Every finding on record at Whispering Creek

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 1, 2026), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.Findings include:CMS PBJ (payroll-based journal) Staffing Data Report dated Quarter 1, 2026 (October 1 - December 31) triggered for failure to have licensed nursing coverage 24 hours/day. The four infraction dates included: 10/4/25, 10/5/25, 11/15/25, and 11/16/25.During record review, reviewed nursing staff schedules and daily staffing postings for the infraction dates. On each of the four dates, licensed nurses had been scheduled 24 hours/day. During record review, timecard sheets and/or agency invoices for each of the five employed and one agency nurse covering the 12 shifts were reviewed and indicated the nurses who had been scheduled had been paid for working the shifts. During an interview on 5/27/26 at 9:03 a.m., licensed practical nurse (LPN)-A stated a nurse worked in the charge nurse capacity every shift - either an LPN or a registered nurse. During an interview on 5/27/26, at 9:57 a.m., the administrator was informed the facility PBJ report had triggered for failure to have licensed nursing coverage 24 hours/day on 10/5/25, 10/5/25, 11/15/25, and 11/16/25. The administrator was informed schedules, time sheets and agency invoices verified licensed nursing staff had worked the infraction dates. The administrator stated the facility scheduled one licensed nurse each shift; they checked and verified all shifts were covered. Data for employed nurses and data from staffing agencies were uploaded to the CMS database. The administrator couldn't explain the discrepancy.During an interview on 5/27/26 at 10:07 a.m., the administrator stated he realized the problem. The individual who uploaded the data had not been informed the facility had started utilizing a particular agency in 2025, and had not added those agency nurses to the database.During an interview on 5/27/26 at 2:26 p.m., the director of nursing (DON) stated she did scheduling for the nursing staff, and verified a licensed nurse was scheduled as the charge nurse for each shift. The facility Reporting Direct Care Staffing Information (Payroll-Based Journal) policy with revised date of August 2022, indicated direct care staffing information was reported electronically to CMS through the Payroll-Based Journal system. Complete and accurate direct care staffing information was reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. For auditing purposes, reported staffing information was based on payroll records, invoices, tied back to a contract, or other verifiable information.

Based on interview and document review, the facility failed to submit accurate data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed- Quarter 2, 2025, (January to March), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: The CMS payroll-based journal (PBJ) staffing data report indicated the following infraction: Excessively Low Weekend Staffing- Submitted Weekend Staffing data is excessively low.During interview on 8/4/25 at 12:45 p.m., director of nursing (DON) stated she was unsure why they would have triggered for low staffing and that they always had staff on the weekends. DON further stated they used agency staff on weekends to fill shifts their staff could not cover.During interview on 8/4/25 at 1:10 p.m., administrator, who oversees submission of the PBJ data, stated he recalled there may have been a delay in getting staffing hours from the agencies they work with to fill shifts, and that may be why it appeared they had low weekend staffing. Administrator further stated he was not aware of actual low weekend staffing and that weekends were always staffed by hired staff or agency staff. Administrator stated he would work with agencies to get accurate staffing hours submitted.Review of facility provided documents titled 2025 Master Nursing Staff Schedule and Time Card Report dated 1/1/25 -3/31/25, indicated the facility did not have low weekend staffing on any weekend during that time period.A facility policy on Payroll Based Journal Submission was not received.

Based on interview and document review, the facility failed to ensure resident status was accurately identified on the Minimum Data Set (MDS) assessment for 1 of 2 resident (R25) reviewed for anticoagulant use. Findings include: R25's Face Sheet printed 8/6/25, included diagnoses of peripheral vascular disease (narrowing or blockage of blood vessels) , chronic atrial fibrillation (irregular heart rhythm), edema and chronic venous hypertension (high blood pressure in veins leading to insufficiency causing swelling) with ulcer and inflammation of bilateral lower extremities. R25's quarterly Minimum Data Set (MDS) dated [DATE], section N, included R25 was receiving a diuretic, antiplatelet, hypoglycemic and antidepressant medication. Anticoagulant medication was not checked as receiving. R25's physician orders dated 7/20/25, included warfarin sodium (anticoagulant/blood thinner) 1 mg tablet by mouth six times per week on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday and 1.5 mg tablet of warfarin sodium one time a week on Sunday. During interview on 8/6/25 at 3:35 a.m., the director of nursing confirmed the MDS was coded incorrectly and confirmed R25 had received warfarin when the MDS was completed in June 2025. During interview 8/6/25 at 3:05 p.m., registered nurse (RN)-C, also identified as MDS coordinator, stated R25 has always been on warfarin so she must have just forgotten to check the anticoagulant box when she completed R25's MDS in June 2025. A policy on MDS coding was requested and not received.

Based on observation, interview and document review, the facility failed to ensure fall risk interventions were completed after a fall for 1 of 2 residents (R6) identified at risk for falls to prevent further falls.Findings include: R6's Face Sheet printed 8/6/25, indicated R6 had diagnoses including heart failure, dementia, chronic kidney disease stage IV (severe irreversible damage to the kidneys) and chronic respiratory failure. R6's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R6 had a severe cognitive impairment with no delirium or behaviors. Activities of daily living (ADL's) included R6 uses a wheelchair and requires partial/moderate assistance for oral care and eating, and substantial to maximal assistance for toileting, showering, personal hygiene, bed mobility and transfers. Walking was not attempted. R6 has had one fall without injury since prior assessment. R6's Care Area assessment dated [DATE], indicated R6 was at risk for falls. See plan of care for fall interventions. Fall assessment last completed 8/4/25, identified R6 was at risk for falls and has had 1-2 falls in the past 3 months, has decreased safety awareness with impaired mobility. R6's plan of care last updated 5/27/25, indicated R6 was at risk for falls related to heart problems, terminal diagnosis of heart failure, takes medications that cause resident to be dizzy, tired, confused or weak and have trouble sleeping. Interventions included: bed low to the ground with wheels locked, remind to ask for help, therapy department performed Lift Chair Safety Assessment and is safe to use recliner chair in her room, keep important items within reach, frequent checks and night light on at night. Facility Incident Report dated 4/19/25 at 3:48 a.m., by licensed practical nurse (LPN)-A indicated R6 was trying to get up and go the bathroom and was found on the floor. Was observed in bed at 1:30 a.m. Current interventions and other factors included reclining chair, tray table, room close to nurses station, call light was in reach, but call light was not on. New intervention included floor alarm and teaching use of call light. No injuries noted. Interdisciplinary team review (IDT) completed 4/21/25, included R6 has had 1 fall within the last year. Intervention included floor alarm placed on floor while in bed and teaching of use of call light. Facility Incident Report dated 6/3/25 at 7:30 p.m., by LPN-B indicated resident was observed on floor and stated I thought I could get into my bed myself so I tried. R6 stated she landed on buttocks then onto her back and hit her head on the floor. Current interventions and factors included low bed, attempting to transfer without staff assist, call light in reach but was not on. No injuries. New interventions included a personal alarm and teaching on safe transfer techniques, and use of call light for assistance. IDT review, undated, included personal alarm was placed on person. 2 falls within the last 2 months. Facility Incident Report 7/30/25 at 4:00 p.m., by registered nurse (RN)-A included resident was observed on floor in front of her recliner. Recliner was elevated for her legs to be up. Call light was in reach but call light was not on. No injuries noted. IDT team review, undated, included 3 falls with the past 3 months. New intervention included recliner was unplugged and foot elevation pedal will not be used. On observation and interview 8/4/25 at 3:34 p.m., R6 was sitting in her wheelchair with a personal alarm on her chair and clipped to resident. Family member (FM)-A was sitting in R6's recliner in her room and stated R6 used her lift chair and fell out last week. FM-A stated they notified her of the fall and said they were going to unplug the recliner. FM-A used buttons on side of recliner and recliner began to put feet up and stated I guess they didn't unplug it as it still works. On observation and interview 8/5/25 at 9:23 a.m., R6 was sitting in her wheelchair with personal alarm on. R6 stated she does sit in her recliner sometimes but doesn't want to right now. R6 sorting through her drawers. Power recliner remains plugged in and working. On observation and interview 8/6/25 at 7:54 a.m., R8 was assisted to tub room by nursing assistant for hospice (NA)-A. Electric recliner continues to be plugged in and functioning. NA-A stated she has seen R6 in her recliner periodically when she comes. NA-A was unaware of any recent falls and is unsure if it should be plugged in or not. On interview 8/6/25 at 9:04 a.m., NA-B stated R6 has been evaluated for use of her electric chair and has been okayed to use it. NA-B stated she hasn't been told anything different and wasn't aware it needed to be unplugged. On interview 8/6/25 at 9:19 a.m., NA-C stated R6 does use her recliner and after lunch staff will generally put her in the recliner for awhile. NA-C stated we do have to watch her close or she will try to climb out of it when she gets tired of sitting there. NA-C stated he didn't believe R6 could use the electric chair control buttons but was not aware the recliner was not supposed to be plugged in. On interview 8/6/25 at 9:20 a.m., RN-B stated two weeks ago R6 was in her recliner with the legs up and she tried to climb out of it without putting the feet down. The recliner tipped down and she slid out. RN-B stated she was not aware the recliner was to be unplugged. RN-B confirmed the electric chair was plugged in and operational. On interview 8/6/25 at 10:42 a.m., the director of nursing (DON) stated she had heard the recliner was unplugged but never actually checked it herself. The DON stated it should not be plugged in and will see if therapy can evaluate R6 again for safe use and possibly remove the chair since it is easy for staff to just plug it back in if they want to use it. The DON stated after a new intervention is put into place, it should be documented in the communication book which staff review prior to working their next shift. The DON reviewed the communication book and stated no communication note was present regarding the unplugging of the electric chair. Facility Falls and Managing Fall risk policy dated 3/2018, included: - - Staff will implement a resident centered fall prevention plan to reduce the risk factor(s) of falls for each resident at risk or with a history of falls. - -If falling reoccurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. - -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. - - Position-change alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 2, 2024), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: CMS PBJ (payroll-based journal) Staffing Data Report dated Quarter 2, 2024 (January 1 - March 31) triggered for failure to have licensed nursing coverage 24 hours/day. The infraction dates included: 1/28/24, 2/4/24, 2/25/24, 3/10/24, 3/24/24, and 3/31/24. During an interview on 7/16/24 at 10:39 a.m., with nursing staff scheduler (NSS)-C reviewed nursing staff schedules for the infraction dates. On each of the six dates, there had been licensed nurses scheduled 24 hours/day. During record review, timecard sheets for each of the 10 nurses covering the 18 shifts were reviewed and indicated the nurses who had been scheduled had been paid for working each of the 18 shifts. During an interview on 7/16/24 at 1:34 p.m., the director of nursing (DON) verified the facility always had a licensed nurse working 24 hours/day. During an interview on 7/16/24 at 1:55 p.m., the administrator was informed of the results of the PBJ Staffing Data Report and given a copy. The administrator stated the staffing file was automatically uploaded to CMS, and due to the formatting, was not able to see where a potential problem could have occurred. The administrator stated the facility did not use agency nurses for staffing, and if nursing leadership worked a shift, their hours were reflected in the data. The administrator was not sure why there had been inaccurate reporting and would investigate it. The facility Reporting Direct Care Staffing Information (Payroll-Based Journal) policy with revised date of August 2022, indicated direct care staffing information was reported electronically to CMS through the Payroll-Based Journal system. Complete and accurate direct care staffing information was reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. For auditing purposes, reported staffing information was based on payroll records, invoices, tied back to a contract, or other verifiable information.

