Every finding on record at First Care Living Center

Based on observation, interview and document review the facility failed to thoroughly investigate, perform root cause analysis and implement interventions to reduce the risk for falls for 1 of 3 residents (R1) who sustained falls related to improper use of equipment.Findings include:R1's Resident Face Sheet indicated he admitted to the facility 7/2/26. R1's diagnosis included surgical wound, paraplegia and fall.R1's admission Minimum Data Set, dated [DATE], identified intact cognition. R1 had lower extremity impairments, required substantial/maximal assistance for bed mobility and was dependent for transfers.R1's physical therapy evaluation and treatment plan dated 7/2/26, indicated he required maximal assistance from two staff to roll side to side.R1's John Hopkins Fall Risk assessment dated [DATE], indicated a high risk for falls. Assessment did not include recommendations for interventions.R1's care plan dated 7/25/26, identified a risk for falls related to weakness, impaired mobility, no feeling from waist down and need for assistance with transfers. The care plan indicated he had a fall on 7/25/26. The care plan directed staff to ensure proper footwear, clutter free environment and ensure call light was in reach and 30-minute checks. The care plan indicated R1 required the use of a mechanical lift for transfers and directed staff to the closet for transfer sheet with size and type of sling. The care plan further identified impaired mobility but lacked direction related to need for staff assistance for bed mobility.R1's Event Report dated 7/25/26, indicated on 7/25/26 at 2:30 p.m., R1 had a witnessed fall. R1 said staff hooked up his upper body to the lift and when staff attempted to hook his lower body up, he slid out of the recliner. The report indicated R1 had increased pain as a result of the fall. Investigation indicated nursing assistants (NA)'s were attempting to transfer R1 from his recliner to his bed. Staff hooked R1's upper body to the lift and when they attempted to hook his lower body up, he slid out of the recliner onto the floor. The event report lacked interviews with the staff involved.R1's Event Report dated 7/26/26, indicated on 7/26/26 at 7:10 p.m., R1 fell onto the floor by his bed. R1 sustained cuts to his wrist and forearm. The report indicated R1 fell while being turned by staff. The event report lacked interviews with R1 and the staff involved.During observation and interview on 7/31/26 at 11:25 a.m., R1 was lying in bed. R1 had a bandage on his right wrist and a scab on his right forearm. R1 stated he had fallen three times since he admitted to the facility. The first fall was out of bed and said the second fall happened when staff was getting him out of his recliner. R1 said staff told him they strapped him in right but R1 did not think they had crossed the straps between his legs and said he slid out of the sling when staff were lifting him with the mechanical lift. R1 said the third fall happened when the staff was washing him up in bed. Staff forgot to lock the brakes on the bed. When the staff pushed him over to his side, the bed shot out from the wall, and R1 landed on the floor between the bed and the wall. R1 stated his leg hurt from his hip to his knee because of the falls. R1's room was observed and a sling was on his recliner chair under a pillow. The sling was blue and did not have straps that crossed between the legs. R1 said that was not the sling staff had used during the transfer when he fell. In addition, R1's closet did not contain a transfer sheet as indicated in the care plan.During interview on 7/31/26 at 2:11 p.m., registered nurse (RN)-A stated the day R1 fell from the recliner she was in another room and staff called for assistance. RN-A said R1's upper body was on the recliner, and his lower body was on the floor. When RN-A asked R1 what happened, he said the staff hooked him up to the lift and the next thing he knew he was on the floor. RN-A said the lift sheet was hooked to the top of the sling to the mechanical lift and before staff could hook up the bottom of the sling to the mechanical lift, R1 had slid down. RN-A thought the sling type used was the full body type not the style that crossed between the legs. RN-A said she educated the staff involved to hook the bottom of the lift sheet to the mechanical lift first and then the top.On 7/31/26 at 2:33 p.m., RN-B and RN-C were interviewed. RN-B said when R1 fell when staff were transferring him with the mechanical lift. Staff hooked the top straps to the mechanical lift, when they tried to attach the bottom straps, R1 slid to the floor. RN-C said she was told R1 was not being lifted when he fell and said RN-A re-educated staff to hook up the bottom straps to the mechanical lift first. RN-B said after the fall from the recliner, education had been placed in a communication book for all staff to read and sign. The education was an untitled, undated document and had no staff signatures. RN-C said she had removed the transfer sheet from R1's closet earlier that week to update it and it had not been returned to the closet. The transfer sheet indicated a crisscross sling type and RN-B said that was the type of sling used when R1 fell during transfer. RN-B said when the third fall occurred, staff had been rolling R1 toward them and said R1's legs slid off the bed causing him to fall to the floor. RN-C stated R1 should have been assisted by two staff while turning in bed. RN-C said after R1's fall out of bed, he got a different mattress. The director of nursing (DON) was present and said at the time of the third fall, staff were applying lotion to R1's skin and had used the sheet to pull him toward them. The momentum propelled R1 too far, causing him to fall off the bed. The DON stated she did not know if staff had been assisting R1 alone or if another staff was present. RN-B and RN-C