Every finding on record at Valley Care and Rehab LLC

Based on observation, interview and document review, food items were not served in a sanitary and clean manner to residents observed during meals served from the steamer table in the kitchen. This deficient practice had the potential to affect all 10 residents who were served bread during their meal. Findings include: During an observation on 4/21/25 at 12:14 p.m. ,dietary manager (DM)-A removed the saran wrap over the cold items, and covers over other items in the steam table after washing hands and applying gloves. DM-A placed the resident meal choice slips of paper which were approximately three by three inches onto the metal counter area in the front of the steam table with gloved hands. DM-A began to set up a plate of taco salad which she used utensils to place the lettuce, tomatoes, cheese and taco meat and chips onto the plate. DM-A picked up a piece of bread with her right hand, held it in her left hand while buttering the bread, and placed it onto the plate. DM-A proceeded to dish up other plates of food with either the chicken Kiev meal, or the taco salad. Not all plates included the buttered bread slice. DM-A continued to touch the meal choice slips, with one or both hands, moving them around, turning them over and continued to pick up bread slices and butter them without changing her gloves after touching the meal choice slips. DM-A indicated meal choice slips were filled out by the residents, nursing assistants or activity staff during the lunch the day before. At 12:18 p.m. DM-A took two slices of bread with her left gloved hand over to the toaster, used both gloved hands and put the bread in the toaster. DM-A removed the gloves and applied new gloves. DM-A went back to the steam table, touched multiple meal choice slips, and began to dish up more meals. DM-A moved the slips around again, removed gloves, applied new gloves, went to the toaster and removed the toast from the toaster with gloved hands, applied peanut butter to the toast, and went back to the steam table to finish dishing up that meal. DM-A removed gloves and applied new gloves and began to touch and move around the meal slips and dished up other meals. DM-A indicated not all residents received the bread and picked up a meal choice slip to show surveyor. On the meal slip the word bread was circled. DM-A indicated those residents would be served bread. DM-A proceeded to pick up bread slices and butter them with her gloved hands, after touching the meal choice slips. During an interview on 4/22/25 at 10:56 a.m., DM-A stated their usual process for serving foods, was not to touch the foods with hands and were expected to use utensils. DM-A stated if they walked away from the steam table they changed their gloves. DM-A confirmed she had touched the meal choice slips with gloved hands and touched the bread without changing gloves between. DM-A indicated she had felt flustered yesterday during the observation. DM-A indicated her usual process was to have all bread buttered and to use tongs to put onto plates. DM-A stated she would usually have all the meal choice slips laid out so she could read them and confirmed yesterday during the observation it had not been done that way. DM-A stated it was important not to touch foods with gloved hands after touching the slips to prevent cross contamination and stated the slips were considered dirty. Review of facility policy titled Food Procurement, Store/Prepare/Serve-Sanitary revised 3/5/24, identified the facility would ensure they followed sanitation and food handling practices, and ensured food safety was maintained during buffet style or steam table food serving opportunities. The policy identified gloved hands were considered a food contact surface that could become contaminated or soiled. The policy identified failure to change gloves and wash hands between tasks, including handling ready to eat foods, could contribute to cross-contamination. Cross contamination could occur between harmful substances or disease-causing microorganism transferred to food by hands, including gloved hands. Food would be handled with new clean gloves, clean equipment and utensils.

Based on interview and document review, the facility failed to protect the resident's right to be free from mental abuse for 1 of 1 resident (R1) reviewed for abuse when staff, while providing cares, took a photo of R1 who was covered in feces and posted the photo to social media. Findings include: Nursing Assistant (NA)-A's Employee Acknowledgment dated and signed on 6/23/21, identified she had received, read, and understood and comply with the Valley Care and Rehab's Social Media policy. Any questions regarding this policy would be addressed by human resources. A violation of Social Media policy would result in disciplinary action and/or termination. Nursing assistant (NA)-A's personnel file identified the following: -On 7/19/21, director of nursing (DON) was made aware NA-A had utilized snapchat (social media) during work without regard as to who was in the background. NA-A admitted she had used her phone on the shift during the night. She verbalized understanding of phone expectations and when/where it was appropriate to use. -On 9/14/23, NA-A had posted pictures on social media of herself with diarrhea on covered pants in the hopper room (dirty utility room) with a caption what a shitty Friday and a thumbs up. She was informed even though the picture did not have personal information, the resident family could probably identify or suspect, with the style and color of the pants. She was informed this displayed unprofessional, and many companies would consider posting a picture such this to any online platform would be grounds for termination. She did not agree it was unprofessional and only wanted to know who had shown it to the facility. She was informed by the facility it was expected she stop posting things of that nature from this facility. According to the State Operations Manual Appendix PP dated 8/8/24, identified the definition of mental abuse includes abuse that was facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging. If a photograph or recording of a resident, or the manner that it is used, demeans, or humiliates a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status, include, but is not limited to, photographs and recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, using the bathroom, providing perineal care such as after an incontinence episode, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part such as breasts or buttocks without the resident's face, labeling resident's pictures and/or providing comments in a demeaning manner, directing a resident to use inappropriate language, and showing the resident in a compromised position. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition without behaviors. He required supervision with sit to stand, chair to bed transfers, and ambulation up to 10 feet, partial/moderate assistance with upper body dressing, personal hygiene, substantial/maximal assistance with lower body dressing, roll left/right in bed, dependent upon staff for toileting hygiene, and used a walker and wheelchair for mobility. He had an indwelling urinary catheter and colostomy (a surgical procedure that creates an opening in the abdomen for feces waste to exit the body). R1's diagnoses included neurogenic (lack of bladder control due to brain, spinal cord, or nerve problems), arthritis, and depression. R1's care plan dated 12/12/24, identified he had an assisted daily living (ADL) self-care performance deficit related to supra pubic (empties the bladder through an incision in the abdomen instead of a tube in the urethra) urinary catheter and colostomy, and was dependent upon staff to manage these external devices and provide assistance with toilet hygiene. Review of nursing assistant schedule from 1/13/25 through 1/26/25, identified NA-A was scheduled to work on 1/17/25, Friday 4:00 p.m. to 9:30 p.m. Facility investigation report dated 1/18/25, identified DON received a telephone call from a police department and a phone text message from a citizen in town regarding actions by one of the staff members of the facility. The picture showed a resident's right hand with liquid stool on it, a catheter bag on the floor with tubing attached to a stat lock (a cassette that held the urinary catheter tubing in place) and the resident's colostomy bag which had leaked. The caption to the photo was my 13th reason name at the top of photo identified a name of social media account and below it was NA-A's name. The post identified the staff member as NA-A. DON spoke with NA-A and she stated she had not made any snaps today and once she was informed of the photo evidence she confessed and told DON she had posted something to her private story, had taken it down, but not soon enough, when she realized it was inappropriate. She had a rough night prior to her shift and had influenced her decision making. NA-A had received verbal warnings in July 2021 and 2023 regarding cell phone use and social media. Education regarding facility policy on social media and electronic devices were reviewed with her and verbalized understanding. It was determined that despite the education, she lacked understanding of the seriousness of this incident as was at risk for repeat offenses, employment was terminated on 1/21/25. The photographs contained no identifying information to breach Health Insurance Portability and Accountability Ace of 1996 (HIPAA) (prohibiting the disclosure of protected health information). The photograph was not explicit in nature. The resident did not have any verbal/nonverbal distress to the incident. All resident needs were met, and it was not identified that NA-A acted in a willful manner. There was no physical confinement, punishment, or intimidation identified. DON and interdisciplinary team (IDT) determined the incident was poor judgment it would not be reported. Strict enforcement of facility cell phone policy will be implemented to protect residents, moving forward. During an interview on 1/24/25 at 1:00 p.m. complainant (C) stated NA-A had taken a picture of a resident who sat at edge of bed after the colostomy bag had exploded. The picture showed stool on the resident hand and leg and caption on the picture was 13 Reasons why. C stated she must have had a crappy day and most likely the reason she posted it. C stated this was an invasion of privacy and a HIPAA violation. During review on 1/26/25 of a photo taken by NA-A and posted to social media, the photo identified a person sitting on the edge of a bed, with the right lower arm positioned on a mattress and the right hand hung over the edge with dark golden mushy yellow substance (appeared to be stool) located on the thumb, pointer and middle fingers. The person's right leg was bare from the center of the upper thigh down to the upper calf. Located on the middle top part of the right thigh was a stat lock that held the urinary catheter tubing in place with tubing attached to the catheter bag that was located on the floor folded over. The person had a colostomy bag that hung down from their abdomen area to the right upper thigh area that contained the same stool substance located on the fingers. Top of colostomy bag was covered with material. The end of the colostomy bag clamp appeared to have let loose, and stool was located on the bed sheet off to the right side of the person and had run down the side of the mattress. There was a moderate amount of stool on the floor underneath the person's right leg. Written towards the bottom of the picture was my 13th reason and at the top of the picture identified 2 hours ago by NA-A's name. During an interview on 1/27/25 at 12:12 p.m. NA-A stated she had been terminated, was wrongful just from an incident with her cell phone. She had used her cell phone while she cared for a resident in his room. R1's colostomy bag had exploded, she had taken a picture of the feces, his hand, colostomy, the bed, floor, and part of his bare leg. She did not think family could have identified him in the picture there was not a picture of his face. She posted the picture of R1 on 1/17/25, while she was at work on a private social media site snapchat with only a handful of people on it. She removed it an hour later because she was ashamed, embarrassed, was unprofessional, and she let her emotions get the best of her. She knew what she was doing, did it anyway, and regrets it. R1 was not asked if the picture could be taken nor was, he aware it was taken, he had dementia. She said if R1 knew it had been taken and posted on social media it would have affected him negatively, he would have felt embarrassed and was an invasion of his privacy. NA-A stated this would not be a HIPPA violation because there were not any specific identifiers therefore, unable to identify him. On her private social media site there were at least 15 people and at least two of them worked with her at this facility. She stated only one resident currently had a colostomy and never thought about those that worked with her, and they could have identified him. Staff were allowed to have had their cell phones and used them while they worked at the facility with residents. She was unable recall any write ups in the past regarding issues with her use of cell phone at work and social media posts. During an interview on 1/27/25 at 3:11 p.m. family member (FM) stated R1 was a very private person, made sure his colostomy and urinary catheter bags were always covered. R1 was consciousness and did not want them exposed. If a picture was taken of anyone for that matter and posted on social media even without a face would be demeaning and humiliating. R1 did not know this happened but if he did, it would have bothered him and was an invasion of his privacy. During an interview on 1/27/25 at 3:37 p.m. DON stated 2021 NA-A had taken a picture with her cell phone along with another staff member at work and there was a resident behind her. She stated 2023 NA-A had taken a picture with her cell phone in a utility room by herself, held up resident's pants soiled with stool, and posted it to social media. Education was provided and included facility policy and expectations. DON stated on 1/18/27 she was made aware by a police officer (PO) on 1/17/25, NA-A had taken a picture of R1 and posted it onto social media for anyone on her account to see, unsure of how many but was too many. R1 was not aware of what happened, had a poor memory and was not interviewable. The facility had a cell phone policy in place since she became DON (2015), and staff were expected to leave their cell phones in the staff locker room while on the floor working with residents. DON stated NA-A made a poor choice in the moment, had taken a photo of a resident, and posted it to social media which affects privacy and dignity. The incident was not filed with SA, the resident was not identifiable in the photo. She stated NA-A was immature, knew what she did was wrong, used poor decision making that led her to take the picture. The incident was not a willful act and was not done to hurt or embarrass R1. A reasonable person would been upset about this and asked why are you taking a picture of my colostomy. The picture was not taken to complete cares or replace the appliance and was not necessary. Any normal person would have been embarrassed, humiliated, and felt it was demeaning. During an interview on 1/27/25 at 4:07 p.m. administrator stated on 1/18/25, he was made aware of the incident when NA-A had taken a picture of a resident and posted it on social media. The incident was not reported to the SA, did not meet the reportable guidelines of the algorithm. The person in the photo was unidentifiable. This employee had worked at other faculties and not sure where the photo was taken, location, or which employer. He was aware of two other incidents where NA-A used her cell phone at work and posted pictures to social media. He stated staff were expected to leave their cell phones in the locker room while at work and a sign was posted by the back door for years, no cell phones beyond these doors. Immediate action was taken to ensure that there was no other staff with personal devices on the floor, provider and family notified, educated staff, and terminated staff involved. The resident was not made aware of this incident per family request. Facility policy Free from Abuse and Neglect dated 11/1/22, identified the facility will ensure that each resident has the right to be free form abuse, neglect, and corporal punishment of any type by anyone. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, and mental abuse including abuse facilitated or enabled using technology. Willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental and verbal abuse was defined as verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Facility Social Media Policy dated 11/1/24, identified Valley Care and Rehab respects the desire of employees to use social media including but not limited to all social networking communications, electronic communications, and electronic information for personal expression. However, employees' use of social media can pose risks to the residents' confidential, proprietary and sensitive information, can harm the facility: reputation in the community, expose facility to discrimination and harassment claims, jeopardize facility compliance with business rules and laws including but not limited to the Health Insurance Portability and Accountability Act (HIPPA) and related laws and regulations protecting residents' protected health information (PHI). Electronic devices were defined as any device used for electronic communication or electronic information included: computers, laptops, tablets, digital cameras, video recorders, fax machines, copiers, scanners, telephone system, smart phones, cell phones, and pagers. Employees are absolutely prohibited from using social media in any way that would violate HIPPA or otherwise disclose or compromise residents' public health information (PHI). This includes but is not limited to the following: Do not use social media to post, upload, send or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law. You must use Valley Care and Rehab's authorization form to obtain such prior written permission. This prohibition includes photos and videos where the resident is not easily identifiable (e.g., a photo of the resident's hand, a close-up photo of any part of a resident's body, or a photo of the back of a resident in the far background of the photo). It also includes photos or video where the resident is easily identifiable, whether in the photo or video itself or through a caption. Personal use of social media is never permitted on working time. Facility resident Consent to Photograph dated 1/1/25, located in the resident admission packet, identified I hereby authorize consent to the making of photographs of me while I am a resident at Valley Care Rehab. I understand that the photographs maybe made by my attending physician or an employee of the facility. I understand that such photographs maybe used for treatment purposes, including the assessment and evaluation of my wound(s). I understand that these images will be stored in a secure manner and will protect privacy and that they will be kept for the time required by law.

