Every finding on record at Viking Manor Nursing Home

Based on observation and interview, the facility failed to properly store food under sanitary conditions by placing medical gel ice packs in a freezer designated for resident food in a common area. This had the potential to affect all residents storing food in the freezer.During an observation on 08/26/2026 at 11:11 a.m., five medical gel ice packs were in the freezer of the unit. The Following items were in the freezer with the medical gel ice packs:Five undated and not labeled Ziploc bags of dough.Two one-gallon pails of ice cream that did not contain opened date. One pint ice cream in a bag that was labeled with resident name. Three opened boxes of ice cream bars unlabeled with name or date opened. One undated Ziplock bag of doughnuts with name of resident. During interview on 08/26/2026 at 11:17 a.m., with licensed practical nurse (LPN)-A confirmed that ice packs used for patients should be stored in freezer in med room and not in the common area. LPN-A reports the aids have been putting them in common area freezer and education continues to be provided to store ice packs in med room freezer. LPN-A removed the ice packs from the common area freezer. During an interview on 08/26/2026 at 12:03 p.m., dietary manager (DM)-A confirmed they were unaware that staff was storing ice packs in common area freezer. DM-A confirmed that ice packs should not be stored in the freezer in common areas. DM-A confirmed that there is not a specific policy stating that medical ice packs should not be stored in common area freezer. During an interview on 08/26/2026 at 12:21 p.m., the facility administration confirmed they were made aware of the ice packs being stored in common area freezer and confirmed the ice packs should be stored in the med room freezer.Policy was requested, none received.

R29's quarterly MDS dated [DATE], identified R29 was severely cognitively impaired and had diagnoses of Alzheimer's disease, dementia and depression. R29 needed total assistance with dressing, toileting and transfers. R29's care plan revised 3/31/25, identified R29 had an alteration in gastro intestinal status related to the presence of a cholecystectomy (gallbladder) tube and R29 was on EBP. R29's signed physicians orders dated 6/5/25, identified staff were to monitor the dressing to the biliary (gallbladder) draining daily and as needed (PRN). Further indicated staff were to change the dressing when soiled PRN. During an observation and interview on 6/9/25 at 4:30 p.m., NA-B and NA-C were in R29's room and transferred R29 into bed using a mechanical lift. NA-C grabbed two pairs of gloves from R29's bedside table and gave NA-B one pair. NA-C and NA-B applied gloves and removed R29's brief. NA-B provided R29 the urinal and R29 voided. RN-B removed the urinal and disposed the urine in the bathroom. NA-B returned to assist NA-C with cleaning R29's bottom and applying a new brief. NA-C and NA-B removed their gloves and transferred R29 back into the wheelchair with the mechanical lift. NA-B and NA-C did not wear gowns while providing cares to R29. NA-B and NA-C stated staff only needed to wear a gown when they were providing cares to R29's cholecystectomy tube. NA-B and NA-C confirmed they had not worn a gown when they were changing or transferring R29. During an interview on 6/11/25 at 9:28 a.m., director of nursing (DON) who also worked as the infection preventionist indicated staff should be wearing gowns when providing activities of daily living such as dressing, catheter care, transferring, and changing bedding. DON indicated wearing gowns was important to prevent the spread of possible infections to other residents. Review of facility policy titled Enhanced Barrier Precautions dated 2025, personal protective equipment (PPE) for enhanced barrier precautions was only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High-contact resident care activities included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted central catheter) lines, midline catheters. Based on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for 2 of 3 residents (R17, R29) observed for enhanced barrier precautions (EBP), (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Findings Include: Review of Centers for Disease Control (CDC) guidance dated 4/1/24, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for EBP included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R17's quarterly Minimal Data Set (MDS) dated [DATE], identified R17 was cognitively intact and had diagnoses of cerebral infarction (stroke), benign prostatic hyperplasia (prostate increasing in size making urination difficult), hemiplegia (paralysis), and hemiparesis (weakness on one side). R17 needed maximal assistance with upper body dressing and was dependent on staff for lower body dressing and toileting hygiene. R17's care plan revised on 2/14/24, identified that R17 required the assistance of one staff and a mechanical standing lift for toileting. R17 had a Foley catheter, and staff were to empty the urinary catheter as needed. R17's care plan revised on 5/10/25, identified staff needed to follow EBP when changing the Foley catheter, emptying the urinary drainage bag, performing peri care, and assisting the resident with bowel hygiene. R17's order summary report dated 6/5/25, identified staff needed to change the suprapubic catheter with 18 French once every 42 days and give the resident a new leg/bed catheter bag at bedtime every Sunday for catheter care. During an interview on 6/9/25 at 2:45 p.m., R17 indicated that staff typically did not wear a gown while providing care. During an observation on 6/11/25 at 7:21 a.m., nursing assistant (NA)-A applied gloves and did not apply a gown. NA-A took the mechanical standing lift into R17's room, applied R17's shoes and helped R17 sit on the side of the bed. NA-A assisted R17 with putting his feet on the standing mechanical lift. NA-A hooked R17's catheter bag on the mechanical lift and put the sling around R17. NA-A lifted R17 from the bed and transferred him to the bathroom and removed his brief and placed in the garbage. NA-A transferred R17 to the shower chair and brought R17 to the shower room down the hallway. At 8:11 a.m., NA-A came out of the shower room without a gown to grab the standing mechanical lift and brought the lift into the shower room. During an interview on 6/11/25 at 7:33 a.m., NA-A indicated staff would wear a gown when changing the catheter and switching the night bag to a leg bag. NA-A did not believe staff needed to wear a gown when getting R17 dressed or during a bath. During an interview on 6/11/25 at 8:55 a.m., licensed practical nurse (LPN)-A, indicated staff needed to wear a gown when changing the suprapubic catheter or the urine night bag to a leg bag. LPN-A did not think a gown would need to be worn when giving R17 a bath or dressing R17.

Based on interview and document review, the facility failed to ensure 2 of 6 residents (R40, R21) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Pneumococcal Vaccine Timing for Adults, dated 10/24, from the CDC identified adults [AGE] years of age or older who had previously received the Pneumococcal 13-valent Conjugate Vaccine (PCV13) and the Pneumococcal Polysaccharide Vaccine 23 (PPSV23) should receive one dose of the 20-valent Pneumococcal Conjugate Vaccine (PCV20) or 21-valent Pneumococcal Conjugate Vaccine (PCV21). Review of R40's Minnesota Immunization Information Connection (MIIC) identified R40 had received the PPSV23 vaccination on 9/21/18. R40's medical record lacked documentation R40 had been offered or received the PCV20 or PCV21 vaccination. R40's medical record further revealed R40 had consented to receive the PCV20 or PCV21 vaccination on 5/6/25. Review of R21's MIIC identified R21 had received the PCV-13 vaccination on 2/25/16, and the PPSV23 vaccination on 10/1/09. R21's medical record lacked documentation R21 had been offered or received the PCV20 or PCV21 vaccination. R21's medical record further revealed R21's significant other consented for R21 to receive the PCV20 or PCV21 vaccination on 4/28/25. During an interview on 6/10/25 at 12:17 p.m., infection preventionist (IP) indicated she contacted the pharmacist via email on 6/9/25, requesting residents get caught up on their pneumococcal immunizations. IP did not specify R40 or R21 were included in the email. During a follow-up interview on 6/10/25 at 3:11 p.m., IP stated she was unaware why R40 did not receive the PCV20 or PCV21 vaccination. IP further stated the vaccinations were given by the pharmacist and it would only take one to two days after placing the order for the immunization to be available. IP confirmed R40 and R21 had consented to the PCV20 or PCV21 however, had not received the immunizations. IP further confirmed the pharmacist had not been contacted prior to the email on 6/9/25, to provide the immunizations to R40 and R21. During an interview on 6/11/25 at 9:35 a.m., director of nursing (DON) stated R40 and R21 should have received either the PCV20 or PCV21 immunizations. DON stated her expectations were every resident was to receive up to date immunizations following CDC guidelines. Review of facility policy titled, Pneumococcal Vaccine undated, indicated the facility would offer residents immunizations against pneumococcal disease in accordance with current CDC guidelines and recommendations.

Based on observation, interview, and document review, the facility failed to ensure personal laundry was transported and delivered in a manner that prevented risk of contamination for 2 of 4 hallways observed for linen transportation. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. During an observation on 3/19/24 at 1:10 p.m., housekeeper aide (HA)-A pushed the uncovered laundry rack to R27's room, removed clothing from the uncovered laundry rack, placed clothing into R27's closet, returned hangers to the rack and sanitized hands. HA-A pushed the uncovered laundry rack past the nurses' station where one staff member and one resident were located and proceeded down to the middle of the next hallway. HA-B joined HA-A, then HA-B delivered clothing from the uncovered laundry rack to R19's dresser and closet. HA-B removed R30's clothing from the rack, knocked, returned, placed the clothing back on the uncovered rack, removed clothing from the uncovered laundry rack and proceeded to deliver clothing to R17's room. HA-B did not sanitize hands during that time. HA-A delivered clothing to R16, R1, then to R30's room and sanitized hands. HA-A pushed the uncovered clothing rack with one pair of pants remaining back to the clean laundry room. During an interview on 3/19/24 at 1:28 p.m., HA-A confirmed the laundry rack was uncovered, stated they had never covered the personal laundry rack and had never been instructed to cover it. HA-A indicated was aware should sanitize hands after leaving each resident's room and indicated at times may have forgotten. During an interview on 3/19/24 at 1:34 p.m., DON indicated she would expect staff to sanitize their hands after they exited a resident's room if they touched items in the room such as drawers and closet handles. DON confirmed the personal laundry rack was not covered and stated was unaware it was required to be covered. During an interview on 3/19/24 at 1:47 p.m., administrator reviewed a page from the State Operations Manual (SOM) with surveyor and indicated they had been unaware the personal laundry rack should have been covered while laundry was transported and delivered and confirmed they had never covered it while transporting laundry in the facility. During an interview on 3/20/24 at 8:06 a.m., HA-B stated she was aware staff should sanitize hands after delivering laundry to resident's rooms and stated she had forgotten a few times on 3/19/24 while delivering laundry. HA-B indicated it was important to prevent the residents from getting sick. HA-B confirmed the laundry rack was uncovered while they delivered the laundry on 3/19/24. The facility policy titled Laundry, revised 3/19/24, identified housekeeping staff would be in-serviced on handling linens and laundry on a regular basis. Indicated personal laundry would be placed on a cart with the resident's name and distributed to the resident's room. A hand written addition made and verified by the administrator on 3/19/24, included: clean laundry must be transported by methods that ensure cleanliness and protect from dust and soil during intra or inter facility loading, transport, and unloading. The facility policy titled Hand Hygiene undated, identified all staff would perform proper hand hygiene procedures to prevent the spread of infection to personnel, residents, and visitors. The policy identified that would apply to all staff working in all locations within the facility. The policy identified hand hygiene would be performed under the conditions listed to the attached hand hygiene table. The Hand Hygiene Table conditions included: after handling contaminated objects, before and after handling clean or soiled dressings, linens, etc, and when in doubt.

Based on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 resident (R16) who was observed to self administer a nebulizer and had not been assessed as safe to self administer medications. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 had moderate cognitive impairment and had diagnoses which included Alzheimer's, chronic obstructive pulmonary disease (COPD) and anxiety disorder. Identified R16 received oxygen therapy and required staff assistance for self care and mobility. Review of R16's electronic health record (EHR) lacked documentation a Self Medication Administration (SAM) assessment has been completed. R16's Physician Telephone Orders dated 2/12/24, and signed 2/1/24, directed staff to administer Ipratropium-albuterol inhalation solution DuoNeb (medication used to relax the muscles in the airways and increase air flow to the lungs) two times daily (BID) and every four hours as needed for congestion. R16's Medication Administration Record dated 10/19/23 to 3/19/24, indicated R16 had been taking (DuoNeb) 0.5-2.5 3 milligrams (mg) per three milliliters (ml) two times per day. R16's care plan dated 11/12/23, indicated R16 had an activities of daily living (ADL) deficit related to activity intolerance and required staff assistance with self care. During an observation on 3/18/24 at 7:25 p.m., licensed practical nurse (LPN)-A opened R16's vial of Ipratropium-Albuterol inhalation solution and poured it into the nebulizer cup and attached the cup to the nebulizer mask. LPN-A applied the nebulizer mask onto R16's face, turned on the nebulizer machine, informed R16 she would return when the nebulizer was completed and exited the room. No staff were observed in R16's room. At 7:35 p.m., LPN-A returned to R16's room and R16 stated she had removed the mask and turned off the machine. During an interview on 3/18/24 at 7:40 p.m., R16 stated she had not been taught by the staff how to use the nebulizer machine however indicated she had taught herself how to use the machine. R16 verified staff did not remain in the room while the treatment was being administered. During an interview on 3/18/24 at 7:45 p.m., LPN-A verified she had placed the nebulizer treatment on R16 and exited the room. LPN-A stated she was unsure if a SAM assessment had been completed for R16. LPN-A stated her usual practice was to place the nebulizer mask on R16, leave the room and return once the nebulizer treatment was completed. LPN-A indicated sometimes R16 would remove the mask herself and sometimes LPN-A would remove the mask when the nebulizer was completed. During an interview on 3/19/24 at 2:16 p.m., registered nurse (RN)-A confirmed R16 did not have a SAM assessment completed for her nebulizer treatment. RN- stated her expectation was that a SAM assessment would have been completed for R16 or staff would have stayed in the room during the nebulizer treatment until an assessment had been completed to ensure R16 received the nebulizer treatment appropriately. During an interview on 3/19/24 at 10:50 a.m., director of nursing (DON) verified R16 did not have a SAM assessment completed. DON indicated her expectation was R16 would have had a SAM assessment completed or staff were expected to remain with the resident during the entire nebulizer treatment. Review of a facility policy titled Resident Self-Administration of Medication revised 2/2012, identified a resident may only self-administer medications after the facility's interdisciplinary team had determined which medications may be self-administered safely. Indicated if resdient was deemed safe to self administer a medication it would have been documented in the medical record and the care plan. Identified the decision for a resident to self- administer a medication was reassessed periodically based on changes in the resident's medical and/or decision making status.

Based on observation, interview and document review, the facility failed to follow standards of practice related to medication administration of an inhalation medication for 1 of 1 resident (R16) observed for medication administration. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had moderate cognitive impairment and had diagnoses which included Alzheimer's, chronic obstructive pulmonary disease (COPD), and anxiety disorder. Identified R16 received oxygen therapy. R16's comprehensive care plan dated 1/31/24, identified R16 required staff assistance with dressing, hygiene and transfers. Indicated R16 had diagnosis of COPD, with goals which included would be free of respiratory infections and complications related to respiratory disease. R16's Order Summary Report signed 2/1/24, identified Breztri (steroid) inhalation Aerosol 160-9-4.8 microgram (MCG) 2 puffs orally two times a day for COPD. Rinse mouth after each use. During an observation on 3/18/24 at 7:38 p.m., R16 stood in her room holding onto her walker. Licensed practical nurse (LPN)-A entered R16's room and held an inhaler which included the Breztri medication up to R16's mouth and instructed R16 to take two puffs of the inhaler. R16 took two puffs of inhaler as instructed,.LPN-A then took the inhaler and exited the room. R16 was not observed to rinse her mouth out and LPN-A had not instructed R16 to rinse her mouth out as ordered after taking the Breztri inhaler. During an interview on 3/18/24 at 7:41 p.m., R16 indicated she received the Breztri inhaler twice a day. R16 confirmed she had not rinsed her mouth after just receiving the inhaler. R16 was not aware she was expected to rinse her mouth after using the inhaler and stated only once in a while staff would instruct her to rinse her mouth out however not every time she used the inhaler. During an interview on 3/18/24 at 7:46 p.m., LPN-A confirmed she had not instructed R16 to rinse her mouth after receiving the Breztri inhaler. LPN-A stated she had not seen the order instructions to rinse mouth after use. LPN-A indicated it was important to rinse the mouth after a steroid inhaler was received to prevent any infections. During a phone interview on 3/19/24 at 9:10 a.m., pharmacy consultant (PC)-A stated it was important to rinse the mouth after receiving Breztri inhaler because it was a steroid. PC-A indicated it could cause thrush, a fungal infection inside the mouth. PC-A stated it was her expectation nursing staff would instruct the resident to rinse their mouth after each use. During an interview on 3/19/24 at 10:50 a.m., director of nursing (DON) confirmed R16's Breztri inhaler label included instructions to rinse mouth after use. DON stated it was important for residents to rinse their mouth after use to prevent infections in the mouth. DON stated her expectation was for nursing staff to instruct R16 to rinse mouth after receiving the Breztri inhaler. R16's Breztri inhaler box instructions indicated take two puffs in the morning and two puffs in the evening and rinse mouth out after using the inhaler to reduce your chance of getting a fungal infection. Review of a facility policy titled Medication Administration revised 2/2013, indicated medications were administered by licensed nurses as ordered by the physician and in accordance with the professional standards of practice in a manner to prevent contamination or infections. Further indicated to administer medications in accordance with manufacturer's specifications.

