Every finding on record at Clara City Care Center

Based on observation, interview and document review, the facility failed to ensure refrigerated food items were properly labeled, dated, and closed after the packaging was opened to prevent cross contamination which had the potential to affect all 28 residents currently residing in the facility. In addition, the facility failed to ensure refrigerated food items were disposed of after the expiration date or opened per facility policy. Findings Include:During the initial tour of the main kitchen on 3/30/26 at 12:36 p.m., with the dietary manager (DM)-A, the following areas of concern were identified and confirmed by DM-A:Upright refrigerator:-small disposable covered container of cake dated 3/5/26.-plastic half bag of salami slices, opened, undated.Walk In refrigerator:-opened gallon plastic container of ranch dressing, undated, expiration date of 9/25/25. -opened container of thousand island dressing, undated, expiration date 3/21/26.During a follow up interview on 3/31/26 at 1:33 p.m., DM-A stated most items that were opened should be disposed of after seven days. DM-A confirmed her expectation would be condiments would be disposed of after expiration date. DM-A indicated foods should be dated when opened, so staff knew how old an item was, and then disposed of per facility policy for food safety. The facility policy titled Food Storage dated 2021, identified food would be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. The policy identified leftover foods would be clearly labeled and dated and used within seven days or discarded. Refridgerator foods should be covered, labeled, dated, and routinely monitored to assure foods would be consumed by their safe use by dates, frozen, or discarded.

Based on interview and record review the facility failed to adequately supervise a resident to reduce the risk of falls for 1 of 3 residents (R1) reviewed for accidents and supervision. R1 had a chair alarm that would sound when R1 would stand. The chair alarm prompted staff to respond to R1 after standing. R1 was found on her bathroom floor, transferred to the hospital with a left hip fracture.Findings include: According to the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Rev. 229, Issued: 04/25/25 supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. Devices such as position change alarms may help to monitor a resident's movement temporarily, but do not eliminate the need for adequate supervision. Position change alarms are not prohibited from being included as part of a plan, they should not be the primary or sole intervention to prevent falls. If facility staff choose to implement alarms, they should document their use aimed at assisting the staff to assess patterns and routines of the resident. Use of these devices, like any care planning intervention, must be based on assessment of the resident and monitored for efficacy on an on-going basis. Position change alarms have been used to monitor a resident's movement in chairs or beds, etc. However, there must be sufficient staff and supervision to meet the resident's needs and staff must be vigilant in order to respond to alarms in a timely manner. Alarms do not replace necessary supervision. Facilities must take steps to identify issues that place the resident at risk for falls and implement approaches to address those risks in a manner that enables the resident to achieve or maintain their highest practicable physical, mental, and psychosocial well-being. R1's nursing order dated 3/29/24 at 2:26 p.m. indicated R1 had a fall alarm on her wheelchair and in her bed due to repeated falls. The order was open ended. The alarms were to be checked three times a day, a.m., p.m., and at the hour of sleep (HS). R1's care plan dated 4/2/24 indicated R1's problem was safety/falls indicating she was at risk for falls and injuries as evidenced by unsteady gait and balance, need for assistance to transfer on and off the toilet, recent emergency department visit, use of assistive devices, cognitive status, history of falls. R1 was taking Donepezil (for treatment of dementia), risperidone (anti-psychotic), and sertraline (anti-depressant). She had diagnoses of fracture of the fifth metatarsal bone of the left foot, generalized anxiety and imbalance. Interventions were: Wander guard to ankle to alert staff if she left the building Adequate bed height Adequate lighting Call light in reach Clear path to the bathroom Clothing fits properly Complete an incident report for any falls or injuries Consult with registered nurse (RN) supervisor as needed Electrical cords and call light cords in proper placement Equipment in good repair Floor clean and dry Furniture in adequate placement Hallways free of clutter Notify family member and medical doctor (M.D.) if an incident report is completed Proper non-slip footwear when not in bed Report any confusion or light headedness to charge nurse Report any indication of pain or unsteadiness to charge nurse Room free of clutter The following alarms were in place - bed and chair sensor alarm Safety risk and physical device assessment quarterly and as needed (PRN) R1's care plan failed to provide any interventions of staff supervisor for R1 to reduce the risk of falls. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 8 indicating R1 was cognitively impaired. R1's mobility devices used were a walker and a wheelchair. She required maximum assistance with toileting hygiene, showering, lower body dressing and walking. She required moderate assistance with upper body dressing, sitting to standing and transferring from chair to bed/bed to chair. R1 was frequently incontinent of urine and bowel. Her pertinent diagnoses were nondisplaced fracture of the fifth metatarsal bone left foot, open-angle glaucoma, age related osteoporosis. R1 used a bed alarm, chair alarm, and a wander/elopement alarm daily. R1's incident report dated 11/15/25 at 2:08 p.m. indicated R1 had a fall in the bathroom. The evaluation details indicated the root cause was R1 was a fall in her room due to the alarm on her chair was not turned on. R1 was transferred from the toilet in a different room. Staff flipped the alarm switch off when getting her to the toilet. A staff member was passing water and found R1 on the floor. The immediate intervention was R1 was sent to the emergency department (ED) due to hip pain. She was found to have a left femur fracture. The intervention on her hospital return was the sensor alarm was changed to one that automatically comes on. Staff education was completed to remind staff to make sure alarms are in place and on. R1's nursing progress note dated 11/15/25 indicated R1 was admitted to the hospital due to fall after staff found her between her wall and the bathroom door. 911 was called due to R1 stating that her help felt broken and was unable to move. R1 was diagnosed with a hip fracture. R1's nursing progress note dated 11/18/25 indicated R1 returned from the hospital following left hip fracture repair. R1 had three incision sites along the left lateral hip that were approximated with stables. The upper incision site had nine stables, the medial incision had five staples, and the lower incision site had three staples. R1's progress note dated 12/3/25 at 8:41 a.m. indicated R1 was in severe pain that morning and was sent via ambulance to the emergency department. She was admitted to the hospital. Therefore, R1 was not available for observations and interview during the survey process. Upon interview on 12/3/25 at 11:55 a.m. trained medication assistant (TMA)-A stated the staff was to make sure residents who have sensor alarms visualize that the alarms are in place under the wheelchair or in their bed. Anyone with a fall alarm should not be left alone in the bathroom and to make sure the alarm is always on except for when helping a resident with cares. She denied any staff supervision of residents with the alarms. Upon interview on 12/3/25 at 1:39 p.m. TMA-B stated on the day R1 fell she was found in an unoccupied resident's room attempting to toilet herself. He heard the alarm sound, found R1 and assisted her toilet. TMA-B stated he forgot to turn the alarm back on when he wheeled her into the commons area and left her there. An hour later nursing assistant (NA)-A was passing water and found R1 on the floor pushed against her bathroom door. R1 was found on the floor without her alarm sounding. The staff relies on the alarm to know if R1 had attempted to stand-up alone. He stated the alarm was the main intervention for residents with fall risks. He stated the process was if staff hear an alarm sound, they hear a number of which alarm was sounding (each resident has their own number with their personalized alarm). The staff then uses their walkie talkies to communicate with other staff to find the resident who was attempting to stand-up. TMA-B stated the staff catch a lot of residents before they actually fall with the alarms. He denied staff supervision for R1. Upon interview on 12/3/25 at 3:46 p.m. registered nurse, (RN)-A stated the facility tried to keep the residents with alarms in the lobby and staff check on all residents as they walk by their rooms. RN-A stated she was not certain what was meant by resident supervision interventions for residents at risk for falls. Upon interview on 12/4/25 at 11:48 a.m. NA-B stated there were not specific supervision interventions on the residents, but staff should always keep an eye on them. She stated R1 had a chair alarm and staff would find her all over the facility as she moved quickly in her wheelchair. Upon interview on 12/4/25 at 11:55 a.m. RN-B stated the facility used the motion sensor alarms to supervise the residents and many falls were avoided because of having the alarms. Unfortunately, R1's alarm was not turned on when she fell and broke her hip. Upon interview on 12/4/25 at 12:18 p.m. occupational therapist (OT)-A stated R1 was a very confused lady who wandered. R1 was fragile due to her age of 95, therefor it would be important to anticipate her needs and have eyes on supervision. She was not certain of the facilities inventions for R1. Upon interview on 12/4/25 at 12:51 p.m. the director of nursing (DON) stated all residents have interventions. Staff were to follow interventions on each resident's care plan. The residents have alarms for supervision. The DON was not aware that residents with safety alarms also required supervision defined by type and frequency of supervision as the alarms do not eliminate the need for adequate supervision. Multiple attempts were made to interview R1's family via phone, however calls were not returned. A facility policy titled Fall Prevention and Management Program dated 11/6/2019 indicated: The purpose of the falls prevention and management program is to develop, implement, monitor and evaluate an interdisciplinary team fall prevention approach and management strategies that foster resident independence and quality of life while ensuring safety of the resident and other residents and staff. The program focuses on reducing the incidence of resident's falls and mitigating risks of falls through a resident focused team approach which ensures that a resident's environment and social, physical, cognitive, and emotional strengths are supported. The program ensures team training, communication, and effective care planning. The facility will ensure that a fall interdisciplinary prevention and management program will be maintained to reduce the incidence of falls and the risk of injury to the resident and promote resident independence. A policy regarding safety alarms was requested however none provided.

Based on interview and document review, the facility failed to ensure doors were secured and failed to implement individualized interventions to prevent/reduce the risk of elopement for 1 of 3 residents (R1) who had a history of exit seeking behaviors. This resulted in an immediate jeopardy (IJ) when R1 eloped from the facility through two unsecured doors and the wander guard alarm did not work. R1 was later found and returned to the facility by a passerby. The IJ began on 10/13/25, when staff failed to identify doors were not secured and failed to develop and implement appropriate interventions when R1 displayed exit seeking behaviors and left the building unwitnessed. The director of nursing (DON) was notified of the IJ on 10/22/25 at 3:05 p.m. The IJ was removed on 10/23/25 at 4:15 p.m., when the facility implemented immediate corrective action to prevent recurrence, but noncompliance remained at a lower scope and severity of D with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1 was admitted to the facility on [DATE]. R1's face sheet dated 10/22/25, indicated diagnoses of dementia, depression, and anxiety. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had mild cognitive impairment and required staff assistance for activities of daily living with transfers and ambulation. R1 used a wheelchair for locomotion. R1 did not have behaviors or range of motion limitations. R1's elopement risk assessment dated [DATE], identified at risk for elopement related to resident being independent in wheelchair locomotion, cognitive impairment and making statements that he was leaving. R1's care plan dated 9/26/25, identified an elopement problem. The care plan indicated R1 was a t risk for elopement related to making statements of leaving to go home. The goal was for R1 to not elope from the facility during the next 90 days. The only intervention was a Wander Guard on R1's ankle. The care plan also identified R1 as a fall risk. R1's progress note dated 10/2/25, at 3:41 p.m., indicated R1 had exit seeking behaviors when he put on his coat, went towards an exit and stated he was going home. There was no indication R1's care plan was reviewed/revised after R1 demonstrated exit seeking behaviors (Documentation for subsequent care planning or new interventions following this incident was requested but not received.) R1's progress note dated 10/7/25, indicated R1 had an unwitnessed fall with no injuries. R1's progress note dated 10/13/25 at 3:45 a.m., identified registered nurse (RN)-A received a call from a passerby that they had a resident (R1). No injuries identified during the skin assessment. R1 was put back to bed, safety checks were implemented. RN-A assessed all doors in the facility besides the emergency only doors in the unused part of the building. On 10/13/25 at 11 p.m., the temperature in [NAME] City was 49 degrees Fahrenheit per Localconditions.com The nursing home is located on the corner of Division Street (one of the main roads in town) and 40th street where curbs buffer the street right outside the facility. The east side of the building is next to corn fields. There is an operating railroad approximately one mile south of the facility. The State Agency 5-day report dated 10/16/25, included nursing assistant (NA)-A's interview. The report indicated on the evening of 10/13/25 at around 11:00 p.m. R1 asked NA-A to help tie his bag with his belongings. NA-A asked if he was leaving and R1 said yes. NA-A said ok and went to the nursing station. Approximately 5 minutes later, R1 came to the nurse's station and asked how to sign out. NA-A told R1 to go talk to the nurse about it. On 10/21/25 at 12:04 p.m., a call was placed to nursing assistant (NA)-A however it was not answered, there was no return call. During an interview on 10/21/25 at 3:07 p.m., RN-A indicated the evening of 10/13/25, R1 asked her about the sign out book and stated he was leaving. RN-A told R1 it is the middle of the night, and no one is coming to pick you up. R1 turned around and wheeled himself to the other end of the building. RN-A did not communicate to NA's R1 was exit seeking nor increased supervision and/or changed the care plan. RN-A was not aware R1 had exited the building until the passerby called the facility; she did not get any specific information from the passerby such as exact location where R1 was found and R1's mental status. RN-A indicated she had seen R1 approximately 30 minutes prior to the call when he had asked to leave; R1 had been wearing a sweatshirt, sweatpants, and tennis shoes. RN-A was not aware that the exit doors that were supposed to be locked were unlocked at the time R1 left the facility because she had not checked them. RN-A stated she implemented every 2-hour checks, however, was unable to articulate how she determined every two hours was appropriate or individualized. During an interview on 10/21/25 at 2:08 p.m., social worker (SW) stated R1 was able to show her which hallway he went down and which doors he exited the facility from. He recognized duct work in between the two exit doors. Outside, R1 told the social worker he recognized the curb that he went down in his wheelchair. During an interview on 10/22/25 at 8:22 a.m., maintenance manager (MM) indicated R1 exited through two unsecured unlocked doors that were supposed to be locked. The Wander Guard system on the last door was not functioning properly. It was a known issue that the Wander Guard on that door does not beep, it was discussed at department head meetings several times. MM indicated there previously was not a system in place to ensure the exit doors were always locked. After the incident MM inspected all the doors and only found that the doors were unlocked not that there were mechanical issues. During an interview on 10/22/25 at 9:19 a.m., DON reviewed R1's record, she explained there was no interventions put into place after R1 demonstrated exit seeking behaviors on 10/2/25. The evening of 10/13/25, after RN-A became aware of the exit seeking behavior there was a lack of communication between staff and no immediate interventions were implemented to prevent/mitigate R1's risk for elopement. After R1 eloped on 10/13/25, immediate interventions of two-hour checks were implemented, but no other individualized interventions were implemented that addressed R1's exit seeking behavior. DON stated prior to the elopement there was not a system in place to assure all the doors in the facility were secured. After the elopement and prior to survey entrance on 10/21/25, every-two hour safety checks were changed to every one hour, a bed alarm as placed on R1's bed, and a system to check the doors only during the evening was implemented. Additionally, staff had received education on elopement procedures and checking locked doors however, indicated staff were not educated on developing interventions, revision of the care plan, and implementing interventions that addressed exit seeking behaviors was not addressed. During an interview at 10/22/25 at 12:30 p.m., trained medication aide (TMA)-A stated he had received training on the elopement procedure but exit seeking interventions was not addressed. He stated care plans should include elopement risks and interventions. During an interview at 10/22/25 at 1:30 p.m., NA-B stated she had education on the elopement procedure but there was no mention of interventions for exit seeking behavior. The facility policy Missing Resident/Elopement Policy and Procedure last revised 10/14/25 directed that after an elopement, the charge nurse will update the resident's assessment and care plan as needed. The charge nurse will orient staff to any new interventions or procedures to reduce the risk of future problems for this or other residents. The IJ was removed on 10/23/25 at 4:15 p.m., when it was verified the facility implemented the following corrective actions: *The facility provided education with knowledge checks to all nursing staff on revising care plans for individualized, immediate interventions for exit seeking behaviors. *The facility provided education with knowledge checks to all staff on identifying exit seeking behaviors, implementing appropriate interventions for redirection and increased supervision. When to notify and communicate with other staff about elopement risk concerns. When to ask passerby citizens about an elopement, such as where the resident was found, what the resident was doing and what their mental status was. *Identified staff who have a key to the locked door. *Developed a door lock check system that assures the two doors involved with the elopement are locked. The doors are checked at least once per shift by nursing staff and documented in a sign off sheet. *Reviewed the elopement policy and procedure. Educated staff on the elopement policy and procedure.

