Every finding on record at Ebenezer Ridges Geriatric Care Center

Based on interview and document review, the facility failed to collaborate care with hospice agency to ensure proper training and safety with mechanical lift transfers, when hospice aide (H)-A and facility registered nurse (RN)-A did not follow manufacturer instruction in properly securing the lift sling for 1 of 1 resident (R1). This resulted in an immediate Jeopardy (IJ) when R1 fell from the lift and sustained a fracture. The IJ began on 7/30/26, at 7:30 am. when H-A hooked up the Hoyer sling to get R1 ready for shower and requested RN-A to assist with transfer to the shower chair. H-A did not cross the leg straps and during the transfer R1 slid out of the Hoyer sling and hit her leg on the bed while RN-A was attempting to lower R1 to the floor. An X-Ray was taken and R1 was found to have a Tibia/[NAME] fracture. The director of nursing (DON) and administrator were notified of the IJ on 8/05/26 at 12:15 p.m. The facility implemented corrective action prior to the start of survey, and this is issued in past noncompliance. The administrator and the DON were informed of the IJ removal on 7/30/26, when the facility trained their staff on sling inspection and safety, EZ Way Smart Lift Competency and transfer audits. R1's significant change minimum data set (MDS) dated [DATE], indicated R1 was moderately cognitively impaired, had no mood or behavioral issues. R1's MDS further indicated R1 was dependent with transfers and had medically complex conditions which included dementia, hypertension, and depression. R1's Care Plan dated 4/20/26, indicated R1 needed total assist of two using mechanical Hoyer lift, using a medium sling due to right sided weakness. A Facility Reported Incident dated 7/30/26 at 11:15 a.m., indicated on 7/30/26 at 7:30 a.m. R1 was hooked up the Hoyer sling by H-A to get R1 ready for shower and requested RN-A to assist with transfer to the shower chair. H-A did not cross the leg straps and during the transfer R1 slid out of the Hoyer sling and hit her leg on the bed while RN-A was attempting to lower R1 to the floor. An X-Ray was taken and R1 was found to have a Tibia/[NAME] fracture.R1's Fall Risk Assessment (FRA) dated 7/26/26, indicated R1 was high risk for falls due to intermittent confusion, chair bound, non-ambulatory and predisposing diseases. R1's FRA dated 7/30/26, indicated R1 was high risk for falls due to intermittent confusion, chair bound, non-ambulatory and predisposing diseases. R1's Radiology Results Report dated 7/30/26, indicated there is an acute mildly displaced fracture of the proximal tibia and fibula metaphysis (the main shinbone (tibia) and the smaller outer leg bone (fibula) are broken near the top (proximal end) in the flared area before the knee joint (metaphysis), and the broken pieces are out of place displaced) . Distal tibia and fibula are otherwise intact. During interview on 8/04/26 at 9:45 a.m., director of nursing (DON) stated H-A had training from the hospice agency on 7/14/26 and started coming to the facility the following day, and it was assumed the agency had trained the H-A on lifts but found out after the incident he was not trained on the lifts and slings, they use. The DON stated the RN-A that assisted H-A had been working at the facility several years and RN-A did not see the leg slings were not crossed correctly. The DON stated the RN-A realized during the transfer R1 was sliding through the lower part of the sling, while H-A froze and RN-A guided R1 to the floor and R1 was contracted and frail and hit the side of the bed on her right side which caused the fracture. The DON stated after review of the incident it was decided to no longer allow any hospice agencies to assist with any mechanical lift transfers and signs were placed in all hospice patient's rooms and emailed all hospice companies. During interview on 8/04/26 at 1:36 p.m. nursing assistant (NA)-A stated he had completed a transfer with H-A with R1, and he had to remind him to criss cross the lower leg straps under her legs prior to hooking up the Hoyer lift. During interview on 8/04/26 at 2:54 p.m., RN-A stated during the incident on 7/30/26 she was asked by H-A to assist with the transfer with R1, and she was called into the room to quick help and she stated she asked him if he knew the resident and if he had transferred her before and he told me he had. RN-A stated R1 was hooked up to the lift and while in mid-air she noticed R1 was sliding out of the sling and H-A froze and she guided R1 to the floor and she had hit her right side on the bed frame. RN-A stated she had transferred R1 approximately 20 times before with no issues but was never the lead using the lift machine. RN-A stated usually the hospice staff knew how to transfer the residents. During interview on 8/04/26 at 7:08 p.m., NA-B stated he has completed transfers with H-A and he has had to remind him to cross the leg straps before on another resident on a different floor. NA-B stated after he found out about the fall of R1 he stated, Oh looking back I wished he received better training on the Hoyer lifts. NA-B stated they have had several hospice aides there with no issues and sometimes they take the lead with the Hoyer lift with no issues, this was just an unfortunate incident. NA-B stated I should have said something for him to be retrained. During interview on 8/05/26 at 11:13 a.m., the DON stated she was surprised the hospice agency did not train their staff on the slings they used and finding out they only trained on a hammock sling which does not require a lower leg [NAME]-cross. In addition, the administrator stated in their contract with the hospice agency they signed the durable medical equipment (DME) they would properly train their staff which would include Hoyer lifts and slings. Hospice Agreement dated 2/21/17, indicated the facility shall provide room and board services including, but not limited to supervising and assisting in the use of the facilities DME.inovihealthcare Universal sling is commonly used for seated transfers to and from wheelchair, commode, chair, recliner & bed. They can also be used to assist with bed pan and chux pad placement post bed transfer and during floor rescues. They've even been used to help support the pannus prior to providing cares. l before any sling is selected to ensure safety for both patient and caregiver.Steps when placing the sling on individual:1) With label and handles facing away from the individual, place U shape webbing at tailbone/coccyx.2) Keeping webbing flat bring leg straps along outside both thighs keeping equal length ensuring sling is centered.3) Two options for placement of leg straps under legs:A) Safely bring each leg strap under and up between the legs and crisscross legs straps by threading one leg strap through the other strap. This locks the straps in place, so they don't migrate up into the groin.B) Safely bring each leg strap under both legs to create a hammock. (Place pillow between legs to avoid pinching before lifting)4) Bring hanger bar down to individuals' chest:5) Connect shorter (White) loops on shoulder to keep individual sitting up.6) Connect longer (Yellow) loops on legs to keep individuals' legs lower.7) When initiating lift, raise patient 1 to 2 inches, then stop and perform a safety check to ensure all straps are securely attached to spreader bar.8) Complete transferThe IJ that began on 7/30/26, at 7:30 a.m. was removed on 7/30/26, when the facility completed the following prior to the start of survey re-education and competency testing completed with all staff regarding the use of mechanical lists and lift slings, education completed with facility staff regarding hospice staff not able to assist with mechanical list transfers, education completed with facility staff regarding alerting management when noted further training needed, hospice agencies contracted with the facility were made aware their stare staff are not able to assist with mechanical lift transfers, signs placed in hospice resident rooms with directions for hospice staff not to assist with mechanical lift transfers, hospice staff and lift policy updated to indicate hospice staff are not able to assist with mechanical lift transfers, facility management staff completing mechanical lift transfer audits.

Based on interview and record review the facility failed to ensure that 1 of 3 residents (R1) reviewed was free from a significant medication error. R1 was given another residents insulin causing her to be sent to the hospital for treatment. Findings include: R1's clinical physician orders dated 7/15/25 - 7/29/25 did not indicate R1 was ordered insulin. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) was a 15 indicating she was cognitively intact. R1 did not receive any injections including insulin. R1's diagnosis's were urinary tract infection, overactive bladder, hypothyroidism (the thyroid gland does not produce enough thyroid hormone), gastro-esophageal reflux disease, muscle weakness, encephalopathy (a condition where the brains function is impaired) and ischemic cardiomyopathy (damage of a heart muscle making it difficult for the heart to pump blood). R1's diagnoses did not include diabetes. R1‘s nursing progress note dated 7/23/25 at 7:57 p.m. indicated misadministration of Novolog insulin 31 units to R1 and R1 was a non-diabetic resident. LPN-A was distracted by nursing assistant (NA)-A while ready to enter the residents room to administer insulin. NA-A asked LPN-A to speak to the resident in the next room regarding a concern he had, and it was urgent. LPN-A was already with the insulin in her hand. LPN-A entered the resident's room who had a concern. On the way-out LPN-A noticed two more call lights going off including the one who was administered the insulin. LPN-A accidentally entered the wrong room that had all light on thinking it was the room of the resident who needed the insulin. LPN-A apologized to the resident for being late with the insulin. R1 did not say anything at first but after administering the dose LPN-A realized she administered the insulin to the wrong resident. R1 was also surprised stating she was not diabetic. LPN-A apologized and called the charge nurse right away. LPN-A also called 911 but was unable to talk. The charge nurse arrived, and LPN-A handed over the phone. LPN-A checked R1's blood sugar after 15 minutes following the insulin administration and her blood glucose level was 142. A glass of orange juice was administered. The ambulance arrived and R1 was taken to the emergency department. R1's emergency department document dated 7/23/25 at 8:13 p.m. indicated the clinical impression was a diagnosis of hypoglycemia (blood glucose levels are too low). R1's hospital history and physical dated 7/23/25 indicated R1 was evaluated after inadvertently administered insulin at her transitional care unit. R1 was noted to have a glucose level of 52 (normal range 70-99) upon arrival to the emergency room. R1 had no history of diabetes and not on insulin therapy. R1 was given D50 (a concentrated sterile glucose 50% in 50% water) in the emergency room and started on dextrose infusion. R1's blood sugar dropped to 48 and was started on D10 (a concentrated sterile solution of 10% glucose and 90% water) at 150 milliliters per hour. R1's hospital summary of visit dated 7/23/25 indicated R1 was admitted to the hospital for concerns of hypoglycemia after inadvertently receiving insulin at the transitional care unit. R1's blood sugar had maintained with dexterous fluid and then subsequently eating adequately oral intake. A facility Medication/Treatment Error Report dated 7/23/25 indicated the medication involved with Insulin Aspart (rapid acting insulin) used for managing blood glucose levels in diabetics. R1 was not ordered Aspart Insulin, R2 was ordered the insulin needed and was due for 31 units. R1 did not have any immediate symptoms insulin at the facility. Emergency Medical Services arrived and started IV Dextrose (glucose given intravenously). R2's MDS dated [DATE] was not completed as R2 admitted on [DATE] and discharged on 7/27/25. R2's care plan dated 7/28/25 indicated R2 had Diabetes Mellitus R2 was to have blood glucose checks per providers orders and as needed. In addition, R2 was be administered diabetes medications as ordered by her provider. R2's Clinical Physician Orders dated 7/22/25 indicated R2 was to have Insulin Aspart FlexPen subcutaneous 100 unit/milliliter inject 28 units twice daily. Upon interview on 7/29/25 at 9:22 a.m. R1 stated in the evening on 7/23/25 a nurse entered her room and stated she had her medication. The nurse lifted her shirt and gave her an injection. R1 asked licensed practical nurse (LPN)-A what she had given her. LPN-A replied that she had given her the insulin she had requested. R1 told LPN-A she is not on insulin, and she was not diabetic. The next thing R1 recalled was getting orange juice and then the ambulance showed up. R1 was taken to the hospital where an IV was started and she spent the night in the hospital where staff was monitoring her all night. R1 stated she was told in the hospital that she received a lot of insulin. Upon interview on 7/29/25 at 12:17 p.m. the director of nursing (DON) stated she was notified immediately of the medication error and the facility acted immediately with administering orange juice to R1 and calling for emergency medical services. The DON stated LPN-A had been suspended during the facility investigation, a pharmacy review had been completed, and nursing staff were re-educated before working with residents. In addition, R2 had a specialized order on her chart to have two nurses verify the five rights before the administration of her insulin since it was a high dose of short acting insulin, however R2 had been discharged from the facility on 7/27/25. Upon interview on 7/29/25 at 2:07 p.m. R1's family member (FM)-A stated she received a call from the facility that R1 was taken by ambulance to the emergency department because she had been given another residents insulin. Later that evening FM-A spoke with R1 and R1 told her she would be spending the night in the hospital. R1 told FM-A she did not give LPN-A consent to give the insulin it just happened so fast. FM-A stated the amount of short acting insulin could have killed R1 if R1 would not have cognitive enough to tell LPN-A she was not diabetic. FM-A also stated concerns after speaking with hospital staff that R1 had been tested for blood borne pathogens (infectious microorganisms such as bacterial or viruses that live in the blood) from the needle stick. FM-A was worried what those findings may result in. Upon interview on 7/29/25 at 3:53 p.m. LPN-A stated she was distracted when she administered insulin to the wrong resident. She was told by NA-A that another resident needed her, and it was urgent. LPN-A had already drawn-up R2's insulin when she checked on the unidentified resident. LPN-A then left the unidentified resident's room and answered a call light for R1 mistaking her for R2. LPN-A stated she apologized to R1 about being late with her medication and injected the insulin. LPN-A denied verifying R1's name. After she administered the insulin R1 asked what she have given her. LPN-A told her it was her insulin. R1 told LPN-A she was not on insulin and not diabetic. LPN-A immediately called the charge nurse and emergency medical services were notified. LPN-A stated she was suspended immediately following the medication error. A facility policy titled Medication Administration-General Guidelines with a revision date of 6/13/25 indicated Residents are identified before medication is administered using two methods of identification, methods of identification include:-Checking residents name band-Asking a reliable resident for their first and last name-By referring to the photo attached to the electronic medical record (EMAR)-If necessary, verifying resident identification with other facility personnel.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., showers) was completed for 4 of 5 residents (R89, R103, R159, R162) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R89 R89's admissions Minimum Data Set (MDS) dated [DATE], identified R89 with admission to facility's transitional care unit (TCU) on 10/26/24, had severe cognitive impairment, required substantial to maximal assistance with showers, upper and lower body dressing, and personal hygiene. In addition, R89 was documented with an indwelling catheter (drain urine from the bladder) and had diagnoses of left arm fracture, non-Alzheimer's dementia, depression, and urinary retention. Furthermore, the MDS stated R89 and family participated in the assessment and goal setting process. During initial screening on 11/18/24 at 12:15 a.m., surveyor provided with undated TCU nursing assistant care sheet. During interview with nursing assistant (NA)-A on 11/19/24 at 12:49 a.m., NA-A stated she had worked full-time on the TCU since, January [2024]. NA-A stated the expectation of nursing assistants at start of their shifts was to look at the resident's care plan in the computer system and review the paper care sheets on each unit to see what shower days and times are assigned. NA-A pointed to the paper care sheet and stated, Showers are assigned per room. NA-A stated, [nursing assistants] always go by the sheet here. NA-A stated nursing assistants document in the Task[s] section of the electronic medical record (EMR) for assigned tasks. Review R89's of undated nursing assistant care sheet indicated R89's assigned bathing day and time was Saturday evenings. Per bathing task in the electronic medical record (EMR) indicating a shower was missed or not documented on 11/9/24. R89's progress note dated 10/26/24 to 11/20/24, failed to identify R89 refused a shower on 11/9/24. During interview with R89 on 11/21/24 at 8:21 a.m., R89 stated, my daughter [FM-A] is helping with the arrangements [for discharge]. I get confused. I like to get washed up. It makes me feel normal and less gross. It is important to me to have my hair washed. I cannot remember the last time I had it washed. It does feel like its ben a least a week since it was washed. During interview with family member (FM)-A on 11/21/24 at 8:38 a.m., FM-A stated she recalled being present for R89's admissions assessment. FM-A stated, Mom [R89] likes showers in the morning but I am quite sure she was never asked if she preferred a specific day or time of the day for the shower. I think [R89] missed a shower while she was there. They [staff] said they were going to do it but I believe they forgot. [R89] is a lot of work to get in and out of the shower so I am sure it was forgotten, or they did not have enough staff to do it. She had one last week, I think. And, Yes, she likes her hair washed. Makes her feel good, like it does for all of us. A wet washcloth is not the same as a shower. I feel disgusting if I don't have a shower and I am quite sure she would not like missing a good shower or bath. She used to shower every day. During interview with registered nurse (RN)-A on 11/19/24 at 1:25 p.m., RN-A stated the expectation of nursing assistants was to look at the care sheet first to identify shower days and times. RN-A indicated shower day assignments are scheduled per room. R159 R159's admissions MDS dated [DATE], identified R159 with admission to facility's TCU on 11/4/24, R159 had impaired cognition, and required substantial to maximum assistance with showers or baths, toileting, lower body dressing, and personal hygiene. Also, R159 was documented with diagnoses of fracture to right hip, and arthritis. In addition, section F0400 of the MDS titled Interview for Daily Preferences. C. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Answer coded was, 1. Very important. During interview with NA-B on 11/19/24 at 1:06 p.m., NA-B stated he worked at facility on TCU for sixteen years and noted that R159 was to receive showers on Fridays in the evening per the nursing aide care sheet. NA-B stated the expectation of staff was to document showers including refusals in the EMR under Tasks. NA-B verified R159's EMR lacked documentation of showers or refusals from R159. During interview with NA-A on 11/19/24 at 12:49 a.m., NA-A stated she had worked full-time on the TCU since, January [2024]. NA-A stated the expectation of nursing assistants is to look in resident's care plan, Kardex and (undated) care sheet to determine what assistance is required for each resident. NA-A stated the expectation of nursing assistants was to document in the Task[s] section of the electronic medical record EMR for assigned tasks, subsequently, NA-A reviewed R159's care sheet and noted shower day is Fridays in the evening and stated the EMR lacked documentation of showers or refusals from R159. During interview with TCU nursing manager, registered nurse (RN)-A on 11/19/24 at 1:06 p.m., RN-A stated the expectation of nursing assistants was to look at the resident's care plan, Kardex and (undated) paper care sheet to determine the assistance needed and shower days and times. RN-A looked at R159's EMR and verified no documentation of showers or refusals since he was admitted [DATE]. RN-A stated, It was not being documented of being offered, refused, ecetera and it should be. RN-A stated, I expect documentation in a progress note if he refuses a shower. It horrifies me that he hasn't had shower since he was admitted . It is important that our residents get a shower and cleaned up. R162 R162's admission MDS dated [DATE], identified R162 with admission to facility's TCU on 11/1/24, with moderately impaired cognition, and required partial to moderate assistance with upper body dressing and personal hygiene and required substantial to maximal assistance with showers or bathes and lower body dressing. In addition, R162 was documented with diagnoses of a stroke, cancer, and hypertension (high blood pressure). During interview with R162 on 11/18/24 at 3:42 p.m., R162 stated, I prefer a shower if they [staff] could do it. I don't recall if I was asked. R162's undated care sheet identified R162's showers were assigned for Friday mornings. R162's Tasks tab in EMR identified documentation of having a shower on 11/15/24, missing 11/1/24 and 11/8/24. R159 progress notes dating from 11/4/24 to 11/19/24, failed to document a shower was offered or declined on 11/1/24 and 11/8/24. During interview with RN-A on 11/20/24 at 10:40 a.m., RN-A stated, She [R162] should have been given a shower. Additionally stating we [facility] have noticed that some [residents] have missed the showers and we are not documenting it. During interview with director of nursing (DON) on 11/21/24 at 9:52 a.m., DON verified showers are not being charted. Showers were missed. Showers are important to everyone, and they should not have been missed. Facility policy titled BATH, SHOWER updated 2/24 identify, 23. Document bath/shower in the EHR (electronic health record). 49339 R103 R103's admission Minimum Data Set (MDS) assessment, dated 11/4/24, indicated R103 had intact cognition with no hallucinations or delusions with an admitted [DATE]. Diagnoses included: displaced bicondylar fracture of left tibia (fracture in left lower leg), muscle weakness, other abnormalities of gait and mobility, left foot drop (dragging of front of foot when walking and/or inability to raise toes or the foot from the ankle), and infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts (an infection caused related to implanted devices from surgery). In addition, R103 was dependent on staff for showers/bathing and transfers, and required maximal assistance from staff for dressing, personal hygiene and mobility. R103's care plan, printed 11/18/24, indicated R103 has an ADL [activity of daily living] self-care performance deficit with the following intervention: -BATHING/SHOWERING: Assistance by (2) staff with bathing/showering. Staff to provide nail care as needed. If diabetic, nail care to be done by nurse. Report need of nail care to nurse. -PERSONAL HYGIENE: assist of 2 staffs. R103's Kardex, printed 11/20/24, indicated R103's bathing was Saturday PM (evening). Further, indicated assistance by (2) staff with bathing/showering prefers to have a bath. R103's task log, printed 11/20/24, indicated R103's bathing was completed with total dependence with one person physical assist. The document lacked evidence for an entry on 11/16/24, which would be the next scheduled bathing/showering day per schedule. R103's progress notes, dated 10/29/24 to 11/21/24, were reviewed. Progress notes lacked evidence of R103 refusing showers or staff assistance with ADLs. Furthermore, lacked documentation of staff offering an additional showers/bed bath/partial bath since last documented bath/shower on 11/9/24. R103's November Administration Record, printed 11/18/24, indicated an order for: -Complete weekly/bath and pain sheet assessment in PCC [electronic health record - EHR]. If any new alterations in skin integrity, follow the skin alterations and wounds checklist. Bath declined, skin audit must still be completed. Every evening shift every Saturday. It was documented the assessment was completed for 11/2/24, 11/9/24, and 11/16/24. During an interview on 11/18/24 at 3:12 p.m., R103 stated that her shower/bath day was scheduled to be on Saturdays. She stated that she not offered and did not get a bath or shower this past Saturday (11/16/24) and the last shower/bath she had was on 11/9/24. R103 was displeased that she was not offered a shower in 9 days. R103 indicated her preference was to have a shower/bath daily, understood that this was likely not possible but going 9 days without a shower was not acceptable. R103 stated she had told staff that she would like more than one shower/bath a week. R103 indicated she was told that they offer one shower/bath a week. On 11/20/24 at 9:20 a.m., registered nurse (RN)-C stated that upon admission, residents are assessed to determine if they want one or two showers a week, in the morning or evening, and that is added to the care plan. RN-C stated that if a shower or bath is missed, for any reason, the nursing assistant is expected to notify the nurse and the shower is to be attempted again another day. RN-C indicated the skin assessment, which is documented on the administration record, is completed by the nurse on the scheduled shower day, whether the shower is completed or not. RN-C indicated that a progress note is entered when a resident refuses a shower and when a shower is attempted or offered again. On 11/20/24 at 10:07 a.m., nurse manager on the 3rd floor RN-D verified that residents are expected to be showered at least once a week and can get an additional shower if requested. RN-D verified the nurse should document in the progress notes when a shower is refused or not given. RN-D reviewed R103's EHR, verified the weekly skin assessment was completed on 11/16/24 and verified R103 did not receive a shower on 11/16/24. RN-D verified R103's last shower was 11/9/24 which was 11 days ago, at time of interview. RN-D verified R103 needed assistance with showering/bathing and would not be able to complete this task independently. RN-D stated the expectation is that residents are showered or bathed at least weekly. RN-D indicated they would follow up with R103 regarding her showers. A facility policy titled Bath Shower, revised 2/24, indicated the purpose of the policy was that a resident feels cleansed and refreshed per resident's wishes after bathing, and indicated baths/showers to be documented in EHR.