Based on interview and document review, the facility failed to immediately report no later than two hours, an allegation of abuse to the State Agency (SA) for 1 of 1 residents (R1) reviewed for abuse. Findings include: Nursing Assistant (NA)-A's Employee Acknowledgment dated and signed on 6/23/21, identified she had received, read, and understood and comply with the Valley Care and Rehab's Social Media policy. Any questions regarding this policy would be addressed by human resources. A violation of Social Media policy would result in disciplinary action and/or termination. NA-A's personnel file identified previous write-ups completed on the following dates: -On 7/19/21, director of nursing (DON) was made aware NA-A had utilized snapchat (social media) during work without regard as to who was in the background. NA-A admitted she had used her phone on the shift during the night. She verbalized understanding of phone expectations and when/where it was appropriate to use. -On 9/14/23, the writer had been made aware NA-A had posted pictures on social media of herself with diarrhea on covered pants in the hopper room (dirty utility room) with a caption what a shitty Friday and a thumbs up. She was informed even though the picture did not have personal information, the resident family could probably identify or suspect, with the style and color of the pants. She was informed this displayed unprofessional, and many companies would consider posting a picture such this to any online platform would be grounds for termination. She did not agree it was unprofessional and only wanted to know who had shown it to the writer. She was informed by writer it was expected she stop posting things of that nature from this facility. According to the State Operations Manual Appendix PP dated 8/8/24, identified the definition of mental abuse includes abuse that was facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging. If a photograph or recording of a resident, or the manner that it is used, demeans or humiliates a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. include, but is not limited to, photographs and recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, using the bathroom, providing perineal care such as after an incontinence episode, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part such as breasts or buttocks without the resident's face, labeling resident's pictures and/or providing comments in a demeaning manner, directing a resident to use inappropriate language, and showing the resident in a compromised position. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition without behaviors. He required supervision with sit to stand, chair to bed transfers, and ambulation up to 10 feet, partial/moderate assistance with upper body dressing, personal hygiene, substantial/maximal assistance with lower body dressing, roll left/right in bed, dependent upon staff for toileting hygiene, and used a walker and wheelchair for mobility. He had an indwelling urinary catheter and colostomy (a surgical procedure that creates an opening in the abdomen for waste to exit the body). R1's diagnoses included neurogenic (lack of bladder control due to brain, spinal cord, or nerve problems), arthritis, and depression. R1's care plan dated 12/12/24, identified he had an assisted daily living (ADL) self-care performance deficit related to supra pubic (empties the bladder through an incision in the abdomen instead of a tube in the urethra) urinary catheter and colostomy, and was dependent upon staff to manage these external devices and provide assistance with toilet hygiene. Review of nursing assistant schedule from 1/13/25 through 1/26/25, identified NA-A was scheduled to work on 1/17/25, Friday 4:00 p.m. to 9:30 p.m. Facility investigation report dated 1/18/25, identified DON received a telephone call from Barnesville Police department and a phone text message from a citizen in Barnesville regarding actions by one of the staff members of the facility. The picture showed a resident's right hand with liquid stool on it, a catheter bag on the floor with tubing attached to a stat lock (a cassette that held the urinary catheter tubing in place) and the resident's colostomy bag which had leaked. The caption to the photo was my 13 th reason name at the top of photo identified a name of social media account and below it was NA-A's name. The PO identified the staff member as NA-A. DON spoke with NA-A and she stated she had not made any snaps today and once she was informed of the photo evidence she confessed and told DON she had posted something to her private story, had taken it down, but not soon enough, when she realized it was inappropriate. She had a rough night prior to her shift and had influenced her decision making. NA-A had received verbal warnings in July 2021 and 2023 regarding cell phone use and social media. Education regarding facility policy on social media and electronic devices were reviewed with her and verbalized understanding. It was determined that despite the education, she lacked understanding of the seriousness of this incident as was at risk for repeat offenses, employment was terminated on 1/21/25. The photographs contained no identifying information to breach Health Insurance Portability and Accountability Ace of 1996 (HIPAA) (prohibiting the disclosure of protected health information). The photograph was not explicit in nature. The resident did not have any verbal/nonverbal distress to the incident. All resident needs were met and it was not identified that NA-A acted in a willful manner. There was no physical confinement, punishment, or intimidation identified. DON and interdisciplinary team (IDT) determined the incident was poor judgment it would not be reported. Strict enforcement of facility cell phone policy will be implemented to protect residents, moving forward. During an interview on 1/24/25 at 1:00 p.m. complainant (C) stated NA-A had taken a picture of a resident who sat at edge of bed after the colostomy bag had exploded. The picture showed stool on the resident hand and leg and caption on the picture was 13 Reasons why. C stated she must have had a crappy day and most likely the reason she posted it. C stated this was an invasion of privacy and a HIPAA violation. During review of a photo attachment on 1/26/25 submitted with complaint identified a person sat with right lower arm positioned on a mattress and right hand hung over the edge with dark golden mushy yellow substance (appeared to be stool) located on the thumb, pointer and middle fingers. The person's right leg was bare from the center of the upper thigh down to the upper calf. Located on the middle top part of the right thigh was a stat lock that held the urinary catheter tubing in place with tubing attached to the catheter bag that was located on the floor folded over. The person had a colostomy bag that hung down from their right upper thigh area that contained the same stool substance located on the fingers. Top of colostomy bag was covered with material. The end of the colostomy bag clamp appeared to have let loose, and stool was located on the bed sheet off to the right side of the person and had ran down the side of the mattress. There was a moderate amount of stool on the floor underneath the person's right leg. Written towards the bottom of the picture was my 13th reason and at the top of the picture identified 2 hours ago by NA-A's name. During an interview on 1/27/25 at 11:07 a.m. licensed practical nurse (LPN)-A stated taking photos of residents and posting them on social media would be considered very serious HIPPA violation, and an invasion of their privacy. She had told staff in report cell phone must be placed in the staff locker room and were not allowed out on the floor while they worked. The facility had posted a yellow sign a long time ago on the door by the kitchen area that indicated: No Cell Phones Allowed Beyond this Point. During an interview on 1/27/25 at 11:17 a.m. NA-B stated staff were not allowed to have their cell phones on them while on duty and caring for residents. Residents needed to be protected and it would not be ok to take pictures and post them on social media, would be considered a HIPPA violation and most likely embarrass the resident for sure. During an interview on 1/27/25 at 12:12 p.m. NA-A stated she had been terminated, was wrongful just from an incident with her cell phone. She had used her cell phone while she cared for a resident in his room. R1's colostomy bag had exploded, she had taken a picture of the feces, his hand, colostomy, the bed, floor, and part of his bare leg. She did not think family could have identified him in the picture there was not a picture of his face. She posted the picture of R1 on 1/17/25, while she was at work on a private social media site snapchat with only a handful of people on it. She removed it an hour later because she was ashamed, embarrassed, was unprofessional, and she had let her emotions get the best of her. She knew what she was doing, did it anyway, and regrets it. R1 was not asked if the picture could be taken nor was he aware it was taken, he had dementia. She said if R1 knew it had been taken and posted on social media it would have affected him negatively, he would feel embarrassed and was an invasion of his privacy. NA-A stated this would not be a HIPPA violation because there were not any specific identifiers therefore, unable to identify him. On her private social media site there were at least 15 people and at least two of them worked with her at this facility. She stated only one resident currently had a colostomy and never though about those that worked with her, they could have identified him. Staff were allowed to have had their cell phones and used them while they worked at the facility with residents. She was unable to recall any write ups in the past regarding issues with her use of cell phone at work and social media posts. During an interview on 1/27/25 at 3:11 p.m. family member (FM) stated R1 was a very private person, made sure his colostomy and urinary catheter bags were always covered. R1 was consciousness and did not want them exposed. If a picture was taken of anyone for that matter and posted on social media even without a face would be demeaning and humiliating. R1 did not know this happened but if he did, it would have bothered him and was an invasion of his privacy. During an interview on 1/27/25 at 3:37 p.m. DON stated 2021 NA-A had taken a picture with her cell phone along with another staff member at work and there was a resident behind her. She stated 2023 NA-A had taken a picture with her cell phone in a utility room by herself, held up resident's pants soiled with stool, and posted it to social media. Education was provided and included facility policy and expectations. DON stated on 1/18/27 she was made aware by a police officer (PO) on 1/17/25, NA-A had taken a picture of R1 and posted it onto social media for anyone on her account to see, unsure of how many but was too many. R1 was not aware of what happened, had a poor memory and was not interviewable. The facility had a cell phone policy in place since she became DON (2015) and staff were expected to leave their cell phones in the staff locker room while on the floor working with residents. DON stated NA-A made a poor choice in the moment, had taken a photo of a resident and posted it to social media which affects privacy and dignity. The incident was not filed with SA, the resident was not identifiable in the photo. She stated NA-A was immature, knew what she did was wrong, used poor decision making that led her to take the picture. The incident was not a willful act and was not done to hurt or embarrass R1. A reasonable person would been upset about this and asked why are you taking a picture of my colostomy. The picture was not taken to complete cares or replace the appliance and was not necessary. Any normal person would have been embarrassed, humiliated and felt it was demeaning. During an interview on 1/27/25 at 4:07 p.m. administrator stated on 1/18/25, he was made aware of the incident when NA-A had taken a picture of a resident and posted it on social media. The incident was not reported to the SA, did not meet the reportable guidelines of the algorithm. The person in the photo was unidentifiable. This employee had worked at other faculties and not sure where the photo was taken, location, or which employer. He was aware of two other incidents where NA-A used her cell phone at work and posted pictures to social media. He stated staff were expected to leave their cell phones in the locker room while at work and a sign was posted by the back door for years, no cell phones beyond these doors. Immediate action was taken to ensure that there was no other staff with personal devices on the floor, provider and family notified, educated staff, and terminated staff involved. The resident was not made aware of this incident per family request. Facility Combined Federal and State [NAME] of Rights last revised 2/1/17, identified each resident must be treated with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his/her quality of life. The resident has the right to be free from abuse, neglect and misappropriation of resident property, and exploitation of this subject. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Facility policy Free from Abuse and Neglect dated 11/1/22, identified the facility will ensure that each resident has the right to be free form abuse, neglect, and corporal punishment of any type by anyone. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, and mental abuse including abuse facilitated or enabled using technology. Willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental and verbal abuse was defined as verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Facility policy titled Reporting of Reasonable Suspicion of a Crime/Reporting of Alleged Violations dated 2/14/24, identified: -What should be reported: all alleged violation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property. -Who is required to report: the facility. -To whom: Facility administrator, Office of Health Facility Complaints (OHFC), Clay County Social Services, Law Enforcement, Attending Physician, and Resident's Representative. -When: All alleged violations. Immediately, but not later than 2 hours. If alleged violation involves abuse or results in serious bodily injury. Facility Social Media Policy dated 11/1/24, identified Valley Care and Rehab respects the desire of employees to use social media including but not limited to all social networking communications, electronic communications, and electronic information for personal expression. However, employees' use of social media can pose risks to the residents' confidential, proprietary and sensitive information, can harm the facility: reputation in the community, expose facility to discrimination and harassment claims, jeopardize facility compliance with business rules and laws including but not limited to the Health Insurance Portability and Accountability Act (HIPPA) and related laws and regulations protecting residents' protected health information (PHI). Electronic devices were defined as any device used for electronic communication or electronic information included: computers, laptops, tablets, digital cameras, video recorders, fax machines, copiers, scanners, telephone system, smart phones, cell phones, and pagers. Employees are absolutely prohibited from using social media in any way that would violate HIPPA or otherwise disclose or compromise residents' public health information (PHI). This includes but is not limited to the following: Do not use social media to post, upload, send or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law. You must use Valley Care and Rehab's authorization form to obtain such prior written permission. This prohibition includes photos and videos where the resident is not easily identifiable (e.g., a photo of the resident's hand, a close up photo of any part of a resident's body, or a photo of the back of a resident in the far background of the photo). It also includes photos or video where the resident is easily identifiable, whether in the photo or video itself or through a caption. Personal use of social media is never permitted on working time.

Based on observation, interview, and document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 2 of 2 hallways observed for linen transportation. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. During an observation on 3/4/24 at 3:56 p.m., housekeeping aid (HA)-A exited R16's room with laundry, lifted linen bin cover off of dirty linen bin in hallway next to transmission based precaution room and placed laundry in dirty linen bin. HA-A removed laundry from uncovered cart, delivered laundry to R26's room and exited room. HA-A entered R20's room and was observed to take a blanket off of R20's bed and placed blanket on R20 who was laying in the recliner. HA-A removed laundry from uncovered cart, placed laundry in R20's room, took empty hangers out of R20's room and hung on cart. HA-A removed laundry from cart, knocked on R18's door, opened closet door, hung laundry in closet, opened drawer, placed laundry in drawer, exited R18's room with empty hangers and hung hangers on cart. HA-A removed laundry from uncovered cart, knocked on R9's door, entered R9's room, opened drawer, placed laundry in drawer, opened closet, hung laundry in closet and exited R9's room. HA-A removed laundry from cart, placed laundry on R21's bed, opened closet, hung laundry in closet, opened drawer, placed laundry in drawer, exited R21's room with empty hanger and hung on cart. HA-A removed laundry from cart, entered R7's room, opened drawer, placed laundry in drawer, opened closet, placed laundry in closet, left R7's room with empty hangers and hung on cart. HA-A covered empty laundry cart and returned it to the laundry room. HA-A removed another laundry cart from the laundry room and pushed the covered cart down the north hall. HA-A uncovered the cart, removed laundry from cart, entered R35's room, opened closet door, hung laundry in closet, opened drawer, placed laundry in drawer and exited R35's room. HA-A removed laundry from the uncovered cart, entered R19's room, opened closet door, hung laundry in closet, opened drawer, placed laundry in drawer and exited R19's room. HA-A removed laundry from cart, placed in R17's closet, exited R17's room with empty hanger and hung hanger in cart. HA-A removed laundry from cart, entered R28's room, opened closet door, hung laundry in closet, exited R28's room with empty hanger and hung hanger on uncovered cart. HA-A removed laundry from cart, placed laundry in R81's closet, emptied R81's room with empty hangers and hung on cart. HA-A removed laundry from cart, knocked on R22's door, placed laundry in R22's closet and exited R22's room. Three visitors were observed to walk past the uncovered cart. In addition, R22 and two visitors walked past uncovered cart. HA-A removed laundry from cart, entered R23's room, opened closet door, hung laundry, opened drawer, placed laundry in drawer, exited R23's room with empty hangers and hung hangers on cart. HA-A removed laundry from cart, entered R27's room, opened closet door and hung laundry, opened drawer, placed laundry in drawer, exited R27's room with empty hangers and hung on cart. HA-A removed laundry from cart, knocked on R13's door, opened door, opened closet and hung laundry, opened drawer and placed laundry in drawer. HA-A exited R13's room with empty hangers and hung hangers on cart. HA-A removed laundry (blankets/quilts) from cart and placed laundry in R13's closet. HA-A closed door to R13's room, covered cart and pulled the cart down hall. HA-A returned the cart to the laundry room, opened door and pushed cart into clean area of laundry room. HA-A did not sanitize her hands during the entire observation. The laundry carts remained uncovered during the entire observation while in the resident hallways. During an interview on 3/4/24 at 4:25 p.m., HA-A stated the facility policy for laundry was to keep the cart covered when transporting down hallways. HA-A confirmed she did not cover the linen cart while in the hallway distributing laundry. HA-A stated she sanitized her hands before she started distributing laundry and when she was completely done distributing laundry. HA-A verified she knocked on resident doors, touched closet handles, drawer handles, assisted with resident cares, removed hangers from resident rooms and put into laundry cart. HA-A confirmed that resident and family members walked past the uncovered cart and could potentially contaminate the laundry when the cart was left uncovered. Environmental service director (EVS) walked down hallway and joined the conversation. EVS confirmed the facility could improve on their process for preventing cross contamination and that hand hygiene should have been completed in between resident rooms. During an interview on 3/5/24 at 2:13 p.m., the director of nursing/infection preventionist (DON) stated the expectation was staff would complete hand hygiene in between resident rooms and the cart would be covered during laundry/ linen delivery to prevent the spread of infections. Review of a facility policy titled Handling Clean Linen Policy dated 5/24/22, indicated laundry should be packaged, transported and stored in a manner that ensured cleanliness and protected the laundry from dust and soil. Clothing would be taken out of cart and covered again while unattended in the hallways.

Based on observation, interview, and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 8 of 8 residents (R2, R3, R5, R6, R8, R13, R24, R28) reviewed for dining services. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact and was independent with eating. R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact and was independent with eating. R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and was independent with eating. R6's significant change Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact and was independent with eating. R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated R8 was cognitively intact and required supervision with eating. R13's annual Minimum Data Set (MDS) dated [DATE], indicated R13 was cognitively intact and was independent with eating. R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated 24 was cognitively intact and was independent with eating. R28's significant change Minimum Data Set (MDS) dated [DATE], indicated R28 was cognitively intact and was independent with eating. During an observation on 3/4/24 at 12:00 p.m., dietary manager (DM) was observed pushing the food cart from the kitchen down the hall, unzipped clear cover on cart, delivered food tray to R6, sanitized hands, returned to food cart, delivered tray to R5 and exited room. DM sanitized hands, delivered tray to R24. DM, pushed cart down hall, delivered tray to R28 and returned cart to the kitchen. During an observation on 3/4/24 at 12:06 p.m., DM was observed placing food from steam table onto individual uncovered food trays and placed onto food cart that was covered with a clear plastic cover in the kitchen. DM pushed food cart down hall to deliver tray to R4. At 12:13 p.m., DM was asked to temp the food before delivering to R4. Temperatures were noted to be as follows: fish 100 degrees Fahrenheit (F) rice 122 (F) vegetables 99.2 (F) DM took tray to kitchen and threw food away. DM confirmed she was unable to retain heat to food during transport without individual tray covers or plate warmers that were not available at the facility. During an observation on 3/4/24 at 12:18 p.m., DM placed three food trays onto food cart, and at 12:24 p.m., placed another food tray onto the food cart. DM pushed food cart down hallway and knocked on R8's door. DM was asked to temp food prior to delivering to R8. Temperatures were noted to be as follows: fish 60 degrees (F) DM left pudding with R8 stating, fish was cold and would bring back fresh fish. DM delivered food tray to room [ROOM NUMBER] with alternative food choice of chicken nuggets. At 12:27 p.m., DM was asked to temp food tray to be delivered to R2. Temperatures were noted to be as follows: chicken 100 degrees (F) rice 110 (F) vegetables 101 (F) R2 asked why she wasn't getting her food, DM stated, it was cold and was going to get her fresh warm food. R2 replied, my food is always cold. During an interview on 3/4/24 at 2:05 p.m., R6 stated the food was not very good and lunch was warm but not hot. During an interview on 3/4/24 at 2:12 p.m., R5 reported the food was normally cold when served in the room. During an interview on 3/4/24 at 2:20 p.m., R24 stated he had informed staff numerous times about the poor food quality and hot foods not being hot when delivered to his room and R24 indicated nothing had changed. R24 stated lunch today was barely warm enough to eat. During an interview on 3/5/24 at 2:22 p.m., DM stated the expectation of staff were to know their job procedures, policies and health codes of the kitchen. Staff were provided specific education on food temps and cooks had serve safe certification for proper food temp storage and preventing cross contamination. DM verified food temps needed to be at safe parameters to prevent food borne illnesses and infections. During a interview on 3/6/24 at 2:32 p.m., director of nursing (DON) verified the food cart should have been covered with no interruptions in delivery to maintain proper temps. DON stated she did not know how to keep food delivery trays to rooms warm without hot plates or covers. DON confirmed food temps should remain at the recommended levels according to food service guidelines and if hot food was cold and not at appropriate temperatures residents could develop gastrointestinal illness. Review of the facility policy titled Food Procurement, Store/Prepare/Serve- Sanitary policy revised 3/5/24, indicated all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. \ A copy of the policy prior to date of 3/5/24, was requested however had not been received.

Based on interview and document review, the facility failed to report to the State Agency (SA) immediately for an injury of unknown origin for 1 of 1 residents (R1) who fell , resulting in a fractured right leg. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairments. R1's diagnoses included heart failure, diabetes, major depression, unspecified dementia and anemia. R1's care plan dated 1/25/24, indicated R1 was a fall risk and goal indicated to be free from falls. Interventions included call light within reach, floor mats alongside R1's bed, and bed positioned to the lowest setting before staff were to leave. R1's fall management program dated 2/3/24, indicated at 1:00 a.m., R1 was found sitting on the floor by bed. R1 reported he had not hit his head however reported pain all over body; R1 refused hospital evaluation. R1's fall management program dated 2/3/24, indicated at 6:30 a.m., R1 was found lying on the floor near bed. R1 was unable to state what happened. Pain was located on right lower leg and R1 agreed after approximately 1 hour to be evaluated at the hospital. Hospital diagnosis was right lower leg fracture (oblique proximal tibial). Facility failed to report injury of unknown origin to the SA. R1 was unable to inform facility how fall occurred and outcome was fractured right leg. During interview on 2/9/24 at 2:32 p.m., registered nurse (RN) stated she was present after R1's fall at 6:30 a.m. on 2/3/24. RN stated R1 could not tell what caused the fall, and later agreed to go the hospital after pain medications were given. RN stated a call to the assistant director of nursing (ADON) was completed and RN reminded ADON to call in the incident to the SA as he didn't know how the fall occurred. During interview on 2/9/24 at 3:48 p.m. ADON stated R1's last fall at 6:30 am on 2/3/24 a preliminary investigation was started and was determined to not report to SA as there was no abuse that occurred. ADON further explained the preliminary investigation consisted of only the report from RN at the time of the fall. ADON stated the preliminary investigation took longer than the 2 hour which was required by the facilities policy. ADON agreed this incident should had been reported to the SA and continue the investigation. Review of facility's internal investigation lacked evidence a report was submitted to SA. The facility's policy titled Reporting of Reasonable Suspicion of a Crime Reporting of Alleged Violations, revised date 11/1/2022, indicated serious bodily injury-immediately but not later than 2 hours after forming the suspicion.

