Every finding on record at Carondelet Village Care Center

Based on observation, interview, and document review, the facility failed to implement care plan interventions for 1 of 1 resident (R34) reviewed with a history of falls. Findings include:Findings:R34's Optional State Assessment (OSA) dated 8/8/25, indicated moderate cognitive impairment, did not reject care, required extensive assistance with bed mobility, transfers, and toilet use. R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 used a walker and wheelchair, had Parkinsonism (a syndrome characterized by different movement disorders such as walking and balance problems), heart failure, non-Alzheimer's dementia, and an artificial hip joint. Further, R34 fell two or more times with no injury since the prior assessment and fell one time with a non-major injury. R34's care sheet updated 11/17/25, indicated R34 required assist of one with a gait belt and rolling walker to use the bathroom and further indicated R34's walker was to always remain within reach because R34 self-transferred in the room and was at risk for falling. R34's care plan dated 8/19/25, indicated R34 had limited physical mobility due to Parkinsonism, cardiac disease and would self-transfer or self-ambulate often when in the room with or without adaptive equipment and required assist of 1 staff for transfers and ambulation. R34 had impaired cognition and required cueing, reorienting, and supervision as needed, additionally R34 was incontinent. R34 was at risk for falls due to dementia, Parkinsonism, and heart disease and required signage on the walker to remind R34 to take it with wherever she went. R34's Resident Occurrence Report dated 4/29/25, indicated R34 had fallen in her room, sustained a hip fracture and interdisciplinary team (IDT) interventions were deferred until R34 returned from the hospital. A handwritten note on the form indicated physical therapy (PT) and occupational therapy (OT) was initiated with a review date 5/7/25. R34's Resident Occurrence Report dated 6/22/25, indicated R34 fell while standing and washing her hands and the long-term interventions included R34 being in her wheelchair for all cares. Additionally, staff were educated on the use of a gait belt and use of a walker when completing cares. R34's Resident Occurrence Report and Falls Follow Up Forms dated 7/4/25, indicated R34 was on the floor and had a bump and bruise to the top of her right hand. Further, a long-term intervention included a sign was placed to always keep the walker with R34. R34's Resident Occurrence Report and Falls Follow Up Form dated 8/20/25, indicated R34 did not have her walker and fell going back to bed and sustained an abrasion and laceration. Further, the form indicated R34's walker was not within reach and staff were educated to keep the walker by R34 and follow the care plan. R34's care conference note dated 8/25/25, indicated R34 fell recently and sustained a laceration of her forehead and a skin tear on her wrist. Additionally, staff were re-educated to always have the walker right beside R34. During observation on 11/18/25 at 9:50 a.m., licensed practical nurse (LPN)-A left R34's room and R34's walker was folded up against the wall next to R34's television. A nebulizer was heard running and LPN-A stated she would be back. R34 was not observed to be near the walker. During interview and observation on 11/18/25 at 9:56 a.m., LPN-A verified R34 was receiving a nebulizer in her room. During observation on 11/18/25 at 10:00 a.m., LPN-A went into R34's room and turned off the nebulizer. R34's walker was still folded up by the television. At 10:02 a.m., LPN-A walked out of R34's room and the walker remained folded next to the television and away from R34. During observation on 11/18/25 at 10:04 a.m., R34 was in her wheelchair in her room with the call light next to her. Signage was located on the walker that indicated to always keep the walker with R34. R34's walker was folded in the corner by the television and out of R34's reach. During interview and observation on 11/18/25 at 10:07 a.m., nursing assistant (NA)-A stated they looked at the care plan to know what cares a resident required. NA-A stated R34 hadn't fallen recently but was at risk for falling and was supposed to have the walker with her at all times in case R34 tried to self-transfer to aide in her balance and further stated R34 even had a sign on her walker as a reminder. NA-A verified R34's walker was in the corner and stated the walker should be by R34. NA-A unfolded the walker and placed it next to R34. During interview on 11/18/25 at 10:12 a.m., LPN-A stated nurses looked at the care plan to know what cares a resident required and the NA's used care sheets. During interview on 11/18/25 at 10:17 a.m., NA-B viewed R34's care sheet dated 11/17/25, and verified the care sheet indicated R34's walker was to be kept within reach at all times. NA-B stated R34 needed the walker because she tried to get out of the chair or bed by herself and was prone to falls. During interview on 11/18/25 at 10:20 a.m., LPN-A stated care sheets were updated with the care plan and added she hadn't worked in R34's neighborhood for approximately four months and stated R34 needed the walker in case R34 got up on her own and if R34 didn't have her walker, her safety would be at risk. LPN-A further stated it was on R34's care plan to be within reach and added R34 could get up on her own and suffer injuries from a fall that possibly could have been prevented. LPN-A acknowledged she was not previously aware it was part of R34's care plan. During interview on 11/18/25 at 1:23 registered nurse (RN)-A stated staff entered the resident room after a fall to determine the cause and document the fall in the electronic medical record (EMR). A falls form was completed by floor staff. The clinical coordinators conducted the investigation. Falls were discussed at IDT, an intervention was implemented. After a week, the intervention was re-evaluated to determine if the intervention was effective. RN-A stated she expected the care sheet to be followed. During interview on 11/18/25 at 1:47 p.m., physical therapist (PT)-A stated R34 was seen by PT and was on a walking program. PT-A stated R34 was at risk for falls due to Parkinsonism and a history of falling and further stated R34 was probably impulsive; if R34 self-transferred, it would be better to have the walker with her at all times and expected the care sheet to be followed. During interview on 11/18/25 at 2:46 p.m., with the director of nursing (DON) and the regional director of clinical services (RDCS), the DON stated R34 fell during a self-transfer in July and IDT placed a sign to keep the walker with R34 at all times and stated they expected staff to keep the walker with R34 at all times. Further, when R34 fell on 8/20/25, the DON verified R34 did not have her walker within reach and RDCS stated staff were educated to follow the care plan. A policy, Fall Prevention and Management Program Policy, dated 9/2025, indicated the purpose of the policy was to provide a procedure for residents at risk for falls, assess fall risk factors, provide guidelines for fall and repeat fall preventative interventions. Prevention strategies include care plans will indicate the resident specific interventions to prevent falls. All staff are responsible for implementing the intent and directives contained within the policy and creating a safe environment.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R34, R38) were offered and/or provided updated vaccination for pneumococcal disease, in accordance with Centers for Disease Control (CDC). Findings:Review of the current, 10/26/24, Centers for Disease Control (CDC) Pneumococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, identified based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both the PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. Additionally, if an adult 50 years or older received PCV13 only, a single dose of PCV21 or PCV20 may be given after one year of receiving the PCV13 dose. R34:R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 admitted [DATE], and further, R34's pneumococcal vaccine was up to date.R34's Physician's Orders form indicated the following order: 12/4/24, may receive pneumococcal vaccinations if not already received.R34's Pneumococcal Vaccinations Consent form signed 12/4/24, indicated R34 wanted to receive the pneumococcal vaccinations that were recommended according to ACIP/CDC.R34's Minnesota Immunization Report (MIIC) dated 12/19/24, indicated R34 received PPSV23 on 3/25/2005, and PCV13 on 2/23/15. R34's Care Conference Summary note dated 5/19/25 indicated R34 was due for a pneumococcal vaccination. R34's Immunizations form saved 11/19/25, indicated R34 was [AGE] years old and received PPSV23 on 3/25/2005, and PCV13 on 2/23/15. The form lacked information R34 received PCV20 or PCV21.R34's medical record was reviewed and lacked evidence a shared clinical decision-making conversation took place or that R34 received PCV20 or PCV21. R38:R38's comprehensive MDS dated [DATE], indicated R38 admitted to the facility 10/16/25, and R34's pneumococcal vaccinations were up to date. R38's Physician's Orders form indicated R38 was [AGE] years old and had an order dated 10/16/25, to receive pneumococcal vaccinations if not already received.R38's medication administration record (MAR) and treatment administration record (TAR) dated October 2025 and November 2025 were reviewed and lacked information R38 received pneumococcal vaccinations.R38's Pneumococcal Vaccinations Consent form dated 10/16/25, indicated R38's pneumococcal vaccination status was up to date.R38's Immunizations form indicated R38 received PCV13 on 9/15/2015. No other pneumococcal vaccinations were documented as administered. The form lacked information PCV20 or PCV21 was administered at least 1 year after PCV13 was given. During interview on 11/19/25 at 1:32 p.m., with the infection preventionist (IP) and regional director of clinical services (RDCS), the IP stated on admission, the health unit coordinator accesses the MIIC, and the facility provides information on the pneumococcal vaccine and obtain consents. IP stated they used the CDC PneumoRecs Advisor application for use in determining residents eligible for vaccination and stated R34 was due for additional vaccination and would check to see if a conversation took place. Further, RDCS would check the MIIC for R38 and verified R38 was also due for another pneumococcal vaccination. During interview on 11/19/25 at 3:12 p.m., IP stated she would ask for an order for the pneumococcal vaccination for R38 and would update R38's family and would investigate whether a conversation took place for R34.During interview on 11/20/25 at 11:04 a.m., with RDCS and the director of nursing, the RDCS verified information in R34's and R38's medical record was correct. The DON stated they had vaccination plans and RDCS stated when a resident admitted to the facility, pneumococcal vaccinations were administered and further stated R34 and R38, missed them, and should have gotten the vaccinations.During interview on 11/20/25 at 11:21 a.m., IP stated it was their responsibility to see if pneumococcal vaccinations were up to date and offer the vaccinations to help elderly residents build an immunity to pneumonia and further stated it was important for vaccinations to be as up to date as possible.A policy, Pneumococcal Vaccination Policy, dated November 2024, indicated each resident was offered the pneumococcal immunization unless the immunization was contraindicated, declined, or the resident has already been immunized, and the purpose of pneumococcal vaccinations was to reduce the incidence of pneumococcal disease and the morbidity and mortality attributed to this infection. All residents who have never received a pneumococcal vaccination will be offered the vaccine upon admission and as needed in accordance with current ACIP/CDC recommendations. Each resident's pneumococcal immunization status will be determined upon admission or soon thereafter and if vaccination has occurred, the vaccination date will be documented in the resident's medical record. Complete shared clinical decision making if applicable.

Based on interview and document review, the facility failed to respect resident wishes for 1 of 3 residents (R1) reviewed for resuscitation status, resulting in receiving cardiac pulmonary resuscitation (CPR) against her wishes established in her Provider Orders for Life Sustaining Treatment (POLST). The IJ began on [DATE] when R1 was found unresponsive in her room and staff performed CPR based on an outdated POLST that was not corrected in R1's electronic medical record (EMR). R1's current POLST on [DATE] indicated DNR/DNI. The IJ was identified on [DATE]. The administrator, the director of nursing, and the regional clinical director were notified on [DATE] at 1:30 p.m. The IJ was removed on [DATE] and the deficient practice was corrected on [DATE], prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's hospital discharge paperwork indicated R1 was full code status, dated [DATE]. A physician order dated [DATE] at 9:36 a.m. was entered by a health information management (HIM)-A and verified by the clinical coordinator RN-A at 1:14 p.m. The order identified R1 to be a full code. R1's POLST, witnessed by RN-B and R1 on [DATE], and signed by the practitioner on [DATE], indicated R1 wished to be Do Not Attempt Resuscitation / DNR (Allow Natural Death). R1's POLST was uploaded to R1's EMR on [DATE]. R1's medical diagnosis list indicated R1 admitted to the facility on [DATE] for a displaced fracture of the left femur. R1's relevant diagnoses included fractures of the thoracic vertebrae, chronic pain, history of falling, and generalized muscle weakness. R1's Minimum Data Set (MDS) dated [DATE], indicated R1 admitted to the facility on [DATE]. R1's Brief Interview for Mental Status (BIMS) was 15, indicating she was fully cognitively intact. A progress note dated [DATE] at 5:12 a.m. indicated on [DATE] at approximately 11:40 p.m., RN-C and RN-D were alerted by the nursing assistant (NA)-A there was an emergency with R1. RN-C and RN-D responded to R1 and determined she was unresponsive without breathing or pulse. RN-C and RN-D began CPR. At 11:45 p.m. emergency medical services (EMS) were contacted. At 11:58 p.m., EMS arrived, assumed care, and continued providing CPR. The clinical administrator (DON) was contacted at 12:00 a.m. EMS pronounced R1's time of death at 12:15 a.m. on [DATE]. R1's family and provider were contacted. During an interview on [DATE] at 12:53 p.m., RN-E stated a resident's code status is displayed on the resident's home page in the EMR and in the physician order's tab. Part of their admission process is to obtain a POLST from the resident. The facility previously process was to have the resident sign a new POLST, then place it in the provider's box for review, which lead to a gap in communication of code statuses. They recently received training on the new process for changing code status. RN-E stated if a resident wants to change their code status and the provider is not available, they must go through POLST paperwork with the resident, and then call the on-call provider to get a verbal order, which is immediately entered into the resident's EMR. Entering the new code status order automatically changes the resident's banner in the EMR. The nurse must then fax the POLST form to the provider, and have the provider sign the POLST and fax it back. RN-E stated then they must scan the POLST into the EMR, put the physical copy in a box for filing, or give it directly to the HIM, then write a progress note detailing the resident's new code status. During an interview on [DATE] at 1:48 p.m., RN-F stated a resident's code status can be found in the resident's EMR profile on their banner. If a resident wants to change their code status, they need to complete a POLST form with them and call a provider for a verbal order. Then enter the verbal order on the resident's EMR, fax the form to the provider, and when a nurse receives the provider's signature, then uploads it to the EMR. RN-F stated then the POLST is put in the HIM's box for filing. During an interview on [DATE] at 2:18 p.m., RN-C indicated he was coming onto his shift the night of [DATE]. RN-C stated NA-A came running to him while he was receiving report from RN-D. RN-C and RN-D ran to R1's room and immediately took action. He retrieved an ambubag, and when he returned, R1 did not have a pulse. He and RN-D used the EMR to verify R1's code status as full code. He and RN-D initiated CPR, and EMS were contacted. RN-C stated when EMS arrived, they assumed care and requested R1's code status documentation and when they checked the paper chart, they found the physical POLST indicating R1 was DNR/DNI and informed EMS of the current POLST. R1 was pronounced dead shortly afterwards. POLST reeducation was received from the DON regarding respecting resident wishes and rights. Their process for new code statuses is to complete a POLST with a resident and then contact a provider for a verbal order immediately. RN-C stated once the POLST is faxed and signed by the provider, he would upload it into the computer and put the document on the HIM's desk for filing. During an interview on [DATE] at 3:15 p.m., RN-D stated when she and RN-C arrived in R1's room, R1's respirations were shallow, and her pulse was thready. She checked R1's code status in the EMR while RN-C retrieved an ambubag, and identified R1 was a full code. When she and RN-C reentered the room, R1 did not have a pulse and was not breathing, so they initiated CPR. RN-D stated EMS was called and when they arrived, they assumed care, pulled R1 onto the ground, continued CPR, and asked for R1's code status paperwork. RN-D went to the nursing station, retrieved R1's POLST, and saw R1 had a signed POLST indicating she was DNR/DNI. RN-D stated she immediately called the DON for guidance, and the DON directed her to have EMS stop CPR. EMS stopped CPR and announced R1 was deceased . RN-D stated she received reeducation that night from the DON about honoring a resident's wishes and signed it before leaving the facility on [DATE] at approximately 2:30 a.m. During her shift on [DATE], the DON held an all-staff meeting regarding code statuses. Their process if a resident wants to change their code status is to go through a POLST form with the resident and then call the provider. They will receive a verbal order from the provider and enter it as an order in the resident's EMR. RN-D stated the POLST is then uploaded to the EMR by herself or the HIM. During an interview on [DATE] at 3:34 p.m., RN-A stated any orders entered by the HIM must be confirmed by a licensed RN. Their new process for changing code status documentation is to obtain a new POLST from the resident and contact the provider for a verbal order. RN-A stated the nurse would enter the order into the EMR. This would either be done by the resident's nurse, or herself or the DON if they were available. It was the responsibility of the nurse who completed the POLST that did not match their current code status to contact the provider and update the EMR. RN-A stated there was reeducation completed with all staff regarding this process and their preexisting expectations and policies, including individual education for RN-A, RN-B, RN-C, and RN-D. During an interview on [DATE], the DON stated on [DATE] at approximately 12:00 a.m., he got a call at home from RN-D. RN-D explained she and RN-C completed CPR under the understanding R1 was full code per the EMR, but discovered when reviewing the paper charts R1 had a DNR/DNI POLST signed by the provider on [DATE]. He instructed RN-D to inform EMS of R1's code status, at which point CPR stopped and R1 was pronounced dead. The DON stated he immediately conducted an audit of all other remaining residents to ensure their documented code statuses matched their most recent signed POLST orders. Starting [DATE], he and RN-A completed reeducation for all staff on their new process for changing a resident's code status. Their new process if a resident wants to change their code status is for nursing staff to receive a new POLST, and then immediately contact the on-call provider to receive a verbal code status order. The nurse must then enter the verbal order into the EMR, then either upload it directly to the EMR, or give it to the HIM for uploading if they are present in the building. The POLST then goes to the in-house provider's box for review. This process can either be completed by the resident's nurse, or by himself or RN-A. RN-A received reeducation on ensuring the POLST orders match in PCC prior to giving it to the HIM for filing. RN-B received reeducation to make a progress note if a resident wants to change their code status. RN-C and RN-D received reeducation about respecting resident rights and wishes immediately following R1's death. The DON stated the facility has added this process to their QAPI initiates. The facility began conducting Code Blue drills for unresponsive residents on [DATE] and will continue with these initiatives monthly for four months, and then quarterly. During an interview on [DATE] at 8:50 a.m., RN-B stated she admitted R1 to the facility on [DATE]. R1 informed her she wanted to be DNR/DNI, and she completed a POLST with R1. She then put the POLST in the provider's box to be reviewed. She did not know R1 had been full code in the hospital, and that she could not see the order on her EMR. RN-B stated orders can be entered by the HIM but will not become visible on the EMR until they are approved by an RN. RN-B stated if she had known R1 wanted to change her code status, she would have called the provider immediately and gotten a verbal order, then placed the POLST in the box for provider review and HIM to file. During an interview on [DATE] at 10:45 a.m., HIM-A stated she is no longer allowed to put code status orders from the hospital into the EMR. HIM-A stated she does not remember if she saw R1's POLST order. During an interview on [DATE] at 10:45 a.m., RN-A stated POLSTs go to the HIM for scanning if they are in the building, otherwise it is the responsibility of the RN obtaining the new POLST. RN-A stated the HIM does not enter the code status orders for residents. A RN must enter new code status orders. This IJ was called at past noncompliance due to action the facility took prior to the survey entrance. Action included all staff were educated on how to change a resident's code status. The Code Status: Physician's Order for Life Sustaining Treatment policy reviewed by management and reviewed with all licensed staff. All staff directly involved in the incident and inputting code status order were reeducated on existing system and the importance of a code status. All the facility residents were audited to ensure their code status was correctly input in the software system and was current. A policy titled Code Status: Physician's Order for Life Sustaining Treatment Policy, dated [DATE], indicated resident orders must match the resident's POLST. The policy indicated if a resident chooses to become DNR/DNI, a telephone order should be obtained until the original document can be reviewed and signed by the physician.