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented or followed for 2 of 2 residents (R46 and R21) reviewed for EBP. Findings include: The CDC article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, indicated MDRO transmission in skilled nursing facilities was common and contributed to substantial resident morbidity. EBP is an infection control intervention to reduce transmission of MDROs by using gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing that lead to indirect transfer of MDROs from resident to resident. The article indicated high-contact activities include changing linens, bathing, dressing, transferring, changing briefs, feeding tube care, etc. The article indicated EBP should be implemented (when contact precautions did not apply) for residents with wounds or indwelling medical devices (central lines, urinary catheter, feeding tube) regardless of MDRO colonization status. R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated R46 had severely impaired cognition, was diagnosed with a stroke, and required total assistance with all care activities. The MDS indicated R46 received his nutrition through a feeding tube. R46's order summary report dated 11/4/24, indicated R46 had an enteral feeding tube. R46's progress note dated 11/19/24 at 12:21 p.m., indicated the staff development director/ registered nurse (SDD) had instructed podiatry per the nurse manager that R46 would like podiatry services in his room in bed but the SDD advised podiatry staff that they would not need to utilize EBP. The SDD explained to podiatry staff that working on his feet would not prevent a splash risk so they would not need to don or doff PPE for this encounter. During an observation on 11/19/24 at 11:42 a.m., licensed practical nurse (LPN)-B was observed in R46's room with gloves on but no gown. LPN-B was observed to lean into R46's bed, pull back his covers, and reposition R46's legs. LPN-B was then observed to continue leaning against R46's bed to adjust the pillows between R46's legs before removing his gloves and leaving the room. During an interview on 11/21/24 at 8:04 a.m., the SDD stated she completed EBP education for nursing staff. The SDD stated staff should utilize EBP when there was a splash risk but if an activity did have a splash risk such as transferring a resident or completing foot care EBP would not be needed. During an interview on 11/21/24 at 9:34 a.m. with the director of nursing (DON) and the infection preventionist (IP), the IP stated the SDD completed all staff infection prevention education. The IP stated it was important for staff to read the CDC infection control signs that outline when PPE was needed for residents on EBP. The IP stated she would expect nursing staff to utilize EBP when they were transferring a resident per the CDC sign. The DON stated when care was being given to a resident in bed and involved staff-to-resident contact, she would expect nursing staff to utilize PPE, given the possible burden of MDROs in the resident ' s room. The facility's EBP policy dated 11/8/24, indicated EBP was needed for residents with chronic wounds and indwelling medical devices such as feeding tubes. The policy indicated that glove and gown use should be utilized for dressing, bathing, transferring, providing hygiene, changing linens, assisting with toileting, etc. 48065 R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated R21 had moderate cognitive impairment, was diagnosed with severe vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), left side hemiplegia (paralysis of the left side of the body), and a pressure area (pressure areas are injuries to the skin and the tissue below the skin that are due to extended pressure on the skin). The MDS also indicated R21 required substantial assistance with mobility, and total assistance with toileting and hygiene. R21's Clinical Diagnosis report printed 11/21/24, documented R21 was on enhanced barrier precautions related to a wound. R21's Order Summary report dated 11/21/24, indicated orders for wound care to right posterior thigh. The order directed nurses to 1. Clean right posterior thigh with unscented soap [Cetaphil/dove]. 2. Apply small amount of VASHE [a wound cleanser solution] on gauze, lay into wound bed, let it sit for 10 minutes, remove gauze, do not rinse. 3. Gently pack with VASHE moistened plain packing strip to fill depth of wound, ensure to leave a tail for easy removal. Do not overpack. 4. Cover with Mepilex dressing [Mepilex Ag is a soft and conformable dressing that absorbs exudate and inactivates wound pathogens]. Change every- day shift and as needed if soiled/saturated/dislodged. During observation on 11/20/24 at 10:22 a.m., nursing assistant (NA)-C was observed providing personal cares to R21 without wearing a gown. R21 was in bed, turned on her right side facing the wall and NA-C was adjusting R21's brief. NAR's legs were touching the bed linen and NA-C was wearing gloves. NA-C finished adjusting R21's pants and left the room to find another NA to help him transfer R21 with a mechanical lift. NA-C came back to the room followed by NA-D who was pushing the mechanical lift. Before entering R21's room, NA-C and NA-D put on gloves, but did not wear gowns and transferred R21 from her bed to her wheelchair. During interview on 11/20/24 at 10:27 a.m., NA-D confirmed she didn't use a gown when she assisted R21 during transfer. When asked regarding the EBP sign posted to the right side of R21's room, NA-D started reading it aloud. After she finished reading the sign NA-D said, I was supposed to clean my hands before I entered the room, wear gloves and a gown. NA-D stated she didn't know what EBP meant, but she could find out by asking the nurse. During interview on 11/20/24 at 10:41 a.m., NA-C stated he didn't wear a gown while changing R21's brief and added I wore gloves. When directed to the EBP sign next to R21's door, NA-C asked, do I have to use a gown all the time? NA-C proceeded to read the sign and stated, we [staff] need to follow precautions to prevent further disease and infections to go around. During interview on 11/20/24 at 10:47 a.m., LPN-A, who was caring for R21 stated, it is concerning when staff don't follow EBP precautions due to the potential of spreading pathogens and diseases. LPN-A added the expectation was for all staff to follow the infection precautions as indicated by the signs posted adjacent to the resident's rooms.

Based on interview and document review, the facility failed to ensure as-needed (PRN) antipsychotic medications were limited to 14 days of use or re-evaluated by the medical provider to ensure necessity and reduce the risk of complication for 1 of 5 residents (R6) reviewed for unnecessary medication use. Findings include: R6's significant change Minimum Data Set (MDS) dated [DATE], indicated R6 had moderately impaired cognition and was receiving hospice services. R6 was dependent on staff for toileting, personal hygiene, and bed mobility. The MDS indicated R6 was diagnosed with dementia, anxiety, and depression. R6's Verbal Orders report dated 10/23/24, indicated a hospice provider (MD)-A had ordered two milligrams (mg) haloperidol (an antipsychotic medication) three times a day as needed (PRN) starting on 10/23/24. The report had a column titled Date Discontinued that was left blank and the order did not include an end date. R6's order summary report dated 10/23/24, indicated R6 had an order for two milligrams (mg) haloperidol three times a day as needed (PRN) starting on 10/23/24 for agitation or nausea ordered by nurse practitioner (NP)-A. The report included a section titled End Date that did not include a date for this order. R6's Medication Administration Record (MAR) dated 10/23/24 through 11/19/24, indicated R6 had received the PRN haloperidol with the order date 10/23/24 over ten times during the period. During an interview on 11/20/24 at 10:47 a.m., registered nurse (RN)-E, the unit nurse manager, stated she had reviewed R6's medical record and confirmed R6's PRN haloperidol order had been active for longer than fourteen days and a provider had not re-evaluated her during that time and renewed the order if needed. During an interview on 11/20/24 at 11:23 a.m., NP-A stated she was R6's primary care provider but R6 also received hospice care and the Haldol was managed by them. NP-A stated she would have expected the hospice provider to order PRN haloperidol for a maximum of 14 days and then reevaluate R6 for the appropriateness of continued haloperidol use prior to reordering it. NP-A stated she had not reassessed R6 for the appropriateness of this medication as it was ordered by hospice. During an interview on 11/20/24 at 11:35 a.m., RN-F, R6's hospice nurse, confirmed the hospice provider had not re-evaluated R6 after 14 days of PRN haloperidol use and had not ordered an end date for the medication. RN-F stated she had reviewed R6's hospice medical record and confirmed the order had not been renewed after 14 days of use. During an interview on 11/21/24 at 8:30 a.m., the director of nursing (DON) stated R6's medical record had been reviewed and facility staff did not find that R6's PRN haloperidol had an ordered stop date or had been renewed by a provider after 14 days. The facility Psychopharmacologic Drug Use policy dated 7/8/24, indicated PRN psychotropic medications should be limited to 14 days unless the prescribing practitioner believes it was appropriate to extend past 14 days and documented the rationale in the medical record and indicated the duration. The policy did not include additional instruction for PRN antipsychotic medication use

Based on interview and document review, the facility failed to ensure care conferences were conducted upon admission for 1 of 2 residents (R103) reviewed for care conferences. Findings include: R103's admission Minimum Data Set (MDS) assessment, dated 11/4/24, indicated R103 had intact cognition with no hallucinations or delusions with an admitted [DATE]. Diagnoses included: displaced bicondylar fracture of left tibia (fracture in left lower leg), muscle weakness, other abnormalities of gait and mobility, left foot drop (dragging of front of foot when walking and/or inability to raise toes or the foot from the ankle), and infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts (an infection caused related to implanted devices from surgery). R103's care plan, printed 11/18/24, indicated R103 discharge planning: [R103] was living at home where she is planning to return home at discharge with an intervention of arrange for in home services as ordered, with an initiation date of 11/18/24. R103's progress notes, dated 10/29/24 to 11/21/24, were reviewed. Progress notes lacked evidence of R103 having a care conference since admission on 10/29/24. Furthermore, lacked documentation of a planning of a care conference. On 11/18/24 at 3:12 p.m., R103 indicated she has not had a care conference since admission. R103 indicated there has been no meeting of any kind to talk about discharge or the plan around this. R103 stated she asked the nurse practitioner at the facility last week about having a care conference as they are thinking she might discharge in a couple of weeks but has not heard anything about any sort of meeting or care conference. R103's provider note, dated 11/18/24, was reviewed. The provider note did not mention a care conference and potential discharge plan or date. On 11/20/24 at 10:19 a.m., nurse manager on third floor registered nurse (RN)-D verified R103 has not had a care conference since admission to the facility on [DATE] [22 days ago]. R103 indicated that social worker sets up the care conferences for residents. RN-D indicated they talked about R103 in rounds yesterday and will going to do a care conference soon as R103 has a home assessment set up on 11/22/24. RN-D stated they think the social worker wanted to wait until closer to dischage for a care conference. On 11/21/24 at 9:33 a.m., social worker (SW)-A verified that she is the social worker for R103. SW-A verified that when a resident is admitted to the facility, specifically transitional care unit (TCU), they try to do a care conference within the first week or two of admission. SW-A stated it is expected that a care conference is done no later than 21 days after admission. SW-A verified R103's care conference is probably beyond 21 days and verified R103 has not had a care conference since arriving at the facility. SW-A verified R103's admission was 10/29/24 which was more than 21 days ago. SW-A stated R103's care conference was missed. On 11/21/24 at 10:18 a.m., director of nursing (DON) stated the expectation is that a care conference is held no later than 21 days after admission. A facility policy titled Care Conference Process, revised 10/18, indicated a care conference is held for every resident receiving care within our facilities upon admission, quarterly, with significant change and as needed. Furthermore indicating care conference for an individual resident is held within 21 days of an admission.