Based on observation, interview and document review the facility failed to follow care planned interventions to reduce the risk for falls and failed to comprehensively assess falls for 1 of 3 residents (R1) reviewed for falls. Findings include: R1's Admission Record indicated she admitted to the facility on [DATE]. A Diagnosis Report dated 6/17/22, identified diagnosis that included Alzheimer's, dementia without behaviors and delusions. R1's Care Area Assessment (CAA) worksheet dated 3/16/22, identified impaired balance, [CONDITION(S)] drug use, [CONDITION(S)], agitation and Alzheimer's disease. Care plan considerations indicated, slow or minimize decline, avoid complications and minimize risk. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. The MDS indicated she required extensive assistance from two staff for bed mobility, transfers and toileting, did not ambulate and was frequently incontinent of bowel and bladder. R1's care plan updated 6/1/22, identified a risk for falls related to confusion. The care plan directed staff to anticipate and meet R1's needs, keep call light in reach and encourage R1 to use it, complete routine safety checks and toilet immediately following meals. The care plan further directed staff to review information on past falls and attempt to determine cause of falls. The care plan identified a self care deficit and directed staff to assist R1 with toileting every 2-3 hours. R1's KARDEX (nursing assistant care guide) dated 6/16/22, identified the following safety interventions: Encourage the resident to use bell to call for assistance. Ensure that the resident is wearing appropriate footwear when ambulating. Ambulates independently with no assistive devices. Safety Checks every 2-3 hours. Not always aware of safety needs at times. Staff to do routine safety checks frequently and as needed. Toilet use: Assist of one with toilet use every 2-3 hours. During observation on 6/16/22, at 12:13 p.m. R1 was seated in the dining room for lunch. At 12:25 p.m. staff assisted R1 from the dining room and placed her in the hallway outside the nurses station in her wheel chair. R1 remained seated in the hallway until 12:59 p.m. when staff assisted her to her room to use the bathroom. A Fall assessment dated [DATE], indicated R1 fell ,d+[DATE] times in the previous six months. The assessment identified the use of diuretics, antihypertensives, narcotics, [CONDITION(S)]'s and sedatives/hypnotics. The assessment further indicated R1 had been using a wheel chair and assistance from one staff while walking and shuffled when walking. A Fall Scene Investigation Report dated 3/23/22, indicated R1 was found lying on the floor in the bathroom at 1:25 p.m. The report indicated a loss of balance while ambulating. The report did not indicate if the care plan had been followed at the time of the fall nor did the report identify the last time R1 had been assisted to the toilet. Recommendation identified as staff to offer bathroom every two hours. Root cause analysis indicated: Unsure why resident was up and fell , question bathroom. A Fall assessment dated [DATE], indicated R1 had been ambulating backward pulling her wheel chair and tripped over her feet. R1 fell backwards and hit her head. Staff question if R1 was looking for the bathroom. A facility Progress Note indicated R1 received a golf ball sized hematoma to the back of her head. A Fall Scene Investigation Report dated 5/9/22, indicated R1 lost her balance while ambulating backwards and fell in her room at 4:50 p.m. The root cause analysis indicated: R1 was walking backwards pulling her wheelchair with auto locking brakes. She fell backward and the wheel chair landed on top of her. Intervention included neurological checks. A Fall assessment dated [DATE], indicated R1 had multiple falls in the past six months. The assessment indicated R1 was found sitting on the floor in the bathroom with towels and wash cloths in her hands. A Fall Scene Investigation Report dated 5/27/22, indicated R1 was found on the floor in her bathroom at 4:40 a.m. The report did not identify the last time R1 had been toileted. Root cause analysis indicated: unknown, question if needed the bathroom. Intervention: no changes. A quarterly Fall assessment dated [DATE], indicated R1 had been using a wheel chair and assistance from one staff to ambulate, walked occasionally with a shuffling step. The assessment identified and increase in leg pain and swelling. A Fall Scene Investigation Report dated 6/13/22, indicated R1 was found lying on the floor on her left side in the bathroom at 3:50 a.m. The report did not identify the last time R1 had been toileted. Root cause analysis indicated R1 needed to use the bathroom. The interdisciplinary team (IDT) discussed taking R1 to the bathroom around 3:00 a.m. but staff thought it might be hard on her due to her dementia. The report further indicated R1 was sent to the clinic for and x-ray of her left wrist. A Fall assessment dated [DATE], indicated R1 had been using a wheel chair and assistance from one staff to ambulate, walked occasionally with a shuffling step. The assessment identified and increase in leg pain and swelling. The assessment further indicated an increase in dementia, decrease in vocalization and an increase in combativeness with cares. R1's medical record lacked evidence a comprehensive assessment of R1's falls had been completed. During interview on 6/16/22, at 1:06 p.m. registered nurse (RN)-A stated she completed the resident MDS assessments. RN-A stated she completed the CAA worksheet but did not complete any CAA summaries to evaluate resident status. At 1:12 p.m. the director of nursing (DON) stated following a resident fall, the nurse filled out the risk assessment form and completed a fall assessment. The DON stated a post fall assessment was also completed. The DON stated the IDT met weekly to try to determine the cause of the fall. At 2:49 p.m. nursing assistant (NA)-A stated R1 had been having more difficulty communicating her needs recently. NA-A stated staff assist R1 to the toilet every two hours and check on her at least every two hours. NA-A said R1 had two soft touch call lights in her bed to alert staff if she moved in the bed. NA-A further stated R1 did not ambulate for the last few months but said she still tried. NA-A stated changes in the care plan were communicated in the communication book or on the Kardex in the computer. At 3:02 p.m. NA-B stated R1 was on an every two hour toileting schedule. NA-B said R1's legs had gotten weaker lately and her ability to comprehend was almost non-existent. NA-B said the toileting schedule was to try to prevent self transfers. At 3:37 p.m. the DON stated staff were instructed at the time of a fall to view the area to determine if there was clutter, a housekeeping concern, etc. The DON stated a few months before, R1 had been ambulating by herself but had a decline and now was dependent on staff for assistance. She said R1 could walk but she should not by herself. The DON stated a lot of R1's falls were in the bathroom but no patterns had been established. The DON said when R1 fell on [DATE], they talked about getting her up at night to use the bathroom but staff were concerned it would agitate her. The DON stated changes in resident cares were communicated in a communication book, verbally and in the care plan. The DON stated a comprehensive assessment was completed on admission and at that time they looked at falls, medications, etc. The DON confirmed staff had not assisted R1 to the bathroom immediately after lunch as directed in the care plan. A facility policy, Falls- Clinical Protocol dated March 2018, indicated for an individual who has fallen staff and the practitioner will begin to try to identify possible causes of the fall within 24 hours. The staff and the physician will continue to evaluate information until either the cause of the falling is identified or it is determined the cause cannot be found or it is not correctable.

Based on observation, interview, and document review, the facility failed to implement appropriate hand hygiene for 3 of 3 residents (R1, R2, R3) observed during personal cares during a COVID-19 focused infection control survey. Findings include: R1's Admission [DIAGNOSES REDACTED]. R1's annual Minimum Data Set ((MDS) dated [DATE], indicated she required total dependence on staff for toileting, and was and incontinent. R1's care plan dated 9/22/20, indicated she required one to two staff for personal hygiene, and perineal cares after incontinent episodes. R2's Admission [DIAGNOSES REDACTED]. R2's annual MDS assessment dated [DATE], indicated she required extensive assistance with transfers, and toileting. R2's care plan dated 10/14/20, indicated she was incontinent of bowel and bladder. On 12/4/20, at 12:43 p.m. R1 was observed in a wheelchair next to the bed with nursing assistant (NA)-B present in the room. NA-A entered R1's room to assist NA-B with a total lift transfer, and to check and change R1's incontinent brief. NA-A and NA-B attached the straps to the total lift machine, lined up the total lift and lowered her down on the bed. NA-A and NA-B applied gloves, and assisted R1 to roll side to side to complete perineal cares and change her incontinent product. NA-A and NA-B then removed their soiled gloves, adjusted R1's pants, and repositioned her lower legs on top of a pillow. After NA-B disposed of R1's soiled incontinent brief, she washed her hands and exited the room. NA-A placed a new trash bag in the trash can, and exited room without performing hand hygiene. NA-A went and stood at the nurse's station. -At 1:00 p.m. NA-A pushed R2 into her room. NA-A briefly exited the room, and returned with a stand lift. NA-C entered R2's room to assist. NA-A and NA-C hooked up the lift straps and transferred R2 from the wheel chair to the toilet. NA-A applied gloves, removed R2's soiled incontinent brief, lowered R2 onto the toilet, and removed her soiled gloves. Without performing hand hygiene, NA-A raised R2 off the toilet. NA-C applied gloves and completed perineal care for R2. NA-C removed her soiled gloves, and without performing hand hygiene, applied a clean pair. NA-A pulled up R2's incontinent brief and pants. NA-A moved R2 in the stand lift, lowered her down on to bed, covered her up with a blanket. NA-C removed her soiled gloves, performed hand hygiene, and exited R2's room. NA-A removed her soiled gloves and exited room without performing hand hygiene. On 12/2/20, at 1:15 p.m. NA-A was interviewed. NA-A confirmed she had performed hand hygiene after removing her soiled gloves, completing cares with R1, or prior to leaving R1's room. NA-A also stated she did not perform hand hygiene while performing cares for R2. NA-A stated it would have been a good idea to wash her hands. On 12/4/20, at 1:40 p.m. the director of nursing (DON) was interviewed and stated all staff were expected to perform hand hygiene at the start of a shift, anytime such as after cares with a resident, after removing gloves, when they were visibly soiled, and in between touching residents. The facility policy Infection Control and Prevention Manual Standard Precautions dated 2020, directed staff to perform hand hygiene before and after contact with a resident, after contact with objects in a resident's room, before performing an aseptic task, before donning personal protective equipment, and after removing personal protective equipment. Hand hygiene continues to be the primary means of preventing the transmission of infection. R3's quarterly MDS dated [DATE], identified R3 had severe cognitive impairment and had [DIAGNOSES REDACTED]. R3's care plan revised 11/25/20, identified R3 required extensive to total assist with most incontinence cares. The care plan indicated R3 required oxygen use due to [MEDICAL CONDITION] and was on hospice services for end of life care. On 12/4/20, at 12:44 p.m. R3 was observed in bed on her back with oxygen tubing in her nose. NA-D and NA-E applied gloves after sanitizing hands. NA-E moved the bed height up and proceeded to remove R3's incontinent brief. NA-E and NA-D turned R3 to her right side, and R3 was noted to have a large amount of stool present. NA-E completed pericares, removed her soiled gloves and did not perform hand hygiene. NA-D and NA-E turned R3 on her back, and NA-E proceeded to apply a new incontinence brief with no gloves on. NA-D and NA-E turned R3 to her left side, and NA-D completed pericares on R3. NA-E disposed of the soiled brief in the garbage. NA-D and NA-E turned R3 to her back, and applied the clean incontinent brief, and pulled up R3's pants. Without gloved hands, NA-E removed R3's oxygen tubing from her nose, and brought the mechanical lift over to the bed. NA-D and NA-E applied the loops of the sling to the lift, lifted R3 up out of the bed, brought R3 over to her wheelchair, and lowered her into the wheelchair. NA-D removed her soiled gloves, and without performing hand hygiene, donned a new pair of gloves. NA-D then re-applied R3's oxygen tubing to her nose, placed R3 glasses on and brushed R3's hair. NA-E brought the lift to R3's bathroom and at that time performed hand hygiene. NA-D removed her soiled gloves, and brought the trash out of R3's room to the soiled utility room. NA-D then completed hand hygiene in the soiled utility room. On 12/4/20, at 12:57 p.m. NA-D stated it was expected staff wash their hands after removing gloves, prior to applying new gloves, and after completing pericares. NA-D stated handwashing was expected to prevent the spread of infection. NA-D confirmed she did not wash her hands after removing her gloves, or anytime while providing cares to R3 and stated she should have done so especially after completing pericares. On 12/4/20, at 1:00 p.m. NA-E stated it was expected staff wash their hands after completing pericares, and after removing gloves. NA-E confirmed she did not wash her hands until after all cares had been completed, and stated she should have completed hand hygiene after doing pericares when she removed her gloves. NA-E stated hand washing was important to prevent cross contamination between residents. NA-E further stated gloves should be worn during high contact activities which included changing incontinence briefs.

Based on interview and document review, the facility failed to obtain physician ordered TSH (a blood test to evaluate [MEDICAL CONDITION] function) for 1 of 1 residents (R7) who had a recent increase in dosage and received a routine dose of [MEDICATION NAME] sodium ([MEDICAL CONDITION] stimulating hormone (TSH) medication). Findings include: R7's annual Minimum Data Set ((MDS) dated [DATE], indicated R7 had [DIAGNOSES REDACTED]. The MDS identified R7 had moderate cognitive impairment and required extensive assistance for all activities of daily living (ADL), and had no rejection of care. R7's Care Area Assessments (CAA) dated 4/30/19, indicated R7 had a poor memory, a [MEDICAL CONDITION] problem and required assistance with ADLs from staff. The CAA's section for abnormal laboratory values from the clinical record listed the possibility of [MEDICAL CONDITION] function, however this section remained blank. R7's care plan last reviewed 5/8/19, indicated R7 had a [DIAGNOSES REDACTED]. R7's Medication Administration Record [REDACTED]. Review of R7's MAR from (MONTH) 2019 to (MONTH) 2019, revealed: -February 2019, [MEDICATION NAME] sodium 75 micrograms (mcg) once daily related to [MEDICAL CONDITION], with a start dated of 1/9/19, and a discontinued date of 2/15/19. On 2/16/19, a new order for [MEDICATION NAME] sodium was started for 88 mcg once daily related to [MEDICAL CONDITION]. -March 2019, [MEDICATION NAME] sodium 88 mcg once daily related to [MEDICAL CONDITION]. -April 2019, [MEDICATION NAME] sodium 88 mcg once daily related to [MEDICAL CONDITION]. -May 2019, [MEDICATION NAME] sodium 88 mcg once daily related to [MEDICAL CONDITION]. Review of Result Notes for TSH ([MEDICAL CONDITION] Stimulating Hormone), a blood test that measures this hormone, dated 2/15/19, indicated a note from R7's physician please call the nursing home and have them increase (R7) [MEDICATION NAME] ([MEDICATION NAME] sodium) by 1 dose level and then recheck again in a month. Review of Physician's Telephone Orders signed by R7's physician, dated 2/15/19, identified an order to increase [MEDICATION NAME] sodium to 88 mcg daily and recheck a TSH lab in one month. Review of R7's medical record was completed on 6/27/19, and revealed no TSH lab results after 2/15/19. On 6/27/19, at 5:58 p.m. registered nurse (RN)-C indicated the usual facility practice for when a lab order was received was to write out a telephone order (TO), then fill out a lab request sheet and fax the request to the clinic lab manager. RN-C stated the lab would then bring the lab order to the facility and then draws the lab. RN-C reviewed R7's medical record and confirmed R7 had no TSH lab results after the 2/15/19, ordered TSH. RN-C stated after R7's TSH was due, the facility had implemented a new process for lab orders to ensure one was not missed. RN-C stated due to R7's missed TSH lab, R7 was at risk for an abnormal TSH lab result. On 6/27/19, at 6:07 p.m. the director of nursing (DON) reviewed R7's medical record and confirmed the 2/15/19, TSH lab was not completed as ordered. Review of the facility policy titled Lab and Diagnostic Test Results-Clinical Protocol revised 11/18, indicated the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The policy identified the facility staff would process test requisitions and arrange for tests.

Based on interview and document review, the facility's consulting pharmacist failed to identify irregularities during medication regimen review related to laboratory monitoring for 1 of 5 residents (R7) reviewed for unnecessary medications. Findings include: R7's annual Minimum Data Set ((MDS) dated [DATE], indicated R7 had [DIAGNOSES REDACTED]. The MDS identified R7 had moderate cognitive impairment and required extensive assistance for all activities of daily living (ADL), and had no rejection of care. R7's Care Area Assessments (CAA) dated 4/30/19, indicated R7 had a poor memory, a [MEDICAL CONDITION] problem and required assistance with ADLs from staff. The CAA's section for abnormal laboratory values from the clinical record listed the possibility of [MEDICAL CONDITION] function, however this section remained blank. R7's care plan last reviewed 5/8/19, indicated R7 had a [DIAGNOSES REDACTED]. R7's Medication Administration Record [REDACTED]. Review of R7's MAR from (MONTH) 2019 to (MONTH) 2019, revealed: -February 2019, [MEDICATION NAME] sodium 75 micrograms (mcg) once daily related to [MEDICAL CONDITION], with a start dated of 1/9/19, and a discontinued date of 2/15/19. On 2/16/19, a new order for [MEDICATION NAME] sodium was started for 88 mcg once daily related to [MEDICAL CONDITION]. -March 2019, [MEDICATION NAME] sodium 88 mcg once daily related to [MEDICAL CONDITION]. -April 2019, [MEDICATION NAME] sodium 88 mcg once daily related to [MEDICAL CONDITION]. -May 2019, [MEDICATION NAME] sodium 88 mcg once daily related to [MEDICAL CONDITION]. Review of Result Notes for TSH ([MEDICAL CONDITION] Stimulating Hormone), a blood test that measures this hormone, dated 2/15/19, indicated a note from R7's physician please call the nursing home and have them increase (R7) [MEDICATION NAME] ([MEDICATION NAME] sodium) by 1 dose level and then recheck again in a month. Review of Physician's Telephone Orders signed by R7's physician, dated 2/15/19, identified an order to increase [MEDICATION NAME] sodium to 88 mcg daily and recheck a TSH lab in one month. Review of R7's medical record was completed on 6/27/19, and revealed no TSH lab results after 2/15/19. Facility provided Consultant Pharmacist Drug Regimen Review Summary (CPDRRS) from 2/6/19 to 6/21/19, indicated recommendations from the facility's consultant pharmacist (CP) each month. Review of CPDRRS revealed : -2/6/19, R7, recheck TSH lab. No further mention of R7's TSH lab or [MEDICATION NAME] dose in the CPDRRS through 6/21/19. Review of R7's CP progress notes from 1/2/19 to 6/21/19, revealed; -1/2/19, (R7) currently receiving [MEDICATION NAME] 50 mcg daily. Last TSH level available in (R7'S) chart is from 8/17. Please get updated TSH level at time of next lab draw. -2/6/19, (R7's) dose of [MEDICATION NAME] was increased 1/2019. Please get updated TSH level at time of next lab draw. -3/13/19, No recommendations at this visit. TSH was rechecked 2/2019 in response to 2/2019 pharmacy recommendation. TSH was still elevated and dose of [MEDICATION NAME] was increased again. Recheck of TSH level scheduled for (MONTH) 2019. On 6/27/19, at 5:58 p.m. registered nurse (RN)-C indicated the usual facility practice for when a lab order was received was to write out a telephone order (TO), then fill out a lab request sheet and fax the request to the clinic lab manager. RN-C stated the lab manager would then bring the lab order to the facility and then draws the lab. RN-C reviewed R7's medical record and confirmed R7 had no TSH lab results after the 2/15/19, ordered TSH. RN-C stated after R7's TSH was due, the facility had implemented a new process for lab orders to ensure one was not missed. RN-C indicated the facility's CP would review R7's medical record and make a recommendation if a lab was missed. RN-C stated due to R7's missed TSH lab, R7 was at risk for an abnormal TSH lab result. On 6/27/19, at 6:07 p.m. the director of nursing (DON) stated the facility's CP monitored resident lab orders which need to be drawn. The DON indicated the CP's role included identifying medication irregularities and reporting them to the facility. The DON stated if the facility's CP documented the irregularity, she would have followed through to ensure it was addressed. On 6/27/19, at 6:12 p.m. during a telephone interview with CP-A, CP-A stated her role at the facility included reviewing resident medications for appropriateness, review ordered labs, identify potential dose reductions and writing recommendations of identified irregularities. CP-A indicated if R7 had an ordered TSH lab, it would have been done. CP-A reviewed her facility documentation and indicated she did not have R7's TSH results written down, but indicated her documentation indicated it was completed as ordered, but added I guess I don't have anything written down. CP-A stated she felt R7 would not be at risk for any adverse events due to not having TSH lab drawn. Review of the facility policy titled Lab and Diagnostic Test Results-Clinical Protocol revised 11/18, indicated the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The policy identified the facility staff would process test requisitions and arrange for tests. Review of the facility policy titled Pharmacy Consultant/Drug Regimen Review Policy, undated, defined medication regiment review (MMR) as a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting and resolving medication related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. The policy further defined monitoring as the ongoing collection and analysis of information (such as diagnostic test results) and comparison to a baseline data in order to ascertain the individual's response to treatment and care, including progress or lack of progress toward a therapeutic goal.