Based on observation, interview and document review, the facility failed to ensure ice packs were stored separately from food storage in all three of the unit kitchenette refrigerators. In addition, the facility failed to ensure the proper use of hair restraints during food service. These practices had the potential to affect all 45 residents residing in the care center who received food from the kitchen or snacks from the unit refrigerators/freezers. Findings include: Ice packs During observation on 10/15/24 at 9:55 a.m., freezer in kitchenette of neighborhood one contained two boxed frozen meals, one tub of ice cream, three ice cream bars and one ice cream cone. In addition, there was one ice pack labelled with a current resident name and three additional unlabeled ice packs sitting among the frozen food items. in a plastic bag with J. [NAME] listed on it. there are also three additional ice packs unlabeled. During observation on 10/15/24 at 10:06 a.m., freezer in kitchenette of neighborhood two contained three ice cream cups, two yogurt cups, and two ice cream cones-one with the wrapper split open and an unlabeled ice pack lying on top of it). In addition, there was one ice pack with another current resident's first name and room number and four additional unlabeled ice packs. During observation on 10/15/24 at 10:11 a.m., refrigerator of neighborhood three contained two unlabeled cold packs and several food items including applesauce, yogurt, prune juice and pudding. In addition, the freezer contained two unlabeled ice packs and food items including a numerous assortment of individual ice cream products. During interview on 10/15/24 at 10:33 a.m., nursing assistant (NA)-A stated the snacks and ice packs stored in the kitchenette refrigerator/freezer were for resident use. During interview on 10/15/24 at 10:43 a.m., NA-B stated the snacks in kitchenettes were for the residents and that nursing would stock and retrieve items from them. NA-B further stated NAs would sanitize and return ice packs to the freezer when removed from a resident's room. During interview on 10/15/24 at 11:32 a.m., care center food service supervisor (FSS) stated food services was responsible for maintaining the temperature logs for the kitchenette refrigerator/freezers and would look for and remove outdated food items. FSS could not explain why the ice packs were stored in the kitchenettes or what they were used for. During interview on 10/15/24 at 11:47 a.m., culinary director (CD) stated would not expect ice packs for resident use to be stored in the same place as food was stored due to sanitary reasons. CD stated was not aware of that practice and that the ice packs should be removed. During observation and interview on 10/15/24 at 11:58 a.m., CD confirmed the presence of the ice packs in the kitchenette refrigerator/freezers and removed them. During interview on 10/16/24 at 12:36 p.m., director of nursing (DON) stated expectation was that ice packs for resident use would not be stored with food products and that the facility was changing to single use snap-to-chill ice packs. Facility policy Cold Pack, Dry, dated September 2018, indicated, Re-usable commercially prepared ice packs are to be disinfected after each use following the [organization's] Infection Control manual. These are stored in a dedicated freezer area, and not to be stored with food. Hair restraints During observation and interview on 10/15/24 at 12:00 p.m., the care center main dining area cook (C)-A plated food from inside the kitchen through a window for distribution. C-A had a full beard with approximately 1/4 inch growth. C-A was not wearing a facial hair/beard guard while serving food. C-A stated he did not usually wear one. During interview on 10/15/24 at 12:04 p.m., FSS stated facial hairnets/beard guards were available and that C-A should have been wearing one while in the kitchen serving food. During observation and interview on 10/15/24 at 12:15 p.m., CD restocked the hair restraint supply bin with beard guards. CD stated expected practice for staff in the kitchen while plating food was to wear hair nets which included facial hair restraints/beard guards. During interview on 10/16/24 at 12:36 p.m., DON stated expectation for staff to wear hair restraints-including beard guards-while in the kitchen during food service. Facility policy Hairnet Restraint Policy dated May 2015, indicated, Beards must be covered with a beard bag, and must be on before entering the kitchens or area where food is being prepared.

Based on interview and document review, the facility failed to ensure 1 of 5 residents (R23) were offered or received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Current CDC recommendations 03/15/23, revealed the CDC identified individuals who previously received 23-valent pneumococcal polysaccharide vaccine (PPSV23) and have not received any other pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20) should receive one dose of PCV15 or PCV20 at least one year after receiving the PPSV23. R23's admission Minimum Data Set (MDS) dated [DATE], indicated R23 was cognitively intact and had diagnoses of chronic heart failure. R23's nursing admission assessment dated lacked indication R23 was assessed for the pneumococcal vaccine. R23's immunizations dated 10/10/23, indicated R23 had a historical vaccination of PPSV23 in 2014, however lacked indication R23 had been assessed, offered, or declined the pneumococcal vaccine. When interviewed on 11/15/23 at 1:24 p.m., the infection preventionist (IP) stated pneumococcal vaccination status was assessed upon admission. If the nurse determined a resident was due for a pneumococcal vaccine, the provider was notified, and an order obtained. IP verified R23 had not had a pneumococcal assessment completed upon admission and expected staff to complete the assessment. Furthermore, the IP stated vaccine assessments were important to complete to help residents maintain their health. A facility policy titled Pneumococcal Vaccination Policy revised 7/2023, directed staff to determine residents' pneumococcal vaccination status upon admission. Furthermore, all residents are offered the pneumococcal immunization unless medically contraindicated or refused.

Based on observation, interview, and document review the facility failed to ensure privacy was provided when administering a topical medication (medication that is applied to the skin) for 1 of 1 residents (R18) observed during medication administration. Findings include: R18's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R18 had severe cognitive impairment and diagnoses of Alzheimer's Disease, and arthritis of the knees. R18's provider order dated 6/8/23, indicated R18 required, Aspercreme external cream 10% (topical medication for pain control) applied to both knees topically twice daily for pain. During an observation on 11/13/23 at 8:14 a.m., trained medication assistant (TMA)-A administered R18's morning medications. R18 was sitting in the common area at a table. There was another resident sitting across the table from R18 and two other residents seated at a nearby table. TMA-A went into R18's locked medication cabinet obtained her Aspercreme. TMA -A then proceeded to R18 and explained where TMA-A was going to apply the Aspercreme. R18 just smiled. TMA- A then pulled up both of R18's pant legs to rub the medication on both knees. TMA-A then removed gloves and pulled R18's pant legs back down. When interviewed on 11/13/23 at 8:25 a.m., TMA- A verified topical medications were supposed to be given in the resident's room for privacy. TMA-A further stated he should have taken R18 back to her room. When interviewed on 11/14/23 at 8:50 a.m. power of attorney (POA)-A stated R18 had severe confusion with Alzheimer's disease. POA-A stated R18 would be absolutely offended by having her pant legs lifted and medication applied to her legs. R18 would want privacy. When interviewed on 11/15/23 at 1:53 p.m., the Director of Nursing (DON) stated staff were expected to give any medications in the resident's room. DON further stated staff should not be lifting clothing to administer topical medications outside of their room as they are not providing dignity or privacy for the resident. A facility policy titled Medication Administration Procedures revised 1/17/19, directed staff to ensure resident privacy before expose areas of skin where topical medication was to be applied.

Based on observation, interview, and document review, the facility failed to ensure residents were free from physical restraints for 2 of 2 residents (R31, R41) who had pillows or perimeter mattresses placed on their beds preventing them from getting out of bed. Findings include: R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 was severely cognitively impaired, required one-person physical assistance with most activities of daily living (ADL) and did not use any physical restraints. R31's MDS indicated R31 used a walker and wheelchair for mobility. R31's diagnoses included Alzheimer's disease, dementia, and anxiety. R31's nursing assessment dated [DATE], indicated R31 had a perimeter/defined edge mattress for falls prevention. The assessment further indicated an informed consent had been obtained and signed by the responsible party. R31's care plan dated 9/29/23, indicated R31 was at risk for falls related to a history of falls, cognition, incontinence, and medication use. The care plan included an intervention added 4/6/23, of a perimeter mattress for R31 to better identify the edge of bed. R31's progress notes (PN) indicated the following falls: -1/3/23 a fall after independently standing up from her wheelchair. Which was a fall after standing from her wheelchair. -1/15/23 witnessed slip from bed. -2/1/23 found in room by dresser. -2/7/23 found on floor next to bed. -2/20/23 found in bedroom with location not specified. -3/4/23 found sitting parallel to bed. -3/13/23 found on floor in front of bed. -3/29/23 She stated that she got out of bed, fell and crawl [sic] to the middle of her room where she was found sitting. -4/3/23 fall from wheelchair in common area. -4/5/23 found in room in front of wheelchair. -4/18/23 She was trying to transfer herself to the chair next to her bed. R31's medical record (MR) included falls follow up reports for falls dated 12/12/22, 5/5/23, 5/28/23, 6/30/23, 8/14/23, 8/18/23, and 11/2/23. R31's falls follow up report dated 12/12/22 indicated R31 fell in the bathroom. R31's MR lacked evidence of a fall follow up reports for falls between 12/12/22 and 5/5/23 when the addition of the perimeter mattress intervention was added. R31's physician orders lacked evidence of an order for a perimeter mattress. R31's medical record lacked evidence of a signed informed consent for a perimeter mattress. R31's PN lacked evidence of any interdisciplinary evaluation or recommendation to add a perimeter mattress as a falls prevention intervention. R31's medical record lacked evidence of a formal physical device assessment for the perimeter mattress. During observation and interview on 11/13/23 at 1:31 p.m., R31 was in her room in a wheelchair. R31 stated she could not get out of bed on her own due to having such high edges on her mattress(pointing to the perimeter mattress-which had an approximate eight-inch edge). R31 stated she could self-transfer to and from the wheelchair to the recliner and toilet, but was told to use her call light to ask for assistance. R31 stated, I think they threw those things on my bed so I cannot get out of it. During observation and interview on 11/15/23 at 7:46 a.m., nursing assistance (NA)-A was completing R31's morning cares. NA-A stated R31 cannot get out of bed on her own and that the perimeter mattress was in place because she often put her legs out of the side of the bed. While R31 was seated on the side of the bed, NA-A gathered supplies and clothing for morning cares and reminded R31 not to get up on her own. During an interview on 11/15/23 at 2:14 p.m., NA-B stated R31 cannot get up out of bed on her own, but the bed was kept in the low position in case she attempted. NA-B could not explain why R31 had a perimeter mattress and stated perhaps to prevent her from rolling out of bed. During interview on 11/16/23 at 8:44 a.m., registered nurse (RN) stated not sure why R31 had a perimeter mattress. During interview on 11/16/23 at 9:10 a.m., director of nursing (DON) stated R31 had the perimeter mattress on to better identify the edge of the bed and would have to check to see if an assessment had been completed to determine if she could get out of bed so that it would not be considered a restraint. During interview on 11/16/23 at 9:38 a.m., maintenance director stated he received a work order for the perimeter mattress for R31's bed on 4/6/23 and installed it on 4/7/23. During follow up interview on 11/16/23 at 10:06 a.m., DON stated he could not locate an assessment for the perimeter mattress and that there should have been one completed to ensure it was not a restraint. During observation and interview on 11/16/23 at 11:07 a.m., R31 was on the toilet in her bathroom with no staff present. R31 stated she self-transferred to the toilet. RN-A was notified of R31's situation and stated she must have self-transferred. During interview on 11/16/23 at 1:04 p.m., administrator stated if there was no indication for use of a perimeter mattress or assessment regarding the resident's ability to get out of bed; the mattress could be considered a restraint. 44647 R41's significant change MDS assessment dated [DATE], indicated R41 had mild cognitive impairment and diagnoses of failure to thrive and Parkinson's Disease. Furthermore, R41's MDS indicated R41 had delusional thinking, had 2 or more falls with injury since admission, and no restraint use. R41's care plan revised 7/11/23, indicated R41 had limited physical mobility and at risk for falls related to weakness and failure to thrive and a history of falling. Fall interventions included a perimeter mattress and bed in lowest position. Furthermore, R41's care plan indicated R41 did not use restraints. An observation on 11/15/23 at 7:10 a.m., trained medication assistant (TMA)-B entered R41's room to administer morning medications. R41 was laying on his back in bed. R41's bed was low and next to the floor with one side against a wall. The side of the bed that was not against the wall had a pillow placed under the fitted sheet on the lower end of the bed by R41's legs. R41 had a perimeter mattress in place however the pillow in place was taller than the height of the perimeter mattress. When interviewed on 11/15/23 at 7:20 a.m., TMA-B stated R41 had crawled out of bed and was found on the other side of the room near his closet. TMA-B stated R41 had open sores on his knees from crawling on the carpeted floor. TMA-B stated the pillow was like a restraint but was for R41's safety as even with the perimeter mattress, R41 could still get out of bed and the pillow under the sheet was for R41's protection. When interviewed on 11/15/23 at 1:55 p.m., the Director of Nursing (DON) stated the facility did not use resident restraints. Furthermore, DON stated pillows were not to be used under sheets for a fall intervention, but only for positioning, support, and comfort. Facility policy Physical Restrain Policy dated November 2022, indicated the facility had a stringent policy regarding the use of restraints and the belief was for residents to maintain their dignity and independence by supporting them to take the normal risks of everyday life. The policy further indicated any device that cannot be removed easily by the resident and restricted the resident's freedom of movement would be considered a restraint. All physical devices required quarterly and annual assessments.

Based on observation, interview, and document review, the facility failed to ensure a walking program was maintained for 1 of 1 resident (R31) reviewed for ambulation. Findings included: R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 was severely cognitively impaired, required one-person assistance with most activities of daily living (ADL). R31's MDS indicated R31 used a walker and wheelchair for mobility and walked in room and corridor only once or twice during the seven day look back period. The MDS further indicated R31 did not exhibit rejection of care behaviors. R31's diagnoses included Alzheimer's disease, dementia, anxiety, and muscle weakness. R31's care plan dated 9/29/23, indicated R31 had limited physical mobility related to Alzheimer's disease, dementia, knee pain and muscle weakness. R31's care plan indicated R31 was on a walking program, Ax1 [assist of one] 50-100 feet daily with wheelchair to follow. R31's maintenance program (MP) dated 5/25/23, indicated a daily ambulation program with assist of 1 to walk 50-100 feet with wheelchair to follow. R31's nursing care sheet updated 11/14/23, indicated R31 was on a walking program 50-100 feet daily on day shift with wheelchair to follow. R31's point of care (POC) ambulation task dated 7/15/23 through 11/15/23 (119 opportunities), indicated R31 ambulated 19 times. All other opportunities had documentation indicated resident refusal or not applicable. Of the 19 times documented, R31 met or surpassed the goal of 50-100 feet six times. R31's progress note (PN) dated 2/20/23 at 7:15 a.m., indicated R31 had a fall, and the recommended intervention was to encourage her to participate with her walking program to increase strength. R31's PN dated 7/13/23 at 3:30 p.m., indicated, per clinical record, R31 does walk with staff assist in room approx. 3x (times) a week and does not walk in the hall. IDT [interdisciplinary team] will talk about possible change needed. R31's PN lacked additional discussion with IDT regarding her walking program. During observation on 11/15/23 at 7:46 a.m., nursing assistance (NA)-A completing R31's morning cares. NA-A assisted R31 to stand and pivot into the wheelchair and wheeled her into the bathroom and onto the toilet. After toileting, R31 stood to allow NA-A to assist with peri care. R31 stood steady with one hand on the assist bar next to the toilet for several minutes. R31's walker was folded and stored in her shower. NA-A did not offer R31 to walk to or from the bathroom with the walker. During interview on 11/15/23 at 8:17 a.m., nursing assistant (NA)-A stated R31 did not walk very much and only did so with therapy. During observation and interview on 11/15/23 at 10:28 a.m., R31 was sitting in the common area in wheelchair. R31 stated she could not remember the last time she walked and did not think she had a walker available. R31 could not recall anyone offering to walk with her recently. During observation on 11/15/23 at 11:29 a.m., licensed practical nurse (LPN)-A assisted R31 up from the recliner into the wheelchair and pushed her to the common area where NA-B took over and pushed R31 to the dining room for lunch. LPN-A nor NA-B offered R31 to ambulate to the dining room. During interview on 11/16/23 at 10:19 a.m., physical therapist (PT) stated R31 was not currently on therapy's case load. PT stated R31 was on a daily nursing walking program of 50-100 feet. PT stated if R31 was consistently refusing or not meeting her ambulation goal, PT would expect to be notified so PT could follow up and re-evaluate her program and potential change her program. During interview on 11/16/23 at 11:16 a.m., NA-B stated R31 was on a walking program for the nursing assistants to complete. NA-B stated R31 could ambulate up to 25 steps, but she often refused. NA-B stated she documented the steps or refusal in the computer but did not report anything to the nurse. During interview on 11/16/23 at 11:21 a.m., registered nurse (RN)-A stated she would expect the NAs to report if a resident on a walking program was consistently refusing or not meeting the goal. RN-A further stated it was the nurse's responsibility to review the tasks and ensure they were being completed and that she would report concerns to the clinical coordinator and therapy so they could re-evaluate the resident. During interview on 11/16/23 at 12:48 p.m., director of nursing (DON) stated expectation was for NAs to report to nurse and for nurses to report to DON if a resident on an ambulation program consistently refused to ambulate or was not meeting their goal. DON stated that would then be discussed in daily meeting in which PT attended and they would perhaps re-evaluate the resident and adjust the goals or discontinue the program if appropriate. Facility policy Maintenance Programs and IDT Forms dated March 2023, indicated residents on a MP would have the program reviewed on a regular basis to ensure the program was still appropriate for their functional level. The policy further indicated the review of the MP would include the level of the resident's participation and whether they were consistently meeting their goal. The program would be discussed by the IDT and revised when appropriate.