Based on interview and document review the facility failed to provide the required CMS (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to 2 of 3 residents (R28, R12) whose Medicare Part A coverage ended, and the residents remained in the facility. Findings include: R28's facesheet printed on 8/23/23 indicated R28 was admitted on [DATE]. On 5/29/23, R28 signed form CMS 10123 titled Notice of Medicare Non-Coverage (NOMNC) indicated coverage of skilled nursing services would end on 5/31/23. Review of R28's documentation indicated a SNF ABN form had not been provided to R28 to inform her of the estimated cost per day, or an explanation of the extended care services or items to be furnished, reduced, or terminated if she stayed in the facility. R12's facesheet printed on 8/23/23 indicated R12 was admitted on [DATE]. On 5/2/23, R12 signed a NOMNC form which indicated coverage of skilled nursing services would end on 5/4/23. Review of R12's documentation indicated a SNF ABN form had not been provided to R12 to inform her of the estimated cost per day, or an explanation of the extended care services or items to be furnished, reduced, or terminated if she stayed in the facility. . During an interview on 8/22/23 at 4:12 p.m., office manager (OM)-B stated the facility had overlooked providing SNF ABN's to R28 and R12. The employee responsible for administering the notices, and who was not available for interview, had informed OM-B it had been an oversight on her part. During an interview on 8/23/23 at 10:14 a.m., registered nurse (RN)-A who was also the facility nurse consultant stated the facility had previously identified a gap in the facility giving residents an SNF ABN. At that time, education and training had been provided to the individual responsible for administering SNF ABN's. RN-A stated the facility would work to again re-train the individual. A booklet located in the admission packet and titled Care Providers of Minnesota dated 6/8/19 indicated: --The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. --Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. A policy on administering SNF ABN forms was requested. On 8/23/23 at 8:17 a.m., the director of nursing (DON) stated the facility did not have a policy; that regulatory requirements were to be followed.

Based on observation, interview, and document review the facility failed to ensure multi-use glucometers (blood sugar monitor machines) were disinfected between resident use for 2 out of 3 diabetic residents (R5, R11) observed to have blood sugar check. Furthermore, the facility failed to ensure hand hygiene was performed prior to entering and exiting the resident's room observed for infection control practices, this had the potential to effect all 28 residents residing in the facility. Findings include: Glucometer: On 6/21/22, at 4:09 p.m. registered nurse (RN)-A was observed to check R11's blood sugar in a private area adjacent to the dining room. RN-A used a community glucometer, donned gloves, utilized the lancet to obtain a blood drop, and placed the blood on the glucometer strip in the machine. Once the glucometer reading registered, RN-A placed the glucometer with the strip in a small plastic container with cotton balls, and alcohol wipes. RN-A was further observed to administer R11's insulin, removed her gloves, and returned to the nursing station. RN-A was further observed to disinfected her hands and failed to disinfect the glucometer. On 6/21/21, at 4:17 p.m. RN-A was observed at the nursing station, picked up the unclean community glucometer from the plastic container, a lancet, a test strip, and a cotton ball. RN-A donned gloves and obtained a blood sample from R11 with the lancet. RN-A placed the blood on the glucometer strip and obtained the blood sugar reading. RN-A administered R11's insulin, removed her gloves, placed the lancet into the sharps container and placed the glucometer on the medication cart. RN-B utilized hand sanitizer to wash her hand and indicated she was completed with resident blood sugar checks and insulin administration. RN-A further was observed to disinfect the glucometer with a sanitizer wipe. On 6/21/21, at 4:20 p.m. when asked, RN-A confirmed the glucometer was not disinfected between R5 and R11, and RN-A further indicated she forgot to disinfect the glucometer. RN-A confirmed the glucometer was expected to be disinfected between residents to reduce the risk of spreading germs, and risk of spreading blood born pathogens. RN-A further stated the facility had two community glucometers and she was expected to use the other glucometer, when the other glucometer was not disinfected. RN-A stated she received glucometer training and confirmed disinfection of the glucometers were part of the training. On 6/23/22, at 9:33 a.m. interview RN-B indicated glucometers were expected to be disinfected with sanitizing wipes after each resident use and stated upon hire nurses were educated on disinfection of the community glucose meters. On 6/23/22, at 1:00 p.m. interview with director of nursing (DON)-B stated staff were to clean the glucometer with disinfecting wipes before and after the use of the glucometer. The DON verified not disinfecting the glucometer was not appropriate for the cleansing of the glucometers. R5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Policy Title Shared Glucometer Cleaning Policy dated 4/12/18, indicated: - Glucometers shared by multiple patients will be thoroughly wipe with Sani-Cloth Plus and allowed to air dry after every use and between every patient. - Use a fresh Sani-Cloth Plus wipe each time the glucometer is used - wipe all surfaces, top, bottom inside. Allow surface two remain wet for three minutes. Contact time, also known as kill time or 12 time, as the mountain time and EPA registered disinfecting product needs to be present on the surface in order to be effective against the microorganisms listed on its label. Allowed to air dry use on the next patient Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. Disinfection Instruction: The meter must be disinfected between patient uses by wiping it with a Sani-Wipe towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The disinfection process reduces the risk of transmitting infectious diseases if it is performed properly. Step 1. Before disinfecting, clean the meter as described in Cleaning Instructions above. Step 2. Wash hands with soap and water and put on single-use medical protective gloves. Step 3. Prepare the Sani-Wipe towelette or other EPA-registered disinfecting wipe. Take out a wipe from the container and follow the instructions on the package. If needed, squeeze the wipe slightly to remove the excess liquid. Step 4. Wipe the glucose meter thoroughly including the front, back and sides, and take care not to get any liquid in the test strip port and serial port. Do not wrap the meter in a wipe. Step 5. If using the Sani-Wipe towelette, allow to remain wet for two minutes. For other EPA registered disinfecting wipes, allow the surface of the meter to remain wet for the contact time listed on the disinfecting wipe's instructions for use. Dispose of wipe when finished. Step 6. After disinfection, user should take off gloves and wash hands thoroughly with soap and water before proceeding to the next patient. Hand Hygiene: On 6/21/22, at 2:16 p.m. observed the north hallway and the north hallway failed to have hand sanitizer or dispensers. On 6/22/22, at 12:50 p.m. nursing assistant NA-B confirmed she did not carry hand sanitizer in her pocket and further indicated to find or use the hand sanitizer she would had to walk to the nursing station. On 6/22/22, at 1:43 p.m. nursing assistant (NA)-A was observed to enter room [ROOM NUMBER] and failed to disinfect hands prior to entering the room. On 6/21/22, at 2:11 p.m. observed the east hallway and the facility failed to have hand sanitizer or dispensers in resident rooms or the hallway, and when asked trained medication aide (TMA)-A stated facility staff had requested hand disinfectant placed throughout the facility. On 6/22/22, at 2:22 p.m. NA-A indicated she tried her best to wash her hands in the resident bathrooms prior to exiting the resident rooms, NA-A confirmed she does not carry hand sanitizer in her pocket and indicated hand sanitizer was not easily accessible throughout the facility and created difficulty to wash her hands when she entered and/or exited resident rooms. NA-A stated staff do not wash or sanitize their hands frequent as we needed. NA-A stated she went room to room at times, without hands sanitized or washed, when hand sanitizer was not available. On 6/23/22, at 8:36 a.m. occupational therapist (OT)-A was observed to enter R18's room and failed to disinfect hands prior to entering and prior to exiting the room, when asked OT-A confirmed she failed to wash hands and indicated she was expected to disinfect or wash her hands prior to entering resident rooms. OT-A further indicated she usually would go into the bathroom to wash her hands, and stated there was no hand disinfectant available currently in the east hallway. On 6/23/22, at 1:00 p.m. during an interview with director of nursing (DON)-B stated she was the infection prevention nurse and had communicated to the facility director regarding the lack of hand disinfectant throughout the facility and the need for hand disinfectant and/or dispenses for the staff use. DON- B stated staff were expected to disinfect hands prior to and exiting resident's rooms. DON-B indicated staff received training and ongoing education related to hand hygiene. On 6/23/22, at 1:44 p.m. during an interview with the facility administrator, he indicated staff were expected staff to wash hands prior to entering and exiting resident's room. The administrator indicated staff were expected to wash hands in bathroom and/or carry hand sanitizer. The administrator stated he was aware there was not disinfectant dispensers available outside or inside of the resident rooms. Policy Titled Handwashing/Hand Hygiene dated 8/19, indicated: -all personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors -hand hygiene products and supplies(sinks, soap, towels, alcohol based hand rub, etc) shall be readily accessible and convenient for staff used to encourage compliance with hand hygiene policies. -use an alcohol based hand rub containing at least 62% alcohol; or alternatively, soap(antimicrobial or non-antimicrobial) in water for the following situations: -before and after coming on duty -before and after direct contact with residents -before preparing or handling medications -after contact with residents intact skin -after contact with objects in the immediate vicinity of the resident -before and after eating or handling food -before and after assisting a resident with meals

Based on interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the medical record to ensure correct implementation in an emergent situation for 1 of 16 residents (R18) reviewed for advanced directives. Findings include: R18's face sheet printed [DATE], indicated R18 was admitted on [DATE], and advance directive section indicated do CPR; POLST. R18's cumulative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R18's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R18 had moderate impaired cognition. Review of R18's electronic and paper medical records revealed the following: R18's Provider Orders for Life-Sustaining Treatment (POLST) dated [DATE], indicated attempt resuscitation/CPR. R18's Physicians Telephone orders dated [DATE], indicated DNR status. R18's Admission conference notes dated [DATE], indicated code status was DNR. During interview on [DATE], at 11:24 a.m. licensed practical nurse (LPN)-A indicated in the event of an emergency such as a resident who stopped breathing, she would check the binder located at the nursing station with resident's POLST information, and further indicated R18's POLST indicated CPR. During interview on [DATE], at 11:30 a.m. director of nursing (DON)-A, when asked if R18 was a full code or DNR, DON-A stated, that's a good question. DON-A verified she completed the POLST with R18, before she determined R18's cognitive status and R18 indicated she wanted CPR. DON-A indicated due to R18's impaired cognition, she was expected to have clarified the POLST with family member (FM)-B. DON-A indicated FM-B was the person responsible for making decisions for R18. DON-A confirmed the code status and the POLST were expected to be accurate and stated staff used the POLST for code status. DON-A discussed she needed to clarify R18's DNR doctor order and admitting paper work for accuracy. DON-A further verified R18's current POLST indicated R18's POLST was CPR. DON-A stated in the event of an emergency, such as a resident who stopped breathing, staff were expected to utilize the binder with the POLST's. On [DATE], at 12:36 p.m. during a a phone interview with FM-B indicated R18 was expected to have been been admitted to the facility as a DNR/DNI, and stated the R18's POLST of CPR was incorrect, and verified R18 had severe dementia. FM-A indicated the facility had not called prior [DATE]. to discuss R18's code status. On [DATE], at 1:23 p.m. DON-A indicated she verified conflicting documentation on R18's code status with FM-B and indicated R18 code status was DNR. DON-A indicated she would have the POLST updated to reflect the correct code status. The facility policy titled Advance Directives, dated ,d+[DATE] indicated: -If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information maybe e provided to the residents legal representative. -Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members or her legal representative about the existence of any written directives. -The plan of care for each will be consistent with his or her documented treatment preferences and/or advance directive -Nurse manager directives so that appropriate orders can be documented in the residence medical record and planet care. Position will not be required to write orders for which he or she has ethical or conscientious objection. -Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members or her legal representative about the existence of any written directives. -The plan of care for each will be consistent with his or her documented treatment preferences and/or advance directive -Nurse manager or designee will notify the attending physician of advance directions so that appropriate orders can be documented in the resident's medical record and plan of care. Nursing Policy titled Health Care Directive/CPR Status Procedure dated ,d+[DATE], indicated -Specifically during the admission process, the question of CPR status is addressed. Each resident and/or health care representative is asked whether CPR should be performed if cardiac or respiratory arrest occurs. Existing health care directives are referred to in making this decision. A POLST form, provider orders for life sustaining treatment, is completed and signed indicating this decision as well as others. If a resident admits with a POLST form already in place a conversation will be had with the resident and/ or health care agent to identify the previous identified directive are still current and correct with the resident's wishes. The original is stored in the medical record behind the face sheet. a. if the decision is not to perform CPR, a DNR is obtained from the doctor and indicated on the doctor's orders and face sheet. b. If the decision is to perform CPR, the decision is indicated on the doctors' orders, face sheet and at the nurses station