stated neither of them had talked with R1 or the staff involved after the two falls had occurred.During interview on 8/4/26 at 1:45 p.m., nursing assistant (NA)-A stated she was present when R1 fell while being transferred from the recliner and when he fell off the bed during cares. NA-A said during the transfer from the recliner, the lift sheet was under R1, the bottom straps were hooked to the mechanical lift and when they tried to hook up the top straps, R1 slid out of the lift sheet. NA-A said when they tried to hook the top straps, they had to lower the lift bar and raise the power recliner. NA-A said she did not remember what type of sling was used at the time of the transfer. NA-A stated the next day she was getting R1 ready for bed and said while she was trying to replace the sheet on his bed, R1 rolled a little too far and landed on the floor between the bed and the wall. NA-A said she thought the bed was locked but said it did move away from the wall. NA-A said she had been working alone when the fall from bed occurred. NA-A said she did receive education after either fall and added, I have been an aide [NA] for 20 years, I think I would know what to do. You get to know the resident and what they are capable of, turning and things like that.During interview on 8/4/26 at 1:45 p.m., the DON stated typically the RN's reviewed falls and looked to see if there was something that needed to be done differently such as positioning, room arrangement, etc., depending on how the fall occurred. The DON said the RN on duty should have interviewed the staff involved with both falls and then RN-C should have followed up on the falls. The DON said they were working on documentation related to the falls.Facility policy Fall Prevention and follow up dated 3/12/26, indicated risk for falls was completed prior to admission and directed staff to ensure fall preventions were care planned. The policy indicated when a fall occurred the nurse was responsible for completing a fall report and a fall scene investigation to include a drawing of the scene to determine the root cause of the fall. The fall scene should include the staff that witnessed or found the resident, licensed staff and any other staff available. The licensed staff must conduct a root cause analysis and implement immediate interventions relevant to the cause of the fall. Interventions are communicated to the staff and placed in the care plan. Review falls documentation and root cause analysis daily in interdisciplinary team huddle.

Based on interview and document review the facility failed to develop a care plan to include turning and repositioning resulting in a fall for 1 of 3 residents (R1) reviewed for falls.Findings include:R1's Resident Face Sheet indicated he admitted to the facility 7/2/26. R1's diagnosis included surgical wound, paraplegia and fall.R1's admission Minimum Data Set, dated [DATE], identified intact cognition. R1 had lower extremity impairments, required substantial/maximal assistance for bed mobility and was dependent for transfers.R1's physical therapy evaluation and treatment plan dated 7/2/26, indicated he required maximal assistance from two staff to roll side to side.R1's care plan dated 7/2/26, identified impaired mobility related to a spinal cord injury and indicated: usual functional ability for bed mobility (rolling side to side, lying and sitting on edge of bed)- section was left blank.During observation and interview on 7/31/26 at 11:25 a.m., R1 was lying in bed. R1 had a bandage on his right wrist and a scab on his forearm. R1 stated he had fallen three times since he admitted to the facility. The first fall was out of bed and said the second fall happened when staff was getting him out of his recliner. R1 said staff told him they strapped him in right but R1 did not think they had crossed the straps between his legs and said he slid out of the sling when staff were lifting him with the mechanical lift. R1 said the third fall happened when the staff was washing him up in bed. Staff forgot to lock the brakes on the bed. When the staff pushed him over to his side, the bed shot out from the wall, and R1 landed on the floor between the bed and the wall. R1 stated his leg hurt from his hip to his knee because of the falls.During record review and interview on 7/31/26 at 2:33 p.m., RN-B and RN-C were interviewed. RN-B said when R1 fell when staff were transferring him with the lift, staff hooked up the top straps and when they tried to attach the bottom straps, R1 slid to the floor. RN-C said she was told R1 had not been lifted or moved when he fell and said RN-A re-educated staff to hook up the bottom straps first. RN-B said after the fall from the recliner, education was placed in a communication book for all staff to read and sign. The education was an untitled, undated document and had no staff signatures. RN-B reviewed the document with the surveyor and confirmed the communication did not have any staff signatures. RN-B said when the third fall occurred, staff had been rolling R1 toward her and said R1's legs slid off the bed causing him to fall to the floor. RN-C stated R1 should have been assisted by two staff while turning in bed. RN-B reviewed the care plan and confirmed the care plan did not identify how many staff were required to perform turning and repositioning.During interview on 8/4/26 at 1:45 p.m., the director of nursing stated at the time of R1's fall during cares, she thought he was care planned for assistance from two staff.Facility policy Care Planning dated 9/15/25, indicated each resident has an individualized care plan to provide the necessary care to achieve and maintain the highest practicable level of physical, mental and psychological well-being. The policy directed staff to establish a baseline care plan within 48 hours and to review and updated the care plan quarterly and with any change in resident condition or care needs.