Based on observation, interview, and document review, the facility failed to ensure effective collaboration between the facility and a contracted hospice organization that affected 1 of 1 resident (R5) reviewed for hospice services. Findings include: R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated no rejection of cares or had behaviors, R5 required extensive assistance for bed mobility, dressing, eating, toileting, and personal hygiene, and was totally dependent on staff for bathing. R5's Medical Diagnosis included: degenerative disease of basal ganglia, multisystem degeneration of the autonomic nervous system, and muscle weakness. R5's care plan dated 3/19/23, indicated R5 required one assist for showers on Monday, Wednesday, and Friday p.m. Additionally, the care plan indicated R5 liked to wash her hair at the hair salon and not to wash R5's hair. R5's care sheet updated 11/10/23, indicated R5 had a bed bath on Wednesdays from hospice and had a shower on Friday p.m. shift. Additionally, the care sheet indicated do not wash hair put in w/c on beauty shop on Mondays. R5's hospice notice of election indicated R5 began hospice services on 3/2/23. R5's hospice binder included a hand written note undated, that indicated the nurse came every Monday and Friday and the aide visited every Monday to complete a bath or shower. R5's hospice certification and plan of care dated 3/2/23, indicated the home health aide visited once a week. R5's hospice recertification plan of care update dated 5/22/23, 8/16/23, and 10/13/23, indicated the home health aide visited once a week. The weekly bath schedule indicated R5's room number had an h in parenthesis following the room number on Monday during the day; on Wednesday, R5's room number had ba in parenthesis on the evening shift, and on Friday, R5's room number was located on the evening shift. R5's Bathing task form reviewed from the past 30 days on 11/15/23 at 7:41 a.m., and indicated two baths were provided and the following was documented: 10/18/23 Wednesday, documented as Not Applicable 10/19/23 Thursday, documented as Not Applicable 10/20/23 Friday, documented as Not Applicable 10/27/23 Friday, documented as Total Dependence with one person physical assistance. 11/5/23 Sunday, documented as Not Applicable 11/8/23 Wednesday, documented as Not Applicable 11/10/23 Friday, documented as Total Dependence with two person physical dependence. R5's hospice communication notes from the past two months indicated the hospice aide visited on the following dates: 9/5/23 (Tuesday) and documented the next visit would be on 9/11/23. 9/18/23 (Monday) and documented the next visit would be on 9/25/23. 9/25/23 (Monday) and documented the next visit would be on 10/2/23. 10/9/23 (Monday) and documented the next visit would be on 10/16/23. 10/16/23 (Monday) and documented the next visit would be on 10/28/23. 10/30/23 (Monday) and documented the next visit would be 10/7/23. 11/15/23 (Wednesday) and documented the next visit would be on 11/22/23. During interview on 11/13/23 at 5:20 p.m., family member (FM)-J stated the facility does not provide a bath for R5 and further stated R5 was incontinent and did not feel it was outrageous to ask for a bath two to three times a week and added they were paying more money, but receiving less services. FM-J further stated the hospice aide came once a week. During interview on 11/15/23 at 12:01 p.m., nursing assistant (NA)-C stated hospice came on Mondays to provide a bath and stated the facility also gave a bath and looked at R5's care sheet and stated Hospice came on Monday and Wednesday and the facility gave a bath on Fridays. NA-C stated when a resident received a bath, it was documented. During interview on 11/15/23 at 12:54 p.m., hospice registered nurse (RN)-H stated the hospice nurse visited twice a week and R5 received a home health aide (HHA) once a week and thought the HHA visits changed to Wednesdays and at the end of the month would go back to Monday and R5 had a HHA once a week since starting hospice. The hospice RN-H stated the facility completed a bath once a week as well. During interview on 11/15/23 at 2:24 p.m., registered nurse (RN)-C stated the aides documented baths in Point of Care and will let the nurse know if a resident refused. RN-C viewed R5's care sheet and stated R5 received a bath from hospice on Wednesdays and the facility provided a bath on Friday p.m.'s. RN-C verified R5's care plan indicated R5 received a bath three times a week. RN-C further stated the bathing came up on the electronic medical record (EMR) for R5 as an as needed task, and stated it should have been scheduled. During interview on 11/15/23 at 2:30 p.m., NA-E stated if a bath was provided, it was documented in Point of Care. NA-E further stated hospice gave one bath and the facility gave the other two baths a week. NA-E viewed R5's care sheet and stated R5 received a bath by the facility on Friday p.m., and hospice gave a bath on Wednesdays. During interview on 11/15/23 at 2:42 p.m., NA-E stated R5 did not receive a shower on 11/13/23, and stated she did not know the specific schedule when the hospice aide came and stated, they used to come on Monday, but came today and stated she did not know what the hospice schedule was and verified R5 had a calendar in her room, but the calendar was not completed to indicate when hospice was visiting. NA-E stated hospice staff will let the facility know when they are here, but don't inform them when they are leaving or when they will be coming next. NA-E further stated they did not know if R5 received a bath on Mondays and referenced the weekly bath schedule and stated R5 had an H next to her room number on Monday that indicated hospice gave the bath on Mondays. During interview on 11/15/23 at 2:54 p.m., the director of nursing (DON) stated the aide documented when a bath was provided and when a resident was admitted to hospice, the hospice communicated with the facility regarding the bath schedule. DON further stated hospice should have a calendar in the room and stated without a completed calendar, it made it difficult to know when someone was coming. DON viewed nursing assistant documentation for R5's baths and stated it looked like R5 was not receiving a bath and they were working on making sure all the communication was cohesive. During interview and observation on 11/16/23 at 9:22 a.m., licensed practical nurse (LPN)-B stated the hospice aide came on Mondays. LPN-B opened R5's hospice binder and located a handwritten piece of paper that indicated, Nurse comes every Mon and Fri Aid comes every Monday: Aid will do a bath/shower every Monday. LPN-B stated some hospices provide a calendar in a resident's room. During observation on 11/16/23 at 9:19 a.m., a dry erase board calendar with the hospice logo was located in R5's room, but the calendar lacked any planned visits from hospice. During interview on 11/16/23 at 9:30 a.m., RN-D stated some hospices talk to the nurse or send an email and provide a form on what day they are coming for bathing and stated the information was supposed to go on the care sheet. During interview on 11/16/23 at 9:53 a.m., the hospice clinical director (HCD)-I stated hospice patients had a calendar of the days staff came to visit and should be located in their hospice binder. HCD-I further stated the dry board calendar in the resident's room was more for the patient to see. During interview and observation on 11/16/23 at 10:04 a.m., LPN-B looked through R5's hospice communication notes written by the hospice nurse, chaplain, and home health aide and stated some of the notes indicated the date of next visit and verified not all notes contained this information. LPN-B verified there was no calendar in the hospice binder and verified the calendar in R5's room had no pending or past visits documented. At 10:15 a.m., LPN-B asked NA-C about a possible calendar and NA-C stated the hospice hadn't left a calendar. During interview on 11/16/23 at 12:20 p.m., LPN-B stated she followed up with the hospice and the hospice faxed the facility a calendar of hospice scheduled visits for the month of November on 11/16/23. A policy, Hospice Care Coordination dated November 2017, indicated the purpose of the policy was to provide guidance and clarity for facility staff to ensure coordination of care when a resident chooses to enroll in a Medicare or Medicaid approved hospice benefit program. The facility will continue to maintain 24 hour accountability for the resident when a resident chooses the hospice benefit. This includes but is not limited to continue to meet the residents personal and medical needs. The facility's services must be consistent with the coordinated plan of care developed with the hospice provider, and the facility must continue to offer the same services to the resident who chooses the hospice benefit as they do to those who have not chosen the hospice benefit. This includes what would normally be provided to a resident in the nursing home, including, but not limited to the following: comprehensive assessments and the RAI process, medication administration and medication regimen review, support for ADL's (activities of daily living), and monitoring the condition of the resident. A communication process will be established and maintained between the facility and the hospice which will be maintained 24 hours a day to ensure resident care.

Based on observation, interview, and document review, the facility failed to implement care plan interventions for 3 of 3 residents (R31, R22, R21) reviewed with a history of falls. In addition, the facility failed to ensure the environment was free from accident hazards for 1 of 1 resident (R20) found to have a space heater operating in their room. Findings include: R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 was severely cognitively impaired, required one-person assistance with most activities of daily living (ADL) and had fallen two or more times since admission. R31's diagnoses included Alzheimer's disease, dementia, anxiety, and muscle weakness. R31's care plan (CP) dated 9/29/23, indicated R31 was at risk for falls related to a history of falls, cognition, incontinence, and medication. R31's CP included falls interventions of gripper socks when in bed, do not leave alone in bathroom, ensure wheelchair was parallel to my bed when in bed and perimeter mattress to better identify edge of bed. R31's nursing care sheet updated 11/14/23, indicated R31 was independent with bed mobility, was not to be alone in the bathroom, required grip socks when in bed and ensure wheelchair was parallel to bed when in bed. R31's progress note dated 6/30/23 at 4:47p.m., indicated, Root Cause Analysis: Resident needs to go to bathroom and attempted by self-transferring. Intervention based on root cause analysis: Check antiroll-back brakes on w/c; W/C should be parallel to bed when resident is in bed; toileting schedule between 3-4 am. R31's medical record (MR) included falls follow up reports from falls dated 12/12/22, 5/5/23, 5/28/23, 6/30/23, 8/14/23, 8/18/23, and 11/2/23. During observation on 11/14/23 at 3:07 p.m., R31 was in bed sleeping with her wheelchair facing away from the bed approximately four feet from her bed. R31's shoes were on the other side of the room approximately six feet from her bed. During observation on 11/15/23 at 7:11 a.m., R31 was in bed sleeping with her wheelchair on the opposite side of the room from the bed. During observation on 11/15/23 at 1:52 p.m., nursing assistant (NA)-B assisted R31 into bed. R31's wheelchair was placed across the room and her shoes removed. R31 had [NAME] hose on and no gripper socks. During interview on 11/15/23 at 2:14 p.m., NA-B stated R31 had a history of falls due to self-transferring. NA-B stated the wheelchair was placed away from the bed because they wanted R31 to use the call light to have staff assist with transfers. NA-B further stated she did not think R31 needed gripper socks on while in bed and that R31 could put her shoes on independently. During interview on 11/16/23 at 9:10 a.m., director of nursing (DON) stated R31's falls interventions should be followed such as gripper socks when in bed, and wheelchair next to the bed. DON further stated the expectation was that the care plan should be followed. During observation on 11/16/23 at 11:07 a.m., R31 was on her toilet with her wheelchair in front of her and no staff present. During interview on 11/16/23 at 11:11 a.m., registered nurse (RN)-A stated R31 must have self-transferred to the toilet and was not supposed to be in the toilet alone. R22 R22's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R22 was severely cognitively impaired, was dependent on staff for most activities of daily living (ADLs) and had a history of falls. R22s diagnoses included medically complex conditions, heart failure and kidney failure. R22's care plan dated 9/18/23, indicated R22 was at risk for falls with interventions of call light in reach, monitor for medication side effects, follow fall protocol and have physical therapy to evaluate and treat as needed. The care plan lacked evidence of a large mattress or bed extender. R22's falls follow up form dated 9/17/23, indicated R22 fell from bed and required long term intervention of bed extension under mattress. R22's progress note dated 9/19/23 at 11:36 a.m., indicated, One recent fall on 9/17/23 due to rolling out of bed. No injury noted and we are in the process of ordering a wider bed to help prevent accidental rolling out of bed. R22's progress note dated 9/19/23 at 8:37 p.m., indicated, Root Cause Analysis: Resident may have rolled out of bed during repositioning. Intervention based on root cause analysis: Provide a wider bed: bed extension and a wider mattress. Evaluation of Intervention : Mattresses were ordered; bed frame will be installed once mattress is delivered. Ongoing plan: Mattresses were ordered; bed frame will be installed once mattress is delivered. Facility work order for R22's room dated 9/27/23, indicated, Shift bed to a bigger/wider bed .Mattress is available in the care center and can be taken as soon as the bed frame is installed and ready. During observation on 11/14/23 at 1:09 p.m., R22 was lying in bed sleeping. The bed was in a low position and call light within reach. The bed and mattress were standard size. During interview on 11/16/23 at 8:34 a.m., registered nurse (RN)-A was in R22's room and stated the bed appeared to be a standard sized bed and mattress and did not appear to have a bed extender or large mattress. During interview on 11/16/23 at 8:52 a.m., director of nursing (DON) stated R22 did not have a bed extender on her bed or a wider mattress. DON stated the facility had a wide mattress for her, but the bed extender was ordered but not yet received. During interview on 11/16/23 at 9:35 a.m., maintenance director (MD) stated the bed extender was never ordered and that he had been waiting for clarification. MD stated he had the wider mattress in stock, but needed the bed extender in order to install the mattress. MD could not explain why the bed extender was never ordered or followed up on. Accident Hazards: R20's significant change Minimum Data Set (MDS) dated [DATE], indicated R20 had moderate cognitive impairment and required 1-2-person physical assistance with most activities of daily living (ADL). R20's MDS indicate R20 did not use a walker or wheelchair for mobility. R20's diagnoses included congestive heart failure, adult failure to thrive, and anxiety. R20's care plan dated 8/25/23, indicated R20 had limited physical mobility related to weakness, fatigue and cognitive impairment. The care plan further indicated R20 did not ambulate and was bed bound. R20's neighborhood communication sheet updated 11/14/23, indicated R20 was bed bound by personal choice. During observation and interview on 11/13/23 at 2:28 p.m., a Delonghi brand electric space heater (model number EW7507EB) was found in R20's room operating and set to 80 degrees. R20 stated he did not know where the space heater had come from or how long it had been there. During interview on 11/13/23 at 2:43 p.m., registered nurse (RN)-B stated not sure where the space heater came from or how long it had been in R20's room. RN-B confirmed the space heater was operating and providing heat. During interview on 11/13/23 3:09 p.m., administrator stated being aware space heaters pose a fire risk and they were not allowed in the resident rooms. Facility policy Space Heaters and Electric Fireplaces dated November 2022, indicated, portable heating units are NOT allowed in care center or assisted living resident areas per NFPA 101 Life Safety Code.19.7.8. 46885 R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, did not reject cares, required extensive assist with bed mobility, transfers, and toileting, set up or clean up assistance with eating, and was frequently incontinent of bladder. R21's Medical Diagnosis form indicated the following diagnoses: dysphagia, oropharyngeal phase, history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke), weakness, and difficulty in walking. R21's physician order dated 11/13/23, indicated physical and occupational therapy (PT) and (OT) to evaluate and treat multiple falls. R21's care plan dated 3/22/23, indicated R21 had an activity of daily living (ADL) self care performance deficit due to weakness, impaired balance, dementia, history of stroke, and interventions included one assist for dressing, grooming and hygiene, encourage and remind R21 to use the call light, and required a regular diet with thin liquids and no straws. R21's care plan dated 6/21/23, indicated R21 was at risk for falls due to impaired mobility and cognition and had a history of falls and self transfers. Interventions included: review information on past falls and attempt to determine cause of falls. Record possible root causes and alter or remove and potential causes if possible, be sure call light is within reach and encourage R21 to use it for assistance, ensure R21 is wearing appropriate footwear as allows. R21's care sheet updated 11/10/23, indicated R21 required regular liquids and no straws, R21 was a risk for falling and attempted to self transfer and the soft touch call light was to be clipped on R21's shirt. Additionally, the care sheet indicated R21 ambulated with assist of one and a gait belt and rolling walker. The care sheet lacked an intervention to ensure appropriate footwear, and lacked information regarding the placement location of the walker. R21's nursing progress notes were reviewed 10/3/23, through 11/13/23, and indicated R21 had a fall on 11/9/23, after losing his balance and on 11/3/23, R21 was found sitting on the floor in front of his bedside table. The progress note dated 11/3/23, indicated the intervention based on the root cause analysis was to encourage R21 to ask for help and to use his walker if he was going to stand. R21's Falls Follow Up form dated 11/3/23, indicated a short term intervention to encourage R21 to use his walker if he decided to stand up. Long term interventions indicated R21 would have labs drawn and discussed lower shelves for the pictures in R21's room. R21's Falls Follow Up form dated 11/9/23, indicated a short term intervention to remind R21 not to self transfer and call for assistance. Long term interventions indicated R21 would have a PT and OT evaluation and treatment and had a urinalysis and urine culture which was negative. During observation on 11/14/23 at 11:46 a.m., R21 had a water glass with a straw in the covered cup on his bedside table located next to R21's television and out of R21's reach. R21 was in his reclining chair sleeping. During interview and observation on 11/14/23 at 12:02 p.m., R21 stated he needed water and nursing assistant (NA)-D brought R21's bedside table with the covered water glass next to him in his reclining chair in the room. NA-D stated R21 fell last week and stated R21 allowed shoes and socks to be donned and stated R21 did not have his shoes on because R21 was not going to try to transfer himself and verified R21's call light was clipped to the bed sheet out of R21's reach. NA-D removed the call light from the bed sheet and clipped the call light to R21's chair. NA-D further stated R21 was not supposed to have a straw in his water and stated he was usually in the dining room and NA-D left R21's room and left the straw in the cup. During interview on 11/14/23 at 12:10 p.m., trained medication aide (TMA)-A stated R21 was supposed to have a straw and should have foot wear to prevent a blood clot and should have a call light. TMA-A verified the care sheet indicated R21 was not supposed to have a straw and stated R21 usually used a straw and had no concerns with the straw in the water. TMA-A further stated R21 was at risk for falling and was checked in on. During interview on 11/14/23 at 12:15 p.m., licensed practical nurse (LPN)-B stated they would take the straw out of the covered cup because the care sheet indicated R21 could not have straws. LPN-B stated R21 was at risk for falls and attempted to self transfer and did not ask for help and verified R21's shoes were by the window and asked R21 if he wanted his shoes on and R21 stated he did not want his shoes on. During interview on 11/14/23 at 1:12 p.m., nursing assistant (NA)-C stated she looked at the care plan and pointed to the care sheet titled Communication Sheet in order to know what kind of cares a resident required. NA-C stated R21 could not have a straw because he could choke and needed his call light so he didn't fall. NA-C stated R21 used his call light and added, R21 was calling for assistance at that time. NA-C further stated all residents have to have proper footwear and if R21 took off his footwear, they had to put them back on. During interview on 11/14/23 at 1:34 p.m., registered nurse (RN)-B stated if a resident had a change in condition the care plan was updated and the aides had a care sheet they carried along with them that reminded them of tasks. RN-B stated R21 was at risk for falling and interventions included to anticipate his needs. RN-B stated she would have expected staff to give R21 the call light and stated appropriate foot wear during the day included shoes and verified that appropriate footwear was not on the care sheet and would have expected the intervention to be on the care sheet for the aides. During interview on 11/14/23 at 1:58 p.m., the director of nursing stated he expected the call light to be in place and appropriate foot wear could be added to the aide care sheets so they were more aware and would have expected staff to follow the care sheet that had special instructions to not have straws because part of the risk was aspiration. During interview on 11/16/23 at 11:01 a.m., speech therapist (ST)-G stated it depended on the situation why a resident had instructions for no straws and did not recall the circumstances for R21. Additionally, they had a different electronic medical record (EMR) and would have expected staff to follow the care plan. A policy, Fall Prevention and Management Program dated April 2021, indicated the purpose of the policy was to establish a policy, assign responsibility and provide procedure for residents at risk for falls; to systematically assess fall risk factors; provide guidelines for fall and repeat fall preventive interventions; and outline procedures for documentation and communication. Clinical coordinator or designee is responsible for implementation and oversight of individualized residents fall prevention care as follows: assessing fall risk upon admission, quarterly, with significant change in condition, determining risk for fall and establishing appropriate interventions in the care plan related to fall risk in the plan of care, implementing the interventions specific to fall risk data collection, evaluating the effectiveness of interventions in relation to the resident specific plan of care, appropriately managing residents who experience a fall by implementing interventions to prevent further falls. Nursing staff will implement interventions according to resident specific risk factors. Care plans will indicate the resident specific interventions to prevent falls. Following a fall, the nurse will recommend interventions and changes to plan of care to prevent a repeat fall, assess all factors contributing to the fall including intrinsic and extrinsic factors and which interventions were in place at the time of the fall using Falls Follow Up Form as a guideline. The new intervention will be monitored for effectiveness every shift for 48 hours after implementation notation of effectiveness should occur in the medical record. A policy, Care Plan Policy and Procedure dated November 2022, indicated interventions should be written to help meet the goal and the interventions should be individualized to the resident. Identify a discipline or department which will be responsible for the interventions. This may be more than one discipline. The care plan is to be changed and updated as the care changes for the resident and as the resident changes occur it will be updated in the EMR. It is to be current at all times.