Based on observation, interview and record review the facility failed to revise the comprehensive care plan to care of [MEDICAL CONDITION] for 1 of 3 residents (R11) reviewed with a skin condition and 1 of 3 residents (R7) currently receiving hospice services. Findings include: R7's significant change in status assessment (SCSA) Minimal Data Set ((MDS) dated [DATE], identified R7 had moderate cognitive impairment and [DIAGNOSES REDACTED]. The MDS identified R7 required extensive assistance for all activities of daily living (ADLs) and received hospice care. R7's SCSA Care Area Assessments (CAA) dated 4/25/19, identified R7 had a [DIAGNOSES REDACTED]. R7's care plan last reviewed 5/20/19, indicated R7 was followed by hospice services. The care plan lacked any additional details regarding R7's hospice services. On 6/26/19, at 7:07 a.m. R7 was lying in a low bed with the lights to the room off and a nebulizer machine running. R7's eyes remained closed as he reached for the nebulizer mask and removed it and placed it on his lap. At 9:02 a.m. R7 sat in a wheelchair in the facility's dining room after eating breakfast, with a nasal cannula in his nose. R7 sat at the table by himself with eyes closed and reached up and removed the nasal cannula which supplied him with supplemental oxygen. An unidentified staff member stopped beside R7 and offered to assist to replace the nasal cannula. R7 agreed and continued to sit at the dining room table. On 6/27/19, at 9:00 a.m. R7 was seated in a wheelchair by the nurse's station. R7 had a nasal cannula in place and R7 sat quietly and looked around the area. On 6/27/19, at 10:26 a.m. RN-D indicated she worked for hospice as R7's case manager. RN-D stated R7 was being seen twice a week by hospice nursing. RN-D indicated upon arrival at the facility, she would check in with facility staff to see if R7 had any changes she was not already aware of, assess R7 and document the visit. RN-D indicated she did not enter information or interventions on R7's care plan, and added she did not know how or have access to R7's care plan in the facility's electronic health record (EHR). RN-D stated R7's hospice care was coordinated with RN-C, but RN-D did attend R7's care conferences. On 6/27/19, at 10:34 a.m. RN-C indicated she was the primary RN for R7's end of the facility and her duties included MDS assessments and care plans. RN-C stated care plans are started with a baseline care plan and then after an MDS assessment, the triggers from that are integrated into the resident's care plan. RN-C stated care plans are updated as needed and at least quarterly. RN-C stated hospice staff do not edit the care plans, but they communicate with the facility and facility RNs would update the care plan. RN-C stated the facility integrated hospice services into a resident's care plan by starting a section for the terminal [DIAGNOSES REDACTED]. RN-C reviewed R7's care plan and indicated the terminal [DIAGNOSES REDACTED]. On 6/27/19, at 2:51 p.m. the director of nursing (DON) indicated resident care plans are updated every three months after a care planning meeting with the interdisciplinary team (IDT) and as needed. The DON stated hospice staff attend the care planning meetings, and added for the most part hospice is an additional service, the facility had their care plan and hospice has theirs. The DON reviewed R7's care plan and indicated it probably needed some work. R11 R11's quarterly Minimum Data Set ((MDS) dated [DATE], identified R11 had severe cognitive impairment, had [DIAGNOSES REDACTED]. The MDS identified R11 required total assistance for locomotion, extensive assistance for all other ADLs (Activities of daily living) and did not walk. The MDS indicated R11 had no behaviors or specialized treatments during the assessment period. R11's care plan revised 5/9/19, included R11's lack of ability for self preservation, cognitive deficit, visual impairment and other various care needs; however, lacked inclusion of risks and interventions associated with [MEDICAL CONDITION] lesion on R11's left cheek. On 6/24/19, at 7:39 p.m. R11 was observed to have a lesion on the left cheek. The lesion was shiny and tight, reddish in color, and shaped like a letter T. The lesion was approximately 1 centimeter (cm) wide by 1 cm long. R11 was observed to repeatedly rub and pick at the lesion with her fingertips through out the supper meal. At the end of the meal, the lesion was noted to be darker red in color, but the area remained intact. On 6/26/19, at 8:09 a.m. R11 was seated in her wheel chair in the hall outside of dining room. R11 sat quietly looking forward. R11 was observed to rub and scratch at the lesion on her left cheek. Review of R11's wound and skin notes revealed the following: 1/24/19, left cheek hard crusty white area. 3/14/19, scabbed area on left upper cheek. 3/24/19, area to left cheek bleeding due to resident picking at it. 5/1/19, Chronic area on left cheek. 6/14/19, Resident continues to have a scabbed area on left upper cheek and dark pink around it. A form titled, Nursing Quarterly Note, dated 5/8/19, identified, Skin Care: Skin is intact at this time. Does have an area on her face that is scabbed and she will sometimes pick at. On 6/27/19, at 3:43 p.m. nursing assistant (NA)-A verified R11 had a sore like area on her face which had been present for greater than a year and a half. NA-A indicated R11 routinely picked at the area. On 6/27/19, at 4:14 p.m. licensed practical nurse (LPN)-A identified the lesion on R11's left cheek had been present as long as LPN-A has worked in the facility. LPN-A stated,she some times messes with it. LPN-A identified R11 picked at the area and had required treatments in the past for the lesion. On 6/27/19, at 4:16 p.m. registered nurse (RN)-A indicated the lesion had been present on R11's face as long as RN-A had worked at the facility and believed it to be addressed in the care plan. With review of R11's current care plan, RN-A verified the skin condition was not included. With review of R11's computerized medical record RN-A verified R11 had [DIAGNOSES REDACTED] on the cheek for greater than a year. RN-A verified the skin condition should have been included in the care plan due to R11 picking at the area and that caused a risk of infection. On 6/27/19, at 4:58 p.m. the director of nursing (DON) identified skin conditions to be included on resident care plans included bruising, skin tears, growths, moles, and skin conditions receiving treatments. The DON verified R11's lesion on the left side of her face was a chronic condition and was expected it to be on the care plan. DON verified R11's care plan did not identify the condition, goals, nor did it address interventions regarding R11's [DIAGNOSES REDACTED]. The DON indicated R11's lesion would potentially be at risk of infection, bleeding, or growth. The DON verified it was a potential problem and should be included in the care plan. Review of the facility policy titled Hospice Program, revised (MONTH) (YEAR), indicated, 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. 14. The coordinated care plan will reflect the resident's goals and wishes, as stated in his or her advance directives and during ongoing communication with the resident or representative, including: a. Palliative goals and objectives; b. Palliative interventions; and c. Medical treatment and diagnostic tests. 15. The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status including, but not limited to: a. Diagnosis; b. Problem list; c. Symptom management (pain, nausea, vomiting, etc.); d. Bowel and bladder care; e. Nutrition and hydration needs; Oral health; g. Skin integrity; h. Spiritual, activity and psychosocial needs; and i. Mobility and positioning. Review of the facility policy titled Comprehensive Person-Centered Care Plans, revised 12/16, indicated 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When a desired outcome is not met; c. When the resident has be readmitted to the faciltiy from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and document review, the facility failed to conduct a thorough investigation for 1 of 3 resident (R13) who had an injury of unknown source. Findings include: R13 R13's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R13 was severely cognitively impaired with [DIAGNOSES REDACTED]. The MDS indicated R13 required extensive assistance of two staff with bed mobility, transfers, bathing dressing and toileting. R13's current care plan revised on 6/13/19, indicated R13 had potential for injury related to vulnerable adult status and staff were to follow abuse and neglect prevention plan of the home and was not to neglect R13's daily needs. Review of R13 Progress Notes from 4/1/19 to 6/25/19 revealed the following: - 6/11/19 at 2:27 p.m. indicated bath aid skin observation was conducted and R13 had no bruising, redness, skin tears and no behaviors noted during her bath. - 6/25/19 at 6:19 a.m. indicated bath aid skin observation was conducted and R13 had no redness, had one centimeter (cm) in diameter bruise on out left breast, bath aid did not see it before R13 was transferred onto the bath chair. R13 had no skin tears, no behaviors noted during her bath and was singing. - 6/25/19 at 4:58 p.m. registered nurse (RN)-C notified R13 had bruising to her left breast. Areas measured 1.2 cm x 1.5 cm with two smaller bruises noted to be 0.5 cm x 0.5 cm and 1 cm x 0.5 cm. R13 denies injury to area, R13 stated what I have something wrong. RN-C explained to R13 had a bruise and asked R13 if anyone had hurt her and R13 stated no honey you are all so nice. Assistant Administrator (AA), director of nursing (DON), medical doctor and family notified. Report made to the Office of Health Facilty Complaints (OHFC). Review of untitled document number 417 undated, revealed at 6/25/19 at 4:51 p.m. RN-C was notified R13's had bruising to her left breast. Areas measured 1.2 cm x 1.5 cm with two smaller bruises noted to be 0.5 cm x 0.5 cm and 1 cm x 0.5 cm. AA, DON, medical doctor and family notified. OHFC report filed. Review of Incident Report # 8, Submitted to the SA on 6/25/19 at 5:03 p.m. listed an allegation of physical abuse for R13 of unexplained injury. The report indicated the incident had occurred on 6/25/19 at 8:00 a.m. and RN-C was notified R13 had bruising to her left breast. Areas measured 1.2 cm x 1.5 cm with two smaller bruises noted to be 0.5 cm x 0.5 cm and 1 cm x 0.5 cm. RN-A explained to R13 had a bruise and asked R13 if anyone had hurt her and R13 stated no honey you are all so nice. AA, DON, medical doctor and family notified. OHFC report filed. Review of Investigation Status Report, indicated the investigation was submitted on 6/27/19 at 11:59 a.m. The facility reviewed R13's care plan, the facility policy was followed and no changes were made to the policy. The report indicated R13 was noted to have a bruise to the left breast. This writer RN-C was notified of bruising and measured as follows were taken: areas measured 1.2 cm x 1.5 cm with two smaller bruises noted to be 0.5 cm x 0.5 cm and 1 cm x 0.5 cm. R13 denies injury to the area and denies pain to the area and states you are all so nice. Unsure of the nature of the bruise. R13 was transferred with the hoyer lift and the bucket does not touch this area and no specific patterns. Medical doctor, AA, DON, and family member notified. R13 family member stated R13 has always bruised easy, this was not concerning to me. The report indicated action taken: education for safe patient care to staff and was a isolated incident. On 6/27/19 at 4:19 p.m. DON confirmed R13 had bruising to her left breast and the bath aid had reported it after her bath. The DON indicated she did not do the investigation and was not sure who was leading the investigation and verified the facility policy. On 6/27/19 at 4:48 p.m. AA R13 had bruising on her left breast, was reported after her bath on 6/25/19 to the nurse. The AA indicated they report first, do an investigation and they have 5 days submit the investigation to the SA. The AA indicated RN-A was doing the investigation in regards to R13's bruising on her breast area. AA confirmed the facility policy. On 6/27/19 at 5:02 p.m. in a follow up interview with the AA and RN-C, both confirmed a thorough investigation was not done in regards to R13's bruising on her left breast and AA stated you no that is not a thorough investigation after reviewing the investigation document. RN-C indicated she had talked to the staff involved in her bath and did not talk to any other staff from other shifts to find out how R13 had gotten the bruises to her left breast. AA indicated they should of called other staff from other shifts and talked to them about the bruising as well to see if they forgot to report it. RN-C indicated the staff she did talk to, she had not document on what they had to said about the bruising on R13's breast area. Review of facility policy titled, Viking Manor Abuse and Neglect Policy, undated, indicated all alleged violations involving abuse neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. If the events that cause allegation involve abuse or result in serious bodily injury, the alleged violation will be reported immediately but no later than 2 hours after the allegation is made. If the event that cause allegation do not involve abuse or do not result on serious bodily injury, the violations will be reported immediately , but no later than 24 hours. All alleged violations will be reported immediately to the Administrator and to other officials including the SA. Under investigations: it indicates the DON , thoroughly investigates complaints, determining whether they are true or false possible to substantiate or disprove through interviews and examination with involved parties.

