Every finding on record at Valley View Healthcare & Rehab

Based on interview and document review the facility failed to complete a comprehensive assessment, monitor, and notify the physician for a sudden change in mental and physical status for 1 of 3 residents (R1) who had a change in condition. The deficiency was identified as past non-compliance and issued at Immediate Jeopardy. The Immediate Jeopardy (IJ) began on [DATE], when R1 demonstrated changes to mental status, speech, and mobility in which licensed nursing staff failed to comprehensively assess, monitor, and notify the physician. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 5:30 p.m. The facility had implemented immediate corrective action on [DATE] to prevent recurrence, the IJ was issued at past non complinace. Findings include: R1's face sheet dated [DATE], identified R1 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes, obstructive sleep apnea, weakness, and falls. R1 had physical and occupational therapy. R1's comprehensive SLUMS (St. Louis University Mental Status) assessment dated [DATE], identified R1 had a score of ,d+[DATE], which indicated mild cognitive impairment. R1's temporary care plan dated [DATE], identified R1 was stand by assist (SBA)/contact guard assist with walking with a walker. R1's point of care (POC) documentation dated [DATE], identified at 10:41 a.m., R1's balance was always steady from seated to standing, walking, turning around, moving on and off the toilet, and transferring between surfaces. R1's progress note dated [DATE] at 2:47 p.m., identified R1 was alert and orientated and able to let needs be known to staff. Assist of one with gait belt for transfers, toileting, bathing and activities of daily living. R1 participated with physical and occupational therapies for strengthening, needed staff assistance with meals as she had problems with holding a glass. Planed to return home after rehab. R1's progress note dated [DATE] at 10:00 p.m., was a late progress note entered by registered nurse (RN)-A for 7:04 p.m., included, This nurse was called into residents room as she got weak with transferring in the bathroom and staff lowered her to her knees without incident. Staff attempted several times to assist resident back to her feet and remained on her hands and knees. This nurse asked staff what to do and one staff stated to call 911. This nurse called 911 and told them that staff was having a difficult time assisting resident from the floor. By the time the ambulance arrived staff was able to get her to lay flat so the full body mechanical lift was able to be used. This nurse apologized to ambulance crew. She was put to bed, and she is stable at this time. Review of R1's record dated [DATE] did not include any documentation of comprehensive post fall assessments, physical condition, mental status, and vital signs. Review of R1's record identified no indication that R1 had supper, snacks, or fluids provided on [DATE] from 2:00 p.m.-10:00 p.m. R1's ambulance run report printed [DATE], identified emergency medical services (EMS) arrived on scene at 7:13 p.m. and were informed patient was in bed and did not need medical attention. EMS clarified the statement, and the response remained no, medical attention was not necessary. EMS left scene at 7:15 p.m. R1's call light report dated [DATE], identified on [DATE] at 9:30:24 p.m. R1's call light was activated, the call light was cancelled after 37 seconds. Then at 9:31:17, R1's call light was again activated and cancelled after 37 seconds. At 9:31:17 p.m., R1's call light was turned on, and remained on for 24 minutes and 24 seconds, shut off time was 9:55:41 p.m. R1's progress note dated [DATE] at 10:59 p.m., identified RN-A was called to R1's room for R1's passing. Nursing assistant (NA) had went to the room for rounds and R1 had passed away in her sleep. During an interview on [DATE] at 1:38 p.m., trained medication aide (TMA)-A stated she worked with R1 on [DATE] during the day. R1 was perfectly fine, could independently move and staff would just walk next to her to use the bathroom. During an interview on [DATE] at 2:07 p.m., TMA-D stated on [DATE] around 2:00 p.m., she was able to transfer R1 to the toilet independently with little to no difficulty. Then when R1 was done, TMA-D attempted to stand R1 back up but R1 was not able to at all. TMA-D stated it took three staff members to stand R1 to get her back into her wheelchair. TMA-D stated, she was out of it, R1 could answer questions but could not follow directions. When R1 was directed to let go of the grab bar, she held on tighter but told us she had let go, when she did not. TMA-D stated she reported R1 needing more assistance to the on-coming nurse. R1's progress notes and vital sign record did not identify any documentation of assessment pertaining to R1's episode as reported by TMA-D. During an interview on [DATE] at 3:00 p.m., physical therapist assistant (PTA)-A indicated the first time he had worked with R1 was sometime after lunch on [DATE]. PTA-A reported after a few exercises R1 became tired and wanted to go to bed. Since PTA-A had not worked with R1 before, he was not aware that R1's tiredness was a change from her baseline. During an interview on [DATE] at 9:59 a.m., occupational therapy assistant (OTA)-A stated she had first worked with R1 on [DATE]. On [DATE], OTA-A indicated R1 demonstrated changes since [DATE]'s session. On [DATE], at 3:58 p.m. OTA-A started R1's session in her room. When OTA-A attempted to have R1 work on arm exercises, R1 could not follow direction, R1's eyes started closing, and she was not able to articulate her speech. Around 4:10 p.m., R1 told OTA-A she was okay but stuck out her tongue while trying to talk three different times. After the therapy session, OTA-A left R1's room and notified infection preventionist (IP)-A something was wrong with R1, but IP-A directed OT-A to notify registered nurse (RN)-A. When OTA-A notified RN-A of R1's condition, RN-A told her R1 had influenza, and nothing could be done. OTA-A stated RN-A then put on her coat and went outside and did not go to R1's room to assess her. During an interview on [DATE] at 11:24 a.m., IP-A indicated R1 did not have influenza. OTA-A had came to IP-A's office and reported R1 did not seem like herself. Nothing the therapist told her sounded like it was infectious related, so she directed the therapist to tell RN-A. R1's progress notes and vital sign record did not identify any documentation of assessment pertaining to R1's episode as reported by OTA-A. During an interview on [DATE] at 2:51 p.m., nursing assistant (NA)-B stated on [DATE] around 7:00 p.m., she assisted R1 during a transfer in the bathroom from her wheelchair. During the transfer R1 began shaking and was too scared to sit down on the toilet because she was just too weak. NA-B then proceeded to lower R1 to the floor and requested a nurse over a walkie talkie. When RN-A came into R1's bathroom, she asked R1 if she was in pain, but did not perform any vital signs. RN-A then proceeded to call an ambulance. NA-A, NA-B and NA-D then used a total mechanical lift to assist R1 off the floor and placed R1 back in bed. During an interview on [DATE] at 5:21 p.m., NA-D indicated she had worked the evening shift on [DATE] and had not worked with R1 prior. NA-D had assisted R1 to get off the toilet prior to supper. R1 was strong, but slow and unsure of her steps. R1 ate normal at supper. Then around 7:00 p.m. she had become aware R1 was on the floor by a walkie talkie call by NA-B. When she entered R1's room, R1 was on the floor in the entrance of the bathroom on her hands and knees very anxious and shaking. NA-D then came into R1's room and even though R1 was anxious, shaking, and no assessment completed, the NAs told R1 to crawl out of the bathroom so they could assist her to roll onto the lift sling, and transfer her back to her bed. While R1 was on the floor she was not right, not comprehending well, not cooperating, a lot of anxiety, breathing heavy, and shaking. NA-D stated when R1 was on the floor, RN-A never came into the room, but stood in the doorway watching. RN-A left the room, but NA-D was not sure where she went or what she was doing. NA-D stated RN-A did not seem right that night, she was not fit to work and struggled to breath [because of respiratory virus]. NA-D recalled around 8:00 or 8:30 p.m., she answered R1's call light. R1 wanted to be re-adjusted in bed because she had foot pain and wanted her head of the bed elevated. NA-D thought R1 was ok at that time. During a follow-up interview on [DATE] at 2:49 p.m., NA-D stated she did not remember going into R1's room to answer the call light on [DATE] at 9:30 p.m. NA-D was certain the last time she had interacted with R1 was around 8:30 p.m. when she had boosted her up in bed. During an interview on [DATE] at 10:47 a.m., NA-A indicated prior to [DATE], R1 was alert and orientated, not confused, and walked with a walker with only supervision. On [DATE], NA-A worked the evening shift. At approximately 7:00 p.m. NA-A overheard on his walkie-talkie NA-B requesting RN-A's assistance in R1's room. NA-A went from the hallway he was working on to R1's hallway past the central nurse's station where RN-A was sitting. NA-A told RN-A that NA-B was calling her to R1's room for help. NA-A entered R1's room and found R1 half in and half out of the bathroom doorway propped on her wheelchair, with NA-B on her knees, attempting to help R1. RN-A came to the room and observed the situation. R1 was grunting and groaning but not talking much and told the NA's she felt a bit off. NA-A directed RN-A to call 911 as R1 was not participating much and both NAs were not sure if they could get R1 into a position where they could move her to her bed. RN-A left the room without assessing or assisting R1. NA-A and NA-B were able to get R1 situated into a crawling position and eased her into the room and out of the bathroom where they had her lay down and used a mechanical lift to get her back into bed. RN-A returned to the room as NA-A and NA-B were moving R1 to the bed. R1 was verbally responding at that time. NA-A stated he told RN-A that the paramedics should still check out R1 as she still was not herself because normally R1 was able to walk by herself with just supervision. RN-A did not take the lead in the situation and was asking NA-A what to do. During a phone interview on [DATE] at 10:51 a.m., NA-C stated she worked the evening shift on [DATE], that was the first time NA-C had ever laid eyes on R1 and had no previous encounters. NA-C answered R1's call light on [DATE], at 9:55 p.m. NA-C recalled she had knocked on R1's door that was open, R1 did not respond so she entered the room. NA-C entered the room, knocked on the bedside table, and turned the overhead light on. When she turned on the light, she knew R1 was deceased . R1 had her mouth open and emesis trailing from her mouth and into her hair. NA-C called over the walkie-talkie to have RN-A come to the room. RN-A came into the room, looked at R1, with a blank look on her face turned to NA-C and said, what do I do?. NA-C responded that she did not know as she was not a nurse. NA-C stated she was positive RN-A never touched R1 to assess vital signs to verify death. NA-C and RN-A left the room together. RN-A returned to the desk and called the director of nursing (DON). During a follow-up interview on [DATE] at 9:00 p.m. NA-C stated the only staff that were working after 9:00 p.m. was herself, NA-D, and RN-A. NA-C had not answered any other call lights aside from the one at 9:55 p.m. and did not know how the call light was reset the other two times at 9:30 and 9:31 p.m. During a phone interview on [DATE] at 9:26 a.m., RN-A stated she had worked the evening shift on [DATE]. RN-A could not recall if TMA-A had notified her that R1 required more assistance. RN-A did remember occupational therapist had notified her R1 was not herself around 4:30. RN-A went to R1's room, R1 was in bed, looked tired, but did not appear in any distress. RN-A asked R1 how she was doing. R1 reported to her she was doing ok and was just tired. RN-A took R1's blood sugar and it was a little high, RN-A administered scheduled insulin, did not complete any further assessments, and did not take R1's vital signs. R1 then ate most of her dinner. Around 7:00 p.m. R1 needed to be lowered to the floor in the bathroom. RN-A went to R1's room, she was on the floor with the NAs, RN-A only asked R1 if she was ok, R1 said she was ok and was not injured. RN-A did not perform any other assessment but called the ambulance because NAs could not get R1 off the floor. By the time the ambulance arrived, NAs had been able to get R1 off the floor using a full body mechanical lift. RN-A dismissed the ambulance without evaluating R1. After R1 was transferred back into bed, RN-A took R1's blood sugar, it was in the mid 100's, but did not record it into the medical record and did not complete any further assessments. RN-A stated the next time she went into R1's room was to administer scheduled medications between 8:00 and 8:30 and thought R1 was fine. RN-A indicated after each time she was notified by staff of R1's condition, she went into R1's room, but R1 was not demonstrating any symptoms that any of the staff had reported to her. RN-A did not go beyond asking R1 if she was ok and relied solely on R1's self-reports. RN-A indicated only relying on R1's self-assessment was an error in judgment. During an interview on [DATE] at 1:57 p.m., DON stated that she had worked during the day on [DATE] and also came back and worked the night shift. DON indicated she had received a call from RN-A while driving back to the facility, R1 had passed away. When she got to the facility, she had thought RN-A was scattered and sent her home. When DON was reviewing R1's record she had identified RN-A had prematurely documented the required skilled charting at the beginning of shift around 2:30 p.m. instead of at the end of her shift. Further identified the lack of assessments throughout the shift. DON stated there was nothing going on in the facility on [DATE] that would have taken RN-A's time away from assessing R1. DON was unsure why RN-C thought R1 had influenza. It was DON's expectation that when a resident exhibits a change in condition such as needing a higher level of assistance, cognitive/mental status changes, not feeling well, falling, and death that vital signs and comprehensive assessments be completed and increased monitoring be implemented and documented. Additionally, the physician should be notified with changes for further treatment needs. After the incident, DON terminated RN-A's employment and provided staff education on the aforementioned expectations. During a phone interview on [DATE] at 2:27 p.m., medical doctor (MD)-F stated any change in mental status would be considered emergent as it could be an infection, stroke, or cardiac. The resident should be brought to the emergency department for an evaluation and treatment. MD-F stated that when R1 was not able to respond to questions correctly, needed a higher level of assistance than normal the nurse should have evaluated R1 and notified him to the change of condition. In R1's case her symptoms could have been related to a stroke, hypoglycemia, hypercapnia, or heart issues that need to be taken care of. The outcome may have been different if R1 had been sent to the emergency department. The failure to complete assessment on those type of symptoms assessed could put any resident at risk for serious injury, harm, and death, which occurred with R1. The facility policy Change in a Resident's Condition or Status dated [DATE], identified the nurse will notify the residents attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition a significant change of condition is a major decline or improvement in the resident's status that: a.Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions b.Impacts more than one are of the residents health status c.Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the resident assessment instrument. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The nurse will record in the resident medical record information relative to changes in the residents medical/mental condition or status. If a significant change in the residents physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required. The past non-compliance IJ that began on [DATE], and was removed on [DATE], when it was verified the facility implemented the following: -Immediately sent RN-C home pending further investigation then was terminated from employment. -Educare on change of condition assessment for all nurses with competency on [DATE] -Change of condition education is assigned for completion -All licensed staff were given written communication on change of condition-notification to the provider. -Education on death policy [DATE] -Interviews conducted with licensed and unlicensed staff conducted confirmed competency of the facility process.