Based on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect upper body impairment for 1 of 2 residents (R162) reviewed for MDS accuracy. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2018, identified the purpose of the RAI process was to help ensure holistic care was provided. According to the RAI/MDS, the definition of functional limitation in range of motion is, limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living or places the resident at risk of injury. Coding instructions for GG0115A Functional Limitation in Range of Motion question, the Upper Extremity (Shoulder, Elbow, Wrist, Hand) include: Code 0, no impairment: if resident has full functional range of motion on the right and left side of upper/lower extremities. Code 1, impairment on one side: if resident has an upper-and/or lower-extremity impairment on one side that interferes with daily functioning or places the resident at risk of injury. Code 2, impairment on both sides: if resident has an upper-and/or lower extremity impairment on both sides that interferes with daily functioning or places the resident at risk of injury. Examples of coding instructions include: 1. The resident can perform all arm, hand, and leg motions on the right side, with smooth coordinated movements. They are able to perform grooming activities (e.g., brush their teeth, comb their hair) with their right upper extremity and are also able to pivot to their wheelchair with the assistance of one person. They are, however, unable to voluntarily move their left side (limited arm, hand, and leg motions), as they have a flaccid left hemiparesis from a prior stroke. Coding: GG0115A would be coded 1, upper-extremity impairment on one side. R162's admissions Minimum Data Set (MDS) dated [DATE], identified R162 with admission to facility's transitional care unit (TCU) on 11/1/24, with moderately impaired cognition, and required partial to moderate assistance with upper body dressing and personal hygiene and required substantial to maximal assistance with showers or bathes and lower body dressing. The MDS section GG0115: Functional Limitation in Range of Motion identified R162 with, No impairment of upper and lower extremity. In addition, R162 with diagnoses of a stroke, cancer, and hypertension (high blood pressure). R162's initial visit notes from physician dated 11/4/24, [R162] originally presented with left upper extremity weakness. And not able to move her left arm. During observation and interview on 11/18/24 at 3:42 p.m., R162 was observed seated in a recliner watching television in her room. R162 was observed with her left arm in shoulder sling with left arm immobilized. R162 stated, I have this [pointing to sling] because I had a stroke. R162 stated it was important for the sling to be on so her left arm would not flop down as she had no control or feeling in it. R162 stated that she admitted to the facility with the sling and that staff at the facility were applying it and removing it daily. Review of R162 care plan, orders, and nursing assistant care sheet and Kardex failed to mention an assessment for use about the sling, including purpose for it, who was responsible for applying and removing it, and when it should be done. During interview with rehabilitation supervisor (RS) on 11/20/24 at 9:38 a.m., stated, R162 came in after stroke and diagnoses with metastatic [wide spread] brain and lung cancer. RS stated R162 had Left arm weakness was fully flaccid [paralyzed as a result of interrupted communication within the nervous system]. RS stated the assessment for use of a sling was a therapy department responsibility and was unable to determine if R162 was assessed for use of the sling. RS stated the process was for therapy to assess use and appropriateness of a sling and a nursing communication form would be filled out by therapy and given to nursing department who would upload the information in resident's care plan and Kardex. RS stated the expectation was staff would not apply or remove the sling without orders and recommendations from the therapy department. During interview with nursing assistant (NA)-B on 11/20/24 at 10:00 a.m., NA-B stated, Yes [R162] had a sling on her left arm. She could not use the arm at all. No nothing in care plan or our Kardex for us to do anything with the sling. And [R162] had therapy every day so I think they took care of it. During interview with TCU nurse manager registered nurse (RN)-A on 11/20/24 at 10:40 a.m., RN-A stated, [R162] had splint on her for support and arm [sic] she cannot control it. RN-B stated there were no instructions to use, apply or remove the sling. It is important for the staff to know what they need to look out for and why. In this instance it was not done. During interview with the director of Resident Assessment Instrument (RAI)/MDS (DR) on 11/20/24 at 11:13 a.m., DR reviewed R162's admission MDS information and stated, looks like no impairment was noted for the upper and lower extremities. DR stated, 'if patient has no use of arm and it is not their previous norm then this was coded incorrectly. During interview with RN-A on 11/20/24 at 11:32 a.m., RN-A looked at R162's admission MDS and stated, not correct because of left arm in sling. It should have been coded accurately. During interview with director of nursing (DON) on 11/21/24 at 9:58 a.m., DON stated, [R162] had impairment of arm. The MDS response was inaccurate and should not have been coded as, 'No impairment'. Facility policy titled MDS/CARE PLAN PROCESS/RESIDENT ASSESSMENT updated 11/11/24 identified Use the Minimum Data set forms and CAA's (Care Area Assessment) collect data and supplemental forms as needed to complete a comprehensive, review of the resident's status. And MDS coordinator does MDS coding and prioritizing.

Based on observation, interview, and document review, the facility failed to accommodate bathing/shower preferences for 1 of 1 residents (R159) reviewed for choices. Findings include: R159's admissions Minimum Data Set (MDS) dated [DATE] identified admission to facility on 11/4/24, had impaired cognition, required substantial to maximal assistance for showering, toileting, lower body dressing, and personal hygiene. Review of transitional care unit (TCU) care sheet identified all residents by room number, name, primary diagnoses, and day of the week with AM or PM next to it. R159 identified Fri PM associated with it. R159's care plan dated 11/4/24 identified, Care Plan: I will have my preferences followed. During interview with R159 and family member (FM)-B on 11/18/24 at 3:14 p.m., R159 stated facility never offered or asked preferences on day and time of showers. R159 and FM-B stated he was informed that the showers and bath schedules were assigned per room number. R159 stated, I prefer to shower in the morning because I get too tired to participate in showering [in] the evenings after I work with physical therapy. FM-B stated, [R159] likes mornings better than evenings for showers. During interview with nursing assistant (NA)-A on 11/19/24 at 12:49 a.m., NA-A stated she worked full-time on the TCU where R159 resided. NA-A stated the expectation of nursing assistants at start of their shifts was to look at the resident's care plan in computer system and review the paper care sheets on each unit to see what shower days and times are assigned. NA-A pointed to the paper care sheet and stated, Showers are assigned per room. He[R159] is Friday PMs. NA-A stated, [nursing assistants] always go by the sheet here. During interview with NA-B on 11/19/24 at 1:06 p.m., NA-B stated he worked full-time on the TCU and I look at the care sheets which say what room and shower days [are assigned]. Shower days and times [are] with the room and not preference of the resident. During interview with registered nurse (RN)-A on 11/19/24 at 1:25 p.m., RN-A stated expectation of nursing assistants to look at the care sheet first to identify shower days and times. RN-A indicated shower day assignments are scheduled per room. During interview with director of nursing (DON) on 11/21/24 at 9:47 a.m., DON stated, the baths and showers are divided out by room number on the TCU. DON stated, [assigned shower days] are not reflective of [R159] preferences. It makes sense he would like a shower in the morning before therapy instead of later in the day after he is tired out from working with therapy. We should not be assigning shower days per room. Requested policy on choices and preferences and did not receive.

Based on observation, interview, and record review the facility failed to follow recommended precaution process for disinfecting medical equipment between resident use for 1 of 1 resident (R4) when observed. Licensed staff failed to disinfect the vital signs machine following the use on R4 who was on contact precautions and then used on another resident. In addition, the facility had placed R4 on incorrect isolation precautions. R4 was found to be on precautions due to suspicion of Covid requiring droplet precautions and he was on contact precautions. Findings include: Upon observation on 5/13/24 at 8:19 a.m. licensed practical nurse (LPN)-A was taking vital signs in R4's room. R4 had a cart with gowns, gloves, hand sanitizer and masks out of side of his room. The sign on the wall indicated R4 was on contact precautions that required staff to cleanse hands before entering and exiting room, don gloves and a gown when in room and discard before exiting the room. In addition, the staff were to use dedicated or disposable equipment or clean and disinfect reusable equipment before use on another person. LPN-A wheeled the vital sign machine out P4's room and placed the machine by the medication cart without sanitizing it. Upon observation and interview on 5/13/24 at 8:28 a.m. LPN-A wheeled the same vital sign machine into an unidentified resident's room and proceeded to take her vitals signs. LPN-A stated she usually wipes down the machine between each resident but was having a busy morning and realized she should have disinfected it. LPN-A was not certain why R4 was on contact precautions. She stated, I think because he is a new admit. LPN-A stated the facility constantly had Covid-19 outbreaks. Upon observation on 5/13/24 at 8:37 a.m. LPN-B used a vital sign machine on an unidentified resident room. The resident was on contact precautions. LPN-B did not sanitize the machine prior to taking the vitals signs. LPN-B placed the vital signs machine by her medication cart without disinfecting it after use. There is not an observation of LPN-B, or another staff member using the unsanitized machine on another resident. R4's nursing progress notes dated 5/10/24 - 5/13/24 did not indicate reason R4 was on contact isolation precautions. R4's care plan dated 5/13/24 indicated R4 had a localized infection that does not require precautions. R4's admission minimum data set (MDS) dated [DATE] was in progress, no isolation data identified. Upon interview on 5/13/24 at 7:52 a.m. the Administrator stated the facility is in Covid-19 outbreak and the facility had 11 cases between two units. Upon interview on 5/13/24 at 3:02 p.m. the director or nursing (DON) stated she was uncertain why R4 was on contact precautions. She stated the expectation of the staff is to disinfect equipment after use on each patient. She stated ideally equipment would be disinfected before and after each use. Upon interview on 5/13/24 at 3:58 p.m. the infection preventionist (IP) stated R4 admitted with suspicions of Covid-19 since he was a new admission from a hospital setting. The IP was uncertain which precautions R4 was on. She stated R4's Covid test came back on 5/13/24 as negative so he could be taken off any precautions for Covid-19, however, would be assessed for enhanced barrier precautions due to a new pacemaker and surgical wound. A facility policy titled Transmission/Isolation precautions dated 11/1/23 indicated: DROPLET: Examples; Influenza, Mumps, Respiratory Disease, COVID-19, Mpox Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets (larger than 5 mm in size) containing microorganisms generated from a person who has a clinical disease or is a carrier of the disease. Droplets are generated from the source person primarily during coughing, sneezing, talking, Transmission of large-particle droplets requires close contact between source and recipient persons. Private room and when a private room are not available, cohort with patient(s) who has active infection with the same microorganism but with no other infection. Perform hand hygiene. Mask, face shield/goggles, gown and gloves required prior to entering room. Isolation gowns must be impermeable to fluids. N95 mask to be worn when providing care for COVID-19 positive or suspected COVID-19 positive residents or unvaccinated residents during COVID-19 outbreak and with Mpox positive or suspected Mpox residents. -Remove PPE before leaving the patient's room. -Perform hand hygiene. -Eye protection should only be removed and reprocessed if it becomes visibly soiled or difficult to see through. -Use disposable equipment or patient dedicated equipment to stay in patient room if possible, disinfect between patient use, follow product wet times. -Limit the movement/transport of patients from room to essential purposes only. Place a universal mask on patient if possible, during transportation. -Maintain at least 6 feet from other patients and visitors when possible.