Based on observation, interview, and document review, the facility failed to comprehensively assess to identify root cause of falls for 3 of 4 residents (R10, R12, R11) who had multiple falls in the facility. Findings include: R10's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R10 had severely impaired cognition and had [DIAGNOSES REDACTED]. The MDS identified R10 required extensive assistance with activities of daily living (ADL'S) which included bed mobility, transfers, toileting, walking and locomotion. The MDS further identified R10 required physical assistance to maintain balance during transfers, walking and toileting. The MDS revealed R10 had two or more falls with one injury since the last assessment. R10's admission Care Area Assessment (CAA) dated 4/26/18, identified R10 had short term memory loss and was forgetful and required extensive assistance with ADL'S which included transfers, bed mobility and toileting. The CAA identified R10 had urinary incontinence and forgot to use her call light to ask for assistance with toileting due to confusion. The CAA indicated R10 was at risk for falls related to balance impairment, forgetting to use her call light and history of falls. Review of R10's Falls assessment dated [DATE], identified R10 was at high risk for falls, had impaired memory and recall, impaired gait, incontinence and had a history of [REDACTED]. R10's care plan, revised 1/22/19, indicated R10 was at risk for falls related to unawareness of safety needs. R10's care plan instructed staff to encourage R10 to use the call light and to respond promptly. R10's care plan further instructed staff to explain the importance of using the call light and to re-approach R10 5-10 minutes later if R10 refused offer of assistance. On 2/21/19, at 10:40 a.m. R10 was seated in her wheelchair at the dining room table reading a newspaper. R10 was noted to have a small purple colored bruise to her right forearm and had gripper socks on both feet. On 2/21/19, 11:57 a.m. R10 was seated in her wheelchair, in the bathroom with nursing assistant (NA)-C present. NA-C applied a transfer belt to R10's waist, locked the wheelchair brakes and provided verbal cues to R10 to hold the hand bar. NA-C held onto the transfer belt around her waist and assisted R10 onto the toilet. NA-C stood in the bathroom door to observe R10 while she toileted as NA-C explained R10 would stand up by herself otherwise. NA-C assisted in providing peri cares and adjusted brief and pants. NA-C assisted R10 while continuing to use the transfer belt and cued R10 to turn while holding the hand bar and proceeded to guide her into the wheelchair. During the transfer to the wheelchair, R10 stated What do you want me to do? and NA-C verbally cued R10 to sit down in the wheelchair. NA-C removed transfer belt and wheeled R10 back to the dining room for lunch. Review of R10's incident reports from 12/4/18 to 2/17/19, revealed the following: -On 12/4/18, at 7:15 p.m. staff entered R10's room and found R10 sitting on the floor beside her bed. R10 had stated she tripped and fell on to buttocks. -On 12/6/18, 12:15 a.m. staff heard a noise and found R10 seated on her buttocks by her bed with her back up against the dresser. R10 stated she had been on her way to the bathroom and R10 was noted to be incontinent of urine. R10 had a 5 centimeter (cm.) bruise to her right upper arm and a bruise to the back of her left femur that was faint in color. The report indicated R10 had a history of [REDACTED]. -On 12/11/18, at 8:30 p.m. staff heard a loud noise from R10's room and found her lying on her right side on the floor in front of bathroom. The report indicated R10 stated I just slipped, room lights off, call light not activated, and R10 wore regular socks. Gripper socks had been applied at that time. -On 12/18/18, at 3:45 a.m. staff heard R10 calling out for help to get up. Staff found R10 sitting on the bathroom floor and R10 confirmed she had hit her head. R10 was noted to have a black left eye, a skin tear to her left hand, three bruises to left forearm and a large bruise to her left breast area. The report indicated R10 stated she fell and must of hit her head on nightstand by door in bathroom. -On 1/4/19, at 2:03 p.m. staff heard R10 calling out for help and R10 was found facing out of the bathroom on the floor on her buttocks. R10 wore socks with no shoes. Staff noted a bruise which measured 9 cm. by 2 cm. and 8/10 cm. to right elbow with an open area which measured 8/10 of a cm. in the center of the bruise. Additionally, R10 had a bruise to her lower right forearm which measured 6 cm. by 4 cm. and a 1 cm. open slit to R10's right wrist area. Staff cleansed R10's open areas and applied normal saline, [MEDICATION NAME] (antibiotic ointment) and steri strips, and applied gripper socks. -On 1/19/19, at 4 p.m. R10 had a fall in her room near the bathroom doorway next to her wheelchair. R10 stated she had fallen on her way to the bathroom and indicated she hit her head on the floor. R10 was noted to have a reddened area to her right shoulder and a bruise to her right forearm measuring 14 cm. by 5 cm which had a cut in the middle of the bruise that measured 1 cm. by 1 cm. Additionally, R10 developed a bruise to another area of her right forearm that measured 4 cm. by 4 cm. R10 stated I don't know what happened, I was trying to walk into the restroom and I tripped and fell . -On 1/24/19, at 10:00 a.m. nursing staff were alerted by the hair dresser R10 was on the floor in her room. Staff found R10 sitting by her bed with her back to the night stand and R10 explained she was trying to walk to the bathroom and fell . The report indicted R10 did not know why she fell . -On 1/27/19, at 5:00 a.m. staff heard a noise and found R10 seated on the floor in front of her wheelchair Staff noted the door to the bathroom was partly opened and R10 indicated she was attempting to go to the bathroom, lost her balance and fell . R10 stated she had hit her head against the wall. R10 was noted to have a bump on the back of her head and skin tear to her right middle finger. - R10's Progress Note dated 1/28/19, at 6:40 a.m. indicated staff heard a loud noise and found R10 laying on her left side on the floor in front of the bathroom. R10 was noted to not have any injuries when first assessed. On 1/30/19, a large bruise to R10's left buttock was noted which measured 7 cm. by 3 cm. An incident report for this fall had not been provided. -On 2/17/19, at 10:45 a.m. staff found R10 on the floor in the dining room, with both legs in front of her and her wheelchair behind her. The report indicated R10 had been reaching forward to pick up a paper off the floor and slid off the seat of the chair. Review of the incident reports from 12/4/18, through 2/17/19, lacked documentation of a comprehensive assessment. Review of R10's Progress Notes from 12/4/18, through 2/17/19, revealed the following; -On 12/4/18, R10's Progress Notes lacked documentation of a comprehensive assessment and a review or adjustment of the current fall prevention interventions. -On 12/6/18, a root cause analysis indicated R10 had multiple falls and often self transferred. The analysis further indicated a low bed would not be an appropriate intervention due to R10's history of self transferring. The note lacked further analysis of R10's falls. -On 12/11/18, R10's Progress Notes lacked documentation of a comprehensive assessment and a review or adjustment of the current fall preventions interventions. -On 12/18/18, R10's Progress Notes lacked documentation of a comprehensive assessment and a review or adjustment of the current fall prevention interventions. -On 1/4/19, R10's Progress Notes lacked documentation of a comprehensive assessment and a review or adjustment of the current fall prevention interventions. -On 1/19/19, R10's Progress Notes lacked documentation of a comprehensive assessment and review or adjustment of the current fall prevention interventions. -On 1/22/19, R10's care plan had been updated which instructed staff to explain the importance of asking for assistance and if R10 refused the offer of toileting, staff were to reapproach five to ten minutes later. The note lacked further analysis of R10's falls. -On 1/24/19, a root cause analysis documented in R10's Progress Notes lacked a comprehensive assessment and did not include a review or adjustment of the current fall prevention interventions. -On 1/27/19, R10's Progress Notes lacked documentation of a comprehensive assessment and a review or adjustment of the current fall prevention interventions. -On 1/28/19, R10's Progress Notes lacked documentation of a comprehensive assessment and a review or adjustment of the current fall prevention interventions. -On 1/29/19, a root cause analysis documented in R10's Progress Notes revealed R10 was impulsive and had not used her call light to ask for assistance. The note lacked further analysis of R10's fall. -On 2/1/19, an order for [REDACTED]. -On 2/17/19, R10's Progress Notes lacked documentation of a comprehensive assessment and a review or adjustment of the current fall prevention interventions. On 2/21/19, at 10:40 a.m. speech language pathologist (SLP) stated she was currently working R10 for cognitive training and fall prevention. SLP indicated R10 would be discontinued from services in the near future due to lack of significant improvement expected with cognitive status. -On 2/22/19, at 11:57 a.m. NA-C stated she felt R10 was at risk for falls due to R10's history of self transferring. NA-C indicated staff were to place R10's bed in low position, remind R10 to use her call light and check her every two hours. Additionally, NA-C stated R10 was working with therapy to reduce falls. On 2/22/19, at 1:44 p.m. nursing assistant (NA)-B stated R10 required assistance with all ADL'S and was at risk for falls. She stated R10 did not use her call light and staff completed every two hour checks on R10. NA-B stated R10 often self transferred and did not remember to use her call light. On 2/22/19, at 12:31 p.m. trained medication aide (TMA)-A stated she felt R10 was at risk for falls and required assistance with ADL'S. TMA-A stated R10 required significant cueing from staff and did not remember to use her call light. TMA-A indicated R10 did self transfer at times. TMA-A stated R10 had a soft touch call light and staff checked on R10 every two hours for toileting needs. On 2/22/19, 1:02 p.m. Clinical Manager (CM) stated R10 required assistance from staff with ADL'S. CM further stated R10 had memory and cognitive impairment and staff could not rely on R10 remembering to use her call light. CM confirmed expecting R10 to use her call light consistently was not an effective intervention. CM indicated the process for falls involved completing a post fall note weekly for six weeks after the fall. CM confirmed a root cause analysis had not been completed after each fall, nor a review of current interventions completed after each fall. R12 R12's quarterly Minimum Data Set ((MDS) dated [DATE], identified R12 had moderately impaired cognition and had [DIAGNOSES REDACTED]. The MDS identified R12 required extensive assistance with ADL's which included bed mobility, transfers, toileting, and locomotion. The MDS further indicated R12 did not walk. The MDS identified R12 required physical assistance to maintain balance during transfers. The MDS revealed R12 has had two or more falls since the last assessment. R12's annual Care Area Assessments (CAAS) dated 4/3/2018, identified R12 had short term memory loss and confusion at times. The CAA indicated R12 required extensive assistance with ADL's which included transfers and bed mobility. The CAA identified R12 was at risk for falls related to the following conditions: impaired balance, the use of diuretics(water pills) to increase the need of using the bathroom more frequently, urinary incontinence, confusion which could cause her to have the urge to toilet herself. Review of R12's Falls Assessment, dated 12/11/18, indicated R12 was at high risk for falls and had experienced multiple falls within the last six months. The falls assessment further identified R12 had memory issues and was frequently incontinent of bladder at least daily. The falls assessment indicated R12 was confined to a chair, did not ambulate and was disoriented. R12's care plan, revised 12/19/18, indicated R12 was at risk for falls related to R12's inability to identify safety needs. R12's care plan instructed staff to respond quickly to call lights and to ensure that the R12 would wear appropriate footwear when ambulating or mobilizing in a wheelchair. R12's care plan further instructed staff to encourage R12 to use her call light and to ask staff for assistance. On 2/21/19, at 10:23 a.m. R12 was observed in the beauty shop seated in her wheelchair getting her hair done with cape noted across her lap. On 2/21/19, at 11:41 a.m. nursing assistant (NA)-A assisted R12 from her wheelchair while utilizing the standing lift and transferred R12 to the toilet in the bathroom. At 11:55 a.m. NA-A assisted R12 from the toilet in the bathroom to her wheelchair again utilizing the standing lift. R12 had gripper socks present on both feet. At 11:59 a.m. NA-A wheeled R12 to the dining room for lunch. On 2/21/9, at 1:37 a.m. R12 was sitting up in recliner reading the newspaper with legs elevated and blanket covering her lap. R12's call light was within reach and gripper socks was noted on both feet. Review of R12's fall reports from 12/11/19, through 2/16/19, revealed the following: -On 2/11/19, at 6:20 a.m. R12 was was found sitting on the floor by her bedside. R12 stated she had attempted to stand up on her own and had slid down the edge of the bed to the floor. - On 2/16/19, at 3:53 p.m. staff were alerted to the dining room by a visitor. R12 was found on the floor beside a table after attempting to seat herself in another chair in the dining room. Review of R12's progress notes in the medical record revealed a lack of documentation of a root cause analysis of R12's falls. On 2/22/19, at 11:45 a.m. NA-A indicated R12 required assistance with ADL'S. NA-A indicated R12 did forget to use call light some times and had fallen in the past due to self transferring. -On 2/22/19, at 1:38 p.m. nursing assistant (NA)-B felt R12 required assistance with ADL's and was at risk for falls. NA-B indicated R12 had falls and staff checked on R12 every two hours. -On 2/22/19, at 1:23 p.m. CM indicated R12 was at high risk for falls and had been known to self transfer. CM stated R12 had two falls and confirmed a root cause analysis had not been completed and confirmed a lack of review or adjustment of the current fall prevention interventions had been documented. On 2/21/19, at 2:24 p.m. director of nursing (DON) stated the root cause analysis of incidents and falls was documented in the progress notes of each resident's medical record. DON confirmed if there was no documentation in the progress notes the root cause analysis had not been completed. On 2/22/19, at 2:10 p.m. during follow up interview, DON stated expectations for falls follow-up consisted of staff completing an assessment to evaluate for injuries, notifying the proper people of the fall and reviewing the care plan. DON indicated falls were discussed at interdisciplinary team meetings (IDT) but stated documentation of these meetings were not documented in the medical records. DON confirmed a root cause analysis or review or adjustment of current fall prevention interventions had not been documented after each fall for R10 and R12. Futher, DON stated the facility was in need of revising their falls prevention processes and indicated a new process for falls prevention had been considered by the facility, but not implemented at present. R11 R11's significant change MDS dated [DATE], identified R11 was severally cognitively impaired and had [DIAGNOSES REDACTED]. R11's MDS further identified she required extensive assistance with all activities of daily living (ADLs) except eating, and used a walker and wheelchair. R11's MDS further identified she had no history of falls. R11's quarterly MDS dated [DATE], identified R11 was severely cognitively impaired and required extensive assitance with transfers and supervision with walking and locomotion and used a walker and wheelchair. R11's MDS identified she had a history of [REDACTED]. R11's significant change fall CAA, dated 9/27/18, identified R 11 had increase risk of falls. Risk factors identified included: difficulty maintaining sitting balance and impaired balance during transitions. Other risk factors identified included: incontinence, arthritis, dementia, anxiety and [MEDICAL CONDITION]. R11's CAA summary identified R11 was forgetful and often confused which led to falls and R11 had poor ROM (range of motion) and strength at that time. R11's care plan, revised 2/21/19, identified R11 was at risk for falls and included various interventions which included assist of one PRN (as needed) with transfers. R11 had difficulty at times with going from sitting to standing and needed assist of one, especially when she was sitting on her walker seat. Interventions also included R11 forget to lock walker brakes when using it to sit on, encourage and remind her to do this especially when in dining room and nursing rehab to assist with one staff for ambulation in nursing home with walker, 3-5 days a week. R11's care plan directed staff to assist of 1-2 with transfers and to use PAL (mechanical lift) PRN with assist of 1-2. On 2/21/19, at 10:19 a.m. R11 was lying in her bed with eyes closed. R11's bed was in the low position, grab bars bilaterally and call light lying across her chest, with a wheelchair and four wheeled walker in her room near the window. On 2/21/19. at 12:32 p.m. R11 was seated in the dining room, in a regular chair next to the table. Nursing assistant (NA)-D turned R11's chair and applied a gait belt around R11's waist. Speech therapist (ST)-A obtained R11's four wheeled walker from near the wall and placed it in front of R11. R11 was assisted to stand by ST-A and NA-D. NA-D began to walk R11 around the table, then stopped. ST-A held onto R11 while NA-D tied R11's tennis shoe lace. NA-D then proceeded to assist R11 with walking,while holding onto the gait belt, back to her room from the dining room, then into R11's bathroom. NA-D cued R11 to hold on to the grab bar in the bathroom, while she assisted her to sit onto the toilet after NA-D removed her pants. At 12:39 p.m. NA-D assisted R11 with peri cares then assisted R11 to stand while cuing her again to use the grab bar. R11 held onto her walker while NA-D held R11's gait belt and walked her to her bed, then assisted her to lay down. R11's Fall assessment dated [DATE], identified R11 had no history of falls and was at moderate risk of falls. R11's Fall assessment dated [DATE], identified R11 had a history of [REDACTED]. Review of R11's incident reports 11/29/18, to 2/20/19, identified the following: -11/29/18, 11:15 a.m. R11 found in bathroom leaning with back and head against wall and toilet, not wearing her glasses, with feet straight out in front of her. R11's walker was in the bathroom with her, call light was not activated and the toilet seat was lying upside down in front of the toilet. R11's outer back of head was bleeding and R11 complained of pain in her left buttock and head. Physician assistant was notified and indicated he would go to nursing home to assess laceration to back of head. R11 was alert and had ambulated without assistance and used a walker. -12/19/18, 7:30 a.m. R11 had fallen while walking per self with walker to the dining room. Staff reported R11 fell on to her right side and did not hit her head. R11 had a skin tear to her right elbow and was alert, confused and repetitive with impaired memory. R11 had ambulated without assistance and used a walker. R11's incident reports lacked comprehensive assessments of R11's falls. Review of R11's Progress Notes from 11/29/18 to 2/20/19, identified the following: -11/29/18, R11 found in bathroom leaning with back and head against wall and toilet with feet straight out in front of her. R11's walker was in the bathroom with her, and the toilet seat was lying upside down in front of the toilet. R11 was not wearing her glasses. R11's outer back of head was bleeding she complained of pain in her left buttock and head. Physician assistant was notified and came to the nursing home and applied three staples to the wound on R11's head. -12/1/18, fall note, root cause analysis: identified R11 was independent with toileting and assist of one as needed. R11 was found in bathroom but had not used her call light. Tennis shoes in place and walker in bathroom when resident found. R11 may have lost balance or tripped. No visible objects [DIAGNOSES REDACTED] floor but toilet seat riser was off the toilet. Resident denied feeling dizzy before hand. The note lacked further assessment of R11's fall. -12/7/18; post fall follow up week one. R11 continued normal routine and to be unsure of self and independently ambulated and transferred self at times, but other times would ask for assistance. R11 required wheelchair that morning and it was reported R11 was leaning back. Continued to monitor for need in change of care plan. -12/13/18, post fall follow up week two. R11 had been following normal routine. No complaints of pain or difficulty with transfers. R11 had not needed the wheelchair that week. Continued with current plan of care. -12/19/18, R11 was observed by dietary staff during a fall in the dining room. R11 was confused and did not answer questions appropriately. R11 obtained a skin tear three centimeters to her right elbow due to the fall. R11 followed her normal routine after the fall. Staff walked R11 with a gait belt and assisted R11 to sit in chairs. At 6:34 p.m. R11 had a near fall in dining room during supper. R11 went forward when turning, and held the table which caught her fall. R11 was assisted into the dining room chair by two staff. No documentation of a root cause analysis was documented after fall. -12/22/18, post fall follow up. R11 had another fall earlier this week. No change to plan of care. R11 liked to sit on her walker seat at meals and no longer comprehended how to lock brakes properly, to monitor. -12/30/18, post fall follow up. R11 needed more assistance with ambulation in the halls and with transfers. R11 needed PAL lift at times to get out of her bed, care plan was updated, and continued to monitor. -1/4/19, post fall follow up. R11 has had no further falls. R11 continued to be unsure of self with transfers and waited for staff assistance with transfers. -1/11/18, post fall follow up. R11 now required assistance of one with ambulation. R11 had no recent falls and continue current plan of care. -1/22/19, post fall follow up. R11 ambulated self at times, and required Pal lift transfers at times. R11 had no recent falls. -2/2/19, fall follow up. R11 had been ambulating with assist of one. No futher falls, continue current plan of care. Review of R11's Progress Notes revealed lacked of analysis of R11's falls. On 2/21/19, at 1:49 p.m. NA-C indicated R11 required extensive assistance with activities of daily living (ADL). NA-C felt R11 was at risk for falls, but had not had a recent fall. NA-C indicated R11 had walked by herself, but they had been helping her walk now for a few months. NA-C indicated to help prevent falls R11 had a low bed and staff checked on her every two hours. On 2/21/19, at 1:52 p.m. licensed practical nurse (LPN)-A indicated R11 required assistance to transfer. LPN-A indicated she was not aware R11 had any recent falls, but indicated she usually worked the other end of the facility. LPN-A indicated if a resident had a fall, the usual facility process was for the registered nurses (RN) to do any follow up charting and implementation of new interventions after the fall. On 2/21/19, at 2:04 p.m. NA-D indicated she felt was at risk of falls and required assistance with walking and the use of the gait belt and walker. On 2/22/19, at 9:30 a.m. CM-A indicated R11 was anxious, transferred herself , toileted herself at times and would forget to use her call light. CM-A indicated she usually worked on the other end of the facility, but was aware R11 had a fall in (MONTH) when she hit her head and required staples, and again in the dining room. CM-A indicated after a fall the usual facility practice included six weeks of weekly follow up monitoring for any further changes or injuries from the fall. CM-A indicated the facility had weekly IDT (interdisciplinary team) meetings every week, which included therapy and they would cue the therapist of the fall to see if they could work with the resident. On 2/22/19, at 9:44 a.m. trained medication aide (TMA)-A indicated R11 required extensive assistance to stand and limited assistance while walking. TMA-A felt R11 was at risk of falls and indicated he was aware R11 had a fall a while back. TMA-A indicated he was not aware of any changes made for R11 after the fall, and indicated no changes recently. On 2/22/19, at 2:41 p.m. DON confirmed no comprehensive assessment was completed after R11's falls and confirmed R11 had fallen in the past. DON indicated the usual facility practice for falls included discussing them at weekly IDT meetings to determine if any new interventions should be put in place. DON confirmed not all fall IDT discussions were documented in resident charts. DON indicated if any new ideas were identified, they would be put in the residents chart, care plan and in the facility communication book. DON indicated she would expect the residents care plan to be reviewed after a fall. DON indicated the facility was working on improving their fall process, and the new plan was to begin using a post fall huddle form after the fall, to look at the root cause of the fall, document findings and to assure interventions were working. Review of policy titled IDT (Interdisciplinary Team) indicated IDT meetings would occur at least monthly with a goal of meeting weekly and falls would be one of the topics to be discussed.