Based on observation, interview, and record review the facility failed to ensure a complete wireless call light system in which staff were provided with functioning devices in their possession. This had the potential to affect all 33 residents at the facility. Findings include: During a phone interview on 1/29/25 at 9:26 a.m., registered nurse (RN)-A stated the facility's call light system was the worst she had ever seen. The call lights could not be heard and could not tell if they were going off unless she was in the hallway looking at the thin display bar that identified which call lights were going off. During an interview on 1/29/25 at 11:31 a.m., nursing assistant (NA)-E stated the call lights show up on the scroll board that showed the room number and bed 'A' or 'B'. The board makes one high pitched beep when a call light was activated. If there was more than one call light on, the board would scroll through the ones activated in the order that they were activated. The board did not identify how long the call light was activated for. The call system was separated by wings so the board located on each wing only showed the call lights that were activated on each hall. During an observation on 1/29/25 at 11:43 a.m., no scroll board was located in the transitional care unit suites. A scroll board was located outside of the suites at the end of the two other hallways. During an interview on 1/29/25 at 2:12 p.m., director of nursing (DON) stated when residents are admitted to the transitional care suites she alerts them that their call light may take longer to be answered. These residents would be directed to put their light on when they think they may have to use the bathroom instead of when they do have to use the bathroom. At 2:58 p.m., DON went to the infection preventionist (IP) office and pointed to a computer that had call light system software installed on it. DON indicated the computer was showed how long the call lights were going on, did not sound an alert with call light activation, and was unaware if the computer could be moved. The IP's office was locked after business hours and not accessible to floor staff. During an interview on 1/29/25 at 1:09 p.m., Administrator indicated the facility had a wireless call light system that used pagers to alert staff of call light activation, however the facility was not using the pagers. The call light system did not alert to the walkie-talkies that staff used for communication. The staff would know a call light was on by reading the boards in the hallways. During a phone interview on 1/31/25 at 8:39 a.m., call system employee (REP)-A stated the wireless system is complete with pagers/walkie talkies. The facility utilized pagers at one point, but had not ordered any since late 2022. The facility needs to have a functioning device that the employees would carry on them while they were working to alert them of an activated call light. The facility Residents Call System dated 9/22, identified residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member. 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 3. The resident call system remains functional at all times.

Based on interview and document review, the facility failed to process and implement bilevel positive airway pressure (BIPAP) order for 1 of 1 resident (R1) reviewed for respiratory care. Findings include: R1's face sheet dated 1/31/25, identified diagnoses of congestive heart failure (a condition where the heart does not pump blood as well as it should), atherosclerotic heart disease (a condition where fatty deposits build up in the arteries of the heart), obstructive sleep apnea (condition of intermittent airflow blockage during sleep), R1's outside physician orders for admission to the facility dated 1/8/25, included a BIPAP was ordered for a diagnosis of obstructive sleep apnea (condition of intermittent airflow blockage during sleep). R1's electronic health record for physician orders between 1/9/25 through 1/13/25, did not identify the order had for BIPAP had been transcribed into the facility record. Further treatment administration records did not identify R1 received the BIPAP therapy between the dates identified. R1's baseline care plan dated 1/9/25, did not identify R1 required BIPAP therapy and the condition in which is was ordered for. R1's progress notes from 1/9/25 to 1/13/25, did not identify a physician was notified R1 did not BIPAP machine nor evident of communication with R1 or resident representative that the facility did not have a BIPAP available for use. Further the record did not include ongoing assessments and monitoring for signs and symptoms related the diagnosis for which it was prescribed and/or possible symptoms if any related to the omission of BIPAP therapy. During an interview on 1/27/25 at 4:45 pm., licensed practical nurse (LPN)-A stated she did not recall if R1 had a BIPAP while she was here and it and if she had an order, it would have been placed in the treatment administration record (TAR) for the nurses to sign off each night. LPN-A indicated R1's family would have had to have brought the device from home to use at the facility. During an interview on 1/29/25 at 2:12 p.m., the director of nursing (DON) stated she was aware R1 had a physician order for BIPAP on admission on 1/9/25, however did not have a BIPAP in the facility and family would need to bring one in. DON stated the physician was not notified of R1 not having a BIPAP available and stated family had not been contacted to bring one from home. During an interview on 1/28/25 at 2:27 p.m., R1's physician (MD)-F stated when another provider saw her in November of 2024, he became aware R1 was not tolerating her BIPAP and was unsure of what was in that providers documentation for that visit. MD-F stated if a person needs a BIPAP and did not use it they would have snoring, gasping for air and could be sleepy during the day. An undated policy on BIPAP identified BIPAP use requires physician orders, resident's medical history, diagnosis, and oxygen need must be reviewed before initiation, and resident and/or responsible party must provide informed consent.

Based on interview and document review, the facility failed to appropriately vaccinate against pneumonia upon admission for 5 of 5 residents (R4, R7, R10, R16, and R20) who were reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal Vaccine-20 (PCV20) for patients who had received Pneumococcal Vaccine-13 (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R4's 2/01/24, significant change Minimum Data Set (MDS) assessment identified R4 was [AGE] years old. R4's MDS under Section O- Special Treatments and Programs indicated R4's pneumococcal vaccinations were up to date. R4's vaccination record identified she received PPSV23 on 12/11/03 followed by PCV13 on 3/20/15. However, the record lacked evidence R4 had received the PCV20 despite the consent for it being obtained last month. R7's 1/12/24, quarterly MDS identified R7 was [AGE] years old. R7's MDS under Section O- Special Treatments and Programs indicated R7's pneumococcal vaccinations were up to date. R7's vaccination record identified he received PPSV23 on 11/08/01 followed by the PCV13 on 11/28/18. However, the record lacked evidence R7 had received the PCV20 despite the consent for it being obtained last month. R10's 2/16/24, annual MDS identified R10 was [AGE] years old. R10's MDS under Section O- Special Treatments and Programs indicated R10's pneumococcal vaccinations were up to date. R10's vaccination record identified she received PPSV23 on 7/09/14 followed by the PCV13 on 8/07/17. However, the record lacked evidence R10 had received the PCV20 despite the consent for it being obtained last month. R16's 2/13/24, quarterly MDS identified R16 was [AGE] years old. R16's MDS under Section O- Special Treatments and Programs indicated R16's pneumococcal vaccinations were up to date. R10's vaccination record identified she received PCV13 on 5/31/2016 followed by PPSV23 on 10/24/17. However, the record lacked evidence R16 had received the PCV20 despite the consent for it being obtained last month. R20's 1/26/24, quarterly MDS identified R20 was [AGE] years old. R20's MDS under Section O- Special Treatments and Programs indicated R20's pneumococcal vaccinations were up to date. R20's vaccination record identified he received PCV13 on 3/20/15. However, the record lacked evidence R20 had received the PCV20 despite the consent for it being obtained a last month. Interview on 3/12/24 at 3:55 p.m., with registered nurse (RN)-A who is the facility infection preventionist (IP) stated immunizations were verified upon admission through MIIC (Minnesota Immunization Information Connection). IP stated the PCV were offered to residents and would collaborate with the local clinic for residents to receive the pneumococcal vaccine. Interview on 3/13/24 at 8:52 a.m., with nurse consultant (NC) stated the facility completed a vaccination audit when Center of Disease Control (CDC) announced pneumococcal mandates for health care providers and acknowledged the facility had no process for compliance of the vaccine. NC agreed the facility had not administered the pneumococcal vaccines to residents. Interview on 3/13/24 at 9:47 a.m., with director of nursing (DON) stated her expectation would be for residents to receive the pneumococcal vaccines in a timely manner. Review of 2/19/24, Pneumococcal Vaccine policy identified the facility would conduct pneumococcal assessments within 5 working days of residents' admission to the facility and would provide pneumococcal vaccines, according to the Center of Disease Control (CDC), within thirty days of admission unless medically contraindicated, already immunized, or the resident declines the vaccine.