Based on interview and record review the facility failed to provide a systematic approach to assess and evaluate residents' fluid status to monitor the effectiveness of interventions for 2 of 2 residents (R1 and R3) assessed. R1 and R3 were on a daily fluid restriction, the facility was documenting the intake. The facility did not have a system in place to evaluate the total daily fluid intake to determine adequacy or if the provider required notification. Findings include: R1's nursing progress notes dated 4/24/24 - 5/7/24 did not include any documentation regarding R1's fluid restriction, except on 4/25/24 at 1:29 a.m. a note indicated drank 300 cc. R1's physician orders dated 4/25/24 indicated P1 was on a fluid restriction of 1200 milliliters (ml) per day. 500 cubic centimeters (cc) day shift, 500 cc evening shift and 200 cc night shift. R1's care plan dated 4/26/24 indicated to monitor intake and record every meal. Staff was to provide and serve diet as ordered: Heart Healthy/regular textures and regular liquid. The care plan did not indicate R1 had a fluid restriction. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental status (BIMs) score of 15 indicating R1 was cognitively intact. R1 required maximum assistance with toileting hygiene, showering and dressing. She required moderate assistance with rolling in bed, positioning from sitting to lying and she was dependent from sitting to standing with transfers. R1 was dependent in her manual wheelchair. R1 was frequently incontinent of urine and bowel. R1's pertinent diagnoses were cirrhosis of the liver, acute respiratory failure with hypoxia, portal hypertension (increased pressure in the venous system), morbid obesity and type 2 diabetes mellitus with neuropathy (nerve damage from diabetes). R1's Point of Care response history for the task of fluids consumed indicated: 4/24/24 240 cc at 8:03 p.m. 4/25/24 400 cc at 8:49 p.m. 4/26/24 150 cc at 10:13 a.m. and 250 cc at 2:26 p.m. 4/27/24 400 cc at 10:07 a.m. and 380 cc at 1:07 p.m. 4/28/24 400 cc at 11:31 a.m. and 370 cc at 2:44 p.m. and 360 cc at 8:31 p.m. 4/29/24 400 cc at 9:52 a.m. and 390 cc at 1:10 p.m. and 480 cc at 8:54 p.m. 4/30/24 380 cc at 10:04 a.m. 5/1/24 360 cc at 2:23 p.m. and 560 cc at 2:23 p.m. [sic] 5/2/24 360 cc at 10:01 a.m. and 240 cc at 1:53 p.m. and 200 cc at 8:55 p.m. 5/3/24 480 cc at 9:18 a.m. and 240 cc at 1:53 p.m. 5/4/24 360 cc at 10:01 a.m. and 240 cc at 1:53 p.m. and 200 cc at 8:55 p.m. 5/5/24 360 cc at 2:42 p.m. and 420 cc at 2:42 p.m. 5/6/24 240 cc at 9:21 a.m. and 220 cc at 1:42 p.m. and 240 cc at 10:37 p.m. 5/7/24 400 cc at 9:33 a.m. R1's electronic treatment record (eTAR) dated 4/25/24 - 5/7/24 indicated R1's fluid intake was: 4/25/24 200 cc on the p.m. shift and 200 cc on the night shift 4/26/24 500 cc on the a.m. shift and 500 cc on the p.m. shift and 150 on the night shift 4/27/24 500 cc on the a.m. shift and 240 cc on the p.m. shift and 150 cc on the night shift 4/28/24 240 cc on the a.m. shift and 240 cc on the p.m. shift and 200 cc on the night shift 4/29/24 280 cc on the a.m. shift and 480 cc on the p.m. shift and 200 cc on the night shift 4/30/24 400 cc on the a.m. shift and 480 cc on the p.m. shift and 120 cc on the night shift 5/1/24 500 cc on the a.m. shift and 80 cc on the p.m. shift and 120 on the night shift 5/2/24 500 cc on the a.m. shift and 80 cc on the p.m. shift and 120 cc on the night shift 5/3/24 240 cc on the a.m. shift and 110 cc on the p.m. shift and 200 cc on the night shift 5/4/24 500 cc on the a.m. shift and 200 cc on the p.m. shift and 200 cc on the night shift 5/5/24 480 cc on the a.m. shift and 400 cc the p.m. shift and 200 on the night shift 5/6/24 480 cc on the a.m. shift and 400 cc on the p.m. shift and 100 cc on the night shift R1's Hospital emergency department (ED) note dated 5/7/24 at 11:11 a.m. indicated R1's chief complaint was abdominal pain. R1 had a history of pleural effusion (build-up of fluid between the lungs), and liver cirrhosis with ascites (fluid build-up in the abdomen) who presented to the ED for abdominal pain and bloating. On 5/7/24 at 12:00 p.m. R1 was diagnosed with severe sepsis (a life-threatening infection). R1's other admission to the hospital diagnoses were portal vein thrombosis, acute urinary tract infection, liver cirrhosis and pleural effusion. Clinically significant risk factors were hyperkalemia (high potassium in the blood), hypercalcemia (high calcium in the blood), hypoalbuminemia (a condition when the body doesn't produce enough albumin protein that's responsible for keeping fluid in your blood vessels). Upon interview on 5/13/24 at 11:46 a.m. R1 stated she was still in the hospital stating she had been admitted with portal vein hypertension, a urinary tract infection and a bunch of my labs were off. R1 stated she did not understand how the facility was managing her fluid restrictions. She stated no one talked to her about it, other than one unidentified nursing assistant (NA) told her that the fluids on her meals were planned out. R3's eTAR dated 4/14/24 - 5/13/24 indicated R3 had an order for a 1200 cc fluid restriction. The nursing staff did not documentation how much fluid R3 consumed during the shift. The nursing staff only checked the boxes indicating the fluid restriction was administered. R3's nursing progress notes reviewed from 4/4/24 - 5/13/24 did not have any documentation of a fluid restriction or intake measures. R3's care plan dated 4/8/24 indicated R3 was at risk for nutritional altercation related to dialysis. R3 had a renal-dialysis diet. Staff was to monitor food and fluid intake at meals and monitor for signs of dehydration. R3's care plan did not indicate any fluid restrictions. R3's Point of Care Response History for the tasks of fluid consumed dated 4/14/24 - 5/13/24 indicated: 4/14/24 480 cc at 10:11 a.m. and 480 cc at 1:59 p.m. and 550 cc at 10:19 p.m. 4/15/24 R3 not available in the a.m. and 200 cc at 1:04 p.m. 4/16/24 300 cc at 9:38 a.m. and 300 cc at 1:10 p.m. 4/17/24 R3 not available in the a.m. and 500 cc at 10:28 p.m. 4/18/24 360 cc at 11:00 a.m. and 360 cc at 2:12 p.m. and 300 cc at 10:13 p.m. 4/17/24 R3 not available in the a.m. and 500 cc at 10:28 p.m. 4/18/24 360 cc at 11:00 a.m. and 360 cc at 2:12 p.m. and 300 cc at 10:13 p.m. 4/19/24 R3 not available in the a.m. and 120 cc at 2:24 p.m. 4/20/24 480 cc at 11:04 a.m. and 240 cc at 2:21 p.m. and 120 cc at 7:08 p.m. 4/21/24 480 cc at 9:14 a.m. and 480 cc at 2:24 p.m. and 120 cc at 7:18 p.m. 4/22/24 R3 not available in the a.m. and 300 cc at 12:53 p.m. and 120 cc at 7:08 p.m. 4/23/24 300 cc at 9:17 a.m. and 300 cc at 1:03 p.m. and 120 cc at 7:39 p.m. 4/24/24 R3 not available in the a.m. and 200 cc at 1:18 p.m. and 500 cc at 10:05 p.m. 4/25/24 380 cc at 10:07 a.m. and 280 cc at 1:48 p.m. and 120 cc at 7:09 p.m. 4/26/24 R3 not available in the a.m. and 360 cc at 1:55 p.m. and 120 cc at 7:26 p.m. 4/27/24 240 cc at 1:17 p.m. and 180 cc at 1:18 p.m. and 120 cc at 6:32 p.m. 4/28/24 300 cc at 9:11 a.m. and 300 cc at 2:10 p.m. and 500 cc at 10:57 p.m. 4/29/24 R3 not available in the a.m. and 240 cc at 2:05 p.m. 4/30/24 300 cc at 9:10 a.m. and 300 cc at 2:10 p.m. and 550 cc at 10:57 p.m. 5/1/24 R3 not available in the a.m. and 300 cc at 2:22 p.m. and 120 cc at 6:46 p.m. 5/2/24 R3 not available in the a.m. and 240 cc at 1:12 p.m. and 120 at 8:02 p.m. 5/3/24 R3 not available in the a.m. and 250 cc at 2:11 p.m. 5/4/24 480 cc at 11:21 p.m. and 240 cc at 2:13 p.m. and 120 cc at 7:17 p.m. 5/5/24 390 cc at 9:08 a.m. and 400 cc at 2:14 p.m. 5/6/25 R3 not available in the a.m. and 300 cc at 1:07 p.m. 5/7/24 300 cc at 9:04 a.m. and 300 cc at 1:32 p.m. and 120 cc at 8:09 p.m. 5/8/24 R3 not available in the a.m. and 300 cc at 2:23 p.m. and 500 cc at 6:00 p.m. 5/9/24 360 cc at 10:48 a.m. and 200 cc at 2:01 p.m. and 120 cc at 7:46 p.m. 5/10/24 R3 not available in the a.m. and 120 cc at 7:11 p.m. 5/11/24 240 cc at 12:55 p.m. and 120 cc at 12:55 p.m. and 550 cc at 10:00 p.m. 5/12/24 300 cc at 8:59 a.m. and 300 cc at 1:02 p.m. and 550 cc at 6:12 p.m. 5/13/24 R3 not available in the a.m. R3's quarterly MDS dated [DATE] indicated R3 had a BIMs score of 15 indicating she was cognitively intact. R3 required extensive assistance with bed mobility and total dependence for transferring. R3's pertinent diagnoses were Asthma, respiratory failure, end stage renal disease and congestive heart failure. R3's clinical physician order dated 4/30/24 indicated R3 had a fluid restriction of 120 ml at nighttime, 180 ml in the a.m. and p.m. and 240 ml with meals. Upon interview on 5/13/24 at 1:23 R3 stated she wasn't certain how the facility monitored her fluid intake. She stated she has never had a discussion from the nursing or dietary department. R3 was a former health care professional and stated she watches her intake on her own. Upon interview on 5/13/24 at 1:45 p.m. LPN-A stated the nursing staff enforce fluid restriction by educating the residents and the nursing assistants. She was uncertain who is responsible for auditing the total daily intake and reporting to the provider if there are concerns. Upon interview on 5/13/24 at 1:54 p.m. RN-A the unit manager stated she was uncertain who manages the fluid restrictions. She stated, I think dietary does. Upon interview on 5/13/24 at 2:02 p.m. the assistant dietary manager stated the facility does not have a dietician currently, so the corporate dietician provides direction to the facility. She stated the Point of Care forms are where the NA's document after resident eats. The kitchen supplies fluid restriction residents with the order provided on their trays. She stated the eTAR where the nursing staff document the resident fluid intake with their medication administration. The manager was uncertain who monitored the fluid restrictions daily. Upon interview on 5/13/24 at 3:02 p.m. the director of nursing (DON) stated the dieticians are responsible for watching for an increase in fluid concerns with the residents. She stated the dialysis department watches the fluid levels for R3. The DON stated if the nursing staff were to notice any symptoms of a fluid concerns for a resident, they would report the concern to the dietician and/or the provider. The DON was unable to provide daily fluid totals for R1 or R3. Upon interview on 5/13/24 at 3:46 p.m. the corporate registered dietician (RD)-A stated she was new to her role and was not completely familiar with the process of fluid restriction. She stated she is aware the kitchen follows the restriction orders when placing beverages on the meal trays. She was not certain who was to be watching fluid restrictions at the end of the day. She stated she looks closely at the resident assessment and completes her own assessment quarterly for the MDS. The RD attempted to run a report on the Point Click Care (the facilities software system) to find daily intake totals and stated, I can't find this, it would be helpful, this is a concern. A facility policy titled Intake and Output Monitoring revision date of 12/13 indicated. -Enter Resident name and/or identification on the daily intake and output record. -Measure and record all liquids ingested. -Estimate and record ice and foods that becomes liquid at room temperature (i.e., ice cream, Jello). -Instruct Resident to urinate in bedpan, urinal, or collection graduate in toilet. -Measure urine and record amount on individual record. -If any bleeding, emesis, diarrhea, or drainage occurs, measure and record as output. -When enteral nutritional therapy, or intravenous fluid is administered record amount on individual record. -The intake and output are to be totaled and recorded in medical record every shift. -Intake and output are totaled every twenty-four hours. -The total I & O is placed in the Resident's medical record. -The nurse is responsible to evaluate the total I & O per shift. If the intake and output is not adequate, notify the MD/NP. -Take action per physician orders. -Licensed nurses will evaluate the resident's I & O on a 24-hour bases and weekly basis to determine adequacy.

Based on interview and record review the facility failed to promote dignity and respect to 1 of 4 (R1) residents reviewed. R1 was not properly dressed when leaving her room for therapy services. R1 did not have an incontinent brief on and upon standing urinated on herself, her wheelchair, and the floor in the presence of other residents and staff. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental status (BIMs) score of 15 indicating R1 was cognitively intact. R1 required maximum assistance with toileting hygiene, showering and dressing. She required moderate assistance with rolling in bed, positioning from sitting to lying and she was dependent from sitting to standing with transfers. R1 was dependent in her manual wheelchair. R1 was frequently incontinent of urine and bowel. R1's pertinent diagnoses were cirrhosis of the liver, acute respirator failure with hypoxia, portal hypertension (increased pressure in the venous system), morbid obesity and type 2 diabetes mellitus with neuropathy (nerve damage from diabetes). R1's care plan dated 5/4/24 indicated R1 required the assistance of one staff member to dress and undress. R1 had actual impairment to her skin bilaterally on her buttocks. The intervention was to wear no incontinent brief while in bed and be gentle with peri-cares. The care plan did not indicate what R1 was to wear for incontinence protection when she was out of bed. In addition, the care plan did not indicate to use towels for incontinence concerns while R1 was in bed. Upon interview on 5/13/24 at 9:46 a.m. occupation therapy assistant (OTA)-A stated she would go to R1's room to get her out of bed for therapy. R1 would be dressed in a hospital gown per her choice. She stated when staff would stand her up towels that were placed between R1's legs would fall to the floor. She stated that the therapy staff did not put a brief on her stating that the responsibility of the nursing staff. OTA-A did recall an incident in therapy where her and another therapy staff member were assisting R1 to stand and upon standing R1 became incontinent of urine on herself, her wheelchair, and the floor in the therapy room. R1 was immediately sat down in her chair, as a fall prevention, then was wheeled back to her room. OTA-A left R1 in her room and notified the nursing staff to assist her to be cleaned up. Upon interview on 5/13/24 at 11:41 R1 stated she was usually taken to therapy without anything covering her peri-area. She stated she was o.k. with wearing a hospital gown if staff dressed her in two gowns, one to cover the front and one to cover the back of her body. She stated one day in therapy the staff assisted her to stand by the parallel bars and upon impact her bladder released, and she urinated on herself, her wheelchair, and the floor. She stated she was sat down in the urine saturated chair and taken back to her room for clean-up. She stated she humiliated as other residents witnessed the event and staff as well. In addition, R1 stated some staff would place towels between her legs since she urinated so much in bed requiring frequent bed changes. Upon interview on 5/13/24 at 11:50 a.m. R1's family member (FM)-A stated he visited R1 almost daily and was present the day she was incontinent of urine with no urinary protection in therapy. He stated he stayed with R1 all afternoon as R1 could not stop crying because she was so humiliated. Upon interview on 5/13/24 at 12:17 p.m. registered nurse (RN)-A unit manager stated she was not aware of an incident where R1 became incontinent in therapy. She stated the therapy staff proceeded correctly after the incontinence episode by bringing R1 back to her room for nursing staff to clean her up. RN-A stated therapy staff can and should be dressing and making sure the residents leave their room in appropriate attire. She stated if they are uncertain of how to dress a person than they should ask the nursing staff. Upon interview on 5/13/24 at 12:29 p.m. RN-B stated she had worked with R1 and stated she was unaware that staff were placing towels between her legs and unaware or R1 was going to therapy without an incontinent brief on. She stated the facility uses blue pads that wick away moisture from incontinent patients to assist in avoiding bed changes. RN-B was unaware of the incontinence incident therapy, stating therapy staff should be putting an incontinence brief on a resident if they are not wearing one before taking them out of their room. Upon interview on 5/13/24 at 12:45 p.m. physical therapy assistant (PTA)-A stated RN would not wear an incontinent brief in bed and therapy would find her in bed with towels between her legs. She stated after the day R1 became incontinent during a therapy session she would make sure R1 had an incontinence brief on before taking her out of her room. Upon interview on 5/13/24 at 3:02 p.m. the director of nursing (DON) stated she was aware that R1 was to be left in bed without anything covering her peri-area for skin healing. She stated she would not expect staff to be placing towels on R1, but rather be checking and changing her wicking pad. The DON stated that therapy has been trained and should be part of morning cares including insuring residents leave their room in proper attire. A facility policy titled Dignity with a revision date of 10/21 indicated the facility promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. This means staff must carry out activities which assists the resident to maintain and enhance his/her self-esteem and self-worth. Assisting residents to dress in their own clothes appropriate with time of day and individual preferences.

Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 2 of 2 residents (R2, R35) reviewed for urinary catheters. Findings include: R2 R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition, dependence on staff for all efforts of self-care including all forms of hygiene, bathing, upper and lower body dressing, positioning and mobility. Also, indicated R2 had an indwelling catheter. R2's Diagnoses Report dated on 1/31/24, indicated R2 had diagnoses of multiple sclerosis (disabling disease of the brain and spinal cord), diabetes, depression, neuromuscular dysfunction of the bladder, and quadriplegia (paralysis of both upper and lower body). R2's physician orders (PO) dated 8/22/23, indicated R2, admitted to AccentCare Fairview Hospice on 8/22/23, with terminal Dx [diagnosis] of MS [multiple sclerosis] with life expectancy of 6 months or less. R2's care plan with a review date of 5/4/23 indicated, Foley catheter bags must be placed in a drainage bag holder. R2's kardex (nursing assistant care sheet) printed 1/31/24 indicated, Foley catheter bags must be placed in a drainage bag holder. During observation on 1/30/24 at 8:29 a.m., R2 was laying in bed with a large catheter drainage bag attached to the bed frame facing the doorway to the facility hallway. The top half of R2's catheter drainage bag was covered in a privacy bag while the lower half of the catheter drainage bag was uncovered showing dark amber urine visible from the facility hallway. During interview with nursing assistant (NA)-A on 1/30/24 at 11:18 a.m., NA-A stated resident catheter drainage bags were to be covered at all times, even in the [bed]room. NA-A stated the facility provides privacy covers for all residents with catheter drainage bags. During interview with family member (FM)-A on 1/20/24 at 1:25 p.m., FM-A stated R2's catheter drainage bag, should always be covered and R2, would not like it if his pee was visible. During interview with R2 on 1/30/24 at 2:04 p.m., R2 stated, yes it [catheter drainage bag] is sometimes uncovered when I am in bed. I don't like. It should be covered. During interview with NA-C on 1/31/24 at 8:59 a.m., NA-C stated the expectation of nursing assistants was to review resident kardex's upon arrival to work each shift, tells us what the resident needs. R35 R35's annual MDS dated [DATE], indicated R35 with total dependence on staff for all efforts of self-care including all forms of hygiene, bathing, upper and lower body dressing, positioning and mobility. Also, R35 had an indwelling catheter. R35's Diagnosis Report printed 12/31/24, indicated R35 had diagnoses of Alzheimer's disease, dementia, obstructive and reflux uropathy (a condition where urine flows backward, or refluxes, into the kidneys) and retention of urine. R35's care plan intervention revised on 10/12/22, indicated, Ask simple yes/no questions or simple short questions to determine needs. R35's kardex printed 1/31/24, indicated, Catheter care every shift and as needed. During observation on 1/29/24 at 1:24 p.m., R35 was observed to be sleeping in bed with an uncovered catheter drainage bag attached to bed frame facing the doorway to the facility hallway. During observation on 1/29/24 at 4:08 p.m., R35 was observed to be sleeping in bed with an uncovered catheter drainage bag attached to bed frame facing the doorway to the facility hallway. During observation on 1/30/24 at 10:43 a.m., R35 was observed to be sleeping on left side in bed with an uncovered catheter drainage bag attached to bed frame facing the doorway to the facility hallway. During observation and interview with R35 on 1/30/24 at 1:21 p.m., R35 was observed to be laying in bed with an uncovered catheter drainage bag attached to bed frame facing the doorway to the facility hallway. R35 nodded her head up and down when asked if it bothered her to have her catheter drainage bag uncovered and visible to the facility hallway. During observation on 1/30/24 at 3:02 p.m., R35 was observed to be in bed with an uncovered catheter drainage bag attached to bed frame facing the doorway to the facility hallway. Registered nurse (RN)-A was observed to exit R35's room with vital sign machine. During observation and interview on 1/31/24 at 8:14 a.m., R35 up in wheelchair positioned at dining room table for breakfast. R35's catheter drainage bag was attached to underside of wheelchair and uncovered with urine visible in the catheter drainage bag. Seven other residents were seated in the dining room at the time. NA-B stated R35's catheter drainage bag, is uncovered and stated, it should be covered because it is a dignity issue. During interview with RN-A on 1/31/24 at 8:25 a.m., RN-A stated R35's catheter drainage bag, is visible to other residents, staff, and visitors in the dining room. RN-A stated the expectation of facility staff is to place the catheter drainage bag, in a privacy bag so the other people don't look at it. During interview with director of nursing (DON) on 1/31/24 at 10:06 a.m., the DON stated expectation of catheter drainage bags to be covered, at all times. Even when resident is in the room. Facility policy titled Catheter Care, revised 9/23 state, It is the policy of this facility to provide care to the individual who must use an indwelling catheter with care that meets the necessary standards of infection control and dignity. Also, All foley catheter bags must be placed in a drainage bag holder.