Based on observation, interview and document review, the facility failed to ensure resident advance directives were accurately documented in the electronic health record (EHR) and displayed correctly on the doorframe to reflect the residents current wishes (green dot indicated- cardiopulmonary resuscitation (CPR); red dot indicated- do not resuscitate (DNR), which affected 2 of 16 residents (R10 and R29) reviewed for advance directives. This deficient practice resulted in an immediate jeopardy (IJ) for (R10) who would not have received CPR, contrary to her wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R10's current physician's order for life sustaining treatment (POLST) signed on [DATE], identified R10 was to receive CPR, however R10's EHR's main screen (banner), physician orders and the magnetic red dot identified R10's wishes were DNR. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 1:06 p.m. The IJ was removed on [DATE] at 6:51 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: R10 During an interview on [DATE] at 11:17 a.m., R10 confirmed in the event her heart stopped or she was not breathing, she would want staff to perform CPR and she stated, that's what I want them to do. R10's admission Minimum Data Set (MDS) dated [DATE], identified R10 had diagnoses which included: heart failure and malnutrition. R10's current POLST signed by her on [DATE], identified R10's wishes were to receive CPR in the event she had no pulse or respirations. The POLST was scanned into her EHR and signed by her primary physician on [DATE]. Review of R10's EHR Order Summary Report dated [DATE], identified R10 had an order for DNR and was signed by her primary physician on [DATE]. Review of R10's EHR banner on [DATE] at 6:03 p.m., identified R10 was a DNR. R10's care plan revised on [DATE], lacked R10's advance directives and wishes. Review of R10's Progress Notes from [DATE] to [DATE], lacked any documentation regarding her advanced directive or her wishes. During an observation on [DATE] at 6:09 p.m., a red magnetic dot was affixed to the inside of the doorway frame in the left upper corner of R10's door indicating R10's wishes were to be DNR. During an interview on [DATE] at 6:03 p.m., assistant director of nursing (ADON)-B indicated in the event a resident did not have a pulse or respirations, she would refer to the magnetic dot on the resident's doorframe to determine if CPR should be administered or not and would have proceeded accordingly. During an interview on [DATE] at 6:04 p.m., ADON-A indicated in the event a resident did not have a pulse or respirations, she would refer to the resident's EHR's banner to determine what their wishes were and proceed accordingly. Stated if she did not have access to the EHR, she would look at the magnetic dot located on the resident's doorway. Indicated the social worker reviewed and completed the POLST with each resident during the admission process and was then signed by the resident's primary physician. Once the POLST was signed, a copy would be provided to her and she was responsible for updating the EHR's banner and scanning it into the EHR. During an interview on [DATE] at 6:09 p.m., registered nurse (RN)-A indicated in the event a resident did not have a pulse or was not breathing, she would look at the magnetic dot located on the resident's doorway frame to determine if she should initiate CPR or not. During an interview on [DATE] at 6:14 p.m., licensed practical nurse (LPN)-C indicated in the event a resident did not have a pulse or was not breathing, she would look to see if there was a magnetic dot on the door to determine if she should initiate CPR or not. During an interview on [DATE] at 9:13 a.m., LPN-A indicated in the event a resident did not have a pulse or no respirations, she would look at the dot on the doorway to determine if she should initiate CPR or not. During an interview on [DATE] at 9:14 a.m., LPN-B indicated in the event a resident coded she would look at the EHR banner to determine if the resident wanted CPR or was DNR. During an interview on [DATE] at 9:13 a.m., RN-B indicated in the event a resident did not have a pulse or respirations, she would look at the dot on the doorway to determine is she should initiate CPR or not. During a follow up in interview on [DATE] at 9:54 a.m., ADON-B indicated R10's current POLST dated [DATE], identified R10's wishes were to be CPR. ADON-B verified R10's EHR banner and the magnetic dot on the inside of R10's doorway indicated DNR was inaccurate according to the POLST. ADON-B indicated in the event R10 did not have a pulse or respirations, CPR would not have been initiated per her wishes. The ADON-B verified the POLST was to be completed during the admission process with the social worker and was provided to her after completion and she or ADON-A were responsible to update the EHR. During an interview on [DATE] at 11:21 a.m., the DON indicated the social worker completed the POLST with each resident upon admission, provided a copy to the ADON's and the EHR would then be updated with the resident's wishes. She confirmed there was a discrepancy and R10's EHR, the red dot on R10's doorway and her current POLST did not match to accurately reflect R10's wishes. DON confirmed in the event R10 did not have a pulse or respirations, CPR would not have been initiated per R10's wishes and could have resulted in an unnecessary death. She indicated she would expect staff to follow the POLST, the resident wishes and to follow the facility policy. Review of the facility policy titled, Cardio-Pulmonary Resuscitation (CPR) revised [DATE], identified all residents would be informed of their option to formulate an advance directive. If a resident had a valid advanced directive, the facility would ensure the care reflects the resident's wishes as expressed on the directive. Identified, upon admission all residents/representatives would complete a POLST. The medical orders were based on the resident's current medical condition and preferences. The policy indicated the facility would maintain the original copy of the signed POLST, the status would be in the medical record, care plan, care guides, nurse's notes, and indicator (red-DNR and green-CPR) would be affixed to the inside of the door jam. The IJ was removed on [DATE] at 6:51 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, the electronic medical records were updated to ensure resident's wishes for advance directives, red and green dot system was accurately in place and care plan interventions were accurate on [DATE]. - Advanced Directive audit tool reviewed by interdisciplinary team and found to be appropriate in preventing future deficient practices related to documentation of advance directives. - All current direct care staff (certified nursing assistants & licensed nurses) were educated on the policy for advanced directives, obtaining and documenting the POLST to reflect the resident's wishes, on [DATE], as evidenced by the Education Sign in Sheet and interviews. - A process was implemented to assure all other nursing staff completed mandatory education prior to the start of their next shift on [DATE], by notification of required mandatory education via phone/text. Education to all future shifts would be provided by the charge nurse, ADON, or DON prior to the start of the shift. Education would be verbal and written. Direct care staff would sign off once education had been completed. - The Advanced Directive policy was reviewed and revised to reflect changes on [DATE]. 48740 R29 R29's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R29 had diagnoses which included: heart failure and hypertension. R29's POLST form dated [DATE], located in R29's EHR indicated R29 wanted CPR. Review of R29's EHR current Physician Orders dated [DATE], revealed R29 had an order for CPR. R29's care plan dated [DATE], indicated R29 requested CPR. During an observation on [DATE] at 6:25 p.m., R29's door frame lacked a magnet in place to identify what his code status was. During an interview on [DATE] at 12:42 p.m., ADON-A stated R29's room lacked a magnet to alert staff what his code status was. She indicated she placed a magnet on the door frame of R29's room on the evening of [DATE], after she had learned the magnet was not in place to identify R29 wanted CPR. During a follow up interview on [DATE] at 1:42 p.m., ADON stated his code status was CPR as verified by his order signed on [DATE]. During an interview on [DATE] at 2:41 p.m., R29 confirmed he would want CPR administered in the event he experienced cardiac arrest.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R7, R10, R21 and R24) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the current CDC recommendations 3/15/2023, revealed The CDC identified Adults [AGE] years of age or older who had not previously received Pneumococcal 13-valent Conjugate Vaccine (PCV13) and who had previously received one or more doses of Pneumococcal Polysaccharide Vaccine 23 (PPSV23) should receive a dose of Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Pneumococcal 20-valent Conjugate Vaccine (PCV20). The dose of PCV15 or PCV20 should be administered at least one year after the most recent PPSV23 dose. In addition, the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 was received at age 65 and older, based on shared clinical decision-making, one dose of PCV20 at least five years after the last pneumococcal vaccine dose. In addition CDC guidelines dated 2/13/23, identified Adults [AGE] years of age or older who have not received any pneumococcal vaccines should receive one dose of PCV15 or PCV20. Review of R7's facesheet, identified R7, age 81, was admitted to the facility on [DATE]. Review of R7's Minnesota Immunization Information Connection (MIIC) undated, identified R7 had received Pneumo-PPSV13 on 11/30/2015, and the Pneumo- PPSV23 on 10/10/13. R7's medical record lacked documentation R7 had been offered or received the PCV20 vaccine. Review of 10's face sheet, identified R10, was admitted to the facility on [DATE]. Review of R10's MIIC undated, identified R10 had received Pneumo-PPSV13 on 11/19/2002, and 9/13/2017. In addition, MIIC identified R10 received Pneumo-PPSV23 on 9/29/2014. R10's medical record lacked documentation R10 had been offered or received the PCV20 vaccine. Review of R24's facesheet, identified R24, age 92, was admitted to the facility on [DATE]. Review of R24's MIIC undated, identified R24 had not received any of the Pneumococcal vaccines. R24's medical record lacked documentation R24 had been offered or received the PCV15 or PCV20. Review of R21's facesheet, identified R21 age 78, was admitted to the facility on [DATE]. Review of R21's MIIC undated, identified R21 had received Pneumo-PPSV13 on 12/12/2005, and 10/26/2015. In addition, MIIC identified R21 had received Pneumo-PPSV23 on 12/12/2005, and 2/19/2013. R21's medical record lacked documentation R21 had been offered or received the PCV20. During an interview on 7/26/23 at 1:50 p.m., director of nursing (DON) confirmed the facility process was to review the MIIC report and to administer pneumococcal vaccinations according to the CDC recommendations. DON confirmed R7, R10, R21, and R24 had not received the pneumococcal vaccinations as recommended by the CDC. Facility policy titled Influenza and pneumococcal Immunizations revised 11/1/22, identified unless medically contraindicated or previously immunized, all residents would be offered pneumococcal immunizations per CDC/Minnesota Department of Health (MDH) guidelines. The policy indicated the facility would maintain documentation as to why the vaccine was not administered.

Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 1 residents (R7) who utilized an indwelling catheter. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition and diagnoses which included cancer and renal insufficiency (poor functioning kidneys). Identified R7 required extensive assistance with activities of daily living which included personal hygiene and toileting. Indicated R7 had an indwelling catheter. R7's significant change in status Care Area Assessment (CAA) dated, 4/10/23, identified R7 required extensive assistance with toileting. Indicated R7 had an indwelling catheter related to urinary retention (unable to completely empty the bladder). R7's care plan revised on 1/26/23, identified R7 had an indwelling catheter due to urinary retention. Care plan instructed staff to position catheter bag and tubing below the level of the bladder and away from entrance of the door. Care plan indicated R7 required extensive staff assistance for toilet use. During an observation on 7/24/23 at 1:12 p.m., R7 was seated in his wheelchair in the hallway and a visitor walked by. R7's indwelling catheter leg bag which contained dark yellow urine was hanging out the bottom of his left pant leg and was visible to anyone who walked by. During an interview on 7/24/23 at 1:17 p.m. ,R7 stated it would be nice if his leg bag was higher on his leg or covered so that it was not visible to everyone who walked by. During an observation on 7/25/23 at 8:55 a.m., R7 was seated in his wheelchair in the dining room. R7's indwelling catheter leg bag which contained dark yellow urine was hanging out the bottom of his left pant leg. The leg bag was visible to visitors and other residents who were in the dining room. During an observation on 7/25/23 at 12:21 p.m., R7 was seated in his wheelchair in the dining room with several residents and two visitors present. R7's indwelling catheter leg bag which contained dark yellow urine was hanging out the bottom of his left pant leg. The leg bag was visible to other residents and visitors who were in the dining room. During an interview on 7/25/23 at 12:23 p.m., nursing assistant (NA)-A verified R7's indwelling catheter leg bag was visible to other residents and visitors. NA-A indicated it was not dignified for R7's leg bag to be visible and the expectation was R7's leg bag would have been covered with a catheter bag cover. During an interview on 7/25/23 at 12:27 p.m., licensed practical nurse (LPN)-A verified R7's indwelling catheter leg bag was visible to other residents and visitors. LPN-A stated it was not dignified for R7's leg bag to be visible and the expectation was R7's leg bag would have been covered. During an interview on 7/26/23 at 8:50 a.m. , director of nursing (DON) confirmed R7 required extensive staff assistance with his indwelling catheter leg bag. DON stated her expectation would have been R7's indwelling catheter leg bag would not have been visible to other residents or visitors. Review of a facility policy titled Resident Rights-Respect & Dignity revised 11/2/22, identified all residents were to be treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his/her quality of life. The policy indicated staff were to assist in maintaining dignity of a resident requiring a catheter by covering catheter bags.

Based on interview and document review, the facility failed to notify the Long-Term Care (LTC) ombudsman of facility initiated transfers/discharges for 1 of 1 residents (R21) who was transferred to an acute care facility on an emergency basis and discharged to the hospital. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated R21 had severe cognitive impairment and had diagnoses which included: Parkinson's, anxiety, dementia. Identified R21 required limited assistance of one staff for bed mobility, dressing, toileting, personal hygiene, and bathing. Review of R21's Progress Notes from 4/16/23 to 7/25/23, revealed the following: - On 4/21/23, R21 complained of chest pain, upper back pain and was having difficulty breathing during dinner. R21 indicated she was having anxiety and R21's oxygen saturations were 92% - 93% on three liters of oxygen. - On 4/22/23, R21 continued to have chest and back pain and was sent to the emergency room for further evaluation. R21 was admitted to the hospital for blood transfusions due to low hemoglobin. - On 4/26/23, R21 returned to the facility after receiving a blood transfusion, iron transfusion, and receiving antibiotics for a urinary tract infection (UTI). After further review of R21's medical record, lacked documentation the LTC ombudsman had been notified of R21's transfer/discharge to the hospital. During an interview on 7/25/23 at 4:24 p.m., social services designee (SSD) confirmed R21 had been hospitalized on [DATE]. SSD indicated she was not an employee during R21's hospitalization and stated she was not aware if the ombudsman had been notified. The SSD stated the facility's process was to fax the ombudsman on a monthly basis of the facility's transfer/discharges which included the resident's name, transfer/discharge location, when the transfer occurred, and the reason for the transfer/discharge. The SSD indicated a copy of the notification to the ombudsman was to be placed into the electronic health record (EHR). During an interview on 7/26/23 at 10:42 a.m., the director of nursing (DON) confirmed the above findings and indicated there was no documentation the ombudsman had been notified of R21's transfer/discharge to the hospital on 4/22/23. The DON indicated she would expect staff to follow facility policy and notify the ombudsman of transfer/discharges on a monthly basis. Review of the policy titled, Notice of Transfer or Discharge revised 11/2/22, indicated the facility would copy all transfers/discharges and would be sent to the ombudsman. The facility indicated the transfer/discharges may be sent when practicable, such as a list of residents monthly. The facility would maintain a fax transmittal receipt of the fax being successfully sent.

Based on observation, interview and document review, the facility failed to provide assistance with providing oral cares for 1 of 2 residents (R22) who was dependent upon staff for activities of daily living (ADLs). Findings include: R22's quarterly Minimum Data Set (MDS), dated [DATE], identified R22 had diagnoses which include: cerebral vascular accident (CVA/stroke), dementia, and depression. Indicated R22 required assistance of one staff with transfers, toileting, dressing, bathing, personal hygiene, and oral cares. R22's care plan revised on 6/14/23, indicated R22 had ADL self-care deficits related to infection, old stroke, carotid artery disease, and peripheral vascular disease (PVD). The care plan indicated R22 required staff assistance with oral cares and personal hygiene. Identified R22 had dentures and staff were to brush, rinse, and place dentures into R22's mouth. Review of Admission/Annual Nursing assessment dated [DATE], indicated R22 had natural teeth and required assistance with ADLs due to weakness and contractures of left hand. During an observation on 07/26/23 at 8:13 a.m., R22 laid in bed covered with a blanket. Nursing assistant (NA)-B entered R22's room, asked R22 if she was ready to get up for breakfast and R22 agreed. NA-B gathered her supplies and proceeded to assist R22 with morning cares which included washing her up, providing incontinent cares, dressing, and assisting with personal hygiene. NA-B transferred R22 via mechanical standing lift from her bed to her wheelchair. NA-B wheeled R22 out of her room, down the hallway when licensed practical nurse (LPN)-A indicated R22 needed her medication. NA-B wheeled R22 back to her room and LPN-A entered R22's room and administered R22's medications. LPN-A proceeded to wheel R22 down the hallway and into the dining room for breakfast. R22 began eating her breakfast independently. R22 had natural teeth that were stained and discolored yellow. NA-B and LPN-A were not observed to offer or provide oral cares to R22 while getting her ready for the day. During an interview on 7/26/23 at 12:09 p.m., NA-B confirmed R22 required staff assistance with oral cares and personal hygiene and never refused cares. NA-B verified she had not offered or provided oral cares to R22 because she had forgotten. During an interview on 7/26/23 at 12:46 p.m., LPN-A confirmed R22 required staff assistance with oral cares and personal hygiene. LPN-A verified she had not offered oral cares to R22 because she indicated the NA's usually provide oral cares during morning cares. LPN-A further indicated she would expect nursing staff to follow the resident care guides/care plan and to communicate with her if the residents are refusing oral cares. During an interview on 7/26/23 at 12:53 p.m., director of nursing (DON) confirmed the above findings and indicated R22 required assistance of one staff for ADLs. The DON indicated she would expect staff to follow facility policy and R22's care plan as written. Review of facility policy titled, Oral Cares revised 11/1/22, indicated the facility would provide oral cares twice daily with morning and evening cares.

Based on observation, interview and document review the facility failed to provide shaving assistance for 1 of 1 residents (R6) who was dependent on staff for activities of daily living (ADL's). Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 had severe cognitive impairments and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R6 required extensive assistance of one staff with dressing, personal hygiene and two staff for bed mobility and was totally dependent on two staff for transfers, toileting and bathing. R6's care plan revised on 2/7/22, identified R6 had an ADL self care deficit related to short term memory impairment and required total staff assistance with personal hygiene cares. R6's Nursing Aid Care Sheets dated 3/10/22, indicated R6 required staff assistance of one for grooming. During observations on 3/8/22, at 2:06 p.m. R6 laid in bed, covered with blankets, was awake and had several long white facial hairs present on her lower chin area that were approximately 1/4 inch long. - at 2:35 p.m. R6 continued to rest in bed and her facial hair remained the same. - at 2:51 p.m. R6 continued to rest in bed and her facial hair remained the same. - at 3:10 p.m. R6 continued to rest in bed and her facial hair remained the same. - at 3:51 p.m. R6 was seated in her wheel chair in her room looking around and her facial hair remained the same. During observations on 3/9/22, at 12:21 p.m. R6 was seated in her wheelchair at the dining room table with other residents and staff. R6 ate her lunch independently and continued to have several long white facial hairs on her lower chin area that were approximately 1/4 inch long. - at 12:48 p.m. R6 continued to eat her lunch in the dining room and her facial hair remained the same. - at 1:20 p.m. R6 continued to eat her lunch in the dining room and her facial hair remained the same. During an observation on 3/10/22, at 7:37 a.m. R6 laid in bed, covered with blankets, was awake and continued to have several long white facial hairs present on her lower chin area that were approximately 1/4 inch long. - at 8:15 a.m. R6 was seated in her wheel chair in her room and the director of nursing (DON) provided morning cares. The DON assisted R6 by combing her hair, placed her glasses on, cleaned her dentures and placed them in her mouth. The DON confirmed R6 had several white facial hairs present on her chin area. The DON proceeded to push R6 via wheel chair out of her room and down to the dining room area and set her up to the table for breakfast. On 3/9/22, at 8:45 a.m. family member (FM)-A indicated staff assisted R6 with cares and personal hygiene. FM-A indicated R6 in her younger years would have removed the long chin hairs and confirmed R6 did not like to have hairs present on her chin. FM-A indicated he had bought R6 a razor and indicated staff should have shaved her chin hairs every other day. On 3/10/22, at 12:14 p.m. nursing assistant (NA)-A confirmed R6 required assistance with personal hygiene, grooming and shaving. NA-A indicated the NAs were responsible for making sure residents were shaved and indicated she attempted to shave R6 yesterday however her razor had not worked properly and a new one needed to be purchased. On 3/10/22, at 12:18 p.m. licensed practical nurse (LPN)-A confirmed R6 required total assistance with personal hygiene and grooming. LPN-A indicated she would expect staff to make sure R6 was neat and clean, well groomed and to make sure her chin hairs were shaved. On 3/10/22, at 12:28 p.m. the DON confirmed the above findings and indicated she would expect staff to manage grooming tasks and make sure the residents faces were clean shaven and without facial hair if the resident allowed. The DON stated residents should look dignified and respectable and staff should have been following the care plan as written. Review of the facility policy titled, Resident Personal Care- AM and PM revised on 1/18/19, indicated it was the policy of Valley Care and Rehab to ensure all residents received personal care twice a day to maintain health, hygiene and dignity.