Based on observation, interview, and document review, the facility failed to monitor and provide the necessary care for 1of 3 resident (R1) who was currently received a routine dose of [MEDICATION NAME] ([MEDICATION NAME]).The deficient practice resulted in an immediate jeopardy (IJ) situation for R1 when the facility failed to properly monitor and evaluate, notify the physician and [MEDICATION NAME] clinic of R1's development of bloody stools which resulted in R1's hospitalization with a hemoglobin of 6.1 and subsequent blood product [MEDICAL CONDITION]. The immediate jeopardy began on 12/27/18 when the facility failed to notify to physician and [MEDICATION NAME] clinic of R1's continued use of [MEDICATION NAME] while having bloody stools and was identified on 1/16/19. The assistant administrator (AA) and the director of nursing (DON) were notified of the immediate jeopardy at 2:45 p.m. on 1/16/19. The immediate jeopardy was removed on 1/17/19, at 6:08 p.m., but noncompliance remained at the lower scope and severity level G-isolated, which indicated actual harm that is not immediate jeopardy. Finding include: R1's admission Minimum Data Set (MDS) dated , 11/15/19, indicated R1 was moderately cognitively impaired and had [DIAGNOSES REDACTED]. The MDS indicated R1 required supervision of one staff to assist with activities of daily living, required extensive assistance of one staff for dressing and was occasionally incontinent of urine. The MDS further indicated R1 had received anticoagulant and antibiotic medications for the past seven days. Review of R1's care plan, revised on 11/28/18, indicated R1 was on anticoagulant therapy ([MEDICATION NAME]) related to [MEDICAL CONDITION] and blood clots. The care plan listed several interventions which included staff were to monitor/document/report to the medical doctor as needed signs and symptoms anticoagulant complications such as: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain , lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden change in mental status, and significant or sudden changes in vital signs. On 1/15/19 at 9:59 a.m. R1 was in her room standing on a square platform block with her walker in front of her. Physical therapist (PT)-A stood on the right side of her and held R1's walker steady. The PT indicated R1 was working on balancing exercises. R1 continued to participate in the balance exercises, with cuing done by PT-A until 10:17 a.m. when PT-A indicated the session was done. R1's color was pink and had no signs of shortness of breath, or distress while participating in the balancing exercises. Review of R1's Progress Notes from 12/25/18 to 1/4/18 revealed the following: On 12/27/18 at 6:55 a.m. nurse called to room due to R1 having a large amount of red blood after having a bowel movement. Noted large amount of red blood in the toilet with small amount of stool with dark brown/black edges. No external hemorrhoids noted and registered nurse (RN) updated at 7:10 a.m. - at 9:17 a.m. [MEDICATION NAME] clinic updated that facility was unable to get labs done today as the local clinic was closed and orders received. - at 9:50 a.m. R1 had second large jelly like red/black stool again and complaining of abdominal pain. Physician updated and started her on [MEDICATION NAME] and labs were to be drawn on Monday. - at 11:10 a.m. R1 had been more weak today, has been using wheelchair, more pale and complained of abdominal pain earlier. On 12/28/18 at 3:00 p.m. nursing assistant (NA) reported a small amount of bright red blood was noted in the toilet. On 12/29/18 at 8:32 a.m. RN entered bathroom and noted blood in the garbage and on the toilet. RN assisted R1 to clean up had blood on hands and in between legs. - at 9:00 a.m. NA reported blood was noted in toilet to RN. Vitals taken, R1 complaints of feeling short of breath after ambulating to breakfast. R1 complained of stomach pain that come and goes rating the pain 1 to 3 out of 10 on the pain scale (numerical rating on a scale of 0-10, 10 being the most pain) and did not want to eat breakfast. - at 9:11 a.m. R1 became short of breath walking from the dining room and was pale in color and stated I just don't feel right R1 daughter coming to take R1 to seek medical treatment. - at 10:34 a.m. R1 had two large episodes of bleeding in the toilet with going to the bathroom after being assisted on the toilet by RN and family member (FM)-A. R1 became very pale, weak and FM-A decided to take R1 to(NAME)emergency department without waiting for other FM. - at 2:53 p.m. R1 left facility with FM-A around 10:30 or 11:00 a.m. And a later note at 7:53 p.m. indicated R1 had been admitted to the hospital. -12/30/18 at 9:30 a.m. updated from(NAME)Hospital R1's hemoglobin on admission was 11.2 , then went to 6.1. R1 was given given 2 units of fresh frozen plasma and 2 units of whole blood along with vitamin K. R1 hemoglobin today was 7.4 On 1/4/18 at 11:18 a.m. RN called hospital and was told R1's hemoglobin currently 8.1 this morning and the medical doctor stated R1 was still having bowel movements with old blood in them and R1's [MEDICATION NAME] had been discontinued. Reviewed R1's Anticoagulation Reports from 11/8/18 to 12/27/18 revealed R1 had been receiving [MEDICATION NAME] since 11/8/18 and had a dosage change on 12/27/18. -12/20/18, R1's International Normalized Ratio (INR) (standardized measurement of the time it takes for blood to clot) was 1.7 and orders were received for [MEDICATION NAME] 5 mg on Saturday, Sunday, Tuesdays and Thursday and 2.5 mg all other days, recheck INR on 12/27/18. -12/27/18, no results of R1's INR was listed and included a note that indicated nursing home nurse called and reported lab personnel were not available to draw R1's INR today. She was requesting orders through Sunday, INR can be drawn on 12/31/18, please advise. The report listed instructions Ok to continue on weekly dose. Orders were given for [MEDICATION NAME] 5 mg on 12/27/18, 2.5 mg on 12/28/18, 5 mg on 12/29/18, 5 mg 12/30/18 and recheck INR on 12/31/18. The DON had been notified of R1's [MEDICATION NAME] ([MEDICATION NAME]) dosing, to recheck INR and had voiced understanding of disposition and recommendations. The note lacked documentation the [MEDICATION NAME] clinic had been notified of R1's bloody stools. Review of R1's Medication Administration Record [REDACTED]. R1's hospital Admission History and Physical, dated 12/30/18, indicated R1 had acute [MEDICAL CONDITION] (GI) bleed (bleeding in the gastrointestinal tract), guaiac (fecal occult blood test) was positive and hemoglobin (a protein in red blood cells that carries oxygen throughout the body) dropped from 11 to 8 and patient was on [MEDICATION NAME]. The plan was to reverse R1's INR to normal, given orally 5 mg of vitamin K(helps the blood clot and prevents excessive bleeding), was given fresh frozen plasma and R1's hemoglobin was monitored every 6 hours. The report indicated R1 would receive blood products as needed for hemoglobin below 7. R1's procedure report dated 12/30/18, indicated R1 had a flexible sigmoidoscopy (test to check the inner lining of rectum and the lower part of colon) done and revealed clotted blood diffusely in the rectum and sigmoid colon no active bleeding, severe sigmoid [DIAGNOSES REDACTED] (small pouches that bulge outward through the colon, or large intestine), no rectal or sigmoid ulcers, masses or polyps and suspect diverticular bleeding. Review of R1's Interagency Handoff Report, dated 12/29/18, indicated R1 had history of femoral artery [MEDICAL CONDITION] and received [MEDICATION NAME]. The report indicated R1 had experienced a GI bleed, hemoglobin had dropped to 6.1 and had been given 2 units of packed red blood cells and fresh frozen plasma. Further, the report indicated on 1/2/19, R1's hemoglobin had been 7.8 and INR 1.1. On 1/15/19 at 3:14 p.m. during a telephone interview, physician (P)-A confirmed R1 had developed bloody stools and indicated he was not aware if the facility staff had reviewed the order for the continued use of [MEDICATION NAME] when they notified him of the bloody stools. He indicated the usual practice was for the [MEDICATION NAME] clinic to deal with the ongoing [MEDICATION NAME] dosing. P-A indicated the facility should have notified the [MEDICATION NAME] clinic of R1 having blood in her stool and the facility should have known the effects of the [MEDICATION NAME] in relation to bloody stools. He confirmed R1 had been hospitalized for [REDACTED]. On 1/15/19 at 3:28 p.m. during a telephone interview with the [MEDICATION NAME] clinic's registered pharmacist (RPH)-A she indicated the facility had contacted the [MEDICATION NAME] clinic on 12/27/18 to request orders for R1 to continue her regular dose of [MEDICATION NAME] until 12/31/18 due to not being able to draw labs that day because the local clinic was closed. The RPH-A confirmed she gave the order to continue R1's regular dose of [MEDICATION NAME] until 12/31/18 and to recheck INR at that time. The RPH-A indicated she had not been informed by the facility R1 had blood in her stool. RPH-A indicated if she would have known R1 was having blood in her stool, she would of given orders to hold the [MEDICATION NAME], draw an INR as soon as possible and to seek medical attention. RPH-A indicated she felt the facility should have updated the clinic of R1's bloody stool and contacted her doctor. RPH-A stated she would have definitely changed R1's [MEDICATION NAME] order if she had been aware of R1's bloody stool. On 1/15/19 at 3:50 p.m. registered nurse (RN)-A confirmed R1 had blood in her stool for multiple days and indicated she had not notified the physician or the [MEDICATION NAME] clinic because she thought the DON had called the doctor and [MEDICATION NAME] clinic of the bloody stools. The RN-A confirmed on 12/29/18 she had noticed blood on R1's toilet, hands and in between her legs and assisted to clean her up. The RN-A indicated R1 had shortness of breath with ambulating, and was sent to the emergency room at that time. On 1/15/19 at 4:10 p.m. DON confirmed she was aware R1 had a bloody stool on 12/27/18 at 6:55 a.m. and had notified the family shortly after that. DON indicated she had called the [MEDICATION NAME] clinic for orders to continue current dose of [MEDICATION NAME] because the local clinic was not available to draw blood that day. She indicated R1 had a second bloody stool with abdominal pain and she had notified R1's physican of the bloody stools but had not notified him of the continued orders for [MEDICATION NAME]. DON indicated she had planned to contact the [MEDICATION NAME] clinic next, but she got distracted by staff scheduling due to weather concerns. DON confirmed she had not notified the clinic personnel of R1's bloody stools. DON confirmed R1 continued to receive the usual dose of [MEDICATION NAME] on 12/27/18, 12/28/18 and had been sent to the hospital on [DATE] for a diverticular bleed. The DON confirmed the [MEDICATION NAME] clinic should of been notified of R1's bloody stools and confirmed P-A should of been updated R1 was currently receiving [MEDICATION NAME] while having bloody stools. The DON indicated she would expect facility staff to monitor residents that were currently receiving [MEDICATION NAME] for any signs/symptoms of bleeding or bruising and would notify the doctor, [MEDICATION NAME] clinic, family and send to hospital if needed. On 1/16/18 at 3:29 p.m. trained medication aide (TMA)-A indicated she had been aware of reports of R1 having blood in her stool and confirmed R1 had received [MEDICATION NAME] on 12/27/18 and 12/28/18. The TMA-A indicated her usual practice for a resident on blood thinners was to monitor and report any physical signs of bleeding or bruising to the charge nurse and then the charge nurse would address any issues. The immediate jeopardy that began on 12/27/18, was removed on 1/17/19, when the facility implemented the following interventions which were verified as completed. However, the noncompliance remained at the lower scope and severity level of G-isolated-actual harm which is not immediate jeopardy because the facility had not provided the necessary care and services for R1 and resulted in hospitalization with a hemoglobin of 6.1 and subsequent blood product [MEDICAL CONDITION]. -medical director reviewed the policies and procedures for Anticoagulation Clinical Protocol -P-A educate the DON in comprehensively assessing, monitoring and providing the necessary care for residents receiving [MEDICATION NAME] and any change in condition -DON completed compentency testing with return demonstration of licensed staff responsible for assessing, monitoring and providing care to residents receiving [MEDICATION NAME] and change in condition -educated all staff on the Anticoagulant policy, change in condition, routine monitoring of bruising and bleeding, to call the [MEDICATION NAME] Clinic or primary physician for direction if clinic is closed -DON and P-A performed audits on residents currently receiving [MEDICATION NAME], the DON completed audits on all other residents residing in the facility for any change in condition and monitoring for signs of bruising and bleeding and any concerns will be brought to the facility's quality assurance, pharmacist notified and did not make any recommendations - interdisciplinary team discussed and reviewed the policy and procedures for Anticoagulation use -new calendar placed at nursing station to monitor when INR's should be completed. Review of Facility policy titled, Anticoagulation Clinic Protocol revised on 4/2007, indicated staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next dose of anticoagulant. In individuals receiving [MEDICATION NAME] show are bleeding or who have markedly elevated PT/INR staff are to notify [MEDICATION NAME] Clinic, primary physician and resident representative. Staff will be educated on monitoring for increased bleeding and to notify charge nurse.