Based on observation, interview, and document review, the facility failed to provide weekly baths to 1 of 1 resident (R26) reviewed for activities of daily living. Findings include, R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 had moderate cognitive impairment, verbal behaviors directed toward others and no refusal of cares. MDS indicated R26 needed set up or clean-up for eating; moderate assistance with oral hygiene; maximal assistance with dressing, personal hygiene, toileting, bathing; total dependency to put on shoes, and unable to ambulate. R26's Admission Record dated 2/1/24, indicated R26 had diagnoses of vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to the brain), major depressive disorder, gastro-esophageal reflux disease (chronic disease that occurs when stomach acids or bile flows back into the tube connecting your mouth and stomach), abnormalities of gait and mobility, chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breath) , chronic pain and history of transient ischemic attack (temporary period of symptoms similar to those of a stroke that usually lasts a few minutes and doesn't cause permanent damage) and cerebral infarction (area of damaged tissue on the brain) without residual deficits. R26's undated care plan indicated R26 had an activities of daily living (ADL) self-care performance deficit. The care plan indicated R26 needed assistance with bathing and all personal hygiene, including shaving. The care plan also indicated R26 often refuses showers. R26's Kardex (an electronic document used to describe residents need for assistance with ADLS) dated 2/1/24, indicated R26 needed assist of one for bathing, and personal hygiene including shaving. R26's electronic medical record on Point Click Care (PCC) under the bathing task for the month of January 2024, lacked documentation whether R26 had a shower or refused a shower. This information was verified by registered nurse (RN)-A. R26's progress notes between 11/1/23 and 1/31/24, had two entries related to bathing. A note dated 1/4/24 indicated R26 refused to shower, and a second note dated 1/25/24 indicated R26 was physically aggressive during her shower. During observation on 1/29/24 at 4:46 p.m., R26's hair appeared dull and the hair on the top of her head was separated in greasy locks of hair. During observation on 1/30/24 at 11:34 a.m., R26's hair was combed however her hair still appeared unwashed and oily. During interview on 1/30/24 at 11:44 a.m., RN-A verified R26's hair appeared greasy. RN-A stated the nursing assistants documented baths on PCC's bathing task. RN-A reviewed the January documentation on PCC's bathing task and there was no documentation indicating R26 had a shower or refused a shower during the month of January. During interview on 1/30/24 at 11:53 a.m., nursing assistant (NA)-F stated she had worked at facility for two months and during that time R26 had never been aggressive during personal cares. NA-F said, some staff say R26 is aggressive, but I believe it depends on how they [staff] approach her [R26]. During interview on 1/31/24 at 12:26 p.m., nurse manager-licensed practical nurse (LPN)-B stated nursing assistants documented baths in PCC under the bathing task and expected NAs documented refusals of shower under that task. LPN-B also indicated the NA should notified the nurse if a resident refused to shower, and the nurse was expected to note the refusal in a progress note. During interview on 2/1/24 at 9:41 a.m., director of nursing (DON) stated baths and refusal of baths needed to be documented. DON stated it was a dignity concern when a resident was not properly groomed. DON also stated the nursing staff should assess residents' preferences and accommodate baths as necessary. Facility's policy titled Bath, Shower dated 11/9/22 indicated the purpose was resident feels cleansed and refreshed. The procedure included shampoo hair and document bath.

Based on observation, interview and record review, the facility failed to ensure call lights were accessible for 1 of 1 (R35) reviewed for call light accessibility. Findings include: R35's annual Minimum Data Set (MDS) dated [DATE], indicated R35 had total dependence on staff for all efforts of self-care including all forms of hygiene, bathing, upper and lower body dressing, positioning and mobility. Also, had R35 an with indwelling catheter. R35's Diagnosis Report dated 12/31/24, indicated R35 had diagnoses of Alzheimer's disease, dementia, obstructive and reflux uropathy (a condition where urine flows backward, or refluxes, into the kidneys) , and retention of urine. R35's care plan documented an intervention initiated on 12/31/19, which indicated, Be sure call light is within reach and encourage to use it for assistance as needed. During observation on 1/29/24 at 1:52 p.m., R35 was observed laying in bed with the call light on the floor out of reach. During observation 1/29/24 at 4:08 p.m., R35 was observed laying in bed with the call light on the floor out of reach. During observation on 1/30/24 at 1:32 p.m., R35 was observed laying in bed with the call light on the floor out of reach. During observation on 1/30/24 at 2:06 p.m., R35 was observed laying in bed with the call light on the floor out of reach. During observation and interview on 1/31/24 at 10:22 a.m., R35 was obserbed sitting in a wheelchair R25's bedroom facing away from the hallway. The call light was coiled up under her bed and out of R35's reach. Nursing assistant (NA)-D entered R35's room and stated the, call light is on the floor and out of reach. And, [R35] needs it to call for help if R35 needs it for her safety. During interview with director of nursing (DON) on 1/31/24 at 9:58 a.m., DON stated call lights, should be in reach of the patient for access. Facility policy titled Call Lights with revision 4/23 state, Position call light conveniently within reach for the resident to use.

Based on observation, interview and document review, the facility failed to ensure a provider was notified in a timely manner of a change in status for 1 of 1 resident (R15) reviewed for change in condition. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 had severe cognitive impairment, had no behaviors, didn't refused cares, and was dependent for dressing, showers, and personal hygiene. MDS also indicated R15 needed substantial assistance to stand up, with transfers and needed assistance to set up meals. R15's Admission Record dated 2/1/24, indicated diagnoses of polyosteoarthritis (condition characterized by joint pain and stiffness), moderate vascular dementia with agitation, idiopathic gout (a condition caused by too much uric acid in the body which causes swelling and pain around the affected joint), essential hypertension (an abnormally high blood pressure that's not the result of a medical condition), atherosclerotic heart disease (damage or disease in the heart's major blood vessels), moderate protein-calorie malnutrition , type 2 diabetes with diabetic autonomic polyneuropathy (damage to nerves that control internal organs and can lead to heart, blood pressure and digestive system problems). R15's Order Summary dated 9/18/23 indicated, Complete weekly bath and pain assessment in PPC (Point Click Care/electronic record). If any new alterations in skin integrity, follow the skin alterations and wounds checklist. R15's Weekly Skin and Pain assessment dated [DATE] and 1/30/24, identified bruises in R15's right and left palm. R15's progress note dated 12/9/23 indicated R15's left wrist was swollen, bruised and painful. On 12/10/23 resident was started on 4 milligrams of Methylprednisolone every morning for 4 days. R15's progress notes between 12/12/23 and 1/30/24 lacked documentation regarding R15's left bruised swollen hand, and/or contacting family or provider. The first note documenting R15's left hand concern was on 1/31/24 after the charge nurse was made aware of R15's left swollen hand. Medical record review indicated R15 had not been seen by her provider since or after 1/23/24. During observation on 1/29/24 at 4:13 p.m., R15 was in the dining room, seated in her wheelchair. R15 was folding a napkin, her left hand was swollen, and the lateral aspect of her hand had a light purple color. During observation and interview on 1/30/24 at 12:57 p.m., R15 was in the dining room. R15's left finger and the left exterior part of her hand and left side of her palm were swollen and light purple. R15 used her left hand to grab a cup of coffee, winced and proceeded to use both hands to hold the cup. R15 stated her left hand hurt. R15's right hand was not swollen or bruised. During observation and interview on 1/31/24 at 7:32 a.m., nursing assistant (NA)-F helped R15 put on a sweater and R15 pulled her left hand away. NA-F stated R15's hand had been swollen since she started working at the facility two months ago. During interview on 1/31/24 at 7:33 a.m., R15 stated I fell two weeks ago and hurt myself when a heavy furniture fell over on me. R15 was able to move her left hand and wiggled her fingers and said, it hurts. During interview on 1/31/24 at 7:47 a.m., charge nurse-registered nurse (RN)-D stated R15 had a fall on 1/27/24 but the fall assessment had no documentation about R15's swollen hand. RN-D stated when a new bruise, skin tear or any other skin issue was identified, the nurses needed to measure the affected area, enter a progress note, complete a risk management assessment in PCC and report to the manager or director of nursing (DON). RN-D stated any new concern needed to be immediately reported, investigated, and the doctor and family needed to be updated. During observation and interview on 1/31/24 at 7:58 a.m., RN-D assessed R15's left hand and arm and stated, her left hand is swollen, discolored and has edema from her wrist up to her elbow. RN-D asked R15 if she was in pain. R15 stated yes and rated her pain at 6 on the scale of 1 to 10. RN-D stated he needed to complete the risk management assessment and call the nurse practitioner (NP) and family. During interview on 1/31/24 at 8:31 a.m., RN-A stated when a new skin impairment area was identified, the nurse manager and DON needed to be informed right away. During interview on 1/31/24 at 10 a.m., RN-D stated he called the NP on 1/31/24 and based on R15's symptoms and medical history of gout, the nurse practitioner (NP) ordered prednisone (treats conditions associated with inflammation) 4 milligrams (mg) every day for 5 days for swelling, furosemide (treats fluid retention/edema) 20 mg for 3 days for edema, and instructed staff to use pain medications as needed for left hand pain. RN-D stated that he had talked to R15's son and updated him about R15's swollen hand and NP orders. During interview on 1/31/24 at 12:00 p.m., nurse manager-licensed practical nurse (LPN)-B stated the Weekly Skin and Pain Assessment was completed on shower days, and a risk management assessment was needed to be completed if a new area of concern was identified. LPN-B stated the managers and director of nursing (DON) reviewed the risk management assessments and completed investigations when necessary. LPN-B was not aware of R15's swollen hand and verified the left-hand bruise was identified on the skin weekly assessments dated 1/23 and 1/30. LPN-B verified a risk management assessment was not completed on 1/23/24 or 1/30/24. On 1/31/24 at 1:30 p.m. attempted to contact R15's family member, left voice mail but didn't receive a call back. During interview on 2/1/24 at 8:38 a.m. NP stated on 1/31/24 she was informed for the first time by the facility about R15's swollen hand. NP stated she was not aware R15's had a swollen hand until 1/31/24 and when she was informed she ordered interventions for the left hand. NP stated it was important for her to know about the change in condition in a timely manner to start treatment as soon as possible and added R15 is due for a visit. During interview on 2/1/24 at 9:31 a.m., the DON stated the nurses needed to complete a risk management assessment, write a progress note, and notify family and provider. DON stated the nursing staff needed to be re-educated regarding completion of risk assessments and provider notification, also, any new concerns needed to be identified, investigated, and reported as necessary. Facility's undated Skin Alterations and Wounds checklist and the facility's policy titled Management of Skin alterations dated 10/6/22 indicated, With the identification of any change in skin integrity, a checklist for skin alteration and wound will be implemented. Policy directed staff to notify nursing management, NP/MD, resident and/or resident representative, dietician. Policy also directed staff to use standing house orders or orders from NP/MD, to complete weekly documentation and measurements as indicated and to inform nursing assistants of resident changes in skin integrity and changes in interventions via the electronic health record.

Based on interview and document review, the facility failed to comprehensively assess, develop, and implement interventions for ongoing weight loss for 1 of 1 resident (R15) reviewed for weight loss. Findings include, R15's quarterly Minimum Data Set (MDS) dated [DATE] indicated, R15 had severe cognitive impairment, had no behaviors, didn't refused cares, and was dependent for dressing, showers, and personal hygiene. MDS also indicated R15 needed substantial assistance to stand up, transfer and needed assistance to set up her meal. R15's Admission Record dated 2/1/24, indicated diagnoses of polyosteoarthritis (condition characterized by joint pain and stiffness), moderate vascular dementia with agitation, idiopathic gout (a condition caused by too much uric acid in the body which causes swelling and pain around the affected joint), essential hypertension (an abnormally high blood pressure that's not the result of a medical condition), atherosclerotic heart disease (damage or disease in the heart's major blood vessels), moderate protein-calorie malnutrition , type 2 diabetes with diabetic autonomic polyneuropathy (damage to nerves that control internal organs and can lead to heart, blood pressure and digestive system problems). R15's Order Summary dated 9/18/23, indicated a regular textured diet. R15's MDS dated [DATE] indicated resident weighed 101 pounds compared to 116 lbs on 12/24/22 which was a significant weight loss of 11% in 6 months compared to 116lbs on 12/24/22. The MDS dated [DATE] indicated R15 weighed 88 pounds which was a loss of more than 5% over the last 3 months. R15's Treatment Assessment Record (TAR) dated January 2024 indicated a weight of 82.6 pounds on 1/23/24 which represented a weight loss of 6.14% in 5 months and a 18.22% weight loss since 5/7/23. R15's Nutritional Care Plan with a review start date of 2/2/24, indicated R15 has a nutritional problem related to significant weight loss the past 6 months. Dx [diagnosis]; dementia. Receives hospice care. Care plan interventions indicated to monitor, record and report to doctor as needed for symptoms of malnutrition, emaciation, muscle wasting and significant weight loss. Care plan also indicated registered dietician and/or dietician technician will do a Nutrition Risk Monitoring. During interview on 1/31/24 at 9:43 a.m., registered dietician (RD) stated when a resident was on hospice, the facility will not necessarily implement or use nutritional supplements to allow the natural process to progress. RD stated R15 was not receiving nutritional supplements. RD stated the dietary technician completed the nutritional section of the MDS but had failed to complete a nutritional assessment since 5/23/23. RD stated the nutritional assessment which is documented in PCC should have been done. Attempted to interview family member, left voice mail with contact information but R15's son did not call back. During interview on 2/1/24 at 8:38 a.m., nurse practitioner (NP) stated the nutritional assessment was done quarterly and was concerned since the last assessment was done on 5/23/23. NP stated if the assessments were not done, the resident was not properly assessed, and her plan of care was not reviewed or adjusted. During interview on 2/1/24 at 9:38 a.m., the director of nursing (DON) stated nutritional assessments needed to be done quarterly. DON stated the concern for residents with ongoing weight loss was the lost opportunity to implement residents' preferred food which could improve their quality of life, even when weight loss was unavoidable. Facility's policy titled Initial Clinical Nutrition Visit and Clinical Nutrition assessments dated 7/2019 indicated residents will have nutritional assessments completed upon admission/readmission, quarterly, annually and in case of Significant Change of status to determine nutritional risk and plan of care.