Based on interview and document review, the facility failed to assess COVID-19 vaccination status and ensure current CDC-recommended COVID-19 vaccination was offered and documented for 2 of 5 residents (R20, R27) reviewed for immunizations. Findings include:R20:R20's admission Minimum Data Set (MDS) dated [DATE], identified R20 was admitted on [DATE], was cognitively intact and able to make her needs known. R20's diagnoses included diabetes and hypertension.R20's Preventative Health Care Report identified the last documented COVID-19 vaccination was administered on 11/23/21. The medical record lacked evidence the resident's COVID-19 vaccination status was assessed upon admission, that current CDC recommendations were discussed, or that the resident was offered recommended COVID-19 vaccination since admission on [DATE]. R27:R27's annual MDS dated [DATE] identified R27 was admitted to the facility on [DATE] and was [AGE] years old. R27's diagnoses included coronary heart disease, heart failure, and thyroid disease.R27's medical record lacked evidence staff assessed the resident's COVID-19 vaccination status upon admission, provided education regarding current CDC recommendations, offered vaccination, or obtained a documented declination. On 5/27/26 at 1:28 p.m., registered nurse (RN)-D, who is also the infection preventionist, stated immunizations were offered upon admission and seasonally. RN-A stated she reviewed the resident's immunization status upon admission. Immunizations were either administered, or a declination was signed after they were discussed with the resident and/or resident representative.On 5/28/26 at 8:53 a.m., the director of nursing (DON) stated she expected all immunizations would be discussed with the resident and/or resident representative upon admission and per CDC guidance, as well as documenting a progress note in the resident's medical record.The Essentia Health Standard Work Process dated 3/5/26, identified staff reviewed vaccination history for all residents at the time of admission and assess if the resident needed vaccinations including COVIS-19. Staff provided and discussed the most current Vaccination Information Statement (VIS) with each resident and/or resident representative prior to administration, and document administration or declination in the resident's medical record. The Centers for Disease Control 2025-2026 COVID-19 Vaccination Guidance dated 11/4/25, identified COVID-19 vaccination is recommended for all adults ages 65 years and older based on individual-based decision-making (also known as shared clinical decision-making). For people ages 6 months-64 years, vaccination is recommended based on individual-based decision-making (also known as shared clinical decision-making)-with an emphasis that the risk-benefit of vaccination is most favorable for individuals who are at an increased risk for severe COVID-19 disease and lowest for individuals who are not at an increased risk, according to the CDC list of COVID-19 risk factors. In addition to the CDC list, the Moderna (Spikevax) package insert states that prematurity (birth at <37 weeks gestational age) has been associated with COVID-19-related hospitalizations in children ages 6-23 months. Ages 65 years and older Unvaccinated: Administer 2 doses of 2025-2026 vaccine; Unvaccinated 2025-2026 Dose 1 (Moderna, Novavax, or Pfizer-BioNTech): Day 0 2025-2026 Dose 2 (Moderna [Spikevax], Novavax, or Pfizer-BioNTech): 6 months (minimum interval 2 months) after 2025-2026 Dose 1; (Moderna [mNexspike]): 6 months (minimum interval 3 months) after 2025-2026 Dose 1. Previously vaccinated before 2025-2026 vaccine: Administer 2 doses of 2025-2026 vaccine 1 or more doses any COVID-19 vaccine (Moderna, Novavax, or Pfizer-BioNTech) 2025-2026 Dose 1 (Moderna [Spikevax], Novavax, or Pfizer-BioNTech): At least 8 weeks after last dose; (Moderna [mNexspike]): At least 3 months after last dose 2025-2026 Dose 2 (Moderna [Spikevax], Novavax, or Pfizer-BioNTech): 6 months (minimum interval 2 months) after 2025-2026 Dose 1; (Moderna [mNexspike]): 6 months (minimum interval 3 months) after 2025-2026 Dose 1.

Based on observation, interview and document review, the facility failed to assess and evaluate wandering behaviors, including entering other residents' rooms and going through personal belongings, for 1 of 3 residents (R8) reviewed for behavioral symptoms.Findings include:R8's significant change Minimum Data Set (MDS) dated [DATE], identified R8 had severe cognitive impairment and identified a worsening of behaviors. R8's diagnoses included: non-Alzheimer's dementia, depression, hallucinations and a psychotic disorder other than schizophrenia. R8's behavioral symptoms Care Area Assessment (CAA) dated 4/9/26, identified R8 had worsening behaviors along with hallucinations. R8's behaviors included: isolation, pain, anxiety, hollering out, and disruptive sounds; however, did not comprehensively assess wandering or a plan to minimize it. R8's progress note dated 5/20/26, identified R8 had been wandering into three other resident's rooms tonight and had been caught by staff digging in drawers. During observations on 5/26/26 at 12:53 p.m., R8 had wandered down the south hallway and entered another resident's room. As the surveyor walked by R8 came out of the room and asked where her room was. During an interview on 5/26/26 at 1:12 p.m., R22 stated R8 came into his room and accused him of stealing her things, especially R8's dentures. I tell her I don't need her teeth, that I have my own. R8 would call R22 every name in the book. R8 was rummaging in R22's closet and said all R22's things belonged to R8. R22 stated R8 just kept stating it's mine! R22 told R8 to get out of his room and R22 was upset by what R8 said and did. R22 stated he turned on his call light but by the time staff arrived R8 had already left. R22 stated he had told staff he didn't like R8 coming into his room and they told him to turn on his call light if R8 did. [R22's quarterly MDS dated [DATE] identified R22 was cognitively intact.]During an interview on 5/28/26 at 8:53 a.m., registered nurse (RN)-D stated R8 did wander into other residents' rooms from time to time. For a long time, R8 believed R22 was the doctor and would go into R22's room to talk to him. After meals, staff tried to direct her to her room. RN-D stated she did not work in the evening or night but believed R8 wandered into other rooms more frequently during that time because R8's sundowning (a state of increased confusion, anxiety, and agitation that affects people with dementia.) RN-D did not know of any interventions to prevent R8 from entering