Based on observation, interview and document review, the facility failed to conduct a comprehensive reassessment after fall incident to identify root cause and ensure new interventions were implemented to prevent further falls for 1 of 1 resident (R27) reviewed for falls. Findings include: R27's Admission Worksheet, printed 6/23/22, identified diagnosis including: heart block (when electrical signals from top chambers of the heart don't conduct properly to the bottom chambers), repeated falls, signs and symptoms involving cognitive functions and awareness; moderate cognitive impairment. A fall assessment completed 6/3/22, included 1 previous falls over past three months, on one [CONDITION(S)] medications and has decreased safety awareness. R27's quarterly Minimum Data Sheet (MDS) assessment, dated 6/3/22, indicated moderately impaired cognition, requiring extensive assistance of one person for toileting and personal hygiene, supervision with walking on unit, frequently incontinent of urine and bowel and had one fall without injury. R27's plan of care dated 6/14/22, identified R27 unaware of safety risks, sometimes get confused, has trouble sleeping and has a cognitive deficit related to dementia. R27 has fallen and last fall was 9/26/21 when fell in his room while walking with walker resulting in a fractured left hip which has healed. R27 is impulsive, loses balance, wanders, bumps into things, tires easily, and gets lost. Interventions included, request therapy screen as needed, remind R27 to ask for help by using call light, however R27 is known not to use call light and will call out when needing assistance, keep bed in lowest locked position, non-skid footwear, encourage assistance when tired and weak. Therapy recommends R27 needs a staff member to walk with when unstable and keep a night light on. A physical therapy (PT) discharge note dated 2/18/22, included R27 made little to no progress due to refusal to participate. Goal included R27 will ambulate with front wheeled walker (FWW) in his living environment with stand by assist was not met. A second goal that included R27 will safely complete all functional transfers requiring stand by assist also was not met. Discharge plan and instructions included supervision for all mobility and ambulation. The most recent Care Area Assessment (CAA) dated 12/21/21, indicated resident is a fall risk. His last fall was on 11/22/21. R27 had a fall a few months ago and fractured his left hip. Resident is impulsive with transfers. R27 has a poor appetite, has heart issues and receives [MEDICATION(S)] (antidepressant) daily which are all risk factors for a fall to occur. During interview and observation on 6/21/22, at 4:39 p.m., R27 denied any falls while at the facility. R27 stated I don't need any help when asked about toileting, transfers and walking. R27 was sitting in his chair and call light was attached to the bed and not in reach. R27 had on socks and shoes and FWW was next to his chair. During observation on 6/21/22, at 5:37 p.m., R27 was in his room, standing on the front side of his walker, attempting to push it forward and had 2 glasses in his right hand that were empty. R27 was unsteady on his feet and was attempting to pick up the walker with one hand as the walker wouldn't roll backwards. R27 was able to safely get to a chair and sat down. The facility incident report included: Incident type, activity at time, date, time, shift, day of week, location, mental state, current interventions, injury, first aide, and other factors. Other documentation included staff involved, witnesses, neuro checks, physician and family notification, actions, new interventions and teaching done. Review of incident reports for R27 revealed 5 fall incidents: On 9/26/21, at 10:54 a.m. R27 was observed on floor laying with head up by roommates bed on his back. R27 was standing and trying to ambulate when he fell on the floor. Resident was confused and disoriented. Current intervention included room close to nurses station. No apparent injury was noted. Other factors included resident has dementia and is able to ambulate without staff assist. No action was taken and resident was instructed on using his call light to transfer if he is feeling dizzy. A progress note dated 9/26/2021, at 1:57 p.m., indicated R27 was transferred to emergency department (ED) for evaluation after falling and experiencing left leg pain. An addition progress noted dated 9/26/2021, at 9:04 p.m., indicated R27 was sent to another hospital with fracture of his hip. A progress note dated 09/27/2021, at 6:22 p.m., R27 returned from hospital stay. An incident report dated 11/22/21, at 4:21 a.m., R27 was observed on floor and was last seen in bed on rounds. R27 indicated he was picking up his jacket and change and fell and could not get back up. Current interventions included low bed, room close to nurses station. New interventions included make sure his slippers are right next to bed and remind to use call light. An incident report dated 12/31/21, at 8:52 p.m., indicated R27 was observed on floor in his bathroom indicating he was trying to sit down and missed the toilet and sat on the floor. Actions included continue to monitor and resident was instructed to call for help to toilet. Activity at the time was defined as resident saw his stool fall to floor and was going to pick it up. His hands were covered in stool. New interventions was not applicable. An incident report dated 3/23/22, at 4:15 a.m., R27 was observed on the floor and was last seen in bed at 3:30 a.m. by the nursing assistant (NA). Activity at the time was resident was in the bathroom urinating and slipped. Current interventions included low bed, reclining chair, tray table, room close to nurses station. Call light was not on. New interventions included R27 to have grippy socks in case he forgets his shoes. An incident report at 4/26/22, at 2:14 a.m., R27 was observed on the floor and had been in his bed sleeping. R27 stated he sat up and slid off the bed. R27 was found sitting up with feet in front of him and resting against the bed. Actions included encourage resident to call for help. New interventions included resident did not fall, slipped off the edge of bed. Review of the communication book included a note dated 3/25/22, for night staff: Per care conference, R27's family would like an alarm used on night shift mainly in his room. They want staff to be alerted when R27 is getting up so he can be assisted. Last fall was on night shift and they don't want him laying on the floor to long. If any other solutions like putting an alarm on the bathroom door let charge nurse know. Grippy socks was listed below. On 6/22/22, the following was observed: 9:01 a.m., asleep in chair with walker in front of him in his room. 9:32 a.m., R27 ambulated from his room to entry way of the facility unsupervised and sat in chair. Has shoes and socks on and used walker. 9:38 a.m., activities aide approached R27 asking if he wanted to play bingo which he declined. 9:55 a.m., R27 remains in chair dozing. 10:39 a.m., R27 remains in front lobby asleep in the chair. 11:55 a.m., NA attempted to arouse R27 to go to lunch and R27 stated no and went back to sleep. 1:12 p.m., R27 remains sleeping in the front lobby in chair. 1:34 p.m., R27 woke up and ambulated self down the hallway past the nurses station to his room unsupervised. 1:43 p.m., R27 came out of his room independently, using his walker and ambulated back to front lobby and sat in corner sun room. During interview on 6/22/22, at 1:13 p.m., NA-A indicated R27 decides when he will get up. NA-A included R27 had a rough night and was wandering the facility and in other resident rooms and has these bad nights occasionally. NA-A stated they check on him frequently but R27 does what he wants to do. NA-A indicated R27 is independent with ambulation and toileting and there is no position change alarms in his room. During interview on 6/22/22, at 1:37 p.m., licensed practical nurse (LPN)-A indicated R27 tends to nap all day and is up all night pacing. LPN-A indicated R27 has had some falls at the facility and broke his hip with one of them. LPN-A indicated for prevention of falls, staff check on him frequently and make sure he has his socks and shoes on when he is walking, have him close to the nurses station and a low bed. LPN-A indicated R27 does not have any position changing alarms in his room. LPN-A indicated the nurse on shift is responsible for completing the incident report, which included new fall interventions. This is then placed in the communication book for other staff members to review. LPN-A indicated the director of nursing (DON) is responsible for the plan of care and the report completed is forwarded to the DON. During interview on 6/22/22, at 3:03 p.m., director of nursing (DON)-A indicated staff try to keep an eye on R27 and if he is unsteady assist him. DON-A indicated R27 is more active on nights than he is on days so staff try to keep an eye on all hallways. DON-A indicated the staff nurse completes an incident report when a fall occurs which includes new interventions and casual factors. New interventions are then put in communication book and all staff are expected to review this prior to their shifts. DON-A was not aware of any alarm being used for R27 except a wander guard. The DON-A indicated the facility previously had a falls committee that met weekly, but meeting notes were for 2020 and none were present for 2021 or 2022. DON-A indicated she updates the plan of care and uses the communication book every 3 months to complete this. DON-A did state that the previous DON left in April and no fall meetings have been held since that time. DON-A confirmed falls were not completed using the interdisciplinary teams and thought the nurses were ensuring new interventions were in place and being evaluated. During interview on 6/23/22, at 8:19 a.m., R27 was in dining room having breakfast. R27 denied any falls while at the facility and indicated he slept all night. During interview on 6/23/22, ay 7:53 a.m., trained medication aide (TMA)-A indicated R27 is sleepy some days and very active the next. He varies day to day. For falls prevention, we watch him very closely and if he is unsteady staff will assist him, but sometimes there is no stopping him. R27 thinks he is capable. TMA-A indicated R27 can be up independently without assistance or supervision. During interview on 6/23/22, at 10:08 a.m., occupational therapy (OT)-A indicated the last time R27 received therapy, it was recommended he should be a one person assist when he is walking. R27's abilities fluctuate a lot and he has issues with his balance at times. R27 did not cooperate with therapy in January so it was discontinued. During interview on 6/23/22, at 1:56 p.m., LPN-B indicated R27 generally sleeps in the chair in the lobby on overnight shifts. LPN-B indicated someone tries to stay at the desk area to keep an eye on R27 over nights but it isn't always possible if staff are answering call lights. LPN-B indicated they do let him wander around unsupervised as long as he doesn't go into other resident rooms. A policy on Falls and Fall Risk, Managing last revised March 2018 included: -A fall is declined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (a resident pushes another resident). - Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent eh resident from falling and to try to minimize complications from falling. -Fall risk factors include environmental, resident conditions, and medical factors. -The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls as applicable. -Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the light. -In conjunction with the pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature of category of falling, until falling is reduced or stopped, or until the reason for continuation of the falling is identified as unavoidable. -Position -change alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. -The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. -If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. -The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls.