Based on interview and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded before administration of as-needed (PRN) narcotic medication to reduce the risk of potential complications for 2 of 2 residents (R36, R264) reviewed for unnecessary medication use. Findings include: R36 R36 ' s quarterly Minimum Data Set (MDS) dated [DATE], indicated R36 had intact cognition and was diagnosed with anxiety, depression, and schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). The MDS indicated that R36 required substantial assistance with transfers, dressing, and personal hygiene and received opioids (narcotic pain medication) in the look-back period (LBP). The MDS indicated that R36 received PRN pain medication and scheduled pain medication but did not receive non-medication pain interventions during the LBP. The MDS indicated that R36 frequently had pain and this pain frequently affected her sleep. R36's care plan dated 10/20/23, indicated that R36 was on pain medication therapy with a goal of no discomfort or adverse side effects. The following interventions were included in the pain plan: administer analgesic medications as ordered, monitor for increased risk for falls and adverse reactions to medications, and encourage R36 to report pain at onset. The care plan did not address non-pharmacological pain interventions. R36's Medication Administration Record (MAR) dated 1/1/24 - 1/31/24, indicated that R36 had the following PRN pain medications available: - A half 5-325 milligram (mg) tablet of hydrocodone-acetaminophen (narcotic pain medication) for pain scores ranging from six to 10/10 and available up to twice a day. This medication was given on seven occasions (1/1/24, 1/3/24, 1/4/24, 1/5/24, 1/12/24, 1/16/24, and 1/29/24) for pain ranging from seven to nine out of ten. - 650 mg of acetaminophen (non-narcotic pain medication) was available up to 4 times a day for pain ranging from one to five out of 10 and was not given as a PRN medication during this period. - Two grams of diclofenac sodium gel (topical medication used for pain control) (active from 12/7/23-1/18/24) applied to the calves, abdomen/sides, and neck was available every 12 hours and was not given as a PRN medication. R36's treatment administration record (TAR) dated 1/1/24-1/31/24, indicated that staff should attempt non-pharmacological interventions before giving R36 medication, such as: encouraging expression of feelings, medication/muscle relaxation, encouraging deep breathing, distraction, music, warm blanket, calling family, or a back rub, indicated that none or zero of these interventions were attempted on 1/1/24, 1/3/24, 1/4/24, 1/5/24, 1/12/24, 1/16/24, and 1/29/24. The treatment administration record contained the following scheduled nonpharmacological interventions: elevating and applying compression socks to the right lower leg for pain and swelling. R36's progress notes for the period of 1/1/24- 1/31/24, were reviewed and did not indicate that non-pharmacological interventions had been attempted before administering PRN narcotic medication during this period. During an observation and interview on 1/29/24 at 2:46 p.m., R36 was observed sitting in her wheelchair in her room with her knees at a 90-degree angle and her feet planted on her wheelchair pedals below her. R36 stated that she had issues with pain, especially on the right side of her body and both of her legs. R36 stated that staff occasionally gave her pain medication but did not recall staff attempting any non-pharmacological interventions but she would have been open to this. During an interview on 2/1/24 at 10:51 a.m., registered nurse (RN)-B stated that R36 had a history of pain in both of her legs and her neck and it normally occurred at night and she worked mostly day shifts. RN-B stated that when R36 had pain she was given pain pills as an intervention. RN-B stated she was unsure what other interventions were done but thought an ice pack or repositioning could have been helpful interventions. RN-B stated that if nursing staff had attempted these, they would have been charted in the progress notes. R264 R264's admission MDS dated [DATE], indicated that R264 had mildly impaired cognition and required substantial assistance with transferring, dressing, and personal hygiene. The MDS indicated that R264 received opioids in the LBP. The MDS indicated that R264 frequently had pain and this pain frequently interfered with her sleep and day-to-day activities. The MDS indicated that R264 received PRN (as needed) pain medication and scheduled pain medication but did not receive non-medication pain interventions during the LBP. R264's diagnostic report dated 1/16/24, indicated R264 was diagnosed with diabetes, muscle weakness, a left hip fracture, and a vertebrae (back bone) fracture. R264's care plan dated 1/16/24, indicated that R264 had limited physical mobility related to weakness and pain from her hip fracture, vertebrae fracture, and left leg blood clot. The care plan indicated R264's goal was to verbalize adequate pain relief and the ability to cope with pain when not fully relieved. The care plan indicated that staff should have assessed for R264's pain, the affected extremity should have been elevated as necessary, and ice or cold compresses used PRN, as well as the use of pain medication. R264's medication administration record (MAR) dated 1/16/24-1/30/24, indicated R264 had the following as-needed (PRN) pain medications available: - 650 mg of acetaminophen every four hours that was given twice from 1/16/24-1/29/24 for the pain of six and nine out of 10. - 650 mg of acetaminophen available every eight hours that was given three times for pain levels of three, seven, and eight out of 10. - 2.5 mg of oxycodone was available every four hours for pain ratings of three to six out of 10 and was given 22 times for pain ranging from three to eight out of 10. This medication was received on 1/20/24 and every day from 1/22/24-1/30/24. - Five mg of oxycodone was available every four hours for a pain rating of seven to ten out of ten and was given 34 times for pain ranging from four to nine out of 10. This medication was administered every day from 1/16/24-1/31/24 except for 1/22/24 and 1/26/24. R264's progress notes dated 1/16/24-1/31/24, were reviewed for non-pharmacological pain interventions usage and were not found for the following dates with corresponding oxycodone administration: 1/16/24 (1 dose), 1/17/24 (4 doses), 1/18/23 (3 doses), 1/20/24 (3 doses), 1/21/24 (4 doses), 1/23/24 (4 doses), 1/24/24 (3 doses), 1/25/24 (4 doses), and 1/30/24 (4 doses). The TAR dated 1/16/24-1/31/24, did not indicate non-pharmacological pain interventions for R264 had been ordered or completed. During an observation and interview on 1/31/24 at 10:11 a.m., R264 was observed sitting in her wheelchair in her room. R264 stated that she had pain throughout her left leg because she had just been transferred back to her wheelchair from the bathroom and her left foot had not been placed in a comfortable position. Registered nurse (RN)-C was observed entering R264's room and asked R264 how she would rate her pain. R264 stated that her pain was at a seven out of 10 and RN-C stated she would double-check R264's PRN pain medication order. RN-C left the room and R264 stated that repositioning her leg would have been helpful for her pain. RN-C was observed to knock on R264's door and re-enter her room. RN-C stated that she had brought her five milligrams of oxycodone which she administered to R264 on a spoon. RN-C was not observed to offer repositioning or other non-pharmacological pain interventions before administrating the PRN oxycodone. During interview on 1/31/24 at 10:22 a.m., RN-C stated R264's pain was due to a left hip fracture from a fall. RN-C stated that she had not attempted a non-pharmacological pain intervention before administering the PRN oxycodone because R264 had a high pain level, and she did not think it would have been helpful. RN-C stated that she was unsure where they charted when non-pharmacological pain interventions were attempted before administering pain medication but that when non-pharmacological pain interventions were completed throughout the shift, nursing staff documented these in the nursing progress notes. During interview on 1/31/24 at 11:26 a.m., nurse practitioner (NP)-A stated that R264 received Tylenol and oxycodone to assist with her pain. NP-A stated that nursing staff should have always been offering and attempting non-pharmacological pain interventions before giving the narcotic pain medication to assist residents with managing their pain. NP-A stated that R36 had a history of multifactorial pain in her legs and neck. NP-A stated that R36 had been to a pain clinic and a clear source of her pain had not been found and, related to this, non-pharmacological pain interventions such as distraction and ice could have benefited R36 and should have been attempted before administering narcotic pain medication. During interview on 2/1/24 at 10:31 a.m., the director of nursing (DON) stated nursing staff should have assessed if a resident would like something such as a cold or hot pack before administering PRN pain medication, but if the resident had a high pain level that may not have been appropriate. The DON stated that with orthopedic pain, such as hip pain, interventions such as ice or repositioning would have likely been effective in treating pain. The DON stated that non-pharmacological pain interventions were also an important part of decreasing the likelihood of opioid dependency and helping the resident wean off the opioids when appropriate. The facility's Pain Management policy dated 10/6/22, indicated that all residents had the right to appropriate pain assessment and pain management. The policy indicated that non-pharmacological pain interventions should have been considered for new onset of pain. The policy indicated that the lowest possible effective dose of opioids should have been used for the shortest amount of time possible.

Based on observation, interview and document review, the facility failed to ensure coordinated services were documented as scheduled for 1 of 1 resident (R70) reviewed for hospice services. Findings include: R70's significant change Minimum Set Data (MDS) dated [DATE], indicated R70 had severe cognitive impairment, needed supervision to eat, required maximal assistance with oral hygiene and was dependent for toileting, bathing, dressing, personal hygiene, transfers, and repositioning in bed. MDS also indicated R70 had no behaviors and did not refuse personal cares. MDS indicated R70 was on hospice and had diagnosis of atrial fibrillation (irregular heart rhythm that can lead to blood clots in the heart), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), anxiety, and depressive disorder. R70's undated care plan indicated R70 had a terminal diagnosis related to Parkinson's disease and was enrolled in hospice care. Care plan indicated hospice will provide the following services: registered nurse (RN), social worker, chaplain, music therapy, massage, pet therapy, hospice physician, nurses, home health aides, other counselors, and trained volunteers. The care plan also indicated work with nursing staff to provide maximum comfort. A hospice document titled IDG (inter-disciplinary group) Meeting Review dated 1/10/24, indicated CNA (certified nursing assistant) once a week for 13 weeks starting 11/8/23 with an end date of 2/3/24. Hospice chart lacked any documentation of CNA's visits. During interview on 1/30/24 at 2:45 p.m., nurse manager-registered nurse (RN)-E stated R26 enrolled in hospice on 11/8/23. RN-E also stated hospice had a binder for each resident used to document their visits. RN-E verified there was no documentation of CNA visits since 11/8/23 in the hospice chart or facility documentation. During telephone interview on 1/30/24 at 3:11 p.m., hospice nurse case manager (HM) stated the IDG meeting reviews were attended by all disciplines and conducted every two weeks to discuss residents' status, care plan, goals, and interventions. HM stated she was revising R70's information in their hospice records and verified R70 had orders for CNA, RN/LPN, and social worker services. HM indicated the CNAs should document their visits on the hospice chart (hospice binder) and according to R26's care plan CNA visits were to be done once a week. During interview on 2/1/24 at 9:51 a.m., director of nursing (DON) stated the contractors should be entering a report on their chart and also provide a verbal report after their visits. DON expected the nurse managers to review the hospice documentation and address any concerns with providers. DON also stated, the lack of surveillance could negatively impact residents due to poor coordination of care. Facility's policy titled Hospice Care and Referrals in SNF dated 1/2020, indicated Under a written agreement the facility will work with the Hospice in following direction regarding end-of-life care and provide 24-hour room and board, meet the resident's personal care and nursing needs in coordination with the hospice ensuring that the level of care provided is appropriately based on the individual resident's needs.

Based on observation, interview, and document review, the facility failed to ensure the required nurse staffing information contained accurate staffing information. This had the potential to affect all 109 residents residing in the facility and/or visitors who may wish to view the information. Findings include: The facility staff postings dated 1/1/24- 1/29/24, all indicated that on the day shift the facility had three nurse managers, 13 (104 hours) nursing assistants (NA), and one (eight hours) trained medication aide (TMA), three (24 hours) licensed practical nurses (LPN), six (48 hours) registered nurses (RN). The staff postings also indicated that on the evening shift the facility had 13 (104 hours) NAs, four (32 hours) LPNs, and eight (64 hours) RNs. The staff postings indicated that on night shifts they had eight (64 hours) NAs, one (eight hours) LPN, and four (32 hours) RNs. The staffing report dated 1/26/24, indicated 12 NAs, five LPNs, and six RNs worked direct care hours on the day shift. The report indicated that 14 NAs, five LPNs, and six RNs worked direct care hours on the evening shift. The report indicated that eight NAs, two LPNs, and three RNs had direct care hours on the night shift. The staffing report dated 1/27/24, indicated 13 NAs, one TMA, three LPNs, and eight RNs worked direct care hours on the day shift. The report indicated that 12 NAs, five LPNs, and six RNs worked direct care hours on the evening shift. The report indicated that eight NAs, one LPN, and four RNs worked direct care hours on the evening shift. The staffing report dated 1/28/24, indicated 12 NAs, two TMAs, two LPNs, and eight RNs worked direct care hours on the day shift. The report indicated that 13 NAs, five LPNs, and six RNs worked direct care hours on the evening shift. The report indicated that seven NAs, one LPN, and four RNs had direct care hours on the night shift. During observation and interview on 1/30/24 at 12:49 p.m., a stack of approximately 25 staff postings with a blank to add the current date and census was observed to have the staffing numbers listed above for 1/1/24-1/29/24. The lead receptionist (LR) stated that she used the same formatted staff posting document every day. The LR stated that she used these staff postings, pointed at the stack, and updated them with the current date and census number every morning, but the staffing numbers stayed the same. During an interview on 1/31/24 at 1:57 p.m., the staffing coordinator (SC) stated that her process for the staff posting prior to the start of the survey was printing out a sheet that contained their standard staffing levels and having that posted every day. The SC stated that RN and LPN levels occasionally fluctuate and would not have been demonstrated on the staff posting. The SC stated that she had been completing the staff posting incorrectly and should have been updating the posting as necessary with the accurate staffing numbers. During an interview on 2/1/24 at 10:33 a.m., the director of nursing (DON) stated that the staff posting template should have been updated to display the correct number of staff and hours every morning and if changes occur during the day, the staff posting should have been updated in the afternoon as well. The facility's Nursing Staffing Hours policy dated 10/23, indicated that they must post the total number and actual hours worked by RNs, LPNs, and NAs directly responsible for resident care during each shift. The policy indicated this posting should have been updated at the start of each shift to reflect actual numbers of staff and corresponding hours.