Based on interview and record review, the facility failed to ensure the medical practioner acted upon the consultant pharmacist (CP) recommendations for 1 of 5 residents (R7) reviewed for unnecessary medications. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had diagnoses which included unspecified dementia with behavioral disturbance, anxiety disorder and hypertension (high blood pressure). The MDS identified R7 had moderate cognitive impairment and required supervision from staff with activities of daily living (ADL's) which included bed mobility, transfers and toileting. The MDS indicated R7 had no behaviors during the look back period. Review of R7's medication administration record (MAR) from 3/2022, revealed R7 had an order for [MEDICATION(S)] (an antipsychotic medication)12.5 milligrams (mg) orally (po) every four (4) hours as needed (prn) up to three doses per day with a start date of 12/24/21. Review of R7's Consultant Pharmacist's (CP) Medication forms from 11/2021, to 2/2022, revealed the following: - medication review form dated 11/24/21, indicated a recommendation for [MEDICATION(S)] 12.5 mg every 4 hours prn take as directed. The form further indicated this medication was classified as an antipsychotic and can only be continued for 14 days at a time and required the resident be seen by a provider face-to- face every 14 days and a new order written each time. R7's Practioner had signed the form on 1/11/22, and indicated a new order for [MEDICATION(S)] had been obtained. - medication review form dated 12/12/21, lacked recommendations regarding the use of [MEDICATION(S)] on an as needed basis. - medication review form dated 1/26/22, lacked recommendations regarding the use of [MEDICATION(S)] on an as needed basis. - medication review from dated 2/18/22, indicated a recommendation for [MEDICATION(S)] 12.5 mg every four hours prn, and revealed this medication was classified as an antipsychotic and could only be continued for 14 days at a time and required the resident be seen by a provider face-to-face every 14 days with a new order written each time. Form further revealed a recommendation, if R7's [MEDICATION(S)] was continued to consider decreasing the dose. The form lacked any response from R7's practioner. R7's medical record lacked documentation of R7's practioner being updated on the CP recommendations regarding the continued use of the as needed [MEDICATION(S)]. R7's psychiatry progress notes from 11/10/21, to 2/9/22, revealed the following: -11/10/21, R7 had been seen for a routine visit by her primary psychiatric nurse practioner (NP) via tele-health and the following recommendations were made, continue [MEDICATION(S)] 12.5 mg TID (three times a day) as needed, and continue for 30 days. -12/15/22, R7 had been seen for a routine visit by a psychiatric NP via tele-health, the note lacked any recommendations for R7's continued use of as needed [MEDICATION(S)]. On 1/12/22, R7 had been seen for a routine visit by a psychiatric NP via tele-health, the following recommendations were made for R7 to continue [MEDICATION(S)] 12.5 mg every four hours up to three times daily for agitation/[CONDITION(S)] for 30 days. On 2/9/22, R7 had been seen for a routine visit by a psychiatric NP via tele-health, the following recommendations were made for R7 to continue [MEDICATION(S)] 12.5 mg every four hours up to three times daily for agitation / [CONDITION(S)] for 30 days. On 3/10/22, at 11:54 a.m. during a telephone interview, the facility's CP indicated she completed medication reviews monthly for the residents of the facility. The CP confirmed as needed antipsychotic medications required a face to face visit every 14 days with a physician or a nurse practioner to continue the medication. The CP indicated she had addressed R7's use of an as needed antipsychotic medication in November 2021, and December 2021, however stated she was unaware if R7's order for as needed [MEDICATION(S)] had been addressed by a physician or a nurse practioner. The CP further stated she had discussed the 14 day rule on as needed antipsychotic medication with the facility and she would have expected R7 would have had a face to face evaluation completed every 14 days to continue the as needed antipsychotic medication. On 3/10/22, at 12:15 p.m. during an interview, the assistant director of nursing (ADON) confirmed the facility's CP had recommended R7 have a face to face evaluation for the use of the as needed [MEDICATION(S)] in November 2021, and February 2022. The ADON indicated she had discussed the need for a face to face evaluation every fourteen days for the continued use of the as needed [MEDICATION(S)] with R7's psychiatric advanced NP. The ADON stated R7's NP indicated the as needed order would be continued for 30 days. The ADON stated her expectation would be the facility would follow-up on the Pharmacy recommendations. On 3/10/22, at 12:50 p.m during a telephone interview the psychiatric advanced nurse practioner (NP) stated she saw R7 on a monthly basis via tele-health for psychiatric care and had ordered an antipsycotic medication, [MEDICATION(S)], on an as needed basis to manage R7's aggressive behaviors. The NP confirmed she had ordered R7 as needed [MEDICATION(S)] for a 30 day duration. The NP stated she was not aware of the 14 day face to face requirement for continued use of R7's as needed [MEDICATION(S)]. The NP confirmed she had not reviewed any pharmacy recommendations for R7. Review of facility policy titled, Drug Regimen Review (Monthly report) revised on 7/12/21, indicated resident specific drug recommendations / irregularities were documented and acted upon by the facility and/or physician at 30 and 60 day routine physician visits following the medication record review (MRR). Irregularities identified requiring immediate action would be acted upon by facility and/or physician within 24 hours of receiving (MRR).

Based on interview and record review, the facility failed to ensure an as needed (prn) antipsychotic medication was not renewed beyond 14 days without the practioner providing a face to face evaluation for the appropriateness of the medication for 1 of 5 residents (R7) reviewed for unnecessary medications. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had diagnoses which included unspecified dementia with behavioral disturbance, anxiety disorder and hypertension (high blood pressure). The MDS identified R7 had moderate cognitive impairment and required supervision from the staff with activities of daily living (ADL's) which included bed mobility, transfers and toileting. The MDS identified R7 had no behaviors. Review of R7's care plan printed on 3/10/22, last updated 11/5/21, identified R7 utilized a [CONDITION(S)] medication for behavior management, and directed staff to monitor for adverse reactions to the [CONDITION(S)] medication which included unsteady gait, tardive dyskinesia (a condition affecting the nervous system caused by long term use of psychiatric drugs.), frequent falls and difficulty swallowing. The Care plan instructed staff to consult with pharmacy, MD to consider dosage reduction when clinically appropriate and at least quarterly. Review of R7's medication administration record (MAR) from March, 2022, revealed R7 had an order for [MEDICATION(S)] (an antipsychotic medication)12.5 milligrams (mg) orally (po) every four hours as needed up (prn) to three doses per day with a start date of 12/24/21, and a Discontinue date of 3/9/22. Review of R7's MAR's for the months of January 2022, and February 2022, revealed the following: -January MAR revealed R7 had received [MEDICATION(S)] four times. -February MAR revealed R7 had received [MEDICATION(S)] twice during the month of February. Review of R7's Consultant Pharmacist's (CP) Medication forms from 11/2021, to 2/2022, revealed the following: - medication review form dated 11/24/21, indicated a recommendation for [MEDICATION(S)] 12.5 mg every 4 hours prn take as directed. The form identified the medication was classified as an antipsychotic and could only be continued for 14 days at a time and required the resident be seen by a provider face-to- face every 14 days and a new order written each time. R7's Practioner had signed the form on 1/11/22, and indicated a new order for [MEDICATION(S)] had been obtained. - medication review form dated 12/12/21, lacked recommendations regarding the use of [MEDICATION(S)] on a prn basis. - medication review form dated 1/26/22, lacked recommendations regarding the use of [MEDICATION(S)] on a prn basis. - medication review from dated 2/18/22, indicated a recommendation for [MEDICATION(S)] 12.5 mg every four hours prn, and revealed the medication was classified as an antipsychotic and could only be continued for 14 days at a time and required the resident be seen by a provider face-to-face every 14 days with a new order written each time. The form identified a recommendation, if R7's [MEDICATION(S)] was continued to consider decreasing the dose. The form lacked any response from R7's practioner. R7's medical record lacked documentation of R7's practioner being updated on the CP recommendations regarding the continued use of the prn [MEDICATION(S)]. Review of R7's psychiatry progress notes from 11/10/21, to 2/9/22, revealed the following: -11/10/21, R7 had been seen for a routine visit by her primary psychiatric nurse practioner (NP) via tele-health and the following recommendations were made, continue [MEDICATION(S)] 12.5 mg TID (three times a day) as needed, and continue for 30 days. -12/15/22, R7 had been seen for a routine visit by a psychiatric NP via tele-health, the note lacked any recommendations for R7's continued use of as needed [MEDICATION(S)]. - 1/12/22, R7 had been seen for a routine visit by a psychiatric NP via tele-health, the following recommendations were made for R7 to continue [MEDICATION(S)] 12.5 mg every four hours up to three times daily for agitation/[CONDITION(S)] for 30 days. - 2/9/22, R7 had been seen for a routine visit by a psychiatric NP via tele- health, the following recommendations were made for R7 to continue [MEDICATION(S)] 12.5 mg every four hours up to three times daily for agitation / [CONDITION(S)] for 30 days. On 3/10/22, at 11:54 a.m. during a telephone interview, the facility's CP indicated she completed medication reviews monthly for the residents of the facility. The CP confirmed as needed antipsychotic medications required a face to face visit every 14 days with a physician or a nurse practioner to continue the medication. The CP indicated she had addressed R7's use of an as needed antipsychotic medication in November 2021, and December 2021, however stated she was unaware if her recommendations had been addressed by R7's physician or a nurse practioner. The CP indicated she had discussed the 14 day rule on as needed antipsychotic medications with the facility and she would have expected R7 would have had a face to face evaluation completed every 14 days to continue the as needed antipsychotic medication. On 3/10/22, at 12:15 p.m. during an interview, the assistant director of nursing (ADON) confirmed the facility's CP had recommended R7 have a face to face evaluation for the use of the as needed [MEDICATION(S)] in November 2021, and February 2022. The ADON indicated she had discussed the need for a face to face evaluation every fourteen days for the continued use of the as needed [MEDICATION(S)] with R7's psychiatric advanced NP. The ADON stated R7's NP indicated the as needed order could be continued for 30 days. The ADON stated her expectation would be the Pharmacy recommendations would be followed-up on. On 3/10/22, at 12:50 p.m during a telephone interview the psychiatric advanced nurse practioner (NP) stated she saw R7 on a monthly basis via tele-health for psychiatric care and had ordered an antipsycotic medication, [MEDICATION(S)], on an as needed basis to manage R7's aggressive behaviors. The NP confirmed she had ordered R7 as needed [MEDICATION(S)] for a 30 day duration. The NP stated she was not aware of the 14 day face to face requirement for continued use of R7's as needed [MEDICATION(S)]. The NP confirmed she had not reviewed any pharmacy recommendations for R7. Review of the facility policy titled PRN Orders for [CONDITION(S)] Medication revised on 3/12/2018, indicated all as needed or PRN orders for [CONDITION(S)] medications would be limited to 14 days and could not be renewed until the attending physician or prescribing practioner evaluated the resident for the appropriateness of the medication. An intent of the policy was to have facilities implement gradual dose reduction and non pharmacological interventions prior to indicating or instead of continuing [CONDITION(S)] medications. The policy identified PRN [CONDITION(S)] medication use should be limited to only when medically necessary.

Based on interview and documentation review, the facility failed to follow recommendations from the Centers for Disease Control (CDC) to prevent the spread of COVID-19 in long term care facilities related to the use of isolation gowns. The facility policy and practice for 2 of 2 rooms, which were set aside as rooms to quarantine new admissions, hospital return and return from leave of absence residents, was to don a clean isolation gown at the beginning of the shift prior to entry of the quarantine room, doff the gown prior to leaving the room, then don the same used gown for subsequent encounters with the resident on quarantine. Findings include: During an interview on 12/21/20, at 12:25 pm a registered nurse (RN)-A indicated staff are expected to reuse the washable gown throughout the shift when in a quarantine room. The gown would be reused and worn for only that shift. RN-A verified staff are expected to label the gown nurse aide or nurse, and then the gown be placed on a hanger on the rack located in the room. This would require donning upon entrance to the room, and doffing upon exit of the same gown multiple times during the shift. During an interview on 12/21/20, at 1:40 p.m. nursing assistant (NA)-A indicated staff are expected to wear a washable gown throughout their shift when in a quarantine room. NA-A verified the gown is placed on a hook located in the room prior to leaving the room. NA-A indicated hooks are labeled with NA or nurse. NA-A also verified the staff are expected to reuse the washable gown throughout the shift then, dispose of it in the dirty laundry. During an interview on 12/21/20, at 2:30 p.m. the director of nursing (DON) indicated, staff are expected to reuse a black washable gown throughout their shift while caring for a resident in quarantine. The staff are instructed to place the black gown on a hanger on the rack provided in the room. DON verified the hanger is labeled nurse or NA and only one nurse and one NA care for each resident during a shift. DON also indicated staff are expected to place the gown in a dedicated bucket to be washed separately from the other laundry at the end of the shift. DON verified they currently have no residents on quarantine, but had used this practice since May 2020 for residents on quarantine. The facility policy titled Covid-19 Personal Protective Equipment, revised 8/28/20, identified the purpose was to provide guidelines to staff for proper and appropriate gown use for those Covid-19 negative residents in isolation to help in the prevention of the transmission of infection. The policy further identified staff are required to wear a gown for those residents placed in isolation. The gown should be reused throughout the shift and placed in the linen bucket at the end of their shift. The Center's for Disease and Control (CDC) Isolation Precautions updated April 2019, identified standard precautions, before leaving the patient's room or cubicle, remove and discard PPE (personal protective equipment). Do not reuse gowns, even for repeated contacts with the same patient.

