA and the nurse would look at the resident's skin. Also, if the NA's would notice a skin issue they would notify the nurse. RN-B stated the nurses have a 24 hour report they use to report to the next shift. RN-B stated the director of nursing indicated there was a high resident acuity and the NA's have a heavy resident assignment. An interview was conducted with RN-A on 11/1/17, at 3:07 p.m. RN-A verified the only skin documentation for R1's left calf was on the clinic appointment sheet when R1 saw the physician. At 3:36 p.m. RN-A stated when R1 returned from the hospital on [DATE], her skin was intact. RN-A stated the RN's would look at any skin issues. An interview was conducted with RN-B on 11/2/17, 8:44 a.m. RN-B stated R1's left calf should have been documented on the skin and wound log per policy. RN-B stated R1 was changed to an hourly repositioning schedule on 7/7/17. RN-B verified the hourly repositioning was never documented in R1's medical record.An interview with family member (FM)-L was conducted on 11/15/17, at 5:03 p.m. FM-L stated three to four months prior to R1's death she did not want to get up so the facility did not get her up for meals. FM-L stated when R1 developed the sore on her left calf, the facility stated it had been there for a couple of days. FM-L stated the physician told family the left calf pressure ulcer had been there for 2-1/2 to 3 weeks. FM-L stated shortly after the left leg amputation, we noticed an area on her right leg. FM-L stated R1 had a big sore on her head from not being moved. FM-L stated the NA's were reporting R1's left leg to superiors and it was getting brushed off. An interview with LPN-J was conducted on 11/16/17, at 10:03 a.m. LPN-J stated there was a suspicious area on R1's left extremity that was monitored for quite awhile. LPN-J stated R1 would get suspicious areas quickly when there was any pressure on her skin and it would start breaking down. LPN-J stated the repositioning would make the areas go away. LPN-J stated any area of R1's skin that touched the bed would become red in minutes. LPN-J stated the RN should assess the open area within the same shift. LPN-J stated she did not document when she reported R1's skin areas to the RN. LPN-J stated the charting falls between the cracks. LPN-J stated there was no documentation to identify when staff would have provided repositioning for R1. LPN-J stated she observed R1's right leg and it looked like something more than a scab. LPN-J stated she had reported R1's right leg area to the RN. An interview with nursing assistant (NA)-I was conducted on 11/16/17, at 10:37 a.m. NA-I stated R1 was to be repositioned every two to three hours. NA-I stated towards the end of R1's life possibly the beginning of June the repositioning schedule was to be hourly. NA-I stated she did not know how R1 developed the sore on her head. NA-I stated the pillow may have caused more pressure and my feeling was that it was realized a little to late. NA-I stated they took a piece of wool and made it into a neck pillow. NA-I stated after they stopped using a pillow the sore did not get any bigger. An interview with RN-G was conducted on 11/16/17, at 11:27 a.m. RN-G stated she should have measured the coccyx area and the stage 2 pressure ulcer on the right buttocks. RN-G stated her and RN-S had looked at R1's right leg. RN-G stated she was working on the medication cart that day and RN-T had updated the physician. RN-G stated she was not sure why the RN's were not assessing R1's wounds as nurses were aware of the areas. RN-G stated there were frequent discussions of R1's skin issues, however; the documentation was not put in writing. An interview with medical doctor MD-N was conducted on 11/29/17, at 1:07 p.m. The physician who was R1's vascular surgeon stated the wound on R1's left calf was an unstageable (a full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer. MD-N stated the pressure ulcer developed due to lack of repositioning and was avoidable. MD-N also stated R1 would not have required the left above the knee amputation if the pressure ulcer would not have occurred. MD-N stated the standard of care when a wound was identified was to measure the wound, assess, and monitor to determine improvement or worsening of the wound. MD-N stated R1 had vascular disease, however; there was no ischemic issues (restriction in blood supply to tissues) going on with the left foot which meant the vascular disease did not cause the wound. MD-N stated R1 also had developed an early stage pressure ulcer on her coccyx that was due to lack of repositioning. An interview was conducted with FM-M on 12/6/17, at 4:32 p.m. FM-M stated he would visit R1 between 3:30 p.m. and 6:00 