Based on observation, interview and document review, the facility failed to comprehensively assess and develop individualized interventions to address exhibited behaviors of dementia for 1 of 1 resident (R41) observed to wander into other resident rooms and attempts to exit facility doors. Findings include: R27's Admission Worksheet, printed 6/23/22, identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R27's quarterly Minimum Data Sheet (MDS) assessment, dated 6/3/22, indicated moderately impaired cognition, requiring extensive assistance of one person for toileting and personal hygiene, supervision with walking on unit, had behaviors not directed at others 1-3 days, no [CONDITION(S)], had one fall without injury and received 7 days of antidepressant medication. R27's plan of care dated 6/14/22, identified R27 is forgetful, has a cognitive deficit, dementia and is confused about time, often thinking it is night time when it is day time. Staff will remind what time it is and what day. R27 is not able to remember things that happened a short time ago, unable to make decisions, behavior problems such as rummaging through drawers that may be in someone else's room, increased confusion and disorientation. Interventions include ask questions that can be answered yes or no, give step by step instruction, encourage daily routine, acknowledge and accept feeling, assess for unmet needs such as pain, toileting, hunger, thirst, allow extra time to respond, watch if behavior changes. Nursing assistant (NA) interventions included help R27 the same way every time, offer fluids, allow to wander when able, acknowledge that you understand R27, remind where am, keep items in the same place, make sure wearing glasses and if depressed offer 1:1 conversation, offer activities or offer to call family. Requested Elopement and Cognitive/Dementia assessments and none was received. Review of behavioral note documentation included: On 12/8/21, at 1:24 a.m., R27 wheeled down the halls and entered conference room and break room, pulling drawers open. On 12/8/21, at 3:14 a.m., R27 was up at 3 a.m., and when staff left the desk area resident went into the dining room, when staff returned had found that resident pulled 2 little round red decorations off the Christmas tree and had them in his mouth. Also had some in his pocket. On 12/8/21, at 3:10 p.m., R27 was taking decorations off the trees and eating them. Call placed to R27's provider asking for something to ease his anxiety and depression. On 12/9/21, at 1:00 p.m., R27 is more confused today . He is restless and up and down the halls in his wheelchair. He did try this morning to get to the Christmas tree to pull off ornaments and eat them, he was given a sucker and this did keep from trying to eat the ornaments. On 12/10/21, at 12:56 p.m., Staff found R27 in lobby taking ornaments of the tree and attempting to eat them. Has been cruising the halls going into tub room, blue room, break room and conference room. Very restless behavior. On 12/10/21, at 10:36 p.m., R27 trying to eat decorations off the trees; going into other peoples rooms; rude to staff and others. On 12/11/21, at 1:56 p.m., R27 continues to take berry type ornaments off of the Christmas tree in the dining area and chewing/eating them throughout the day whenever he gets the opportunity; R27 redirected on several occasions, becomes very angry & defensive with staff when asked to spit out the ornaments. When the ornaments are taken away & he is redirected away from the tree On 12/11/21, at 6:22 p.m., R27 behavior problems continue. On 12/12/21, at 2:02 p.m, R27 continues to eat berry like ornaments off of tree, requiring redirection. At lunch it was discovered R27 had a small candy cane type ornament in his mouth he was chewing on, R27 became very angry when writer told him he had to spit it out but did eventually spit it out and reluctantly handed it over. On 12/13/21, at 12:37 p.m., Resident continues to pull off the Christmas ornaments and trying to eat them. He is given different food to eat but he continues to go after the trees. On 12/14/21, at 3:00 a.m., R27 was given a bag of cookies and still went into Blue room next to nurses station and started to take ornament off tree. Got ornaments away from him and redirected him out of room and shut the door. On 12/14/21, at 11:17 a.m., Attending physician visit. Changes included to stop [MEDICATION(S)] and begin [MEDICATION(S)] 5 mg. On 1/29/22, at 3:41 a.m., R27 was going in 2 other resident rooms and was pacing the facility. Asked if he wanted some pudding or toast? He said, I only want a sucker. He was given a sucker and he continued to pace. When he tried to go into staff lounge, the writer told him that it was for staff only. He said that , I am staff!, I get paid once a month. On 1/31/22, at 2:41 a.m., R27 was pacing the halls of facility. He sat down in the NA's chair and started playing with her phone, book, and cracker. When the writer told him to put it down, he got mad and threw the bag of crackers and the book on the floor. On 2/4/22, at 4:32 a.m., R27 went into 8 different resident rooms, 6 of them were females rooms. He tried to go out the front door and was going in the staff lunch room. Offered resident toast, pudding, jello, and chips. He did eat a pudding, but refused the rest. Has been constantly pacing the facility since 9:30 p.m. last night. On 2/20/22, at 10:21 p.m., R27 was eating stones out of planters. Resident was receptive to redirection. On 2/22/22, No time listed: Digging through stuff that does not belong to him looking for candy. Redirected out of the break room. R27's wandering and behavior occurred daily. Wandering put resident at significant risk of getting to a potentially dangerous place and intrudes on privacy. On 2/25/22, at 9:28 p.m., Resident went for a ride with son this afternoon and this evening is very restless, stating he has to go to work, wants his jacket on and zipped, keeps walking up and down the hall, and attempted to leave the nursing home once set off the door alarm, but staff were able to convince him not to go outside. On 2/28/22, at 2:52 a.m., Resident is pacing up and down the halls, pushing EZ stand purposely against the wall to make noise and was picking up his walker and banging it on the floor. On 3/3/22, at 4:50 a.m., Resident was going in other resident rooms and searching for suckers. Even after he was given one. He went in three room [ROOM NUMBER] male and 1 female. Did one on one with resident for 30 minutes to keep him out of other residents rooms. On 3/12/22, at 5:13 a.m., R27 was pacing the halls and took sat down in another residents wheelchair in the hallway. Staff requested he get out of the chair, because it was not his. He got angry and threw his walker down the hallway. Also entered another resident's room. On 4/12/22, at 11:07 a.m., Attending provider visit. [MEDICATION(S)] increased to 10 mg daily. On 4/24/22, at 2:11 a.m., R27 was picking up staff phone and book and playing with it. Was looking in the resident rooms and lingering in the females rooms. Staff were in a females room and he was hollering, what are doing? Told him that we are helping a resident and shut the door. He used walker and hit the door several times. On 5/7/22, at 12:12 p.m., R27's behaviors occurred daily. R27 was found in another residents room using the bathroom, and had urinated all over toilet seat. On 5/9/2, at 2 3:49 a.m., Resident was wandering into two other residents rooms. He urinated all over the bathroom seat in his bathroom, then went into tub room on south hall and urinated on that toilet seat. R27 continues to pick-up anything that is in his reach phones, papers, boxes, and cups on the medications cart. On 5/13/22, at 3:44 a.m., Resident came out of room with no clothing on lower half of body at 1 am in the morning. Resident had BM on buttocks, and toilet seat. He also had urine on toilet seat and floor. His brief was on the floor in the bathroom. Behavior occurred 1-3 days in the last 7 days, On 5/15/22, at 8:03 a.m., R27 was yelling for [NAME], and help. When staff went into room he said that there was a little boy trying to crawl into bed with him. Explained that it was the middle of the night and their were no little kid here at the time. Resident calmed down and went to sleep. Behavior occurred 1-3 days in the last 7 days, On 5/24/22, no time documented: Resident frequently goes into other people's rooms and goes through their belongings. Wandering is significantly intruding on privacy. Resident has become more confused needing redirection more often. Resident frequently has to ask where is room is located at. On 5/25/22, at 7:04 a.m., On the night shift R27 was very restless, and went into 4 other residents rooms. Staff took him out and would put him back into his room. Tonight he went into a females room and was talking with the resident. When staff heard him talking he was removed from the room and taken back to his room. On 5/26/22, at 7:26 a.m., R27 was in another female's room and trying to get into the staff lunch room. Asked resident if he was hungry and he said no. R27 was later yelling ,who is out there at 11:30 p.m. Resident did quiet down and rest for a short period after talking to him, and re-showing him his call light. On 5/27/22, at 6:19 a.m., Resident was out in the lobby twice on this shift, had to have resident put the butterfly's container down. He was picking it up and shaking it and turning it around. He did his normal pacing during the night. On 6/3/22, at 6:59 a.m., Resident was going through staff items while staff were doing rounds. He was also playing with decorations in the lobby area. Resident was also in another residents room at 3 a.m., this morning. On 6/10/22, at 4:41 a.m., Resident went into another residents room tonight. Brought resident to his room were he laid down in his bed. Resident spent most of the shift in the brown chair in the lobby. Review of Medical doctor (MD) note dated 3/8/22, indicated R27 continues to struggle with confusion and behaviors. He has been roaming into others residents rooms and has been eating pebbles out of the current decorations. Nursing does have some concern that these behaviors are worse after social outings with his son to the bar. Will call to discuss this concern with patient's son to see if there are alternative social outings that may lead to improvement in patients behaviors and cognitive status to avoid self injury. Last primary MD visit on 4/12/22 included behaviors improved since last visit with alcohol cessation and addition of [MEDICATION(S)] 10 mg daily, however patient continues to have confusion and eating non-nutritive items such as rocks and flowers. Will increase [MEDICATION(S)] to 20 mg daily as he did well with the addition of this. During interview on 6/21/22, at 2:43 p.m., R78 indicated she has experienced R27 in her room on occasion in the middle of the night going through her drawers. R78 stated she told R27 this wasn't her room, but R27 told her she was in the wrong room so R78 put on call light and a nurse came and escorted R27 out of her room. During interview on 6/21/22, at 5:02 p.m., R15 indicated R27 comes into her room on occasion and the last time was a few weeks ago. R27 indicated R27 did not know where he was so she put on her call light and staff came and escorted him out of the room. During interview and observation on 6/21/22, at 5:37 p.m., R27 was sitting in his room in his chair with his walker in front of him. R27 was unable to give an answer regarding his location, date, month or year. R27 had a wanderguard on his left wrist. R27's room had multiple pictures of family on the walls. R27 talked about his family and was able to identify where he grew up and lived previously. A television was on the wall and was on. No radio, newspapers, magazines or other activity items were present. During observation on 6/21/22, at 8:02 p.m., an audible alarm sounded in the facility and registered nurse (RN)-A responded to the main entrance door where R27 was noted in between the 1st and 2nd door (2nd was locked). RN-A indicated if the outer door wasn't locked, R27 would likely fall down the big step outside the main entrance. During observation at 8:07 p.m., witnessed R27 just outside the door of the south entrance. A staff member appeared shortly after and redirected him back into the building. On 6/22/22 the following was observed: 9:01 a.m., asleep in chair with walker in front of him in his room. 9:32 a.m., R27 ambulated from his room to entry way of the facility unsupervised and sat in chair. Has shoes and socks on and used walker. 9:38 a.m., activities aide approached R27 asking if he wanted to play bingo which he declined. No further attempts were observed. 9:55 a.m., R27 remains in chair dozing. 10:39 a.m., R27 remains in front lobby asleep in the chair. 11:55 a.m., NA attempted to arouse R27 to go to lunch and R27 stated no and went back to sleep. 1:12 p.m., R27 remains sleeping in the front lobby in chair. 1:34 p.m., R27 woke up and ambulated self down the hallway past the nurses station to his room unsupervised. 1:43 p.m., R27 came out of his room independently, using his walker and ambulated back to front lobby and sat in corner sun room. During interview on 6/22/22, at 1:13 p.m., nursing assistant (NA)-A indicated R27 had a bad night last night and was in other resident's rooms. Intervention include redirecting R27 back to his room or give him a sucker which he likes. R27 indicated in December 2021, R27 had behaviors that included trying to eat the decoration balls that were on the Christmas tree. NA-A added R27 has also gone into the fish bowls and taken out the rocks and tried to eat them, thinking they were candy. NA-A indicated staff would offer him a snack and relocate resident to his room when this occurred. NA-A indicated his behavior has improved but he continues to have bad nights where he wanders into other resident rooms and attempts to leave the facility. An observation on 6/23/22 included: 7:11 a.m., sitting in front lobby in chair asleep. 7:52 a.m., remains in front lobby in chair, aroused briefly and asked what day it was and trained medication aide (TMA-A) answered Thursday and R27 went back to sleep. 8:55 a.m., R27 woke up and ambulated self to dining room. R27 looked out the window until breakfast was served. 9:57 a.m., R27 sitting in chair in front lobby dozing. 11:05 a.m., R27 remains dozing in the front lobby chair. 12:05 p.m., R27 awoke and TMA-A assisted R27 into dining room. 1:06 p.m., R27 was back in chair in front lobby asleep. 2:10 p.m., R27 remains in chair in front lobby asleep 3:00 p.m., R27 remains asleep in chair in front lobby. During interview on 6/22/22, at 1:33 p.m., nursing assistant (NA)-A indicated R27 is at risk for elopement and does wander into other residents room. NA-A indicated his attempts to eat things has lessened. NA-A indicated they redirect him, give him suckers, take him to his room when behaviors occur. NA-A indicated R27 seems to have less behaviors for awhile, but behaviors continue to come and go. He still has bad nights. During interview on 6/22/22, at 1:37 p.m., licensed practical nurse (LPN)-A indicated R27 wears a wander guard (alarm) to prevent elopement from the facility which is checked daily. LPN-A indicated R27 naps most of the day and is up all night pacing. LPN-A indicated staff do encourage him to get up and go to meals, give him supplemental drinks and offer activities. R27 will sometimes play bingo, and likes to listen to music. LPN-A indicated R27 does wander and he goes into other residents rooms but generally they put on their call light and we go and get him. LPN-A indicated R27 is friendly with everyone and isn't argumentative with other residents or aggressive. During interview on 6/22/22, at 2:48 p.m., trained medication aide (TMA)-A and LPN-A indicated discussions of a plan of care for R27's behaviors has occurred but some of the medications would be more detrimental than they would help. LPN-A indicated wandering is part of his daily behaviors and we are supposed to let him wander. Staff try hard to keep an eye on him. We have not had any residents complain about him being in their rooms to their knowledge. During interview on 6/22/22, at 3:03 p.m., director of nursing (DON)-A indicated R27's behaviors have been addressed during physician rounds and with family members during care conferences. DON-A indicated the provider addressed the situation with the family that R27 was wandering too much and should consider putting him in a memory care unit. DON-A indicated she found this out during a care conference in March as the family was upset and does not want him moved. DON-A indicated R27s behaviors have changed over the last few months and at times requires 1:1 staff ratio. Other interventions include a wander guard to prevent elopement, keeping a closer eye on him, and redirection R27 is up more at night and sleeps most of the day. DON-A indicated it isn't safe for R27 and other residents with R27 wandering into their rooms and residents deserve their privacy. DON-A indicated they would continue to work on interventions. DON-A indicated R27 has not seen any other doctor, psychiatrist or psychologist other than R27's primary doctor over the last year. During interview on 6/22/22, at 3:10 p.m., social services (SS) indicated staff have instructed other resident to put on their call light versus asking R27 to leave themselves. SS indicated they are not sure how to deal with his wandering and most residents don't want their doors closed. During interview on 6/23/22, at 7:53 a.m., TMA-A indicated R27 likes his television on and they try to get him to attend activities. TMA-A also indicated R27 also likes suckers so they keep a bag at the nurses station. TMA-A indicated we just keep a close eye on him. TMA-A indicated she has found R27 in other resident's rooms and generally he is easy to redirect. During interview on 6/23/22, at 8:05 a.m., activities aide (AA) indicated R27 loves music so they attempt to get him to those activities when offered. AA indicated he also enjoys checkers, sitting outside and looking through hot rod magazines. AA indicated sometimes R27 attends activities and other times he doesn't but probably less than 50% of the time. During interview on 6/23/22, at 11:45 a.m., registered nurse (RN)-B indicated a more extensive comprehensive assessment and interventions should be completed to prevent R27 from trying to exit the facility, to protect the other residents and try to stop his wandering. During interview on 6/23/22, at 1:56 p.m., licensed practice nurse (LPN)-A indicated R27 spends most nights in the front lobby. When R27 is wandering one of the night shift generally tries to stay at the desk. Interventions used is offering him snacks, shutting doors, turning on his television or have him sit in the family room across from the nurses station. LPN-A indicated sometimes they work and sometimes they don't. A policy on dementia care was requested and none was received.