Based on observation, interview and document review the facility failed to ensure an environment free from accident hazards during the use of mechanical lifts for resident transfers for 1 of 1 resident (R14) reviewed who required the use of mechanical lift, did not have the sling safety safety strap secured and had a fall with a major injury. This deficient practice caused actual harm to R14 who was propelled out of the wheelchair when the sling strap caught on the wheel of the wheelchair, and fractured her femur. The facility had implemented corrective action so the deficient practice is being issued at past non-compliance harm level. Findings include: R14's quarterly Minimum (MDS) data set [DATE], identified R14 had [DIAGNOSES REDACTED]. The MDS identified R14 was cognitively intact and required extensive assistance with activities of daily living (ADL's) which included bed mobility, toileting and was totally dependent with transfers. The MDS identified R14 had functional limitation in range of motion (ROM) of both upper and lower extremities and used a wheelchair. The MDS identified R14 had no falls since her last MDS assessment and had no major surgeries within the last six months. R14's annual MDS dated [DATE], identified R14 had [DIAGNOSES REDACTED]. The MDS identified R14 was cognitively intact and was totally dependent for transfers. The MDS revealed R14 had functional limitation in range of motion of both upper and lower extremities and used a wheelchair. Further, the MDS identified R14 had a fall with a major injury (fracture.) R14's annual Care Area Assessment (CAA) dated [DATE], identified R14 had a [DIAGNOSES REDACTED]. The CAA identified R14 was chair bound and required extensive assistance with ADL's and the use of a full mechanical lift for transfers. The CAA identified R14 had suffered a fractured leg as a result of a fall from the wheelchair on [DATE], which was not surgically repaired. The CAA revealed R14 was transported in the corridor in her wheelchair when she had fallen and indicated she was unable to work with physical therapy due to the unstable fracture. R14's current care plan, revised [DATE], revealed R14 required assistance of two staff and a full mechanical lift for transfers. The care plan revealed R14 preferred the full sling and indicated the full sling was to be kept under R14 when she was in a wheelchair. R14's care plan did not address her fall risk or recent fracture. R14's undated nursing assistant care guide revealed R14 required assistance of two with a Hoyer lift (full mechanical lift) for transfers, was non-ambulatory and used a wheelchair. The NA care guide did not address the lift sling or placement of sling straps. On [DATE], at 12::47 p.m. R14 was seated in a cushioned wheelchair in her room, faced her bed and had her eyes closed. R14 stated she had very touchy joints was at risk for fractures and dislocations due to her progresive joint and skeletal disease, which she had since she was born. R14 stated she was unable to bear any weight on her legs and required the use of a mechanical lift for all of her transfers. R14 pointed to the seat of her wheelchair which revealed a blue fabric mechanical lift sling with the straps tucked on either side of her upper thighs and armrest of the wheelchair. R14 stated she always had the sling underneath her and the nursing staff would attach the straps to the mechanical lift when she needed to transfer. R14 stated she had been flung out of her wheelchair in [DATE], when one of the straps caught in the front wheel when a nursing assistant (NA) wheeled her out to the dining room. R14 stated she had sustained an inoperable fracture of her left femur. R14 stated she had a history of [REDACTED]. She indicated she could not recall if the NA had tucked the sling straps alongside the armrests of the wheelchair prior to the transport, however, stated since she returned from the hospital the facility's nursing staff made sure the sling straps were tucked alongside her and the armrest of the wheelchair before they assist her with transport. On [DATE], at 5:27 p.m. NA-G indicated she had worked with R14 when she had fallen out of the wheelchair and sustained a fracture. NA-G indicated she felt R14's sling straps were secure prior to her wheeling R14 out of her room and into the hallway, and could not recall if she had physically tucked in R14's sling straps prior. NA-G indicated R14's wheelchair had abruptly stopped, R14 fell forwards out of the wheelchair and the sling strap was caught on the front wheel of her wheelchair. She indicated R14 had complained of pain to her left hip/leg area. NA-G stated she was unsure of how the straps had come loose and became lodged in the wheel of the wheelchair. NA-G stated immediately following the incident, she received education to ensure sling straps were secure in residents wheelchairs, which included R14, prior to transport. On [DATE], at 8:37 a m. R14 was lying in bed on her back, eyes open, covered with a blanket from her feet to her mid chest. At that time, NA-D and NA-C entered R14's room with a full mechanical lift. NA-D and NA-C proceeded to place a full bodied sling underneath R14 and assisted her to transfer from her bed to a wheelchair. NA-D then proceeded to carefully tuck the bilateral lift straps alongside R14's upper thigh and the arm rest of her the wheelchair. NA-C then proceeded to assist R14 with morning cares and wheeled her to the dining room. On [DATE], at 8:43 a.m. NA-D stated R14 was totally dependent for transfers and used a full mechanical lift with a full body sling. NA-D stated she R14's sling remained underneath her while she was in the wheelchair due to the type of sling she used. NA- D indicated she had received education after R14's fall in [DATE], to ensure the sling straps were tucked in on the sides of R14 to prevent entanglement with the wheels of her wheelchair. On [DATE], at 2:04 p.m. NA-H stated she ensured R14's sling straps were tucked in on both sides and had received education regarding sling strap placement in August of 2019, following R14's fall from her wheelchair. On [DATE], at 2:33 p.m. NA-A stated residents who required the use of the Hoyer lift had full bodied slings which remained in the wheelchairs underneath the resident, which included R14. NA-A stated she had received education regarding sling strap placement in August of 2019, following R14's fall from her wheelchair. She stated she made sure sling straps were secure prior to transport for residents were used the full body lift sling. R14's fall note dated [DATE], identified R14 had been seated in a wheelchair, wheeled down the hallway by an nursing assistant (NA) to supper when she fell from her wheelchair and landed on her left side. The note revealed R14 had hit her head, had pain on her left thigh which was warm and swollen. The note indicated R14 was assisted off of the floor with a Hoyer lift (full body lift) and had been sent to the emergency room . R14's Hospital History and Physical (H&P) dated [DATE], revealed R14 had fallen from her wheelchair when she was transported in the wheelchair by a facility staff member. The H&P revealed R14 had x-rays which revealed the following; - left second finger fracture at the base of the finger -left [MEDICAL CONDITION] at the distal end of left hip arthroplasty. R14's Hospital Discharge Summary dated [DATE], revealed R14 was admitted to the hospital on [DATE], with a left periprosthetic femur fracture (broken bone that occurs around the implants of a total hip replacement, a serious complication that most often requires surgery.) The H&P revealed R14 a [DIAGNOSES REDACTED]. The H&P indicated R14 had refused amputation of her leg, refused surgical repair of the fracture due to health complications and had opted for medical management. The H&P revealed R14's hospitalization course was complicated with the following; blood loss [MEDICAL CONDITION] which required transfusion, hemorrhagic shock, acute kidney injury, acute hypoxic [MEDICAL CONDITION] secondary to fluid overload and narcotic use. R14's internal investigation form included a 5 day summary dated [DATE], which revealed R14 fell from the wheelchair when she was wheeled down the hallway by an NA when the wheelchair came to an abrupt stop. The cause of the wheelchair to stop was the sling strap became entangled in the front wheel of her wheelchair. The summary revealed R14 had fallen on her left side and had been transported by ambulance to the emergency room . R14's internal fall investigation form revealed all staff were educated to ensure sling straps were secure as of [DATE], and the facility mechanical lift policy had been updated. Review of the mechanical lift operating manual titled, Invacare Reliant 450 RHL450-I, identified instructions/directions for using the lift to transfer residents from one a lying to a seated position. The manual identified full body slings were to remain underneath residents when seated in a wheelchair or other surface. The manual did not address sling strap placement. On [DATE], at 10:03 a.m. a telephone interview was conducted with Direct Supply representative. She confirmed the facility's mechanical lift, Invacare, full bodied sling was to remain in position, underneath a resident when seated in a wheelchair type device. She confirmed the operating manual did not indicate or address sling strap placement. The representative stated she felt it was common sense to ensure sling straps were secured prior to resident transport. Review of the facility policy titled, Mechanical Lift Policy, revised [DATE], revealed the following procedure for Hoyer slings; top sling straps should be secured to push handles on the back of the wheelchair, bottom sling straps should be rolled and tucked between wheelchair cushion and side of armrest. On [DATE], at 10:34 a.m. the director of nursing (DON) confirmed R14 had a fall from her wheelchair when the strap of her full body sling became entangled in the front wheel of her wheelchair. The DON stated she had been unable to determine how R14's full body sling strap had come loose, however she had immediately re-educated the NA who witnessed the incident, and then all other nursing staff to ensure resident sling straps were secure prior to transport. The DON confirmed the facility had updated the mechanical lift policy following R14's fall from the wheelchair on [DATE]. The DON stated the policy was updated to include ensuring sling straps were secured following mechanical lift transfer. On [DATE], at 2:23 p.m. the facility administrator stated he had been immediately notified of R14's fall and subsequent fracture and hospitalization . The administrator stated he was aware R17's sling straps had caught on the wheel of her wheelchair and felt R14's fall had been a complete accident. He indicated he did not feel the NA or the facility was responsible for R14's fall or her injuries. Facility policy titled, Fall Prevention Program, revised [DATE], identified the purpose of the policy was to provide safety to residents by the following; evaluating the environment, awareness of risks and potential hazards and to establish systems to keep residents safe. The past non-compliance that began on [DATE], was verified during the [DATE], onsite visit and was corrected by the facility on [DATE]. The verification of corrective action was confirmed by interview with a variety of nursing staff, observation of residents who used full body slings and documentation of education provided the nursing staff. In addition, the facility updated the Mechanical Lift Policy to address Hoyer strap placement. The facility identified all nursing assistants and nurses were re-educated on the updated facility's mechanical lift policy to address Hoyer sling straps by [DATE].

Based on interview and document review, the facility failed to ensure resident's clinical record accurately reflected current wishes for resuscitation status for 1 of 1 residents (R30) reviewed for advanced directives. Findings include: R30's admission Minimum Data Set (MDS) [DATE], indicated R30 had moderate cognitive impairment, and was able to understand and be understood, and had [DIAGNOSES REDACTED]. In addition, the MDS indicated R30 required limited assistance from staff with bed mobility, transfers, ambulation, eating, personal hygiene, and toileting. R30's admission Care Area Assessment (CAA), dated [DATE], indicated R30 was alert and oriented but occasionally forgetful, and able to make her own decisions. The CAA indicated R30 needed limited assist for completion of ADL cares due to weakness. R30's care plan dated [DATE] listed R30 had completed a physicians order for life sustaining treatment (POLST) that instructed the facility staff that her wishes were for cardiopulmonary resuscitation (CPR) and her decisions would be reviewed annually at care conference and/or as needed and update. On [DATE], at 9:00 a.m during a review of R30 electronic medical record (EMR) the header information in R30's chart indicated R30's advanced directive/code status was for do not resuscitate (DNR). R30's electronic record included a scanned copy of a POLST dated [DATE], which indicated R30's advanced directive/code status was for CPR. No other POLST was found in the EMR scanned documents. On [DATE], at 10:22 a.m. during an interview with family member(FM)-A and R30, FM-A stated last week during a care conference R30 had requested her advanced directive/code status be changed from CPR to DNR. R30 verified her current advanced directive code status wishes were DNR, and stated R30 had completed out an updated form at that time. R30's progress note dated [DATE], indicated during a care conference with family, R30 had requested to update her POLST status from CPR to DNR. The progress note indicated R30 had completed a new POLST form at that time. A review of R30's orders summary report signed by the provider on [DATE], revealed R30's advanced directive/code status was CPR. Review of the facility undated document titled Nurses Notes, which listed each resident individually by name and location and listed the individual resident code status. The document listed R30's advanced directive/code status as CPR. A review of the facilities undated document identified by the facility as the nursing assistant care guide, listed R30 code status as CPR. On [DATE], at 2:33 p.m. nursing assistant (NA)-A reviewed the facility document identified as the nursing assistant (NA) care guide and stated the NA care guide had important care information on it including code status, and indicated R30's code status was CPR. On [DATE], at 2:43 p.m. director of nurses (DON) stated she recalled R30 had requested to change her advanced directive code status from CPR to DNR at a care conference on [DATE]. The DON stated R30 had completed a new POLST, signed by the provider on [DATE]. The DON verified the POLST had not been scanned into R30's EMR yet and retrieved it from a red folder in the file cabinet. The DON verified R30's care plan, nurses note sheet, and NA care guide did not accurately reflect R30's current advanced directive/code status information, and stated it should have been updated promptly. The DON indicated she would expect nurses to check the code status/POLST book at the nurses desk for all residents advanced directive/code status information. The blue 3 ring binder labeled Code Status/POLST book at the nurses desk was reviewed with the DON, and included a copy of R30's POLST form dated [DATE]. On [DATE], at 3:03 p.m. registered nurse (RN)-B stated she would look at her nurses note worksheet to identify a residents advanced directive/code status. RN-B verified she had just come on shift, reviewed the nurses shift note worksheet and stated R30's code status indicated CPR, but she would always check the code status/POLST book because it was the most up to date. On [DATE], at 3:05 p.m. RN-A stated she would always check the code status/POLST book to verify a residents code status information. A review of the facility policy titled Advanced Directive Policy/POLST, revised on [DATE], indicated the DON or assist director of nurses would update the orders in the EMR, nurses shift sheets, and NA care guides on admission and with any changes to advanced directive code status. However, the policy did not address the use of a code status/POLST book for the current code status of each resident.

Based on observation, interview and document review the facilty failed to provide assistance with grooming which included facial hair removal and nail cares for 2 of 3 residents (R15 and R18) who were dependent on facility staff for activities of daily living (ADL's). Findings include: R15's annual Minimum Data Set ((MDS) dated [DATE], identified R15 had [DIAGNOSES REDACTED]. The MDS identified R15 had severe cognitive impairment, and required extensive assistance with ADL's of dressing, personal hygiene and bathing. The MDS revealed R15 had no rejection of cares during the assessment period. R15's annual Care Area assessment dated [DATE], identified R15 had significant cognitive impairment, was mostly non-verbal and was not comprehensible when speaking. The CAA revealed R15 required extensive assistance with all of her ADL' and indicated staff were to anticipate R15's needs. R15's current care plan revised, 12/31/19, revealed R15 required extensive to total assistance with personal hygiene, dressing, and bathing. The care plan revealed R15 was no longer able to verbalize her needs and wishes and indicated staff were to anticipate her needs. The care plan did not identify R15's facial hair removal or shaving needs. On 3/2/20, at 12:44 p.m. R15 was seated in a wheelchair in the dining room at a table with three other residents and staff members. R15 had patches of several thick, coarse, black facial hairs approximately three (3) to six (6) millimeters (mm) along her chin and jaw line. On 3/2/20, at 6:39 p.m. family member (FM)-C indicated at least one of R15's family members visited her daily and assisted with at least one meals. FM-C indicated R15 had severe dementia and continued to decline physically. FM-C stated R15's grooming and personal appearance had been important to her prior to her memory loss and felt R15 would want to look her best when she interacted with others. FM-C stated he routinely assisted R15 with her evening meal and R15 routinely had flat hair on the back of her head (bed head,) indicated he combed the back of her hair when he arrived. FM-C stated he had noticed R15 had several facial hairs which he felt would have bothered her if she knew they were there. He indicated he would want staff to check her face for any facial hairs and remove them as needed. FM-C stated R15 had a razor and had not been notified anything had happened to it. On 3/3/20, at 8:40 a.m. R15 was lying on her back in bed, covered with a blanket from her feet to her torso, her eyes were closed. R15 continued to have patches of several thick, coarse, black facial hairs approximately 3 to 6 mm along her chin and jaw line. At that time, the assistant director of nursing (ADON) and R15's primary physician entered her room for a routine visit. On 3/3/20, at 1:20 p.m. R15 was lying on her back on her bed, covered with a blanket from her feet to her mid chest. R15 continued to have patches of several thick, coarse, black facial hairs approximately 3 to 6 mm along her chin and jaw line. On 3/4/20, at 7:06 a.m. R15 was lying in bed on her back, at that time nursing assistant (NA)-E and NA-J entered her room and proceeded to assist with morning cares. R15 was assisted from her bed to a wheelchair, at that time, NA-E confirmed R15 had patches of several thick, coarse, black facial hairs approximately 3 to 4 mm along her chin and jaw line. NA-E stated R15 usually had her facial hair removed daily, and proceeded to shave R15 with her personal electric razor. NA-E indicated R15's razor did not work well and indicated R15 continued to have several thick, black, coarse chin hairs which were approximately two (2) to 6 mm in length. NA-E stated she would inform the nurse to notify R15's family member she needed a new razor. On 3/4/20, at 1:20 p.m. licensed practical nurse (LPN)-A stated R15 was totally dependent on staff for all of her ADL's which included facial hair removal. LPN-A stated she would expect R15's facial hair to be removed daily with cares and weekly with her bath. LPN-A stated R15's family members come to see her daily and felt they would have no problem obtaining another razor for her. On 3/4/20, at 1:40 p.m. R15 was lying in bed on her back, eyes were closed and she was covered with a blanket from her feet to her mid chest with the director of nursing (DON) present in the room. She confirmed R15 had patches of several thick, black, coarse facial hairs on her chin and jaw line which were approximately 3-4 mm in length. The DON confirmed R15's care plan identified she required extensive to total assistance with grooming and personal hygiene. The DON confirmed R15's care plan did not specifically identify facial hair removal, however, indicated it was a standard with daily cares. R18 R18's quarterly Minimum Data Set ((MDS) dated [DATE], identified R18 had moderate cognitive impairment and [DIAGNOSES REDACTED]. R18's MDS further identified she required assistance with hygiene, toileting and transfers, and was independent with eating. R18's activities of daily living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 6/16/19, identified R18 had dementia, depression, mood disorder and [MEDICATION NAME] degeneration. R18's CAA further identified she also had unsteadiness with gait and transfers. R18's CAA identified she had a need for physical assistance to complete ADL cares and was able to feed self. R18's CAA indicated she preferred a fairly established pattern of activity. R18's care plan, revised 4/2/19, identified R18 had a self-care performance deficit related to impaired cognition, behaviors and impaired vision. R18's care plan identified she required assistance with bathing, dressing, personal hygiene and toileting. R18's care plan interventions included; assistance with washing hands and combing hair and to check nail length and to trim and clean on bath days and as necessary. R18's care plan identified she had behavioral disturbance related to dementia with behaviors listed, which included digging in rectum and resisting direction/assistance for basic care needs. On 3/2/20, at 1:01 p.m. R18 was in her room, in her recliner. R18's fingernails were painted and had brown substance under multiple fingernails, her left hand had brown substance noticeably under her pinky and ring fingernails, and her right hand had brown substance under her thumb and ring fingernails. R18's hair was flat and matted with some areas sticking straight out in the back and right side of her head, and her hair appeared uncombed. At 5:49 p.m. R18 was in the dining room feeding self, and her hair remained uncombed. On 3/3/20, at 8:45 a.m. R18 was in the dining room, sitting in a chair at a table. R18's hair continued to appear uncombed, and was flat and matted with some hair sticking straight out on the right side and back of her head. On 3/3/20, at 1:15 p.m. R18 was in the recliner in her room, lap blanket on her lap, dressed in street clothes. R18's hair remained the same, flat and matted on the right side and back of her head with hair sticking straight out on her right side and back of head. R18's fingernails continued to have brown substance under 2-3 fingernails on each hand. At 1:20 p.m. nursing assistant (NA)-A briefly entered R18's room talked with her and then exited the room. NA-A did not assist R18 with combing her hair or cleaning under her fingernails. At 2:08 p.m. another unknown staff member entered her room, assisted R18 to take a drink of water, and immediately left the room without assisting R18 to comb her hair or clean under her fingernails On 3/4/20, at 7:38 a.m. R18 was in her room with night clothes on, she indicated she was going to get a bath soon. At 8:38 a.m. R18 was seated in a chair next to a table in the dining room. R18's hair still appeared messy, with hair sticking out on the right side and back. Review of R18's progress notes from 12/2/19, to 3/4/20, identified on 2/16/20, at 10:21 p.m. R18 was digging in her groin/buttocks area on the toilet while the nursing assistant was getting her ready for bed. R18 was told not to continue that behavior and her nails were cleaned, as this was identified as a potential infection control issue. On 3/3/20, at 2:37 p.m. NA-A indicated R18 had a history of [REDACTED]. NA-A indicated the last time she had witnessed this behavior was in August. NA-A indicated R18 received a bath every Wednesday and would get her hair done at the beauty shop after her bath. NA-A indicated R18 was very particular about her hair, NA-A indicated R18's hair looked messy, and R18 had refused to allow her to comb her hair that morning and had she had not attempted to comb her hair the rest of the day. On 3/3/20, at 2:48 p.m. registered nurse (RN)-B was present in R18's room. RN-B observed R18's fingernails and confirmed they needed to be cleaned. RN-B indicated they would get an orange stick (manicure tool used to clean fingernails) to clean under R18's fingernails, which were available for staff to use and confirmed R18 had a history of [REDACTED]. RN-B confirmed R18's hair appeared uncombed and messy. On 3/4/20, at 1:19 p.m. during a telephone interview family member (FM)-A indicated it was very important for R18 to have her hair neat and her nails done. FM-A indicated it was especially important to R18 that her hair was neat, and that was why she went to the beauty shop every week. FM-A indicated R18's hair would get flat in the back at times, and she did not comb it herself. FM-A indicated the family members would comb her hair and fluff it up before they took her on outings. FM-A indicated he and R18's brother had discussed R18 having gunk under her fingernails and had spoken to the facility about their concern and indicated they felt it was not sanitary. On 3/4/20, at 2:32 p.m. NA-B indicated R18 did not like her hair combed, but would let them do it lightly and in the back. NA-B indicated R18 usually went to the beauty shop weekly, but the beautician had been unavailable the present week. NA-B indicated her usual practice for resident nail care was to clip and deep clean fingernails on bath days, and to use a nail brush and clean them between the bath days if needed. On 3/4/20 at 2:49 p.m. director of nursing (DON) indicated she would expect every residents' hair to be combed with morning and evening cares. DON indicated R18 required a lot of encouragement to complete cares and indicated she would expect nursing staff to comb R18's hair and to clean under R18's fingernails as needed. DON indicated the facility had orange sticks available to use to keep fingernails clean also. DON indicated residents' fingernails needed to be kept clean for infection control. A facility policy titled, Resident Personal Cares-AM & PM, revised 1/18/19, identified it was the policy of the facility that all residents received personal cares twice daily to maintain health, hygiene and dignity. The policy revealed various procedures for assisting with personal cares which included grooming. The policy revealed residents hair would be combed, females would have whiskers shaved in accordance to their preferences.