Based on observation, interview, and document review, the facility failed to ensure the physician was notified of a change in condition for 1 of 1 resident (R1) who was receiving [MEDICATION NAME] ([MEDICATION NAME]) and developed bloody stools. This deficient practice resulted in an immediate jeopardy (IJ) situation for R1 when the facility failed to notify the physician and the [MEDICATION NAME] clinic which resulted in R1's hospitalization with a hemoglobin of 6.1 and subsequent blood product [MEDICAL CONDITION]. The immediate jeopardy began on 12/27/18, and was identified on 1/16/19, when the facility failed to notify the physician of R1's change in condition with continued use of [MEDICATION NAME] while having bloody stools. The assistant administrator (AA) and the director of nursing (DON) were notified of the immediate jeopardy at 2:45 p.m. on 1/16/19. The immediate jeopardy was removed on 1/17/19, at 6:08 p.m., but noncompliance remained at the lower scope and severity level G-isolated, which indicated actual harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set (MDS) dated , 11/15/19, indicated R1 was moderately cognitively impaired and had [DIAGNOSES REDACTED]. The MDS indicated R1 required supervision of one staff to assist with activities of daily living, required extensive assistance of one staff for dressing and was occasionally incontinent of urine. The MDS further indicated R1 had received anticoagulant and antibiotic medications for the past seven days. Review of R1's care plan, revised 11/28/18, identified R1 was on anticoagulant therapy ([MEDICATION NAME]) related to [MEDICAL CONDITION] and blood clots. The care plan listed various interventions which included staff were to monitor/document/report to the medical doctor as needed signs and symptoms anticoagulant complications such as: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain , lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden change in mental status, and significant or sudden changes in vital signs. On 1/15/19 at 9:59 a.m. R1 was in her room, standing on a square platform block with her walker in front of her. Physical therapist (PT)-A stood on the right side of her and held R1's walker steady. The PT indicated R1 was working on balancing exercises. R1 continued to participate in the balance exercises, with cuing done by PT-A until 10:17 a.m. when PT-A indicated the session was done. R1's color was pink and had no signs of shortness of breath, or distress while participating in the balancing exercises. Review of R1's Progress Notes from 12/25/18 to 1/4/19 revealed the following: On 12/27/18 at 6:55 a.m. nurse called to room due to R1 having a large amount of red blood after having a bowel movement. Noted large amount of red blood in the toilet with small amount of stool with dark brown/black edges. No external hemorrhoids noted and registered nurse (RN) updated at 7:10 a.m. - at 9:17 a.m. [MEDICATION NAME] clinic updated that facility was unable to get labs done today as the local clinic was closed and orders received. - at 9:50 a.m. R1 had second large jelly like red/black stool again and complaining of abdominal pain. Physician updated and started her on [MEDICATION NAME] and labs were to be drawn on Monday. - at 11:10 a.m. R1 had been more weak today, had been using wheelchair, more pale and complained of abdominal pain earlier. On 12/28/18 at 3:00 p.m. nursing assistant (NA) reported a small amount of bright red blood was noted in the toilet. On 12/29/18 at 8:32 a.m. RN entered bathroom and noted blood in the garbage and on the toilet. RN assisted R1 to clean up had blood on hands and in between legs. - at 9:00 a.m. NA reported blood was noted in toilet to RN. Vitals taken, R1 complaints of feeling short of breath after ambulating to breakfast. R1 complained of stomach pain that come and goes rating the pain 1 to 3 out of 10 on the pain scale(numerical rating on a scale of 0-10, 10 being the most pain) and did not want to eat breakfast. - at 9:11 a.m. R1 became short of breath walking from the dining room and was pale in color and stated I just don't feel right R1 daughter coming to take R1 to seek medical treatment. - at 10:34 a.m. R1 had two large episodes of bleeding in the toilet with going to the bathroom after being assisted on the toilet by RN and family member (FM)-A, R1 became very pale, weak and FM-A decided to take R1 to(NAME)emergency department without waiting for other FM. - at 2:53 p.m. R1 left facility with FM-A around 10:30 or 11:00 a.m. And a later note at 7:53 p.m. indicated R1 had been admitted to the hospital. -12/30/18 at 9:30 a.m. updated from(NAME)Hospital R1's hemoglobin on admission was 11.2 , then went to 6.1. R1 was given given 2 units of fresh frozen plasma and 2 units of whole blood along with vitamin K (helps the blood clot and prevents excessive bleeding). R1 hemoglobin today was 7.4. On 1/4/18 at 11:18 a.m. RN called hospital and was told R1's hemoglobin currently 8.1 this morning and the medical doctor stated R1 was still having bowel movements with old blood in them and R1's [MEDICATION NAME] had been discontinued. Review of R1's Anticoagulation Reports from 11/8/18 to 12/27/18 revealed R1 had been receiving [MEDICATION NAME] since 11/8/18 and had a dosage change on 12/27/18. -12/20/18, R1's International Normalized Ratio (INR) (standardized measurement of the time it takes for blood to clot) was 1.7 and orders were received for [MEDICATION NAME] 5 mg on Saturday, Sunday, Tuesdays and Thursday and 2.5 mg all other days, recheck INR on 12/27/18. -12/27/18, no results of R1's INR was listed and included a note that indicated nursing home nurse called and there was not lab personnel available to draw R1's INR today. She was requesting orders through Sunday, INR can be drawn on 12/31/18, please advise. The report listed instructions Ok to continue on weekly dose. Orders were given for [MEDICATION NAME] 5 mg on 12/27/18, 2.5 mg on 12/28/18, 5 mg on 12/29/18, 5 mg 12/30/18 and recheck INR on 12/31/18. The report listed the DON had been notified of R1's [MEDICATION NAME] ([MEDICATION NAME]) dosing, to recheck INR and had voiced understanding of disposition and recommendations. The note lacked documentation the [MEDICATION NAME] clinic had been notified of R1's bloody stools. Review of R1's Medication Administration Record [REDACTED]. R1's hospital Admission History and Physical, dated 12/30/18, indicated R1 had acute [MEDICAL CONDITION] (GI) bleed (bleeding in the gastrointestinal tract), guaiac (fecal occult blood test) was positive and hemoglobin (a protein in red blood cells that carries oxygen throughout the body) dropped from 11 to 8 and patient was on [MEDICATION NAME]. The plan was to reverse R1's INR to normal, given orally 5 mg of vitamin K, was given fresh frozen plasma and R1's hemoglobin was monitored every 6 hours. The report indicated R1 would receive blood products as needed for hemoglobin below 7. R1's procedure report dated 12/30/18, indicated R1 had a flexible sigmoidoscopy (test to check the inner lining of rectum and the lower part of colon) done and revealed clotted blood diffusely in the rectum and sigmoid colon, no active bleeding, severe sigmoid [DIAGNOSES REDACTED] (small pouches that bulge outward through the colon, or large intestine), no rectal or sigmoid ulcers, masses or polyps and suspect diverticular bleeding. Review of R1's Interagency Handoff Report, dated 12/29/18, indicated R1 had history of femoral artery [MEDICAL CONDITION] and received [MEDICATION NAME]. The report indicated R1 had experienced a GI bleed, hemoglobin had dropped to 6.1 and had been given 2 units of packed red blood cells and fresh frozen plasma. Further, the report indicated on 1/2/19, R1's hemoglobin had been 7.8 and INR 1.1. On 1/15/19 at 3:14 p.m. during a telephone interview, physician (P)-A confirmed R1 had developed bloody stools and indicated he was not aware if the facility staff had reviewed the order for the continued use of [MEDICATION NAME] when they notified him of the bloody stools. He indicated the usual practice was for the [MEDICATION NAME] clinic to deal with the ongoing [MEDICATION NAME] dosing. P-A indicated the facility should have notified the [MEDICATION NAME] Clinic of R1 having blood in her stool and the facility should have known the effects of the [MEDICATION NAME] in relation to bloody stools. He confirmed R1 had been hospitalized for [REDACTED]. On 1/15/19 at 3:28 p.m. during a telephone interview with the [MEDICATION NAME] Clinic's registered pharmacist (RPH)-A, she indicated the facility had contacted the [MEDICATION NAME] Clinic on 12/27/18 to request orders for R1 to continue her regular dose of [MEDICATION NAME] until 12/31/18 due to not being able to draw labs that day because the local clinic was closed. The RPH-A confirmed she gave the order to continue R1's regular dose of [MEDICATION NAME] until 12/31/18 and to recheck INR at that time. The RPH-A indicated she had not been informed by the facility R1 had blood in her stool. RPH-A indicated if she would have known R1 was having blood in her stool, she would of given orders to hold the [MEDICATION NAME], draw an INR as soon as possible and to seek medical attention. RPH-A indicated she felt the facility should have updated the clinic of R1's bloody stool and contacted her doctor. RPH-A stated she would have definitely changed R1's [MEDICATION NAME] order if she had been aware of R1's bloody stool. On 1/15/19 at 3:50 p.m. registered nurse (RN)-A confirmed R1 had blood in her stool for multiple days and indicated she had not notified the physician or the [MEDICATION NAME] Clinic because she thought the DON had called the doctor and [MEDICATION NAME] Clinic of the bloody stools. The RN-A confirmed on 12/29/18 she had noticed blood on R1's toilet, hands and in between her legs and assisted to clean her up. The RN-A indicated R1 had shortness of breath with ambulating, and was sent to the emergency room at that time. On 1/15/19 at 4:10 p.m. DON confirmed she was aware R1 had a bloody stool on 12/27/18 at 6:55 a.m. and had notified the family shortly after that. DON indicated she had called the [MEDICATION NAME] Clinic for orders to continue current dose of [MEDICATION NAME] because the local clinic was not available to draw blood that day. She indicated R1 had a second bloody stool with abdominal pain and she had notified R1's physican of the bloody stools but had not notified him of the continued orders for [MEDICATION NAME]. DON indicated she had planned to contact the [MEDICATION NAME] clinic next, but she got distracted by staff scheduling due to weather concerns. DON confirmed she had not notified the clinic personnel of R1's bloody stools. DON confirmed R1 continued to receive the usual dose of [MEDICATION NAME] on 12/27/18, 12/28/18 and had been sent to the hospital on [DATE] for a diverticular bleed. The DON confirmed the [MEDICATION NAME] Clinic should of been notified of R1's bloody stools and confirmed P-A should of been updated R1 was currently receiving [MEDICATION NAME] while having bloody stools. The immediate jeopardy that began on 12/27/18, was removed on 1/17/19, when the facility implemented the following interventions which were verified as completed. However, the noncompliance remained at the lower scope and severity level of G-isolated-actual harm which is not immediate jeopardy because the facility had not provided the necessary care and services for R1 and resulted in hospitalization with a hemoglobin of 6.1 and subsequent blood product [MEDICAL CONDITION]. -medical director reviewed the policies and procedures for Anticoagulation Clinical Protocol -P-A educate the DON in comprehensively assessing, monitoring and providing the necessary care for residents receiving [MEDICATION NAME] and any change in condition -DON completed compentency testing with return demonstration of licensed staff responsible for assessing, monitoring and providing care to residents receiving [MEDICATION NAME] and change in condition -educated all staff on the Anticoagulant policy, change in condition, routine monitoring of bruising and bleeding, to call the [MEDICATION NAME] Clinic or primary physician for direction if clinic is closed -DON and P-A performed audits on residents currently receiving [MEDICATION NAME], the DON completed audits on all other residents residing in the facility for any change in condition and monitoring for signs of bruising and bleeding and any concerns will be brought to the facility's quality assurance, pharmacist notified and did not make any recommendations - interdisciplinary team discussed and reviewed the policy and procedures for Anticoagulation use -new calendar placed at nursing station to monitor when INR's should be completed. Review of Facility policy titled, Anticoagulation Clinic Protocol revised on 4/2007, indicated staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next dose of anticoagulant. In individuals receiving [MEDICATION NAME] show are bleeding or who have markedly elevated PT/INR staff are to notify [MEDICATION NAME] Clinic, primary physician and resident representative. Staff will be educated on monitoring for increased bleeding and to notify charge nurse.

Based on interview and document review, the facility failed to immediately report to the State Agency (SA) potential neglect of care for 1 of 1 resident (R1) who did not receive the necessary care and services after having bloody stools and continued use of [MEDICATION NAME]. In addition, the facility failed to immediately report, within 2 hours, to the SA allegations of abuse for 2 of 3 (R4 and R5) who had a physical resident to resident altercation. Findings include: R1's Admission Minimum Data Set (MDS) dated , 11/15/19, indicated R1 was moderately cognitively impaired and had [DIAGNOSES REDACTED]. The MDS indicated R1 required supervision of one staff to assist with activities of daily living and required extensive assistance of one staff for dressing. The MDS further indicated R1 had received anticoagulant and antibiotic medications for the past seven days. Review of R1 Care Plan revised on 11/28/18, indicated R1 had potential for injury related to vulnerable adult status. The care plan directed staff to follow the abuse and neglect prevention plan and do not neglect daily needs. The care plan also indicated R1 was on anticoagulant Therapy [MEDICATION NAME] related to [MEDICAL CONDITION] and blood clots. The care plan listed several interventions and directed staff to monitor/document/report to the medical doctor as needed signs and symptoms anticoagulant complications such as: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain , lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden change in mental status, and significant or sudden changes in vital signs. Review of R1's Progress Notes from 12/25/18 to 1/4/19 revealed the following: On 12/27/18 at 6:55 a.m. nurse called to room due to R1 having a large amount of red blood after having a bowel movement. Noted large amount of red blood in the toilet with small amount of stool with dark brown/black edges. No external hemorrhoids noted and registered nurse (RN) updated at 7:10 a.m. - at 9:17 a.m. [MEDICATION NAME] clinic updated that facility was unable to get labs done today as the local clinic was closed and orders received. - at 9:50 a.m. R1 had second large jelly like red/black stool again and complaining of abdominal pain. Physician updated and started her on [MEDICATION NAME] and labs were to be drawn on Monday. - at 11:10 a.m. R1 had been more weak today, had been using wheelchair, more pale and complained of abdominal pain earlier. -12/28/18 at 3:00 p.m. nursing assistant (NA) reported a small amount of bright red blood was noted in the toilet. -12/29/18 at 8:32 a.m. RN entered bathroom and noted blood in the garbage and on the toilet. RN assisted R1 to clean up had blood on hands and in between legs. - at 9:00 a.m. NA reported blood was noted in toilet to RN. Vitals taken, R1 complaints of feeling short of breath after ambulating to breakfast. R1 complained of stomach pain that come and goes rating the pain 1 to 3 out of 10 on the pain scale and did not want to eat breakfast. - at 9:11 a.m. R1 became short of breath walking from the dining room and was pale in color and stated I just don't feel right R1 daughter coming to take R1 to seek medical treatment. - at 10:34 a.m. R1 had two large episodes of bleeding in the toilet with going to the bathroom after being assisted on the toilet by RN and family member (FM)-1. R1 became very pale, weak and FM-1 decided to take R1 to(NAME)emergency department without waiting for other FM. - at 2:53 p.m. R1 left facility with FM-1 around 10:30 or 11:00 a.m. And a later note at 7:53 p.m. indicated R1 had been admitted to the hospital. Resident to resident altercation R4's quarterly Minimum Data Set MDS dated [DATE], indicated R4 was severely cognitively impaired with [DIAGNOSES REDACTED]. The MDS indicated R4 required extensive assistance of one to two staff with all activities of daily living (ADL's) and had no behaviors. R4's current care plan revised on 12/19/18, indicated R4 had potential for injury related to incapacity for self preservation in emergency situations. The care plan listed various intervention which included staff to provide total assistance in an emergency situation. R5's quarterly Minimum Data Set MDS dated [DATE], indicated R5 was severely cognitively impaired with [DIAGNOSES REDACTED]. The MDS indicated R5 required extensive assistance of one to two staff with all activities of ADL's and had no behaviors. R5's current care plan revised on 12/6/2018, indicated R5 had potential for injury related to incapacity for self preservation in emergency situations. The care plan listed various intervention which included staff to provide direction in an emergency situation and for staff to follow the neglect prevention plan and not to neglect daily needs. Review of Incident Report # 2 , submitted to the SA on 12/13/18 at 10:31 a.m. listed an allegation of physical abuse for R4, and listed the incident had occurred on 12/12/18 at 11:15 a.m. A nursing assistant had reported during an activity R4 was talking and was moved to another area next to R5. R5 got upset with R4 and slapped R4's arm and stated shut up. R4 and R5 were separated and moved with no more incidents. On 1/15/19 at 4:10 p.m. DON confirmed she had been aware R1 had bloody stools on 12/27/18. She indicated she was aware R1 continued to receive the usual dose of [MEDICATION NAME] on 12/27/18, 12/28/18 and had been sent to the hospital on [DATE] for a diverticular bleed. On 1/16/19 at 2:58 p.m. during a follow up interview, DON confirmed the Administrator and the assistant Administrator had been notified of R1 having blood in her stool and being sent out to the hospital for a GI bleed. The DON indicated it did not cross her mind to report the allegation to the SA because the 24 hour mark had already passed. The DON indicated she did not think about filing a vulnerable adult report because R1 was finally getting the care she needed. The DON indicated she thought about reporting the allegation on the following Monday but the 24 hour marker was already up. The DON confirmed the allegation should have been reported with in 2 hours after knowing R1 had a GI bleed. On 1/17/19 at 12:39 p.m. during a group interview, DON and the assistant Administrator (AA) indicated the facility utilized a algorithm to assist in determining when a report to the SA needed to be done. The DON indicated staff immediately intervened, separated R4 and R5 and made sure they were safe. The DON verified the resident to resident physical abuse should have been reported right away due to R5 intentionally hitting R4 on the arm. On 1/17/18 at 5:51 p.m. the AA confirmed the facility policy, and indicated the IDT team discussed reporting R1's potential neglect of care to the SA but did not because it was past the time frame for reporting. The IDT team discussed reporting allegations in the future and would report even if the allegation was late. Review of the facility policy titled, Viking Manor Investigation and Reporting Procedure undated, indicated all alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. If the events that cause allegation involve abuse or result in serious bodily injury, the alleged violation well be reported immediately , but not later that 2 hours after the allegation is made. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the violations will be reported immediately , but not later than 24 hours. All alleged violations will be reported immediately to the administrator and to other officials including the SA and adult protective services where state law provides for jurisdiction in the long term care facility.

Based on interview and document review, the facility failed to thoroughly investigate potential neglect of care 1 of resident (R1) who did not receive the necessary care and services after having bloody stools and continued use of [MEDICATION NAME]. Findings include: R1's Admission Minimum Data Set (MDS) dated , 11/15/19, indicated R1 was moderately cognitively impaired and had [DIAGNOSES REDACTED]. The MDS indicated R1 required supervision of one staff to assist with activities of daily living and required extensive assistance of one staff for dressing. The MDS further indicated R1 had received anticoagulant and antibiotic medications for the past seven days. Review of R1 Care Plan revised on 11/28/18, indicated R1 had potential for injury related to vulnerable adult status. The care plan directed staff to follow the abuse and neglect prevention plan and do not neglect daily needs. The care plan also indicated R1 was on anticoagulant Therapy [MEDICATION NAME] related to [MEDICAL CONDITION] and blood clots. The care plan listed several interventions and directed staff to monitor/document/report to the medical doctor as needed signs and symptoms anticoagulant complications such as: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain , lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden change in mental status, and significant or sudden changes in vital signs. Review of R1's Progress Notes from 12/25/18 to 1/4/19 revealed the following: On 12/27/18 at 6:55 a.m. nurse called to room due to R1 having a large amount of red blood after having a bowel movement. Noted large amount of red blood in the toilet with small amount of stool with dark brown/black edges. No external hemorrhoids noted and registered nurse (RN) updated at 7:10 a.m. - at 9:17 a.m. [MEDICATION NAME] clinic updated that facility was unable to get labs done today as the local clinic was closed and orders received. - at 9:50 a.m. R1 had second large jelly like red/black stool again and complaining of abdominal pain. Physician updated and started her on [MEDICATION NAME] and labs were to be drawn on Monday. - at 11:10 a.m. R1 had been more weak today, had been using wheelchair, more pale and complained of abdominal pain earlier. -12/28/18 at 3:00 p.m. nursing assistant (NA) reported a small amount of bright red blood was noted in the toilet. -12/29/18 at 8:32 a.m. RN entered bathroom and noted blood in the garbage and on the toilet. RN assisted R1 to clean up had blood on hands and in between legs. - at 9:00 a.m. NA reported blood was noted in toilet to RN. Vitals taken, R1 complaints of feeling short of breath after ambulating to breakfast. R1 complained of stomach pain that come and goes rating the pain 1 to 3 out of 10 on the pain scale and did not want to eat breakfast. - at 9:11 a.m. R1 became short of breath walking from the dining room and was pale in color and stated I just don't feel right R1 daughter coming to take R1 to seek medical treatment. - at 10:34 a.m. R1 had two large episodes of bleeding in the toilet with going to the bathroom after being assisted on the toilet by RN and family member (FM)-1. R1 became very pale, weak and FM-1 decided to take R1 to(NAME)emergency department without waiting for other FM. - at 2:53 p.m. R1 left facility with FM-1 around 10:30 or 11:00 a.m. And a later note at 7:53 p.m. indicated R1 had been admitted to the hospital. Review of R1's incident report lacked documentation that the facility had conducted a thorough investigation of R1 potential neglect of care related to having bloody stools and continued use of [MEDICATION NAME]. On 1/15/19 at 4:10 p.m. the DON confirmed a thorough investigation had not been completed. The DON indicated she had not been educated on the use of [MEDICATION NAME] and change of condition, although she had educated staff in the facility on reporting to the [MEDICATION NAME] clinic and the physican. She confirmed she had not conducted any monitoring or audits of residents on [MEDICATION NAME] since R1's incident. Review of the facility policy titled, Viking Manor Investigation and Reporting Procedure undated, indicated all alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. If the events that cause allegation involve abuse or result in serious bodily injury, the alleged violation well be reported immediately , but not later that 2 hours after the allegation is made. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the violations will be reported immediately , but not later than 24 hours. All alleged violations will be reported immediately to the administrator and to other officials including the SA and adult protective services where state law provides for jurisdiction in the long term care facility. Under initial reporting of allegations: indicated a follow up investigation will be submitted to the SA within 5 working days.