other residents' rooms. It's just redirection. RN-D did not identify the assessment process for wandering.During an interview on 5/28/26 at 9:08 a.m., trained medication assistant/nursing assistant (NA)-A stated R8 wandered a lot and went in and out of other residents' rooms. R8 was always easily redirected, and she would go to her room. There was nothing care planned about wandering, but staff always kept a close eye on R8 when she was out of her room. During an interview on 5/28/26 at 9:11 a.m., NA-B stated she had never seen R8 go into R22's room but had heard about it. When R8 was wandering staff just tried to keep an eye on R8 and redirect her back to her room. I think that's all you can do. During an interview on 5/28/26 at 10:44 a.m., the social worker designee (SWD) stated at one point, R8 had entered R22's room and accused them of taking her dentures. Staff tried a lot of redirection with R8 because she was fixated on her dentures. There was no regular documentation of R8's behavior. SWD did not identify the assessment process for wandering.During an interview on 5/8/26 at 10:54 a.m., registered nurse supervisor (RN)-A stated R8 would get mixed up on where she was and would wander down the hall and enter other residents' rooms. Most of the time she was easily redirected, but other times R8 would start going through other residents' personal belongings. R8 required a lot of redirection to find her way back to her room. RN-A stated they were currently trying to always keep an eye on R8 when she was out of her room. R8's wandering should have been assessed and identified in the care plan due to being consistent behavior for her. During an interview on 5/28/26 at 11:14 a.m., the director of nursing (DON) stated resident care plans should have identified any regular resident behaviors and any interventions implemented. R8 did wander and enter into other residents' rooms and in recent months and had an escalation in wandering. R8 usually wanders right after meals, and they try to keep an eye on her and will redirect R8 back to her room. R8's should have been assessed and the care plan should have been updated to identify the wandering behavior and interventions in place. A wandering policy was requested, but it was not received.

Based on interview and document review, the facility failed to assess pneumococcal immunization status, provide education, and document discussion and offering of pneumococcal vaccination in accordance with current CDC recommendations for 2 of 5 residents (R20, R27) reviewed for immunizations. Findings include:R20:R20's admission Minimum Data Set (MDS) dated [DATE], identified R20 was admitted on [DATE], was cognitively intact and able to make her needs known. R20's diagnoses included diabetes and hypertension.R20's Preventive Health Care Report dated 5/25/10 through 5/28/26, identified R20 received Prevnar13 on 6/17/15. R20's electronic health record failed to include evidence R20 or R20's representative received education regarding pneumococcal vaccine booster and there was no indication R20 was offered the pneumococcal vaccine per CDC guidance in conjunction with their provider.R27:R27's annual MDS dated [DATE] identified R27 was admitted to the facility on [DATE] and was [AGE] years old. R27's diagnoses included coronary heart disease, heart failure, and thyroid disease.The facility immunization report dated 5/28/26, identified R27 received PCV13 on 8/30/17, and PPSV23 on 11/16/18. R27's electronic health record failed to include evidence R27or R27's representative received education regarding pneumococcal vaccine booster and there was no indication R27 was offered the pneumococcal vaccine per CDC guidance in conjunction with their provider.On 5/27/26 at 1:28 p.m., registered nurse (RN)-D stated immunizations were offered upon admission and seasonally. RN-A stated she reviewed the resident's immunization status upon admission. Immunizations were either administered, or a declination was signed after they were discussed with the resident and/or resident representative.On 5/28/26 at 8:53 a.m., the director of nursing (DON) stated she was uncertain what process the infection preventionist (IP) used to determine when a resident was due for the pneumococcal vaccine, although had recommended using the PnuemoRecs VaxAdvisor App or website (a standalone application that provides patient-specific guidance related to pneumococcal immunization schedule). The DON stated she was uncertain if R27 had received the most recent pneumococcal immunization. The DON stated there were no notes in the medical record identifying that the pneumococcal immunization was discussed or offered to R20 or R20's representative. Further, DON stated she expected all immunizations would be discussed with the resident and/or resident representative upon admission and per CDC guidance, as well as documenting a progress note in the resident's medical record.The Essentia Health Standard Work Process dated 3/5/26, identified staff reviewed vaccination history for all residents at the time of admission and assess if the resident needed vaccinations including pneumococcal. Staff provided and discussed the most current Vaccination Information Statement (VIS) with each resident and/or resident representative prior to administration, and document administration or declination in the resident's medical record.The CDC Pneumococcal Vaccine Recommendations dated 2/25/26 identified The United States uses 2 types of pneumococcal vaccines. Each individual vaccine helps protect against different serotypes of pneumococcal bacteria. Pneumococcal conjugate vaccines (PCVs) PCV15, PCV20 and PCV21; and Pneumococcal polysaccharide vaccine (PPSV23). Adults 50 years or older Administer PCV15, PCV20, or PCV21 for all adults 50 years or older, who have never received any pneumococcal conjugate vaccine, whose previous vaccination history is unknown. PCV15: Additional vaccination recommended If PCV15 is used, administer a dose of PPSV23A one year later. Only one dose of PPSV23 is indicated. If PPSV23 was previously administered, another dose isn't needed. The patient's pneumococcal vaccinations are complete. The minimum interval is 8 weeks and can be considered in adults with: An immunocompromising condition. A cochlear implant, A cerebrospinal fluid leak. PCV20 or PCV21: Additional vaccination not recommended If PCV20 or PCV21 is used, a dose of PPSV23 isn't indicated. Regardless of which vaccine is used (PCV20 or PCV21), the patient's pneumococcal vaccinations are complete. Recommendation for shared clinical decision-making: Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old.