Based on document review and interviews, the facility failed to develop and implement comprehensive care plans for 2 of 3 residents (R1, R2) reviewed for elopement. Findings include: R1 was admitted to the facility on [DATE]. R1's face sheet dated 10/22/25, indicated diagnoses of dementia, depression, and anxiety.R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had mild cognitive impairment and required staff assistance for activities of daily living with transfers and ambulation. R1 used a wheelchair for locomotion. R1's elopement risk assessment dated [DATE], identified at risk for elopement related to resident being independent in wheelchair locomotion, cognitive impairment and making statements that he was leaving. R1 was at risk for elopement. R1's care plan dated 9/26/25, identified an elopement problem. The care plan indicated R1 was a t risk for elopement related to making statement of leaving to go home. The goal was for R1 to not elope from the facility during the next 90 days. The only intervention was a Wander Guard on R1's ankle; the care plan did not identify individualized interventions to manage R1's elopement risk and/or statements of leaving the facility. R1's progress note dated 10/2/25, at 3:41 p.m., indicated R1 had exit seeking behaviors when he put on his coat, went towards an exit and stated he was going home. There was no indication R1's care plan was reviewed/revised after R1 demonstrated exit seeking behaviors. R1's progress note dated 10/13/25 at 3:45 a.m., identified registered nurse (RN)-A received a call from a passerby that they had a resident. No injuries identified during the skin assessment. R1 was put back to bed, safety checks were implemented. RN-A assessed all doors in the facility besides the emergency only doors in the unused part of the building. R2R2 was admitted to the facility on [DATE]. R2's face sheet dated 10/21/25, indicated diagnoses of hemiplegia (partial paralysis) following cerebral infarction (stroke), cognitive deficit following other cerebrovascular disease, insomnia, anxiety and unspecified symptoms involving cognitive functions and awareness. R2's annual MDS assessment dated [DATE] indicated R2 was cognitively intact and required moderate assistance for activities of daily living.R2's elopement evaluation dated 6/9/25 indicated R2 was independent in locomotion, had cognitive impairment and had displayed behavior that may indicate an attempt to leave and that an elopement may be forthcoming. R2 was at risk for elopement. R2's care plan dated 10/21/25, listed a problem with safety and falls. An approach listed for the fall risk was Wander Guard to wheelchair handle. The care plan did not have a focus area related to elopement and did not have any individualized interventions for exit seeking behavior. On 10/21/25 at 3:07 p.m., registered nurse (RN)-A was interviewed and stated on 10/13/25 at approximately 11:00 pm., R1 came over and asked for the sign out book, had all of his belongings with him and said he was leaving. RN-A stated she did not do anything such as increasing supervision or trying elopement interventions because she was busy with another resident. RN-A verified staff had radios to communicate with each other. RN-A did not communicate with the nursing assistants to increase supervision or try elopement interventions. On 10/22/25 at 12:20 p.m , the director of nursing (DON) was interviewed and stated R1's care plan had not been updated yet to include individualized interventions for his exit seeking behavior and it was not part of the remaining follow up after the elopement event. On 10/22/25 at 12:30 p.m., trained medical assistant (TMA)-A, was interviewed and stated that the care plan should indicate if a resident is at risk for elopement. On 10/22/25 at 12:45 p.m., RN-B was interviewed and stated residents who are elopement risks have a section about safety and falls in their care plans. There are interventions staff are doing that is not documented in the care plans when residents had been exit seeking. RN-B said those interventions could be added to the care plans. On 10/22/25 at 1:30 p.m., nursing assistant (NA)-B was interviewed, and was able to list interventions for each resident with exit seeking behaviors but was unsure where those interventions were documented. The facility policy, Resident MDS and Care Planning, last modified on 1/13/21 directs that all residents will have a comprehensive assessment completed upon admission, annually and with a significant change. Risk factors and assessment to be competed by a nurse on an admission, quarterly and PRN and includes elopement.