Based on interview and document review, the facility failed to follow a functional maintenance program (FMP) for 1 of 2 residents (R94) reviewed for rehabilitation/restorative services. Findings include: R94's admission Minimum Data Set assessment dated [DATE], indicated R94 was cognitively intact and required one-person physical assistance to walk in corridor using a walker. R94 did not exhibit rejection of cares and his diagnoses included type 2 diabetes with neurological complications, history of stroke, osteoporosis, recent Covid-19, and muscle weakness. R94's care plan revised 11/2/22, identified R94 had limited physical mobility due to physical deconditioning and adult failure to thrive. R94's care plan identified his goal was to demonstrate the appropriate use of 2WW (2-wheel walker) to increase mobility. R94's Nursing/Rehab/Restorative intervention included a walking program to ambulate approximately 30-50 feet with FWW (front wheel walker) and contact guard assistance (CGA) and wheelchair (w/c) to follow. R94's Walking/Ambulation Program Guidelines Restorative Nursing/Functional Maintenance Recommendations dated 11/16/22, indicated R94's baseline ambulation ability was 30-50 feet with a FWW with w/c to follow. R94's program goal was to maintain ability to walk. During an interview on 12/19/22, at 1:33 p.m. R94 said he wanted to walk but no one ever offered to walk with him. R94 stated he was not aware of a walking program and thought he would have to pay additional money for such a program. R94's physical therapy (PT) discharge note dated 11/16/22, indicated R94's functional mobility assessment at time of discharge from PT was able to ambulate 50 feet with two turns under supervision or touching assistance. The PT note indicated discharge recommendations, For CGA with all aspects of mobility in order to maintain safe environment and to reduce falls risk. Recommended home PT once pt [patient] transitions to ALF [assisted living facility] and while within LTC [long term care] facility FMP [functional maintenance program] for walking using a FWW. During an interview on 12/20/22, at 1:46 p.m. R94 stated he had not been offered to ambulate today and it had been about a month since he walked. R94 further stated he would not refuse if offered to walk but was not sure he still had the ability to walk. During an interview on 12/20/22, at 2:15 p.m. registered nurse (RN)-B stated the nursing assistants (NAs) would log into point click care (PCC) and see the assigned tasks for each resident such as a walking program. The NA would update their nurse when the resident walked and if there were any concerns. RN-B stated she did not have residents on a walking program today (12/20/22) but confirmed R94 was part of her assignment. During an interview on 12/20/22, at 2:25 p.m. NA-A stated R94 was supposed to be on a walking program, but he was too weak to ambulate. NA-A further stated the walking program was supposed to be completed every day but admitted they did not always have time to do so. NA-A stated up until about two weeks ago she did not know R94 could even walk. Since then, she would just take him to the hallway and have him stand using a gait belt and handrails for support. NA-A further stated R94 never refused to stand and in fact had requested to walk down the hallway, but NA-A has never let him attempt to ambulate as she did not think he was strong enough. NA-A stated she discussed R94's condition with RN-A and an unidentified physical therapist (PT) about two weeks ago but was not sure what was happening with therapy. NA-A stated the walking task was supposed to be documented in PCC when either completed or refused. When interviewed on 12/20/22, at 2:37 p.m. PT-A stated R94 was discharged from PT and placed on a restorative nursing program but had heard about two weeks ago that it had not been happening. PT-A stated she had discussed this with RN-A at that time but R94 had not been re-evaluated. PT-A further stated if R94 was not able to ambulate at this time, it would be a decline in function. PT-A stated R94's goal was to discharge to an assisted living facility (ALF) and maintaining walking ability was important. When interviewed on 12/20/22, at 2:45 p.m. RN-A stated when a resident was discharged from PT, they would provide a form that outlined the specifics of the resident's walking program. The task would be entered in PCC for the NAs to do and documented when completed. RN-A stated resident refusals should be documented in PCC as well. RN-A stated R94's walking program was to ambulate 30-50 feet with a FWW and CGA but could not remember the last time she observed R94 walking. RN-A could not recall being made aware of any recent concerns regarding R94's walking program or ability to ambulate. RN-A stated the only recent discussion regarding R94 was about his desire to discharge to an ALF. When interviewed on 12/20/22, at 2:54 p.m. director of nursing (DON) stated the expectation was that the walking program would be completed per PT's FMP and documented appropriately in PCC. On 12/20/22, a review of the task worksheets in PCC for a 30-day look back period indicated the following task and related documentation: NURSING REHAB: Ambulate in room and on unit with assistance by one staff with 2WW and w/c to follow, OK to ambulate as requested/tolerated. -Amount of minutes spent training and skill practice in walking documented: 5 minutes on 12/2/22, at 21:35 and 10 minutes on 12/13/22, at 22:29. Seven days Not Applicable was documented otherwise task not documented. -Distance walked in feet documented: 0 feet on 12/2/22, at 21:35 and 50 feet on 12/13/22, at 22:29. Seven days Not Applicable was documented otherwise task not documented. The facility policy Restorative Nursing Program dated 10/21, indicated the purpose of the program was to prevent the residents' abilities in ADL's (activities of daily living) from deteriorating and to maintain the residents' highest practicable well-being. The policy directed nurses to input therapy recommendations, educate NAs to provide therapy, and to monitor and assess the residents for any changes. The policy further directed NAs to report any difficulties, concerns, accomplishments, and refusals to the nurse.

Based on interview and record review, the facility failed to ensure one of three residents (R2) was free from accidents and received adequate assistance when R2 was transferred by two staff in a mechanical lift with the wrong size and type of sling. R2 fell through the sling to the floor. As a result of the identified noncompliance, immediate Jeopardy (IJ) was called due to the risk of serious injury, serious harm, serious impairment that was likely to occur. The immediate jeopardy began on 9/23/22, when the facility failed to use the correct size and type of sling for a mechanical lift transfer and R2 fell to the floor. The administrator and the director of nursing (DON) were notified of the immediate jeopardy at 1:30 p.m. on 10/3/22 The immediate jeopardy was removed, and the deficient practice was corrected on 9/25/22, prior to the start of the survey, therefore was issued at Past Noncompliance. Findings include: R2's Pain Interview & Evaluation assessment form dated 9/7/22, noted R2 denied pain at the time of assessment but would occasionally say ouch if her legs are moved. R2's quarterly Minimum Data Set (MDS) dated [DATE], noted R2 required total dependence and two staff for transfers from surface to surface and her diagnoses included: late onset Alzheimer's disease and age-related physical debility. A progress note dated 9/23/22, indicated R2 had fallen through the Hoyer (Mechanical lift) sling onto the floor while being transferred from the bed to her wheelchair, the floor nurse and nurse practitioner assessed the resident for injury, vital signs, and felt it safe to lift the resident from the floor using the Hoyer. The note identified an abrasion to the right rear shoulder, a mid/upper back abrasion, and identified the root cause of the fall to be improper fitting of the Hoyer sling before transfer. A Nursing Home Visit form dated 9/23/22, indicated the nurse practitioner provided a visit for assessment following the report of a fall and presumed head strike. The nurse practitioner noted R2 appeared comfortable and denying pain, no gross deformity noted upon exam, but noted R2 did say ow with passive left leg raise, there were no bruises but small superficial abrasions on the left shoulder and scattered midline along the spine. The nurse practitioner noted upon repeat exam with MD present, R2's left leg pain had resolved. An incident report dated 9/23/22, indicated R2 fell through the Hoyer sling to the floor, R2 was assessed for injury by nurse, nurse practitioner, and was lifted from the floor to the bed with assist of four staff. The form noted abrasions to the upper-mid back area as well to the left rear shoulder. A fall risk assessment form dated 9/23/22, noted R2 was not a high risk for falls. R2's care plan revised on 9/23/22, noted R2 required mechanical lift with two staff assistance for transfers. A Pain Interview & Evaluation assessment form dated 9/24/22, noted R2 denied pain at the time of assessment and did not have any complaints of pain with rolling or turning in bed. An undated written statement from NA-A indicated she got the resident ready for the day and went to get assistance from another nursing assistant to transfer R2. The statement noted as they were getting R2 near her wheelchair, she slipped through the sling. The statement noted the nurse mentioned that the sling does not belong to R2 and that NA-A got the sling from R2's wheelchair. An undated written statement from a nursing assistant that provided assist with the transfer indicated she latched the sling to the machine and was guiding the resident towards he chair when R2 fell through the sling to the floor. During an interview on 9/30/22, at 8:42 a.m. nursing assistant (NA)-A stated she was originally assigned to a different group of residents and oriented to that group by a seasoned staff member but had to be reassigned due to someone calling in sick and was not oriented to the new group of residents. NA-A assisted R2 that morning to get ready for the day, she stated she could not find R2's Hoyer sling in the her room so she went into the hallway where resident wheelchairs are kept and found a sling on R2's wheelchair in the hall. NA-A stated it was common that residents had their own Hoyer slings but that the slings were not labeled. NA-A stated she had been assigned to work at the facility by her agency for about 3 months and had never cared for this group of residents before. NA-A stated she had primarily worked on the transitional care unit (TCU) and felt most comfortable on that unit, she had heard that the residents on R2's floor were more challenging and informed the scheduler at the facility she preferred the TCU but was assigned where the facility needed her. NA-A stated she positioned the sling under R2, she hooked her up to the Hoyer lift and went to get help. NA-A stated she and another aide then used the machine to lift R2 from the bed and as they were moving the machine towards R2's wheelchair, R2 slid through the sling and fell on to the floor. NA-A stated the sling she used was different than other slings but that she thought it was appropriate for R2 because it had a shorter width and R2 is of smaller stature. NA-A stated following the incident the administrator and director of nursing (DON) asked her some questions and then asked her to leave, she had not been back to the facility since the incident. NA-A stated it was the wrong sling, it should not have been in the resident's chair and that she encouraged the administrator and DON to label the slings to each resident to prevent incidents in the future. NA-A stated it was a miracle that she wasn't hurt, it wasn't a gentle fall. During an interview on 9/29/22, at 5:04 p.m. the nurse manager (NM)-A stated typically Hoyer slings are kept in resident rooms, they are not labeled, and are planning to go to a different system. NM-A stated slings are typically in resident rooms but they are not labeled. NM-A stated the sling used during the transfer for R2 was an over the commode sling, she had no idea where that sling could have come from and that there was only one resident that uses a commode sling for transfers, but her room was not nearby. NM-A stated in that instance she would have expected the nursing assistant to rely on critical thinking and that she should have noticed something didn't look right and the sling was too big. NM-A stated nursing assistants can refer to the care plan within the electronic medical record (EMR), the two staff involved were agency staff, one had been on that floor once prior and the other had never been there before. NM-A stated when new agency staff were assigned she would verbally orientate them to the group they are assigned to in regards to transfer status and that they will go over the care sheet which includes where the resident eats and whether they require feeding assistance, she stated the facility will be implementing new group sheets but has not yet, the new group sheets will not identify the sling that should be used and that the nursing assistants should use the resident's weight in selecting sling size prior to any transfers. NM-A stated R2 was not injured during the transfer and that she can't even fathom the fact that R2 didn't have any injuries, R2 now has her Hoyer sling listed in her care plan because it is a specialty sling that includes a head rest. NM-A stated the facility has since placed laminated sheets on the mechanical lifts for staff to be able to identify the correct sling based on the resident weight. During an interview on 9/30/22, ay 9:22 a.m. NA-B stated she is an agency staff member and is assigned everywhere throughout the building and that the facility gives verbal report on the basics such as how a resident transfers and level of assistance but feels as though she gets kind of thrown in. NA-B stated she thought that when she worked on the 3rd floor recently she noted there were new care sheets that identified transfer status but not sling size. NA-B stated when she was first assigned to the facility she did not have a login to the residents EMR system and that she was unsure how she would find the resident weight as she didn't think it was on a residents printed care plan in their rooms but would ask the nurse now that there had been recent education on selecting sling size based on resident weight. During and interview on 9/30/22, at 9:36 a.m. the NM-B stated she had initiated new group sheets on her floor that include transfer status and level of assistance with transfers since the incident, the sheets used before did not have the transfer status listed on them . NM-B stated she had thought about adding the sling size to the care sheet but that staff can also look at the printed care plan in the resident room to see transfers status but noted it did not include sling size or weight. NM-B stated staff can ask the nurse or look in the EMR for resident weights in order to identify which sling size to use and that for new agency staff they are supposed to come in 30 minutes prior to the start of their shift to get assigned a login to the EMR system. NM-B stated she expected all staff to find out a resident weight prior to transfer with a mechanical lift and that the nurses should be coordinating with them and telling them. NM-B stated they have now implemented a daily 2:30 p.m. huddle where they go through resident care and weights. During an interview on 9/30/22, at 11:50 a.m. the director of nursing (DON) stated the wrong sling was used for transferring R2 resulting in a fall to the floor. The DON stated prior to her coming to the facility, they had nursing students that were there trying to help size slings and that they performed audits on how many slings per floor. The facility wanted to be sure they had one dedicated sling per resident and that was reviewed on a quarterly basis. The DON stated prior to the incident, staff would need to go by the manufacturer guidance and should have been weight based, and she was not sure what kind of training was provided. A facility policy titled Mechanical Lift last revised on 3/18/20, noted staff should choose the appropriate sling for the resident's weight and to refer to the manufacturer's instructions for specific color sling for each weight requirement. The past noncompliance immediate jeopardy began on 9/23/22. The immediate jeopardy was removed and the deficient practice corrected by 9/25/22, after the facility implemented a systemic plan that included the following actions: R2's specific sling size and type is listed in banner of EMR and in care plan, laminated images of correct slings/sizing guides and tied them to the mechanical lifts, confirmed the two nursing assistants received training in mechanical lifts from their staffing agency, nursing staff education on selection of sling size and use of mechanical lifts, inspecting all mechanical lifts, and slings for proper sizing and function, resident care plans reviewed to ensure proper transfer status, onboarding training documents reviewed, audits on resident transfers and use of proper sling size.

Based on observation, interview and document review, the facility failed to ensure Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines were followed to prevent or minimize the transmission of COVID-19 for 1 of 7 resident (R6) who was not immediately placed on transmission-based precautions (TBP) after exhibiting signs and symptoms of COVID-19. R6 later died from COVID. This had the ability to affect all 41 residents residing on the 3rd floor at the time R6 resided in the facility as well as any staff working on the unit who provided cares. The IJ began on [DATE] when R6 noted to staff he had a productive cough. Staff failed to immediately implement CDC guidelines for TBP. R6 tested positive for COVID-19 on [DATE]. The facility administrator and the director of nursing (DON) were notified of the IJ on [DATE] at 3:26 p.m. The IJ was removed on [DATE] at 2:18 p.m., but non-compliance remained at the lower scope and severity of E: PATTERN, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On [DATE], facility management including the administrator and administrator provided updated information to the surveyors of the status of the COVID outbreak. The facility currently had 27 of 104 residents were currently COVID positive, including 3 resident who died . 8 staff had also been confirmed positive for COVID. R6's quarterly Minimum Data Set (MDS), dated [DATE], indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's [DATE], laboratory results indicated R6 was administered routine [CONDITION(S)]-CoV2 PCR test sent to the laboratory (lab) for COVID-19. R6's test results from [DATE] were received by the lab on [DATE], and shown to be positive for COVID-19 [DATE]. R6's progress notes from [DATE] to [DATE] identified the following: 1) [DATE], at 6:12 a.m., staff noted R6 had a mild cough and was given [MEDICATION(S)] (a cough medicine) per standing house orders. 2) [DATE] at 3:09 p.m., indicated R6 complained to staff he coughed up phlegm overnight. 3) [DATE] at 3:09 a.m., 4:46 a.m., and 10:10 p.m., staff noted R6 was given [MEDICATION(S)]. 4) [DATE] at 12:10 a.m., 5:54 a.m., and 6:55 a.m., staff noted R6 was given [MEDICATION(S)]. 5) [DATE] at 3:41 p.m., R6 was administered a rapid COVID-19 test. R6's rapid COVID-19 test was positive, indicating R6 had the COVID-19 virus and at that time, R6 was placed on TBP. There was no mention TBP had been implemented or the provider was notified of R6's cough after onset on [DATE]. R6's [DATE], Treatment Administration Record (TAR) identified R6 was not placed on TBP until [DATE] due to COVID-19. During interview on [DATE] at 10:10 a.m., infection preventionist (IP)-B verified R6 first displayed cough, a symptom of COVID-19 on [DATE]. IP-B verified R6 was first placed on TBP on [DATE], after showing a positive result on testing. During interview on [DATE], at 11:23 a.m., the medical director (MD) identified his expectation was residents experiencing symptoms of COVID-19, including a cough, were expected to be immediately placed on TBP and the physician notified. He stated the facility had not followed CDC guidance. During interview on [DATE], at 8:09 a.m., registered nurse (RN)-D stated although she administered R6 [MEDICATION(S)] on [DATE], and [DATE], RN-D indicated she did not report R6's cough to the following shift or place R6 on TBP. During interview on [DATE] at 1:05 p.m., the DON stated she did not believe coughing up phlegm was a symptom of COVID-19 or required TBP. Review of the [DATE], COVID Emergency Preparedness Plan policy identified residents with signs or symptoms of COVID-19, vaccinated or not vaccinated, must be tested immediately. While test results are pending, residents with signs or symptoms should be placed on TBP in accordance with CDC guidance. Review of the [DATE], CDC, Symptoms of COVID-19, located at https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html, identified symptoms of COVID-19 are noted to be but not limited to: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. There was no mention by CDC there be multiple instances of a symptom in order to be suspected of COVID-19. The IJ was removed on [DATE] at 12:18 p.m., when it could be verified by observation and interview the facility took steps to ensure staff were able to identify COVID-19 symptoms and initiate appropriate isolation and TBP for residents upon onset of symptoms of COVID-19.