Based on interview and document review, the facility failed to investigate, document, and track resolution of a resident grievance regarding another resident (R8) entering their room and going through their belongings for 1 of 1 resident (R22) reviewed for grievances.Findings include:R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 was cognitively intact and required set up and clean up assistance with eating and oral hygiene. R22 was dependent on staff in all other care areas. Diagnoses included hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness). R8's comprehensive MDS dated [DATE], identified R8 had severe cognitive impairment and had diagnoses that included dementia, depression and psychotic disorder. R22's nursing progress note dated 5/21/26 at 4:57 a.m., identified R22 wanted to talk to someone in charge in the morning about R8 digging in his drawers. R22's care plan revised 4/1/26, failed to identify R22 wishes to prevent other residents from entering his room uninvited. R22's medical record failed to identify any further documentation related to R22's concerns related to R8. A review of the facility's formal grievances and informal grievances dated 8/1/25 through 5/26/26, failed to identify R22's grievance including investigation and action taken by the facility.During an interview on 5/26/26 at 1:12 p.m., R22 stated R8 came into his room and accused him of stealing her things, especially R8's dentures. R22 stated he turned on his call light but by the time staff arrived R8 had already left. R22 stated he had told staff he didn't like R8 coming into his room and they told him to turn on his call light if R8 did. During an interview on 5/28/26 at 10:44 a.m., the social worker designee (SWD) stated when a resident filed a complaint or grievance, staff went over the grievance form with the resident if the resident wanted to make a formal grievance. If the resident just wanted to vent whatever the issue was, they would talk with the resident and make a way to fix it. The SWD kept a spreadsheet so all concerns would be tracked whatever the issue was. However, the SWD stated there was no documentation regarding R22's grievance because R22 had never wanted to file a formal grievance and R22's daughter had stated understanding with the situation. R22 did have a right to privacy in his room, and it was R22's right to file a grievance. The SWD had not documented an informal grievance for R22 and stated there should have been documentation. During an interview on 5/28/26 at 11:18 a.m., the director of nursing (DON) stated she expected staff to follow the grievance process whether it was formal or informal because staff needed to track all grievances to determine if there was a resolution or if the interventions implemented were working or not. The facility policy Resident grievances dated 4/21/26, identified a resident has the right to voice grievances (orally or in writing) without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff or other residents, and other concerns regarding their stay in the SNF. The resident has the right to, and the facility must make, Prompt efforts to resolve grievances the resident may have. The Resident may file grievances orally or in writing and may also file a grievance anonymously. All grievances will be responded to within seven (7) days of receipt. A grievance in which the Resident or Resident Representative requests be handled as a written formal grievance will be investigated and responded to in writing. Written responses to grievances will include a. The date the grievance was received, b. A summary statement of grievance; c. The steps taken to investigate the grievance; d. A summary of the pertinent findings or conclusions e. A statement as to whether the grievance was confirmed or not confirmed, f. Any corrective action taken or to be taken by the facility because of the grievance; and g. The date the written decision was issued, if required. Regardless of whether a written decision is required to be issued to a Resident or Resident Representative, the facility will document in writing (for its own records) all decisions.

Based on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented in accordance with Centers for Disease Control (CDC) recommendations during personal care for 1 of 1 residents (R11) reviewed who had a catheter. Findings include:A CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) manual, dated 7/2022, identified MDRO transmission within a nursing home was common and contributed to substantial resident morbidity and mortality. The feature outlined EBP were defined as, . expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The feature identified several examples of high-contact resident care activities including dressing, bathing, providing hygiene, transferring, changing linens or briefs, and wound care.R11's admission Minimum Data Set (MDS) dated [DATE], identified R11 had moderate impaired cognition and required moderate to maximum assistance with dressing, and grooming and supervision with bed mobility, transfers. R2 had an indwelling catheter. Diagnoses included cystitis and retention of urine. R11's care plan dated 7/22/25, identified R11 had an indwelling catheter due to urinary retention and required enhanced barrier precautions (EBP) during high contact cares. On 7/29/25, at 1:27 p.m. R11's room was observed from the hallway which had an orange-colored sign posted on the door which read Enhanced Barrier Precautions .Providers and staff must also: Wear gloves and gown for the following high contact resident care activities .dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assistance with toileting .the signage was provided from the CDC. Inside the room, a hard plastic cart with drawers with gowns and other PPE supplies was located inside R11's bathroom. During observation on 7/29/25, at 6:47 p.m. nursing assistant (NA)-B was assisting R11 to prepare for bed. R11 was lying on his bed and NA-B was at R11's bedside. NA-B was not wearing a disposable gown. NA-B obtained a wash basin with warm water and washcloth from R11's bathroom and donned disposable gloves, NA-B did not put on a disposable gown. NA-B opened R11's brief and preceded to wash R11's groin and peri area. NA-B leaned