Based on interview, observation and document review, the facility failed to ensure safe use of a mechanical lift per manufacturer's recommendations to transfer 1 of 11 residents (R1), who required a mechanical lift for transfers. This resulted in an immediate jeopardy (IJ) when R1 fell from a full body mechanical lift causing R1 to suffer fractures to her cervical spine (C1 and C6), nasal cavity, and left femur as well as lacerations to facial area requiring hospital admission. In addition, the facility failed to ensure a system for completed comprehensive assessments for sling size and/or care plan development for 9 of 11 residents (R1, R2, R3, R5, R6, R8, R9, R10, R11) reviewed who required mechanical lifts. The IJ began on [DATE], when staff failed to ensure the lift sling was properly secured and the environment was clear prior to the transfer causing R1 to fall from the mechanical lift. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 4:20 p.m. The IJ was removed on [DATE] at 2:11 p.m., when the facility had implemented immediate corrective action to prevent recurrence, but noncompliance remained at a lower scope and severity of a D with no actual harm with potential for more than minimal harm that was not immediate jeopardy.Findings include: A Facility Reported Incident (FRI) submitted to the State Agency (SA) on [DATE] at 9:25 a.m., alleged potential caregiver neglect when R1 fell from the mechanical lift during a transfer and sustained a large gash above right eyebrow and on her nose. R1 was transferred by ambulance to the emergency department (ED). R1's Emergency Department Note dated [DATE] at 7:49 a.m., identified R1 was seen in the ED for assessment after she fell out of a hoyer lift. R1 presented with laceration to right eyebrow, bridge of nose, and some bleeding to the gums of her mouth. R1 also complained of increased difficulty breathing through her nose as well as feeling her head was heavy. The note identified that due to R1's multiple fractures and unstable burst fracture of the first cervical vertebra, R1 was transferred to the St. Cloud Hospital for further assessment and care. Clinical impression included closed unstable burst fracture of the first cervical vertebra, closed odontoid ( is a specific type of cervical spine injury involving the second cervical vertebra (C2)) fracture with displacement, fracture of the sixth cervical vertebra, and open fracture of nasal bone. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition. Diagnoses included at the knee amputations of both legs, paraplegia and rheumatoid arthritis. Identified R1 required staff assist with toileting, dressing, bed mobility, and transferring. R1's care plan last revised on [DATE], indicated R1 had a bilateral above the knee amputation in 2019, and required total assist of two (staff) and Hoyer (brand name of a full body mechanical lift) for transfers. The care plan did not identify the sling size staff were to use for transfers. Identified R1 had sutures to her nose and right forehead above the eyebrow with suture removal scheduled for [DATE]. In addition, R1 had a C1 and C6 (neck) fractures which required a cervical (neck) collar to be worn at all times. In addition, R1 had a nasal fracture and a left femur fracture requiring a leg immobilizer to be worn when R1 was up in wheelchair and during transfers. The facility identified focus sheet (abbreviated care plan for nursing assistants (NA)) as of 714/25, indicated R1 required two staff assist with Hoyer Lift however, the sling size was not identified. R1's progress notes dated [DATE] at 10:33 a.m., identified R1 was transferred to the ED for a C1, C2, and nasal fracture after a fall from a lift while staff transferred her from bed to wheelchair. R1's progress note dated [DATE] at 4:01 p.m., identified R1 returned from the hospital with the following injuries: laceration with five stitches above her right eye brow; laceration with three stitches in the center of her nose; bruising around right eye and down to the right side of her lips; bruising to her left eye under and on the corner of her inner eye; a 2.5 centimeter (cm) x 4 cm bruise near her left lateral elbow; two bruises on her left forearm sized 2 cm x 5.5cm and 5cm x 3.5 cm; neck brace on; and leg immobilizer on. R1's last documented weight on [DATE], was 136 pounds and previous weight on [DATE], was 123.6 pounds. An undated facility document labeled Medcare Products indicated all sling sizing recommendations were provided for patient comfort and fit. For a resident weight of 100-210 lbs. (pounds) a medium sized sling would be indicated. During an observation and interview on [DATE] at 11:12 a.m., R1 was sitting in the common area and was noted to have scabs, bruises, sutures to her face with a neck collar on, and an immobilizer brace on her left upper leg. R1 stated she had just returned from the hospital and was having pain all over, all of the time. R1 further identified she fell out of the lift fell the top sling loop by the right side of her head came off. When she fell out of the lift, she hit her face and nose on the leg of the lift and her legs hit something when she fell however she was not sure what they hit. R1 stated, I don't think they had it [sling] hooked up right as she stated she used the lift for six years and it had not happened before. R1 indicated she had been in the hospital for a couple of days and had lots of pain all the time. R1 expressed fear of getting back into the lift sling. During an observation on [DATE] at 1:19 p.m., nursing assistant (NA)-G and registered nurse (RN)-A transferred R1 from wheelchair to bed. When asked about the size of the sling, NA-G stated R1 used small slings and observed R1 had a small multipurpose sling under her during transfer and a spare small sling stored in the closet. During an observation on [DATE] at 3:02 p.m., NA-F and NA-E prepared to transfer R1 from bed to wheelchair. R1 cried out and moaned in pain while they rolled her to apply a small sling under her. NA-E and NA-F put the loops onto the safety bar and began to lift R1 off the bed. This evaluator stopped the transfer when it was noted that once tension was applied to the sling straps, the sling loop on the upper left side was sitting on top of the safety bar and not down in the hook area where it was supposed to rest for a safe transfer. NA-E stated, oh-oh, didn't I put it [sling loop] all the way down? NA-F lowered the lift and reapplied the loop to the upper left safety bar in the hook, lifted R1, and attempted to transfer to wheelchair. When R1 was approximately twelve inches above the wheelchair, the lift stopped, and NA-E used a walkie talkie to page the nurse. After a few minutes, licensed practical nurse (LPN)-A responded and explained how to operate the emergency lowering mechanism to both NA's and R1 was safely lowered to the wheelchair. NA-F stated that the battery had died and needed the nurse to assist. During an interview on [DATE] at 3:21 p.m., the director of nursing (DON) indicated staff were expected to to use a medium sling for R1, not a small sling. The DON did not know why small slings were stored in R1's room. During an interview with licensed practical nurse (LPN)-A on [DATE] at 2:10 p.m., identified she responded on [DATE] at 6:50 a.m., when R1 fell from the lift but stated she thought the sling used was a medium and was unhooked and underneath R1 on the floor. LPN-A identified she was not sure what had happened to allow R1 to fall and was just more concerned with getting R1 the emergency care she needed at the time. LPN-A further indicated staff should have used a medium sling for R1 because of her weight but a small sling was R1's preference so staff had used small slings most of the time. During an interview on [DATE] at 2:25 p.m., NA-B identified he assisted NA-A with R1's transfer on [DATE], in the morning. NA-B stated they each hooked two loops of the sling up to the safety bar and raised R1 up out of bed. While they were moving the lift towards the chair, the leg of the lift got caught up in the base of R1's fan and R1 started leaning to the right and fell out of the right side of the sling. NA-B further identified one of the sling loops had come unhooked during the transfer and thought it was the one on the side R1 fell out of however stated it happened really fast and was not certain. NA-B denied double checking the placement of the loops once tension was applied to the sling straps. During an interview on [DATE] at 9:35 a.m., RN-B indicated R1 by weight should have had a medium sling used however insists on a small [sling]. R1 felt the medium sling was too big did pretty good in it [small sling] but didn't work when the fall happened. RN-B indicated staff should be checking the placement of the sling loops as soon as pressure had been applied to the sling straps. RN-B did not know where a resident assessment for proper sling size would be in the medical record and did not think it was documented anywhere. During an interview on [DATE] at 9:50 a.m., the maintenance director indicated the full body lift was inspected after R1 fell from it and was found to be in working order. During an interview on [DATE] at 11:25 a.m., Medcare customer service representative (CSR) indicated if the full body lift was in working order, the only way for a resident to fall out of a lift would be improper sling set up or not attaching it to the lift safety bar hooks correctly. R2 R2's MDS dated [DATE], identified R2 had intact cognition, and diagnosis of paraplegia. R2's care plan dated [DATE], indicated R2 transferred with two staff assist and a Hoyer (full body mechanical lift). The care plan did not identify the size sling to use. The facility identified focus sheet (abbreviated care plan for nursing assistants (NA)) as of 714/25, indicated R1 required two staff assist with Hoyer Lift but did not identify the sling size to use. R2's medical record identified R2's weight on [DATE], was 188.4 pounds. An undated facility document labeled Medcare Products indicated all sling sizing recommendations are provided for patient comfort and fit. For a resident weight of 100-210 lbs. (pounds) a medium sized sling was indicated. During an observation on [DATE] at 11:55, NA-C and NA-D transferred R2 out of the tub using a ceiling lift. NA-C indicated R2's sling was a size extra-large but after double checking the size on the sling, it had small written on the sling. NA-C stated, oh no, it looks much bigger than that, and further identified that she picked that sling out because, he [R2] likes the softer ones[slings], not the stiffer ones for his bath. NA-C further identified the resident sling size was not written anywhere and staff were directed to size the sling by the resident's weight and their body size. NA-D stated NA's or the nurses could decide what sling to use. During an interview on [DATE] at 12:00 p.m., RN-A indicated she did not know who determined what sling size a resident was supposed to use. RN-A stated she did not know how the proper sling or belt size was communicated to the NA's doing the transfers. R2's medical record lacked resident assessment for appropriate sizing of the sling. R3 R3's admission MDS dated [DATE], identified R3 had severe cognitive impairment, was dependent on staff for toileting, lower body dressing, transfers, and bed mobility. Diagnoses included dementia, encephalopathy, and osteoarthritis. R3's care plan revised [DATE], indicated R3 required assist of one staff with PAL (sit to stand lift) for transfers. The care plan did not identify what size sling belt to use. The facility identified focus sheet (abbreviated care plan for nursing assistants (NA)) as of 714/25, indicated R3 transferred with one staff assist and PAL lift (sit to stand lift) but did not identify what size belt should be used. The Medcare Operations Manual Belt Sizing Guide indicates recommended belt size was determined by waist size. R3's medical record did not contain R3's waist size. R3's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During observation and interview on [DATE] at 12:35 p.m., R3 was sitting in a recliner with an extra-large belt laying in the wheelchair. NA-D entered the room with the sit to stand lift which had a medium belt slung over the top of the lift. NA-D used the medium belt, placed the belt around R3 and hooked it to the lift. NA-D transferred R3 to the bathroom and then back to the chair. During the transfer back to the chair, R3 did remove her left hand from the lift and was holding on to the lift with her right hand only. No observation was noted of NA-D tightening the belt once R3 was lifted or applying the safety shin straps during the transfers. When asked about the two different belt sizes in R3's room, NA-D stated she did not know why there was an extra-large belt in R3's room but that it keeps showing up in here [R3's room] but had not used it. R3 indicated belt size was determined by the resident chest size and R3 was a smaller lady and if the extra-large belt were used on her, she would fall right through it. When asked about the safety shin strap, NA-D stated, I never use them [shin strap] and thought they were for a previous resident that would not keep his feet on the foot platform. R4 R4's quarterly MDS dated [DATE], identified R5 had moderate cognitive impairment and required staff assist for transfers. Diagnoses included lower limb amputation and osteoporosis. R4's care plan last revised [DATE], identified R4 required assist of one staff and stand by assist with transfers. The care plan did not identify the use of the mechanical lift or size of belt staff were to use with transfer. The facility identified focus sheet as of [DATE], indicated R4 transferred with one staff assist and PAL lift (sit to stand lift) but did not identify what size belt should be used. R4's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During an observation on [DATE] at 1:10 p.m., R4 was noted to have a sit to stand lift in her bathroom with a medium size belt draped over the top. R5 R5's quarterly MDS identified R5 had intact cognition and required staff assistance with transfers. Diagnoses included osteoarthritis and spondylosis (degenerative changes in the spine). R5's care plan last revised [DATE], identified R5 required one staff assist for transfers using a PAL lift (sit to stand lift) but did not identify what size belt should be used. The facility identified focus sheet as of [DATE], indicated R5 transferred with one staff assist and PAL lift (sit to stand lift) but did not identify what size belt staff should use. R5's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During an observation on [DATE] at 1:17 p.m., R5 was noted to have a size large belt laying on his chair in his room. R6 R6's significant change MDS dated [DATE], indicated R6 had severe cognitive impairment and required maximum staff assist with transfers. Diagnosis included dementia. R6's care plan revised initiated on [DATE], indicated R6 transferred with two assist and PAL lift but did not identify belt size to use for safe transfers. The facility identified focus sheet as of [DATE], indicated R6 transferred with two staff assist and PAL (sit to stand lift) lift for all transfers but did not identify what size belt staff should use. R6's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During observation on [DATE], R6 was noted to have a large sling belt in his room. R8 R8's quarterly MDS dated [DATE], identified R8 had moderately impaired cognition and was dependent on staff for all transfers. Diagnoses included cerebral infarction and dementia. R8's care plan reviewed on [DATE], indicated R8 transferred with assist of two and Hoyer (full body mechanical lift) but did not identify sling size to use. The facility identified focus sheet as of [DATE], indicated R8 transferred with two staff assist and Hoyer transfers but did not identify what size sling staff should use. R8's medical record lacked resident assessment for appropriate sizing of mechanical lift sling. R8's vital signs chart indicated R8's weight on [DATE], was 215 pounds which indicated a large sling was recommended. During observation and interview on [DATE] at 1:47 p.m., NA-D and NA-G transferred R8 to bed using a size large sling. Interview with NA-G indicated she determined sling size by the resident's weight and if she did not know the resident weight she would ask the nurse for the weight. NA-G further indicated R8 used a large because a medium is way too small. R9 R9's quarterly MDS dated [DATE], identified R9 had severe cognitive impairment and was dependent on staff for all transfers. Diagnoses included dementia and fracture of the left acetabulum (hip). R9's care plan on [DATE], identified R9 transferred with two staff assist and PAL lift or two staff assist and Hoyer lift but did not identify the size belt or sling to use for transfers. The facility identified focus sheet as of [DATE], indicated R9 transferred with assist of two and PAL lift or assist of two and a Hoyer lift but did not include the size of the sling or belt to use. R9's medical record lacked resident assessment for appropriate sizing of mechanical lift belt and sling. R10 R10's annual MDS dated [DATE] indicated R10 had severe cognitive impairment and required assist with all transfers. Diagnosis included Alzheimer's. R10's care plan on [DATE], identified R10 transferred with two staff assist for pivot transfer; one staff assist with ETAC (unknown meaning) from recliner, wheelchair, bed; or assist of one with PAL lift. The care plan did not identify what belt size to use. The facility identified focus sheet as of [DATE], indicated R10 transferred with assist of one and ETAC (unknown meaning); assist of two with pivot, or assist of one and PAL. R10's medical record lacked a waist size or resident assessment for appropriate sizing of mechanical lift belt. During observation and interview on [DATE] at 3:44 p.m., NA-G applied a large belt and assisted R10 to transfer. NA-G stated the size belt for the resident depended on the resident weight. R11 R11's significant change MDS dated [DATE], indicated R11 had intact cognition and required staff assist with transfers. Diagnosis included Multiple Sclerosis. R11's care plan on [DATE], identified R11 transferred with one staff assist and standing lift but did not identify what size belt to use. The facility identified focus sheet as of [DATE], indicated R11 required assist of one and PAL but did not identify what size belt to use. R11's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During an observation on [DATE] at 9:02 a.m., NA-H assisted R11 with a transfer to the commode using a medium belt. When asked about determining appropriate belt size for a resident, NA-H stated it depended on the size person they are and did not want them too loose so I just judge their size and how it fits and determine their size from there. NA-H further indicated there was not any direction on which belt size to use but most of the residents that used belts, had them hanging on their doors. R12 R12's quarterly MDS dated [DATE], indicated R12 had severe cognitive impairment and was dependent on staff for transfers. Diagnosis included Alzheimer's. R12's care plan on [DATE], identified R12 transferred with one staff assist and standing lift but did not identify what size belt to use. The facility identified focus sheet as of [DATE], indicated R12 assist of one and PAL but did not identify what size belt to use. R12's medical record lacked resident assessment for appropriate sizing of mechanical lift belt. During an interview on [DATE] at 9:13 a.m., NA-I indicated most of the residents that used lifts had slings or belts on the back of their doors that they could use but slings and belts for the mechanical lifts were based on the resident weight. NA-I denied any written communication to instruct what size sling or belt they were to use. During an interview on [DATE] at 9:20 a.m., LPN-A identified NAs should refer to the belt sizing guide in the CNA book binder at the nurse's desk when determining belt size. LPN-A further indicated all sling were determined by a resident's weight but did not know and could not find any sizing recommendation information on the sit to stand belts and stated, I guess they go by weight too. During an interview with on [DATE] at 12:20 p.m., RN C indicated she did not know who did resident assessments for sling sizing and was not aware of a specific assessment process the facility had in place. During a follow-up interview on [DATE] at 12:25 p.m., the DON identified the RN charge nurse should identify the residents sling or belt size based on the size guide sheet from the manufacturer and would be based on the resident body type and weight. The DON confirmed the facility did not have a formal assessment to determine sling or belt size and did not know where staff would document the resident sling and belt sizes. The DON indicated residents should have the appropriate size sling or belt on the back of their doors to ensure safety. The DON identified after R1's fall from the lift, she replaced the small slings in R1's room with the medium sling and did not know how the small slings ended up in use for R1 again after she had removed them. The DON confirmed the facility did not train or complete competencies for lift use on the temporary agency staff however planned to initiate that immediately. The DON verified the facility policy addressed the use of a lift that was not in service at their facility and did not have one specific to the Medcare brand lifts that were currently being used. The facility policy titled, Reliant 450 Lift and Slings (the facility is using Medcare full body lift and slings) dated [DATE], and last modified on [DATE], indicated before beginning procedure, scan the environment for obstacles to making a successful transfer and adjust environment to ensure safety of resident. Step 1 is to select the proper style and size sling (binding around each sling is color coded to size, the sizing chart is in each CNA book). Step 21 is prior to lifting an individual make sure the straps of the slings are securely placed on the hooks of the carry bar. The facility policy titled, Med Care Standing Lift dated [DATE] and last updated [DATE], identified the stand lift is intended for residents who are able to bear partial weight and require some lifting to perform activities of daily living. Appropriate use is to be determined by physical therapy department or nurse managers. Step 5 instructs to hook the leg strap around the resident's calves. Step 7 is prior to lifting an individual make sure the straps of the slings are securely placed on the hooks of the carry bar. Upon admission or change of condition, sit to stand lifts will be two assist, unless deemed to be safe with one assist by a licensed nurse or therapy. The policy does not include any language regarding how to accurately size the harnass (belt) for the resident. The Medcare Sling Sizing Guide directs staff to use the sling sizing chart as a general guide. Keep in mind the patients/residents that are the same weight may have different body types, shapes, and sizes and may require different sized slings. The Medcare Belt Sizing Guide directs staff to use the belt sizing chart as a general guide. Keep in mind the patients/residents that are the same weight may have different body types, shapes, and sizes and may require different sized belts. The sizing guide gives recommended size by waist size. Waist size of 24 inches to 48 inches recommends a small size; 30 inches to 54 inches recommends a medium size; 36 inches to 60 inches recommends a large size; and 42 inches to 66 inches recommends an extra-large size. The sizing guide does not identify that weight is used in sizing the belts. The IJ was removed on [DATE] at 2:11 p.m. when it was verified the facility implemented the following corrective actions:*The facility policy and procedure for safe mechanical lift transfers was updated to include the appropriate mechanical lift company's manufacturer's recommendations and specific time out procedures to do safety checks to ensure all loops were hooked on the appropriate hook before lifting the resident and completing an environmental scan of all the area for possible obstacles prior to beginning the lifting procedure. *The facility developed and implemented a system for an RN to comprehensively assess sling and belt sizes for individual residents utilizing the full body and sit to stand mechanical lifts by utilizing the manufacturer's guidelines and nursing judgement. * Sling and belt sizes for each resident were added to the resident's care plans and the NA care sheets (focus sheets). *The facility provided education with return demonstration to all nursing staff on manufacturer's recommendations to include a safety check, doing an environmental scan, and using proper sling sizes for the residents.

Based on observation, interview and document review, the facility failed to ensure an environment that was free of accident hazards, related to hot water temperatures in 6 of 6 resident rooms ( R9, R11, R16, R28, R31, R32,) tested for safe water temperatures. This deficient practice had the potential to affect all 6 residents who used water from the water faucets. Findings include: On 2/24/25 at 11:00 a.m., during resident screening the water temperatures in R9, R11, R16, R28, R31, and R32's rooms felt very warm to the touch after running water for one minute. During an observation and interview on 2/24/25 at 11:28 a.m., maintenance director (MD) verified the water in R9, R11, R16, R28, R31 and R32's room felt too hot and used the facility digital thermometer to measure the water temperatures in resident rooms. Water temperatures were as follows: -R9's room [ROOM NUMBER] was 129 degrees F. -R11 room [ROOM NUMBER] was 129 degrees F. -R16 room [ROOM NUMBER] was 129 degrees F. -R28 room [ROOM NUMBER] was 129 degrees F. -R31 room [ROOM NUMBER] was 130 degrees F. -R32 room [ROOM NUMBER] was 126 degrees F. During an interview on 2/24/25 at 11:52 a.m., R24 stated the water in his room was too hot and he had to turn the cold water on or he would have burned his hands. During an interview on 2/2/25 at 2:29 p.m., R31 stated the water in his room gets hot when it runs for a while. During an interview on 2/24/25 at 3:19 p.m., R11 stated the water in her room gets too hot. During an interview on 2/25/25 at 2:02 p.m., registered nurse (RN)-A verified all six residents were at risk for potential burns when the water was too hot. During an interview on 2/25/25 at 2:45 p.m., MD verified the above rooms were too hot according to State and Federal guidelines. MD stated he had completed random audits of water temps in the past month. MD stated they purchased a new hot water heater in the past few months which could have affected the water temperatures. MD stated his expectation was that the water temperatures in all resident rooms would remain between 105 and 115 degrees to prevent burns. During an interview on 2/25/25 at 2:19 p.m., administrator stated his expectations were that the water temperatures would remain within the State and Federal guidelines to prevent burns. Review of a facility policy titled Water Management Plan for Legionella updated 10/8/24, identified the facility was required to follow anti-scalding guidelines. Policy identified the water accessible to residents was between 105 and 115 degrees F.