p.m. FM-M stated when R1 would put her call light on to be changed or repositioned it would take from 20-25 minutes for the call light to be answered. FM-M stated this occurred on several occasions. FM-M stated the ulcer that developed on R1's left leg should have been addressed sooner. FM-M stated when R1 saw the surgeon, the surgeon looked shocked. FM-M stated the ulcer did not develop overnight. An interview was conducted with the director of nursing (DON) on 12/6/17, at 1:41 p.m. The DON indicated R1 would have been repositioned according to her care plan since there was documentation of a tissue tolerance being completed. An interview was conducted with the DON on 12/12/17, at 9:28 a.m. The DON stated during this time frame there would be no documentation of when the nursing assistants (NAs) repositioned R1. The DON stated the NAs would use their caregiver sheets and reposition per the schedule. The DON stated she had no concerns that the NAs did not have time to reposition R1. The DON stated there was no documentation that R1's skin was checked on bath day and their current policy did not require documentation. The DON stated the hospice staff ordered an air mattress for R1 on 7/3/17, however; there was no documentation it was ever placed. The DON stated she was frustrated that she could not find the lacking documentation in the medical record. R2's medical record was reviewed. R2's face sheet indicated R2 was diagnosed with [REDACTED]. During observiations on 11/2/17, at 3:19 a.m., R2 was asleep in bed with her right ear directly on the pillow. At 3:42 a.m. R2 remained the same. At 4:15 p.m. R2 remained asleep with her right ear directly on the pillow. At 4:39 a.m. NA-Q placed the bedpan for R2. R2 was positioned on her back. At 4:50 p.m. NA-R entered the room and took R2 off the bedpan. At this time, NA-R asked R2 how she wanted to be positioned and R2 requested to lay on her right side again. NA-Q did not educate R2 that she would once again be lying directly on her right ear. R2 was positioned on her right side. During observations on 11/2/17, at 6:30 a.m., R2 remained on her right side with her ear directly on the pillow. At 6:44 a.m. NA-Q and NA-R positioned R2 on her left side. R2's annual Minimum Data Set ((MDS) dated [DATE], indicated R2 was cognitively intact and required extensive assistance with bed mobility. R2's care plan reviewed 8/9/17, indicated R2 was to be repositioned every two hours. Reposition side to side and limit/avoid repositioning on back. R2's nursing progress notes dated 10/18/17, documented by registered nurse (RN)-G indicated R2's right ear pressure ulcer measured 1.3 centimeters (cm) by .1 cm. 100% eschar (black). The physician was notified of the present status. R2's physican order dated 10/18/17, directed staff to apply [MEDICATION NAME] gel to R2's right ear one time daily. R2's nurse communication fax dated 10/18/17, written to the physician indicated R2 had a .1 cm by 1.4 cm stage 2 area to the right outer ear cartilage. On 10/20/17, the physician responded that R2 should be seen un the clinic. R2's Braden scale (a tool for predicting pressure ulcer risk) dated 10/25/17, (7 days late) indicated R2 was at low risk for pressure ulcer development. R2's documentation dated 10/25/17, indicated the right ear pressure ulcer measured .8 cm by .5 cm by .1 cm. Continue with [MEDICATION NAME] gel and Allevyn dressing. Skin was blanchable, no odor was apparent, drainage consistency was thin, scant drainage was present, color was clear. Pink wound base was 75%, yellow wound base was 25%, granulation tissue was 75%, slough tissue was 25%, surrounding tissue was normal, mucous membranes were moist and pink, skin turgor was fair. R2's tissue tolerance repositioning observation dated 10/31/17, (13 days late) indicated R2 required repositioning every two hours. R2's care plan reviewed 11/1/17, indicated R2 was to be repositioned every two hours. Reposition side to side and limit/avoid repositioning on back. The care plan did not address R2's right ear pressure ulcer. R2's Braden scale dated 11/2/17, indicated R2 was at moderate risk for pressure ulcer development. R2's documentation dated 11/2/17, indicated the right ear pressure ulcer measured 3 cm by .2 cm by .2 cm. Skin was blanchable, no odor was present, drainage consistency was thick, scant drainage was present, color was yellow. The physician was notified of the present status of the site, wound base was not visible. Yellow wound base was 100%, slough tissue was 100%. The wound was measured today, ear cleansed with wound wash, [MEDICATION NAME] gel applied and covered with dressing. Tissue tolerance completed, resident was to be repositioned every two hours, Braden score