over the bedside while washing and NA-B's uniform touched R11's bed and upper thigh, while washing the groin area. NA-B finished washing and drying R11's peri area, removed his gloves and called for the nurse on his walkie. Registered nurse (RN)-D entered R11's room and put on gloves. RN-D did not put on a disposable gown. RN-D manipulated R11's catheter near the tip of the penis, pulled R11's foreskin back and instructed NA-B to continue to try to wash the cream off of R11's groin, stating R11 had a lot of cream build up in the area. RN-D removed her gloves, applied alcohol-based hand sanitizer (ABHR) to her hands and exited the room. NA-B donned disposable gloves and without gowning, continued to wash and then dry R11's groin and peri are. NA-B, after removing their gloves called for the nurse on the walkie. RN-D entered R11's room, donned disposable gloves, but did not don a disposable gown, and applied the prescription cream to R11's groin and penis. RN-D removed her gloves, applied ABHR to her hands and exited the room. After cleaning up the bedside, NA-B washed his hands, put on a disposable gown and donned gloves. NA-B stated he was donning the disposable gown because he planned to drain R11's catheter. NA-B emptied R11's catheter, rinsed and put away the urinal and removed his PPE.During interview on 7/29/25, at 7:38 p.m. NA-B stated he had not been instructed to wear PPE when assisting R11 with personal care, only when working with R11's catheter. NA-B reviewed the EBP signage located on R11's door, NA-B verified the sign instructed staff to wear gown and gloves when assisting the resident with bath, transfers, cares, dressing, grooming and personal care. NA-B stated he should have been wearing a gown and gloves when he assisted R11 to prepare for bed and that was his mistake, he had screwed up. When interviewed on 7/29/25, at 7:39 p.m. RN-D verified she had manipulated R11's catheter near his penis and put on prescribed cream without donning a disposable gown. RN-D stated R11 was on EBP and she should have had a gown on when she assisted with R11's care. It was important to wear a gown and gloves when providing personal care when a resident was under EBP to prevent staff from bringing the germs out into the facility and to protect the other residents. She had not realized NA-B was not wearing a gown when providing care to R11 either and he should have been wearing one as well. During interview on 7/30/25, at 9:21 a.m. RN-E stated she was in charge of the infection control program for the facility. Staff had been educated to wear gown and gloves when they assisted a resident with personal cares if the resident was under EBP. The facility staff had been educated the PPE needed to be worn with all care and not just catheter care when EBP's were in place. RN-E did not know why the appropriate PPE had not been worn when NA-B and RN-D had been assisting R11 with bedtime cares, as they should have known better. When interviewed on 7/30/25, at 1:35 p.m. the director of nursing (DON) stated all staff had been educated on the appropriate use of PPE when a resident was under EBP's and they should have known when and how to use PPE when they had provided assistance to R11 with personal care. The facility policy Enhanced Barrier Precaution's dated 7/1/24, identified EBP was used in long term care settings and referred to the use of gown and gloves during high-contact care activities that provided opportunities for transfer of multidrug resistant organisms (MDROs) to staff hands and clothing. Staff were to initiate PPE use of gowns and gloves during the following high contact resident care activities: dressing, bathing, transferring, providing hygiene, changing linens, and changing briefs or toileting as well as device care or use with central lines, urinary catheters, feeding tubes, or tracheostomy/ventilator care.

Based on interview and document review, the facility failed to revise the care plan to remove restorative nursing ambulation program from the care plan for 1 of 4 resident (R15) reviewed for restorative nurse services. Findings include:R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had severe cognitive impairment and identified R15 was dependent of staff for transfers and bed mobility and R15 did not ambulate (walk).R15's care plan dated 6/3/25 identified:R15 was to ambulate with an assist of two of the restorative aides assisting, until physical therapy (PT) provided further treatment.R15 was on a wellness ambulation program that indicated R15 would ambulate daily or as tolerated with restorative.R15's doctor's note from 11/14/24, identified R15 had declined and was no longer able to walk.R15 behavioral health note from 12/31/24, identified resident was no longer ambulating.During an interview on 7/29/25 at 2:12 p.m., family member (FM)-A stated R15 had not walked for close to a year.During interview on 7/30/25 at 8:21 a.m., trained medication assistant (TMA)-C stated they had been working here for a couple of years and had not seen R15 walk.During interview on 7/30/25 at 9:00 a.m., TMA-A (who also work as a restorative aide) stated R15 was able to stand and transferred from bed to wheelchair. R15 had not been able to walk and was not receiving ambulation services.During interview on 7/30/25 at 12:30 p.m., registered nurse (RN)-B stated at one time R15 was able to walk but it was a long time ago. The care plan should have been updated when there was a change in R15's walking abilities.During interview on 7/30/25 at 12:37 p.m., RN-C stated R15 had not been ambulatory since they were in their current position, which was about a year. Care plans were to be reviewed every three months, or if there was a change in a resident's status. R15 was not ambulating, and the care plan should have reflected that.During interview on 7/30/25 at 12:41 p.m., the director of nursing (DON) stated it was an expectation a resident's care plan was to be reviewed every three months or sooner if there had been a change in a resident's status. R15 was not ambulatory, and the care plan should have been updated.The facility's Care Planning-Care Conferences policy dated 8/9/24, identified to reviewed and updated plan of care quarterly and with any change in resident condition or care needs.