Based on observation, interview, and document review, the facility failed to implement donning/doffing of personal protective equipment (PPE) practices for 2 of 2 residents (R32 and R16) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). In addition, the facility failed to ensure hand hygiene while providing personal cares to prevent the spread of infections for 1 of 3 residents (R30) observed during cares. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance dated 4/1/24, Implementation of PPE use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. EBP R32 R32's significant change Minimum Data Set (MDS) dated [DATE], identified R32 had moderate cognitive impairment and diagnoses which included heart failure, dementia, and arthritis. Identified R32 required extensive assistance for activities of daily living (ADL's) which included toileting, transfer, and dressing. Indicated for ADL's which included toileting, transfer, and dressing. Indicated. Indicated R32 had a pressure ulcer. R32's care plan revised 1/20/25, indicated R32 R32 had an unstageable pressure ulcer to her sacral area. Care plan instructed staff to use Enhanced Barrier Precautions related to R32 being at risk for developing a Multi Drug Resistant Organism (MDRO) infection. R32's weekly wound assessment dated [DATE], identified R32 had an open pressure wound on her left buttocks that measured 1 inch in length and 1 inch in width with a moderate amount of serosanguinous ( clear and bloody) drainage. Assessment identified that a calcium alginate dressing was applied over the wound. During an observation on 2/24/25 at 10:55 a.m., there was a plastic bin with three drawers placed on the floor in R32's room near the bed. Additionally, there was a sign on R32's room door that said Enhanced Barrier Precautions; Everyone Must clean their hands, including before entering and when leaving the room. Wear gloves and gown for the following high contact resident activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. In addition, the sign contained a picture of hand sanitizer, gown, and gloves. During an observation on 2/25/25 at 9:57 a.m., hospice aide (HA)-A entered R32's room wearing a surgical mask, sanitized hands, put soap and water into a basin, put gloves on and proceeded to place a washcloth into the wash basin and used the wash cloth to clean R32's face. HA-A then removed another washcloth from the wash basin and washed the front side of R32's perineal area with the washcloth. HA-A placed the washcloths into a plastic bag. HA-A removed her gloves, sanitized her hands and removed R32's gown and placed a clean gown on R32. HA-A combed R32's hair and adjusted the boots to R32's feet. HA-A covered R32 up with a sheet and sanitized her hands. HA-A was not wearing a gown at any time during this observation. During an interview on 2/25/25 at 10:20 a.m., HA-A stated she was aware R32 had a pressure ulcer on her buttock. HA-A stated she was not required to wear a gown while caring for R32 unless she was assisting the nurse with wound care. HA-A stated she was unaware she should have been wearing a gown while providing personal cares to R32. During an observation on 2/25/25 at 11:21 a.m., nursing assistant (NA)-B entered R32's room sanitized hands, applied gloves and assisted R32 to roll onto her side by placing her left hand on R32's back while using her right hand to remove R32's soiled brief. NA-B used a wipe to wipe R32's perineal area from front to back, removed the gloves, sanitized her hands and placed the a clean brief on R32. NA-B took a mouth swab out of the bedside table and swabbed R32's mouth out with the swab. NA-B was not wearing a gown at any time during this observation. During an interview on 2/25/25 at 11:26 a.m., NA-B stated she was not required to wear a gown while providing cares to R32 unless she was assisting the nurse with wound care. NA-B stated she was unaware she should have been wearing a gown while providing personal cares to R32. 37905 R16 R16's significant change MDS dated [DATE], identified R16 had severe cognitive impairment with diagnoses which included, Alzheimer's disease, heart failure, and anxiety. Identified R16 required substantial/maximal assistance with shower/bathing and upper body dressing, and was dependent for lower body dressing and transfers. R16's care plan revised 2/18/25, identified R16 had ADL self care deficit and needed assistance to complete ADLs. R16 required EBP, related to: open draining wounds to right lower extremity and was at risk of developing a multi-drug resistant organism/infection. Interventions included apply personal protective equipment (PPE) prior to providing wound care. Remove before leaving R16's room. R16's care plan lacked EBP intervention to include use of PPE with all high contact resident care activities. R16's Referral Form signed 2/7/25, included order: -wound on right leg-cleanse wound with wound cleaner, apply collagen (wound gel to promote healing) to wound beds, apply non-adherent super absorbent dressing. Wrap with Kerlix (gauze dressing in a roll). During an observation on 2/24/25 at 5:33 p.m., NA-D assisted R16 back to her room in her wheelchair. R16's door had a CDC EBP sign on the door, which identified providers and staff must wear gloves and a gown for the following high-contact resident care activities, which included dressing. R16 stated she was hot, so NA-D assisted R16 to remove her long sleeve shirt, and applied a short sleeve shirt. NA-D asked R16 if she was comfortable and R16 agreed. NA-D placed R16's long sleeve shirt in her lap as R16 requested, In case I get cold. then NA-D assisted R16 back to the dining room. NA-D did not apply PPE while assisting R16 with dressing. During an observation on 2/25/25 at 2:03 p.m., R16 NA-C answered R16's call light, who requested to go to the bathroom. NA-C informed she would get assistance and be right back. At 2:06 p.m. NA-C and NA-B entered R16's room, applied gloves and assisted R16 to transfer to a commode brought from the bathroom. NA-C and NA-B waited in the room, allowed R16 time to use the commode, assisted R16 to stand, provided perineal cares and assisted her back into her recliner. NA-C and NA-B did not wear a gown, as directed for EBP with high contact cares including transferring and assisting with toileting. During an interview on 2/25/25 at 2:15 p.m., NA-B confirmed R16 had a dressing on her right leg. NA-B indicated the nurses wore PPE when they changed R16's dressing on her wound. NA-B stated the nursing assistants did not wear PPE when they assisted R16 with cares. NA-B indicated the only time they would wear a gown was if they were assisting the nurse with changing R16's dressing or if the dressing came off. 48740 HAND HYGIENE R30's quarterly MDS dated [DATE], identified R30 as having intact cognition, and was diagnosed with depression, dementia, and heart failure. R30 needed maximal assistance with transfers and moderate assistance for ADL's which included toileting, and dressing. R30's care plan revised on 1/31/25, identified R30 needed assistance for dressing and assist of one with the PAL (mechanical standing lift to assist a person from sitting to standing) for toileting and transfers. During an observation on 2/26/25 at 7:20 a.m., NA-E applied gloves, retrieved a warm washcloth and hand towel and prompted R30 to wash her face. R30 was sitting on the side of the bed. NA-E put on a clean brief and applied pants up to R39's knees. NA washed R30's back, arms, underarms, and under her breasts. NA-E applied lotion to R30's back, arms, and chest. NA-E put a bra, shirt, and sweater on R30. NA-E warmed the washcloth in warm water and placed the washcloth on the hand towel on the side table. NA-E applied the mechanical lift sling around R30, hooked R30 to the mechanical standing lift and assisted R30 to stand. NA-E took off the brief R30 was wearing the previous night. NA-E took the warm washcloth and provided perineal hygiene care. NA-E took the hand towel and dried R30 perineal area. NA-E did not remove gloves and proceeded to pulled up R30's clean brief and pants. NA-E adjusted R30's shirt and moved the mechanical standing lift toward the wheelchair. NA-E positioned the wheelchair behind the resident, NA-E pressed the down button on the mechanical standing lift, lowering R30 until sitting in the wheelchair. NA-E removed the mechanical lift sling from R30 and placed the sling on the mechanical standing lift. NA-E unhooked the bed sensor alarm from the bed and hooked the sensor alarm to the wheelchair. NA-E pushed R30 up to the sink, opened the cupboard, and took out R30's toothpaste and toothbrush. R30 requested NA-E to put her phone charger in a basket away from the sink, which NA-E did. NA-E then took R30's hairbrush and brushed R30 hair and gave R30 her glasses, which R30 applied herself. NA-E then removed gloves and pushed R30 to the door and applied R30's foot pedals to the wheelchair. NA-E pushed R30 to the living room area. During an interview on 2/26/25 at 7:50 a.m., NA-E verified she did not remove her gloves after perineal care. NA-E verified she proceeded to touch other items in the room such as her toothbrush and hair brush. NA-E verified she should have removed her gloves after perineal care and before touching other items in the room. During an interview on 2/26/25 at 8:40 a.m., NM-A indicated her expectation was to have staff apply gloves before and remove aftercare. NM-A stated staff should wash hands and apply gloves when walking into a room, and remove gloves after cares, and wash hands. During an interview on 2/25/25 at 1:23 p.m., infection preventionist (IP) verified R32 and R16 had chronic wounds which required a dressing. IP stated her understanding was that staff only had to wear a gown while caring for a resident with chronic wounds if they were directly working with the wound. IP stated her expectation going forward was for staff to wear all of the proper PPE which included a gown while caring for any residents on EBP to prevent the spread of infection. During an interview on 2/26/25 at 8:43 a.m., the IP indicated after staff was done with the soiled part of the perineal cares, staff should remove gloves, wash their hands before applying a clean brief and apply clean gloves before applying creams. During an interview on 2/25/25 at 4:07 p.m., director of nursing (DON) verified R32 and R16 had open wounds with dressings and required EBP. DON stated her expectation was that staff would have followed EBP per CDC guidelines to prevent the spread of infection. Review of a facility policy titled Enhanced Barrier Precautions dated 11/3/23, identified the facility was to follow the direction of federal and state agencies regarding the Enhanced Barrier Precautions and preventing MDRO spread. Identified staff were to use gown and gloves during high -contact resident care activities which included: dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care-central line urinary catheter, feeding tube, wound care: any skin opening requiring a dressing. Review of the policy titled Started Precautions dated 5/21/06 identified 2) Gloves - wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident, and wash hands immediately. Review of the policy titled Hand Hygiene Policy and Procedure dated 11/18/15 revealed 2. Change gloves during patient care if moving from a contaminated body site to a clean body site. 3. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another patient.

Based on observation, interview, and record review the facility failed to ensure 1 of 3 residents (R1) were treated with dignity and respect. Findings include: Review of facility reported incident dated 5/14/24, indicated trained medication aide (TMA-C) was administering R1's morning medications one 5/11/24, when nursing assistant (NA-L) asked if R1 was ready for breakfast. TMA-C stated R1 was finishing her Miralax (a laxative) when NA-L lunged toward R1 from behind R1 and grabbed the cup out of R1's hand when R1 refused to give up the cup. R1 screamed very loudly Damn it stop and leave me alone and continued to hold the cup fiercely. NA-L was hanging on to the cup tightly and TMA-C was trying to get the cup away from both R1 and NA-L. NA-L stated R1 did not need the Miralax right before she attempted to take the cup away from R1. R1 was visibly shaking and upset. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, with diagnoses that included altered mental status, aphasia (inability to communicate), stroke, and constipation. R1 was dependent on staff for wheelchair mobility, required maximal assist of one staff for bed mobility, hygiene, transfers, and dressing. R1 did not have a toileting program and was frequently incontinent of bowel and bladder. R1 had verbal behaviors one to three days towards others. R1's care plan indicated the following: -Behavior Symptoms Care plan dated 10/24/23, with interventions of: -avoid over stimulation, -avoid power struggles, -maintain a calm environment and approach. -Communication care plan dated 11/08/22, with interventions of: -talk with R1 in a quiet environment so it is easier for R1 to hear (dated 11/8/22). Review of R1's physician orders included the following: -Miralax (laxative) 17 grams by mouth every other day for constipation (start date 10/10/23) During an interview on 5/15/24 at 2:00 p.m., TMA-C stated she was administering R1's medications crushed in applesauce and the Miralax mixed in 140 mls of water, when NA-L came and asked if R1 was ready to breakfast. TMA-C stated NA-L quickly moved towards R1 from behind and grabbed the glass of Miralax stating R1 did not need the laxative as she had a blow out the day before. There was struggle between R1 and NA-L. TMA-C intervened and was able to stop the struggle and removed the cup from both R1 and NA-L. TMA-C calmed R1 by reassuring her and removed the glass from R1's hands. R1 was visibly shaking and upset. TMA-C stated NA-L was not treating R1 respectfully. TMA-C sent a text message of the incident to the director of nursing (DON), who was on vacation, and the resource- registered nurse (RN-K). During an interview on 5/15/24 at 1:24 p.m., RN-I stated she was the charge nurse during the time frame of the incident between R1 and NA-L, however, was not aware of the incident until it was brought to her attention by the surveyor. RN-I did not think R1 was treated with respect and dignity by NA-L and should have been. During an interview on 5/15/24 at 1:44 p.m., RN-K stated she was made aware of the incident by text message from TMA-C. RN-K did not think NA-L treated R1 respectfully and should have been. During an interview on 5/15/24 at 2:22 p.m., social worker (SW)-A stated she was not made aware of the incident until 5/13/24, when TMA-C informed her around 2:00 p.m. SW-A did not think NA-L treated R1 with respect and dignity. During an interview on 5/15/24 at 2:48 p.m., DON stated she was on vacation and was made aware of incident on Monday, 5/13/24, by the administrator's phone call. DON stated NA-L did not treat R1 with respect and dignity. DON expected all staff to treat all residents with respect and dignity. Review of the facility's undated policy titled Resident Respect and Dignity, indicated that residents had the right to be treated with respect and dignity.