Based on observation, interview, and document review, the facility failed to provide proper eating utensils and assistance for 1 of 1 resident (R16) reviewed for adaptive equipment. Findings include: R16's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, did not reject care, required extensive assistance for most activities of daily living (ADLs), required limited assistance with eating, required setup or clean up assistance with eating. R16's Medical Diagnosis indicated: unspecified dementia, essential tremor (a movement disorder that features tremors in arms and hands), muscle weakness, and dysphagia (difficulty swallowing). R16's care plan dated 6/24/23, indicated an intervention dated 9/22/23, to cut food into bite sized pieces, finger foods as able, red foam grip utensil in divided plate, and R16 required supervision to limited assist with 1 with eating. R16's clinical physician's order dated 9/1/23, indicated the following: no fish or shell fish per resident request cut food into bite-sized pieces. Divided plate. Red foam grip. finger foods as able. The order did not identify what the red foam grip was. R16's care sheet dated 11/10/23 indicated R16 required supervision to ensure R16 could feed herself, and food was cut into bite sized pieces and finger foods as able. Additionally, R16 required red foam grip utensils in a divided plate. R16's meal ticket sheets indicated on the top of the form highlighted in yellow, Cut food into bite sized pieces/Finger foods as able divided plate and red foam grip utensil. R16's occupational therapy (OT) note dated 8/30/23, indicated R16 did not use silverware without cuing and use of red foam built up handles on the silverware were trialed and R16 demonstrated increased ease of task with the modification. R16's OT note dated 9/27/23, indicated R16 benefited from use of a divided plate with finger foods cut into bite sized pieces. During observation on 11/14/23 at 8:21 a.m., to 8:26 a.m., R16 was in the dining room and had a divided plate and was eating coffee cake with her fingers. Staff were not assisting residents in the dining room, one staff person was wiping down another table. R16 did not have red foam grip utensils. During interview and observation on 11/14/23 at 12:30 p.m., R16 was in the dining room eating lunch with her fingers. R16 had salad, potatoes, and a piece of bread. R16 did not have red foam grip utensils, but had a divided plate. R16 did not eat her salad. The culinary director (CD)-D verified R16 should have red foam grip utensils and stated staffing was not consistent in the kitchen. During interview on 11/14/23 at 12:34 p.m., nursing assistant (NA)-C stated R16 did not refuse cares, and did not use special silverware. NA-C further stated sometimes R16 used silverware, but when NA-C walks away, R16 ate with her fingers. During observation on 11/15/23 at 7:47 a.m., an unidentified staff person brought R16 to the table and asked R16 what she wanted for breakfast but did not ask if R16 wanted special silverware. R16's unrolled her napkin, which contained regular silverware and did not contain the red foam around the handles. The tables in the dining room contained rolled up napkins at all the tables. During observation on 11/15/23 at 7:56 a.m., another unidentified staff person asked R16 what she wanted for breakfast, but did not offer special silverware. At 7:58 a.m., staff delivered a glass of juice. At 8:03 a.m., staff delivered bacon and toast but did not offer special silverware. R16 was eating the bacon with her fingers and dropped the bacon. R16 did not have a divided plate, but had a lipped plate. During interview on 11/15/23 between 8:15 a.m., dietary aide (DA)-A stated she was not aware R16 needed a divided plate and stated R16 was having trouble with her bacon and was going to get R16 some sausage and would cut it up for her and further stated R16 did not have special silverware. At 8:18 a.m., DA-A brought R16 sausage and stated she would cut it up for R16. During interview on 11/15/23 at 8:25 a.m., the care center supervisor cook-A stated diet slips contained the diet and special utensils residents required and further stated the slips were thrown away after a resident was served. During interview on 11/15/23 at 8:26 a.m., DA-B verified R16 had no divided plate or foam silverware. During interview on 11/15/23 at 8:54 a.m., DA-A stated the tickets came late and verified R16 was supposed to have a divided plate with food cut up in bite sized pieces and special silverware. During interview on 11/15/23 at 8:56 a.m., the director of nursing (DON) stated diet slips came from the dietary department and stated it was important to have a communication tool to indicate adaptive equipment, diet texture, and to give staff a guide of the resident's preferences and expected staff to follow the diet slip. During observation on 11/15/23 at 11:52 a.m., R16 was in the dining room eating and did not have the red foam eating utensils, nor the divided plate. R16 was observed eating a thick wide piece of pasta with her fingers. The menu indicated beef lasagna with steamed spinach and garlic bread. R16 was trying to place her glass on her plate. During interview on 11/15/23 at 11:55 a.m. culinary supervisor (CS)-E stated she noticed R16 got the wrong plate and wrong utensils and added she had gotten her stuff out, but did not know what happened to it. CS-E provided R16 the divided plate, but could not locate R16's red foam silverware and gave R16 thicker handled silverware. During interview on 11/16/23 at 8:54 a.m., occupational therapist (OT)-F stated a divided plate contained a built up edge to provide more support when a resident scooped the food so it does not go off the plate. OT-F further stated foam grip utensils helped residents who have fine motor difficulty because it provided a bigger grip to hold onto and increased independence. Additionally, the foam doesn't have a lot of weight and verified those were the reasons R16 required foam grip utensils and a divided plate. OT-F further stated they were working on a divided plate with finger foods and foods cut up into bite sized pieces and R16 preferred finger foods, but verbal cues increased the ease of the task with the modifications and expected staff to follow the instructions from OT because it could otherwise potentially cause increased frustration for R16 and R16 was not a resident who would ask for help and stated meals should be enjoyable and without the adaptive equipment, could lead to more frustration and possibly affect food intake. A policy was requested, however the administrator stated they did not have a policy regarding eating equipment and utensils.

Based on observation, interview, and document review the facility failed to ensure manufacturer recommendations were followed for a mechanical lift transfers and failed to a comprehensive assessment residents safety when using a mechanical lift. This resulted in immediate jeopardy (IJ) when one sling loop detached resulting in head injury, broken neck, and death. In addition the facility failed to comprehensively assess for sling style and size to ensure safe transfers for 1 of 8 residents (R2) that used a full body mechanical lift. The IJ began on [DATE], at approximately 4:45 p.m. when R1 fell from a mechanical lift when two aides did not follow the care plan and facility policy resulting in R1's death. The interim administrator, administrator, director of nursing (DON), and clinical coordinator (CC)-A, were notified of the immediate jeopardy on [DATE], at 5:18 p.m. The immediate jeopardy was removed on [DATE], at 1:34 p.m. but non compliance remained at a lower scope and severity of an D with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings Include: A facility reported incident (FRI) dated [DATE], at 4:45 p.m. indicated that R1 was being transferred from bed to wheelchair via a Golvo full body mechanical lift. The report indicated that during the transfer one of the loops of the sling (a fabric device that directly hooks to the lift that provides patient stability) slipped off the lift hook resulting in R1 falling out of the sling and onto the floor. R1 sustained a laceration to the back of the head and R1 was transferred to the hospital. R1's face sheet identified diagnoses of dementia, unspecified Alzheimer's disease, and osteoporosis. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment. R1 required total dependence of two staff assist with transfers. R1's Resident Transfer assessment dated [DATE], indicated R1 required two person assist for a full body mechanical lift for transfers. The assessment indicated R1 weighed 96.9 pounds (lbs.). Further indicated R1 required three different style slings: a universal sling size medium slim (,d+[DATE] lbs.), amputee sling size medium (,d+[DATE] lbs.), high back sling size medium (,d+[DATE] lbs.) The assessment did not specify which style sling R1 was to use and had the wrong size sling according to her weight. R1's care plan revision, dated [DATE], identified R1 was non-ambulatory. R1 required assist of two staff with a full body mechanical lift and a MEDIUM sized sling to transfer. R1's care plan did not identify the style of the sling as indicated in her transfer assessment. R1's care guide (abbreviated care plan for direct care staff) dated [DATE], indicated R1 required assist of 2 with the use of a full body lift, and an (orange) small size sling, which was inconsistent with the care plan. R1's nursing progress notes dated [DATE] at 4:45 p.m. indicated R1 had a fall from the mechanical full body lift. When (registered nurse (RN-A)) arrived, R1 was lying on the floor on her right side between the lift's leg. (NA-A and NA-B) said they don't know how it happened. R1 had two cuts on the backside of her head that measured 2.0 centimeters (cm) x 0.5 cm, and 1.0 cm by 0.5 cm. Bruising noted to the right side of R1's face. Intervention based on root cause analysis: education given on total lift and sit to stand machine by director of nursing (DON) to all employees on duty. During a phone interview on [DATE], at 2:14 p.m., family member (FM)-A stated R1 had died this morning from her traumatic injury sustained from the lift transfer. FM-A indicated R1 was completely bruised on one whole side of her body, on her arms and legs and suffered horribly. During a phone interview on [DATE], at 2:28 p.m. family member (FM)-B stated she had filed grievances about lift transfers being completed with only one staff; she did not get timely responses. FM-B explained she was at the facility on [DATE] and left at 3:15 p.m. When FM-B left R1 was dressed and had just been laid down in bed. FM-B indicated that she received a call from her brother reporting that R1 had fallen. FM-B arrived back at the facility around 5:45 p.m. R1 was lying in bed actively bleeding from her head and a pool of blood on the floor. FM-B stated the DON informed her R1 had fallen about 3 feet from the lift. FM-B stated she informed and instructed the DON that R1 needed to be transferred to the hospital after she visualized the extent of R1's injuries. A summary record, M Health Fairview, University of Minnesota Medical Center (UMMC) admitted , [DATE]. Record indicated that R1 sustained a T1 compression fracture (a type of broken bone that can cause your vertebrae to collapse, making them shorter), a C2 left transverse process fracture (cervical spine fracture), left distal vertebral artery dissection (occurs when a tear forms in one of the blood vessels running up the back of your neck), and a scalp laceration that required stitches. Further indicated that R1 was initially sent to Woodwinds emergency department (ED), although ultimately sent to UMMC for further work up. R1 went unresponsive on [DATE] and palliative care was initiated. R1 was pronounced dead on [DATE] at 10:08 a.m. During a phone interview on [DATE], at 3:59 p.m., NA-A indicated that on [DATE] at 4:15 p.m. she and NA-B went into R1's room to transfer R1 from the bed to wheelchair. NA-A explained she was in charge of making sure R1 was in the sling correctly; she was the spotter. NA-B was in charge of the operation of the lift. NA-A reported they placed the sling under R1 then had attached the four pieces of the sling loops to the lift and made sure it was fastened correctly; they completed a pause for a cause (double checking the loop positioning prior to the transfer). NA-A then informed NA-B she was going to get R1's wheelchair from the bathroom. While NA-A was getting the wheelchair from the bathroom, NA-B moved the lift backwards away from the bed while R1 was suspended in the air by the sling. NA-A reported NA-B had the lift all the way into the hallway of the room (5 feet) as she was trying to get the chair from the bathroom. When she (NA-A) was in the bathroom R1 fell out of the lift. NA-A indicated the full body mechanical lifts did not require two staff to complete the entire transfer (inconsistent with facility policy). NA-A indicated that R1 was moved too far, too quickly. However, NA-A could not confirm what was happening prior to the fall as she was in the bathroom and could not visualize R1. During a phone interview on [DATE] at 4:26 p.m. NA-B reported during R1's transfer on [DATE], NA-A connected R1 to the lift, verified placement of the sling loops on the machine. NA-B then pulled the machine out from underneath the bed. NA-A walked away and went into the bathroom, and she (NA-B) continued to pull the lift backward towards the hallway approximately 5 feet. NA-B explained in the process, the loop from the right side of the sling came off the lift, causing R1 to fall out of the sling onto the floor. NA-A was not in visual eyesight or R1's reach when the incident occurred. NA-B explained R1's wheelchair was always in the bathroom, so someone always had to step away when getting the wheelchair during the transfer. NA-B indicated R1 was transferred back to bed using the same type of sling that she had fallen from; NA-B was not aware of the difference between a high back sling and a universal sling. During a phone interview on [DATE], at 11:33 a.m. registered nurse (RN)-A indicated that she entered the room on [DATE] just before supper, after hearing screaming. RN-A found R1 on the ground between the lift legs. RN-A indicated NA-A had not witnessed the fall because NA-A had gone into the bathroom to get the wheelchair during lift transfer. RN-A indicated that she applied pressure to R1's head with a washcloth to try and stop the bleeding. RN-A stated, the lift and sling were immediately removed from service. RN-A and the DON transferred R1 from the floor back to R1's bed using a different full body lift and a different universal lift sling. RN-A could not articulate the difference between a high back and universal slings. During a phone interview on [DATE], at 12:29 p.m. lift representative (LR)-B indicated the lift, and the sling were inspected by the manufacturer. There was no equipment failure identified and it could only have been operator error. During a phone interview on [DATE], at 11:07 a.m. LR-A stated, when moving the full body lift around, this could cause the sling to go back and forth with or without someone in the lift. It's best practice and has always been the company's expectation to have two people when transferring with a full body mechanical lift. One person acts as the operator and the other as the spotter. The spotter would be observing the situation including the loop latch and providing protection and compensation to the patient. To ensure safety during the transfer, it is too much for one person to do alone. LR-A stated R1's fall could have been prevented had a second person or spotter been there to lead the lift and the movement of the sling. During an interview on [DATE], at 12:16 p.m. DON stated that NA-A and NA-B did not follow the facility policy when both aides were not in visual line of site during the full body lift transfer with R1. Additionally, R1's wheelchair the shortest distance possible from the transfer (R1 would have had to pushed in the lift while suspended to the transfer surface versus turning the lift to the transfer surface). DON expected staff to follow manufacturer's recommendations and facility policy when transferring residents with mechanical lifts. R2 R2's face sheet indicated diagnoses of dementia with other behavioral disturbance, Alzheimer's disease, delusional disorder, and anxiety disorder. R2's quarterly MDS assessment dated [DATE], indicated R2 has severe cognitive impairment and was dependent on two or more staff with transfers. R2's quarterly Resident Transfer Assessment, dated [DATE], indicated R2 weighed 104.4 lbs. The assessment indicated R1 incorrectly identified R2 required a medium universal sling (132 to 198 lbs.); according to R2's weight the R2 required the universal medium slim sling (,d+[DATE] lbs.) Assessment further identified R2 required a medium full back sling (,d+[DATE] lbs). The assessment did not specifically identify which sling was appropriate for R2. R2's care plan revision date [DATE], indicated R2 was transferred with a full body mechanical lift with two staff and directed to use medium slim sling. R2's undated care guide directed staff to use a yellow medium slim sling (however indicated the wrong color of yellow, the corresponding sling was gray). During an observation on [DATE], at 12:29 p.m., R2 was transferred via full body mechanical lift with a medium yellow high back sling from the chair to the bed. This was completed by NA-C and NA-D. The sling used was not in accordance with the care plan. During an interview on [DATE], at 9:33 a.m. clinical coordinator (CC)-A indicated the DON completed all of the Resident Transfer Assessments (that were not referred to therapy). The care plan and care guide were then updated to reflect the size sling; care guides were updated daily with any changes. CC-A reviewed R2's record, CC-A stated R2's assessment identified all three sling styles (universal, high back, and amputee sling) for R2, but did not specifically identify which sling R2 required and/or appropriate for transfers. CC-A was unable to articulate which sling should be used for any residents when all three slings were identified on the assessment. During an interview on [DATE], at 12:16 p.m. DON stated that R2 was transferred on [DATE], with the wrong size sling. R2 should have been transferred with the high back medium slim gray sling. During interview on [DATE] at 12:18 p.m. occupational therapist (OT-A) indicated sling sizes were determined by weight and sometimes physical attributes such as being an amputee. OT-A stated there were not any other contributing factors when choosing universal sling versus high back. During interview on [DATE] on 2:58 physical therapist (PT-A) indicated the therapy staff is at times involved in sling determination. When therapy completed the lift assessments they would determine sling sized based on resident weights. Therapy would then fill out an interdisciplinary team communication sheet, the clinical coordinator would put it in the care plan. Facility used small, medium, and large size slings. PT-A stated that the facility had only been using universal slings and not high back or amputee slings. During interview on [DATE] at 3:05 Director of Therapy (DOT-A) indicated an unawareness of the facility's sling inventory and would need to verify what size and style slings were on hand. DOT-A was unable to articulate an indication for a high back sling. DOT-A indicated staff need to reference the color coded chart on the lift for what sling to use. DOT-A explained if a resident's weight was not accurate to the size or if manufactures recommendations were not followed then serious risks can occur. During an interview on [DATE], at 9:56 a.m. DON could not articulate the difference between the styles of the slings and indication of use. Further indicated that the facility was not completing individualized comprehensive assessments for the appropriate lift sling size and style and confirmed all residents care plans and care guides were not accurate for identification of sling style and size. Facility policy Resident Transfer Assessment Policy dated [DATE] indicates that the assessment is to be completed by a licensed nurse or therapist. Licensed nurse or therapist will review documentation, interview direct caregivers, and observe a transfer of the resident. If the resident requires a mechanical lift the resident will be assessed for proper sling or harness using the manufactures guidelines. This will be noted in the assessment. The policy indicates that assist of two staff are required for all residents requiring a full mechanical lift. Facility Mechanical Lift Transfer Policy dated [DATE] directed the following: staff to always follow manufacturer's recommendation for the proper use of the equipment and slings. Two staff must remain present through the process of the transfer until the lift is no longer engaged and sling straps are unhooked. Staff are not to leave the resident out of visual line of site while the resident is attached to the lift. Further directs staff to place a wheelchair or other equipment, which the resident is to be transferred to, within the shortest distance possible from the bed, facing the head of the bed. Residents cannot be left hooked to the mechanical lift unless staff are present or directly visualizing. Manufacturer's recommendations for Universal and high-backed slings, dated 2020, indicated, It is important to choose the correct size in order to achieve the highest level of comfort and safety. A sling which is too large increases the risk of the patient sliding out of it, while one which is too small can cut into the groin and cause discomfort. Manufacturer instructions for the Liko Golvo lift dated 2017 included Before lifting always make certain that: -the lift strap is not twisted or worn and that it can move freely in and out of the lift unit; the lifting accessories is selected appropriately in terms of type, size, material and design with regard to the patient's needs; the lifting accessory is correctly applied to the lifting equipment; the lifting accessory is correctly and securely applied to the patient, so that no personal injury can occur; the sling's strap loops are correctly fastened to the slingbar hooks when the sling strap is extended, but before the patient is lifted from the underlying surface. Never leave a patient unattended in a lifting situation! The immediate jeopardy that began on [DATE], was removed on [DATE], when it was verified the facility implemented the following: -The facility reviewed and revised the full body mechanical lift policy to include directives on completing the comprehensive assessment for sling sizes and styles. -The facility comprehensively assessed all residents who utilized full body lifts in accordance with the manufacturers recommendations. -The facility revised care plans and care guides based on the comprehensive assessment for all residents who utilized full body lifts. -The facility educated all nursing staff on required two staff assist for full body transfers, double checking the position of the loops, completing comprehensive assessments for sling style and size, and on the types of slings and sizes. In addition, staff completed competency tested .