Based on interview and document review, the facility failed to monitor medication side effects for 1 of 5 (R13) residents reviewed for unnecessary medications. Findings include: R13's facesheet printed on 6/23/22, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R13 had moderately impaired cognition, clear speech, was understood and could understand. R13 required extensive assistance of one staff for most activities of daily living (ADL), including toileting. In addition, seven days a week, R13 received an opioid medication (pain relieving medication for back pain, which has a known side effect of constipation). R13's care plan dated 5/10/22, indicated R13 had impaired mobility, to assess for constipation and to develop preventive approaches. R13's physicians orders included several medications with side effects of constipation: [MEDICATION(S)] (opioid pain medication), [MEDICATION(S)] (antipsychotic medication), and [MEDICATION(S)] (antidepressant medication). In addition, R13 had orders for the following medications for constipation: 1. Senna, 8.6 milligram (mg)-50 mg 1 tablet by mouth twice a day 2. [MEDICATION(S)] powder, 17 grams daily, dissolved in water 3. Milk of Magnesia, 400 mg/5 millimeters (ml) suspension, 30 ml daily prn (as needed) 4. Dulcolax 10 mg suppository, 1 suppository rectally twice a day as needed 5. Senna, 8.6 milligram (mg)-50 mg 1 tablet by mouth twice a day, prn Bowel movement (BM) logs indicated the following: --April 2022: no BM for 4 days: 4/8 through 4/11. Received a rectal suppository on 4/12, and then had an extra large BM. --May 2022: no BM for 4 days: 5/3 through 5/6. Received an oral [MEDICATION(S)] on 5/5, and a rectal suppository on 5/6 and 5/7, and then had a large and a medium BM. --June 2022: no BM for 4 days: 6/1 through 6/4. Received a rectal suppository on 6/5, then had a medium BM. --Also in June, no BM for 5 days: 6/18 through 6/22, except for one extra small BM on 6/21, after receiving a rectal suppository. During a telephone interview on 6/21/22, at 3:26 p.m., family member (FM)-D stated when R13 was constipated it seemed to affect her mood .seems to make her irritable and less apt to do anything. FM-D stated even when she was still at home, R13 didn't like to do anything or go anywhere if she didn't have a BM. During an interview on 6/22/22, 2:34 p.m., R13 was resting in a wheelchair in her room. When asked if she ever had difficulty moving her bowels or was constipated, R13 stated not too much. When asked if she became uncomfortable if she went two or three days without a BM, R13 admitted to having abdominal discomfort (R13 placed her hand on her lower belly) and stated she often received a suppository. R13 stated she didn't know why it was such a problem for her. During an interview on 6/23/22, at 7:43 a.m., the director of nursing (DON)-B was asked to locate BM history for R13. DON-B stated BM's were documented on a paper log by nursing assistants (NA's) and were not in the electronic medical record (EMR). DON-B obtained the logs for April, May and June and together they were reviewed. When it was pointed out that R13 went four days or more without a BM in April, May and June, DON-B stated their policy was to give a [MEDICATION(S)] on day two and a rectal suppository on day three. DON-B looked in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] --In April, R13 was not given a [MEDICATION(S)] per protocol on day two. In addition, R13 received a suppository on day five of no BM, which, according to DON-B should have been given on day three. --In May, R13 received an oral [MEDICATION(S)] on 5/5 (day three), and a suppository on 5/6 (day four) and another on 5/7 (day five) .Again, it should have been sooner according to DON-B. --In June, R13 did not receive a [MEDICATION(S)] or suppository per parameters of protocol according to DON-B. DON-B acknowledged that R13's pain medication, [MEDICATION(S)], which she had been receiving three times a day since 3/10/22, could cause constipation and did not know if staff were monitoring R13 more closely as a result of this, adding they should have been. DON-B acknowledged constipation caused R13 discomfort. During an interview on 6/23/22, at 9:47 a.m., licensed practical nurse (LPN)-A was asked about the process for monitoring resident BM's. LPN-A stated the night shift nurse looked at the paper log for BM's for all residents. If on day three of no BM, the night nurse gave the resident a rectal suppository. The night nurse left a small hand-written note at the desk each night indicating who received a suppository. Together looked at the June BM log and how twice, R13 went four or more days without a BM. LPN-A stated all nurses were responsible for monitoring resident BM's, adding, but we do count on the night shift for this process. When asked how constipation affected R13, LPN-A acknowledge R13 got uncomfortable when she did not have a BM for a few days and stated she has had to help her out sometimes by doing manual digital extraction. LPN-A stated, I don't think she is able to push it [stool] out easily. During an interview on 6/23/22, at 9:54 a.m., (NA)-B was asked about R13's BM's. NA-B stated, R13 got uncomfortable and it's all she thinks about until she can go. NA-B stated she documented BM's on the log, but did not tell a nurse if a resident had not had a BM for a few days, adding NA's charted it and nurses looked at it. During an interview on 6/23/22, at 12:00 p.m. with DON-A and DON-B, when asked what the policy was for monitoring BM's and addressing constipation, DON-B stated they did not have an actual written policy. DON-B stated nurses and trained medication aides (TMA) were supposed to give a resident a [MEDICATION(S)] if no BM on day two, and a suppository on day three if still no BM. Neither DON monitored this to ensure residents did not go greater than two days without intervention. When informed this did not occur for R13, DON-B stated this had been the practice for years, and nurses and TMA's should know this. Both DON-A and DON-B acknowledged it was apparent not all nurses and TMA's were aware of the unwritten protocol and would need to be educated on it. Facility policy on monitoring resident bowel movements was requested, but not received.