Based on observation, interview and document review, the facility failed to comprehensively assess for a decline in activities in daily living (ADL) and ensure a referral from physical therapy for the decline in ADL's was acted upon for for 1 of 5 residents (R2) reviewed for ADL's Findings include:R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment. R2 was independent with eating and could turn and reposition herself in bed. R2 required moderate assistance to sit up, toilet, transfers and ambulate 10 feet, 50 feet and 150 feet. Diagnoses included malignant neoplasm of breasts, dementia, atrial fibrillation (irregular heartbeat) and low back pain.R2's quarterly MDS dated [DATE], identified severe cognitive impairment. R2 required set up with eating and moderate assistance to turn and reposition when in bed. R2 required maximum assistance to sit up, toilet, transfers and ambulation 10 feet. Ambulation 50 and 150 feet were not attempted due to medical condition or safety concerns. R2's care plan with review date 6/27/25, identified R2 required assistance with activities of daily living (ADLs) and was at risk for needing more assistance due to changing cognitive ability. Staff were instructed to use extensive assist of two or three persons to ambulate, and R2 was independent with bed mobility. R2 needed moderate to maximum assistance with dressing and extensive assist of one to two persons with transfers and toileting. R2's care plan had not been updated to reflect her more current functional assessments and decline in physical mobility. R2's progress notes were reviewed 6/1/25 through 7/27/25 and identified the following;6/4/25, identified staff had concerns with R2's ambulation, needing two persons to ambulate and another with the wheelchair behind as R2 tilted badly to the side with ambulating. R2 was requiring a stand lift to transfer more in the evenings. 6/4/25, an order was obtained for a physical therapy evaluation and treatment for ambulation and transfers. 6/5/25, staff identified R2 needed a lot of encouragement with ambulation. R2 would take shuffling her feet, knees rubbing against each other, taking a bit of time to take a step and then suddenly R2's knees would buckle, and she would start to drop. The medical record lacked an assessment from physical therapy and/or an assessment from nursing related to the decline in physical abilities. During interview on 7/29/25, at 2:40 p.m. trained medical assistant (TMA)-B stated R2 was ambulating a few months ago but did not now. R2 would lean heavily to one side, and it just was not safe for her to ambulate. R2 was still able to stand and pivot most of the time. TMA-B was not sure if therapy worked with R2 after she stopped ambulating. TMA-B did not think anything specific had occurred, and thought it was related to a decline in her general condition. During observation on 7/29/25, at 6:29 p.m., nursing assistant (NA)-A assisted R2 to wash and dry and put on a nightgown. NA-A put a gait belt around R2's waist and instructed her to grab on to the grab bar and stand. NA-A assisted R2 to a standing position and finished peri care and put on a disposable brief. NA-A assisted R2 to pivot and sit in her wheelchair. R2 was able to bear weight but was unable to take a full step to pivot and became unsteady, with knees knocking together. NA-A assisted R2 to sit down in the wheelchair quickly due to R2 was becoming off balance. NA-A stated R2 used to walk but was no longer able to. R2 usually could transfer with one person but occasionally would need two and the stand lift. When interviewed on 7/30/25, at 8:29 a.m. registered nurse (RN)-A stated she completed the MDS's for the residents in the facility. She considered a significant change with residents when they returned from the hospital and there were changes with the resident's abilities, as well as when the facility nurses or nursing assistants reported changes or a decline noted with residents. When a resident needed more assistance with ADLs, had memory changes or wound with delayed healing a significant change MDS would be needed. There had been an order for therapy to see R2 and she had not realized that was not completed yet. They should have seen her to evaluate the decline in physical mobility. She should have followed up with therapy and that had gotten missed. Therapy usually was good about communicating with nursing staff and nursing should have followed up with them to ensure the assessment had been completed as that would have helped them to trigger R2 was a significant change as well. RN-A stated she knew R2 was having some cognitive issues as well. Further, RN-A stated she should have done a significant change instead of her last quarterly or documented why she felt one was not required, if she felt was more of an acute change and was not anticipated to be a permanent decline. During interview on 7/30/25, at 9:30 a.m. physical therapist (PT)-A stated he had received an order to do a physical therapy evaluation with R2 on 6/5/25. He had attempted to see R2 on a few occasions, but she had not been available each time he tried. R2 had either been in the bathroom or attending activities and so an evaluation had not been completed. It was a long time since therapy had received that order and R2 should have been seen. It would be important to have R2 evaluated more timely to correspond with her last MDS observation period to determine if a significant decline in her physical condition had occurred. Usually therapy communicated with the facility staff to notify them the evaluation had not been completed but with R2's case they had not done so. R2's physician had not been notified of the delay with R2's physical therapy evaluation either. During interview on 7/30/25, at 1:35 p.m. the director of nursing (DON) stated therapy should have evaluated R2's ambulation and transfers when they had received the order on 6/5/25. The facility's undated Therapy Order Checklist identified if a therapy evaluation was not completed within three business days for non-medicare stays the therapy would be contacted requesting an anticipated completion date and the provider and resident would be updated with the reason for the delay. Therapy would document all attempts that had been made to complete the resident's evaluation and nursing would continue to follow up with therapies until the evaluation was completed. For skilled therapy orders the evaluation would be completed within twenty-four hours of admission. A physical therapy policy was requested; however, none was received.