Based on interview and document review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) in accordance with Provider Orders for Life-Sustaining Treatment (POLST) for 1 of 1 resident (R1), found without a pulse or respirations. CPR was not immediately initiated and R1 died . This deficient practice had the potential to affect 42 of 106 residents who resided at the facility who had orders for CPR to be performed. The Immediate Jeopardy (IJ) began on [DATE], at 4:32 p.m. when R1 was found without a pulse or respirations, and CPR was not immediately initiated. The administrator and director of nursing (DON) were informed of the IJ on [DATE], at 12:53 p.m. The facility implemented corrective action as of [DATE], therefore the deficiency is being cited as past non-compliance. Findings include: R1's Admission Record facesheet printed [DATE], indicated R1 had been admitted [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's annual Minimum Data Set assessment dated [DATE], indicated she was cognitively intact. R1's POLST indicated under the heading Cardio Pulmonary Resuscitation (CPR) patient has no pulse and is not breathing: Attempt resuscitation/CPR. The POLST was signed by R1 and physician on [DATE]. R1's Order Summary Report dated [DATE], also indicated R1 had a full-code (indicating CPR was to be performed if needed) status. Review of R1's interdisciplinary notes revealed: -A late entry progress note dated [DATE], at 7:24 p.m. indicated at approximately 4:32 p.m. nursing assistant (NA)-A requested licensed practical nurse (LPN)-A to check R1. LPN-A observed R1 was not breathing and had no pulse. CPR was first initiated by LPN-A at 4:36 p.m. At 4:38 p.m. registered nurse (RN)-A brought an automated external defibrillator (AED) and took over chest compressions. At 4:42 p.m. RN-A called 911 and activated Nurse STAT (overhead emergency page). From 4:39 p.m. to 4:48 p.m. both LPN-A and RN-A took turns doing chest compressions. At 4:49 p.m. police arrived and RN-A continued chest compressions. At 4:50 p.m. RN-C took over the chest compressions. At 4:51 p.m. EMS arrived. At 4:52 p.m. EMS assumed care for R1. At 5:09 p.m. EMS stopped CPR and R1 was pronounced dead. -A progress note dated [DATE], at 7:34 p.m. indicated nurse practitioner (NP)-A was notified of R1's death. NP-A gave an order to release R1's body. R1's progress notes lacked indication any additional information was provided to NP-A. -A progress note dated [DATE], at 9:39 p.m. indicated, RN-A had called R1's family to notify them of her death and was given permission to call the funeral home. The progress note indicated R1's body was picked up at 9:10 p.m. -A late entry progress note dated [DATE], at 2:00 p.m. indicated the director of nursing (DON) updated a family member regarding the timeframe of R1's CPR event which occurred on [DATE]. The family member was informed nursing staff observed R1 to be unresponsive, not breathing, and without a pulse at 4:32 p.m. CPR was first initiated by nursing staff at 4:36 p.m. The DON informed the family member there was a delay in initiating CPR and that immediate staff education was completed with nursing staff regarding facility CPR policy and procedure. During interview on [DATE], at 12:48 a.m. NA-A stated she worked with R1 on [DATE]. NA-A stated she had gone into R1's room around 4:30 p.m. and R1 was not responsive. NA-A stated she asked LPN-A to come to R1's room with her. NA-A stated LPN-A told her to get RN-A. NA-A stated when she and RN-A arrived back to R1's room, LPN-A was taking R1's vital signs. During interview on [DATE], at 3:53 p.m. LPN-A verified she worked with R1 on [DATE]. LPN-A stated at approximately 4:30 p.m. NA-A told her she needed to go to R1's room quickly and told her it looked like she's [R1] gone. LPN-A stated when she observed R1 in bed she panicked. LPN-A stated she checked R1's radial pulse (felt on the wrist), apical pulse (heard on the left side of the chest), and brachial (felt at the inner aspect of the elbow) and R1 did not have a pulse and was not breathing. LPN-A stated she instructed NA-A to get RN-A, who came right away. LPN-A stated RN-A checked R1's pulse and verbalized R1 did not have a pulse and was dead. LPN-A stated she asked RN-A, what should we do, and RN-A said he was going to call the DON. LPN-A stated RN-A and herself went to the nurses' station and a voicemail was left for the DON. LPN-A stated at 4:36 p.m. RN-A, who was on the phone, answered another call and handed her the phone. LPN-A stated the DON was on the line and stated she'd received a voice message from RN-A. LPN-A stated the DON verbalized she was unaware of any residents who were actively dying and questioned if R1 had been sick. LPN-A stated she responded by saying R1 was good when she'd checked on her earlier in the evening. LPN-A also stated, During the call with the DON, [RN-A] checked [R1's] code status and verbalized [R1] was a full-code. LPN-A stated she ran to R1's room and started CPR at approximately 4:36 p.m. LPN-A stated that same evening [[DATE]], the DON came to the facility and provided staff re-education to the facility's CPR policy. LPN-A stated the facility had since conducted random CPR drills. LPN-A stated she would not perform CPR if a resident had irreversible signs of death such as if a person's head was cut off or their body was cut up. During interview on [DATE], at 12:56 p.m. RN-A stated he was the charge nurse on the evening of [DATE]. RN-A stated at approximately 4:30 p.m. he was at the nurses' station and LPN-A asked him to go to R1's room. RN-A stated he followed LPN-A into R1's room and LPN-A stated R1 expired. RN-A stated he used his stethoscope and pulse oximeter (a device used to check an oxygen saturation) and conducted an assessment. RN-A stated R1 did not have a pulse, was not breathing and the pulse oximeter read zero. RN-A stated he agreed R1 died and questioned when R1 was last seen alive. RN-A stated NA-A responded R1 was last seen alive around 2:45 p.m. RN-A stated he then sent a text to the DON and left a message for R1's family. RN-A stated when the DON called back, he checked R1's code status and discovered R1 was suppose to be a full-code. RN-A stated he then paged a nurse STAT. RN-A stated he grabbed a mobile phone and obtained an AED as instructed by the 911 operator. RN-A stated RN-B recorded the time of events on paper. RN-A stated LPN-A notified him CPR was delayed three to four minutes and confirmed CPR was not performed timely. RN-A stated the DON came to the facility on [DATE], and conducted staff re-education on their CPR policy. RN-A stated the DON also gave him corrective action. During interview on [DATE], at 11:16 a.m. A family member (F)-A stated the DON called her on [DATE], and verbalized there was a service failure related to R1 death. F-A stated the DON verbalized NA-A told LPN-A something was up with R1 and requested LPN-A to check R1. F-A stated the DON verbalized LPN-A then found R1 unresponsive and not breathing. F-A stated she was told LPN-A went to the desk and learned R1 was a full-code and at that time called 911. F-A stated the DON also verbalized staff returned to R1's room and started CPR. F-A stated the DON verbalized by that time staff stared CPR it was too late and R1 passed away. F-A stated the DON informed her the facility had initiated what she called training on this type of thing. F-A stated R1 was a full-code and wanted to be resuscitated. F-A stated, it seemed like an excessive amount of time before checking that she was full-code. During a follow-up interview on [DATE], at 3:14 p.m. RN-A stated when he went to R1's room, he verified R1's death. RN-A stated he was the second verifier. RN-A stated if a resident was a full-code, CPR needed to be done. RN-A stated he was not aware of any signs to check for on a full-code resident in which he would not start CPR. RN-A stated if a resident was ordered a full-code status he would do CPR until there were no signs of life. During interview on [DATE], at 3:07 p.m. the DON stated the facility CPR policy directed CPR needed be started if a resident was unresponsive, not breathing and was a full-code. The DON stated Basic Life Support (BLS) certified staff should initiate CPR, unless a known Do Not Resuscitate (DNR) order was in-place and there was no obvious signs of irreversible death, such as decapitation. During interview on [DATE], at 10:16 a.m. RN-B stated she responded to an overhead Nurse Stat page on [DATE], and arrived to R1's room around 4:53 p.m. RN-B stated CPR had been initiated when she first arrived at R1's room. RN-B stated LPN-A told her to get a CPR backboard and she recorded the event. During interview on [DATE], at 10:57 a.m. the DON stated the CPR policy was reviewed during re-training after R1's death. The DON stated her expectation was staff were to check a resident's code status and start CPR immediately if a resident was a full-code. The DON stated she had been notified by RN-A that R1 passed away. The DON stated she called the facility back to ask LPN-A if R1 was a full-code. The DON stated LPN-A verified R1 was a full-code and instructed LPN-A to start CPR. The DON stated RN-A and LPN-A informed her they checked R1 for breathing and pulse and based on their clinical assessment R1 had passed away. The DON stated she informed RN-A and LPN-A CPR needed to be started if a resident was a full-code, even if the resident was breathless and pulseless. The DON stated she came in that same evening of [DATE] to initiate re-education of staff to CPR status and the facility's CPR policy. During interview on [DATE], at 9:32 a.m. NP-A stated on the evening of [DATE], she received phone call from the facility but was not any provided information regarding failure to implement CPR. NP-A verified staff were expected to start CPR immediately and call 911 for residents who had a CPR order. The facility's [DATE], Cardiopulmonary Resuscitation policy, directed code status would be verified prior to starting CPR.Verification of full code status (POLST) should not significantly delay the initiation of CPR. There will be times when staff does not have DNR information available and will need to initiate CPR-but this should be rare. If an individual (resident, visitor, or staff) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a) it is known that a Do Not Resuscitate (DNR) order is in place or b) there are obvious signs of irreversible death (e.g. decapitation). If a resident's code status is unclear, CPR will be initiated. The IJ that began on [DATE], was removed as of [DATE] after the facility had implemented corrective actions to prevent recurrence including immediate reeducation of staff to the facility's CPR policy including how to respond to an unresponsive resident. This was conducted for prior to the start of each nurse's next shift. Resident records were audited to ensure all resident's POLST status were clear and mock CPR drills were also initiated. Review of documentation and interview with nursing staff verified completion of these interventions.

Based on observation, interview and document review, the facility failed to ensure 1 of 11 residents (R1) reviewed, were free from abuse when a staff sexually assaulted R1. Findings include: The facility's Vulnerable Adult Abuse Prohibition Plan dated January, 2009 and revised (MONTH) (YEAR), defines abuse as any act against a vulnerable adult, including assault and battery or criminal sexual conduct. Sexual abuse is defined as non-consensual sexual contact of any type with a resident and includes but is not limited to sexual harassment, sexual coercion or sexual assault; any sexual conduct between a staff person or other employee and a resident; any sexual contact with a vulnerable adult who is impaired in judgement or capacity by mental or emotional dysfunction or under influence and is therefore unable to consent to the sexual act; the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; willful means the individual must have acted deliberately. R1's medical record was reviewed. R1's [DIAGNOSES REDACTED]. R1 was assessed as mostly non-verbal and unable to typically express her activity wants or needs except through observation and did not usually attend group activities. R1 had self care and grooming deficits due to dementia and weakness and was totally dependent on staff for personal and oral hygiene. R 1 was non-ambulatory and required two staff assistance for transfers. R1 could feed herself. A change in condition evaluation form dated (MONTH) 10, (YEAR) indicated other change in condition as witness saw a staff member on top of R1. The assessment form indicated R1 had pain but was cognitively unable to rate her pain scale. R1 was sent to the ER via ambulance for a sexual assault exam. An emergency room (ER) note dated (MONTH) 10, (YEAR), indicated R1 was non-verbal and oriented x 0. Emergency medical staff (EMS) and police reported to ER staff that a staff member had barricaded himself in R1's room and was discovered straddling R1 by another staff. A police incident report dated (MONTH) 10, (YEAR) at 7:17 p.m. indicated police were dispatched to the facility for a criminal sexual conduct call. The reporter, nursing assistant (NA)-D told police she had observed a co-worker, the alleged perpetrator, who was NA-E, on top of R1 in a sexual manner. A police report titled Assist Other Officer dated (MONTH) 10, (YEAR) at 7:17 p.m. indicated NA-E told police he had go back into R1's room alone to change R1's incontinent brief. The report indicated that during a search of NA-E's person, the officer observed several smaller white markings on the outside of NA-E's pants near the zipper which the officer photographed. Facility surveillance video footage dated (MONTH) 10, (YEAR) at 7:48:31 p.m. shows police officers escorting NA-E through main lobby and out main door in hand cuffs. The administrator confirmed the handcuffed individual was NA-E. A progress note dated (MONTH) 10, (YEAR) at 8:20 p.m. indicated R1 was escorted out of the facility on a stretcher with EMS staff and went to the ER for a sexual assault exam. The physician was notified. The director of nursing (DON) was notified. A progress note dated (MONTH) 12, (YEAR), indicated the R1 was seen for a follow-up visit by a facility nurse practitioner. An internal investigation note dated (MONTH) 11, (YEAR) indicated the director of nursing (DON)-G attempted to contact R1's guardian three times on (MONTH) 10, (YEAR) without success. The guardian been out of town and was contacted and informed of the incident. An internal investigation note, dated (MONTH) 14, (YEAR), indicated NA-E was placed on an investigative suspension and removed from the staff schedule during the investigation process. The note indicated the facility had applied for a no trespass notice against NA-E. An internal investigation note dated (MONTH) 15, (YEAR), indicated NA-E was called and a voice mail left indicating he was encouraged to give a statement about the alleged assault for the facility's investigation process. NA-E did not respond. A record of corrective action, dated (MONTH) 16, (YEAR), indicated NA-E's employment was terminated due to circumstances under investigation of an alleged incident which may have resulted in the jeopardy of the health and wellness of a vulnerable adult. During an interview on (MONTH) 27, (YEAR) at 3;52 p.m., RN-B said she never had concerns about NA-E's job performance or his interactions with the residents or co-workers. To her knowledge there was no hostility between NA-D and NA-E. One concern RN-B said she had was that some staff might not have solid training on abuse reporting and there could have been behaviors that occurred that went unreported. During an interview on (MONTH) 29, (YEAR) at 11:57 a.m., NA-D said she and NA-E were the only two NAs working that unit and it was a busy evening. NA-D said she and NA-E were getting R1 and his/her roommate ready for bed. R1 was already in bed but his/her roommate needed toileting. NA-D asked NA-E to help R1's roommate to the toilet while she went to check on two residents down the hall. NA-D said she checked on the two resident and went back out to the hallway. She saw the call light to R1's room blinking and said she returned to R1's room wondering what was going on because NA-E was in the room. NA-D pushed R1's door open but it was blocked by something heavy and only opened several inches. NA-D said she saw a dresser pushed up against the door. NA-D said she looked into the room and saw NA-E lying completely on top of R1 in R1's bed in a sexual manner with one leg on the bed and his head in the crook of R1's neck. NA-D said R1 had no brief's on and her gown was pulled up to her middle. NA-D said she was stunned. She closed the door to R1's room and ran to a linen closet down the hallway. NA-D said NA-E followed her to the linen closet. NA-D said she grabbed linens for another resident's room and avoided eye contact with NA-E. NA-D said she noticed a wet spot on NA-E's pants on the zipper and crotch area. NA-D said she and NA-E went to another residents room to prepare them for bed. NA-D siad she was shaking and wanted to get away from NA-E. NA-D told the resident in another room waiting to be transferred to bed that she had to use the bathroom and would be right back. NA-D said she ran and hid in a staff bathroom. During this time NA-D said she received several text messages from NA-E asking to talk to her. NA-D said she called the police. Copies of the text messages from NA-E were requested but not provided. During an interview on (MONTH) 12, (YEAR) at 1:02 p.m., Sexual Assault Nurse Examiner (SANE) RN-H said during R1's exam, R1 was non-verbal until RN-H began the genital exam and R1 said stop, ow. RN-H said R1 appeared very uncomfortable. When RN-H attempted to perform the speculum exam R1 became distressed and appeared to be in pain. RN-H did not perform the speculum exam on R1, who had a considerable amount of swelling in the labia area and some redness. During an interview on (MONTH) 12 at 1:02 p.m., RN-H said she also performed an exam on NA-E who was in police custody. During an interview on (MONTH) 16, (YEAR) at 3:33 p.m., DON-G said staff get abuse training when hired and annually. DON-G said she would be surprised if staff did not know what abuse was or how to report abuse. A facility position description titled Nursing Assistant, Registered, revised (MONTH) (YEAR), indicated abilities required included the ability to communicate effectively and [MEDICATION NAME] with residents and empathy. A performance assessment nursing assistant for (MONTH) (YEAR) to (MONTH) (YEAR) indicated NA-E achieved standard performance. An undated documented titled Safe Patient Handling Culture of Safety, and signed by NA-E (MONTH) 2, (YEAR), acknowledged responsibility to provide a safe environment for the care of the residents. Requests for an interview with NA-E were declined by his/her attorney.