Based on observation and interview, the facility failed to ensure doses of controlled substances were stored in a manner to reduce the risk of theft and/or diversion in 1 of 1 refrigerators observed in use for medication storage. This had potential to affect 1 of 1 resident who received this medication. Findings include: During observation and interview on 6/21/22, at 7:59 p.m. registered nurse (RN)-A unlocked the medication room located at the nursing station and unlocked the medication refrigerator. Inside the refrigerator was a box labeled [MEDICATION(S)] 2 mg/ml. The medication was in the inside of the refrigerator and were not in a separate compartment or affixed to the inside of the refrigerator in order to prevent theft. RN-A indicated she was not aware the [MEDICATION(S)] needed to be permanently affixed to the refrigerator. On 6/23/22, at 9:33 a.m. during an interview and observation of the medication room and medication refrigerator RN-B confirmed the [MEDICATION(S)] was not permanently affixed to the refrigerator. Facility policy titled Storage of Medications dated 11/20, indicated: -Schedule II-V controlled medications are stored in separately, locked, permanently affixed compartments. Access to controlled medication is separate from access to non- controlled medications.

Based on observation, interview and document review, the facility failed to ensure the acting kitchen manager was certified and credentialed to oversee food preparation and service(s) in 1 of 1 main production kitchen(s). This had potential to affect all 28 residents who consumed food from the kitchen. Findings include: On 6/22/21, at 11:35 a.m. dietary manager (DM) stated she was appointed to this position 4/1/21, and was currently enrolled in the Certified Dietary Manager (CDM) online program at North Dakota State University (NDSU). DM indicated she requested an extension from NDSU and was granted one until January 2023 as she would not be finishing the class on time due to working so many hours in the kitchen. DM stated a registered dietitian (RD) was in the facility on a monthly basis, and she also receives assistance from a CDM at another facility which they try for weekly but it doesn't always work out. During interview on 6/22/22, at 12:53 p.m., CDM-A indicated he has been assisting the DM as a preceptor while she is completing her training but is not the covering CDM for the facility. CDM-A indicated the DM has completed 1 module out of 3 and just began her 2nd module. CDM-A indicated he tries to get to the facility weekly, but that doesn't always happen and time varies from an hour to a few hours at a time. During interview on 6/22/22, at 11:13 a.m., the administrator indicated he is aware the DM has not completed her certification and has not met the requirements for CDM but indicated through an arrangement with another facility, the DM has been working under a CDM. The Administrator was unsure how often the CDM was actually on site. During interview on 6/23/22, at 9:46 a.m., a consultant for the facility indicated he was aware of the one year requirement for DM to complete the certification course and has been trying to support her by offering assistance from CDM's from another facility for training. The consultant added they have problems hiring cooks for this facility and staffing has been the main problem the DM has not been able to complete her courses.

Based on observation, interview and document review, the facility failed to implement a comprehensive infection control program to include the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) COVID-19 Long-Term Care (LTC) Facility Guidance for all LTC facility personnel to cancel congregate dining, and all group activities. In addition, the facility failed to ensure COVID-19 screening for employees and visitors was completed immediately upon entering the facility utilizing an active process. This had the potential to affect all 29 residents currently residing in the facility. Findings include: Upon arrival to the facility on [DATE], at 9:15 a.m. the main entrance door was locked. Surveyors were let into the building by an employee and escorted approximately 40 feet, past resident areas, to the nurses station for COVID-19 screening. While waiting at the nurses station to have temperature checked by a registered nurse (RN) and complete screening questions, residents were observed self-propelling in wheelchairs near the nurses station and in the adjacent hallways. In addition, upon entrance into the facility, observed many residents and some staff in the dining room watching worship service on a big screen TV. During interview on 4/7/20, at 9:30 a.m. the director of nursing (DON) stated staff do self-screening for COVID-19 symptoms when they arrive to work. DON stated staff enter through the main entrance or the basement entrance and walk to the conference room where the time clock is located; check their temperature and complete screening questions. During same interview, DON stated residents are still free to attend dining at the time of their choosing (facility has open dining hours: 7 to 9 a.m., 11 a.m. to 1 p.m. and 4 to 6 p.m.) and that meals were not routinely served in resident rooms. DON further stated they are still doing group activities ensuring residents are six feet apart. DON stated the facility was following COVID-19 guidelines from the Mayo Clinic, a three page document and a guide from Pathways. During interview on 4/7/20, at 9:45 a.m. activity aide (AA)-A stated they decreased their activity groups to 13 residents in the dining area, spaced at least six feet apart. In addition, the AA-A stated she was aware of the COVID-19 screening process for employees when arriving to work and stated she screened herself. During observation on 4/7/20, at 9:55 a.m. observed 12 residents and two staff members in the dining room watching worship service on TV. While observing, another resident walked in and sat down at a table. Each resident was at their own table; tables appeared to be at least six feet apart. During observation on 4/7/20, at 10:00 a.m. the worship service ended and staff wheeled some residents back to their rooms. Other residents walked or self-propelled their wheelchairs toward the nurses station and hallways. This resulted in congestion around the nurses station and in the hallway. As staff were returning residents to their rooms in wheelchairs, other residents were self-propelling in wheelchairs going the opposite direction; only inches apart due to the narrow width of the hallway. Staff did not ensure residents maintained a distance of six feet apart. During interview on 4/7/20, at 10:05 a.m. in a resident hallway, nursing assistant (NA)-A stated most residents are taken by wheelchair to the dining room for meals where there is one resident to a table. NA-A further stated group activites are the same with one resident per table in the dining room. While speaking to NA-A, a resident was observed walking in the same hallway that other residents were self-propelling in wheelchairs; not maintaining a distance of six feet. At end of interview, observed two residents sitting in wheelchairs near the nursing station watching the activity of the facility. The nurses station was at a juncture that allows visualization of the dining room and the three hallways. On 4/7/20, at 10:15 a.m. observed an employee arrive at the facility main entrance. She was let in by staff and walked approximately 50 feet through resident areas to the conference room where she punched in, checked her own temperature and wrote on the screening log. She did not put on a mask. Later learned this was the facility social worker (SW) who stated she put on a mask once she arrived to her office, located in a resident hallway. During interview on 4/7/20, at 10:30 a.m., dietary assistant (DA)-A stated residents eat in the dining room, 13 at a time; one resident to a table and six feet apart. DA-A stated she was aware of the new COVID-19 guidelines, and stated she screened herself when arriving to work. On 4/7/20, at 11:05 a.m. observed 11 residents and one staff in the dining room for lunch; each resident at a separate table, all facing the front of the room. On 4/7/20, at 11:09 a.m. observed an employee arrive to the facilty main entrance. She was let in by staff and walked unmasked to the nurses station and stood there until a nurse arrived to check her temperature. Nurse checked her temperature with a temporal thermometer and employee wrote in the screening log. During interview on 4/7/20, at 11:30 a.m. DON stated the facility continued to have residents eat in the dining room and attend group activities in the dining room, but had reduced dining and activities to only 13 residents at one time. DON indicated that having 13 residents spaced six feet apart did not qualify as communal dining or communal activities. DON verified having read the Centers for Medicare & Medicaid Services (CMS) memo regarding canceling communal dining and group activites; but stated he did not interpret the guidance as needing to stop group dining and activites all together. DON confirmed that the residents paths do cross in the hallway and that they are in close range (less than six feet apart) when coming and going from dining and activities. Furthermore, DON again confirmed that employees are self-screening for Covid-19 symptoms. Facility guide titled: Staff Educational Update Infection Control Practices COVID-19 Information and Practices, dated 3/19/20, indicated: 1. Screening process & monitoring A. Staff screening - remember we are part of the screening process. We must self screen when we come into work. Screening station at the time clock. The questions and criteria are listed on the screening form. Pathways Health Services, Inc policy titled Infection Prevention and Control Manual; Interim Policy for Suspected or Confirmed Coronavirus (COVID-19); undated, indicated: 1. Policy: It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic Risk for the COVID-19 and to adhere to the Federal and State/Local recommendations (to include, for example: Admissions, Visitation, Precautions: Standard, Contact, Droplet and/or Airborne Precautions, including the use of eye protection). 2. No group activities (internal or external) or communal dining will occur in the facility at this time. 3. Residents will be reminded to practice social distancing and perform frequent hand hygiene. 4. Screening Employees: a. Facility will actively verify absence of fever and respiratory symptoms when employees report to work-beginning of their shift. Three page document DON stated was from Mayo Clinic; however the document does not include the name Mayo Clinic, titled: Covid-19 Facility Exposure Management; After you have a suspected or confirmed case of Covid-19; dated 3/16/20, indicated: 1. Staff Management a. Take temp of all staff before beginning of shift. Record on temp log and absence of symptoms.