was 14 (moderate risk 13-14). resident had a history of [REDACTED]. Resident was encouraged to lie on the left side, continue to reposition every two hours per the tissue tolerance. New mattress custom care air. [MEDICATION NAME] (liquid vitamin supplement) was started on 11/2/17. R2's skin progress note date 11/15/17, indicated R2's right ear was cleansed with soap and water, patted dry, scab was present over the site, and left open to air. The neck pillow was in place and the resident was educated on the importance of keeping her ear elevated off of the pillow to relieve pressure. The resident indicated understanding. An interview was conducted with nursing assistant (NA)-D on 11/1/17, at 12:35 p.m. NA-D stated R2 stayed in bed all the time. NA-D stated if R2 was repositioned the area on her right ear would not have developed. An interview was conducted with NA-P on 11/2/17, at 4:59 a.m. NA-P stated she placed R2 on the bedpan at 12:30 a.m. and then R2 was positioned on her right side. An interview was conducted with R2 on 11/2/17, at 11:02 a.m. R2 stated she did not know how she had developed the right ear sore. R2 stated the staff did not tell her the importance of not being positioned on her right side. R2 stated she had not been offered a neck pillow and would be willing to try it. An interview was conducted with NA-K on 11/16/17, at 11:04 a.m. NA-K stated R2 had an area on her right ear. NA-K stated R2 had a neck pillow and she was unsure if the neck pillow was supposed to be used. An interview was conducted with RN-H on 11/16/17, at 3:17 p.m. RN-H stated R2's pressure ulcer developed on 10/18/17 to her right ear. RN-H stated the root cause analysis was not completed until 11/2/17, and should have been done on 10/18/17. RN-H stated R2 would rest her head to the right side. RN-H stated last week there was an interdisciplinary team meeting and that was not documented in the medical record. RN-H stated R2's ear was not healing, and they had tried a sheepskin on her regular pillow for 5-7 days with no improvement. RN-H stated on 11/9/17, R2's family was contacted and they brought in a neck pillow. RN-H stated the neck pillow helped to heal the ear and the physician discontinued the dressing change on 11/14/17. An interview was conducted with the director of nursing (DON) on 12/12/17, at 9:06 a.m. The DON stated R2 had a lot of pain related to her [MEDICAL CONDITION] arthritis and therefore chose to be bedridden. The DON stated R2 was to repositioned every two hours and she would push herself back onto her back when side lying. The DON stated they tried using other pillows to brace R3 and rolled up blankets, and when the right ear had no healing they requested a neck pillow from the family. The DON verified R3's ear pressure ulcer and interventions were not addressed on the care plan. The DON stated the nursing assistant care guides were not saved, so there was no documentation to identify if the nursing assistants knew R3's interventions. The facility's Skin Ulcer Protocol policy updated 11/7/16, indicated residents would not develop pressure ulcers unless it was clinically unavoidable and appropriate care and services would be provided to prevent, treat, and monitor progress of all healing ulcers. When an open area developed the following measures would be implemented. A. Report all open skin ulcers to the facility wound nurse. B. Remove source of any possible pressure or trauma. C. Keep area dry and clean. D. Refer to Dietitian for nutritional needs as needed. E. Improve circulation by changing position frequently. F. Repeat Tissue Tolerance (turn/reposition program according to results) G. Repeat Braden scale (address all identified areas-Care plan). H. Review all current interventions to ensure they remain appropriate including pressure relieving/reducing devices. I. Provide wound cares as indicated by facility wound care guidelines, wound care nurse recommendations and physician orders. Wound nurse to complete a Root Cause Analysis of any new skin issue. Daily documentation to address the following: an evaluation of the ulcer, if no dressing present, an evaluation of the status of the dressing (intact, or drainage), the status of the tissue surrounding the ulcer, the presence of possible complications, such as increasing size or infection, and presence of pain before, during and after dressing change. At a minimum weekly wound round documentation to include the following: A. type of wound. B. stage or classification. C. measurements. D. exudate. E. presence of pain. F. wound base tissue. G. description of wound edges and surrounding tissue. H. Interventions in place. I. Current treatment and response to treatment. J. Track wound status.