Based on observation, interview, and document review, the facility failed to appropriately assess a change of condition (COC) for 1 of 2 residents (R9) reviewed for hospitalization who had changes from his baseline health status when oxygen (O2) levels were assessed to be low. The facility failure in assessment resulted in R9 being transported to the emergency department. Findings include: R9's 12/19/23, quarterly Minimum Data Set (MDS) assessment identified R9 had diagnosis of chronic obstructive pulmonary disease (COPD), epilepsy (seizure disorder), malnutrition, schizophrenia, anxiety, depression, quadriplegia (paralysis of the limbs), atrial fibrillation (abnormal heart rhythm) , and dysphagia (swallowing disorder). R9's cognition was intact, he was able to communicate, and he was totally dependent on staff for activities of daily living. R9's current administration record identified he has a physician order started on 10/24/23, for as needed oxygen at 1 LPM (liter per minute) via NC (nasal cannula) due to decreased O2 saturations to maintain oxygen saturations greater than 90%. Check oxygen saturations every shift and as needed. Monitor every shift for signs and symptoms of respiratory distress as evidenced by shortness of breath. Notify physician if oxygen remain less than 90% (percent). During an observation and interview on 3/12/24 at 1:14 p.m., R9 was laying down and noticed a slight tremor. R9 was awake and alert during our interaction and was able to answer yes or no questions about his family and the photos on his wall but he was not able to recall any details regarding his illness or going to the hospital on 2/10/24. During an observation on 3/13/24 at 9:37 a.m., R9 was sitting up in his wheelchair watching television. R9 was smiling and alert, he would look towards the door when staff would walk by. R9's vital sign record was reviewed from 11/18/23 through 2/8/24. R9 received supplemental oxygen on 12/26//23 with an oxygen saturation of 90%. R9's oxygen saturations were checked every shift and generally ran from 90%-97%. R9's nursing progress notes identified on: -2/10/24, 6:32 a.m. a late entry from, registered nurse (RN)-B Resident was pallor (pale) and slow to respond to staff when he was addressed at 4:45 a.m. Resident was a-febrile (no fever)with his temperature at 98.6 tympanic, pulse 112, respirations 14, breathing shallow. Sa02 79%-83%. Resident was placed on 2L(liters) oxygen via concentrator at 5:00 a.m. Oxygen saturation was 90% on 2 liters at 5:20 a.m., with his pulse rate at 83. Continue to monitor status. -2/10/24, 7:21 a.m., RN-C CNA called this nurse into room this morning. R9 appeared to be flushed in the face and warm. Temp was 101.3, he was on 1 liter of oxygen and his saturation was 82% I did turn him up to 3 liters and his oxygen's sats came up to 87%. his pulse is 113, respirations 32 per minute, blood pressure at 147/92. He has not yet had his morning medications. called on call provider and received verbal order to send to emergency department for evaluation. Lung sounds diminished in left side anterior fields right anterior fields are wheezy. -2/10/24 7:59 a.m., RN-C R-9 transported via ambulance to emergency department at 7:50 a.m., daughter and director of nursing notified. -2/16/24 Hospital discharge summary identified R9's sister reported to the attending physician that R9 had developed a cough a couple days prior, she identified that R9 is normally responses answers questions in short phrases but is typically pretty alert and not lethargic as described today. The summary identified R9 presented in the emergency department febrile at 103.8 and substantially tachycardia (elevated heart rate) with heart rates around 130. R9 was placed on 4 liters of oxygen per nasal cannula bringing his sats up to the mid 90's. Tylenol was given and temperature came down to 100. He was treated with IV antibiotics. Initially requiring 3-4 liters oxygen supplementation, however this increased to 5-6 liters. on 2/12/24 he was transferred to the intensive care unit (ICU) due to hypotension requiring pressors (medication used for severely low blood pressure) and he was started on a BIPAP (non-invasive ventilation for breathing) for further respiratory support. R9 was transferred back to the nursing floor on 2/14/24, when R9's blood pressure improved. R9's respiratory status continued to improve and return to baseline. R9 was deemed medically stable for discharge and returned to the facility on [DATE]. During an interview on 3/12/24 at 12:35 p.m., nursing assistant (NA)-B identified she went into R9's room on last rounds between 3:30 a.m. and 4:00 a.m., and found R9 to be red faced and shaking really bad NA-A identified R9 was not responding as he normally did and he was staring at me incoherent and shaking NA-A grabbed the thermometer and pulse oximeter but was unable to get a reading, she went and told the nurse. NA-A identified it was difficult to get a reading on the pulse oximeter but eventually it read 79%. It fluttered between 79%-83%. The nurse started R9 on oxygen and left the room. NA-A stated, I don't feel like the nurse took my concerns seriously. During an interview on 3/12/24 at 12:16 p.m., RN-B identified NA-B told her R9s hands were shaking a little, she checked his temperature, and it was 98.6, he was difficult to arouse. RN-B checked R9's oxygen saturation because in the past when he was failing his oxygen would go down. She identified it had been about 3 months since they had to give him oxygen at night. RN-B reported on that night his oxygen saturations were between 79%-83% on room air but after she started him on 2L oxygen, his saturations came up to 90%. RN-B identified she did not complete a lung assessment and that was the end of her interaction with R9, she further revealed she did not return to R9's room to monitor his condition. During an interview on 3/12/24 at 1:00 p.m., RN-C identified RN-B reported off to her at 6:00 a.m., she told RN-B she told RN-C that R9's oxygen was low and that she started him on 2 liters oxygen. RN-C indicated went into R-9's room sometime later and found R9 warm to touch, shivering. RN-C identified she completed an assessment, Temperature, oxygen saturations were 82-84, temperature was high, and lung sounds were diminished. She increased R9's oxygen supplementation to 3 Liters and called for ambulance transfer to the emergency department. During an interview on 3/12/24 at 2:34 p.m., medical director identified she would expect nursing to follow the facility policy and notify the physician if a resident is experiencing a change in condition. She further identified she would expect registered nurses to have the ability to recognize the symptoms of severe infection and/or sepsis and she would have expected RN-B to have completed a comprehensive assessment to include lung sounds. The medical director also indicated it is important not to delay care when dealing with sepsis or any other serious change in condition as it could cause serious health consequences to the resident. During an interview on 3/12/24, at 1:45 p.m., RN nurse consultant stated, as soon as they found R9 with an oxygen saturation of 79%-83% they should have called the on call doctor. During an interview on 3/12/24 at 1:36 p.m., director of nursing (DON) indicated she would have expected RN-B to immediately complete a comprehensive assessment to include lung sounds and update the physician per the facility policy. DON reports she has not done any competencies or face to face training on assessments or change of condition before or after this incident. Review of the February 2021, Change of Condition Policy identified nursing were to notify attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing a standard disease related clinical intervention (is not self-limiting).

Based on observation, interview, and document review, the facility failed to label, date, and cover food stored in kitchen refrigerator and freezer storage. The facility also failed to discard hot dogs that had signs of spoilage and left-over food stored in refrigeration for greater than seven days. This had the potential to affect 30 residents who consumed food prepared in the facility's kitchen. Findings include: 1. Observation during the initial kitchen inspection on 05/08/23 from 9:45 a.m. to 10:15 a.m., with the dietary manager (DM) present, revealed the following: a. Observation of food stored in a reach-in refrigerator, near the kitchen's tray line area, revealed one bowl of egg salad dated 04/28, six unlabeled and undated raw ground beef patties, one container of undated and unlabeled mozzarella cheese, five unlabeled and undated hard-boiled eggs, and two opened and undated 16-ounce plastic bags of whipped topping. b. Observation of food stored in a reach-in refrigerator, in the kitchen's food preparation area, revealed one container of left-over turkey slices dated 04/26, one container of left-over fruit salad dated 04/30, one container of left-over three bean salad dated 04/30, and undated cheese slices that were wrapped in plastic wrap. c. Observation of food stored in a reach-in freezer, in the kitchen's food preparation area, revealed two opened packages of hot hogs that were discolored with accumulated ice crystals that appeared freezer burnt, a pan of undated and partially covered left-over hash browns, one box of uncovered sausage links, and two packages of undated raisin bread. During an interview on 05/08/23 at 10:15 a.m., the DM confirmed the two packages of opened hot dogs stored in the kitchen's reach-in freezer were freezer burnt and should have been discarded by staff. The DM stated when staff place food in refrigeration and freezer storage the food should be labeled, dated, and completely closed. The DM explained staff should discard any food with signs of spoilage or has not been used within seven days after being placed in refrigeration storage. Review of the facility's policy titled, Food Storage: Cold Foods, revised on 4/18, specified, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent contamination. Review of the facility's policy titled, 'Use By' Dating Guidelines, revised on 12/01/15, specified, Ready-to-eat, Time/Temperature Control for Safety Foods including, but not limited to: Milk, yogurt, cottage cheese, cheese, cooked foods, hard cooked eggs, produce, prepared salads, roasted meats, sliced meats, unused portions Use by date seven days after opening. Meats, eggs and other frozen items that are placed in the refrigeration to thaw: . Ground Meat . Use by date: 1-2 days.

Based on interview, and document review, the facility failed to employ either a full time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service since December 2022. This failure had the potential to affect all 31 residents who resided in the facility. Findings include: During an interview on 05/08/23 at 9:45 a.m., the DM stated she recently completed the Serv Safe course but was not a certified dietary manager (CDM). The DM stated the facility's registered dietitian (RD) was employed on a consultant basis and usually visited the facility once per week. During an interview on 05/10/23 at 9:05 a.m., the DM stated she worked at the facility since 2011 as a part time and full time cook prior to becoming the DM during the end of 2022. The DM stated she had not previously worked as a DM. The DM explained she was not a CDM or a certified food service manager and was not currently enrolled in a CDM course. The DM explained since December 2022 when she started working as the DM the facility's consultant RD only visited the facility about once per week. During an interview on 05/10/23 at 10:40 a.m., the administrator stated the facility's current DM worked at the facility for many years as a cook prior to becoming the DM in December 2022. The administrator stated the current DM recently completed the Serv Safe course but was not a CDM or certified food service manager and was not currently enrolled in a CDM course. The administrator stated she thought the current DM met the required qualifications for the position based on her work experience and completion of the Serv Safe course. The administrator explained since the current DM began working in the capacity in December 2022 the facility had contracted with RDs who only worked at the facility on a consultant basis approximately one day a week and had not employed a full time RD to work at the facility. Review of the facility's policy titled, Professional Staffing, revised 09/17, specified, The Dining Services department will employ sufficient staff, with appropriate competencies and skills sets to carry out the functions of food and nutrition services, taking into consideration the resident assessments, individual plans of care and the number, acuity and diagnosis of the resident population. This includes a qualified dietitian or other clinically qualified nutrition professional, either full time or part time. If the qualified dietitian or other clinically qualified nutrition professional is not employed full time, a director of food and nutrition services who meets the necessary qualifications will be employed. A 'qualified director of food and nutrition services' is one who: Is a certified dietary manager, or, Is a certified food service manager, or Has similar national certification for food service management and safety from a national certifying body; or Has an associate's or higher degree in food service management or in hospitality, if the course of study includes food service or restaurant management, from an accredited institution of higher learning, and In states that have established standards for food service manage or dietary managers meet state requirements for food service managers or dietary managers.