Based on observation, interview, and document review the facility failed to ensure foods were labeled and dated, stored off the floor, and foods past the best by or use by dates were discarded. This had the potential to affect all 42 residents who consumed food from the kitchen. Findings include: During the initial kitchen tour with the culinary director (CD) on 12/12/22, at 11:54 a.m. the CD stated food was prepared in the main kitchen and was sent downstairs in hot carts and served in steam wells. The following was observed during tour of the main kitchen: -Uncovered and unlabeled cheese in the cooler. The CD confirmed this should not be used. -A frozen bag of carrots with a best by date of 9/24. The CD stated stickers should be placed on the bags when foods are taken out of the box. -10 bags of frozen fried rice with no date on the bags. The CD stated she did not know when the rice came in and verified there was no use by or best by date indicated on the bags. -Two bags of frozen cooked shrimp and the CD verified there was no use by or best by date indicated on the bags. -1 bag of frozen chicken breasts with no date indicated on the bag. -1 bag of opened frozen chicken with no date indicated on the bag. -1 bag of frozen onion rings that was undated. The CD stated there was no date indicated on the bag. -The CD stated there was spilled ice cream on the floor of the freezer and stated there was a freezer malfunction. -1 bag of frozen fish undated and the CD discarded. -1 bag of frozen fajita meat that was undated. The CD stated it would be discarded. -2 bags the CD identified as being frozen chicken or pork and undated. The CD stated they would be thrown. -1 package of frozen turkey breast with no date located on the package. -1 package of frozen hamburger with a use by date of 6/11. The CD stated she was going to throw it away because it did not have a year and did not look nice. -Bread sticks undated in the freezer -1 package of bread undated in the freezer -Pastries that were undated in the freezer -Corn bread muffins undated in the freezer -Blueberry muffins undated in the freezer -3 packages of chocolate muffins undated in the freezer. The CD stated unfortunately they are not dated. -2 unopened boxes of honey nut cheerios located on the floor in the dry storage room. -1 prune juice located on the floor. The CD stated it should not be stored on the floor, it should be on a shelf. -1 bag of undated Rice Crispies and the CD verified there was no date on the package. -10 packages of hamburger buns with no date -2 loaves of rye bread with no date located on the bag During interview and observation on 12/15/22, at8:33 a.m., the main kitchenette in the care center the dietary aide (DA)-A stated there was undated french toast that would be thrown. There was also a bag of 6 waffles that was undated, and a package of cheese dated 12/12. DA-A stated the cheese was good for four or five days. During interview and observation on 12/15/22 8:44 a.m., observed the following in the refrigerator on unit one: -4 pitchers of fluid in the refrigerator, and none had been dated -11 apple juice cartons in the refrigerator with instructions that indicated to store frozen 0 or below and thaw under refrigeration 40 degrees Fahrenheit or below and after thawing keep refrigerated and use within 14 days after thawing. There was no date on the cartons to indicate when they were placed in the refrigerator. Additionally, there was no thermometer located in the refrigerator. -2 four ounce containers of apple banana yogurt with a best by date of June 28, 2022 -1 half gallon of fat free skim milk with a best by date of 12-10-22 -6 bottles of chocolate flavored syrup unlabeled. One bottle had chocolate sauce running down the side. -1 open container of antipasto italiano. The package was unsealed and a best before 9/9/22, date was located on the package. -1 package of opened cheese with fuzzy blue gray growth on the cheeses. During interview on 12/15/22, at 8:59 a.m. registered nurse (RN)-B stated the apple cranberry juice containers should have been dated and thought they should be dated prior to going into the refrigerator. RN-B stated that was mold on the cheeses which had a use by date of 9/21/22, and stated the cheese had been in the refrigerator a while. RN-B threw the antipasto italiano sausage and cheese packages away. RN-B stated there was a sign on the refrigerator door that indicated each shake was to be dated and verified that there were no dates on the shakes and verified there was no thermometer in the refrigerator. RN-B stated juice containers should be dated and products past shelf life should be discarded. During interview and observation on 12/15/22, at 9:08 a.m. the resident assistant (RA) took four containers of apple cranberry juice out of the refrigerator on unit one. The RA stated the kitchen would know when the juices were put in the refrigerator and stated she would call the kitchen to find out. The RA stated neighborhood one was the only unit that had nutritional drinks. During interview and observation on 12/15/22, at 9:19 a.m. the CD stated she could not say for sure what date the juices were brought down to the refrigerator. The CD stated she checked the temp a month ago and the refrigerator had a thermometer, and verified there should be a thermometer in the unit refrigerator and stated it looked like mold on the cheese and stated it wasn't labeled. The CD also verified the refrigerator needed to be cleaned and all items dated and include an opened date. The CD verified there were four undated pitchers in the refrigerator, one being water, and three being juice. The CD stated she was concerned of the milk being in the refrigerator with no thermometer and past it's date and pulled it out of the refrigerator and stated dietary staff would be completing serve safe training. During interview and observation on 12/15/22, from 9:28 a.m. to 9:33 a.m. observed the following on unit two: -1 unlabeled container the CD stated looked like soup -1 unlabled prune juice with no opened by date -1 unlabled container of rice During interview and observation on 12/15/22, from 9:34 a.m. to 9:41 a.m. observed the following on unit three: -The CD stated there was spilled prune juice leaking on the refrigerator shelve and on the thermometer -Strawberry and vanilla shakes in the refrigerator undated for thawing with instructions to use within 14 days of thawing -1 package of unwrapped cream cheese the CD threw away The CD stated she did not think the temperature was being monitored and stated she would take the milk out and dump it. A policy Labeling and Dating Policy (Ready to Eat and or Potentially Hazardous Food) updated 8/2019 indicated ready to eat and potentially hazardous foods that are opened should be labeled and dated to indicate when food was opened or prepared or when the food must be used or discarded. Foods unmarked were to be discarded. Condiments were stored in the original containers and dated when opened and discarded prior to or on the expiration date noted on the original container. A policy Infection Prevention and Control Manual Dietary Department dated 2020, indicated dry goods were stored six inches off the floor on pallets that permitted cleaning underneath. A policy Infection Prevention and Control Manual Food Safety Requirements dated 2020, indicated food, food products, or beverages delivered to the nursing home was inspected by facility staff and covered, labeled, and dated.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R30, R1, R36, R8) received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: The CDC's Pneumococcal Vaccine Timing for Adults, dated 4/1/22, identified adults [AGE] years of age or older who had previously received PPSV23 (pneumococcal polysaccharide vaccine 23) but had not received any pneumococcal conjugate vaccine (e.g. PCV13 (Pneumococcal 13-valent Conjugate Vaccine, PCV15 (15-valent Conjugate Vaccine) PCV20 (20-valent Conjugate Vaccine) should have received a dose of PCV15 or PCV20 at least one year after the most recent PPSV23 dose. R30's admitted [DATE], had a diagnosis of muscle weakness. R30's immunization records undated, indicated R30 received the first dose of the PPSV23 on 10/4/07, but had not received any of the pneumococcal conjugate vaccines as recommended by the CDC. R30's medical record lacked documentation of accurate screening for the pneumococcal vaccination and lacked evidence the facility offered the vaccine. R1's admitted [DATE],had diagnoses of dementia and weakness. R1's immunization records undated, indicated R1 received the first does of the PPSV23 on 10/30/10, but had not received any of the pneumococcal conjugate vaccines as recommended by the CDC. R1's medical record lacked documentation of accurate screening for the pneumococcal vaccination and lacked evidence the facility offered the vaccine. R36's admitted [DATE], diagnoses of palliative care, sepsis, streptococcus arthritis due to bacteria, chronic kidney disease, and malignant neoplasm. R36's immunization records undated, indicated R36 received the first dose of the (PPSV23) on 1/10/94, but had not received any of the pneumococcal conjugate vaccines as recommended by the CDC. R36's medical record lacked documentation of accurate screening for the pneumococcal vaccination and lacked evidence the facility offered the vaccine. R8's admitted [DATE], diagnoses of palliative care, atherosclerosis, and osteoporosis. R8's immunization records undated indicated R8 did not receive any dose of the pneumococcal vaccines as recommended by the CDC. R8's medical record lacked documentation of accurate screening for the pneumococcal vaccination and lacked evidence the facility offered the vaccine. During an interview on 12/14/22, at 11:44 a.m. the infection preventionist (IP) stated nursing completed an admission assessment and annual assessment which included pneumococcal vaccination screening. The IP reviewed R30, R1, R36 and R8's medical records, and verified the assessment had not been completed correctly to indicate the pneumococcal vaccination statuses. The IP stated pneumococcal vaccination screenings should be done accurately and the IP should have been notified of any discrepancies to ensure vaccination statuses were up to date. The facilities Pneumococcal Vaccination Policy dated 4/22 that each resident is offered the pneumococcal immunization as recommended. The purpose of the pneumococcal vaccination(s) is to reduce the incidence of pneumococcal disease and the morbidity and mortality attributed to the infection.

Based on observation, interview, and record review, the facility failed to verify orders prior to administration of oxygen and was not labeling the tubing's for 1 of 1 resident (R23) reviewed for oxygen use. Findings include: During observation on 12/12/22, at 7:18 p.m. R23 stated she utilized two liters of oxygen. The water bottle and oxygen tubing was not dated. During interview on 12/12/22, at 7:25 p.m. licensed practical nurse (LPN)-A stated R23 had been a resident at the facility for more than five years and was recently hospitalized . LPN-A stated R23 had been on oxygen for a while and did not see a written order for R23's oxygen, and did not know if the oxygen had been discontinued, but added R23 had been on oxygen for more than six months. LPN-A stated oxygen tubing and water bottles are changed weekly and stated he knew tubing and water bottles were changed because the date the tubing and water bottle was changed was added to the tubing and water bottle. LPN-A stated he did not know when R23's oxygen tubing and water bottle was last changed and verified there was no date on the oxygen tubing and water bottle. LPN-A stated R23 returned from the hospital on 11/28/22. R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R23 had intact cognition, and had oxygen therapy. R23's diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, emphysema, and anemia. R23's medication administration record (MAR) and treatment administration record (TAR) for December 2022, lacked orders for oxygen therapy and orders for changing the oxygen tubing and the water bottle. R23's discharge summary dated 11/28/22, lacked orders for oxygen therapy. During interview on 12/12/22, at 7:25 p.m. registered nurse (RN)-A stated orders were discontinued when residents went into the hospital and the order for oxygen was potentially missed if the discharge physician did not add the order for oxygen upon return to the facility. During interview on 12/12/22, at 7:25 p.m. the director of nursing (DON) stated changing oxygen tubing and the water bottle should be on the MAR and on the orders. During interview on 12/13/22, at 9:20 a.m. RN-A stated they received the order for R23 to have oxygen and to change the oxygen tubing on 12/12/22. During interview on 12/13/22, at 1:21 p.m. the DON stated the oxygen order was not on the discharge summary and planned to view R23's paper chart. The DON stated orders were entered by two staff, one staff checked the order and the other confirmed orders and stated the oxygen order was missed by two people. A policy was requested on changing oxygen tubing and the water bottle along with a policy on transcribing orders when a resident returned from the hospital. During interview on 12/14/22, at 8:10 a.m. the DON she did not find the order for oxygen and stated it may be in the paper chart. During interview on 12/14/22, at 8:44 a.m. the DON reviewed the paper chart and stated she did not see an order for the oxygen.

Based on observation, interview, and document review the facility failed to implement a person centered comprehensive care plan for 1 of 2 resident (R8) reviewed for abuse. Findings include: R8's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment. R8's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R8 required limited assist with transferring, dressing, personal hygiene, and extensive assistance with toilet use. R8's diagnoses included major depressive disorder, anxiety disorder, unspecified visual loss, unspecified hearing loss, unspecified macular degeneration, and cerebral atherosclerosis. R8's five day investigation report submitted 11/29/22 at 6:39 p.m. indicated R8 reported to the hospice nurse and health care agent that someone had fondled her breasts on 11/21/22. R8 was not able to provide additional information to her health care agent, and R8 declined body audits from the facility and was unable to provide additional information to the administrator. The report indicated that buddy cares was implemented. R8's communication sheet updated 12/11/22, indicated utilize buddy cares at all times. During interview on 12/13/22, at 2:39 p.m. nursing assistant (NA)-A stated a few weeks ago R8 reported someone had touched her and NA-A stated they had to buddy up and have two people when providing cares to R8. During interview on 12/13/22 at 4:03 p.m. resident representative (RR)-A stated she thought R8 was confused and stated the facility took steps to make sure R8 was safe by having two people going into R8's room. During interview on 12/14/22, at 9:30 a.m. NA-B stated R8 required assist with toileting, going to the dining room and dressing. NA-B stated normally R8 required one staff person when R8 needed cares. During interview and observation, on 12/14/22, at 9:37 a.m. R8 was sitting on her bed in her gown and stated she needed to use the bathroom, but someone had to help her. During interview and observation on 12/14/22, at 9:48 a.m. NA-B went into R8's room alone contrary to the communication sheet indicated buddy cares at all times. NA-C stated R8 declined cares earlier and she planned to check back with her. NA-C stated R8 required two staff because R8 was combative. If R8 was combative then NA-B would call and stated NA-B was in R8's room by himself. NA-C stated she attempted to help R8 three times. During observation at 12/14/22, at 10:00 a.m. NA-B brought resident out of her room and R8 was cleaned and groomed. During interview on 12/14/22, at 1:45 p.m. NA-B stated R8 was very good, he asked if R8 wanted to go to breakfast, and he was able to take R8 to the toilet, cleaned her face, and combed R8's hair with no yelling. During interview on 12/15/22, at 11:57 a.m. the director of nursing (DON) stated in the past, R8 would yell at staff and tell them to get out. The DON stated they tried to complete a body audit, however R8 would not allow any assessment and stated they were doing buddy cares where two staff went into R8's room at a time. The DON stated it was clearly marked on the care plan and buddy cares was implemented to protect themselves and R8 and stated it was on the care sheet to use buddy cares at all times. The DON stated her expectation was that all staff would go in with two so they could be witness to what the other person was doing. She stated that buddy cares meant two staff and she thought all staff knew what buddy cares meant. The DON stated when they put something in place they go to the resident's neighborhood and talk with the aides to inform them something new was implemented, and expected staff to read and know the care plan. During interview on 12/15/22, at 1:21 p.m. NA-B stated he viewed the care plan in order to know what cares a resident required. NA-B took out the communication sheet and stated he took a care plan each time he worked. A policy Vulnerable Adult Abuse Prevention Plan modified December 2022, indicated as applicable, the care plan and staff assignment sheets were updated as an action plan for follow up following an incident investigation. A policy Care Plan Policy and Procedure modified November 2022, indicated the person centered care plan ensured the resident had the appropriate care required to maintain or attain the resident's highest practicable physical, mental, and psychosocial well-being and included unique interventions that met the needs of that resident.