Based on interview and document review, the facility failed to thoroughly investigate an injury of unknown origin for 1 of 1 resident (R15) reviewed for bilateral upper thigh and upper arm bruising and abuse. In addition, the facility failed to protect all 38 other residents who resided in the facility while the investigation was conducted. Findings include: R15's annual Minimum Data Set ((MDS) dated [DATE], identified R15 had [DIAGNOSES REDACTED]. The MDS identified R15 had severe cognitive impairment, and required extensive assistance with activities of daily living (ADL)'s bed mobility, transfers, eating and toileting. The MDS revealed R15 had no physical or verbal behaviors towards self or others and had no rejection of cares during the assessment period. R15's annual Care Area Assessment (CAA) dated 12/19/19, identified R15 had significant cognitive impairment, was mostly non-verbal and was not comprehensible when speaking. The CAA revealed R15 required extensive assistance with all of her ADL' and indicated staff were to anticipate R15's needs. R15's current care plan revised, 12/31/19, revealed R15 had impaired cognitive function, impaired thought process and memory impairment. R15's care plan revealed she required extensive to total assistance with all of her ADL cares which included bed mobility, transfers, eating and toileting. The care plan further revealed R15 was no longer able to verbalize her needs and wishes and indicated staff were to anticipate her needs. Review of R15's skin/wound progress notes from 1/31/20, to 3/4/20, revealed the following: - 1/31/20, R15 had bruising to her upper left arm and on her inner right and left thighs. The note revealed R15's bruising measured as follows: -right inner thigh had three (3) purple bruises which measured 3.0 centimeters (cm) in length by one (1) 1.0 cm in width, 3.0 cm by 1.0 cm and 1 cm by 1 cm. -left inner thigh had one purple bruise which measured two (2) 2.0 cm by 1.0 cm. -left upper arm had one purple bruise which measured 2.0 cm by 2.0 cm. The note indicated R15's five bruises were washed, dried, left open to air and would be monitored. R15's progress note lacked any documentation the cause of R15's five bruises, whether any other nursing staff had been interviewed, any changes in R15's mood/behavior or possible etiology of R15's bruises. Further, the note did not identify when or how R15 obtained five purple bruises on her bilateral inner thighs and upper left arm. - 2/14/20, identified R15 had yellow bruising to her inner right and left thighs were healing and had decreased in size. The note revealed R15 had no pain and all other skin was intact. -2/21/20, identified R15 had fading yellow bruising to her inner right and left thighs, current treatments included encourage repositioning, proper peri-cares, treatments as ordered. The note revealed R15 would continue to be monitored. -2/28/29, identified R15 had a bruise to her right hand, healing bruises to bilateral shins and a small scab to her upper chest. The note revealed R15 had lotion applied and her fingernails trimmed. The note did not identify whether R15's bilateral inner thigh bruises had healed. On 3/3/20, at 1:20 p.m. R15 was lying in bed on her back, held a teddy bear in her arms and was covered with a blanket from her feet to her chest. R15's eyes were closed, lights of her room were off and she had a fall mat on the floor next to her bed. On 3/3/20, at 2:11 p.m. NA-D stated R15 was dependent on staff for all of her ADL's which included bed mobility, transfers, eating and toileting. NA-D stated R15's needs were to be anticipated, she was unable to verbalize her needs and wishes. NA-D stated R15 had recent bruising on her legs, unable to recall the exact location, however she indicated the licensed nurse was already aware when she notified her. On 3/4/20, at 7:06 a.m. nursing assistant (NA)-E stated R15 was dependent for all of her ADL's, used a full mechanical lift with a full body sling (arms and legs remain inside the sling) for all of her transfers. NA-E stated R15 had some bruises on her legs a few weeks ago and was unsure of where R15's bruises originated from . NA-E indicated R15 had no rejection of cares and was not combative with cares. On 3/4/20, at 1:20 p.m. licensed practical nurse (LPN)-A stated she had first observed R15's bilateral inner thigh bruising and upper left arm bruising when she checked her skin after a bath on 1/31/20. LPN-A stated she had not asked R15 about the bruises and indicated R15 had severe cognitive impairment and was not a reliable historian. LPN-A indicated she had not asked any other staff if they knew how R15 sustained the bruises. LPN-A indicated she could not recall if she had notified the DON or adminstrator and did not feel R15's bruises were suspicious in nature. On 3/4/20, at 1:40 p.m. the DON confirmed R15's medical record lacked any type of incident report or investigation of the bilateral upper thigh bruising and upper left arm bruising. The DON stated she was made aware of R15's bruises the following day and the facility's interdisciplinary team (IDT) discussed the bruises the following day during stand up meeting. The DON stated R15 had periods of anxiety and liked to have her hands together between her thighs. The DON confirmed staff were not asked if they knew how R15's bilateral upper thighs and left upper arm were injured and had observed cares to see if R15 had any behaviors. The DON confirmed R15's inner thighs were not a typical areas or an area prone to bruising, however, did not feel R15's bruises were suspicious. The DON confirmed R15's bilateral upper thigh bruises and upper left arm bruises had not been reported to the State Agency (SA). During a follow up interview, at 2:15 p.m. the DON indicated the day prior to when R15's bruising was first observed, the facility had a large puppy visit, who had put its paws on R15's upper legs. The DON stated the IDT team had discussed it as a potential cause of R15's bruises when they were investigating the source of her bruising. DON offered no further information regarding investigation of bruising for R15. On 3/4/20, at 2:18 p.m. the facility administrator confirmed he had been informed of R15's bilateral upper thigh bruising and upper left arm bruising the following day during the facility's routine daily stand up meeting. The administrator stated he expected the nursing staff to identify the origin of R15's bruises. He indicated he was not aware whether a cause or origin or R15's bruises had been identified. The administrator stated he would expect injuries of unknown origin to be reported to him immediately and the the SA within two hours. However, the administrator stated due to the location and extent of R15's bruising, he would have expected the incident to have been reported and investigated. Review of the facility policy titled, Abuse/Neglect Prevention Plan and Policy, revised 1/25/19, identified it was the purpose of the policy to ensure all alleged violations which involved mistreatment, neglect, or abuse including injuries of unknown source, and misappropriation of resident property were immediately reported to the administrator of the facility and to the SA and an investigation would be conducted and reported to the SA within five (5) days. The policy identified an injury of unknown source would be classified as such when both of the following conditions were met: -the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and -the injury was suspicious because of the extent of the injury or the location of the injury (the injury was located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. The policy further, identified residents were to be protected during an investigation if an employee had been identified.

Based on interview and document review, the facility failed to immediately report, no later than 24 hours, an injury of unknown origin to the State Agency (SA) for 1 of 1 resident (R15) who was dependent on staff for all activities of daily living, had several inner thigh bruises and was reviewed for abuse. Findings include: R15's annual Minimum Data Set ((MDS) dated [DATE], identified R15 had [DIAGNOSES REDACTED]. The MDS identified R15 had severe cognitive impairment, and required extensive assistance with activities of daily living (ADL)'s of bed mobility, transfers, eating and toileting. The MDS revealed R15 had no physical or verbal behaviors towards self or others and had no rejection of cares during the assessment period. R15's annual Care Area Assessment (CAA) dated 12/19/19, identified R15 had significant cognitive impairment, was mostly non-verbal and was not comprehensible when speaking. The CAA revealed R15 required extensive assistance with all of her ADL's and indicated staff were to anticipate R15's needs. R15's current care plan revised, 12/31/19, revealed R15 had impaired cognitive function, impaired thought process and memory impairment. R15's care plan revealed she required extensive to total assistance with all of her ADL cares which included bed mobility, transfers, eating and toileting. The care plan further revealed R15 was no longer able to verbalize her needs and wishes and indicated staff were to anticipate her needs. Review of R15's skin/wound progress notes from 1/31/20, to 3/4/20, revealed the following: - 1/31/20, R15 had bruising to her upper left arm and on her inner right and left thighs. The note revealed R15's bruising measured as follows: -right inner thigh had three (3) purple bruises which measured 3.0 centimeters (cm) in length by one (1) 1.0 cm in width, 3.0 cm by 1.0 cm and 1 cm by 1 cm. -left inner thigh had one purple bruise which measured two (2) 2.0 cm by 1.0 cm. -left upper arm had one purple bruise which measured 2.0 cm by 2.0 cm. The note indicated R15's five bruises were washed, dried, left open to air and would be monitored. R15's progress note lacked any documentation the cause of R15's five bruises, whether any other nursing staff had been interviewed, any changes in R15's mood/behavior or possible etiology of R15's bruises. Further, the note did not identify when or how R15 obtained five purple bruises on her bilateral inner thighs and upper left arm. - 2/14/20, identified R15 had yellow bruising to her inner right and left thighs were healing and had decreased in size. The note revealed R15 had no pain and all other skin was intact. -2/21/20, identified R15 had fading yellow bruising to her inner right and left thighs, current treatments included encourage repositioning, proper peri-cares, treatments as ordered. The note revealed R15 would continue to be monitored. -2/28/29, identified R15 had a bruise to her right hand, healing bruises to bilateral shins and a small scab to her upper chest. The note revealed R15 had lotion applied and her fingernails trimmed. The note did not identify whether R15's bilateral inner thigh bruises had healed. R15's monthly behavior review note dated 2/4/20, revealed R15 had significantly less anxiety reported within the last month and had no reported behaviors. The note revealed R15 was more relaxed, had frequent rest periods and did not express herself verbally very much. On 3/2/20, at 6:39 p.m. R15 family member (FM)-C indicated at least one of R15's family members visited her daily and assisted with at least one meal. FM-C indicated R15 had severe dementia stated as far as he was aware R15 had no recent or current skin conditions or any injuries, which included bruising. FM-C indicated R15 had thin skin, had bruising on her hands in the past, however he did not feel it was typical for R15 to have bruising. On 3/3/20, at 1:20 p.m. R15 was lying in bed on her back, covered with a blanket from her feet to her chest. Her eyes were closed and a fall mat was observed on the floor next to her bed. R15 held a teddy bear in her arms. On 3/3/20, at 2:11 p.m. NA-D stated R15 had recent bruising on her legs, unable to recall the exact location, however she indicated the licensed nurse was already aware when she notified her. On 3/3/20, at 3:07 p.m. the director of nursing (DON) indicated the facility did not complete incident reports for skin injures such as bruising and skin concerns were tracked on an Excel spreadsheet she maintained. The DON stated all residents, which included R15, skin was checked weekly with their bath and a skin/wound note was entered into their medical record. The DON stated she reviewed all resident notes daily in the mornings for skin/wound notes. On 3/4/20, at 1:40 p.m. The DON confirmed R15's inner thighs were not a typical areas or an area prone to bruising, however did not feel R15's bruises were suspicious. The DON confirmed R15's bilateral upper thigh bruises and upper left arm bruises had not been reported to the SA. The DON confirmed R15's medical record lacked any type of incident report or investigation of the bilateral upper thigh bruising and upper left arm bruising. The DON stated she was made aware of R15's bruises the following day and the facility's interdisciplinary team (IDT) discussed the bruises the following day during stand up meeting. The DON stated R15 had periods of anxiety and liked to have her hands together between her thighs. The DON confirmed staff were not asked if they knew how R15's bilateral upper thighs and left upper arm were injured and had observed cares to see if R15 had any behaviors. On 3/4/20, at 2:18 p.m. the facility administrator confirmed he had been informed of R15's bilateral upper thigh bruising and upper left arm bruising the following day during the facility's routine daily stand up meeting. The administrator stated he expected the nursing staff to identify the origin of R15's bruises. He indicated he was not aware whether a cause or origin or R15's bruises had been identified. The administrator stated he would expect injuries of unknown origin to be reported to him immediately and the the SA within 24 hours. However, the administrator stated due to the location and extent of R15's bruising, he would have expected the incident to have been reported and investigated. Review of the facility policy titled, Abuse/Neglect Prevention Plan and Policy, revised 1/25/19, identified it was the purpose of the policy to ensure all alleged violations which involved mistreatment, neglect, or abuse including injuries of unknown source, and misappropriation of resident property were immediately reported to the administrator of the facility and to the SA. The policy identified an injury of unknown source would be classified as such when both of the following conditions were met: -the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and -the injury was suspicious because of the extent of the injury or the location of the injury (the injury was located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.