Based on document review and interview, the facility failed to ensure the required members and/or their designee attended the quarterly meetings for 3 of 4 quarterly Quality Assurance Performance Improvement (QAPI) meetings. Findings include: Review of the quarter 1 QAPI meeting attendance form for 1/10/23, identified the facility administrator was not present at the meeting. There was no documentation related to his absence and if there had been someone designated in his absence. Review of the quarter 3 QAPI meeting attendance form for 7/11/23, identified the facility infection preventionist was not present at the meeting. There was no documentation related to her absence and if there had been someone designated in her absence. Review of the quarter 4 QAPI meeting attendance form for 10/24/23, identified the facility administrator was not present at the meeting. There was no documentation related to his absence and if there had been someone designated in his absence. Interview on 3/4/24 at 2:42 p.m., with the director of nursing confirmed that the administrator had not been present at the 1/10/23 and the 10/24/23 QAPI meetings. She further confirmed that the infection preventionist had not been present at the 7/11/23 meeting. Interview on 3/4/23 at 6:39 p.m., with administrator confirmed he was not present at the 1/10/23 and the 10/24/23 QAPI meetings and should have been or designated someone in his place. He reported going forward if a committee member was unable to attend for some reason the facility would ensure documentation of the absence and who was designated in their place. Review of the January 2019, Quality Assurance and Process Improvement Plan identified the administrator, director of nursing, infection preventionist, medical director, consulting pharmacist, select department managers, resident and/or family representatives (if appropriate), and additional general staff was the framework for the QAPI committee. The committee would meet monthly.

Based on observation, interview, and document review the facility failed to ensure alcoholic beverages were secure in 1 of 1 resident refrigerator located in the east dining room. This had the potential to affect 4 out of 20 residents with diagnoses of dementia and with known confusion that ate in the east dining room (R21, R24, R27, R30) Findings include: Observation on 3/4/24 at 11:46 a.m., of the east dining room refrigerator identified 3 cans of Michelob Ultra left in a 12 pack, 5 bottles of [NAME] light in refrigerator door, and 1 bottle of Michelob golden. The refrigerator was unsecured, and all residents had access to the refrigerator. Interview on 3/4/24 at 3:18 p.m., with activity director identified the facility typically held activities in the west dining room related to some sound issues. She reported that the activity department did utilize the resident refrigerator in the east dining room. She stated that the facility did have a monthly activity called the Ritz where she invited all the residents and the residents of the attached assisted living. She reported that activity was held in the east dining room as it was larger than the west dining room. During that activity they had a happy hour where residents could have a glass of beer and appetizers. She confirmed that residents with dementia also attend. Interview on 3/4/24 at 3:28 p.m., with licensed practical nurse (LPN)-B identified if a resident wanted alcohol that the facility kept that locked in the medication room. She reported there were only 3 residents who had alcohol that was locked in the medication room. Interview on 3/4/24 at 3:31 p.m., with registered nurse (RN)-A identified the facility protocol if a resident wanted alcohol at the facility was to get an order from their provider and then lock it in the mediation room. Interview on 3/4/24 at 3:50 p.m., with dietary manager and regional dietary consultant confirmed no alcohol should be kept in the unsecured refrigerator in the east dining room. The alcohol was moved to a secured refrigerator located inside the kitchen. Interview on 3/4/24 at 3:56 p.m., with director of nursing identified she was unaware that alcohol had been kept in the unsecured refrigerator in the east dining room. She agreed alcohol needed to be secured in the facility related to safety risk. Review of the 5/8/14, Resident Illegal Substance and Alcohol Use/Abuse policy identified alcoholic beverages may not be stored in resident rooms. Alcoholic beverages must be locked in a secure area as determined by nursing staff.

Based on interview and document review, the facility failed to offer and/or administer the most recent Centers for Disease Control (CDC) pneumococcal vaccine for 2 of 5 residents (R23 and R24) reviewed for immunizations. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose e) Received PCV-13 at any age AND PPSV-23 AFTER Age [AGE] years: aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. R23's Continuity of Care Document printed 3/5/24, identified R23 was [AGE] years old and had diagnoses of hypertension, hypothyroidism, osteoarthritis, and nutritional anemia. R23's Immunization record printed 3/5/24, identified R23 had received the pneumococcal conjugated vaccine (PCV-13) on 4/23/15, the pneumococcal polysaccharide vaccine (PPSV-23) 10/11/16. R23's medical record did not include evidence R23 or R23's representative received education regarding pneumococcal vaccine booster, the physician had been consulted, or indication R23 was offered the PCV-20 at least 5 years after prior pneumococcal vaccine per CDC guidance. R24's Continuity of Care Document printed 3/5/24, identified R24 was [AGE] years old and had diagnoses of Parkinson's disease, neurocognitive disorder with Lewy bodies, dementia, hypertension, hypothyroidism, and hyperlipidemia. R24's Immunization record printed 3/5/24, identified R24 had received the PCV-13 on 12/30/16 and the PPSV-23 on 4/24/18. R24's medical record did not include evidence R24 or R24's representative received education regarding pneumococcal vaccine booster, the physician had been consulted, or indication R24 was offered the PCV-20 at least 5 years after prior pneumococcal vaccine per CDC guidance. Interview on 3/5/24 at 9:47 a.m., with registered nurse (RN)-A who reported she was responsible for offering and administering vaccinations upon admission and annually if the resident remained in house. RN-A confirmed she had not offered R23 nor R24 the PVC-20 vaccination. She reported she had been working on reviewing all the current residents and offering the vaccinations to the residents who were eligible but had not offered to R23 or R24 yet. She identified she had not been able to come up with a good way to track the resident vaccination to offer vaccination when residents were eligible and to be consistent however, she had been working on that. Interview on 3/5/24 at 2:46 p.m., with director of nursing identified she was unaware that the infection preventionist had not offered all residents who were eligible the PCV-20. She would expect that the infection preventionist would review and offer vaccination that the residents were eligible to receive. Review of the 1/23/24, Pneumococcal vaccine policy, identified all residents would be offered Pneumococcal conjugate vaccines (PVC13, PVC15, or PCV20) and/or the pneumococcal polysaccharide vaccine (PPSV23). Residents would be assessed upon admission for eligibility to receive using the current CDC guidelines. Residents and/or representative would receive educational information and offered unless medically contraindicated. Residents and/or representatives have the right to refuse vaccinations. Documentation in the resident's record would indicate if refused and/or given.

Based on observation, interview, and document review, the facility failed to maintain and monitor their system for the the disposition and security of emergency medication kits (E-kit) that contained controlled and/or narcotic substances for 1 of 3 E-kits to immediately detect and reconcile to prevent potential drug diversion. Findings include: Observation and interview on 3/5/24 at 10:02 a.m., with licensed practical nurse (LPN)-A of the facility's large emergency kit (E-kit) located in the medication room inside the medication cupboard was an attached inventory record that identified controlled medication of Morphine oral solution 10 mg/0.5 ml, lorazepam for injection 2 mg/ml injection, hydrocodone/APAP (Norco) 5/325 mg, and lorazepam 0.5 mg tablet. The large E-kit had a plastic lock with the number 1249464. A small red emergency kit also located in medication room cupboard with an attached inventory record identified controlled medications of Hydrocodone/APAP (Norco) 5/325 mg tables quantity 6, morphine oral solution syringe 10 mg/0.5 ml quantity 6 syringes, oxycodone oral tablet 5 mg quantity 6, oxycodone/APAP (Percocet) oral tablet 5/325 mg quantity 6, and lorazepam tablets 0.5 mg quantity 6. The small red emergency kit had 3 plastic locks with numbers 0341712, 0341713, and 0341714. Lastly a small emergency kit located in the medication room refrigerator with an attached inventory record identified lorazepam oral 2 mg/ml quantity 30 ml. The E-kit in the refrigerator had a plastic lock with number 0271337. LPN-A revealed that the facility staff check and sign that they checked the E-kits shift to shift. Review of the E-kit Verification Signoff Sheet identified staff were signing off however, they were not logging the plastic lock numbers. LPN-a confirmed there would be no way for her to know if someone had opened one of the E-kits and removed something and placed a new plastic lock. Observation and interview on 3/5/24 at 10:16 a.m., with director of nursing (DON) confirmed the contents of the E-kits and that staff had not been documenting the plastic locks shift to shift. She revealed staff should have been logging the locks of each E-kit to confirm nothing had changed. Review of the 9/10/19, Emergency Kit Checklist policy identified goal was to ensure E-kit contents were accounted for and the E-kit remained intact. Staff were to conduct an E-kit verification shift to shift in addition to the narcotic count. The policy had no mention of confirming the plastic lock numbers to ensure the kit had not been compromised.

Based on interview and record review, the facility failed to immediately but not later than 2 hours allegations of neglect to the State Agency for 1 of 1 residents (R3) reviewed who wandered outside and sustained a fracture. Finding include: Facility reported incident (FRI) received by state agency (SA) dated 5/27/23 at 9:10 p.m., indicated that R1 was found outside the building laying on the ground at 12:20 p.m., with her right wrist swollen and painful. R1 was sent to the emergency room (ER) by ambulance. R1's quarterly Minimum Data Set (MDS) 3/3/023, included diagnoses of Parkinson's Disease, depression and mild cognitive impairment. R1's MDS further indicated R1 had severe cognitive impairment and did not have wandering behaviors. R1 required extensive assist of one staff for bed mobility, transfers, toilet use, personal hygiene and bathing. R1 was unsteady but able to stabilize without assist and required supervision with walking in her room and corridor. R1 used a walker. R1's progress note dated 5/27/23, at 12:39 p.m. indicated that R1 received her medication at 11:55 a.m. then went to the bathroom before dinner. Staff found R1's walker with the wanderguard device on it in her room but R1 was not there. At 12:20 p.m. Nursing assistant (NA)-L and another staff person heard resident yelling for help outside. R1 was lying on her back. R1 was assessed with injury to her right wrist. R1 was sent to the ER at 1:18 p.m. by ambulance. During an interview on 6/1/23 at 3:56 p.m., director of nursing (DON) was not able to articulate the time frame for reporting an incident to the SA. During an interview on 6/2/23 at 9:15 a.m. Administrator acknowledged the incident was reported late. Administrator indicated allegations need to be reported to the SA within two hours. Review of the facility's policy titled Abuse, neglect, mistreatment and misappropriation of resident property, indicated the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do no involve abuse and do not result in serious bodily injury, to the administrator of the facility and to officials including the state agency.

Based on observation, interview, and document review the facility failed to provide hairnets for staff who needed to enter the kitchen at 3 of 3 entrances, failed to ensure 3 of 3 kitchen fans were maintained and free of debris and/or dust, and failed to appropriately store 3 of 3 scoops outside of their bulk dry goods containers. This deficient practice had the potential to affect all 32 residents who received nourishment from the facility kitchen. Findings include: Observation and interview on 11/28/2022 at 9:44 a.m., with the dietary manager (DM), revealed there were no hairnets at the entrances for staff or visitors who would need to enter the kitchen. The DM needed to obtain them from drawer inside the kitchen area. The DM confirmed no hairnets were accessible at any of the 3 entrances into kitchen as there was no place to store them. The DM confirmed there should be a designated place for hairnets for staff or visitors prior to entering kitchen. Observation of the bulk sugar container, identified it contained 2 scoops immersed in the sugar. Observation of bulk flour container identified it contained 1 scoop immersed in the flour The DM confirmed there should be no utensils left in dry good containers. Observation and interview on 11/29/22 at 10:46 a.m., with dietary aide (DA)-A, of the fan located in the dirty dish room facing clean dishes with black lint-like debris approximately 2 cm throughout the fan which was blowing towards the clean dishes that were air-drying on counter. Maintenance was to clean and maintain the fans. Observation and interview on 11/29/22 at 10:52 a.m., with DM observed all 3 fans located in kitchen. All had dirt-like debris. 1 fan in the dirty dish room was blowing onto clean dishes. A second fan was observed to be blowing towards the oven and stovetop area, and the 3rd fan was blowing towards clean counter tops and the food preparation area. The DM confirmed all 3 fans were dirty with lint or dirt-like debris hanging from front of each fan and needed to be cleaned immediately as they had the potential to contaminate food and/or dishes. Fans were to be cleaned weekly and were reported to be on a cleaning schedule. Interview and document review on 11/29/22 at 11:00 a.m., with the DM identified she reviewed the November 21-27, 2022 cleaning schedule and check-off. She confirmed there were multiple areas of kitchen that had been assigned to be cleaned, however cleaning of the fans was not on the kitchen cleaning schedule. Interview on 11/29/22 at 11:51 a.m., with the registered dietician (RD) identified no utensils should ever to be left in bulk containers or any type of food during storage. The RD further confirmed if fans were to be used in the kitchen, they should be cleaned routinely to ensure no debris would build up on the fans. The RD further confirmed hairnets should be located outside each entrance the kitchen so staff or visitors had access to apply those hairnets prior to entering. Review of the 2021, Food Storage policy identified scoops for bulk foods should not be kept in the container. Scoops should be washed and sanitized and placed in a covered area next to the product. Review of 2021, Cleaning and Sanitation of Dining and Food Service Area policy identified staff should maintain cleanliness in the food service area by following a cleaning schedule. Staff were to be trained on proper cleaning and techniques to maintain the cleanliness in food service area to maintain sanitation.