Based on observation,interview and document review the facility failed to post current contact information of all pertinent State agencies and advocacy groups for residents and/or resident representatives to view. This had the potential to affect all 38 residents currently residing in the facility. Findings include: On 4/12/18, at 12:20 p.m. the Bill of Rights (BOR) posting was observed in an approximate four by four foot, wooden display case just to the right of the main entrance door and was dated (MONTH) of 2009, which was not the most current version. Another BOR was noted to be posted across from the business office on the wall next to the social service designee's office. It was posted in an approximate two by three foot wooden frame and was dated (MONTH) (YEAR). On the bottom of this BOR was contact information for three State agencies, which was not the most current information. No other posting of current contact information for advocacy groups or the State agency were noted in the facility. On 4/12/18, at 12:42 p.m. the assistant administrator (AA) reviewed both facility BOR and confirmed that neither postings had current contact information for the State agencies or advocacy groups listed. AA confirmed the current contact information for the State agencies or advocacy groups was not posted in the building. AA stated she was aware the resident BOR were updated and included the updated contact information for the State agency, as the facility had sent out new BOR pamphlets to the families and residents.

Based on interview and document review, the facility failed to ensure laboratory monitoring was completed to ensure therapeutic dosing for 1 of 5 residents (R40) reviewed for unnecessary medication use. Findings include: R40's annual Minimum Data Set ((MDS) dated [DATE], identified R40 had severe cognitive impairment and required extensive assistance with personal hygiene. Further, the MDS identified R40 had anxiety and depression, however, did not have any [MEDICAL CONDITION] related disorders. R40's Physician's Telephone Orders sheet dated 4/29/16, identified an order for [REDACTED]. R40's care plan dated 3/14/17, identified R40 used [MEDICAL CONDITION] medications due to a, Potential for injury to self or others, and listed a goal for R40, Be/remain free of drug related complications . The care plan listed several interventions for staff to implement which included administer medications as ordered. Monitor/document for side effects and effectiveness. However, R40's care plan lacked any routine laboratory monitoring. R40's Medication Administration Record [REDACTED]., with administration twice a day. The MAR indicated [REDACTED]. R40's Consultant Pharmacist Progress Note dated 9/13/16, identified a pharmacy request to consider checking CBC (complete blood count), BMP (basic metabolic panel), and VPA (valporic acid ([MEDICATION NAME]) level) for routine medication monitoring. R40's medical record was reviewed and lacked any collected valporic laboratory value (a way to ensure [MEDICATION NAME] is at a therapeutic dose with normal value being 50-125 microgram per milliliter) to ensure R40's administered [MEDICATION NAME] was within therapeutic range. During interview on 3/22/17, at 11:11 a.m. registered nurse (RN)-A stated the facility had never drawn a valporic acid laboratory value on R40 as it, Kinda got missed. RN-A stated elevated valporic acid levels could cause someone to be drowsy and have, Serious side effects, and having no valporic acid level for reference on R40 was, A little concerning. During interview on 3/22/17, at 12:19 p.m. the director of nursing (DON) stated a valporic acid level had never been drawn on R40 as it, Wasn't noticed it was requested (by pharmacist). Further, DON stated staff would obtain a valporic acid level on R40 during the next laboratory visit. On 3/22/17, at 12:37 p.m. a call was placed to R40's primary physician with a request for call back; however, no return call was received.

Based on observation, interview and document review, the facility failed to ensure dental recommendations were acted upon timely for 1 of 1 residents (R40) reviewed for dental hygiene and who had missing teeth. Findings include: R40's annual Minimum Data Set ((MDS) dated [DATE], identified R40 had severe cognitive impairment, required extensive assistance with personal hygiene. Further, the MDS section labeled Oral / Dental Status section had not been completed and left blank. R40's Payer Setup Information sheet dated 3/22/17, identified R40 was private pay. During observation on 3/21/17, at 9:15 a.m. R40 was seated in her wheelchair in her room. R40 smiled and showed the surveyor she had a missing tooth on her upper palate along with visible brown colored staining on several other teeth. R40 denied having any oral pain; however, was unable to recall when she had last been to the dentist. When interviewed on 3/21/17, at 10:43 a.m. family member (FM)-A stated R40's teeth were getting worse and, Looking more and more decayed. FM-A stated R40 had not been seen by a dentist in the past several years to her knowledge, but added it, Probably wouldn't be a bad idea. FM-A stated she was unaware of the nursing home's process for having a resident seen by a dentist. R40's Apple Tree Dental, Oral/Dental Assessment Form dated 1/19/17, signed by a dental hygienist, identified R40 had obvious or likely cavity or broken natural teeth. The assessment note identified R40 had natural teeth, moderate amount of plaque and some caries and suggested (R40) be seen by a dentist for a dental cleaning (and) exam. R40's facility Oral Health Assessment Form completed 2/28/17, identified R40 did not wear any dentures, had no obviously broken teeth or cavities; however, identified R40 had inflamed or bleeding gums or loose natural teeth. R40's medical record lacked any evidence R40 had been referred to or seen by a dentist as requested in the 1/19/17, dental hygienist assessment, nor after her gums were identified to be bleeding in the subsequent 2/28/17, facility completed assessment. A facility provided Appletree Dentist Master Patient List dated 3/22/17, identified several residents on the dentist' list to be seen during the next visit. R40's name was not identified on the list. When interviewed on 3/22/17, at 10:20 a.m. nursing assistant (NA)-A stated R40 had her own teeth and did not wear dentures. NA-A stated R40 was, Somedays, able to complete her own oral care, however, staff would help her at other times. Further, NA-A stated R40's teeth were, Not the greatest, adding she was unaware if R40 had ever seen a dentist. On 3/22/17, at 10:34 a.m. registered nurse (RN)-A and RN-B were interviewed. RN-A stated R40's teeth, Are not the greatest, and, Look like they have some build up (plaque). RN-A stated the facility had a dentist coming on-site to see residents, however, it was dependent on if their was, Enough people to be seen, otherwise residents could be taken to off-site dentists for appointments. RN-A stated R40 had never been referred to the dentist, and stated I didn't see that note. RN-A stated R40 should have been referred to the dentist as worsening teeth, Can cause a lot of issues (trouble eating, pain). An undated Facility Visits & Dental Patient Schedule policy identified the on-site dentist services varied from three or four times a year or four times a month depending on the size of the facility and the rate at which dental services were utilized and directed the list of residents to be seen at facility be updated on a monthly basis.

Based on observation, interview and document review, the facility failed to comprehensively assess residents at risk for falls and failed to ensure appropriate interventions were implemented to minimize risk for falls for 1 of 3 (R16) residents reviewed for falls. This deficient practice resulted in an immediate jeopardy situation for R16. Findings include: The immediate jeopardy began on 7/22/14 when findings revealed R16 had not been comprehensively assessed for root cause of self-transfers leading to falls. The facility administrator and the director of nursing (DON) were notified of the immediate jeopardy on 8/13/14, at 3:39 p.m. The immediate jeopardy was removed at 12:20 p.m. on 8/15/14, after the facility submitted an acceptable removal plan, but noncompliance remained at the lower scope and severity level of D which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. R16's 5-day Medicare Minimum Data Set ((MDS) dated [DATE], identified [DIAGNOSES REDACTED]. The MDS identified R16 had severe cognitive impairment, required extensive assistance with bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, dressing, toilet use and personal hygiene. R16 was not steady during transitions (moving from seated to standing position, turning around and facing opposite direction, moving on and off toilet, transfer between bed and chair) or walking. R16 used walker and wheelchair as mobility devices. Further, the MDS identified R16 had fallen and sustained a fracture prior to admission, and had fallen since admission with no injury. R16's Care Area Assessment (CAA) dated 4/3/14, indicated R16 was forgetful, had memory loss and confusion at times, mood decline, communication problems, and received psychoactive medications. The CAA identified R16 had risk factors for falls that included osteoporosis, arthritis, cognitive impairment, depression, and hearing impairments. The Fall CAA identified R16 was at high risk for falls related to use of psychotropic medications and required use of assistive device and indicated interventions would be implemented in an attempt to prevent or minimize further falls. R16's Fall Assessment form dated 7/30/14, identified R16 was at moderate risk for falls due to history of falls. The assessment identified R16 had a recent hip fracture, occasional incontinence of bladder and bowel, some agitated behaviors, was not able to stand independently, required assist of one with gait belt for transfers, and used walker for mobility. R16's current care plan, last revised on 7/29/14, identified R16 had dementia, and was at "low risk" for falls. The care plan indicated R16 required assistance with transfers with a gait belt and walker, repositioning every 2 hours, and offer toileting every 2 to 3 hours and as needed. Further, the care plan directed staff to place call light within reach, encourage to use call light for assistance as needed and to be prompt in responding to all requests for assistance. Review of R16's incident reports from 7/16/14 to 8/12/14 revealed the following: -On 7/16/14, at 4:45 a.m. R16 was found on floor in the hallway, lying on right side. The report indicated R16 stated she had a "hip broken." The report indicated R16's left shoe lace had been untied and R16 was not using her walker at the time of fall. R16 had been sent to the hospital and had required surgical repair of the left hip fracture on 7/17/14. -On 7/22/14, at 7:15 p.m. R16 was found on the bathroom floor, yelling "Help!" R16 had just been readmitted to the facility after the hip fracture at 12:15 p.m. on 7/22/14, (7 hours prior to this fall). A Root Cause Analysis Tool dated 7/22/14, indicated R16 had been alone in the room, there was no documentation regarding the last time she'd been to the bathroom, staff should have kept close to nursing station, and also identified the resident did not use call light. There was no evidence of actions taken to reduce the risk of additional falls such as keeping R16 close to the nurses' station or ensuring scheduled toileting. The care plan was not revised. Nursing notes on 7/24/14, at 8:30 a.m. and 9:40 a.m. described ongoing self transfers. At 7/24/14, the nursing note indicated a TABS alarm (electronic alarm) on the wheelchair was sounding because R16 had self transferred. The care plan did not address the use of a TABS alarm. Staff reminded R16 to use the call light. Nursing notes on 7/26/14 and 7/27/14 described additional self transfers with no interventions other than reminders to use the call light. Nursing notes on 7/27/14, at 10:30 p.m. indicated R16 was setting off the laser alarm but didn't want anything. There was no mention of a laser alarm on the care plan. On 7/28/14, at 3:10 p.m. the nurse's note indicated R16 was upset by the TABS alarm and wheelchair, having forgotten about her hip fracture. On 7/29/14, at 1:10 p.m., the note indicated R16 had broken both the laser alarm and TABS alarm. Nursing notes on 8/1/14, at 10:15 a.m. indicated R16 had been found on her knees on the floor in her room while holding onto her walker. Interventions and recommendations included removal of glider chair in room, continue to encourage resident to use call light when needing help, currently working with PT/OT (physical therapy and occupational therapy), and to keep call light within reach. Nursing notes on 8/3/14, at 1:45 p.m. indicated R16 was transferring self "multiple times today." R16 was educated about call light use. On 8/6/14, at 7:20 p.m. R16 was transferring self without asking for assistance and was reminded to wait for staff for help. Nursing notes on 8/9/14, at 1:15 p.m. indicated R16 was noted to have "walked per self" to bathroom from w/c (wheelchair). R16 used wheeled walker. Staff assisted R16 for toilet use and walked R16 back to bed with gait belt and walker. R16 was noted to be unsteady and was instructed to use the call light. On Nursing notes on 8/10/14, at 7:40 a.m. indicated R16 transferred herself to the bathroom without shoes on. Staff reminded R16 that it was unsafe to wear stocking feet and showed R16 how to use call light to get staff assistance. R16 was quoted to have said, "I know but I just forget." Nursing notes from 8/11/14, at 10:10 a.m. indicated R16 was found in room, flat on back next to window. The incident report indicated R16 stated she was trying to get back into recliner. Staff found a recliner arm cover on floor next to R16 and the recliner was "pushed up against wall next to bed." The report indicated the occupational therapist had assisted R16 into the recliner with the call light within reach at 9:00 a.m., one hour prior to the falls. The report indicated the therapist had observed R16 seated in the wheelchair at some point between 9:00 a.m., and the fall. The report indicated nursing assistant assigned to care for R16 at that time admitted not having re-positioned R16 between a.m. and the fall so R16 was transferring independently. The intervention implemented was removal of arm protectors from the recliner. On 8/12/14, at 1:20 p.m. R16 was observed seated in a wheelchair in her room. R16 propelled the wheelchair using her legs from the middle of the room to the window briefly then back to the middle of the room. A blue cloth covered recliner was observed near the window in the room. Nursing notes on 8/12/14, at 3:00 p.m. indicated R16 was found in room, sitting on buttocks with her back up against the bed. The report indicated R16 was, "Trying to get something out of her drawer." The recommendations/interventions section of the report indicated R16 had dementia and did not realize the need for, "More assistance with cares, transfers, & ambulation." The report did not indicate interventions aside from, "Continue to monitor," and no changes to be implemented at that time. On 8/13/14, at 7:24 a.m. R16 was observed seated in a wheelchair in her room. R16 propelled her wheelchair with her legs toward the bathroom, reached out and opened up the door and wheeled herself up to the toilet stool. R16 stood up and slowly walked a step forward, pulled her slacks and underwear down, turned around and sat on the toilet seat. R16 did not lock the wheelchair brakes or use the call light to summon assistance for staff prior to self-transferring. At 7:27 a.m. R16 grabbed the bars on toilet seat and slowly stood up, pulled up her underwear and pants, walked a step forward, turned and sat in the wheelchair. Staff were unaware of R16's activities. On 8/15/14 at 9:42 a.m. R16 was seated in the wheelchair in her room and there were antilock brakes observed on wheelchair. There were signs on wall next to bed, on edge of dresser and at the foot of bed that warned R16 to remember to call for help. When R16 was asked about the sign, R16 smiled and said, "Oh here and there." Nursing assistant (NA)-B was interviewed on 8/12/14, at 3:00 p.m. and described caring for R16 during night shifts. NA-B stated R16 had fewer episodes of self-transfers and falling because her needs were anticipated and met. On 8/12/14, at 3:03 p.m. NA-A was interviewed and stated R16 would forget that she needed help with transfers and also forgot to use call button for help. NA-A stated she tried to follow R16 when she was observed on her way to her bedroom so she could check on what R16 was doing. On 8/12/14, at 3:15 p.m. the director of nursing (DON) stated the assessment of causal factors of R16's fall on 7/22/14, may have been the addition of PRN (as needed) oxycodone (narcotic pain medication). The DON also stated R16 had dementia but was used to being independent and that R16 thought she still was. The DON stated that attempted interventions included the use of a TABS alarm and laser alarm. She verified the alarms were not added to the care plan and were discontinued when R16 had broken them. The DON further stated R16 was being followed by PT/OT, staff were frequently monitoring R16's whereabouts, and the furniture was changed. The DON verified the lack of documented assessment related to potential causative factors related to falls or attempted interventions to reduce the risk of injury from falls. On 8/13/14, at 9:02 a.m. registered nurse (RN)-A stated that attempted interventions after the first fall included the call light within reach, reminders to use the call light, a laser alarm to the bed and a TABS alarm to the wheelchair. R16 was upset by the alarms and destroyed them both. RN-A verified R16 was not independent and required assistance per PT/OT evaluation. RN-A stated R16 had dementia and was forgetful, but interventions included to "educate" R16 to use call light. RN-A further verified there was no assessment to determine potential interventions to reduce the risk of falls and there were no new interventions. On 8/13/14, at 12:30 p.m. physical therapist (PT)-A stated R16 was working on endurance, balance and safety issues. PT-A verified R16 attempts self-transfers despite having been "spoken to daily." PT-A stated R16 had difficulty standing and did not use wheelchair brakes. PT-A added R16 did not understand instructions and was not safe to self-transfer. On 8/13/14, at 12:57 p.m. NA-C stated R16 self-transfers "every time you turn around." According to NA-C, a laser alarm was attempted but did not work. NA-C stated R16 was reminded to use the call light but would forget. When interviewed on 8/13/14, at 2:00 p.m. the DON stated suggested interventions included hourly rounds, however, rounds were not initiated because R16 was getting physical therapy. On 8/14/14, at 9:00 a.m. RN-A verified and affixed her initials to signify she just updated R16's care plan on 8/13/14, to include hourly safety checks. On 8/14/14, at 9:19 a.m. a telephone interview was conducted with R16's family member (FM)-A, who stated R16 had attempted to self-transfer four times during FM-A's visit on 8/13/14. FM-A stated R16 was resistant to using a nurse call light. On 8/14/14, at 1:20 p.m. the DON reviewed the incident reports regarding R16's falls on 7/16/14, 7/22/14, 8/1/14, 8/11/14 and 8/12/14. The DON verified the documentation on the incident reports was accurate and lacked evidence of assessment or interventions. The Treatment/Management section of facility's undated Falls - Clinical protocol, directed staff to "identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling" following the assessment of a previous fall. In addition, the Monitoring and Follow-Up section indicated that if fall continues, staff would re-evaluate the situation and the "continued relevance of current interventions." The facility's Managing Falls and Fall Risk policy revised on 12/2007, directed staff to implement additional or different interventions if falling recurs despite initial interventions. The facility's Fall Prevention Policy (undated), directed "primary RN will re-evaluate and revise resident's care plan and/or facility practice to prevent the likely hood (sic) of another fall." The immediate jeopardy was removed on 8/15/14, at 12:20 p.m. when the facility had reviewed and assessed R16's falls and had identified interventions to reduce the risk of injury from falls. The care plan was updated to reflect the interventions. Immediate interventions included hourly safety checks, scheduled ambulation and activities. Physical Therapy and pharmacy reviews were completed. The physician was updated and medication changes were initiated. Staff were provided education related to the updated care plan. Staff interviews and observations were completed to verify staff understanding of the plan for R16. The removal plan included changes in the way resident falls were documented, assessed, and outcomes monitored. Comprehensive falls assessments were completed for all residents identified at risk of falls.