Based on observation, interview, and document review, the facility failed to keep the kitchen's small mixer, sheet pans, two kitchen drawers, and a shelf where food preparation equipment was stored clean. The facility also failed to maintain the kitchen's walk-in freezer in safe operating condition by failing to prevent ice buildup inside the freezer. This failure had the potential to affect 30 residents who consumed food prepared in the facility's kitchen. Findings include: 1. Observation during the initial inspection of the facility's kitchen on 05/08/23 from 9:45 a.m. to 10:15 a.m., with the dietary manager (DM) present, revealed the following: a. The kitchen's small mixer, covered and ready for use, was unclean with dried food splatters. b. Two kitchen drawers, with food preparation equipment including: scoops, metal and rubber spatulas, serving spoons, tongs and whisks stored in them, were unclean with greasy residues and food debris. c. A kitchen shelf, with food preparation pans stored on it, was unclean with a greasy residue and food debris. d. Five of five food preparation sheet pans, stored as clean and stacked directly on top of each other, were unclean with a heavy grease residue. During an interview on 05/08/23 at 9:55 a.m., the DM confirmed the kitchen's small mixer, five sheet pans, and the interior of two drawers and a shelf where food preparation equipment was stored were unclean. The DM stated staff were expected to make sure kitchen equipment was clean prior to storing it for use. 2. Observation on 05/08/23 at 10:10 a.m., with the DM present, revealed the kitchen's walk-in freezer had accumulated ice buildup on the freezer's door, door frame, floor, ceiling, shelves and on boxes of food stored inside the freezer. Areas of the freezer's floor not covered by a rubber mat were very slick. During an interview on 05/08/23 at 10:10 a.m., the DM stated the accumulated ice buildup in the kitchen's walk-in freezer was an ongoing issue. The DM stated the facility's maintenance staff were aware of the ice build up in the walk-in freezer. Observation on 05/09/23 at 9:05 a.m., revealed the kitchen's walk-in freezer had accumulated ice buildup on the freezer's door, door frame, floor, ceiling, shelves, and on boxes of food stored inside the freezer. Areas of the freezer's floor not covered by a rubber mat were very slick. During an interview on 05/09/23 at 9:05 a.m., the DM stated the dietary staff were previously directed to make sure the freezer's door was completely shut to reduce the ice buildup inside of the freezer. The DM was unaware of any plan for the walk-in freezer to be serviced or repaired. Observation on 05/10/23 at 7:15 a.m., revealed the walk-in freezer's door was not completely closed and would not latch shut. The freezer had ice buildup on the door, door frame, floor, ceiling, shelves, and on boxes of food stored inside of the freezer. Areas of the freezer's floor that were not covered by a rubber mat were very slick. Ice buildup on the freezer's door and door frame prevented the door from closing completely. Also, the door's interior gasket (which creates a tight seal when the door is closed to keep cold air inside the freezer and outside air out) was cracked, worn, and not tightly affixed around the door. During an interview on 05/10/23 at 7:17 a.m., cook (C)-1 stated when she came into work on 05/10/23 at 5:30 a.m. the kitchen's walk-in freezer door was not completely closed and would not latch shut. Observation on 05/10/23 at 8:10 a.m., with the maintenance director (MD) present, revealed the kitchen's walk-in freezer had accumulated ice buildup on the door, door frame, floor, ceiling, shelves, and on boxes of food stored inside of the freezer. The ice buildup on freezer's door and door frame prevented the door from closing completely and the door would not latch shut. Also, the door's interior gasket was cracked, worn, and not tightly affixed around the freezer door. During an interview on 05/10/23 at 8:10 a.m., the MD stated an outside repair company checked the walk-in freezer a couple months ago regarding the ice buildup inside the freezer. The MD explained the outside repair company advised the facility to keep the freezer's door closed as much as possible to prevent ice from forming inside the freezer. The MD stated the current ice buildup inside the walk-in freezer was worse than he had previously observed. The MD agreed the ice around the freezer's door prevented the door from being completely shut and the door's gasket was cracked, poorly affixed to the door, and needed to be replaced. The MD stated he did not have a plan in place to fix the walk-in freezer because he had not received a work order regarding the current ice buildup in the walk-in freezer, so he was unaware of this being an ongoing issue that needed to be addressed. Review of the facility's policy titled, Equipment, revised on 9/17, revealed, Policy Statement All foodservice equipment will be clean, sanitary, and in proper working order. Procedures . 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed.

Based on observation, interview, and document review, the facility failed to provide soft bite sized food and encourage to alternate consumption of liquids and solids during meals as ordered for 1 of 1 (R2) resident of the sampled residents who had a diagnosis of dysphagia (difficulty with swallowing) and received a mechanically altered diet. Findings include: R2's undated Face Sheet, provided by the facility, revealed an admitted [DATE], with medical diagnoses which included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominate side, dysphagia following an unspecified cerebrovascular disease, and vascular dementia. The Face Sheet specified R2's most recent readmission to the facility was on 02/22/23. R2's facility-provided hospital After Visit Summary, dated 02/22/23, revealed, . on further swallow evaluation he was found to have some dysphagia (was provided SB6 soft and bite-sized diet, which he continued on discharge) so cannot exclude possible mild aspiration pneumonia to explain CXR (chest x-ray) findings. R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/23, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 9 of 15, which indicated moderate cognitive impairment. Per the MDS, R2 experienced coughing or choking during meals or when swallowing medications during the assessment period. R2's facility-provided current Care Plan revealed a Problem area initiated on 05/30/2018, which specified I am at increased nutritional risk related to a history of CVA (cerebrovascular accident) with dysphagia, diabetes with a need for a therapeutic diet. Care plan approaches included Staff will cut up my meats. I am independent with eating. and I should be sitting upright during any meals/liquid consumption. Encourage me to alternate liquids and solids during mealtimes. I should remain sitting up for 30 minutes after meals. R2's Physician's Order Report: 04/18/2023 - 06/18/2023, revealed the following orders, Diet: Dysphagia soft bite sized/general/thin liquids and Resident should be encouraged to alter liquids and then solids during meals. Continuous observation on 05/08/23 from 11:55 a.m. to 12:19 p.m., revealed R2 was seated by himself at a dining room table independently eating his lunch meal. R2 was served a piece of toasted garlic bread and a cookie with his meal. The toasted garlic bread and cookie appeared to be hard and were not cut into small bite sized pieces. R2 took only a very small bite off the end of the cookie and placed it back onto his plate. R2 was not observed to attempt to eat the toasted garlic bread. During the meal R2 took multiple bites of solid food before he took a drink of liquid. R2 was not encouraged to alter solids with liquids during the meal. At 12:19 p.m., staff assisted R2 from the dining room. R2's finished lunch meal revealed he did not eat the toasted garlic bread and ate only a very small bite of the cookie he received at this meal. Observation on 05/09/23 at 12:15 p.m., revealed R2 was seated by himself at a dining room table independently eating his lunch meal. R2 was served a grilled sandwich that was not cut into bite sized pieces. The resident took multiple bites of food without taking a drink of liquid. R2 was not encouraged to alter solids with liquids during this meal observation. At 12:20 p.m., staff assisted R2 from the dining room. R2's finished lunch meal revealed he did not eat the outer portions of the grilled sandwich which appeared to have a hard texture. During an interview on 05/10/23 at 9:05 a.m., the dietary manager (DM) stated R2 had problems with swallowing and chewing and was to receive a mechanical soft diet with soft bite sized foods at meals. The DM confirmed staff should not have served R2 the toasted garlic bread and hard cookie during the 05/08/23 lunch meal or the grilled sandwich during the 05/09/23 lunch meal. The DM explained staff should have served R2 soft bread with butter instead of the toasted garlic bread, and a soft oatmeal cream pie instead of the hard cookie during the 05/08/23 lunch meal. The DM stated staff should have served R2 either a regular sandwich or a lightly grilled sandwich in place of the grilled sandwich with hard outer edges R2 received during the 05/09/23 lunch meal. During an interview on 05/10/23 at 11:10 a.m., the director of nursing (DON) confirmed staff should encourage R2 to alternate liquids with solids during meals as ordered. The DON stated that she thought R2 was being encouraged by staff to alternate solids and liquids at mealtimes. The facility-provided policy titled, Therapeutic Diets, with a revision date of 09/17, revealed, All residents have a diet order, including regular, therapeutic and texture modification, that is prescribed by the attending physician, physician extender of credible practitioner in accordance with applicable regulatory guidelines. 'Mechanically altered diet' means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physicians' or delegated registered or licensed dietitian's order.

Based on observation, interview, and document review, the facility failed to ensure a resident's preferences to keep his room door shut while unoccupied was honored for 1 of 1 resident (R17) reviewed for choices. Findings include: R17's significant change Minimum Data Set (MDS) dated [DATE], identified R17 was alert and oriented and had diagnoses of schizaffective disorder and mild intellectual disabilities. R17's care plan dated dated 4/28/21, identified R17 experienced delusions and hallucinations in the past. Staff were directed to encourage R17 to spend time out of his room for meals, activities; and to spend time with others. The care plan lacked any resident preferences related to R17's room door. During an interview on 5/8/23 at 1:39 p.m., R17 stated when he was not in his room he wanted to keep his door shut. R17 told social services (SS)-A this, but staff continued to leave it open. During an observation on 5/9/23 at 9:40 a.m., R17 was not in his room and his door was open. During an observation on 5/10/23 at 7:33 a.m., housekeeping (HSKG)-A was cleaning R17's room while R17 was in the dining room eating breakfast. HSKG-A did not close R17's door after cleaning R17's room. During an interview on 5/10/23 at 8:08 a.m., HSKG-A stated they did not know R17 liked to have his door shut. There was not any type of reference for resident's preferences and the only way you knew what someone liked was by getting to know the residents. During an interview on 5/10/23 at 9:08 a.m., SS-A stated R17 liked to have his door shut when he left his room and R17 had let her know that was his preference. SS-A had not communicated R17's preference to the staff. SS-A assumed when staff entered his room and the door was shut they would shut the door when they left. Nursing had a communication book for these things, but housekeeping did not have access to the communication book. Preferences were important because they were apart of the residents' rights and preferences should be followed to ensure a resident was satisfied with their stay. An interview with the administrator and director of nursing (DON) on 5/10/23 at 10:09 a.m., was conducted. The administrator stated staff needed a visual cue to remind them to shut R17's door and the preference should be communicated to all staff. The DON and the administrator both stated there was a communications book available for all staff and staff were expected to review entries. The administrator stated all residents had individual rights to privacy and protection of their belongings and it was not for staff to determine if those preferences were valid or invalid. The DON stated this was R17's home and should be treated as such. The facility communication book dated 7/15/21 through 5/10/23, lacked R17's preference to keep his door shut when his room was unoccupied. The facility policy Resident Rights revised 12/2016, identified employees shall treat all residents with kindness, respect and dignity. Federal laws guaranteed certain basic rights to all residents of this facility. These rights included the resident's right to: 1. Be supported by the facility in exercising his or her rights; 2. Privacy and confidentiality; 3. Voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; 4. Have the facility respond to his or her grievances.