Based on observation, interview, and document review the facility failed to ensure care planned fall risk prevention interventions were followed when R1 was directed to walk without proper footwear and a gait belt was not placed for 1 of 3 residents reviewed for falls. This deficient practice led to R1 falling and sustaining skin tear. Findings include: R1's Face Sheet dated 10/6/21, indicated R1 was admitted to the facility on [DATE], with the following pertinent diagnosis:[CONDITION(S)] ([CONDITION(S)]), (stroke). R1's admission minimum data set (MDS) assessment dated [DATE], identified R1 as having a brief interview for mental status (BIMS) score of 15 (no impairment in cognition). R1 required extensive assistance with activities of daily living (ADL's) including dressing and personal hygiene. The MDS further indicated R1 required extensive assistance with bed mobility, transferring and limited assistance with walking in room. R1's care plan last revised on 10/6/21, indicated R1 was at high fall risk as evidenced by unsteady gait and balance, and history of falls. Interventions included ambulate with the assistance of one, use a transfer belt, ensure proper non-slip footwear, and notify the doctor if there is a fall. During an interview on 10/26/21, 9:29 a.m. R1 stated nursing assistant (NA)-A took off residents shoes, sweater, and shirt to help him get ready for bed on 10/7/21 . NA-A instructed R1 to use his walker and walk the few feet to his bed. R1 stated he did not have a gait belt on and without having non-slip footwear on, he slipped and fell on to the wastebasket. R1 stated his left shoulder landed on the waste basket and the sharp edge of the wastebasket made a skin tear on his upper arm. R1 further stated his right upper arm hit the walker and sustained another skin tear on the right upper arm. R1 stated NA-A grabbed his right arm and pulled on the walker to get him to his feet. R1 pivoted and sat on the bed. Once R1 was on the bed, NA-A quickly left the room. A minute later LPN-A came in and asked R1 what happened. R1 stated he reported to LPN-A he fell on to the wastebasket with his shoulder on the wastebasket, his knees on the floor, and now has an injury on both arms. A progress note dated 10/07/21, at 10:55 p.m. by licensed practical nurse (LPN)-A documented being informed by nursing assistant (NA)-A at 10:35 p.m. that R1 had a skin tear. LPN-A assessed the skin tear and documented finding a 2 cm x 0.8 cm wide skin tear. LPN-A cleansed the wound, completed skin preparation, applied steri strips and a 3 x 3 [MEDICATION(S)] bandage. LPN-A further documented R1 currently had a bruise in the same location as the skin tear. There was no documentation found in the medial record that a post fall assessment was completed to identify potential contributing factors and needed interventions. A progress note dated 10/8/21, at 2:37 p.m. indicated that director of nursing (DON) documented R1's family was notified that he had a fall and sustained a skin tear. A progress note dated 10/08/21, 3:57 p.m. documented registered nurse (RN)-A, was notified by staff at 6:00 a.m. that R1 reported having a fall last evening. R1 stated NA-A was helping him get ready for bed and NA-A took R1's shoes, sweater and shirt off and directed R1 to walk to the bed. R1 stated he was walking unassisted to the bed and his socks were slippery and that fell after taking one step. R1 stated he fell and landed with his left arm/chest on the wastebasket, and his knees were on the floor. A progress note dated 10/11/21, at 12:14 p.m. documented LPN-A created an updated note for the 10/07/21, skin tear. LPN-A documented asking R1 what happened, and his reply was he slipped on the edge of the recliner and sat on the edge of the recliner/garbage can, but at no point did his bottom touch the floor. During an interview on 10/26/21, at 9:49 a.m. NA-A stated on 10/07/21, at approximately 10:30 p.m. he went to help R1 get ready for bed. NA-A stated he took R1's shoes off and that he only had socks on. NA-A indicated it was only a few feet from the recliner to the bed and thought R1 could walk to the bed without falling. NA-A stated he directed R1 to walk to the bed so he could continue to get R1 undressed. NA-A stated the recliner is approximately three feet from the bed and NA-A started walking with only his socks on, and that he did not place a gait belt on R1. NA-A stated R1 took a step, slipped and he tried to catch him. NA-A stated R1 fell to the left and landed on the wastebasket that is between and recliner and the bed, but he had a hold of R1's right arm. NA-A stated he is unsure if R1's knees were on the floor. NA-A then helped R1 to stand, pivot and sit on the bed. NA-A stated he immediately went to the charge nurse (does not remember her name - identified as LPN-A) and informed her that R1 fell and now has a skin tear. LPN-A immediately went to VA's room. NA-A sated he did not return to R1's room as it was the end of his shift and he left the facility. NA-A stated he did not follow the care plan which directed him to use a gait belt and ensure proper footwear were on R1 during the transfer. During an observation on 10/26/21, at 9:45 a.m. R1 was observed in a wheelchair being wheeled into his room by unknown name physical therapist (PT)-A. PT-A assisted R1 to stand and then pivot to the recliner. R1's gait was observed to be unsteady and required the assistance of PT-A to stand and pivot. R1 was observed while lowering to sit in the recliner to abruptly land due to lack of strength. During an interview on 10/26/21, at 11:13 a.m. LPN-A stated NA-A was observed on 10/07/21, at approximately 11:00 p.m. going to the charting area and could be overheard reporting to NA-B that R1 has a skin tear. LPN-A further overheard NA-A state it happened while he was transferring R1 and that he sat on top of the garbage can next to the bed. LPN-A stated she asked NA-A what happened and then went to assess R1's wound. LPN-A stated she asked R1 what happened, and he indicated he did not fall but slipped and sat on the garbage can. LPN-A stated since R1 did not fall to the floor, she did not think it was a fall. LPN-A further stated R1 informed her that NA-A did not use a gait belt and directed him to walk only in his socks, which made him slip. LPN-A stated when she arrived to R1's room, he was sitting on the bed with only his tee shirt and underwear on, so she was able to assess his skin. LPN-A she did not see the right upper arm wound that night, but it was found by another nurse the next day. During an interview on 10/26/21, at 12:33 p.m. DON stated a fall is an unplanned rapid descent. DON stated the fall to the wastebasket is considered a fall and should have been reported immediately. The facility Fall Prevention and Management Program policy, last modified on 01/12/21, directed that any unintentional change in position is considered a fall and in the event of a fall, notify the charge nurse by using the walkie.

Based on observation, interview and record review the facility failed to implement an appropriate infection control program to include data analysis of resident infections, tracking and trending to the risk of spread of infections to other residents in the facility in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guideline for COVID-19. Furthermore, the facility failed to ensure 1 of 1 resident (R1), with known [CONDITION(S)]-Resistant Staphylococcus Aureus ([CONDITION(S)]) (bacterial infection resistant to most antibiotics) infection had their linens appropriately contained and laundered, had appropriate signage and PPE outside R1's door, and performed appropriate infection control technique during 1 of 1 dressing change for R1 to prevent cross-contamination. This had the potential to affect all 36 residents who resided in the facility. Findings include: SURVEILLANCE Review of the facility infection control surveillance documentation identified there was no infection control logs for resident and/or staff infections for tracking, trending and surveillance from January 2021 through September 22, 2021. The facility did have a report form for resident illnesses, entitled: Resident Illness Report, however, the facility was only able to provide evidence of the form being filled out for May 2021. In a review of the facility form, entitled: Staff Illness Report, the facility was only able to provide one report dated May 2020. During interview on 9/23/21, at 2:20 p.m. the facility's infection preventionist (IP) stated she had only been in the position of IP for about 2 weeks and had received her certification in infection control on 9/13/21. The IP stated she had only 5 day of training with the previous IP before that IP left the facility. The IP stated the facility was documenting resident infections in each individual resident records and was not collecting data in real-time to track, trend monitor, and prevent the spread of infections throughout the facility. Review of the 7/8/21, Infection Prevention and Control Program Policy identified facility-wide surveillance was to be be performed to identify opportunities to prevent and/ or reduce the rate of infection in residents, employees and visitors. Standard definitions of infection for surveillance in long-term care facilities were to be utilized. Data was to be collected by chart review, review of microbiological reports, reports from resident care providers and review of other documents as appropriate. Staff were to also to review employee health records and trend data for comparison and reported to the infection prevention committee no less than quarterly. The effectiveness of the infection control program was to be reviewed no less than annually with findings reported to QAPI. There was no mention who or how often data was to be collected, nor that it needed to occur in real-time and measurable for analysis in tracking and trending, critical to prevent potential infection, such as COVID-19. LAUNDRY R1's Face Sheet indicated and entry on 9/2/21, that R1 had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 9/22/21 at 11:15 a.m. of R1's room identified there was no isolation laundry bin for R1's clothing or linens to be placed into while R1 was in isolation. During tour of the facility's laundry on 9/23/21, at 9:46 a.m. the house keeping and laundry director (HLD) stated she was unaware of any of any infection control / isolation cases currently in the resident population. HLD stated house keeping and laundry would be be informed through the interdisciplinary team meetings that are held daily through the week. HLD stated she was unaware of R1's [CONDITION(S)] infection. HLD stated that if she would have known, there would have been yellow isolation bags place in R1's room, so laundry would of been made aware how to handle R1's laundry. In an interview on 9/23/21, at 1:59 p.m. IP stated they did not feel the need to place isolation precautions on R1 while it was felt that R1's [CONDITION(S)] infection was contained by the dressing and felt there was no reason to contain or separate R1's laundry or launder separately from other residents to eliminate potential cross-contamination. Review of the 7/8/21, Infection Prevention and Control Program Policy identified transmission-based precautions were to be utilized in addition to standard precautions, when the route of transmission was not completely interrupted using standard precautions alone. The policy identified [CONDITION(S)] was a bacteria resistant to treatment with traditional antibiotics. There was no mention of how highly infectious or antibiotic resistant organisms with potential for contamination were to be laundered to prevent cross-contamination. DRESSING CHANGE / PPE R1's 8/30/21, Minimum Data Set (MDS) identified R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 required extensive assist of 1 staff for dressing and personal hygiene. Skin conditions identified on the MDS were one Stage 4 pressure ulcer, one unstageable pressure ulcer, and one venous/arterial ulcer. Observation and interview on 9/22/21 at 10:52 a.m., of licensed practical nurse (LPN)- A identified she was performing dressing changes to R1's left calf area, left heel, right heel, and right foot between the great toe and the third toe where the second toe had recently been amputated. LPN-A began by setting up her dressing supplies on an over-bed table by the side of R1's bed, first putting down a clean barrier between the table and the dressing supplies. LPN-A dropped a roll of unopened [MEDICATION(S)] onto the floor. She then picked it up and placed it on the clean barrier with the other dressing supplies. LPN-A donned a pair of gloves and picked up the 1 pair of scissors she had on her table to remove the soiled dressing over the left calf wound. LPN-A reported that wound had a culture taken which was positive for [CONDITION(S)]. LPN-A removed the soiled dressings. After removing the soiled dressing she discarded it in the bio-hazardous container that was beside the R1's closet door. LPN-A proceeded to use the same contaminated scissors to remove old dressings on 3 other sites on R1 and also cut and place new dressings on each wound, cross-contaminating R1's wounds with the scissors she used on the 1st dressing change that was positive for [CONDITION(S)]. LPN-A was unaware she cross-contaminated wounds by not going from a non-infected wound to a cleaner wound and using the same pair of scissors without disinfection. Interview on 9/23/21 at 1:33 p.m. with the IP identified LPN-A should have: 1) Began with the cleanest wound and moved to the infected wound last. 2) Used a new supplies/scissors for each wound as not to allow for cross-contamination. The PPE station that was set up currently inside R1's bathroom should not be hanging inside the room as staff are to donn appropriate PPE prior to entering the room of a resident on precautions. She also verified the door should have had signage indicating R1 was on contact precautions on the outside of his door to prevent staff who were unaware from entering without appropriate PPE. Review of the 1/15/21, Contact Precautions policy identified staff were to wear a gown and gloves prior to entrance of a residents room when substantial contact would be anticipated, uniforms could be exposed to environmental services, items in a residents room, or has wound drainage. When possible, staff were to dedicate resident equipment and or clean and disinfect equipment. Review of the 10/24/12, Wound Dressing Change policy identified staff were to donn and doff gloves appropriately after each task. There was no mention of how staff were to use equipment between multiple dressing changes. there was also no evidence the policy was reviewed annually for accuracy.

Based on interview and document review, the facility failed to ensure the facility assessment was completed annually and/or as needed to include the resident census, specific care required for each resident, the amount and number of equipment required, all facility personnel including managerial staff, and an updated risk assessment including emerging infectious diseases. This had the potential to affect all 36 residents residing in the facility. Findings include: Review of the facility assessment identified the last review date 10/3/18. There was no mention of specific resident or facility information required. The assessment lacked documentation of resident census, specific care required for each resident, the amount and number of equipment required, all facility personnel including managerial staff, and an updated risk assessment including emerging infectious diseases. Interview on 9/23/21 at 4:44 p.m., with the facility administrator identified he agreed, the facility assessment had not been updated since 2018. The administrator identified he had began his employment in 2019, and was aware of the requirement for review the Facility Assessment annually and as needed. He had not ensured completion had occurred as required and contained the necessary components. Review of the 8/5/21 [NAME] City Care Center: QAPI Plan identified the Facility Assessment was to be completed on an annual basis and as needed to include overview of the care and services provided.

Based on interview and document review, the facility failed to implement an antibiotic stewardship program which included development of protocols and a system to monitor antibiotic use to ensure appropriate antibiotics were utilized to prevent antibiotic resistance. This had the potential to affect all 36 residents who resided in the facility. Finding include: The facility form, Infection Surveillance Log tracked infections and antibiotic use included resident name, room number, date of onset, signs and symptoms, location/type of infection, identified pathogen, and treatments. However, on 9/22/21, when requested from the facility's infection preventionist, the last recorded month was December 2019. In a review of R8's electronic medical record, documented R8 had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Although R8's electronic medical record documented the physician's prescribing of R8's antibiotic, why it was prescribed, the dosage and duration of treatment, it was not in the format (line-itemed) so the facility could able to review and compare to other infections diagnosed , without opening each residents individual record. During interview on 9/23/21, at 2:20 p.m. the facility's infection preventionist (IP) stated she had only been in the position of infection preventionist for about 2 weeks receiving her certification in infection control on 9/13/21. IP stated that she had only 5 day of training with the previous IP before that IP left the facility. IP stated the facility was documenting resident infections in each individual resident records, rather than on the facility's Resident Illness Report. Although the facility had been recording resident illnesses in each individual records, the facility had not been utilizing the facility forms that would allow for monitoring for patterns, clusters and variables that could prevent further spread of infection. In review of the facility's policy, entitled: Antibiotic Stewardship Policy, last modified 7/08/21, indicated the following: Purpose: The [NAME] City Care Center's Antibiotic Stewardship program promotes the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The Antibiotic Stewardship program will be incorporated in the overall Infection Prevention and Control Program and be reviewed on an annual basis and as needed.