Based on observation, interview and document review, the facility failed to timely identify, comprehensively assess, and implement appropriate interventions for 1 of 1 resident (R46) reviewed for unstagable pressure ulcers. This deficient practice resulted in actual harm for R46. Findings include: R46's admission Minimum Data Set ((MDS) dated [DATE], identified R46 had [DIAGNOSES REDACTED]. Their was no assessment of R46's cognitive status or presence of [MEDICAL CONDITION]. The MDS identified R46 was at risk for development of pressure ulcers, required extensive assist with all activities of daily living (ADL's) and had no current pressure ulcers. R46's Pressure Ulcer Care Area Assessment (CAA) dated 2/27/2014, listed R46 had risk factors for development of pressure ulcers which included requiring extensive assist in bed mobility and urinary incontinence, antipsychotic and antianxiety medication use, and newly admitted . The CAA identified R46's care plan would address R46's needs. A quarterly MDS dated [DATE], identified R26 had severe cognitive impairment, needed extensive assist with all ADL's and had two unstagable (known pressure ulcer but not stagable due to coverage of wound bed in slough or eschar tissue) pressure ulcers with most severe tissue type of eschar (black, yellow brown tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin and is not evidence of healing). The MDS also indicated skin and ulcer treatments, including a turning and repositioning program, nutritional intervention, pressure ulcer care and dressings to feet were provided for R46. R46's care plan revised 8/4/14, identified R46 was at risk for pressure ulcer development related to decreased mobility. However, the care plan did not identify R46 had current pressure ulcers. The care plan listed various interventions which included: to reposition R46 every 2-3 hours, notify nurse of any concerns, document and report any new pressure areas. Further the care plan directed staff to utilize foot rests and keep both pedals up to help with pain when R46 utilized a wheelchair. The care plan lacked interventions to promote healing of unstagable ulcers to both heels. On 8/12/14, at 3:00 p.m. registered nurse (RN)-B and licensed practical nurse (LPN)-A were observed to provide wound care for R46 to a left lower leg wound, and to both unstageable pressure ulcers to the heels. After wound care was completed for the left leg wound, wound care was provided for bilateral unstagable pressure ulcers to both heels. RN-B removed the dirty dressing from the resident's right heel. The entire pressure ulcer to the right heel measured 2.0 centimeters (cm) by 2.0 cm with an open area in the middle of the ulcer measuring 2 cm by 0.8 cm. The pressure ulcer was black in color and hard to the touch indicating eschar tissue. Then the dirty foam dressing was removed from the left heel. The unstagable pressure ulcer measured 7.1 cm by 3.0 cm, was black in color and hard to the touch indicating eschar tissue was present in wound. Both pressure ulcers were cleansed with normal saline and fresh foam dressings were applied and wrapped with gauze. RN-B then applied [MEDICATION NAME] (elastic stretch band stocking type devices) to both feet covering the heels. RN-B placed a pillow under each calf and elevated R46's heels off the bed. On 8/13/14, 6:56 a.m. R46 was observed in bed lying on her back. One pillow had been placed under both knees, keeping the resident's knees at a 45 degree angle. Beige [MEDICATION NAME] stockings were observed on both heels with both heels resting directly on the surface of the mattress. During continuous observation from 6:56 a.m. to 8:30 a.m. R46 remained lying in bed with both heels directly on the mattress. At 8:30 a.m. at surveyors request, nursing assistant (NA)-I entered R46's room and confirmed R46's heels were resting on the mattress with the pillow under R46's knees. NA-I verified R46 had not been repositioned from 6:56 a.m. to 8:30 a.m. (a total of 1 hour and 36 minutes in which R46's heels were resting on the mattress.) NA-I revealed R46's heels should not have been resting on the mattress as R46 had pressure ulcers to both heels. NA-I exited the room at 8:35 a.m., without having offered, or attempted, to reposition R46's heels off of the mattress. On 8/13/14, at 8:43 a.m. R46 remained lying in bed with both heels resting directly on the surface of the mattress. RN-A entered the room at the surveyor's request and confirmed R46's heels rested on the mattress. RN-A stated she would expect R46's heels would have been "floated" over the mattress using a pillow under both calves to prevent further pressure on both heels. RN-A verified R46 was never to have pressure on her heels at any time due to presence of the pressure ulcers. She confirmed R46's current care plan and confirmed the care plan lacked interventions to float heels at all times. Review of the Nursing Quarterly Note dated 5/28/14, identified R46 was occasionally incontinent of bowel and bladder, required the use of a mechanical lift to utilize the toilet, and required assistance with mobility. The note indicated skin inspections were completed PRN (as needed) and R46 had a current infected skin tear on the left lower leg. No other skin issues were identified on the quarterly nursing note. Review of the facility's form titled, Braden Scale for Predicting Pressure Sore Risk (a tool to identify risk for developing pressure ulcers) dated 8/4/14, identified R46 was at moderate risk for pressure ulcer development. No further assessments were documented for R46. Review of R46's nurses progress notes from 3/18/14 to 6/4/14, revealed the following: various documentation regarding the resident's left leg wound, however, the record lacked documentation of skin checks for R46, and lacked documentation of identification of pressure ulcer development. Continued review of progress notes from 6/5/14 to 8/14/14, revealed the following: -6/5/14, the note indicated a bath aid had reported R46 had pressure areas to both heels. The note indicated the back of the left heel had an unstagable dark purple ulcer which measured 10 cm by 10 cm. The note further identified there was another pressure ulcer to R46's right heel which presented as dark purple, was unstagable, and measured 6 cm by 5 cm. In addition, the note identified R46 had a stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough, may also present as an intact or open blister) pressure ulcer to the left ankle measuring 3 cm by 3 cm. The progress note directed to refer to the care plan for plan of care. The note further indicated a referral had been made to the wound care clinic at that time. - 6/6/14, revealed education to resident regarding use of pressure relieving boots due to pressure ulcers on both heels, but that R46 had declined use of pressure relieving boots. However, the note indicated R46 had agreed to have her heels off of the mattress with a pillow under her lower legs. - 6/8/14, R46 had gone on an outing with her daughter who had called the facility to inform the staff that R46 was being taken to the emergency room due to wound on left lower leg and blister to the right heel. R46 returned to the facility after evaluation from the emergency room with orders including: "no pressure on heels, set up wound nurse clinic". - 6/20/14, R46's right heel had been weeping, area was covered with gauze and wraps, message left for RN. - 6/21/14, R46's right heel blister was open, area measured 6 cm long, no width or depth measurements. - 6/22/14, R46's right heel was bleeding, area cleansed and redressed. - 6/23/14, notification to physician regarding right heel condition, dressing change to right heel with bloody drainage. - 6/26/14, daughter was using two plastic grocery bags filled with rolled up plastic bags one under each of R46's feet. The note indicated staff provided R46 with elevated foot rests to keep pressure off of R46's feet. -6/29/14, dressing change to right heel and also revealed that R46 had a reddened area to coccyx 3 cm x 2 cm red/pink area which was not open. - 7/1/14, stage one pressure ulcer noted to coccyx, measured 2 cm by 1.5 cm red area, non blanchable. - 7/3/14, small bloody drainage form right heel, dressing changed. -7/6/14, dressing change to right heel, drainage was noted on dirty dressing consisting of blood and purulent (greenish/yellowish indicative of infection). The pressure ulcer measured 6 cm by 5.3 cm, purple area above right heel. - 7/10/14, dressing change completed to right heel which measured 5.2 cm by 6.5 cm, peeling skin, dark purple in color. However, at the wound base there was an opening in the pressure ulcer wound bed which measured 3 cm by 2 cm . Black necrotic (dead tissue) was noted at the wound bed. A further note revealed daughter requested to have staff educated to keep R46's heels off of the foot pedals. - 7/14/14, dressing change to left heel, ulcer area was soft and "mushy" with "bruised" center. The ulcer measured 4 cm by 2 cm. The right heel was noted to be scaly in appearance and measured 7 cm by 4.5 cm with 2.1 cm by 1 cm of necrotic tissue noted. - 7/16/14, order to discontinue foam dressing to right heel per daughters request, ordered Vitamin E to right heel daily and to leave area open to air. - 7/17/14, vitamin E discontinued and dressing change with foam was re-ordered. -7/21/14, left heel measured 8 cm by 4 cm with a 4 cm by 1.2 cm dark purple area in the middle of the ulcer. The right heel measured 8 cm by 4 cm with a 2 cm by 2 cm necrotic area in the center of the ulcer bed. -7/25/14, left heel measured 8 cm by 4 cm with a 3.5 cm by 1.0 cm dark purple area in the middle of the ulcer. The right heel measured 8 cm by 4 cm with a 2 cm by 2 cm necrotic area in the center. - 7/29/14, left heel measured 5.5 cm by 4 cm and right heel measured 8 cm by 4 cm with a 2.2 cm by 2.5 cm opening in the middle. Both pressure ulcers had necrotic tissue present on wound bed. - 8/2/14, left heel measured 7 cm by 3 cm, dark purple in color and hard to the touch. The right heel measured 2.1 cm by 2 cm and was black in color. Review of weekly pressure ulcer progress notes from 6/5/14 to 8/12/14, reveled the measurements of the wounds as noted in the progress notes. The weekly pressure ulcer progress notes did not include comprehensive assessment of R46's skin condition. Review of physician order's from 6/10/14 to 7/22/14 revealed the following: -6/10/14, ensure no pressure on heels, keep heels floated at all times with boots or pillows under calves. -6/18/14, keep heels floated at all times, use pillows under calves to float heels, do not need boots if using pillow. - 6/25/14, discontinue heel boots, okay to elevate legs with pillows. -7/2/14, continue with preventative management - 8/5/14, continue with preventative management, please avoid putting pressure on the heels. During interview on 8/12/14, 1:30 p.m. director of nursing (DON) verified R46 had been considered at risk for development of pressure ulcers and that she expected R46's skin would have been checked weekly on bath day, with documentation of such in the resident's chart. The DON also stated she expected R46's skin to be observed daily with cares and any concerns reported to the nurse. The DON stated she would have expected the inspections to be completed daily since R46's admission. The DON verified this had not been completed for R46, and also acknowledged that neither pressure ulcer had been found in a timely manner. The DON stated she would have expected the pressure ulcers "to be found long before they were, because of the size they were." The DON indicated staff had not observed R46's skin as she would have expected, and verified R46 should not have any pressure to her heels at any time. During a second interview on 8/13/14, 10:10 a.m. the DON verified a comprehensive skin assessment had not been completed after R46 had developed the pressure ulcers, and verified R46's care plan had not been updated to reflect interventions for the bilateral unstagable pressure ulcers. The DON confirmed the facility policies and confirmed R46 should always have both heels "floated" to aid in healing and prevent further breakdown. Review of the facility's policy titled Pressure Ulcer Risk Assessment revised 12/28/09, revealed staff were supposed to complete skin assessments weekly and more often as needed, and directed staff to monitor skin daily. Review of the facility's policy titled Prevention of Pressure Ulcers revised 12/28/09 revealed the staff were to provide preventative measures and interventions for those identified at risk for pressure ulcer development. Review of the facility's policy titled Pressure Ulcer Treatment revised 12/28/09, revealed the staff were to assess the resident's pressure ulcer, manage tissue loads, provide pressure ulcer care and provide education and quality improvement. Review of the facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol revised 12/28/09, revealed staff were supposed to assess and recognize those at risk for pressure ulcers, determine cause, provide treatment, and provide management and monitoring of pressure ulcers.

Based on observation, interview and document review, the facility failed to provide ambulation services to prevent loss of function for 1 of 6 residents (R25) who required physical assistance with ambulation. R25 was not provided assistance with ambulation, and was not reassessed upon a decline in ambulation. The resident's decline in ability to ambulate resulted in actual harm. Findings include: R25's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], identified R25 with moderate cognitive impairment and as requiring extensive assistance of one staff to ambulate. The annual MDS dated [DATE], identified R25 with severe cognitive impairment and as requiring extensive assistance of two staff to ambulate. The activities of daily living Care Area Assessment (CAA) dated 8/18/13, identified R25 as having the ability to ambulate in her room and indicated she used a wheelchair. The assessment did not clearly identify how often or how far R25 was able to ambulate, nor did it address R25's inconsistent implementation of the plan of care for ambulation. The plan of care dated 7/6/12, identified R25 as being able to ambulate with a front wheeled walker in room and for short distance in the hallway. It indicated R25 had a history of [REDACTED]. The plan of care did not direct the staff as to how far R25 was to ambulate. The plan of care was revised on 8/29/13, and directed the staff to transfer R25 with a standing lift when R25 expressed increased weakness. However, there was no assessment of R25's condition indicating the need for a mechanical lift. On 9/10/13, at 2:40 p.m. nursing assistant (NA)-B stated R25 was no longer able to ambulate and the staff had been instructed to use the standing lift for transfer. NA-A stated R25 became very anxious when ambulating and was no longer participating. NA-A stated if a resident was unable to participate in the restorative program as directed, they would report the concern to the registered nurse (RN). NA-B explained several times a month, residents were not able to receive their restorative programs because the NA assigned to complete the restorative program would be reassigned to assist with general nursing assistant duties (direct resident care). NA-B stated if the resident did not receive rehabilitation services, the documentation sheets would be blank. The most current Occupational Therapy (OT) Discharge Summary dated 4/16/13, indicated the resident had refused therapy services for transfer ability and OT was discontinued. At that time, R25 was being transferred with minimal assistance of one staff and she was able to ambulate to in her room. On 9/11/13, at 6:55 a.m. R25 was observed sitting on the toilet receiving assistance with cares from NA-A. R25 was connected to a standing mechanical lift when the cares were completed. R25 was transferred out of the bathroom and positioned in a wheelchair via the standing lift. R25's legs were fully extended during the transfer. On 9/11/13, at 11:18 a.m. family member (FM)-A stated R25 had not been able to walk in a while. FM-A was unable to recall the last time R25 was able to ambulate. On 9/11/13, at 11:25 a.m. NA-A stated R25 walked half the length of the hallway (greater than 75 feet) in the past, but due to the increased pain, staff were unable to walk R25 and used the standing lift. NA-A stated R25 did not consistently participate in the restorative program because she may refuse or the facility may not have a nursing assistant designated to restorative therapy. On 9/11/13, at 12:20 p.m. NA-D and registered nurse (RN)-C assisted R25 into a standing positioning. R25 used a four wheeled walker and was able to ambulate six feet with extensive assistance of both staff. R25 stated had pain in the right hip and the left knee when ambulating. The resident stated, "I just can not walk like I used to." The Rehab Flow Sheet directed the staff to ambulate R25 with a four wheeled walker 100-150 feet as tolerated. The rehab sheet did not direct staff how frequently R25 received assistance nor did the sheet indicate how far R25 ambulated. Review of the Rehab Flow Sheets identified the following information related to R25's ambulation. -9/1/13 through 9/11/13, R25 was offered and refused to ambulate one time. -August 2013, R25 ambulated seven times, but the documentation did not indicate how far. -July 2013, R25 ambulated 14 times, but the documentation did not indicate how far. On 9/11/13, at 11:30 a.m. RN-C stated staff were to attempt to transfer R25 with a walker and were only to use the standing lift if the resident was weak. RN-C stated had reviewed R25 during the MDS assessment period in August 2013, and R25 was able to transfer with the walker at the time. RN-C stated received oral reports from the nursing assistants when a resident did not ambulate. When asked what was done with those reports, RN-C stated, "I have not been trained." RN-C stated was not aware of any new concerns related to R25, and the physician was not contacted nor had R25 been re-evaluated by physical therapy. RN-C confirmed the plan of care did not clearly direct staff how far to ambulate R25. On 9/11/13, at 12:05 p.m. the director of nursing (DON) stated the nursing assistants who worked with restorative were to report any changes to RN-C or RN-A depending on which part of the building the residents resided. The DON stated the restorative nursing documentation was not currently being monitored by any of the nursing staff. The DON explained she was new in the position and it had been missed. The DON started working at the facility in March of 2013, and at that time R25 had the ability to ambulate half the length of the hallway (approximately 75 feet). The DON confirmed since then, R25 had not been evaluated by physical therapy. The implementation of the standing lift had occurred in July of 2013, but it was to be used only when R25 was weak. The DON was unaware staff were routinely utilizing the standing lift. On 9/11/13, at 12:10 p.m. the DON confirmed the facility was experiencing nursing staff shortages and when this occurred the aide assigned to perform restorative nursing was reassigned to complete personal cares. The DON stated it occurred one to two times a week. The Rehabilitative Nursing Care policy dated 8/7/13, directed staff to perform rehabilitative services three to five times a week for those residents who required such services. The policy also explained the physical therapist was to develop the goals for rehabilitative nursing cares and the goals were to be reinforced by the therapy services (restorative nursing assistants). On 9/12/13, at 1:51 p.m. RN-A confirmed was aware of the lack of implementation of rehab services and stated did not have an answer as to why the concern was not brought forth to the QA committee. In addition, RN-A stated all staff were aware of the inconsistent implementation of the rehab services. On 9/12/13, at 1:55 p.m. the administrator stated was aware of the lack of implementation of the rehab services and verified it was due to insufficient staffing.