Based on observation, interview, and document review, the facility failed to ensure unvaccinated staff adhered to additional precautions, weekly testing, that were intended to mitigate the spread of COVID-19. This deficient practice had the potential to affect all 34 residents residing within the facility. Findings include: Review of facility staff matrix provided by the facility identified 22 staff were unvaccinated. Licensed practical nurse (LPN) and nursing assistant (NA-A) were identified as unvaccinated. Facility was unable to provide testing results for unvaccinated staff LPN and NA-A. When interviewed on 4/21/22, at 2:01 pm NA-A stated COVID-19 testing is not provided at the facility and NA-A would test at a local pharmacy once a month. NA-A stated he had not shared his test results due to being negative. NA-A was observed wearing goggles for eye protection and mask. When interviewed on 4/21/22, at 2:06 pm LPN stated COVID-19 testing is scheduled at the facility one time a week and that she tests weekly. LPN stated she did not test this week but she did have an exemption and knew the policy was to test weekly for COVID -19. LPN was observed wearing eye protection and a mask. When interviewed on 4/21/22, at 2:16 pm infection control nurse (ICN) stated unvaccinated staff were to be tested at the facility at least one time a week based on county transmission level. ICN stated COVID-19 testing occurred at the facility every Monday and ICN preformed the tests with staff. ICN stated she did not cross reference who came in to the facility to test and who does not with the unvaccinated staff list. ICN stated, I hold staff responsible to come and get tested . INC reviewed unvaccinated staff test results and could not provide testing results for NA-A or LPN. When interviewed on 4/21/22, at 3:23 pm director of nursing (DON) stated unvaccinated staff are to be tested weekly for COVID-19 and ICN was to manage these tests. DON stated the policy had not been followed if there were no test results. DON was not aware of unvaccinated staff not testing. Review of policy Complying with CMS Omnibus COVID-19 Health Care Staff Vaccine Interim Final Rule, dated 2/3/22, indicated precautions for staff not fully vaccinated, or who have a pending or granted exemption: employees will continue to be testing for COVID-19 consistent with current CMS requirements, but at a minimum once weekly.

Based on observation and interview the facility failed to ensure staff followed professional standards of practice of medication administration for 6 of 12 residents (R19, R13, R288, R7, R289, and R286) observed during medication pass. Additionally, the facility failed to ensure staff were properly assessing appropriate placement of a gastronomy tube (G-tube) (a tube inserted through the abdomen delivering nutrition directly into the stomach) per policy before administration of nutrition to 1 of 1 resident (R1) with a G-tube. Findings include: R288's Face Sheet indicated R288 was admitted to the facility with a principle diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's Face Sheet indicated R7 was admitted to the facility with a principle diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at 4:45 p.m., licensed practical nurse (LPN)-A was administering medications to residents after they arrived to the dining room for evening meal. LPN-A entered the dining room with 2 medicine cups of medication and administered one medicine cup to R7 and the second medicine cup to R288 who were seated at the same table. Review of medications indicated R7 was administered acetaminophen 650 mg tablet and [MEDICATION(S)] extended release 100 mg tablet and R288 was administered [MEDICATION(S)] 1 mg tablet, The medication cups did not have any identifiers for resident name or medications present. R19's Face Sheet indicated R19 was admitted to the facility with a principle diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's Face Sheet indicated R13 was admitted to the facility with a principle diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation on [DATE], at 5:05 p.m., LPN-A arrived into the dining room with 2 medicine cups of medication and administered one medicine cup to R19 and observed R19 take them. LPN-A then set down the medication cup next to R13 who was at the same table, and walked away. Neither medicine cup had a resident identifier or medication name present. Review of medications administered included R13 received Vitamin C (Ascorbic Acid) 500 mg tablet, and R19 received Tylenol 500 mg tablets 2 tablets, atrovastatin 40 mg tablet, [MEDICATION(S)] 500 mg tablet, [MEDICATION(S)] 1000 mg tablet, and [MEDICATION(S)] [MEDICATION(S)] tablet 50 mg tablet. During interview on [DATE], at 5:10 p.m., LPN-A indicated she did set up and administer R288 and R7's medications and R18 and R13's medications at the same time. LPN-A was able to identify the medications administered and when asked if setting up and administering 2 separate residents at the same time is standard of practice she stated no my bad, I shouldn't have done that. During medication administration on [DATE], at 5:30 p.m., LPN-A had electronic medication administration record (EMAR) for R286 on the computer screen. Two medications were visible that included Novolog (insulin) 100 units/ml to give 8 units and [MEDICATION(S)] (blood thinner) 4 mg 1 tablet orally. LPN-A indicated she had previously set up the insulin dose and had it pre-checked with another nurse and showed 8 units was preset on the insulin pen injector. LPN-A placed [MEDICATION(S)] 4 mg in a medicine cup. LPN-A then placed [MEDICATION(S)] 1000 mg tablet into the medication cup. When asked how LPN-A knew he was to receive [MEDICATION(S)] 1000 mg, since it was not visible on the computer screen, LPN-A indicated she knows what he gets as she has given it the last ,d+[DATE] nights. LPN-A administered medications to R286 and returned to the medication cart. LPN-A opened R289's EMAR and viewed [MEDICATION(S)] 125 mg 1 capsule four times a day orally for 10 days. LPN-A pulled the [MEDICATION(S)] medication card 125 mg and placed medicine in cup and administered to R289. When questioned if she verified the correct medication and dosage to the EMAR on the medications she administered, LPN-A indicated she looked at the EMAR prior to sitting down but did not verify the medication, or dosage pulled from the cart with the EMAR order. R1 R1's Face Sheet printed [DATE] included primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, and received 51% or greater of calories from tube feeding. R1's Physician's Orders dated [DATE], included check placement of G-tube every shift, [MEDICATION(S)] 1.5 liquid; 0.07 gram-1.5 kcal/ml at 75 milliliters (ml's) per hour giving 1200 ml's total from 6:00 p.m. until 8:00 a.m. and flush G-tube with 120 ml of water every 4 hours. During observation and interview on [DATE], at 6:05 p.m., LPN-A retrieved 5 cartons of [MEDICATION(S)] 1.5 kcal/ml, 240 ml's per carton from refrigerator and placed on the medication cart. The computer screen was black and LPN-A confirmed the battery was dead on the computer. LPN-A entered R1's room, and using tap water flushed the g-tube with 60 ml's of water. LPN-A then filled a new infusion bag with the 5 cartons of [MEDICATION(S)] 1.5 kcal/ml. When questioned how she knows to flush with 60 ml's of water and the amount of [MEDICATION(S)] to give and at what rate, she stated she just knows. LPN-A then primed the tubing on the pump, connected to R1's g-tube and set the pump to run at 75 ml/hour and left the room. The administration pump hung on a pole with a stethoscope hanging on the top. LPN-A indicated she did not check placement of the g-tube and did not look at the medication administration record (MAR) prior to administration of the water or [MEDICATION(S)] stating she knows she is supposed to, but the computer died and she has done this many times and knows what to give and how to do it. A review of LPN-A competencies included medication administration monitoring was completed [DATE] with identification of resident, medication, dosage, route, time, including order verification in EMAR was satisfactory completed. A competency on Enteral Nutritional therapy was last satisfactorily completed on [DATE] that included checking position of the tube by listening for breath sounds at end of tube .Place stethoscope over stomach and instill a small amount of air into enteral feeding tube and listen for air to enter the stomach. During interview on [DATE], at 8:20 a.m., the director of nursing (DON) confirmed the same process is followed for tube feedings as for medication administration and should be verified with the EMAR prior to administration as this is part of the five rights of medication administration., and includes tube feeding solutions and water flushes of g-tubes. The DON also confirmed, medications should not be set up and administered for 2 residents at the same time but should be done one person at a time. The DON indicated if a computer battery was dead, it should have been plugged in or a new cart retrieved to verify the tube feeding instructions with physician orders prior to administration. A policy titled Administering Medications dated ,d+[DATE] included: - The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. A policy titled, Enteral Tube Feeding via Continuous Pump, dated ,d+[DATE] included: - Verify that there is a physician's order for this procedure. - Check the enteral nutrition label against the order before administration checking the following information: - Resident name, ID and room number; - Type of formula; - Date and time formula was prepared - Route of deliver - Access site - Method (pump, gravity, syringe): and - Rate of administration - Verify placement of tube and once correct tube placement has been verified, flush tubing with at least 30 ml's of warm water or prescribed amount.

Based on observation, interview and document review, the facility failed to ensure their system for medication reconciliation was adequate to ensure timely identification of loss or diversion of narcotic medications for 1 of 1 medication room emergency kit. Findings include: On 7/7/21, at 10:12 a.m. the medication room was reviewed with registered nurse (RN)-A. The emergency kit (E-kit) was behind a locked door entry to medication room and a locked cupboard both opened with a physical key. The E-kit included narcotic medications and controlled substances. The E-kit was secured with green numbered lock tags with an identifier number present on it. A loose leafed three ring binder was placed next to the E-kit along with a container of additional green numbered tags. RN-A stated staff documented the five tag identifiers at shift changes, and documented the green tag numbers in the loose leafed three ring binder next to the E-kit. RN-A verified there would be no way of knowing if someone had removed medications from the E-kit along with a page from the three ring binder and changed the green numbered lock tags. During interview on 7/7/21, at 10:29 a.m. director of nursing (DON) confirmed there was a potential for diversion with the loose leaf binder verification system for the E-kit. The DON indicated she can not say for sure the staff are looking at previous dates or verifying the numbers during shift changes. During interview on 7/8/21, at 1:49 p.m. the consultant pharmacist indicated there could be a potential for diversion using a loose leaf three ring binder for verification of green tag identifiers. Requested a copy of E-kit medication reconciliation policy and procedure, but did not receive one.