Based on observation, interview and document review, the facility failed to comprehensively assess, accurately monitor and implement interventions for 1 of 1 resident (R32) with a reoccurring unstageable pressure ulcer to the heel. In addition, the facility failed to implement interventions to prevent development of pressure ulcers for 1 of 1 resident (R20) who was at risk for development of pressure ulcers. This deficient practice resulted in actual harm for R32 with the development of a recurring pressure ulcer. Findings include: R32's admission Minimum Data Set ((MDS) dated [DATE], identified R32 had intact cognition and required extensive assistance with all activities of daily living (ADLs). The MDS further identified R32 was at risk for developing pressure ulcers, had no current pressure ulcers and utilized a pressure reducing device in her chair. R32's admission orders [REDACTED]. R32's Care Area Assessment (CAA) dated 12/1/16, identified R32 was at risk for developing pressure ulcers and required assessment. The CAA identified R32 required a cushion for her chair for pressure relief. R32's care plan dated 12/18/16, identified R32 had limited physical mobility, related to osteo[DIAGNOSES REDACTED] of vertebra, weakness, had a history of [REDACTED]. R32's care plan directed staff to ensure R32 wore appropriate footwear (laced, no skid shoes) when ambulating or mobilizing in wheelchair, and use of a pressure relieving cushion in the wheelchair. The care plan indicated R32 had the potential/actual skin impairment related to contact [MEDICAL CONDITION] and fragile skin and utilized a pressure relieving cushion in wheelchair. The care plan further directed staff R32 required weekly skin inspections to identify redness and open areas and any changes in R32's skin were be reported to the nurse. However, R32's care plan did not identify R32's current pressure ulcer, and lacked direction for the use of Prevalon boots or pillows to keep pressure off of R32's heel. Review of the untitled facility form provided by the facility, identified as the nursing assistant care guide, listed various directions for R32's cares which included assistance with toileting, transferring, dressing and directed the use of shoes at night. The care guide did not include direction for pressure relief for R32's heels or use of the Prevalon boots. R32's Tissue Tolerance Test (TTT) form (tool used to determine appropriate repositiong schedule) dated 11/21/16, identified R32 had no current skin integrity concerns, did not have a history of pressure ulcers and could tolerate a 2 hour repositioning program. No further TTT forms were found in R32's clinical record, despite development of pressure ulcers. R32's Braden Scale Assessment (risk assessment for pressure ulcers) forms dated 11/29/16, 12/2/16, and 12/6/16, identified R32 had very moist skin, had potential problem for friction and shear, walked occasionally, spent the majority of her time in her chair or bed and was at risk for development of pressure ulcers. Review of R32's Skin Observation Tool form dated 11/21/16, identified R32 had purpura (rash of purple spots on the skin caused by internal bleeding from small blood vessels) on upper extremities, and identified no other open areas. Review of the untitled form provided by the facility, dated 12/23/16, revealed the form listed various resident names and reason to be seen. The form listed R32 had 12/20/16, labs for review, had 3 centimeter (cm) blackened area in the middle of her sole of the left foot, edges were pulling away in a blister form, and center was soft. On 2/6/17, at 5:35 p.m. the director of nursing (DON) stated R32 had a current unstageable pressure ulcer on her left heel. On 2/8/17, at 7:12 a.m. R32 had her eyes closed, lying on her back in bed with bed linens covering her torso and lower extremities. At 7:54 a.m. R32 remained on her back in bed and nursing assistant (NA)-C entered the room to assist R32 with morning cares. NA-C pulled down R32' bed linens, and both R32's heels/feet rested directly on a pillow, covered in white cloth socks and a second pillow was observed under R32's calves. The heels/feet were not elevated off the pillow to relieve pressure. An approximately 2.5 centimeter (cm) sized open area on the back of the heel was observed, and an approximately 1.5 cm sized dark brown/black irregular shaped scab in the center of the area with a yellow colored slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) area which surrounded the entire scab. NA-C assisted R32 to lift each foot/leg to remove the socks, apply compression hose to both lower extremities and reapply both socks to her feet. NA-C continued to place R32's heels/feet directly on to the pillow, alternating between assisting to dress R32's lower extremities. R32's heels rested directly on the pillow during morning cares. At 8:00 a.m., NA-C assisted R32 to sit on the edge of the bed, transfer into the seat of a wheelchair and proceeded to assist R32 into the bathroom. On 2/8/17, at 9:03 a.m. NA-C stated she had been unaware R32's heels were resting directly on the pillow and had been unaware she had rested R32's heel directly on the pillow during cares. She indicated she thought the facility had tried the boots (Prevalon) with R32 once, and understood R32 did not like them. On 2/8/17, at 9:16 a.m. NA-A stated R32's heels should be off the bed and heels were to be hanging off the pillow, not directly resting on the bed or pillow. On 2/8/17, 9:24 a.m. licensed practical nurse (LPN)-A stated R32 was at risk for development of pressure ulcers and stated she did not think R32 had a current pressure ulcer. She stated she expected staff to float R32's heels off the bed and pillow. On 2/8/17, 9:27 a.m. registered nurse (RN)-A stated R32 had a pressure ulcer at her left heel in the past which had resolved, and stated she did not have a current pressure ulcer. She stated she felt R32 was not at risk for pressure ulcers at this time. On 2/8/17, at 11:59 a.m. R32 was observed seated in a wheelchair in the dining room. R32 wore brown tie up shoes on both feet, which rested on the foot pedals of the wheelchair. At 12:36 p.m., R32 was seated in her wheelchair in the dining room, with the same brown shoes on both feet. At 3:08 p.m., R32 was seated in her wheelchair in the dining room, participating in an activity with several other residents. R32 continued to wear the same brown tie up shoes on both feet. On 2/8/17, at 12:59 p.m. DON stated R32 was at risk for development of pressure ulcers. DON reviewed R32's clinical record at that time and stated the record indicated R32's previous pressure ulcer had resolved/closed. She indicated the facility had felt the previous pressure ulcer had been caused by R32's brown tie up shoes. DON stated R32 did not have a current ulcer. She confirmed the most current comprehensive skin assessment for R32 had been completed on 12/6/17, prior to the development of R32's previous pressure ulcer. DON confirmed R32's record lacked documentation of weekly skin monitoring, and indicated this was an area the facility needed to improve on. She indicated the facility had become aware of the previous pressure ulcer when R32 told facility staff her foot was uncomfortable in the shoe and felt the pressure ulcer had been caused by friction from the shoe. DON stated the facility should have comprehensively assessed R32's pressure ulcer. On 2/8/17, at 1:14 p.m. R32 was seated in her wheelchair in her room and wore the brown tie up shoes on both feet. The DON was present with the surveyor in the room and visualized R32's pressure ulcer after DON removed the brown shoe from R32's left foot. DON stated R32's current pressure ulcer measured .05 cm wide by 1.0 cm long, with white/back scab and skin surrounding the area was pink in color. She stated she would expect staff to complete a comprehensive reassessment for R32 at the time the reoccurring pressure ulcer had developed. On 2/9/17, at 9:03 a.m. NA-A stated R32 had not worn her brown shoes for about a month after she developed an open area on her foot. NA-A stated she understood since R32's open area had healed, she could wear the brown shoes and indicated she wore them routinely. On 2/9/17, at 9:05 a.m. R32 stated staff routinely place pillows under her heels at night. She stated she needed staff assistance to apply her shoes and she did not remember the last time she wore her shoes. On 2/9/17, at 9:15 a.m. NA-D confirmed R32 currently had an open area on her left heel and indicated she had notified the nurses and DON about the open area in the past. She indicated she felt R32 had not worn shoes since she had been admitted to the facility. On 2/9/17, at 9:40 a.m. during a follow up interview, the DON stated she felt there was no way to accurately determine when R32's current pressure ulcer occurred. She confirmed R32's current pressure ulcer and indicated she felt the current pressure ulcer had reopened soon after 1/10/17 or 1/12/17. On 2/9/17, at 9:40 a.m. DON added the usual facility practice was for the nurses to complete a weekly skin check for all residents, and to document the results of the skin check in the resident clinical record. The DON confirmed R32's care plan and current nursing assistant care guide and stated the facility did not have a designated wound nurse but she expected nursing assistants to report any changes to the nurses and nurses to assess the area. She also indicated she expected all the nurses to complete weekly skin inspections, assess and report abnormalities to the physician for treatment. DON confirmed R32 had developed a pressure ulcer after admission, at that time she felt the shoes had caused the pressure ulcer. She indicated R32 had stopped wearing the shoes and staff had discussed alternative shoes for R32, however, the facility was concerned about causing a blister somewhere else on her foot. DON stated she felt once R32's shoes were worn again, it was like putting gas onto a fire. She stated R32 was a not reliable historian and DON confirmed R32 wore her brown shoes daily at present, and confirmed R32 required assistance with applying her shoes. DON stated R32 had not seen a podiatrist since the past June 2016, she stated she had not had time to assess R32's current pressure ulcer since she was aware of the pressure ulcer. On 2/9/17, at 9:40 a.m. DON stated the facility had R32 remove the brown tie up shoes for 2 weeks after the previous pressure ulcer developed and after the 2 weeks, R32 had resumed wearing the shoes. Further, the DON stated she had not visualized R32's left heel pressure since 12/23/16, when the physician was in the facility. She indicated she was not aware R32 had a current pressure ulcer and the status of the pressure ulcer until 2/8/17, and had not notified the physician of the current pressure ulcer. DON did not offer any other information regarding notifying the survey team on 2/6/17 R32 had a current unstageable pressure ulcer. On 2/9/17, at 12:00 p.m. during a telephone interview, R32's physician (MD)-A confirmed R32 had developed a pressure ulcer in December, the area had been denuded, and had a small amount of [DIAGNOSES REDACTED]. He stated he had been concerned about development of osteo[DIAGNOSES REDACTED] and had started her on antibiotics at that time. MD-A indicated he was unsure of the cause of R32's pressure ulcer, had seen the pressure ulcer last on 1/3/17, and he felt the pressure ulcer was healing at that time and understood it continued to heal. On 2/10/17, at 8:50 a.m. during a follow up interview in the facility, MD-A stated R32's previous pressure ulcer had been open and superficial. He indicated the area had been red and inflamed, and he had ordered a culture of the open area because R32 had a history of [REDACTED]. He stated on 1/3/ 17, he had felt R32's previous pressure ulcer was healing. MD-A stated during exam of R32's left heel, he felt R32's current pressure ulcer was healing, and indicated he felt at that time it was almost healed. Review of R32's physician orders revealed the following: -12//23/16, identified [DIAGNOSES REDACTED]. Further, the orders indicated to follow up with physician in 1 week and sooner as needed. -1/3/17, left heel looked better, and directed staff to continue treatment. Review of R32's Treatment Administration Records (TAR) revealed for December 2016, staff documentation of skin/wound note weekly, every Thursday and Prevalon boots or pillows to keep pressure off of heel which was documented as done every evening and night shift 12/23/16 thru 12/31/16. However, R32's TAR lacked direction for use of Prevalon boots, pillows or pressure relief for left heel during the day. Review of R32's January TAR staff documentation of skin/wound note weekly, every Thursday and Prevalon boots or pillows to keep pressure off of heel which was documented as done every evening and night shift 1/1/17 thru 1/31/17. However, R32's TAR lacked direction for use of Prevalon boots, pillows or pressure relief for left heel during the day. R32's progress notes which included all skin/wound documentation was reviewed from 11/18/16 to 2/09/17 and revealed: -12/16/2016, identified a nickel size black area on R32's left heel with the surrounding area raised like a scab. The note also indicated education was provided regarding offloading of heels, provider was updated and they would continue to monitor. -12/23/2016, identified R32's provider was there and wrote new orders for left sole ulcer which included a wound culture, and medication changes. The note indicated provider would follow up next week for foot. -12/23/2016, identified resident had an open area on her left heel measuring 5 millimeters (mm) in diameter, and a black area surrounding the open area which measured 2.5 cm in diameter. The note indicated R32's wound was cultured and sent to the lab. -12/28/2016, identified R32 had an open left heel ulcer which measured 1.5 cm X .5 cm, was dark in color, no drainage and was improved. -12/29/2016, identified area on heel was not draining, dressing was applied as ordered and did not indicate the status of the ulcer -1/2/2017, identified left heel treatment continued as ordered. -1/3/2017, identified left heel scab had sloughed off, leaving a clean smooth surface and area measured 0.5 cm X .25 cm. -1/5/2017, identified left heel was dry, scabbed over and measured 4 mm and was improving -1/8/2017, identified unstageable pressure ulcer to left heel had closed. -1/12/2017, listed small red dots on the front and side of both knees and had redness at skin fold of stomach. However, the note did not address status of left heel skin/ pressure ulcer. -1/19/17, listed no areas of concern. -1/26/2017, listed had no areas of concern. -2/2/2017, listed no areas of concern. -2/9/17, listed no areas of concern. Review of the facility policy, Prevention and treatment of [REDACTED]. Review of the facility policy, Skin assessment dated [DATE], revealed all residents identified at risk for pressure ulcers would be assessed weekly to identify any new alterations in skin integrity. The policy also identified on residents designated bath days the licensed nurse would compele a head to toe skin assessment and note any alterations in skin condition and document an evaluation of the wound, the status of surrounding tissues and treatments, any changes, signs infection and document findings in the electronic record. R20's quarterly MDS dated [DATE], indicated R20 had [DIAGNOSES REDACTED]. The MDS identified R20 was severely cognitively impaired, required extensive to total assistance for all activities of daily living (ADL). The MDS also indicated R20 was totally dependent on two staff assistance for bed mobility, transfers. Further, the MDS identified R20 was at risk for pressure ulcers, skin was intact, was on a turning and repositioning program and had a pressure reducing device in the wheelchair. R20's CAA dated 6/20/16, indicated R20 was dependent on staff for activities of daily living, including repositioning. The CAA identified R20 was at risk for pressure ulcers related to weakness, limited mobility, and dementia. Further, the CAA identified R20 needed to be offered repositioning every two hours. R20's care plan dated 1/24/16, identified R20 was at risk for altered skin integrity and directed facility staff to assist R20 to reposition every two (2) hours. R20's undated, nursing assistant care guide, indicated R20 required turning and repositioning every two hours. R20's Braden Scale/Skin Risk Assessment for Pressure ulcer dated 12/5/16, indicated R20 was at risk for pressure ulcer development. During continuous observation on 2/8/17, from 7:10 a.m. to 10:12 a m. revealed the following: - At 7:10 a.m. R20 was seated in a wheelchair with a seat cushion in her room, wore a hospital gown, with the TV on. - At 7:47 a.m. R20 remained seated in a wheelchair in her room. R20 had not made any independent changes in position, no staff were observed to offer R20 assistance with repositioning or cares. - At 8:19 a.m. R20 remained seated in the wheelchair in her room in a hospital gown. At that time, nursing assistant (NA)-D entered R20's room, draped a housecoat over R20's chest. At that time NA-E entered R20's room, draped a blanket over R20's lap and proceeded to wheel R20 to the dining room. NA-D and NA-E were not observed to offer R20 assistance with repositioning. - At 8:40 a.m. R20 remained seated in the wheelchair in the dining room and ate independently. R20 was not observed to make any independent changes in position. - At 8:57 a.m. R20 remained seated in the wheelchair in the dining room. R20 was not observed to make any independent changes in position. - At 9:07 a.m. R20 remained seated in the wheelchair in the dining room. At that time RN-A approached R20 and was observed to administer medications to R20 and immediately walked away. - At 9:20 a.m. R20 had remained seated in the wheelchair in the dining room and was wheeled to the resident lobby by an activity aid to listen to trivia. R20 had remained seated in the wheelchair at that time for a total of 2 hours and 10 minutes. - At 9:40 a.m. R20 had remained seated in the wheelchair in the resident lobby. R20 had made no independent changes in position. No staff were observed to offer R20 assistance with repositioning. - At 9:57 a.m. NA-C was notified R20 had been up in the wheelchair without repositioning since 7:10 a.m. At that time NA-C stated R20 needed assistance with repositioning every 2 hours and was unsure of when R20 had last been repositioned. R20 was then wheeled to her room by NA-C. - At 10:08 a.m. R20 remained seated in the wheelchair in her room while NA-C and NA-E placed clean bedding on R20's bed. - At 10:13 a.m. NA-C and NA-E assisted R20 to transfer with a full mechanical lift from the wheelchair to her bed. NA-E removed the lift sling and assisted R20 to roll towards NA-C. NA-C removed R20's dry incontinent brief which revealed R20's skin on buttocks and back of upper thighs were bright red, but intact. -R20 remained in an observed seated position from 7:10 a.m. to 10:13 a.m. a total of 3 hours and 3 minutes. During interview on 2/8/17, at 9:57 a.m. NA-C stated R20 was to be repositioned and toileted every two hours. NA-C stated she was unsure of the last time R20 was repositioned and her usual practice to keep track of repositioning was to keep an eye on the clock. NA-C stated that was the method staff used to ensure residents received timely toileting and repositioning. During interview on 2/8/17, at 10:01 a.m. NA-E stated R20 had not been repositioned or checked and changed for incontinence since 7:00 a.m. NA-E stated was not able to independently reposition. During interview on 2/8/17, at 1:1 p.m. LPN-A confirmed R20 was at risk for developing pressure ulcers. LPN-A stated staff were expected to reposition R20 every two hours and as needed. LPN-A confirmed three hours was too long to sit in the wheelchair without repositioning. During interview on 2/9/17, at 8:37 a.m. the DON confirmed R20 was at risk for development of pressure ulcers due to bowel and bladder incontinence, and immobility. The DON reported she added the specific interventions on the nursing assistance care guides after the comprehensive assessments and considered the care guides as an extension of the resident's care plan. The DON stated she expected R20 would have been repositioned and incontinence care provided every two hours to reduce risk of future skin breakdown. The DON stated there was no formal system in place to ensure timely cares were completed. The DON stated she was unsure how the staff were ensuring residents received timely care. The DON confirmed timely resident cares were not being monitored. The DON stated the point of care system captured resident care documentation, but not in actual time. The facility's policy titled, Prevention and treatment of [REDACTED].

Based on observation, interview and document review, the facility failed to monitor bruising for 1 of 3 residents (R37) reviewed for non-pressure related skin conditions. Findings include: R37's quarterly Minimum Data Set ((MDS) dated [DATE], identified R37 had moderate cognitive impairment, and required extensive assistance with all activities of daily living (ADL). The MDS further identified R37 had no current skin conditions/bruises. R37's care plan dated 12/10/16, identified R37 was on anticoagulant therapy, directed staff to monitor/document/report adverse reactions to anticoagulant therapy which included bruising and directed staff to complete daily skin inspections and report abnormalities to nurse. Review of order summary report dated 1/6/17, revealed R37 received a routine daily dose of [MEDICATION NAME] (medication to thin blood) and was to have every shift monitoring for bruising related to anticoagulant therapy. On 2/07/17, at 12:00 p.m. R37 was seated in her wheelchair in her room with a family member (FM)-A present. Irregular shaped yellow/light green bruises, approximately 1.5 inch in diameter, were observed on both lower cheeks and several purple colored bruises in various sizes were observed on the tops of both hands. FM-A stated R37 had fallen in the facility in the past, and obtained the bruises. She indicated R37 was forgetful and did not remember falling. Review of R37's progress notes from 12/19/16 to 2/5/17, revealed: -12/19/16, R37 had a fall from bed and hit her head on the side table and was bleeding from her left eye and nose and was sent to the emergency room for evaluation. -12/19/16, R37 returned from emergency room and had a laceration to her left eyebrow area which was closed with glue. R37 had bruising to the back top of her left shoulder which measured 40 centimeter (cm) x 50 cm, a bruise to her left elbow area which measured 90 cm x 80 cm, and a bruise to her left upper thigh area which measured 230 cm x 150 cm. -1/2/17, R37 had faded bruises to her left cheekbone, left shoulder and elbow from previously documented fall. Review of the R37's monthly Treatment Administration Records (TAR) for December 2016 and January 2017, revealed R37 had various treatments and monitoring in place which included to monitor for ear wax, elevate feet 20 minutes two times a day, and respiratory monitoring. However, the TARs lacked documentation of monitoring for bruising and other adverse reactions to anticoagulant therapy. No further documentation of monitoring of R37's bruising was found in the clinical record. On 2/10/17, at 12:19 p.m. director of nurses (DON) stated R37 fell on [DATE], was sent to the emergency room and returned with significant bruises. DON confirmed progress notes and lack of monitoring of R37's bruises and stated she felt the measurements of the bruises were likely an error. She stated the usual facility practice when a bruise was identified was for the nurse to set up clinical weekly monitoring in the resident TAR. She stated she expected the nurse should have set up the bruise monitoring in the TAR when R37 returned from the emergency room and document weekly and confirmed the monitoring had not been done. She stated she expected orders to be followed, weekly skin inspections to be completed by nurses and bruises monitored. Review of the facility policy, Skin assessment dated [DATE], identified on residents designated bath days the licensed nurse would complete a head to toe skin assessment and note any alterations in skin condition and document an evaluation in the electronic record.