Based on interview and document review, the facility failed to ensure the necessary services were provided to dementia residents for 2 of 2 residents (R1 and R2) reviewed for care plans when the agency resident assistants ([NAME]) were not orientated to the facility for care of dementia residents. [NAME]-A was assigned to monitor R1 and R2 for wandering off the unsecured unit. The [NAME]-A ended her shift and left the facility without reporting to facility staff she was leaving. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's cognitive ability was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 9/15. The MDS also identified R1 as having diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's elopement risk assessment dated [DATE], indicated R1 was at risk for elopement when agitated and confused. The assessment identified on 8/30/22, R1 went out the unit door near the kitchen, into a hallway, and was brought back by staff members. R1's elopement risk assessment dated [DATE], indicated R1 risk for elopement due to impaired cognition and occasional agitated, but is usually easily redirected. The assessment identified on 9/6/22, R1 went out the unit door to the main hallway, to the elevator, and to the second floor where she previously lived. R1's agency resident assistant contract dated 9/7/22, indicated a service plan to provide 1:1 supervision seven days a week. Other components of the contract included vulnerability and safety assessments, description of the resident's physical and mobility limitations, fall risk profile, diet, mental limitation, client information profile, description of home care services, Health Insurance Portability and Accountability Act of 1996 (HIPAA) notice, client complaint procedures, privacy rights, health care records access, health care directives, and authorizations for activities. The contract did not identify the communication between the agency resident assistants and facility staff when starting and ending shifts. R2's quarterly MDS dated [DATE], identified R1's cognitive ability was severely impaired with a BIMS score of 6/15. The MDS also identified R1 as having diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's elopement risk assessment dated [DATE], indicated R2 was at risk for elopement after R2 went out the unit door to the main hallway, to the elevator but did not get off the elevator. R2's agency resident assistant contract dated 9/9/22, indicated a service plan to provide 1:1 supervision seven days a week. Other components of the contract included vulnerability and safety assessments, description of the resident's physical and mobility limitations, fall risk profile, diet, mental limitation, client information profile, description of home care services, Health Insurance Portability and Accountability Act of 1996 (HIPAA) notice, client complaint procedures, privacy rights, health care records access, health care directives, and authorizations for activities. The contract did not identify the communication between the agency resident assistants and facility staff when starting and ending shifts. Upon interview on 9/12/22, at 10:45 a.m., the facility administrator (FA) stated both R1 and R2 have a recent history of attempted elopement. Both residents are reside in the transitional care unit (TCU), which is not a locked unit. Transfer to the memory care unit, a locked unit, was not possible as there were no beds available. FA stated an agreement was reached with the guardians to hire a sitter from an agency who would monitor the activities of both R1 and R2. This service started on Saturday 9/10/22, at 7:00 a.m. Upon interview on 9/12/22, at 11:45 a.m., facility resident assistant (RA)-A was asked the whereabouts of the [NAME]. RA-A stated the [NAME] was not on the unit. RA-A stated [NAME]-A was seen earlier in the day but did not know the whereabouts of [NAME]-A for the last hour. RA-A stated, maybe [[NAME]-A] will come back this afternoon but I'm not sure. I thought [[NAME]-A] was supposed to be here all day. RA-A also stated staff members are conducting visual checks on both R1 and R3 every 30 minutes. Upon interview on 9/12/22, at 12:10 p.m., clinical nurse manager (CNM) stated [NAME]-A was on site to provide monitoring of R1 and R2's activity and prohibit them from leaving the unit. When asked the whereabouts of [NAME]-A, CNM stated [NAME]-A could be in either resident's room. CNM looked for [NAME]-A but was unsuccessful. CNM reported [NAME]-A's absence to the director of nursing (DON) and the FA. Upon interview on 9/13/22, at 12:30 p.m., DON stated the guardians for R1 and R2 agreed to provide an [NAME] to monitor R1 and R2 from 7:00 a.m. to 10:00 p.m. every day. The [NAME]'s responsibility was to keep R1 and R2 company. No direct physical care would be provided. Regular nursing staff still conduct visual checks every 30 minutes. DON affirmed [NAME]-A was seen earlier in the day but left without telling anyone on staff. DON stated she was not involved in the arrangement between the agency and the facility, and had not seen the contract. Upon interview on 9/12/22, at 12:50 p.m., FA stated [NAME]-A, left the facility and did not report to anyone. FA stated there was an error in the schedule and the assigned time was listed as 7:00 a.m. to 10:00 a.m., instead of 7:00 a.m. to 10:00 p.m. FA stated the orientation process for the [NAME] consisted of meeting with him on their first assigned day. There is no written policy or procedure for orienting agency staff who do not provide direct care. FA stated the sending agency provides orientation and training. Once FA meets with the [NAME], the nursing staff supervises the [NAME]. FA stated the [NAME] were not providing direct care, only monitoring the resident's whereabouts. Upon interview on 9/13/22, at 9:40 a.m., [NAME]-A stated had worked in this facility prior to this assignment but did not recall the date. When asked about responsibilities, [NAME]-A stated, I just watch over them, keep them from wandering, keep an eye on them. Stated she received no orientation from the facility. Stated agency personnel gave her an overview of the residents, what to do with them, and what to expect. [NAME]-A stated general orientation was given by the agency and included proper face mask use, vaccination requirements, handwashing. [NAME]-A stated, I know [MEDICATION(S)] around. Stated if there was any incident would report it to a nurse on duty right away. Stated was not aware of any book of policies, procedures, or reference materials. Upon interview on 9/13/22, at 11:41 a.m., the contracted agency administrator (AA) stated their service provides nurses, certified nursing assistants, and resident assistants for clients. AA stated, for [R1] and [R2], the agency was engaged to watch over the residents. No physical care was included, the [NAME] just keeps eyes on the residents. Stated she received information from the facility about mobility and mental status. Both residents had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Stated the facility provides patient-specific information and they pass information to staff. Stated does not know if employees received orientation or other information from the facility. There were no policies or procedures related to orientation for new agency staff or other personnel unless they were providing direct resident care services. There were no reference materials available.

Based on interview and document review, the facility failed to use the appropriately sized mechanical lift sling for 1 of 3 residents (R1) reviewed for falls. This resulted in an immediate jeopardy (IJ) when R1 was not properly assess for the use of a mechanical lift and appropriate sling size. R1 fell during a mechanical lift transfer resulting in a subarachnoid hemorrhage, and a closed displace pelvis fracture. The IJ began on 6/25/22, at 4:25 p.m. when facility staff utilized improper sized mechanical lift sling. R1 fell , after being suspended in the air, and hit their head resulting in a subarachnoid hemorrhage, and a closed displace pelvis fracture. The campus administrator and director of nursing (DON) were notified of the IJ on 7/6/22, at 5:30 p.m. The facility implemented corrective action on 6/26/22, and the IJ was issued as past non-compliance. Findings include: R1's admission record dated 3/3/2022, identified diagnoses inclusive of encounter for palliative care, malignant neoplasm of the rectum, age-related [CONDITION(S)] with pathological fracture of the vertebrae, [CONDITION(S)], protein malnutrition, and unspecified dementia. R1's care plan dated 3/16/2022, indicated R1 was non-ambulatory and required one assistant to transfer from the bed to a Broda chair using a sit-to-stand lift with a medium sized vest. When in bed, R1 was to be repositioned every three hours. R1 required assistance with eating, dressing, daily hygiene, grooming, bed mobility, and toileting. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that R1 had a Brief Interview for Mental Status (BIMS) score of three indicating severely impaired cognition. An incident report dated 6/25/2022, at 7:00 p.m. indicated, R1 slid out of mechanical lift during transfer. Hit her head on the foot of the lift. R1 was assessed by Registered Nurse (RN)-A who provided an ice pack for a bleeding cut on her head. RN-A summoned the paramedics to transport R1 to the hospital for evaluation and treatment. RN-A notified R1's sister, Our Lady of Peace Hospice, and the director of nursing (DON). A summary record from Regions Hospital Emergency Department dated 6/26/2022 at 8:01 a.m. indicated R1 sustained a subarachnoid hemorrhage, back pain, unspecified location, and closed fracture of the pelvis, unspecified location. A document titled Investigation Report Summary dated 7/1/2022, indicated two resident assistants attempted to transfer R1 from bed to wheelchair using a full body Golvo lift and a medium sized sling. The report further indicated R1 had not been assessed for use of this lift or the size of the sling. Report indicated the root cause analysis indicated the care plan was not followed and the wrong size sling was used. When interviewed on 7/6/22, at 12:35 p.m., R1's sister stated her and R1's son were visiting R1 during the day on 6/52/2022. Stated they observed staff using the sit-to-stand to return R1 from chair to bed. Son noted R1 was in more pain than usual. Stated R1's son spoke with the staff and asked that a full body lift be used in the future so R1 would be more comfortable. Stated staff said they would pass this request on to the nurse. When interviewed on 7/6/22, at 12:35 p.m., the DON stated both nursing assistants (NAs) stated during interview the day shift NAs told them the family wanted the full body sling to be used for R1. NA-B related the care plan was checked and no assessment was done for the use of a full body lift. No sling size was documented. NA-B believed the plan was not updated yet and wanted to honor the family's wishes. The NA's did not consult with the attending RN. The attending RN stated was told by the day shift to keep R1 in bed until R1 could be evaluated for a full body lift. When interviewed by phone on 7/6/22, at 2:40 p.m. nursing assistant (NA)-A stated, me and NA-B were transferring R1 from bed to chair. We were told during report with the day shift aides the family wanted to use a full body sling and stop using the sit-to-stand. NA-B said it was OK to use this lift even though it was not in the care plan. We placed R1 in the sling and lifted her from the bed. Once she was off the bed R1, slid out of the bottom of the sling onto the floor and hit her head on the leg of the lift. I tried to lend assistance but R1 was in a lot of pain, NA-B went to get the nurse who came in right away. When interviewed 7/6/22, at 2:55 p.m. campus administrator (CA) verified NA-A and NA-B did not follow the policy entitled Mechanical Lift Transfer Policy or R1's care plan prior to using the full body lift. CA stated After the incident occurred, the facility immediately implemented measures. The past noncompliance immediate jeopardy began on 6/25/2022. The immediate jeopardy was removed, and the deficient practice corrected by 6/26/2022, after the facility implemented a systemic plan that included the following actions: -The Golvo lift was removed from the unit for further inspection immediately after the incident occurred, the Golvo lift and sling were taken out of service and sent to the maintenance department. Hillrom was notified and a complete assessment of function was ordered to ensure the items were working properly. - Both NA-A and NA-B were placed on administrative leave. - The DON completed an audit of each resident, who utilized a Golvo lift, to ensure the appropriate lift device and sling size was care planned, listed on the care sheet, and the proper sling size was available. An audit of care plans for all residents who used mechanical lifts was done to ensure accuracy of transfer/sling status/size. - Facility completed an investigation which resulted in identification of a root cause - Re-education for all staff included following care plans/care guides. NA's are to notifying nurse of any changes requested by families. The nursing staff were reeducated immediately on the shift the fall occurred. Other nursing staff were educated prior to working their next shift on ensuring appropriate lift and sling size was utilized during transfers. - Training identified the policy, care plan, care sheets, and charge nurse as resources to be used before using the lifts. - Nursing completed weekly mechanical lift audits with the nursing staff. - NA-A, agency staff, was asked not to return to facility, agency notified. - NA-B completed a mechanical lift audit to ensure proper use of a Golvo lift prior, signed and dated Golvo Skills Checklist and Care Guide forms completed. - Multiple staff interviews and verified they had received education on ensuring the appropriate transfer-assist equipment and sling sizes was utilized during transfers identified the policy, care sheets, and care plans as reference sources. Facility policy, Mechanical Lift Transfer Policy, revised November 2018, indicated the following. Procedure 1. Obtain equipment including sling/vest and mechanical lift. Check equipment and sling or vest for proper functioning and lift fort battery charge. Refer to resident specific care plan and transfer assessment for type and size of sling/vest and equipment type for each specific resident.

Based on interviews and document review, the facility failed to ensure an allegation of abuse was reported immediately, but not later than two hours, for 1 of 1 resident (R2) who expressed she had been kicked by another resident. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was moderately cognitively impaired, used a wheel chair for mobility, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress note dated 1/31/22, at 4:02 p.m. indicated a late entry for an incident on 1/30/22, at 3:40 p.m. that indicated R2 was kicked by R3. R3's quarterly MDS dated [DATE], indicated R3 was severely cognitively impaired, used a wheelchair for mobility, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R3's care plan dated 12/13/21, indicated R3 had the potential to demonstrate physical behaviors related to poor impulse control. R3's progress notes dated 1/31/22, at 4:02 p.m. indicated a late entry for an incident on 1/30/22, at 3:40 p.m. in which R3 propelled herself in her wheelchair toward R2 and kicked R2 in the shin. The Minnesota Incident Report filed by the facility that documented the altercation between R3 and R2 was dated 1/31/22, at 5:01 p.m. which was greater than 24 hours after the altercation. When interviewed on 2/19/22, at 1:42 p.m. nursing assistant (NA)-A stated she was required to report abuse immediately to a nurse, as soon as she knew about it. When interviewed on 2/19/22, at 1:48 p.m. registered nurse (RN)-A stated she was required to report abuse to a clinical coordinator within 24 hours. When interviewed on 2/19/22, at 2:08 p.m. NA-B stated she was required to report abuse right away to a nurse on the unit. When interviewed on 2/19/22, at 3:21 p.m. administrator stated the expected timeline for abuse reporting was as soon as the incident occured the incident was to be reported to the administrator, and within two hours to the State. The Vulnerable Adult Abuse Prevention Plan dated July 2021, indicated all cases of maltreatment must be reported immediately to an immediate supervisor, but no later than two hours after the allegation is made.

Based on interview and document review, the facility failed to implement fall interventions as directed by the care plan for 1 of 3 residents (R1) reviewed for falls. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had a moderate cognitive impairment and diagnoses of Alzheimer's Disease, cerebral infarction (stroke) and [CONDITION(S)] (weakness or inability to move on one side of the body) to the right side. Further, R1 required total physical assistance of two staff for transfers, was not steady, and only able to stabilize with human assistance. R1's fall Care Area Assessment (CAA) dated 8/12/21, indicated R1 was at risk for falls related to impaired mobility, incontinence, and dementia. R1 had difficulty maintaining balance while sitting. R1's care plan dated 11/16/21, indicated R! was incontinent of bladder and bowel and needed assistance with toileting. The care plan also directed R1 was not to be left alone in the restroom. R1's Nursing Assistant Task Sheet dated 11/19/21, indicated R1 required R1 required incontinent cares in bed. The Nursing Assistant Task Sheet lacked indicated R1 was not to be left alone in the bathroom. Review of R1's progress notes revealed: - 11/21/21, at 9:11 a.m. indicated R1 had a fall in the bathroom while being toileted. - 11/21/21, at 11:00 a.m. indicated R1 was transferred to the bathroom using a full lift with the assistance of two student nurses. R1 was given privacy to sit on the toilet with frequent checks. R1 was found on the bathroom floor after hearing a loud bang from the students outside the door. An Occurrence Report dated 11/21/21, indicated a factor regarding R1's fall was not following R1's plan of care. During an interview on 12/7/21, at 12:19 p.m. nursing assistant (NA)-A stated she was working on R1's unit on 11/21/21. She had not worked with nursing students before and believed the student nurses were helping with resident cares. The nursing students asked for R1's care sheet and went into R1's room for cares. NA-A had offered to help, but was declined. Further, NA-A was not sure what cares the students intended to complete for R1. The students went into R1's room while their clinical instructor (CI)-A, who was on the computer, sat outside the room. NA-A stated she was surprised when R1 fell in the bathroom as R1 was too weak to use the toilet and incontinence cares were provided when R1 was in bed. NA-A was not aware of what nursing students were able to do when in the facility or how they were assigned. During an interview on 12/7/21, at 2:08 p.m. CI-A stated on 11/21/21, the care center had two nurses scheduled and there were not enough nurses for two of eight nursing students to shadow during their clinical rotation. CI-A stated she spoke with registered nurse (RN)-A on how to utilize the two remaining student nurses, who did not have a nurse to follow, and a decision was made to have the two nursing students help with cares on R1's neighborhood as there was only one nursing assistant scheduled. CI-A then instructed the nursing students to help with resident care and informed the students she would be on the unit to assist them. Further, the nursing students were not scheduled to do resident care on this date (11/21/21) and had not prepared for resident cares. The nursing students had not received report and did not review the residents electronic medical record prior to resident care. CI-A stated the students required a staff member, or herself, in a resident's room when providing any resident cares. CI-A stated, I pushed these two students some as this was shift number eight. I put them in a position to use their clinical thinking and their previous experiences on the unit. R1 needed morning cares completed and the students went to complete the cares as she waited outside the room. CI-A stated she checked on the students a few times when providing cares to R1. CI-A sated she did not think the students would take R1 to the bathroom, but also confirmed she did not provide that instruction to the students. Additionally, CI-A confirmed she did not review R1's care plan with the students and stated, I should not have put them on that unit, and I should have been with them in R1's room and reviewed the care plan with them. CI-A also verbalized there was not meeting prior to clinicals, or detailed list of what students could and could not do when at the facility. During an interview on 12/7/21, at 2:36 p.m. RN-A stated R1 required total assistance of two staff for transfers and was always incontinent. R1 was never placed on the toilet as she was too weak. On 11/21/21, there were two nurses scheduled as there were eight nursing students, so the students were helping with cares on R1's unit. RN-A stated CI-A asked her opinion regarding nursing students helping with cares. RN-A stated they felt it would be okay as the nursing assistant working on R1's unit was regular staff and knew the residents. During an interview on 12/7/21, at 3:00 p.m. the director of nursing (DON) stated there was a meeting with CI-A to discuss the upcoming clinical rotation. The DON stated the meeting was conducted regarding access students required, the nursing students experience (i.e., clinical year), and types of cares the students would be providing. The college was informed about resident care guides, facility policies, and what students were able to do when at the facility. The DON stated her understanding was nursing students would be with the instructor when providing resident cares and was not aware of the plan to have nursing students help with cares on R1's unit and CI-A had not reached out to facility leadership when the decision was made. The DON stated the expectation was for the nursing instructor to be present when a student was providing resident cares. During an interview on 12/7/21, at 4:12 p.m. the administrator stated there was a meeting with CI-A regarding onsite clinicals and her understanding was nursing students would be mainly observing and shadowing nursing assistants and they were not providing direct cares. The administrator explained if direct care was being provided by nursing students, staff needed more communication and understanding of the nursing student roles. The administrator stated there was not any policies guiding what nursing students could/could not do. The administrator stated her expectation was for nursing students to always be with a staff member when providing direct cares to ensure a resident's care plan was followed, when did not occur when R1 had fell . Facility policy titled Agreement for Clinical Experience updated 8/1/15, directed, The facility will retain responsibility for the care of clients and will maintain administrative and professional supervision of students insofar as the presence of the educational program affects direct or indirect care of clients.