Based on observation, interview and document review the facility failed to follow physician's orders for 1 of 1 resident (R29) with specific wound care dressing treatment. Findings include: R29's 8/20/21, Significant Change Minimum Data Set (MDS) assessment identified R29 had intact cognition, and required supervision with activities of daily living (ADLs). R29 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R29's current, undated care plan identified he had a right acromioclavicular joint (AC) (collar bone separates from the shoulder blade) following a fall prior to his admission the facility. R29 was at risk for skin breakdown as a result of the injury, and the MDS identified the presence of a Stage 2 pressure ulcer on the bony prominence of his right shoulder. R29's physician orders identified on 8/3/21, facility staff identified on 8/3/21, the wound nurse consultant recommended a Cutimed Sorbact (antibacterial wound dressing) to be used. R29's physician (MD)-B agreed and signed the order that same day. Interview on 9/20/21 at 2:50 p.m., with R29 identified he had a sore on his right shoulder that had occurred following a fall with a fracture that required surgical repair. R29 identified the fall occurred in the assisted living before he came to the facility. R29 stated the bone had grown following the surgery and caused the problem. He moved his shirt aside to show a dressing on the end of his right clavicle covering a raised area. R29 identified nursing staff changed the dressing daily, but he was not aware if the wound was open or if there was any drainage. Observation and interview on 9/22/21 at 8:55 a.m. with licensed practical nurse (LPN)-B, as she changed the dressing located on R29's right shoulder. LPN-B described the area as reddened with some slight peeling of the top layer of skin, but no open areas or drainage. LPN-B changed the dressing wearing appropriate personal protective equipment (PPE), cleansed the area with a saline pad, and cut a small piece of hydrogel absorbent sheet to fit the raised, reddened area and applied a cushion border dressing. LPN-B identified the wound nurse had utilized hydrogel absorbent sheet on R29's wound the week previously instead of the physician ordered Cutimed Sorbact dressing listed on the current signed provider orders and she was not aware of a change in orders, but had used the Hydrogel absorbent sheet instead of the Cutimed Sorbact dressing as the wound nurse had done. R29's progress notes identified on 8/20/21, R29's wound dressing was changed to a hydrogel dressing. On 8/21/21, staff documented they used a [MEDICATION(S)] and an alginate (wound [MEDICATION(S)]) dressing. On 8/29/21, staff switched back to the Cutimed dressing. There was no documentation in the progress notes to identify why staff had switched out R29's dressing types, nor was there any indication the provider was notified. Interview and document review on 9/22/21 at 1:24 p.m. with registered nurse (RN)-B identified the hydrogel dressing used on R29's shoulder wound was not the ordered dressing identified on the electronic physician's order sheet. The error was not identified until pointed out during the interview with review of the signed provider order. RN-B identified she would need to look into the issue to identify if there was a physician' order that had been hand written rather than entered into the electronic system. Further interview on 9/23/21 at 9:26 a.m., with RN-B identified the dressing being utilized for shoulder wound was not the ordered dressing due to receipt of the incorrect product. RN-B noted it should have been caught. Interview on 9/23/21 at 1:33 p.m., with the RN infection preventionist (IP) identified R29's ordered dressing was indicated for a wound with infected properties and had been changed from the Cutimed Sorbact dressing to the Hydrogel absorbent sheet without obtaining an order from the provider. The IP identified she would have expected the provider to be notified of the request to change treatment, and the order documented in the medical record if there was a change in treatment. A policy for dressing changes and implementation of provider orders was requested but not provided by the end of the survey.

Based on interview and document review, the facility failed to have a policy or procedure to report and investigate the elopment of 1 of 1 resident (R19) to the State Agency for potential neglect. Findings include: R19's 7/23/21, quarterly Minimum Data Set (MDS) identified a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's 9/12/21, nurse's notes identified R19 had eloped from the facility. Staff were not able immediately able to locate R19, so they began a search. Staff looked outside on the patio, outside the front of the building, and out by the road in front of the facility. R19 was not found until about 5 minutes later when R19 walked back into the building through the front door unattended. Review of R19's care plan dated 7/29/21 identified R19 was at risk for elopement and had an intervention of a WanderGuard. There was no mention where on R19's person, the WanderGuard was to be placed. On 9/13/21, the care plan was updated to identify the WanderGuard was to be on R19's ankle. Interview on 9/23/21 at 9:45 a.m., with registered nurse (RN)-B revealed the interdisciplinary team (IDT) had reviewed R19's elopement on 9/13/21. The IDT however, did not classify it as an elopement. RN-B explained the team did not believe R19 had gotten off the property as he came back so quickly, so no report to the State Agency had been filed. Interview on 9/23/21 a.m., with administrator identified he had been made aware R19 had eloped from the building on 9/12/21. He had been in contact with the the social services designee (SSD) and the director of nursing (DON) after the event to review the situation. The administrator was unable to verify if the resident had remained on the property during the time staff were not able to locate R19 in the facility. The administrator reported staff did not believe R19 had gotten off the property. The administrator agreed he was unaware why staff who had been looking for R19 were not able to see him in the front of the building while they were searching for him. The elopement had not been reported to the State Agency. The administrator concluded the only intervention completed was staff moved R19's WanderGuard bracelet to his ankle. There had been no further investigation of the event. Review of undated, Missing Resident policy revealed if a resident not able to be located and is not on a planned absence from the facility, the event was to be considered as a missing resident. Staff were to begin looking for the missing resident as soon as the situation was identified. The policy failed to indicate when a report should be filed with the State Agency following a missing resident event to identify the cause and/or potential negelect.

Based on observation, interview and document review, the facility failed to comprehensively assess resident falls to ensure appropriate interventions were implemented to reduce the risk of accident hazards for 2 of 3 residents (R1 and R2) reviewed for falls. This caused actual harm when R1 fell out of bed and received bruising and a laceration to his face requiring sutures, and severe ongoing shoulder and hip pain. Findings include: R1's significant change 2/20/19, and 8/12/19, Minimum Data Assessment (MDS) identified R1 had [DIAGNOSES REDACTED]. R1 required 2 person physical assist with toileting, and was dependent on staff for transfers. R1 also required extensive assistance of 2 staff for bed mobility. R1's 2/20/19, Care Area Assessment (CAA) identified he was extensive assistance of 2 staff for transferring and toileting and bed mobility. R1's current undated care plan identified he used a bedpan for toileting needs, but did not identify how many staff assistance was needed to assist him with transferring on and off the bedpan. Even though the 2/20/19 CAA identified he needed extensive assistance of 2 staff for toileting and bed mobility. R1's 9/28/19, Event Report identified R1 complained of pain after his fall. He received a laceration (cut) and a scrape from his fall. R1 was noted to have just finished using the bedpan. Nursing assistant (NA)-A had rolled R1 onto his left side after his bedpan use and was cleansing him. R1 moved his right leg over too far on the bed, causing him to slide out of bed, landing on his side. NA-A tried to grab him but could not stop his fall. R1 was found by LPN-A with blood on his face and head, left elbow, a scrape to his left knee and complained of shoulder and hip pain. Family and 911 were called. Management and R1's physician were then notified. Interventions listed were Upon return, plan to change to 2 assist for bed mobility and bed pan use. Review of R1's 9/28/19, emergency room (ER) Discharge Instructions identified he fell at the nursing home. As a result of that fall, R1 had a laceration to his right forehead and received a 2 layer closure (sutures and steri-strips) and a left elbow skin tear. The ER physician recommended a 4 person log roll when turning in bed. Interview on 10/7/19 at 11:10 a.m., with the director of nursing (DON) identified she was aware of R1's 9/28/19 fall from bed while using the bedpan. They placed a new interventions for 2 person to assist using the bed pan as part of a new intervention. The DON was unaware the MDS assessments from 1/19/19, had identified R1 needing a 2 person assist for toileting. That information had not been updated on R1's care plan to prevent R1's fall. Her expectation was the care plan should have been updated after the assessment identifying appropriate staff intervention to prevent future falls. R1 was observed on 10/7/19 at 11:45 a.m., with multiple steri-strips across his right eyebrow with deep purple bruising that extended from the eyebrow to his cheek and nose. R1's bed had bilateral grab bars on his bed. The bed was located in the middle of the room, which allowed staff to stand on either side of the bed. There was approximately 3 to 4 feet between the right side of the bed and the far wall with the window. R1 stated he was using the bedpan the evening of 9/28/19 when he fell . He rolled to his left (right side of bed) facing away from staff while they provided personal care after using the bedpan. He had only had 1 staff assistance with toileting at any time previous to the fall. R1 stated nurse aide (NA)-A tried to stop him from falling but was unsuccessful and fell on my face. They called his family and then went to the emergency room . R1 received stitches but had no fractures. R1 complained of severe shoulder and hip pain since the incident. He would try and rub his neck and shoulder to ease the pain, but had no success. Staff have never used 2 person assist while transferring him in bed prior to the incident, but they had now. Interview on 10/7/19 at 12:05 p.m., with NA-A identified the events surrounding R1's fall. She was sitting at the nurses station desk when R1 placed his call light on. She placed R1 on the bed pan. Once he was finished, she removed the bedpan, and he rolled to his left side. R1 had thrown his right leg over firmly during the move, causing him to fall out of bed. NA-A identified R1 was a 1 person assist prior to the fall, as identified on the care plan. While providing any care for a resident, nurse-aide staff refer to the nurse aide care plan which identified R1 was only a 1 person assist for toileting. NA-A was hired 5 months ago and had always performed 1 staff assist with toileting. She brought the need for 2 staff assist for safety up to nursing a few times but his care plan never changed. NA-A felt it was unsafe to toilet R1 with just 1 staff but the facility has not updated the care plan to identify this. Interview on 10/7/19 at 12:12 p.m., with licensed practical nurse (LPN)-A regarding R1's fall identified LPN-A was called to his room by NA-[NAME] R1 was located on the floor, on far right side of his bed. He was curled up, laying on his left side. R1 had blood under his head and face. LPN-A stated R1 complained of pain in his left shoulder and hip. She called RN-B to assist and they did vital signs and called emergency services (EMS) immediately. She did not want to move R1 for fear of unknown injury. R1 returned from the hospital at approximately 8:00 p.m. that same evening. LPN-A had work with R1 for over one year and knew R1 well and indicated R1's care plan directed staff only 1 assist with toileting. She was not responsible for ensuring assessments followed over to the care plan. RN-C was responsible to update the focus (nurse aide) sheets and care plans. Interview on 10/7/19 at 12:44 p.m., with RN-B identified she was responsible for the day-to-day changes on the care plan, and not the MDS assessment changes. RN-B was aware of the 8/12/19 MDS identifying R1 was to have 2 assist with toileting, but that was his look-back period, not what he maybe needed after. Ultimately it was RN-C's job to update the care plan after an MDS assessment. Interview on 10/7/19 at 12:50 p.m. with RN-C identified she also felt the assessment data collected from the MDS was only valid during that look-back period. RN-C agreed the MDS was used to identify care a resident would need. RN-C felt staff could adjust the information how they determined assistance should be. RN-C was unaware R1 had required 2 assist for toileting since January, 2019. She had not performed any assessment to see if R1 had not required 2 staff. When asked why staff had not updated the care plans with current assessment data derived from the MDS, she would not answer. She had agreed without use of the correct amount of staff, accidents could be likely to occur. R1's care plan had been updated since his 9/28/19 fall and 2 staff were required to assist with toileting to prevent any future similar occurrences. Interview on 10/7/19 at 5:06 p.m., with family member (FM)-A identified he was called immediately after R1's accident. He went to the hospital with R1 whom received stitches but no fractures. FM-A was told R1 had fallen out of bed after they were providing cares using the bed pan. FM-A visits the facility often, even daily, and has only seen 1 staff assisting R1 to use the bed pan. FM-A was unaware R1 had been identified in (MONTH) 2019 of needing 2 staff assist for use of R1's bedpan. FM-A states R1 had complained of pain since his incident and had a hard time moving around in his chair and performing tasks. Interview on 10/9/19 at 3:30 p.m., with physician (MD-A identified he was made aware of R1's fall immediately after the incident. He was told R1 had fallen from the bed after being turned for cares after toileting. MD-A was unaware R1 was identified to be a 2 person assist since (MONTH) 2019. MD-A agreed the care plan should have been updated to reflect staff assistance to prevent the fall of R1. MD-A wrote orders that day for R1 to have physical therapy related to his shoulder and hip pain in an attempt to offer relief. R2's quarterly 9/16/19, MDS identified he had [DIAGNOSES REDACTED]. R2 had moderate cognitive impairment and required supervision for locomotion on and off the unit. R2's annual 1/19/19, Care Area Assessments (CAA) identified he had fallen at his residence prior to admission and had a history of [REDACTED]. R2's 9/26/19, Event Report identified he used a 4 wheeled walker with a seat on it. R2 entered the room for care conference, went to sit on his walker but the brake was not engaged. The walker moved and he fell to the floor on his left side. Interventions identified at that time were to remind R2 to apply his brakes before he sits on the walker seat. R2's Focus Sheet Change Form dated 9/26/19, used immediately after the fall for items needing to be transferred to the care plan, identified he needed reminding to lock his walker brakes. The line indicating nursing staff had updated the care plan was blank. R2's undated current care plan identified he was at high risk for falls with one fall since his admission to the facility. There was no intervention related to R2's 9/26/19, fall identified on the care plan. The intervention that was to be placed after R2's 9/26/19 fall was reminding him to lock his breaks on his walker. Interview on 10/07/19 at 1:45 p.m., with the DON identified she was unaware R1 and R2's care plans had not been updated to reflect appropriate care plan revision, reflecting accurate needs of his MDS or Fall Report. She agreed staff need to ensure accurate information was placed on the care plan to prevent falls. Review of the 7/7/15, Resident MDS and Care Planning Policy and Procedure identified care plans were to be revised as needed or with an assessment. CAA triggers were the basis for the care plan. All care plans were to be updated quarterly and as needed. Review of the 6/27/19, Fall Prevention Program Policy and Procedure identified the expected outcome after a fall was to be fall prevention strategies and interventions were to be implemented promptly after a fall to prevent further falls. The fall risk assessment, nursing [DIAGNOSES REDACTED].