Based on interview and document review facility failed to document rationale for the continued use of a PRN (as needed) [CONDITION(S)] medication beyond 14 days for 1 of 5 (R14) residents reviewed for unnecessary medications. Findings include: R14's electronic health record (EHR) face sheet indicated R14 had the following diagnosis that might require the use of [CONDITION(S)] medication: anxiety disorder unspecified. According to R14's medication orders, among other medications, R14 had an order for lorazepam (a schedule IV controlled substance given for anxiety) one(1)MG at bedtime as needed, with an order start date of 5/19/21 to 11/19/21. A PRN [CONDITION(S)] Medication Evaluation Form was initiated by the facility consulting pharmacist on 5/18/21 and provided to the medical provider for review of R14's lorazepam order that had originally started 5/10/21. A physician assistant (PA-C) updated the order to continue for six more months, but no information was provided on the form as to how many doses R14 had taken, whether the medication was effective or whether or not R14 had any side effects. The form prompts a response for the following questions, brief clinical rationale for continuing or modifying order (required); however, this section was left blank by PA-C. According to an interview 7/09/21, 9:43 a.m. with the Director of Nursing (DON), stated R14 had entered the facility with the order for lorazepam and they [facility] would depend on the pharmacist to review the order and make recommendations. DON was unsure how many days a [CONDITION(S)] PRN medication order should be written for and stated, we just follow the doctor's orders and whether [R14] should continue to be on them. DON stated [CONDITION(S)] medication use was discussed during their interdisciplinary team meetings, but was unable to locate a note documenting a discussion about R14's PRN lorazepam order. A request for a facility policy related to PRN [CONDITION(S)] medication use was requested but not provided.

Based on observation, interview and document review facility failed to ensure the [CONDITION(S)] access site was consistently monitored and assessed for 1 of 1 residents (R25) receiving hemodialysis. In addition, the facility failed to provide a comprehensive [CONDITION(S)] care plan to reflect signs and symptoms of complications with corresponding interventions and clarity on when or how to coordinate care with the [CONDITION(S)] center. Findings include: According to R25's electronic health record (EHR) facesheet, R14 had the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] According to a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Check for redness warmth, and signs of infection. Special Instructions: THIS IS TO BE DONE BY THE NURSE!!!!!!!!!!!!!!!!! [sic] ordered to be done once a day between 6:30 a.m. and 10:30 a.m. According to a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] >150/90. Special instructions: Please continue to check blood pressures as ordered, but you do not need to notify of blood pressures >150/90 as long as he doesn't have any symptoms of chest pain, dyspnea or headache. Please notify if he does have these symptoms. Otherwise is he is asymptomatic you don't need to notify. ordered to be done between 6:30 a.m. and 10:30 a.m. and 7:00 p.m. and 10:30 p.m. daily. Order does not state which provider to notify nor direct nurses to notify [CONDITION(S)]. During an interview 7/07/21, 3:00p.m. a registered nurse (RN-A) stated they communicated with the [CONDITION(S)] unit if R25 had a change in status, but then RN-A said she was not sure and needed to check with the DON. RN-A said they sent a list of R25's medications and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A said the facility checked R25's port, blood pressure and temp before he would go to [CONDITION(S)], but when he came back he is drained and just wants to rest. RN-A said after [CONDITION(S)] they would put R25 in bed and let him rest, bringing him a late supper. According to an interview 7/08/21, 7:35 a.m. RN-C stated they were to check R25's [CONDITION(S)] port every morning for redness, warmth and swelling, but they did not need to be concerned about bleeding or other complications. RN-C also stated his blood-pressure needed to be monitored twice daily because he had been having problems with swings in his blood pressure, both high and low. RN-C also said that R25's blood-pressure should be checked as soon as possible after his return from [CONDITION(S)]. RN-C was unable to say who she would call if R25 was showing complications related to his [CONDITION(S)] and confirmed that this information was not readily available in R25's chart. RN-C said I can't say for 100% but it might be in his admission notes. RN-C did not know the name of a contact person nor a direct phone number to dial, but said, I guess I'm not sure who they should talk to there, maybe the care manager? That's how it was where I worked before. RN-C said that at a facility where she had previously worked they would send people with symptoms of infection to the emergency room and said, I guess that's probably what we should do [here]. RN-C said she knew how to care for R25 because she had previous [CONDITION(S)] experience, but did not relate any facility acquired training. According to an interview 7/08/21, 8:00 a.m. RN-B stated R25's care plan should include information directing nurses on how to monitor a [CONDITION(S)] port and what to do if there were complications or the dressing came off. RN-B also said the care plan should include directions to monitor for fluid or electrolyte imbalances and specifically who to contact if R25 was to have any complications or symptoms indicating a problem. RN-B confirmed that this information was not included in R25's current care plan, and that information about who to contact was not in R25's chart. RN-B located a document titled Memorandum of Understanding Mayo Clinic [CONDITION(S)] Services and said, this was not in his chart, it was in a folder at the nurses station. So I am going to put this in his chart and update his care plan now. RN-B reviewed the EHR and confirmed progress notes failed to show any regular communication with the [CONDITION(S)] unit. According to an interview 7/09/21, 9:10 a.m. R25 stated that the nurses checked his port daily, most of the time, well, usually, well, sometimes they do. According to an interview 7/9/21, 9:34 a.m. the Director of Nursing (DON) stated that only nurses could do an assessment, and an assessment, in general, would be the observation of condition through the nurse's senses and a skill only licensed individuals could do. DON stated an expectation of documentation of assessments and notification to a medical provider if there was a significant change in condition. A [CONDITION(S)] assessment, according to the DON should include as assessment of the access site, the resident's weight, blood pressure, skin color and how they were feeling. Additionally, DON described possible complications of [CONDITION(S)] to be infection, fluid imbalance, weakness, dizziness, nausea, fatigue and changes in blood pressure. DON said a [CONDITION(S)] assessment should be done every day before the resident leaves for their treatment and then again upon return to the facility. DON also said the access site should be checked every shift, and DON said, I just learned that actually. The DON stated the facility should send any abnormal findings with the resident when going to [CONDITION(S)] and confirmed the facility sends R25's medication orders, but does not include the results of any assessments done. DON was unable to recall if education had been provided to the nursing staff. A document titled The Memorandum of Understanding Mayo Clinic [CONDITION(S)] Services (MCDS) Patients Who Are Residents in Long-Term Care Facilities/Nursing Homes dated 12/24/20 with R25's name at the top was received. The document includes all contact information for the [CONDITION(S)] unit and indicates, effective and close communication between the [CONDITION(S)] unit and the long-term care facility is essential to develop an efficient and effective plan of care for each patient. In addition, the document includes the following information, Please remember the patient's access is her/his lifeline. Special attention should be paid to this vascular access so that it does not clot. Patients can experience infections of these fistulas, grafts or intravenous catheters. If there is any unusual redness, swelling, temperature greater than 100.5 F or 38 C or other problems, contact the patient's [CONDITION(S)] unit immediately. If you wish to receive further education regarding the dare of [CONDITION(S)] access sites, please contact the [CONDITION(S)] unit. A policy related to [CONDITION(S)] assessments, cares and communication with the [CONDITION(S)] care team was requested: A document was provided titled End-Stage Renal Disease, Care of a Resident with (no date) indicated staff caring for residents with end-stage renal disease shall be trained in the care and special needs of these residents, and also it indicated the resident's comprehensive care plan will reflect the resident's needs related to [CONDITION(S)]/[CONDITION(S)] care. A document titled Hemodialysis care (no date) was provided and indicated the purpose to be: hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of these devices. It describes the care of Central [CONDITION(S)] Catheters: Do not allow non-[CONDITION(S)] personnel to access the catheter the general medical nurse should document in the resident's medical record every shift as follows: 1. location of catheter. 2. condition of dressing (interventions if needed). 3. Any part of report from [CONDITION(S)] nurse post-[CONDITION(S)] being given. 4. Observations post-[CONDITION(S)]. A request was made for evidence of education or competency testing of nursing staff related to the care of a [CONDITION(S)] patient, but none was provided. A request for any [CONDITION(S)] assessments for the past three months were requested, but were not provided.

Based on observation, interview and document review the facility failed to verify physician orders prior to enteral feeding (nutrition taken through a tube that goes directly to the stomach) and check placement of a gastrostomy tube (g-tube) per facility policy prior to administration for 1 of 1 resident (R1) observed with a g-tube. Findings include: R1's Face Sheet, included primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact, and received 51% or greater of calories from tube feeding. R1's Physician's Orders dated [DATE], included check placement of G-tube every shift, [MEDICATION(S)] (tube feeding formula) 1.5 calorie liquid; 0.07 gram-1.5 kcal/ml at 75 milliliters (ml's) per hour giving 1200 ml's total from 6:00 p.m. until 8:00 a.m. and flush G-tube with 120 ml of water every 4 hours. During observation and interview on [DATE], at 6:05 p.m., LPN-A retrieved 5 cartons of [MEDICATION(S)] 1.5 kcal/ml, 240 ml's per carton from refrigerator and placed on the medication cart. The computer screen was black and LPN-A confirmed the battery was dead on the computer. LPN-A entered R1's room, and using tap water flushed the g-tube with 60 ml's of water. LPN-A then filled a new infusion bag with the 5 cartons of [MEDICATION(S)] 1.5 kcal/ml. When questioned how she knows to flush with 60 ml's of water and the amount of [MEDICATION(S)] to give and at what rate, she stated she just knows. LPN-A then primed the tubing on the pump, connected to R1's g-tube and set the pump to run at 75 ml/hour and left the room. The administration pump hung on a pole with a stethoscope hanging on the top. LPN-A indicated she did not check placement of the g-tube and did not look at the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on [DATE], at 11:06 a.m., registered nurse (RN)-C indicated tube placement for R1 is checked by inserting 15 ml of water into the g-tube, placing a stethoscope on abdomen next to tube site and listening for gurgles. During interview on [DATE], at 8:20 a.m., the director of nursing (DON), confirmed the same process is followed for tube feedings as for medication administration including checking the order and the product three times and following the five rights of medication administration. The DON confirmed if a computer battery was dead, it should have been plugged in or a new cart retrieved to verify the tube feeding product to the provider order prior to administration. A policy titled, Enteral Tube Feeding via Continuous Pump, dated ,d+[DATE] included: - Verify that there is a physician's order for this procedure. - Check the enteral nutrition label against the order before administration checking the following information: - Resident name, ID and room number; - Type of formula; - Date and time formula was prepared - Route of deliver - Access site - Method (pump, gravity, syringe): and - Rate of administration - Verify placement of tube and once correct tube placement has been verified, flush tubing with at least 30 ml's of warm water or prescribed amount.