Based on observation, document review, and staff interview, the facility failed to provide adequate supervision of 1 of 1 resident (R8) reviewed for escalation of aggressive and abusive behaviors directed towards other residents and staff; failed to implement care planned interventions to minimize the risk of falls for 1 of 3 residents (R6) in the sample with a history of falls; and failed to evaluate the root cause of repeated falls to determine appropriate interventions for 1 of 3 residents (R16) who had a history of [REDACTED]. Findings include: The facility failed to provide adequate supervision of (R8) who demonstrated an escalation of aggressive and violent behaviors directed towards residents and staff. Review of the facility's progress notes (PN) from 1/14-2/28/12, revealed an escalation of R8's behavioral outbursts directed towards other residents and facility staff. Although the facility attempted to find alternate placement in a dementia unit, R8 remained in the facility with unmanageable behaviors until an emergency admittance to a psychiatric ward on 2/28/12. R8 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE], identified R8 had severely impaired cognitive skills for daily decision making with short and long term memory problems, inattention and disorganized thinking that fluctuated, delusions, and the behavioral symptoms directed toward others of: physical abuse daily, verbal abuse 4 to 6 days a week, and other behavioral symptoms not directed towards others such as pacing, rummaging, and disrobing in public. In addition, the MDS indicated R8 wandered about the facility on a daily basis with numerous elopement attempts, and was independent in his ability to walk on and off the unit, but required extensive staff assistance with dressing, eating, and toilet use. Review of R8's care plan dated 12/1/11, identified the following behavioral problems: "Resident is a threat to self and/or others R/T (related to) striking out at staff, physically/verbally abusive." Goal: Resident will not harm self and/or others secondary to socially inappropriate/disruptive behavior pattern: aggressive, physically/ verbally abusive. Approaches: Allow distance in seating other residents around resident, observe and report socially inappropriate/disruptive behaviors when around others. Remove resident from other resident's rooms and unsafe situations." The following examples of R8's behavioral disturbances were noted during a review of Resident Progress Notes in R8's medical record: 1/20/12, 6:55 p.m. R8 "Hit nurse in face and yelled at her. . . continues to be very agitated and not easily directed. Resident is grabbing other residents in wheelchairs and tries to push them, staff is able to intervene and get resident away before any injury is caused. Will continue to monitor." The progress note (PN) did not identify which residents were involved in this incident. 1/23/12, 8:31 p.m. R8 "Was in and out of others' rooms. When asked to leave resident would not." The PN did not identify which resident rooms R8 was in and out of. 1/28/12, 6:01 p.m. R8 "Paced through the dining room at supper meal. . . pulled two resident's wheelchairs away from the table at which they were eating at. . .not easily redirected, and continued to pace through the room through out supper." The PN did not identify the other two residents. 1/30/12, 4:20 p.m. R8 "Very agitated this a.m. Not able to redirect and R8 stuck this caregiver on the shoulder. . . spit out first spoonful of medication. Tried again later and R8 did take the rest of meds when offered." The Dr. was called and ordered to increase R8's Seroquel (antipsychotic medication) to 150 mg at 2 p.m. 2/4/12, 7:07 p.m. R8 "Has been wandering quite a bit today. Tried to elope this evening x 3. . . Did pull pants and brief down in the sitting room by main entrance. Was again easily redirected back to his own room. Will continue to monitor." 2/5/12, 8:27 p.m. "After supper R8 became easily upset. He grabbed the cook by the neck and arm, there were no injuries. R8 was directed to his room to get dressed for bed. Has also been observed wandering into other resident's rooms but has been easily directed. Will continue to monitor." 2/7/12, 6:51 p.m. R8 "Tried to walk off with another resident's (R18) silverware at supper. R18 grabbed silverware from R8 and R8 grabbed R18's right forearm. TMA (trained medication aide) and CNA (certified nursing assistant) intervened and R8 was easily directed. 2/8/12, R8 10:00 p.m. "Spilled glass of juice on another resident at supper time. Went through kitchen doors to back hall 3 x, tried to go out front door 2 x . . . fidgeting around with other resident's w/c (wheelchairs) while they were in them. Was found in other resident's rooms 3 x." 2/9/12, 9:19 p.m. R8 "Found in different resident's rooms 4 x, touching other residents 2 x." 2/11/12, 11:09 a.m. R8 "Has been pushing other residents while in their w/c's in t.v. area and making them very agitated and angry. . . continues to wonder in and out of other resident rooms, making the residents very upset. . . Staff continues to monitor resident as closely as is possible. PN did not identify the other residents involved. 2/12/12, 12:39 p.m. R8 "was also walking around dining room taking other residents drinks and clothing protectors, making the residents very angry. . . also came up behind another resident while he was eating and put his hands on the w/c handles very firmly and scared the other resident. Staff has been able to redirect but R8 always cont. to do it again. Will monitor." 2/13/12, 10:56 a.m. "TMA was down hallway and heard resident from room #19 (R18) yelling "get out" and "help!" TMA went into room and R8 was in R18's room with a laundry bucket. R18 was very panicked. TMA assisted R8 out of R18's room quickly and safely. Will continue to monitor." 2/16/12, R8 "Has been wondering all shift since he woke up this morning. At times R8 will wonder into other resident rooms, staff has been able to re direct when they catch him doing so. . . Will continue to monitor." 2/21/12, 8 p.m. R8 was "Trying to take apart a coffee carafe, when nurse took it away from him he tried to push everything off the snack cart and swung his hand to push nurse's arm away hitting nurse's arm and walked away mumbling angry words. At around 9 pm R8 walked into another resident's room (R17) and picked up nebulizer machine and threw it at R17's arm causing skin tears that were bleeding. . . aid walked in right after incident and removed him from room. Shortly after that R8 was wandering again moving objects and walked over to piano and pushed lamp off of top onto floor and then tipped large plant over and walked away mumbling angry. Then R8 started wandering again and grabbed a loose corner of wallpaper and pulled a 3 x 5 section of wallpaper off of the wall. (A)ids tried to put him to bed but R8 wouldn't stay until around 10 pm. Resists taking meds and eating and sitting more than a few minutes at at time on regular basis. Will not stay still or stay busy with a task for more than a few minutes at at time on a regular basis. Does not like it when you walk away from him or take things away from him." 2/22/12, 5:05 p.m. " Received faxed information from (R8's doctor) regarding changes in R8's Seroquel as per new orders from the physician's assistant (PA). If R8 does not take Seroquel this afternoon then will try Zyprexa as suggested by (R8's doctor). " 2/23/12, 9:08 a.m. "Social Services: writer contacted the following memory care units, Bethany, Elim, Sheyenne Crossings, Oak Crossings, Emmanual in D.L. (Detroit Lakes), Edgewood Vista, Waterford and they do not have any bed availability at this time(,) most of them have a waiting list 6-9 months out. Will continue to follow." 2/23/12, 9:14 a.m. "Social Services: Heard back from Rosewood and they have bed available, private room. Writer will contact family and forward information to Rosewood on behalf of resident information via fax. " 2/23/12, 7:23 p.m. "Social Services: Stop sign placed in resident's bathroom to try and prevent further entry into neighbor's room (R17, whom he had thrown the nebulizer machine at) through bathroom door. Staff notified via-my messages and will monitor effectiveness. " 2/24/12, 3:20 p.m. "Received order from PA to transfer to Alzheimer's Unit in lieu of recent escalating behaviors. " 2/26/12, 10:49 p.m. "At night cap (R8) took the milk jug, when writer asked him for the milk he stated, 'no, you don't need anything.' (R8) then proceeded to take the milk and dump it inside the cookie container. Shortly there after (R8) pushed a chair towards another resident, writer stepped in front off the resident, then took that resident back towards their room. (R8) approached another resident, she told him she wasn't afraid of him, R8 then stated, 'I'm not going to hurt you, I'm going to kill you.' Staff separated the residents." 2/27/12, 2:03 p.m. "R8 has been wondering hallways all day and at times in and out of other resident rooms. Continues to pick objects up around the facility and throw them(,) or papers and toss them around . . . has been walking around facility attempting to pull pants down, even when using the restroom is not needed or wanted. . . R8 was also pushing a laundry barrel around and was running it into walls and other residents so CNA attempted to take the barrel and resident slapped CNA very hard on the arm. R8 cont. (continue) to walk up to other residents and trys(sic) pushing residents when not wanted and scares the residents due to what he is doing and his past behaviors. Will cont. to monitor. 2/27/12, 2:19 p.m. "Alerted with yelling of R15's Husband as they were sitting at a dining room table and he (R15's husband) hopped up from his chair. He went over to R8 and said, "I've had enough of you! Face to Face with R8's back towards me. I (the nurse) went over and I stood between them and redirected him (R15's Husband) and he walked away with me. Returning to R15, she said R8 had hit her on the right neck and pulled her O2 (oxygen) cannula, plus according to (R15), (R8) created a scrape on her left forearm this morning at 9:18 a.m." The facility notified the physician's assistant (PA) and an order for [REDACTED]. 2/27/12, 3:48 p.m. "Social Services: R8 has been (in) writers office most of the AM due to increased behaviors and has struck a Resident in the dining room (R19). Writer continue(s) to look for placement for memory care unit. Follow up call with Rosewood indicates they have filled their open room. Further calls made to Villa Maria and Lakewood Reflections Senior Behavioral Health (this would be short term placement and would be to manage his medications and his behaviors as well) will contact family once writer hears determination from Lakewood if they will accept resident. Will continue to look for placement in memory care unit. While R8 was in writer's office R8 was agitated and swearing (')the hell with you [***] .(') Writer was able to redirect and obtained coffee and sandwich. R8 then left and was monitored on the floor by other staff. Further conversation with PA in regards to behaviors, suggestion was made to increase the Zyprexa as well, he states he would make further contact with Psych. (psychiatric)Doctor. Will continue to monitor. " 2/27/12, 10:39 p.m. R8 "was wandering entire shift, entering other rooms . . . agitated entire shift. Picked up plate in dining room and was waving it around by other residents until staff was able to take it away. Took his pants and brief off in dining room after snack, and took them off again in another resident's room." 2/28/12, 10:24 a.m. R8 "wandered into another resident's room, staff entered to redirect out of this room, R8 became agitated and was striking the female (C)NA, she was able to get him out of the room however(;) he was pushing and striking against her. Other staff heard the commotion and assisted with redirecting R8. Writer has R8 in office at this time, phone call placed to PA @ (at) clinic and he is contacting (the doctor) to review to admit on psych, writer also contacted ER (emergency room ) to review how he should be admitted into hosp. (hospital) through ER or direct admit, she suggested direct admit by having (doctor) and attending PA converse and directly admit onto psych. Will continue to follow." Resident Council notes on 2/27/12, identified the following concerns with R8: "A lengthy discussion was held about a particular resident, R8, whom the residents are seeing is becoming more and more aggressive. R23 stated, "He is dangerous & he comes into my room and messes up all of my papers that I am getting ready for my taxes." R17 stated, "He is mean & he scares people." R21 and R20 stated that he comes into their rooms at night after they are in bed. R20 made the comment, "he is throwing things at people and that he takes a lot of time from staff." R17 stated he saw R8 slap his own wife the other day. The SW came and addressed the Resident Council expressing that everyone (all staff) are concerned & very much aware of the situation. (The SW) said that all Clayco employees will do everything in their power to ensure the safety of all residents. She explained about 'confidentiality' and everyone understood and agreed that R8 doesn't understand what he is doing. They do not blame him however; they all expressed they feel something needs to be done. Residents were reassured the situation is being monitored." Interviewed staff and residents indicated the facility was not equipped to manage R8's behaviors: In an interview on 3/7/12, 6:50 a.m. NA (nursing assistant)-K revealed, "R8 was abusing the residents, I was scared to work with him, if you seen him coming, you wanted to go the other way." NA-K verified that R8 had pulled another resident's oxygen tubing and that this resident's Husband was really getting tired of R8 and was ready to "knock him out"." During an interview on 3/8/12, at 1:25 p.m. R23 began to cry while talking about R8. He stated that he was not afraid of him because he could defend himself, but stated there were several residents in the facility who would not be able to take care of themselves. He stated "I was afraid for the women here." In an interview on 3/8/12, 1:30 p.m. TMA-A stated she was afraid of R8 and his behaviors. She stated R8 had struck her while attempting to redirect him. She had informed the administrator and the social service designee. During an interview on 3/8/12, at 1:40 p.m., R20 expressed his concerns with R8, "R8 was always trying to pick a fight with someone, I guess he did pick a fight with R17. . .He tried to pick a fight with me but I just got away from him, he got to be angry and violent, so much so that they hauled him out, I assume to the psych. ward. He also was a kleptomaniac; picking up stuff from rooms at all times of the day and night, scaring people. I was afraid he was going to attack me or something, I was very happy when they hauled him out. The NA's were all scared of him too, they were definitely afraid of him, I think everyone was afraid of him. He would come in the room and stand there looking for something at any hour of the day, I was afraid that if I hit him I would break my hand or something, I wanted to put him down one time when he grabbed my toe. He was up at all times of the day and night: In the day he would come in and take stuff and walk away with it. I feel much better that he's gone because either he's gonna hurt someone, or someone is gonna hurt him." On 3/8/12, at 1:45 p.m. R22 stated he was afraid of R8. He stated R8 would take his walker and act like he was going to hit him. He denied ever being hurt by R8 but stated he was nervous around R8 because he never knew what he may do to the people around him. 3/8/12, 2:39 p.m., NA-H stated, "We definitely did not have enough staff to manage R8's behaviors when he was here." The facility's administrative staff, including the administrator, social worker (SW), and the nurse consultant were interviewed at 12:08 p.m. on 3/8/12. During the interview concerns about the facility's ability to provide adequate supervision and appropriate protection to other residents in the facility was discussed. The administrator, SW and nurse consultant acknowledged the volatility of the situation, however, they expressed frustration that their efforts for immediate more appropriate placement were "blocked" by the facility's PA and R8's doctor as evidenced by the following notations: The facility had first notified the psychiatrist at 9:58 a.m. on 1/30/12, call details included: "Increased behaviors over the past week. He had an unwitnessed fall about one week ago. He is hitting and striking out. He had been gradually more physical over the past week. Had a choke hold on one of the staff and one day threw a cup of coffee at the window. This morning nurse encouraged him to eat breakfast and he hit the nurse on the shoulder. He is doing a lot of wandering into other residents' rooms. He tends to get more physical and harder to redirect in the evenings. He does have some pain but he cannot tell them where the pain is. They are crushing his medications and putting in applesauce." At 10:22 a.m. the psychiatrist returned dictation stating, "Intervention: If he is having pain but not able to communicate, that could be the reason for his agitation. I would recommend giving him pain medications on a scheduled basis. Please discuss this with his primary care physician, also check a UA (urine analysis), change Seroquel to 50 mg, take 3 tablets at 1400 and 1 at bedtime, Watch for falls, call back with concerns." Additional record review revealed progress notes from the local Behavioral Health Clinic. A registered nurse (RN) had documented at 9:35 a.m. on 2/22/12, that the NP had reported the following, "Having increased behavior problems, he is being more aggressive and combative. Last night he struck another resident with his oxygen concentrator. (NP) is wondering about switching his Seroquel doses, move the 2 p.m. to 10 a.m. and 7 p.m. to 4 p.m. and increase the HS (bedtime) dose??? He wants to talk to you about this first. Also wondering if need to move him to a more appropriate facility or behavioral management?? Please call him at the Clacyo Care Center until 10:15 a.m. and then he is at the clinic number." On 2/22/12, at 10:06 a.m. R8's psychiatrist returned the following dictation to the facility: "Discussed with...nurse practitioner. Patient has been increasingly agitated in recent times. Staff at the nursing home feel he is not appropriate candidate there as they do not have an Alzheimer's unit. Patient has been also refusing Seroquel at times and has been very agitated in recent times and also demonstrated inappropriate sexual behaviors. PA also had questions regarding whether Depo-Provera would be useful for patient's sexual behaviors. My recommendation was to look at an Alzheimer's unit. I do not think placing the patient on a psychiatry unit would be helpful. I did discuss medication changes that could be tried. Considering he's refusing the Seroquel I think we could try Zyprexa which can be given both oral and IM form. Recommended trying Zyprexa 2.5 mg 3 times a day. And slowly tapering off the Seroquel. I do not think trying Depo-Provera is indicated for sexual behaviors in dementia, there is no research regarding this as far as I know...(NP) states that he will consider these medication changes." 2/28/12, 2:10 p.m. " Social Services: Follow up call with PA regarding incident that took place this AM, he spoke with R8's psych doctor and he (the psychiatrist) expressed that he would take him if we would agree to take him back following stabilization with meds and current behaviors. Writer discussed option with admin. (a)nd nursing and agree to take this step until further placement of a memory care unit is available." R8's family was in agreement and at 4:04 p.m. on 2/28/12, R8 was transferred via ambulance to an adult psychiatric unit. On 2/29/12, the facility SW had received a phone call from R8's case worker from the hospital who stated that R8 was not appropriate to return to the facility. The case worker revealed that R8 needed one to one staff on the psychiatric unit and indicated that they were presently working on finding alternate placement in a more specialized facility for R8. During an interview on 3/8/12, at 12:08 p.m., the administrator, SW, and nurse consultant discussed their concerns with R8 and indicated some of the ways the facility attempted to manage his behaviors including: (1) A behavior specialist came to the facility to teach staff how to deal with difficult residents. (2) A Quality Assurance (QA) meeting was held in February to address concerns about the timeliness of changes in resident status. (3) R8's Wife would come in from around lunch time to right before supper trying to occupy and walk with him. (4) "Stop Signs" were placed on R17's door and bathroom door. (5) "We (the SW and the administrator) would try to keep him in our offices; would give him coffee and and a snack. (6) The activity aide would try to keep R8 busy with activities on the evening shift to keep R8 busy. Although the facility implemented interventions and sought alternate placement for R8, his aggressive behaviors toward other residents continued to escalate and the facility failed to provide adequate supervision to safeguard the other residents from R8's aggressive behaviors. Interventions, including a low bed, to prevent falls/injury were not implemented for R6 who had a recent history of a fall with a hip fracture. R6 had [DIAGNOSES REDACTED]., swelling of the lower extremities treated with diuretic medication, and a recent history of hip fracture. A significant change in status MDS dated [DATE], identified R6 as severely impaired in cognitive skills for daily decision making. and as having inattention, disorganized thinking, altered levels of consciousness, and psychomotor retardation. The MDS also indicated R6 required extensive physical assistance from staff in bed mobility, transfers, locomotion on and off unit, dressing, eating, and toilet use. The corresponding care area assessment (CAA) dated 1/24/12, revealed, "R6 has had recent falls, and last fall resulted in a fractured hip. R6 has fractured his other hip in the past. R6 is impulsive (and) has poor safety awareness. Current interventions include lipped mattress, bed (and) wheelchair alarms, hip (and) knee protectors, room close to nurses station, gripper socks or non slip shoes to be worn. R6 currently working with therapies for strengthening. . . Staff use hoyer lift or pal lift for transfers, and assist R6 to commode. . .Staff educated to closely monitor resident & anticipate needs due to resident history of falls (and) history of impulsivity. Care plan will be developed to reduce risk of injury related to falls." During observations of R6 at 8:17 a.m. on 3/8/12, R6 was observed lying in bed. The bed was not in the low position, and both of the resident's feet and legs were observed to be dangling off the left side of the bed. NA (nursing assistant)-L came in to assist R6 with cares and verified the bed should have been lowered to the floor as directed in the plan of care. NA-L stated she was hesitant to lower the bed all the way down because it could roll if the wheels were touching the floor. The care plan dated 3/4/12, included: "R6 has history of falling R/T impulsiveness, poor coordination, and weakness. Goal: R6 will remain free from injury. Approach: Keep bed in lowest position with brakes locked." On 3/8/12, at 3:11 p.m. the RN (registered nurse) consultant and the administrator were interviewed. They verified staff should have ensured R6's bed was kept in the low position as directed in the resident's current care plan. R16's repeated falls were not assessed to assure appropriate interventions were implemented. R16 had been admitted to the facility on [DATE] and passed away on 3/5/12. His [DIAGNOSES REDACTED]. An admission MDS dated [DATE], identified R16 as having cognitive impairments, requiring extensive assistance with all activities of daily living and as having a history of falls. The corresponding falls CAA dated 3/6/12, was not completed because the resident had passed away. The admission fall assessment identified him at high risk for falls but it did not include a comprehensive analysis of his fall risk. Review of the nurses' notes identified the following information: 1. On 2/24/12, at 4:39 a.m. the resident was found on the floor in the bathroom. He was unresponsive and was transferred to the emergency room for an evaluation. The resident returned to the facility for continued monitoring. 2. On 2/25/12, at 10:00 p.m. the resident was found on knees on floor near his bed. The bed alarm was sounding. The interdisciplinary team reviewed the incident and indicated that the resident had confusion and moved impulsively without concern for his safety. The team directed the staff to anticipate the resident needs. 3. On 2/25/12, at 4:00 p.m. R16 was found on his knees on the floor next to his bed. No new interventions were reflected in the record. 4. On 2/26/12, at 8:44 a.m. R16 was found on his knees on the floor next to his bed. The record indicated the facility had a bed alarm and fall mats in place, but a root cause analysis of the falls was lacking from the record. 5. On 2/27/12, at 3:11 a.m. R16 was found lying on his back on the floor next to his bed with the bed alarm sounding. 6. On 2/27/12, at 6:07 a.m. the resident had fallen onto the floor next to his bed. 7. On 2/27/12, at 10:52 a.m. the resident was found on the floor next to his bed lying on his stomach. 8. On 2/27/12, at 8:27 p.m. the resident had fallen out of his bed onto the fall mat on the floor next to his bed. After each fall, the interdisciplinary (IDT) team had discussed various interventions and resident behaviors including restlessness and confusion. Although the IDT had implemented a bed alarm and fall mats, there had been no comprehensive analysis of the falls to identify causative factors or patterns to utilize to determine interventions which could minimize the resident's risk for further falls. At 3:00 p.m. on 3/6/12, the RN consultant verified the record lacked a comprehensive assessment of the falls to determine the root cause of the falls so that appropriate interventions could be established to minimized the risk for further falls.