Based on observation, interview and document review, the facility failed to conduct a comprehensive reassessment after fall incident to identify root cause and ensure new interventions were implemented, to prevent further falls for 1 of 3 residents (R9) reviewed for falls. This resulted in actual harm when R9 was found on the floor after multiple falls resulting in a fracture of his femur requiring hospitalization and surgery. Findings include: R9's Admission Worksheet, printed 1/24/20, identified an admitted to the facility as 5/22/19, with [DIAGNOSES REDACTED]. A fall assessment completed 5/24/19, at 6:18 p.m., included five to six previous falls over past three months, on one to two [MEDICAL CONDITION] medications, decreased safety awareness, poor recall, judgement, safety awareness, balance problem with walking and decreased muscular coordination. In addition, the fall assessment identified R9 at risk for falling. R9's quarterly Minimum Data Sheet (MDS) assessment, dated 11/8/19, indicated moderately impaired cognition, requiring extensive assistance of one person for toileting and personal hygiene and extensive assistance of two for bed mobility and transfers, frequently incontinent of urine and has had falls including one with injury (not major). R9's plan of care dated 11/13/19, identified risk for injuring self due to confusion, forgetting where he is and has fallen losing his balance, forgetting to use assistive devices, being impulsive and is known to transfer out of and into wheelchair to bed, recliner or toilet. Approach included keep an eye on behaviors, use an alarm on chair and bed, keep bed low and wheels locked, remind me to ask for help, a floor alarm when in bed or recliner, use front wheeled walker and gait belt when walking, check on frequently, keep important items within reach, make sure hearing aides and glasses are on, assist with transfers or walking, reminders to ask for help and keep a night light on at night. The plan of care updated on 11/21/19, indicated R9 forgetful related to dementia with Lewy bodies, is confused about time, unable to remember things that happened a short time ago, difficult coordinating body movements. During interview and observation on 1/21/20, at 5:57 p.m., a family member (FM)-A indicated prior to R9's [MEDICAL CONDITION], staff tried to remind him frequently to use his call light and stay put until they arrived but with his [DIAGNOSES REDACTED], it just was not enough. FM-A indicated resident has a history of falling at two other nursing homes prior to his admission at facility, one of which he fell and broke some ribs. FM-A indicated the facility has also tried alarms and put bed in lower position. The FM-A indicated since R9's return from the hospital, he has not attempted to self transfer and spends most of the day sleeping in his chair. The FM-A indicated R9 fell on [DATE], and returned to the facility on [DATE], and has not been the same since. R9 was sitting in his recliner chair next to his bed with foot rest up dozing off and on. Review of incident reports revealed 14 fall incidents since admission, 6 of the 14 involved injury and included : -On 5/24/19, R9 was observed on the floor at 5:56 a.m Current interventions: personal alarm and floor alarm. Injury included laceration to right forehead, cleaned and steri strips applied. Other factors included R9 had removed personal alarm as he had removed his gown, also the floor alarm had been picked up and was on his tray table. Teaching included use of call light. Follow up on 5/25/19, included continue to observe. -On 6/25/19, at 6:35 p.m., R9 was observed on floor, sitting on his bottom in front of the bathroom door. R9 had been in his wheelchair and attempted to open bathroom door. No apparent injury except butt was sore. No witnesses. Current interventions included low bed, personal alarm and 1:1. Actions and teaching included continue to observe and instruct resident on use of call light. Follow-up actions on 6/26/19, included continue to observe and remind on use of call light. -On 8/5/19, at 7:05 a.m., R9 was walking back from bathroom with nursing assistant and he went to sit in wheelchair he missed the chair and fell to the floor on high right side. No apparent injury. Current interventions included personal alarm. Actions and teaching included continue to observe and nursing assistant to continue to walk with him for all mobility. Follow up 8/6/19, included continue to observe. -On 8/8/19, at 6:10 p.m., R9 tried to self transfer from wheelchair to bed and was observed per staff to be on the floor. Fall was unwitnessed. Sustained an abrasion 5.3 cm (centimeter) x 2 cm posterior to distal end of left scapular/mid back. Other factors included R9 had removed personal alarm prior to transferring. Actions and teaching included continue to observe and instruct R9 on avoiding removing personal alarm, use of call light and waiting for staff assistance. Follow up on 8/9/19, included continue to observe and educated resident to avoid removing personal alarm, use call light and wait for staff assistance. -On 9/20/19, at 8:00 p.m., R9 observed on the floor in his room, next to table by TV. Resident self transferred self. Other factors included R9 had removed personal alarm and turned off floor alarm. Call light was not on. Actions and Teaching included continue to observe and instructed R9 on importance of leaving alarms in place for safety and use of call light /waiting for staff assistance. Writer educated staff to place floor alarm out of resident's reach. -On 10/2/19, at 2:25 p.m., R9 was observed on the floor. Staff heard door slam and found R9 in his room, sitting on butt on floor, legs out in front and resting on his elbows. He sat up onto his bottom and scooted over so gait belt could be applied and was assisted by three to standing position. Other factors included R9 had been in bed, removed his personal alarm and picked up floor alarm and turned it off. Actions and teaching included continue to observe and safe transfer techniques and use of call light. On 10/4/19, follow up was to continue to observe. - On 10/20/19, at 9:00 a.m., R9 observed on floor without assistive device. Injury included a 1.5 cm by .5 cm at hair line on right side above left eye brow treated with ice and steri strips. Other factors included R9 had removed personal alarm and R9 removes alarm several time a day and self transfers. Actions and teaching included continue to observe and use of call light, safe transfer techniques and safe use of assistive device. Follow-up on 10/22/19, included continue to observe. -On 11/24/19, at 11:21 a.m., R9 was observed on the floor sitting in between recliner and bed on his buttocks. No apparent injury. Was attempting to self transfer to his bed when he was found sitting on his buttocks. Other factors included slipped on floor, sat down without staff assistance. Actions and teaching included continue to observe, and instructed R9 on use of call light to get assistance for him to transfer safely. Follow-up on 11/25/19, included continue to observe. -On 12/13/19, at 11:40 a.m., R9 was observed on the floor on his knees looking towards door in bedroom between bed and recliner. Was self transferring from bed to wheelchair or recliner. Injury included scrape or skin tear on left elbow measuring 2.7 cm by 2.5 cm. Steri-strips and dressing applied. Actions and teaching included continue to observe and R9 instructed on use of call light to get staff for assistance with transfers. Follow-up on 12/15/19, included continue to observe. -On 12/30/19, at 12:10 a.m., R9 was found at the foot end of bed, sitting up with legs out in front of him. Scrape on left knee cleansed with wound cleaner. Actions and teaching included continue to observe and R9 instructed on using call light when he needs to get up. -On 12/30/19, at 10:15 a.m., R9 observed on floor sitting on his bottom with one hand on foot end of bed and one hand on arm of wheelchair. He was in the process of trying to get himself up when staff found him. Other factors included R9 removed his personal alarm. Actions and teaching included continue to observe and instructed R9 on use of call light. Follow-up on 12/31/19, included continue to observe. -On 12/31/19, at 6:50 a.m., R9 was observed on floor at the end of the bed in a sitting position. Other factors included found down without staff assistance. Actions and teaching included continue to observe and R9 educated on safe transfer techniques, use of call light and waiting for help and use of call light. Follow up 1/1/20, included continue to observe. -On 1/4/20, at 6:45 a.m., R9 was observed on the floor sitting between bed and wheelchair that was sitting next to his bed. No apparent injury. Actions and teaching included continue to observe and R9 instructed on calling staff for help. Follow up 1/6/20, included continue to observe. -On 1/7/20, at 6:15 a.m., R9 had been in bed and was seen by housekeeping going from standing to down on the floor. When writer got to the room, R9 was sitting with his left leg behind the right leg and right leg was extended out in front of him. Immediately applied ice pack. Actions and teaching included continue to observe and instructed R9 on calling for help when he needs to get up. Follow up at 11:01 a.m., included R9 was sent to the emergency department after provider visit for evaluation related to his fall this morning. This fall resulted in rib fractures and fracture of left femur ( bone extending from the hip to the knee) Review of incident reports revealed lack of comprehensive assessment of falls/incidents to identify potential causative factors, identify appropriate interventions and determine if current interventions effective. During observation on 1/22/20, at 8:38 a.m., R9 was sitting in his recliner chair with call light in reach with feet elevated, asleep holding a stuffed bear. R9's walker was at end of the bed and wheelchair was parked next to the chair. No bed, or personal or floor alarms present in the room. During observation on 1/22/20, at 12:05 p.m., R9 was in wheelchair and assisted to dining room by staff member. Required assistance of 1 staff member to eat. R9 dozes off and on while sitting in dining room. During interview on 1/22/20, at 2:08 p.m., the director of nursing (DON) indicated a new falls program was started at the first of this year 2020. They have a falls team meeting weekly to review all repeated falls and come up with interventions for them. When questioned about determining the root cause of falls, follow-up assessments previously, the DON indicated the staff did an initial note that addressed the fall and immediate action, then follow up assessment was done to evaluate for further needs. When asked about care plan updates, the DON indicated the staff can alter the care plan as necessary. Request was made for root cause and interventions for R9's falls. The DON indicated he would review the falls and bring a list of these associated with the falls. During observation on 1/23/20, at 8:30 a.m., R9 is in his recliner with his feet elevated and is asleep. Wheelchair is parked 2 feet away from the recliner and walker is parked by bathroom door out of reach. During observation on 1/24/20, at 7:26 a.m., R9 is in the dining room in wheelchair with his head resting on his right hand dozing off and on waiting to eat breakfast. During interview on 1/24/20, at 7:14 a.m., licensed practical nurse (LPN)-C indicated on night shift R9 was checked on rounds, which was identified as three times a night, and if he was awake, staff would get him up right away. LPN-C indicated they used floor alarms that would sense motion and go off as soon as he put his legs over the bed. The nursing assistants (NA) would walk him every morning after getting him up with a gait belt and walker and wheelchair behind. Some days he was steady and other time he was not. Since returning from the hospital, he slept most of the time now. During interview on 1/24/20, at 7:20 a.m., registered nurse (RN)-D indicated R9 would have known to use his call light, though he did not always use it. RN-D indicated R9 was impulsive and thought he could walk by himself. RN-D indicated they have a new falls program that includes a meeting weekly to evaluate falls. Prior to the the fall program, the staff on the floor were responsible to implement interventions. RN-D further indicated they could alter the plan of care, but alarms was the main intervention for falls prevention for R9. During interview on 1/24/20, at 9:31 a.m., NA-D indicated R9 was observed more often than other residents even prior to his fall and fracture as R9 would get his times mixed up and was very determined he was correct. NA-D indicated prior to his hospitalization , R9 was up and down frequently but since returning has not witnessed him attempting to self -transfer. NA-D identified her role to report behaviors and falls to the nurse who determines if they can get the resident up after the fall or not. NA-D indicated interventions prior to the hospitalization included frequent observations, identified as every time they walked by the room, and bed and personal alarms. NA-D was unaware of any other interventions. During interview on 1/24/20, at 11:10 a.m., the DON indicated the documentation in the medical record is everything documented and completed on falls prior to the change in the program (MONTH) 2020. The DON indicated the electronic medical record documentation prompted the staff member to evaluate the cause of the fall and immediate interventions, and the follow up was to address assessments and interventions post fall. A facility policy and procedure titled Falls and fall risk, Managing dated 3/2018, included: - Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. - Fall risk factors .1. environmental factors 2. Resident conditions that may contribute to the risk of falls .3. Medical factors that contribute to the risk of falls . - The staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. - If falling recurs despite [DIAGNOSES REDACTED]il interventions, staff will implement additional or different interventions, or indicate why eh current approach remains relevant. - If underlying causes can not be readily identified or correct, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. - The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. - If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the interventions - If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that my not previously have been identified. - The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls.

Based on observation, interview and document review, the facility failed to accommodate needs and promote independence with dressing for 1 of 1 resident (R18) who had difficulty reaching clothing in her closet due to the way laundry hung clothing. Findings include: R18's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R18 was cognitively intact with adequate hearing and vision; clear speech, was understood and understands; and required extensive assistance of one for walking in her room and dressing. R18's admission care plan dated 12/9/19, indicated R18 was encouraged to be independent; that she liked to choose her own clothing; wanted to make sure important items were within reach, and had falls in the past due to losing her balance. During interview on 1/22/20, at 1:43 p.m. R18 stated laundry hangs her pants on a hanger, then puts a shirt over the pants. R18 stated she doesn't always want to wear the shirt with the pant that are on the hanger, so tries to take just the pants off the hanger and has had times when she nearly lost her balance. R18 stated she was afraid she was going to fall when she did this. Further, R18 stated when she arrived in (MONTH) she told the laundry girl not to put her pants and shirts together, but was told they were too busy to hang pants and shirts on separate hangers. During interview on 1/23/20, at 8:38 a.m. laundry aid (LA)-A stated when clothing is returned to a residents room, they put a pair of pants, a shirt and sometimes a sweater on one hanger because the closets aren't very big and this helps from over-stuffing the closet. During interview on 1/23/20, at 10:13 a.m. LA-A stated R18 told her she wanted her shirts and pants on separate hangers when she first arrived to the facility in November, but R18 didn't tell her that it was a problem for her to separate the pants from the shirts. LA-A stated they got busy and forgot to put R18's pants and shirts on separate hangers. LA-A stated they don't have a laundry preference list for residents, however, if a new resident had a special request then it would be written on a note in the laundry department. LA-A admitted that this was not done for R18. LA-A stated since they are again reminded that R18 wants her pants and shirts on separate hangers, they will accommodate request.