Based on interview and document review, the facility failed to ensure a system to identify a resident's physician orders [REDACTED]. In addition, the facility's policies and practices did not reflect current standards of practice for CPR which placed 6 of 6 residents (R6, R14, R18, R28, R89, R140) whose POLST/code status' identified CPR. This resulted in an immediate jeopardy (IJ) situation placing these residents at risk for death in the event their heart stopped beating and their breathing ceased. The IJ began on [DATE], when R6 changed his wishes for CPR on a physician-signed POLST and these changes were not updated in the EMR to reflect the change from do not resuscitate (DNR) to CPR. These changes were not addressed on R6's care plan, orders section of EMR, face sheet, nor within the hard chart system for identification. In addition, the facility CPR/Full Code/DNR Policy and Procedure dated ,[DATE], did not identify the American Heart Association (AHA) guidelines of when not to initiate CPR, and staff lacked knowledge of when to, and when not to, initiate CPR. The administrator and director of nursing (DON) were informed of the IJ on [DATE], at 6:14 p.m. The IJ was removed on [DATE], at 10:34 a.m. but noncompliance remained at a pattern level of no actual harm with potential for more than minimal harm (Level E). Findings include: The facility CPR/Full Code/DNR Policy and Procedure dated [DATE], identified CPR was initiated on residents who are full code when in respiratory or [MEDICAL CONDITION], unless clinical assessment verified no apparent signs of life. If the resident has a DNR order, no CPR would be performed. If the pupils were fixed and dilated, the skin is cool to touch, there is no response to painful stimuli and no measurable blood pressure or pulse, CPR would not be performed. If CPR needed to be performed CPR would be initiated and 911 called. Further, the policy identified each resident chart with a DNR status would be marked with a yellow dot. Full codes are marked with a bright green sticker on the the chart and were listed on bright green paper at each nurses station. The policy did not identify current AHA guidelines. Further, it did not identify where staff would obtain code status information and when it would be reviewed. R6's annual Minimum Data Set ((MDS) dated [DATE], identified R6 had moderate cognitive impairment. In addition, R6's undated Resident Face Sheet identified R6 had several medical [DIAGNOSES REDACTED]. Further, the face sheet identified R6 had a DNR code status. R6's POLST dated [DATE], signed by R6 and R6's physician, identified R6 wanted a DNR code status in the event R6 had no pulse and was not breathing. However, R6's most recent POLST dated [DATE], signed by R6 and R6's physician, identified R6 wanted a CPR code status in the event R6 had no pulse and was not breathing. This paper copy of R6's POLST was located in the physical, hard chart several pages under the legal section, and the entire chart was contained in a separate room away from each of the nursing stations. Further, the hard chart had a yellow dot affixed to the outside of the chart on the spine which identified a DNR code status, and there were no other advanced directives identified in R6's hard chart. R6's EMR order section identified a code status of DNR dated [DATE], and the heading section of the EMR identified R6 as a DNR. Further, R6's care plan reviewed [DATE], identified a code status of DNR. During interview on [DATE], at 9:31 a.m. R6 stated he had changed his POLST from DNR to CPR. Further, in the event his heart stopped beating and he was not breathing he still continued to want CPR initiated. During interview on [DATE], at 9:18 a.m. licensed practical nurse (LPN)-B stated if a resident had no pulse and was not breathing she would check the EMR for the residents code status, or a cheat sheet located at each desk. The hard charts where the POLST was kept were not in a convenient location within the facility to check the paper POLST in an emergency situation. LPN-B identified the full code list at the nursing station. It was printed on a white sheet of paper and did not include R6 as full code. On [DATE], at 9:27 a.m. LPN-C stated she would look at the EMR to find out if a resident requested a code status of CPR or DNR. LPN-C would not look at the hard chart and she would not know if there was any discrepancies. Further, there was a list at each desk that listed residents who wanted CPR. When interviewed on [DATE], at 2:54 p.m. LPN-A stated in the event she needed to know a residents code status she would look at the cheat sheet behind the desk as well as look in the EMR. LPN-A would only check the hard chart if there was a discrepancy between the EMR and the cheat sheet located at the desk. If the EMR identified a DNR code status and the residents POLST identified a wish of CPR, LPN-A stated CPR would not be initiated and the resident would die. Further, she would hope the residents were communicated consistently in all areas identifying the residents code status. During interview on [DATE], at 3:45 p.m. registered nurse (RN)-D stated upon admission she helped residents compete their POLST form according to their wishes, then it was faxed to their physician for signature. If a resident does not request a DNR status they are treated as wanting CPR. The residents code status is then placed in the EMR which ties to their face sheet, it is entered into the orders section in the EMR and was not sure if it was added to the care plan. The hard charts are to have a green sticker identifying a full code status and a yellow circled sticker was placed on the hard chart identifying a DNR code status. If the POLST is updated all areas should be updated and checked so they match because the floor staff relied on the EMR to be accurate. RN-D did not work on the floor and the hard charts were located in her office area, in the event she needed to check someone's code status she would look in the hard chart. There were full code status lists at each nursing desk, however, those were not updated as often as they should be. On [DATE], at 3:39 p.m. RN-A stated she was not reviewing code status at care conference time, nor checking if the paperwork and all areas the code status in the EMR matched the resident wishes. If a POLST status changed the first thing updated should be the EMR as the floor staff relied on it to be accurate. If the EMR identified a DNR status and the residents POLST identified a wish for CPR, CPR would not be attempted and the resident would die. When interviewed on [DATE], at 3:50 p.m. RN-C stated she had been working at the facility for a long time and just knew the (residents code) status. In the event a resident had no pulse and was not breathing, the floor staff and herself would rely on the EMR to identify a residents code status, it was definitely quicker to check the EMR, because the hard charts are not stored on the floor. Further RN-C was not aware if the facility had a policy on CPR or advanced directives. If the EMR identified DNR and the resident wanted CPR, the resident would likely die because the staff do not look in the hard charts. On [DATE], at 3:59 p.m. the director of nursing (DON) stated she was not sure if the facility had an advanced directive/CPR policy and would look for one. Further, there was an AED (automated external defibrillator) located on the West dining room, however, she thought it was more for visitors than residents as most of the residents in the facility had a DNR code status. After, retrieving the facility policy she stated the facility was not consistently using a sticker system on the hard charts and the full code resident list at the desk was not printed on green paper. The policy did not identify a procedure to follow and where the residents code status should be documented, how often the code status was reviewed and when staff should not do CPR even if requested. DON stated the code status shows on all pages of the EMR and flows to the face sheet and care plans and the EMR was what the floor nurses would follow in the event of an emergency, because the hard charts were not located on the resident units. Further, I don't think going to to the chart is a good use of anyone's time in an emergency, the chart is not the first place I would go (to find the code status). The resident would die and not have CPR attempted if the EMR identified DNR and their POLST identified a CPR status. CPR kept the blood flowing until emergency services were onsite. The DON reviewed R6's POLST and EMR and identified R6's POLST status changed [DATE], and R6's EMR in all areas continued to reflect a DNR status, as well as the sticker on the hard chart identifying a DNR code status. If a resident changed their code status it was expected all areas would be updated as well. Further, POLST's were supposed to be reviewed quarterly for any changes during the care conferences. The DON was not aware the new MDS nurse was not reviewing code status after she took over the position. Further, the resident records were a mess. The DON provided a list of residents who were full code on [DATE], at 4:42 p.m. the list did not identify R6. The list identified R14, R18, R28, R89 and R140. R14's annual MDS dated [DATE], identified R14 had intact cognition. [DIAGNOSES REDACTED]. R14's undated Resident Face Sheet identified a full code status. Additional [DIAGNOSES REDACTED]. R14's medical record did not identify a POLST was addressed. R14 had a copy of a DNR form which was not dated and was not signed. The form did not identify R14 wanted a DNR status and had a hand written code status as full code identified on the top right hand of the form. R14's hard chart did not contain a bright green sticker identifying a full code status. R14's EMR identified a full code status. The EMR order section did not identify a code status. R14's care plan reviewed on [DATE], identified a full code status. R18's quarterly MDS dated [DATE], identified R18 had severe cognitive impairment. [DIAGNOSES REDACTED]. R18's undated Resident Face Sheet identified a full code status. R18's POLST dated [DATE], was signed by the resident's representative. The POLST was not identified as being signed by R18's physician. Further, the POLST identified a CPR code status in the event R18 had no pulse and was not breathing. R18's hard chart had a yellow circle identifying a DNR status, and did not contain a bright green sticker identifying a full code status. R18's EMR identified a full code status. R18's EMR orders section did not identify a code status. R18's care plan reviewed [DATE], identified a full code status. R28's quarterly MDS dated [DATE], identified R28 was cognitively intact. [DIAGNOSES REDACTED]. R28's undated Resident Face Sheet identified a full code status. The face sheet identified additional [DIAGNOSES REDACTED]. R28's POLST dated [DATE], signed by R28 and R28's physician, identified R28 wanted a CPR code status in the event R28's had no pulse and was not breathing. R28's hard chart did not contain a bright green sticker identifying a full code status. R28's EMR identified a full code status. R28's EMR orders section identified a full code status dated [DATE]. R28's care plan reviewed [DATE], identified a full code status. R89's entry tracking MDS notation identified R89 admitted to the facility on [DATE]. R89's undated Resident Face Sheet identified a full code status. [DIAGNOSES REDACTED]. R89's POLST dated [DATE], signed by R89 and R89's physician, identified R89 wanted a CPR code status in the event R89 had no pulse and was not breathing. R89's hard chart contained a bright green sticker identifying a full code status. R89's EMR identified R89's full code status. R89's EMR orders section was blank with a space to enter R89's code status. R89's undated Baseline Care Plan identified full code status R140's undated Resident Face Sheet identified R140 admitted to the facility on [DATE]. The advanced directives section identified there were no advanced directives on file for R140. R140's [DIAGNOSES REDACTED]. R140's POLST dated [DATE], signed by R140's physician, identified R140 wanted a CPR code status in the event R140 had no pulse and was not breathing. R140's hard chart did not contain a bright green sticker identifying a full code status. R140's EMR identified a full code status. R140's Baseline Care plan dated [DATE], did not identify a code status. During follow up interview on [DATE], at 5:24 p.m. LPN-B stated if a resident had no pulse and was not breathing and had a CPR code status she would call 911 and start CPR, unless they were cold or deceased for some time. Also, prior to initiating CPR she would check their body temperature, oxygen levels, check for mottling (discolored spotting on skin due to lack of circulation) and always do a set of vitals before initiating CPR. During follow up interview on [DATE], at 5:25 p.m. LPN-A stated if a resident did not have a pulse and was not breathing she would check the residents code status on the EMR and the cheat sheet at the desk. She would place resident on a back board or on the floor but was not sure where the backboard was located. LPN-A explained she would have some one call 911, she would check airway, circulation and breathing (ABC) and initiate CPR. She stated would not do CPR if the resident was purple or ice cold. During follow up interview on [DATE], at 5:26 p.m. the DON stated if a resident did not have a pulse and was not breathing and wanted CPR to be initiated, she was unsure when not to start CPR and added, I guess, it depends if the resident is cold, would check their temperature, their pupils for reaction prior to the initiation of CPR. She would expect the nurses to know when to and when not to initiate CPR. All the nurses were CPR certified and received recertification training every two years. The AHA current guidelines dated (YEAR), identified: The AHA urged all potential rescuers to initiate CPR unless a valid DNR order was in place; obvious clinical signs of irreversible death (e.g., rigor mortis (stiffening of the joints and muscles of a body a few hours after death, usually [MEDICATION NAME] from one to four days), dependent lividity (pooling of the blood causing purple or red skin discoloration), decapitation (head detached from body), transection (body cut in half), or decomposition (the body is is a state of rotting or decay)) are present; or initiating CPR could cause injury or peril to the rescuer. The immediate jeopardy that began on [DATE], was removed on [DATE], but the noncompliance remained at the lower scope and severity level of an E, pattern scope and severity level, which indicated no actual harm with potential for more than minimal harm. The facility implemented the following interventions: - Ensured all residents requesting CPR were reviewed and ensured their POLST/code status was accurate within the medical record. -Revised their policies and procedures related to identifying a residents code status. Including adding AHA current guidelines. - Started the process of training all CPR trained staff and had a process in place to ensure all CPR trained staff received education on the updated policies and procedures prior to providing resident care. - In addition , the facility started training all CPR certified staff to the new policies and procedures. because the facility had not completed all staff training related to the new policies and procedures. On [DATE], at 3:49 p.m. through [DATE], at 9:44 a.m. all current working CPR certified staff were interviewed and stated the would not do CPR if the resident had a code status of DNR. If the resident had a code status of CPR they would call 911 and initiate CPR unless there was irreversible signs of death including: rigor mortis, dependent lividity, decapitation,transection or decomposition. In addition, the EMR was where they would find the current code status as well as new binders on each unit which had a current copy of their POLST/code status.