Based on document review, interview, and observation, the facility failed to ensure the safety of 1 of 9 residents (R1) who required a full body mechanical lift for transfer. This resulted in harm for R1, who fell from the lift and sustained a traumatic subarachnoid hemorrhage ([MEDICATION NAME] force trauma that caused the brain to move inside the skull, resulting in bleeding between the brain and the tissue that covers it). However, the facility implemented corrective action on 8/3/20, therefore the deficiency is being cited at past non-compliance. Findings include: R1's Minimum Data Set ((MDS) dated [DATE], included, cognitively intact, had impairment on both sides of the lower body, and one side of the upper body, and did not walk. R1 required extensive assist of two staff for bed mobility, and was dependent on two staff for transfers. R1's Care Area Assessments for falls and activities of daily living from the comprehensive MDS dated [DATE], described R1 to have [DIAGNOSES REDACTED]. Care plans were to be developed in these areas to minimize risks. R1's mobility care plan dated 7/24/12, included, limited physical mobility related to [MEDICAL CONDITION] secondary to [DIAGNOSES REDACTED]. R1's progress note dated 7/31/20, at 3:50 p.m. Included, Called (nurse practitioner) at 3:00 p.m. regarding Fall of resident (R1's initials) from the Full lift and getting orders to send resident out for evaluation. Informed NP (nurse practitioner) that resident fell during transfer from Full Lift. During transfer resident fell from a high height and hit her head on the iron bar on the lift. Resident has a bump on the right side at the back of her head. No bleeding. The nurse practitioner (NP) gave orders to send to the emergency department. R1's progress note dated 7/31/20, at 4:10 p.m. read, Staff (aide) reported to writer that resident had a fall from the full lift while she was being transferred from the bed to the chair. Writer found resident on her back on the floor wearing her day clothes and shoes. Head resting on the floor and the metal part of the leg of the full lift. Sling still hanging on the full lift except for the bottom part of the sling (leg area) - left side of resident, which was off from the machine. Resident found near/adjacent to the bed. Resident is conscious, alert, coherent, and oriented; able to move upper extremities. Neuro (neurological exam) VS (vital signs) within normal limits. VS: BP (blood pressure) 150/100, HR (heart rate) 85, O2 (oxygen level) 92% RA (room air), RR (respiratory rate) 16, T (temperature) 96.1; mild headache. Resident said she hit her head on the metal part of the leg of the full lift. No skin tears, abrasions, or fractures noted. Lump noted at the back of head. No bleeding noted. Power wheelchair near the sink. Resident transferred to the wheelchair using a different full lift machine. Resident reassessed, lump on head has petechial red spots, no bleeding and skin is intact. Resident stated she is also scratching her head when her scalp itches. Neurochecks started as per protocol. Writer called (NP) and updated with resident's status (level of consciousness, how the resident fell , lump at the back of head, VS, ROM (range of motion), neuros). Interventions based on root cause analysis: Checked full lift machine, pin (that holds the sling) on left side (resident's left side) not present. R1's progress note dated 7/31/20, at 10:43 p.m. noted R1 was admitted to the hospital with [REDACTED]. R1's progress note dated 8/1/20, at 11:46 a.m. staff talked to a social worker at the hospital regarding R1. Neurology gave consent for R1 to be released from the hospital. Staff spoke with a hospital neurologist who said the right side temporal area subarachnoid bleed had resolved, and R1 had no neurological changes, no symptoms, and was at baseline of arrival at hospital. R1's Discharge Summary from the hospital dated 8/1/20, included, R1, Presented to the (emergency department) after head trauma when she hit her head against a metal rod. The patient was being transferred from the bed to the chair using a (full body mechanical lift) when the hook of the (lift) failed that resulted in a fall from a height of 4-5 feet with the patient hitting her head. The note indicated imaging was done and showed a small subarachnoid hemorrhage and repeat imaging shoed a decrease in the bleeding. R1's Comprehensive Nursing Data Collection dated 8/1/20, upon R1's return from the hospital, assessed R1 was non-weight bearing and needed to transfer with two person assist using the full body mechanical lift. R1 needed a size medium sling for the full body mechanical lift. R1's progress note on 8/3/20, at 5:47 p.m. included follow-up from the interdisciplinary team. After reviewing the fall, the root cause was determined to be the clip from the sling coming off during resident transfer. Staff were re-educated on transferring residents using the full lift, and audits of transfers began. The lift involved in the fall was taken out of use until it was checked by engineering for defaults. When interviewed on 8/4/20, at 10:42 a.m. the administrator stated R1's fall happened on Friday 7/31/20, and staff stayed late to make sure everything was safe for residents. Administrator explained re-education started right away, and everyone was trained right as they came on for their shifts. The lift manufacturer had also come out to inspect the lift involved in the fall, as there was a pin, or safety latch, that, flew off, during the transfer at the time of R1's fall. Staff later found the safety latch on the bedside nightstand. The lift company put the safety latch back in place. Administrator described the safety latch to be used to keep the sling loop over the hook of the lift bar. R1 was described as alert, and having said nothing was unusual during the transfer that day. Various nursing home staff had performed three re-enactments, and were unable to figure out what occurred to cause the sling loop to become unhooked from the lift bar, or the safety latch to, fly off. Staff were transferring R1 from the bed to the wheelchair, and had R1 in the sling, connected to the lift bar hooks with two upper sling loops by the shoulders, and two sling loops that cross at the inner thigh before attaching to the lift bar hooks. Staff lifted R1 off the bed in the sling, and then paused to check everything looked good, before starting to move the lift with one staff operating the lift, and the other guiding R1's legs. Once they started moving the lift, that is when the leg sling loop on the right side of the lift bar (that was crossed at the inner thigh, and coming from the left side of the sling) detached, and the safety latch flew off, and the resident slid from the sling. When interviewed on 8/4/20, at 11:58 a.m. environmental service director (ESD) described the facility lift maintenance schedule. Every mechanical lift in the building was inspected monthly by ESD. The last monthly check took place on 7/24/20, and there were no concerns with the lift involved in the accident. ESD stated the facility will replace wheels, batteries, charging cord, or clean hair out from the wheels, but anything else would be called in to the manufacturer for service. The monthly maintenance check followed a manufacturer form that was recommended at least quarterly by the manufacturer. In addition to the monthly checks performed by ESD, the manufacturer performed annual maintenance on all the lifts, last completed 10/10/19, with no concerns found on the lift involved in the accident. If nursing staff had any concerns on the lift, they can enter it into the TELS building management system for ESD to take a look, and contact the manufacturer for service if required. There had been no recent TELS system requests for maintenance on the lift. ESD stated after the fall, they contacted the manufacturer to come out and perform a field investigation on the lift. The manufacturer investigated the lift on 8/3/20. The Liko (brand name of the full body mechanical lift) Periodic Inspection form dated 7/24/20, had the lift checked off, including the clips, as being inspected with no maintenance required. The Liko Periodic Inspection form dated 7/31/20, after the incident indicated the inspection of the safety latch, Right side not attached but not broken-came loose. A Field Investigation Service Work Order Form from the manufacturer dated 8/3/20, noted in the comments section that the customer reported that the sling bar latch came off during a lift. The technician inspected the lift and sling bar latch. No malfunctions were found. The Lift and sling bar latch were functioning as designed. When interviewed on 8/5/20, at 11:50 a.m. the manufacturer technician (T)-D stated the work order was created to complete a field investigation. That meant T-D was going to check the lift for full functionality, to make sure everything was functioning as designed. When T-D checked the lift on 8/3/20, everything was functioning as designed. The facility asked T-D to put the latch on and ensure it was functioning correctly. T-D stated the latch was functioning correctly. T-D did not look into the fall, just looked at the lift to ensure functionality. On 8/4/20 at 12:53 p.m. observed the Golvo 7007 ES full body mechanical lift that was in use at the time of R1's fall. Administrator attached a size medium, divided leg sling to the lift. Administrator stated that when R1 was lifted off the bed, both staff had visualized the sling loops were hooked in the right place on the lift bar. The safety latches were spring loaded plastic clips that closed the hook to help hold the loops in place. The latch had flown off at the time of the fall, and when found, was not broken. ESD stated during monthly maintenance, the latch was checked to ensure they were in place and spring loaded. The nursing home leader in training (LIT) stated from experience, when a person was in the sling and attached to the lift, the lifts became harder to push on the carpeted floor and staff would, have to give some good force, and that was why they had two staff operating the lift at a time. The administrator thought perhaps R1's body did not move with the lift when the lift was moved, and caused some swinging motion during the transfer. The administrator stated R1 had been audited for the proper sling use, and they found she was using the correct sized sling (medium) per manufacturers guidance, so they kept R1 in the same sling upon return as well. During interview on 8/4/20, at 1:38 p.m. nursing assistant (NA)-A stated care plans say which sling to use for each resident, and also each resident had their own sling in their room to use. On 8/4/20, at 1:43 p.m. R1 was observed in her room seated in an electric wheelchair. R1 stated she ended up in the hospital with bleeding on the brain, and then six hours later the bleeding had stopped but they kept R1 overnight in the hospital to keep an eye on her. R1 described before the fall, R1 was on the bed after cares, and NA-C and NA-D were going to transfer R1 from the bed to the wheelchair. R1 stated one staff kept a hand on her legs, and helped her legs clear the bed frame. The other staff was operating the lift. It happened so fast, R1 believed she blacked out for a few seconds. The next thing R1 knew, she was laying on the floor and staring up to see the sling, swinging away in the breeze. R1 stated NA-C and NA-D stopped the lift when they first started to raise her up in the sling, to make sure things looked good. R1 stated everything seemed normal to her, although she can't say whether she actually looked at the sling loops to see where they were positioned in the lift bar hooks. R1 remembered they did put them on correctly initially. R1 stated although she did not look at the loops during the visual check, NA-C and NA-D did pause and look at the loop placement. R1 heard NA-C and NA-D talking after the fall, and discussing that they both heard a pop or a snapping noise. R1 felt the lift manufacturer should have something more than plastic latches to hold the sling loops in place. R1 felt the latch was, just puny, at around one eighth of an inch wide. R1 did not feel like she was swinging around in the lift before she fell . Since coming back from the hospital, R1 stated the transfers had gone well. When interviewed on 8/4/20, at 2:47 p.m. NA-C described R1's fall. NA-C stated, It happened so fast that it was unbelievable. NA-C did not believe anything could have gone wrong, because she ensured that R1 was balanced in the sling. The only difference that day, was that the three of them (R1, NA-C, and NA-D) had been talking during the transfer. NA-C described being between the bed and the wall, while NA-D operated the Golvo lift. They lifted R1 off the bed and then stopped the lift so that NA-C could move around from the side of the bed to the foot of the bed. NA-C looked, and everything was balanced, and none of the four sling loops were coming up out of the hook. NA-C stated R1's sling loops were good and stiff, and when they were stiffer, they laid nice and flat inside the hook. NA-C scooped up R1's feet to guide them toward the corner of the bed, and NA-D was good to start backing up the lift, and was going nice and slow. Then it was like someone snapped their fingers, and they heard a 'pop' and R1's feet were out of (NA-C's) hands, and (R1) was on the floor 'that fast.' It happened so fast. NA-C did not know what happened, or whether R1 hit her head or feet first. NA-C described the sling bar as still moving while R1 was on the floor. NA-C stopped the bar from swinging with her hand, and that is when NA-C noticed the latch was gone from the side where the loop had become unattached from the sling bar hook. When interviewed on 8/4/20, at 3:15 p.m. NA-D stated there was nothing unusual before R1's fall. NA-D and NA-C had finished three full lifts already that day. At this time, they had just finished changing R1, and were going to transfer R1 from the bed. NA-D was operating the lift, and as always, when the lift picked up the sling and started to take on tension, NA-D checked that the lift was holding the sling. NA-D described looking at the two sling loops on either side to be on the down the side of the hook, because occasionally they did get stuck on the top. So NA-D saw they were down inside the hook. NA-D started pulling the lift out from the bed. NA-C started on the opposite side of the bed, but was walking around to NA-D's side of the bed, and held R1's legs to help them clear the mattress. NA-D started to move the lift to get the lift legs in the right place to go towards the chair, and that's when it happened. NA-D described feeling momentum, as if there were a lot of forces at once, like there was swinging, and then it happened so fast and R1 was on the ground. NA-D did not know if momentum made the sling loop go up and over the hook, but was concerned that a plastic latch would not be able to hold up to the momentum. NA-C described the lift legs as starting under the bed, and needing to be turned 90 degrees from where they started to get R1 to her wheelchair. NA-D was using her upper body to torque the lift, and reported frequently needing to use her leg to pivot the lifts too, You really have to muscle it. NA-D reported difficulty pivoting the lift on the carpet with bodyweight in the sling, and the wheels not seeming to move well. NA-D felt like R1 might have swung, and that's when she heard a loud, snap. NA-D described feeling a swing in her body, because NA-D was holding the lift with both of her hands. In a tight space, NA-D really had to pivot that lift, which might cause more swinging. NA-D explained the snap heard was the clip flying off. NA-D mentioned that someone from the facility was trying to recreate the scenario, and yanked up on the sling loop with force, and caused the loop to come off the bar and the plastic latch to fly off, making the same snap sound. When interviewed on 8/4/20, at 4:08 p.m. the administrator confirmed that during the facility investigation, one staff was able to hold onto the lift bar with one hand, and use the other hand to quickly yank the sling loop upward, causing the plastic latch to fly off, and the loop to come off the hook. That was unable to be duplicated again by others. On 8/5/20, at 9:50 a.m. R1 was observed in bed with a green transfer sling underneath her. R1 was transferred from the bed to a shower chair. Just as R1 cleared the bed, NA-B paused the lift and stated, pause for a cause and tugged down on the sling loops to ensure they were fully seated in the bottom of the hooks, and the safety latches were in place. NA-A had hands on R1 to help guide R1's legs, and NA-B operated the lift and smoothly transferred R1 to the shower chair. There was no momentum, or swaying of the sling or lift bar while R1 was in the air. NA-B stated, this was how transfers normally went with R1. NA-B did not normally have to push the lift hard to move it on the carpet. NA-B said it was more difficult if you had to push the lift over any cords, and then you had to give a quick tug to move the lift over a cord, but the carpet was not an issue for NA-B. When interviewed on 8/5/20, at 11:22 a.m. the lift manufacturer's regional representative (RR) spoke generally about accidents involving their lifts. RR was unaware of the details of the accident involving R1, and stated that accidents like this could be a result of human error, or mechanical failure. RR explained there were multiple possibilities on how this occurred, and without having the details of the incident and performing an investigation, RR would be unable to say what caused the latch to come off the hook, and the sling loop to detach from the lift. RR felt the facility did a nice job of training staff to operate the lifts. The Liko Golvo Instruction Guide dated 7/3/09, required before lifting to always make certain that the patient has the correct type, size, material, and design of the slings and accessories to safely meet the patients lifting needs, and the sling's strap loops were correctly fastened to the sling bar hooks when the sling strap was extended, but before the patient was lifted from the underlying surface. The Liko UniversalSling Instruction Guide copyright 2012, guided before lifting to keep the following points in mind: Although the Liko sling bars are equipped with latches, special caution must be exercised: before the patient is lifted from the underlying surface, but when the straps are fully extended, make sure the straps are correctly connected to the sling bar hooks. When interviewed on 8/5/20, at 1:13 p.m. the administrator stated after the fall, and after talking to the staff involved, they decided to add a verbal check when lifting a resident. So after the fall, staff were being trained to stop the lift transfer and say out loud, pause for cause. At this time staff were to stop everything and double check that the sling loops were correctly attached before continuing the lift. Staff were being re-trained as they arrived for work. When interviewed on 8/5/20, at 2:02 p.m. R1's family member (FM) stated that the way the fall was reported by staff, R1 was in the full body lift, and one of the straps came undone from the latch above, and R1 fell and hit her head on the base of the lift and the floor. FM stated that R1 thought she fell from about four feet in the air. FM was very happy R1 was sent to the hospital, because they were able to find the internal brain bleed. FM stated this was the second time R1 fell during a transfer and sustained injury. FM estimated it was early 2016 when R1 was transferring with staff and fell off the bed and broke a femur. FM felt the facility had great surroundings and provided generally good care, but was concerned about staff training around resident transfer needs. Education documentation provided evidence that NA-C had been trained on operating the Golvo lift on 8/14/19, and NA-D had been trained on the lift 6/23/20. A sign in sheet, Education for RN's & TMA's, RA's dated 8/4/20, showed staff were being retrained prior to the start of their shift. On 8/4/20, the survey team verified the facility had investigated R1's fall, inspected all mechanical lifts, reviewed and revised lift procedure to include a, pause for cause, to ensure the loops were attached correctly, and educated all staff prior to their shift, which had been completed prior 8/4/20. Mechanical Lift Transfer Policy modified 11/18, had the purpose to provide safe resident transfers for each resident who has non-weight bearing status or is requiring the assistance of staff to provide weight bearing support. The policy required staff to always follow manufacturer's recommendations for the proper use of the equipment and slings. Two staff must be present for attaching the sling to the lift, and ensuring proper placement of the loops by each employee to confirm that the sling loops are attached properly.