Based on observation, interview and document review, the facility failed to ensure range of motion (ROM) services were offered and provided according to the therapy recommendations for 1 of 2 resident (R19) reviewed for limited range of motion. Findings include: R19's face sheet, included diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's quarterly Minimum Data Set (MDS) assessment dated [DATE], included R19 understands, had moderate cognitive impairment and required extensive assist of two for bed mobility, toileting and transfers, and extensive assistance of one for personal hygiene. The MDS also indicated R19 had functional limitations of range of motion (ROM) in upper and lower extremities on one side. R19's plan of care dated 6/21/21, indicated a self care deficit in transfers, bed mobility, locomotion related to left sided weakness, stroke and falls. R19 is non-ambulatory. Interventions included R19 will be encouraged to complete exercises with activities and will use heat to his shoulder as needed, use of a Broda chair to decrease postural deviation, to realign posture and function, to enhance my range of motion and overcome limitations prohibited by a recline type of chair, and to prevent contractures and orthopedic deformities, and staff will follow physical and occupational therapy recommendations. During observation and interview on 7/06/21, at 2:15 p.m., R19 was sitting in Broda chair in his room. R19's left hand was curled into a fist. R19 was able to open his fingers and wiggle them upon request with fourth digit remaining lowered and less mobile than other fingers. R19 indicated they do not apply heat or exercise either of his arms or fingers adding they don't do anything like that here. During observation on 7/07/21, at 12:25 p.m., R19 is in the dining room feeding himself with his right hand. Left hand was on arm of chair and curled into a fist. R19 upon request was able to move both arms and all fingers except 4th digit remained down and less mobile than other digits. R19 indicated staff do not exercise has hands. R19's Restorative Program sheet dated 9/11/20 and signed by certified occupational therapy assistant (COTA)-A included R19 updated program to include apply heat pack for 15 minutes prior to session, complete active and passive range of motion (AROM, PROM) to right upper extremity, and should do digits within pain free range as tolerated 10 times and 2 sets. Goal is to decrease pain, increase range of motion and increase activities of daily living participation. R19's Restorative Nursing document dated 4/20/21-7/7/21. Out of 111 opportunities, range of motion was completed 29 times. Reasons documented for not performing included not observed, unavailable, could not assess, no information. deferred due to condition and one refusal. During interview on 7/08/21, at 9:11 a.m., COTA-B indicated R19 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R19 was cooperative with heat stating it felt good and range of motion was done as he could tolerate. Heat would help loosen the joints so ROM could be done with less discomfort. COTA-B indicated R19 did participate in therapy and would actively open and close his right hand on demand. COTA-B indicated she did not remember any issues with his left hand or the 4th digit on his left hand being any different than his other fingers with position or movement. COTA-B further indicated they can only treat and evaluate what the order includes and for this one it was the right shoulder, arm and hand, not the left. During interview on 7/8/21, at 9:32 a.m., nursing assistant (NA)-A indicated R19 refuses heat most of the time and will participate in range of motion exercises on the right side but requires someone to work with him for him to complete it. NA-A included R19 does refuse sometimes. NA-A further indicated she wasn't aware of any issues with his left hand. During interview on 7/8/21, at 10:56 a.m., the director of nursing (DON) stated apparently the staff do not know how to document refused on the Restorative Nursing. The DON further indicated the process has changed over the past few months with NA performing versus a restorative aide they had previously. The DON further indicated the process was documented on paper prior but she shredded them so there are no records that go past what is documented on the Restorative Nursing record. During observation and interview on 7/8/21. at 11:01 a.m., R19 when asked if they offer to put heat on his right shoulder or arm and he stated no, and they do not do ROM with him either. R19 further indicated he does not want heat applied, but cooperated with moving both right and left arm and opening and closing both fists. Left 4th digit remained less mobile and more curled towards his fist than other digits. R19 at rest has left digits curled into a fist. During interview on 7/9/21, at 8:24 a.m., the DON indicated staff should be documenting refused if he refuses which she believes is happening but agreed R19 would cooperate with ROM on his own with some prompting by staff. During interview on 8/9/21 at 8:33 a.m., NA-B indicated R19 will sometimes do ROM on his own, but most of the time requires prompting. NA-B indicated R19 generally cooperatives and will move both his arms and hands upon request. NA-B was not aware of any issues with R19's left hand or fingers. A policy titled Range of Motion Exercises undated included: - The purpose of this procedure is to exercise the resident's joints and muscles. - Review the resident's care plan to assess for any special needs of the resident. - Be gentle with the resident and do not rush the procedure - If the resident becomes weak, or complains of pain, cease the exercise and summon the staff/charge nurse. - Support the extremity at the joint as it is being exercised. - Move each joint through its range of motion 3 times unless otherwise instruction - Move each joint gently, smoothly and slowly through its range of motion - Remember to stop an exercise before the point of pain.