Based on interview and document review, the facility failed to report an allegation of abuse to the State agency within 2 hours of the report for 1 of 1 resident (R24) who reported an allegation of potential abuse. Findings include: R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R24 was cognitively intact with adequate hearing and vision, clear speech, understood and understands. R24 did not walk due to [DIAGNOSES REDACTED]. R24 required extensive assistance of two for bed mobility, transfers and toileting. During interview on 1/21/20, at 3:24 p.m. R24 reported to the surveyor a couple of the girls (nursing assistants) roll you over in bed roughly and it makes me mad. I tell them to take it easy. R24 also stated one woman who is big and when she moves you around, she really moves you. R24 was awaiting surgery for [REDACTED]. R24 indicated this rough handling causes pain to his leg. The resident acknowledged he had not reported this concern to staff. On 1/22/20, at 12:53 p.m. DON was informed by surveyor of R24's potential abuse allegation regarding rough handling by staff. During interview on 1/23/20, at 12:45 p.m. the director of nursing (DON) stated he had not reported R24's allegation of rough handling to the State Agency. The DON stated he discussed it with the administrator and they felt it didn't rise to the level of reporting. The DON stated R24 wasn't physically hurt or harmed and did not sustain injury. During a follow up interview on 1/24/20, at 8:55 a.m. the DON presented a copy of an incident report submitted to the SA with submission date and time of 1/23/20, at 5:28 p.m. The DON again stated after talking to R24, he did not feel R24's allegations were reportable. The facility's 3/19 Facility Prevention of Maltreatment Policy and Procedure, included: C. Reporting Procedure for Suspected Maltreatment: 1. Suspected Abuse shall be reported to the Administrator (or designed representative) and OHFC online reporting process not later than 2 hours after forming the suspicion of abuse. Suspicion of Neglect, Exploitation, or Misappropriation of resident property must be reported to the Administrator (or designated representative) and OHFC online reporting process not later than 2 hours if the incident resulted in serious bodily injury. If the suspected Neglect, Exploitation, or Misappropriation of resident property did didn't result in serious bodily injury, the reports must be made within 24 hours. Five-day follow up is still required. 2. If there is doubt whether a report should be made, report it. 3. If deemed not reportable, the investigator should record the steps taken and the reasons for not reporting on the incident report.

Based on observation, interview and document review, the facility failed to ensure an investigation and protections were initiated, for 1 of 1 resident (R24) who reported staff were rough with him when moving him in bed. Finding include: R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R24 was cognitively intact with adequate hearing and vision, clear speech, understood and understands. R24 did not walk due to [DIAGNOSES REDACTED]. R24 required extensive assistance of two for bed mobility, transfers and toileting. During interview on 1/21/20, at 3:24 p.m. R24 reported to the surveyor a couple of the girls (nursing assistants) roll you over in bed roughly and it makes me mad. I tell them to take it easy. R24 also stated one woman who is big and when she moves you around, she really moves you. R24 was awaiting surgery for [REDACTED]. R24 indicated this rough handling causes pain to his leg. The resident acknowledged he had not reported this concern to staff. On 1/22/20, at 12:53 p.m. DON was informed by surveyor of R24's potential abuse allegation regarding rough handling by staff. During interview on 1/23/20, at 12:45 p.m. the director of nursing (DON) stated he discussed R24's allegation with the administrator and they felt it didn't rise to the level of abuse. The DON stated R24 wasn't physically hurt or harmed and did not sustain injury. The DON stated he spoke to R24 on 1/22/20, about the allegation of abuse, but had not initiated an investigation. The DON stated R24 identified the two staff who handled him roughly but the DON had not yet talked to them. The DON stated rather than singling the employees out, he had scheduled an all-staff nurse meeting for 1/24/20 to address the allegation in general terms. During a follow up interview on 1/23/20, at 13:31 p.m. the DON stated he'd spoken with the resident on 1/22/20. The DON stated he'd left R24 feeling quite confident he was not in danger or unhappy with his care, and there was nothing that had placed him in danger. The DON stated R24 had never previously voiced concerns about being handled roughly stated R24 denied during their conversation that the rough handling caused him pain. DON stated he would remove involved staff from the schedule for that evening if he deemed there to be any risk to R24. The DON stated he had not spoken to the two alleged staff involved, and again stated he believed it best if he met with the staff as a group. The DON stated he had not interviewed other residents regarding rough handling since becoming aware of the allegation. During interview on 1/23/20, at 3:40 p.m. the DON stated TMA-A was scheduled to work the evening shift on 1/23/20 under the supervision of a registered nurse, to pass medications but would not provide cares to residents. During interview on 1/23/20, at 4:00 p.m. R24 arrived back to facility from an orthopedic appointment and stated he had good news; his knee surgery to replace the prosthesis was scheduled for next month. With regard to rough handling in bed, R24 stated I have a broken leg and they just lift you and turn you over, not thinking or caring; it hurts. My bones are loose and they grab your body and pull you over and do it rough, like they're football players. I don't want anything to screw up my surgery. During interview on 1/24/20, at 8:55 a.m. DON confirmed when he interviewed R24, the residents words were that staff were rough like football players. DON further stated R24 indicated to him that some people roll you over slowly, and some respond like 'up and over you go'. DON stated he talked to NA-A yesterday and gave her his expectations of performance and communication with R24. DON stated he did the same with TMA-A prior to her going on duty today. DON stated at their all-nurse staff meeting today, he would review expectations of resident care, customer service and review the facility abuse policy. DON stated he planned to check in with R24 twice a week to see how things are going and if care was up to R24's standards. The facility's 3/19 Facility Prevention of Maltreatment Policy and Procedure, included: B. Investigation of Suspected Maltreatment 1. The incident report will be immediately reviewed by the DON, Administrator or Social Worker. In the absence of these individuals, the charge nurse will attempt to contract one of them at home. Failing to reach any of them, the charge nurse should continue with the procedure. 2. The DON, Administrator or Social Worker will contact the necessary individuals (staff, residents, family members, roommate) to ascertain the facts of the report are correct and to add further details. This information will be recorded on the incident report. 3. The incident report needs to include: a. Identification of the vulnerable adults(s) - name, record number, etc. b. Name of alleged perpetrator and position at NH or relationship to vulnerable adult. c. Nature and extent of suspected abuse, neglect or exploitation d. Witnesses if any (reporters name can be kept confidential) e. Any knowledge of pervious abuse or neglect f. Name of person filing the report and how to contact them g. Any other information that might be helpful in investigating the suspected abuse. h. A plan of correction to prevent further incidents that could result in substantiated abuse or neglect. The facility policy titled: POLICY/PR[NAME]EDURE: Identification of Abuse, with revision date of 3/19 indicated the following: Identification of Abuse: It is the policy of the Janesville Nursing Home to complete a full investigation on the following injuries: -Residents report of abuse. -Family member report of abuse. -Staff members report of abuse.

Based on observation, interview and document review, the facility failed to ensure controlled medications were stored in a manner to prevent and minimize the risk of diversion for 1 of 1 medication storage rooms in the facility. Findings include: During observation and interview 1/24/20, at 2:21 p.m., in the medication room, registered nurse (RN)-D opened the refrigerator which was unlocked and three boxes of [MEDICATION NAME] oral concentration 2 mg per ml was present on the shelf. The medication belonged to a resident who is no longer at the facility, but was not secured separate from other medications and was not in a locked secured box in the refrigerator. RN-D indicated indicated I did not know they had to be stored separate from other medications and double locked but it makes sense. During observation and interview 1/24/20, at 2:51 p.m., the director of nursing indicated he was aware of regulations for storage of narcotics, but did not know [MEDICATION NAME] was being stored in the refrigerator. The DON indicated they would remedy this issue right away. A facility policy titled Controlled Substances II-V with effective date of 6/12/19, only addressed narcotics stored in the medication carts and did not include the medication room or the refrigerator.

Based on interview and document review, the facility failed notify the Office of the State Long-Term Care Ombudsman of hospital transfers for 3 of 3 residents (R10, R21, R78) reviewed for hospitalization s. This practice had the potential to affect all residents residing at the facility. Findings include: R21's undated face sheet indicated an original admitted [DATE]. The face sheet further indicated R21 had a hospital stay from 6/18/19- 6/25/19. A progress note dated 6/18/19, at 10:38 a.m. indicated R21 was transferred to the emergency department for evaluation via ambulance. Upon follow-up R21 was admitted to the hospital following an MRI and required emergency surgery to the spinal column. R21 returned to the facility on [DATE]. The medical record lacked indication that the Office of the State Long-Term Ombudsman was notified of the transfer. A progress note dated 9/24/19, at 11:25 a.m. indicated R21 was experiencing an acute change in mental status. The note further indicated the resident was very lethargic, with low blood pressure and slurred speech. R21 was evaluated by the physician doing rounds and after speaking with the family made the decision to send R21 to the hospital to be evaluated. Follow up progress note dated 9/24/19, at 11:09 p.m. indicated R21 had been admitted to the hospital with [REDACTED]. R21 returned to the facility on [DATE]. The medical record lacked indication that the Office of the State Long-Term Ombudsman was notified of the transfer. R78's Admission Record printed 1/24/20, indicated R78 was admitted [DATE], and included [DIAGNOSES REDACTED]. On 9/27/19, at 12:57 a.m., a progress note indicated R78 was sent to the emergency department on 9/26/19, at 10:45 p.m. via ambulance for shortness of breath or trouble breathing when sitting at rest, and shortness of breath why lying flat. Temperature was 101.9 degrees. R78 did not return to the facility. The medical record lacked indication that the Office of the State Long-Term Ombudsman was notified of the transfer. R10's Admission Record printed 1/24/20, indicated R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A progress noted dated 10/5/19, at 11:55 p.m., indicated R10 was transferred to the emergency department by ambulance for evaluation. Upon follow-up R10 was admitted to the hospital for urinary tract infection and received IV antibiotics. R10 returned 10/10/19. The medical record lacked indication that the Office of the State Long-Term Ombudsman was notified of the transfer. A progress note dated 10/13/19, at 5:39 p.m., indicated R10 was transferred to the emergency department for evaluation and low oxygen saturation levels. R10 was hospitalized and returned to the facility on [DATE]. The medical record lacked indication that the Office of the State Long-Term Ombudsman was notified of the transfer. During interview on 1/23/20, at 12;30 p.m., social services (SS) indicated the director of nursing (DON) was responsible for the bed holds, transfer agreements and notification of the Ombudsman since she covers more than one facility and is not always present. During interview on 1/23/20, at 12:47 p.m., the DON indicated he quit notifying the MN State Ombudsman this summer sometime regarding hospitalization s as he either read something or went to a conference where he was told the Ombudsman's was no longer requiring this. During interview on 1/23/20, at 2:54 p.m., SS indicated she had not heard of any changing and as to her knowledge, the State Ombudsman still require notification of all transfers. On 1/24/20, at 11:10 a.m., the DON confirmed he wasn't sending notification to the State Ombudsman since approximately (MONTH) of 2019. During interview on 1/23/20, at 4:02 p.m., the State Ombudsman for the facility confirmed he had not received any notification of transfer or discharge of residents since (MONTH) of 2019.