Based on observation, interview, and document review, the facility failed to ensure medications were transcribed and administered per providers order for 1 of 3 residents (R1) reviewed for significant medication errors. This resulted in an immediate jeopardy (IJ) situation for R1 who received a dose of [MEDICATION NAME] (a narcotic [MEDICATION NAME]) sixteen times the dose ordered, resulting in unresponsiveness, [MEDICAL CONDITION] (low oxygen level) and respiratory distress. The physician ordered a medication to reverse the effects of the [MEDICATION NAME] overdose, the order was again transcribed incorrectly and a dose was administered to R1 less than what was ordered and via the wrong route of administration. This resulted in drowsiness and intermittent unresponsiveness, [MEDICAL CONDITION], and respiratory distress for R1 for over 24 hours. The immediate jeopardy began on 7/24/20, when two significant medication errors occurred for R1. The facility administrator, director of nursing (DON) and the facility campus administrator were notified of the immediate jeopardy at 3:51 p.m. on 7/29/20. The immediate jeopardy was removed on 7/30/20, but noncompliance remained at the lower scope and severity level of a G - isolated scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings include: R1's significant change Minimum Data Set ((MDS) dated [DATE], included moderate cognitive impairment, required extensive to total assistance with most activities of daily living (ADL's), had pain daily at a level 8 (on a 0-10 scale with 0 being no pain and 10 being excruciating/unmanageable pain), had shortness of breath with exertion, and received an opioid (narcotic) medication 7 out of the 7 day look back period. R1 had [DIAGNOSES REDACTED]. R1's care plan dated 7/15/20, included a recent femur fracture, staff were directed to provide medications as ordered. Hospice care was added to the care plan on 7/20/20 for a [DIAGNOSES REDACTED]. R1's Medication Administration Record [REDACTED]. DO NOT AWAKE TO GIVE MEDICATION. R1's Hospice progress note dated 7/24/20, 2:46 p.m. included, Writer reviewed EHR (electronic health record) and then spoke with facility nurse (name of nurse). She indicated that (R1's name) overall does not look good. She indicated that held 0800 (8:00 a.m.) dose of [MEDICATION NAME] as patient was asleep. Writer indicated that would remove part of the order that says HOLD IF ASLEEP. Writer instructed (nurse) regarding how to slide syringe inside cheek if asleep, and also giving a PRN (as needed) dose when awakens if scheduled dose held. In this way, will get caught up to base line dose, to manage symptoms. (Nurse) also indicated that patient is eating little. Writer informed her regarding family goal of decreasing [MEDICATION NAME] (an antipsychotic medication often used for agitation/hallucinations/delusions when in dying process), but we may need to increase [MEDICATION NAME] if pain persists at present dose. Family is concerned about her being so sleepy. Writer went to (R1's) room. (R1) was sitting in her Broda Chair (reclining chair) dozing. She did arouse when name was stated. (R1) acknowledged that writer was new; writer explained that patient has always been asleep with (sic) writer came into room. Patient stated, 'I don't feel good.' She could not elaborate on that, and did not reply to questions about pain, writer noted that resps (respiratory) rate was elevated at 28 BPM (breaths per minute/normal is 12-16) Asked patient if was having difficulty catching breath, patient stated yes. R1's new physician order [REDACTED]. However, the order was transcribed into the electronic medical record (EMR) and the Medication Administration Record [REDACTED]= 4 ml. This resulted in the [MEDICATION NAME] dose being 16 times higher than the dose actually ordered by the physician. Registered nurse (RN)-A signed off as double checking the order to ensure accuracy on 7/24/20, at 4:20 p.m. R1's progress note dated 7/25/20, at 1:44 a.m. and written by RN-A included, Writer gave 2 separate does of 4 mls of [MEDICATION NAME] to resident. First dose at 1640 (4:40 p.m.), second dose at 2100 (9:00 p.m.) 8 mls in total given to resident when it should have been 0.5 ml give for entire evening shift. Order was entered incorrectly in PCC (Point Click Care, the facilities EMR); writer confirmed incorrect order and that is how medication error occurred. 2330 (11:30 p.m.) is when NOC (night) nurse went to go check on resident and found her RR (respiratory rate) 6-8 per minute (normal 12-16), HR (heart rate) 74 (normal 60-100) and 02 sats (oxygen level) 77% (normal 95-100%). Noc nurse put resident on 2.5 liters of 02 (oxygen) via nasal cannula. Resident 02 went to 90% and later to 98%. Writer called hospice to inform of error and resident condition. Writer corrected error in PCC (the EMR) to reflect correct dosing of 0.25 mls per 4 hours. Writer received order to give 2mg of [MEDICATION NAME] (a narcotic reversal medication) STAT (immediately) injection to resident, up to 10 mgs, until rousable and to proceed with 15 minute checks 8 times for 2 hours, then checks every hours for 6 hours. Resident was rousable after one administration. Writer then called POA (power of attorney) about error and resident condition. Resident is currently on 2.5 liters of O2, sats are 97%. RR 16-18 per minute. Pulse 75. R1's Presbyterian Homes Hospice order dated 7/25/20, at 12:42 a.m. included, [MEDICATION NAME] 2 mg IM (in the muscle) now- May be repeated every 2-3 minutes, as needed until client is rousable, with max dose of 10 mg. VS (vital signs) checks q (every) 15 min. (minutes) x 8 then VS checks q 1 hr (hour) x 6. Call EMS (emergency medical services) for additional support if not arousable, or to get additional [MEDICATION NAME], or if not able to get [MEDICATION NAME]. However, the orders was transcribed by RN-A as, [MEDICATION NAME]. Route inj (injection), Dose: 2 mg to 10 mg. Frequency 2 mg to 10 mg, Diagnosis: [REDACTED]. The order as transcribed failed to indicate the 2 mg could be repeated every 2-3 minutes up to a total dose of 10 mg along with the omission of vital signs transcribed or to call EMS if correct dose of [MEDICATION NAME] was not available. R1's progress note dated 7/25/20, at 7:27 a.m. included, Resident VS checked QH (every hour) through the night and remained stable. RR (respiratory rate) 16/min visually observed; O2 sats 94-97% 2.5L NC (nasal cannula). No periods of apnea (temporary cessation of breathing) observed. Resident rouses easily when name spoken and verbally responds appropriately to simple yes/no questions. No additional scheduled [MEDICATION NAME] administered during the night. R1's Medication Variance Report dated 7/25/20, indicated R1 did not receive the correct dose or route of the [MEDICATION NAME]. The [MEDICATION NAME] had been taken from the emergency kit, which only contained [MEDICATION NAME] 0.4 mg/ml and only 1 ml had been given to R1. The report indicated RN-A had given the 0.4 mg of [MEDICATION NAME] with a [MEDICATION NAME] syringe, in which the needle is made to inject medication under the skin, not into the muscle as ordered. In addition, the [MEDICATION NAME] had not been ordered from the pharmacy and therefore not available when needed in the morning for R1 when she became unresponsive again with periods of apnea. R1's progress note dated 7/25/20, 4:08 p.m. included, 7:30 a.m. Night shift reported to writer that resident is arousable and respiration is 16 b/m (breaths per minute); and response to yes or no questions. 7:45-10:00 a.m. writer took the full set of vital signs; respirations: 8-10 b/m, oxygen saturation: 94% on 2l/min (2 liters per minute) oxygen; BP (blood pressure) 110/70; t-(temperature) 98.2; p-(pulse) 76 b/m (beats per minute); hospice nurse was informed about the residents ongoing health condition and informed that she did not get the proper dose of [MEDICATION NAME]; [MEDICATION NAME] was ordered from the pharmacy as a stat (immediate) order however the pharmacy told that it will take 2 hr (hours) for the process and arrival; family members was informed regarding the resident ongoing health condition and and (sic) give the option if she would like to send the resident to the hospital; responsible party told that she would like (sic) rely on the decision of the hospice nurse and would like to meet with the hospice nurse; hospice nurse was informed that family member want to meet the hospice nurse and leave the decision of the resident to the hospice nurse; hospice nurse arrived around 10:20 and family member was informed about the arrival of the nurse. R1's progress note dated 7/25/20, 2:12 p.m. included, 10:30 a.m. Seen resident not arousable accompanied by hospice nurse; hospice nurse stayed with resident in room; received information that hospice nurse is waiting for family member to come in and make decision if resident will be sent to ER (emergency room ) or not. 10:50 a.m. Resident's POA (power of attorney) arrived; made the decision of not to admit the resident to the hospital and to wait for the [MEDICATION NAME] (brand name for [MEDICATION NAME]) to be delivered; clinical administrator and clinical administrator (sic) was aware. Writer followed up with pharmacy re: time of arrival of [MEDICATION NAME] and pharmacist informed writer that they are processing it and will be sent ASAP. R1's progress note dated 7/25/20, 11:00 a.m. included, Writer checked with AL (assisted living) clinical administrator for availability of [MEDICATION NAME] in their E-kit; AL clinical administrator informed writer to check their medication room; found [MEDICATION NAME] nasal spray in their medication cart, called AL clinical administrator again to inform and gave a go signal to use it if appropriate. 11:05 a.m. Writer approached hospice nurse and asked that since [MEDICATION NAME] medication from pharmacy is still not available, if we can use the [MEDICATION NAME] Nasal Spray; hospice nurse verbalized, I will secure the order later for the spray. 11:10 a.m. Hospice nurse administered 4 mg of [MEDICATION NAME] Nasal Spray, writer present as witness. 11:25 a.m. Resident became responsive and conversant; accompanied by sister in room. 12:45 p.m. [MEDICATION NAME] injection was received from pharmacy; writer verified with hospice nurse if (sic) which form of [MEDICATION NAME] (spray or injection) is to be given; hospice nurse confirmed to stick with the using the spray as indicated in the recent orders. R1's progress note dated 7/25/20, 1:00 p.m. included, Resident drank approximately 60 cc (cubic centimeters) of apple juice and ate a small portion of the cherry cake as reported by hospice nurse and her sister. 1:30 p.m. Hospice nurse reported that she increase O2 @ 5 lpm via nasal cannula; resident is resting comfortably, sleepy but she is arousable to speech and touch; able to make short verbal responses. 2:10 p.m. Resident is responsive to speech and touch; still accompanied by her sister. R1's progress note dated 7/25/20, 4:00 p.m. included a respiratory rate of 12, oxygen level 90% on oxygen at 5 lpm, and resident was not arousable. 5:40 p.m. unable to open mouth for supper. 6:30 p.m. unable to arouse. 7:30 sleeping, respiratory rate of 12 and oxygen level of 99%. 9:00 p.m. R1 was not arousable. opened one eye during bed bath and made a noise. 10:20 p.m. respirations had dropped to 8 and the [MEDICATION NAME] was administered again. 11:00 p.m. unable to arouse and all medications had been held. Although R1 had received doses of [MEDICATION NAME], she continued to have symptoms of respiratory depression and unresponsiveness as a result of the medication error. R1's progress note dated 7/26/20, 7:29 a.m. noted respirations stable through the night, no apnea and did respond verbally when spoken to. When interviewed on 7/28/20, at 2:30 p.m. HIMS-A stated RN-D had written a verbal order for the change in [MEDICATION NAME] on 7/24/20, HIMS-A transcribed the order into the EMR (Point Click Care). However, the order was written as [MEDICATION NAME] 20 mg/ml, 5 mg every 4 hours, there was no milliliter equivalent and the PCC system would not take the order unless there was a milliliter designated for the amount. HIMS-A stated she did the math/drug calculation, by dividing the 20 mg by the 5 mg and came up with 4 milliliters, but was unsure she had calculated this correctly. She had never been trained to calculate drug doses, so she had RN-B review it and RN-B said it was good. She identified it is the facility policy to have a nurse check off on any orders processed by an HIMS, so RN-A signed off on the order later in the shift. When interviewed on 7/28/20, at 12:45 p.m. RN-A stated, she had seen the order for R1's [MEDICATION NAME] in the computer as needing a nurse to sign off on it, she had assumed the dosage calculation had been done correctly and signed off on it without doing the dosage calculation herself. I just signed what (HIMS-A) had written. RN-A stated she had given R1 the incorrect dose of [MEDICATION NAME] as it was transcribed, the 4 ml to equal 80 mg twice during her shift, not noting the discrepancy. When the night shift came on duty they did a narcotic count together and the night nurse (RN-D) noted there was too much [MEDICATION NAME] used and checked on R1 who was unresponsive and having apnea with respirations of only 8 per minute. This was how they found the medication error. She called hospice to report the error and R1's condition. Hospice returned the call and ordered the [MEDICATION NAME], she processed the order and administered the [MEDICATION NAME] to R1 who then became responsive and no longer had apnea. RN-A did not find out she had transcribed the order wrong for the [MEDICATION NAME] or that she had given the wrong dose, using the wrong type of syringe until the next day. She used 2 -1 ml [MEDICATION NAME] syringes and used the vial of [MEDICATION NAME] from the emergency kit, she did not recognize it was only 0.4 mg instead of the 2 mg ordered. RN-A did not order the STAT [MEDICATION NAME] from the pharmacy, since this medication was already in the emergency kit, but did not recognize it was the wrong dose. When interviewed on 7/28/20, at 2:42 p.m. RN-B stated HIMS-A requested she review the [MEDICATION NAME] order for R1 on 7/24/20, and she had done so and approved it. RN-B acknowledged the dosage calculation for the [MEDICATION NAME] was incorrect, but had not noticed it at the time as, was most likely between tasks at the time. When interviewed on 7/29/20, at 10:45 a.m. the director of nursing (DON) stated the dose of [MEDICATION NAME] in the emergency kit only contained 0.4 mg/ml and only contained 1 ml, therefore RN-B could not have given the correct dose, and RN-B had stated she used a [MEDICATION NAME] syringe, with a very short needle, which means it could not have been given into a muscle as ordered either. The DON stated they had started to re-train nurses on transcribing physician orders [REDACTED]. However, the training did not include drug dosage calculations, which was the root cause of the error. When interviewed on 7/29/20, at 10:21 a.m. the consultant pharmacist (CP)-I stated if the facility needs a medication STAT, they can take the medication from the emergency kit and call the pharmacy to get a delivery at any time of the day or night. The pharmacy is also always available to assist with drug calculations as needed. The [MEDICATION NAME] 0.4 mg/ml is a common dose to be used in nursing homes, if the order was for a higher dose, they would have to order the medication STAT. When interviewed on 7/29/20, at 11:30 a.m. medical director (MD)-A indicated that a normal dose of [MEDICATION NAME] to treat a severe opioid overdose would be [MEDICATION NAME] 2-4 mg IM. MD-A stated that a dose of 80 mg of [MEDICATION NAME], Would reduce respirations and cause sleepiness and lethargy. Theoretically it could end their life. MD-A stated they were in the process of reviewing the dosage of [MEDICATION NAME] available in the facilities emergency kit and increasing it to 2 mg. The nurse should have called EMS for support or to get additional [MEDICATION NAME] if not able to get the correct dose STAT. When interviewed on 7/29/20, at 10:47 a.m. hospice nurse, RN-G stated they had arrived at the facility and noted R1 continued to be unresponsive with a respiratory rate of 8 breathes per minute with a repeating pattern of 4 breathes followed by 15 second periods of apnea. RN-G informed RN-E and RN-F to administer any [MEDICATION NAME] available in the facility. RN-H returned from the facility assisted living section with a bottle of [MEDICATION NAME] 4 mg nasal spray, which was administered and R1 began to respond and apnea ceased. When interviewed on 7/30/20, at 9:27 a.m. RN-E stated they had come into work on 7/25/20, at 7:45 a.m. and found R1 unresponsive with a respiratory rate of 10. Hospice was contacted and stated RN-G would come to the facility to assess R1. RN-E checked the emergency kit and noted there was one 1 ml vial of [MEDICATION NAME] 0.4mg/ml remaining. RN-E discussed with RN-F and called the pharmacy and discovered the pharmacy had never received the order for the [MEDICATION NAME] 2 mg STAT. They would fill it ASAP. RN-E stated they decided to await the arrival of the hospice nurse before determining whether to give more [MEDICATION NAME], even though R1 was unresponsive with apnea. When interviewed on 7/30/20, at 10:12 a.m. RN-F stated, they had assessed R1 on 7/25/20, between 7:00 a.m. and 8:00 a.m. R1 had a respiratory rate of 8-10 per minute, had apnea, and was unresponsive. RN-F stated the pharmacy was contacted to find out where the [MEDICATION NAME] was and found out they had not received the order. The emergency kit only contained 0.4 mg of [MEDICATION NAME]. The correct dose was ordered as STAT and RN-F and FN-E decided to wait until the hospice nurse, RN-G arrived to determine next steps. When interviewed on 7/30/20, at 11:57 p.m. nurse practitioner (NP)-A stated, R1 had become severely hypoxic (low oxygen) following the [MEDICATION NAME] overdose and a possible consequence to this could be death. When interviewed on 7/30/20, at 12:03 p.m. the DON stated, HIMS should not do drug dose calculations, nurses need to double check the work of HIMS with medication transcriptions to ensure accuracy. STAT orders should be processed and ordered from the pharmacy immediately, if the correct dose of [MEDICATION NAME] was not in the e-kit, staff should have contacted the ordering physician, or contacted EMS for support. In the case of an overdose, the nurse could use their critical thinking and use the [MEDICATION NAME] dose that is available even if less than ordered. Nurses should be knowledgeable about how to administer each route of medication. The facility submitted a training entitled Intradermal Injection/Subcutaneous Medication/Intramuscular, and Medication Administration Education, which included medication order processing, which showed facility nurses had been retrained on 7/25/20. However, the training lacked any education notification of physician with condition change, monitoring resident's after medication error, calculation drug dosages, or how to choose the appropriate syringe for injections. The facility Medication Administration Policy dated December 2018, identified accurate transcription of orders is the responsibility of licensed nursing staff. The policy did not indicate other staff who could transcribe medication orders. The policy included, the Medication Administration Record [REDACTED]. The facility Order Processing Policy dated February 2016 indicates that physician medication orders should include time and frequency of the medication and should include the route of administration. The immediate jeopardy that began on 7/24/20, was removed on 7/30/20, when the facility educated all licensed nurses on dosage calculation, correct syringes and techniques for injectable medications, how to verify orders that are input into the EMR by unlicensed staff, observation of the resident after a medication error/overdose, notification of physician when there is no access to the correct dose of STAT medications and utilization of the EMS system if needed, ordering STAT medications from the pharmacy, and how to recognize an inappropriate dose of medication. In addition, Mollies staff responsible for inputting orders into the EMR were retrained and educated to consult with a nurse when in doubt of an order. The facility also conducted an audit on all liquid medications to ensure accuracy in the EMR. Audits were started on all new orders, which were to continue for 14 days and be re-evaluated. All nurses and trained medication aides (TMA's) were audited for medication administration. This was verified by observation, interview and document review by the surveyors on 7/30/20. However, the noncompliance remained at the lower scope and severity level of a G, isolated actual harm that is not immediate jeopardy, because R1 was harmed when she received the incorrect doses of [MEDICATION NAME] and became unresponsive with respiratory distress, received the wrong dose of the reversal medication and the unresponsive episodes and respiratory distress continued for over 24 hours.