Based on observation, interview, and document review, the facility failed to consistently assess and monitor increasing weight, and [CONDITION(S)] to the lower extremities for 2 of 2 resident (R14, R4) reviewed for [CONDITION(S)] and hospitalization s. Findings include: According to the facility electronic health record (EHR) face sheet, R14 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Care Plan indicated a care problem of Nutritional status: I am at increased nutrition risk related to advanced age, adult failure to thrive, and moderate protein calorie malnutrition for R14, with a start date of 11/21/20. Corresponding care approaches included providing a general diet with 4 ounces of nutritional supplement three times daily for extra nutrition, monitoring intake of food and fluid daily and monitoring and recording R14's weight at least weekly. Additionally, nursing staff was to notify the primary care provider of any significant weight changes. According to a physician assistant's (PA-C) progress note dated 11/17/20, R14 had no lower extremity [CONDITION(S)] (fluid accumulation in the tissues). According to a physician's progress note by a medical doctor (MD-A) dated 1/20/21, R14 was being seen for a routine visit post-hospitalization (11/3/20) for acute [CONDITION(S)] related to pulmonary [CONDITION(S)] (fluid accumulation in the tissue of the lungs) which required diuresis (the provision of medications to enhance renal function to remove fluid overload). The note indicated nursing staff had no concerns for R14 at that time. MD-A indicated that heart rate was regular and lungs were clear, but chronic [CONDITION(S)] was noted in the lower extremities. According to progress note by PA-C dated 3/9/21, R14 had 3+ [CONDITION(S)] ([CONDITION(S)] of significant severity where pressing on the tissue for several seconds will result in an indentation of 4-6mm (millimeters) that lasts for a minute or more) of both lower legs and R14 was not wearing any tubi-grips (a knitted compression hose). A progress note date 3/16/21 by PA-C indicated R14 had slight [CONDITION(S)] and nursing staff should monitor and notify of any changes or decompensation in R14's condition. Additional progress notes by medical providers after March of 2021 were requested but not provided. According to a nutrition note written by a certified dietary manager (CDM) in the EHR dated 5/12/2021: Diet order is general, cut up foods. Resident does prefer to eat meals in her room. Resident reports appetite is good. Resident does consume 50-100% of food on most meal trays. Offering 4 oz nutrition supplement TID with meals for extra nutrition. Resident does like this and wishes to continue having supplement. Recent weight was 141# on 5/11/21. Weight has increased since admission. Weight on admission was 115# on 11/12/20, this does represent a 22.6% weight gain over the past 6 months. Will continue to monitor weight and oral intake. According to R14's EHR weight record, R14 weighed: 115 pound (lbs) on 11/12/20 121 lbs on 12/09/20 130.3 lbs on 1/13/21 133.2 lbs on 2/16/21 135.2 lbs on 3/9/21 135.4 lbs on 4/20/21 140.5 lbs on 5/11/21 142.9 lbs on 6/22/21 145.1 lbs on 7/6/21 During an observation on 7/6/21, at 2:50 p.m. R14 was sitting in her recliner in her room with her feet dependent (hanging down) and she had visual swelling of both feet, but no compression stockings or tubi-grip observed. On 7/07/21, 11:25 a.m. R14 was observed in her recliner in room, legs dependent and legs visually swollen and tubi-grip compression were on. On 7/08/21, 9:25 a.m. R14 was observed in her recliner napping with legs dependent and visually swollen and tubi-grip compression were on. During an observation 7/09/21, 2:04 p.m. registered nurse (RN-C) demonstrated personal technique for checking [CONDITION(S)]. R14 was sitting in recliner with feet elevated, wearing tubi-grip. The compression tube on the right lower extremity had moved. The lower portion of the right foot was ballooned up to approximately twice the size of the portion that was compressed by the hose. RN-C stated, well, that doesn't look like it was put on right. RN-C then checked for [CONDITION(S)] by quickly touching the puffy portion of the right foot without pressure. RN-C stated a firm touch to compress the tissue was not necessary to check for [CONDITION(S)]. RN-C also stated that persons receiving diuretics should have [CONDITION(S)] checks done daily and documented in the medication administration record. During an interview 7/09/21, 1:08 PM the Director of Nursing (DON) stated she receives a list of weights from the CDM and the CDM is responsible to monitor the resident weights unless there are specific orders for nurses to be sure weights do not go over a defined limit, such as when someone has [CONDITION(S)]. DON did say that nurses should notice if there are changes in weights, but that the CDM should be bringing up any significant changes in weight at the interdisciplinary team meetings. DON state, I was told that is not my area to monitor and this (weight increase) should have been caught. DON also said the nursing assistants enter the resident weights into the EHR, but they are unable to see what a previous weight had been so cannot report a change in weight. During an interview 7/09/21, 1:55 p.m. CDM stated she did not have documentation that she had reported or discussed R14's 22% weight gain with the registered dietician (RD). She sated she was unable to find any documentation that the RD had reviewed or assessed R14, and she was unsure when she should report to the RD. She said she did not document conversations she had with the RD. CDM did state that R14 liked her dietary supplement and had discussed continuing them with the nursing team, but did not recall telling the nursing department about the weight change. During an interview on 7/9/21, 2:07 p.m. RN-B stated any resident with cardiovascular and/or respiratory problems related to fluid overload should have on-going assessment and evaluation of their condition, and nurses should report to the medical care provider if the person has a significant or on-going change in their weight or condition. RN-B stated an expectation for nurses to assess weights, [CONDITION(S)], vital signs, heart and lung sounds on a regular basis for persons with cardiopulmonary problems and said this should be done for R14. RN-B also stated that increases in weight should be evaluated and reported as this could indicate a problem with fluid overload which might lead to a lot of problems and spiral out of control. RN-B gave a definition of significant weight change of an increase or decrease of about 5% in a three month period. RN-B stated he was unable to find nursing documentation in the nurses' notes of assessment or evaluation of R14's condition related to [CONDITION(S)] or weight gain since March 2021. RN-B was able to locate a list of [CONDITION(S)] checks, but no further evaluation or reporting. During an interview 7/09/21, 3:03 p.m. DON stated a trained medication aid (TMA) had brought it to their attention that quite a few residents were wearing tubi-grips and TMA wondered if that indicated a problem. DON stated she had initiated a performance improvement project on [CONDITION(S)] and fluids and said she thought she had started it about a week prior to the survey, and this consisted of adding [CONDITION(S)] checks to the nurses' tasks when a person was receiving diuretics. She stated she had not provided an educational session for nurses, but had posted a sign and indicated they should come to her if they had questions. DON said she wrote the note in May. DON stated checks for [CONDITION(S)] or fluid overload should be done in the morning when tubi-grips were applied and then again when they were removed to determine effectiveness of the treatment. DON also said it was expected that nurses would apply a gentle but firm pressure for several seconds with enough force to indent/compress resident tissue when doing an assessment for pitting [CONDITION(S)]. Anything less would not be sufficient. Facility provided the education posting DON described dated 5/19/21; the education in total is as follows: Nurses- when charting [CONDITION(S)] on residents when giving [MEDICATION(S)] [diuretic] don't put yes or no- please chart amount of [CONDITION(S)] Example 0 +1 +2 . TMAs-please ask your nurse to assess [CONDITION(S)] when charting. In physical examination pitting, tenderness, skin changes and temperature are evaluated. Pitting: there are two types of [CONDITION(S)], pitting and non-pitting [CONDITION(S)]. Pitting [CONDITION(S)] is described as an indentation that remains in the edematous area after pressure is applied. To determine the extent of the pitting [CONDITION(S)], you can push on the skin, measure the depth of the indention [sic] and record how long takes for your skin to rebound back to its original position. Then grade it on a scale from 1-2. If you press a swollen area with your finger and it doesn't cause an indentation in the skin, it's considered non-pitting [CONDITION(S)]. If you need additional education on assessing [CONDITION(S)] please see me (DON). A policy related to monitoring [CONDITION(S)] or fluid overload was requested, but not provided. R4 R4's face sheet identified a re-admitted [DATE], and included primary readmission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R4 to have intact cognition. R4 required extensive assistance of two with transfers, and toileting, received antipsychotic medication daily over past seven days and no diuretic. Weight was recorded as 136 pounds with no weight gain or loss. R4's discharge MDS assessment dated [DATE], indicated a significant weight gain of >5% or more in last 30 days or 10% or greater over past 6 months. Weight was documented as 168 pounds. R4's care plan dated 10/30/20, included R4 is at increased nutrition risk related to recent hospitalization for fluid overload and CHF with history of moderate calorie/protein malnutrition. Goal included R4 will maintain weight at 150 pound plus or minus 5 pounds. Interventions dated 10/30/20, included staff will monitor and record intake of food and fluid daily, and staff will monitor and record weights at least weekly and notify primary care provider (PCP) and family of significant weight changes. Provider orders dated 3/11/21, included Tubigrips (compression stockings used for swelling) on a.m., and off at bedtime. Order written on 3/19/21 included weigh weekly in bath chair on bath day and manual blood pressure and pulse on Monday, Wednesday and Friday with special instructions to not obtain blood pressure with automatic machine. Review of R4's documented weights indicated: 1/8/2021 weighed 127.2 pounds. 2/5/2021 weighed 140.2 pounds. 2/19/21 weighed 153 pounds. 3/12/2021 weighted 156.5 pounds. 4/7/2021 weighed 168.1 pounds. Total weight gain was 40.4 pounds from 1/8/21 until 4/7/21. A nutrition progress note dated 1/19/21 included recent weight was 131 pounds on 1/15/21, which is up from admit weight of 124#'s on 10/28/20. This does represent a 5.6% weight gain over the past 3 months. Will continue to monitor weight and oral intake. A provider progress note dated 1/28/21 included visit was to follow-up to elevated blood pressure and R4 has been on [MEDICATION(S)] 75 twice daily with blood pressures as follows 156/84, 170/88, 148/54, 184/78, 199/81 and 160/74. [MEDICATION(S)] was added for blood pressure. A provider progress note dated 2/11/21 included discussion on blood pressure and how they are all over the place. [MEDICATION(S)] was decreased due to decreased heart rates with blood pressures today of 131/55 but others included 185/46, 145/64, 152/93 and 164/53. Weight was present in note as 140 pounds. A provider progress note dated 3/11/21 included continue to review of blood pressures which were recorded as 138/63, 160/62, 141/45, 150/55, 175/48 and today 148/62. Weight was present as 156.7 pounds. A nurse progress dated 3/11/21 at 10:32 a.m., indicated nursing received an order from therapy and resident is to wear bilateral Tubigrips for [CONDITION(S)], size E. No mention in progress notes regarding [CONDITION(S)] prior to or after this note. A provider progress note dated 3/25/21 included a follow up of her blood pressures with some blood pressures being much lower at 136/75, 149/49, 151/62 and 148/49. No mention of weight present. A progress note dated 4/10/21 at 6:10 a.m. indicated R4 was having hallucinations about children and continued to have thoughts about children throughout shift and also told staff there was two men in her closet all day but they left now. A progress note dated 4/11/21 at 4:03 a.m. indicated resident continued to talk to someone who was in the room and stated that there was a girl there she knew. A progress note dated 4/11/21 at 11:26 a.m. indicated the resident has been experiencing hallucinations and has not slept in over 24 hours. VS: 168/99, HR 55, pulse oximetry 84%, RR 24 and temperature 97.1. On-call physician recommended resident be transferred to ED, which was arranged and completed. Review of Weight Variance Reports indicated R4 was present on multiple weight variance reports run weekly from 11/22/20 through 4/12/21. The Variance Report dated 1/12/21 through 4/12/21 indicated a 9.1% weight gain from 2/5/21 to 2/19/21 in 14 days, and from 3/31/21 to 4/7/21 was a 7.4% weight gain in 7 days. A quality assurance report dated 12/2020 through February 2021 included R4's most recent weight was 154, and 30 days ago was 140 with 10% weight change. Sixty days ago weight was 133 for 15.8% change and 90 days ago weight was 137 for 12.4% weight gain. Findings included a significant weight gain over the past 30/90 days. Recommendations included diet order is general. Resident does prefer small portions. R4 has history of mal calorie and protein malnutrition. Staff reports she eats well. During interview on 7/9/21, at 1:01 p.m., the certified dietary manager (CDM) indicated weekly weights were completed on R4 and whenever there is a significant change, the director of nursing is notified. The CDM did indicate this weight gain was significant and shortly before R4 was transferred to the hospital, she spoke with trained medication aide (TMA)-A questioning her about [CONDITION(S)] and how she was eating. The CDM indicated she reviews weekly weights and does a comparison over the past 3 months then may ask staff questions regarding [CONDITION(S)], how they are eating or may ask to have them re-weighed. CDM added the family also questioned the weight gain. The CDM indicated she did not document any of the above nor the conversation with TMA-A and was unsure if registered dietician was notified regarding R4's weight gain. The CDM did indicate she brought reports multiple times to the interdisciplinary meetings (IDT) and shared those with the director of nursing. During interview on 7/9/21, 1:08 p.m., the DON indicated she does receive a list of weights from the CDM but had been told that it is not her area to monitor. The DON indicated if orders are present to not exceed a certain weight or contact provider with a certain weight parameter, nursing would be responsible or if resident is having symptoms like leg [CONDITION(S)]. The DON indicated in this instance, the CDM should have communicated the weight gain to the nursing staff or brought it up at IDT meeting versus handing her a report. The DON further indicated R4's significant weight gain should have been questioned and reported to the provider by someone. During interview on 7/9/21, at 1:16 p.m., TMA-A indicated she was asked to reweigh R4 around the time of the hospitalization but was unsure the exact date but assumed something was off with the weight. TMA-A indicated that was the extent of the conversation and the CDM did not question her regarding symptoms of fluid overload. During interview on 7/09/21, at 1:45 p.m., registered nurse (RN) -C indicated nursing staff monitor weights that are completed daily but weekly weights are generally the responsibility of dietary to monitor. RN-C further indicated if provider orders include weight parameters, nursing would be the one to contact the provider. During observation and interview on 7/09/21, at 3:30 p.m., R4 indicated the fluid pill has been working for her and she was told her heart isn't in that great of condition and she has heart failure. R4 did not recall being in the hospital, having [CONDITION(S)] or any breathing difficulty in the past 6 months. R4 was sitting in her wheelchair, on room air, with easy respirations and no pedal [CONDITION(S)]. Multiple attempts were made to contact R4's primary care provider (PCP) without return call. Did receive a call back from registered nurse (RN)-D on 7/9/21, at 2:39 p.m. who indicated the above weights should have been initially reported to PCP with the weight gain from January until February. Attempted to reach medical director 7/9/21, at 3:49 p.m., and received a return call from physician assistant, certified (PA-C) on 7/9/21, at 4:21 p.m PA-C indicated she does not have specific parameters but generally a 10 pound weight gain over 30 days would be significant. PA-C further indicated if any symptoms are associated with weight gain such as shortness of breath or [CONDITION(S)], it should be brought to the attention of the PCP. PA-C indicated the above weights should have been discussed by the facility and the nurses made aware of the significant weight gain. PA-C further indicated someone should have to notified the PCP. An After Visit Summary dated 4/15/21 from the hospital indicated R4 was hospitalized with acute diastolic (congestive) Heart Failure 4/11/21 through 4/15/21. A policy titled Weight Change last updated 10/28/20 written by Nutrition Services Director included: - All residents are to be weighed weekly, unless otherwise ordered by their attending physician to insure adequate nutritional status as evidenced by lab within normal limits and weight within ideal body weight range as determined by the dietary supervisor or registered dietitian. - Any resident with a weight change of five (5) or more pounds in 1 week will have a re-weight done to determine the accuracy of the change. - Significant weight change is defined as 5% in 30 days or 7.5% in 90 days, or 10% in 180 days. - The attending physician will be notified of the weight change and orders requested as indicated on physician rounds or per fax. - Care plan will be updated accordingly.

Based on interview and document review, the facility failed to ensure an allegation of employee to resident abuse was thoroughly investigated for 1 of 1 residents (R1) who resided on the long term care unit (LTC). Review of facility investigation documentation did not include interviews of other residents or staff. During an interview on 4/13/21 at 11:28 a.m., DON stated other residents or staff were not interviewed following the alleged abuse. DON verified she only spoke to the alleged perpetrators and R1 who reported it. DON verified the aides perform cares for other residents in the facility but did not feel she needed to interview other residents. DON stated others have been interviewed in other incidents. DON stated they were unable to substantiate the allegation and required the alleged perpetrators to complete abuse education prior to returning to work. DON stated both alleged perpetrators were removed from schedule during the investigation though she had not interviewed alleged perpetrator (AP1) until 4/6/21 and that AP1 had worked 4/5/21 but on a different wing than R1 was on. DON stated AP1 was not aware of the alleged abuse concern until 4/6/21. DON stated that this morning she discovered that AP2 did not complete the education required and had returned to work and worked 2 four hour shifts. DON stated R1 discharged to home on 4/7/21. During an interview on 4/13/21 at 12:49 p.m., R1 stated the incident occurred over the previous weekend and he reported it at the care conference on 4/5/21.

Based on interview and document review, the facility failed to report abuse allegation to State agency (SA) within 2 hours of allegations of abuse, for 1 of 1 resident (R1) reviewed for abuse. Review of state agency incident reporting indicated the incident occurred on 4/5/21 at 00:00 and the report was submitted to Minnesota Health Department on 4/6/21/10:58 a.m. Report indicated R1 reported the alleged abuse on 4/5/21 during a care conference. During an interview on 4/13/21 at 11:28 a.m., DON stated R1 reported the alleged abuse during his care conference on 4/5/21 with the social worker present. DON stated the social worker then filed a grievance concern. DON stated she then interviewed R1. DON stated she had 24 hours to report the allegation of abuse and was not aware of reporting it within 2 hours. DON stated she recieved education regarding abuse and reporting upon hire in December 2020. DON verified that the incident was not reported within 2 hours of the incident according to policy and regulation.