Based on observation, interview and document review, the facility failed to complete a significant change in status assessment (SCSA) when two or more areas of change in resident status were identified on the Minimum Data Set (MDS) for 1 of 5 residents (R2) reviewed for activities of daily living (ADLs). Findings include: R2's quarterly MDS dated [DATE], identified R2 had severe cognitive impairment. R2 was independent with eating and could turn and reposition herself in bed. R2 required moderate assistance to sit up, toilet, transfers and ambulate 10 feet, 50 feet and 150 feet. Diagnoses included malignant neoplasm of breasts, dementia and low back pain. R2's quarterly MDS dated [DATE], identified R2 had severe cognitive impairment. R2 required set up with eating and moderate assistance to turn and reposition when in bed. R2 required maximum assistance to sit up, toilet, transfers and ambulation 10 feet. Ambulation 50 and 150 feet were not attempted due to medical condition or safety concerns. R2's care plan with review date 6/27/25, identified R2 required assistance with activities of daily living (ADLs) and was at risk for needing more assistance due to changing cognitive ability. Staff were instructed to use extensive assist of two or three persons to ambulate, and R2 was independent with bed mobility. R2 needed moderate to maximum assistance with dressing and extensive assist of one to two persons with transfers and toileting. R2's care plan had not been updated to reflect her more current functional assessments and decline in physical mobility. R2's Functional Abilities assessment dated [DATE], identified R2 required setup with eating and assist of one with toileting, grooming, bed mobility, toileting, transfers, and dressing. R2 was having more difficulty with ambulation, dependent with ambulation up to 10 feet and was unable to ambulate any further. R2's progress notes were reviewed 6/1/25 through 7/27/25 and identified the following; -6/4/25, identified staff had concerns with R2's ambulation, needing two persons to ambulate and another with the wheelchair behind as R2 tilted badly to the side with ambulating. R2 was requiring a stand lift to transfer more in the evenings. -6/4/25, an order was obtained for a physical therapy evaluation and treatment for ambulation and transfers. -6/5/25, staff identified R2 needed a lot of encouragement with ambulation. R2 would take shuffling her feet, knees rubbing against each other, taking a bit of time to take a step and then suddenly R2's knees would buckle, and she would start to drop.-6/26/25, a significant weight loss was identified, as R2 had lost 8 pounds, 5 percent, in 28 days. During interview on 7/29/25, at 2:40 p.m. trained medical assistant (TMA)-B stated R2 used to ambulate but did not now. R2 would lean heavily to one side, and it just was not safe for her to ambulate. R2 was still able to stand and pivot most of the time. TMA-B was not sure if therapy worked with R2 after she stopped ambulating. TMA-B did not think anything specific had occurred, and thought it was related to a decline in her general condition. During observation on 7/29/25, at 6:29 p.m., nursing assistant (NA)-A was assisting R2 to wash and dry and put on a nightgown, NA-A put a gait belt around R2's waist and instructed her to grab on to the grab bar and stand. NA-A assisted R2 to a standing position and finished peri care and put on a disposable brief. NA-A assisted R2 to pivot and sit in her wheelchair. R2 was able to bear weight but unable to take a full step to pivot and became unsteady, with knees knocking together. NA-A assisted R2 to sit down in the wheelchair quickly due to R2 becoming off balance. NA-A stated R2 used to walk but was no longer able to. R2 usually could transfer with one person but occasionally would need two and the stand lift. When interviewed on 7/30/25, at 8:29 a.m. registered nurse (RN)-A stated she completed the MDS's for the residents in the facility. She considered a significant change with residents when they returned from the hospital and there were changes with the resident's abilities, as well as when the facility nurses or nursing assistants reported changes or a decline noted with residents. When a resident needed more assistance with ADLs, had memory changes or wound with delayed healing a significant change MDS would be needed. There had been an order for therapy to see R2 and she had not realized that was not completed yet. They should have seen her to evaluate the decline in physical mobility. She should have followed up with therapy and that had gotten missed. Therapy usually was good about communicating with nursing staff and nursing should have followed up with them to ensure the assessment had been completed as that would have helped them to trigger R2 was a significant change as well. RN-A stated she knew R2 was having some cognitive issues as well. Further, RN-A stated she should have done a significant change instead of her last quarterly or documented why she felt one was not required, if she felt was more of an acute change and was not anticipated to be a permanent decline. During interview on 7/30/25, at 1:35 p.m. the director of nursing (DON) stated R2 should have had a significant change MDS completed instead of a quarterly due to the decline in her physical abilities. The Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual pages 2-21 through 2-28 identified a significant change in assessment (SCSA) was appropriate if there were two or more changes in the following areas: decision making ability, presence of a mood item not previously recorded, changes in frequency or severity of behaviors, any decline in an ADL physical functioning area where a resident was newly coded as moderate, maximum assistance, dependent or activity not attempted since last assessment, incontinence pattern changes, placement of indwelling catheter, or the emergence of unplanned weight loss of 5% in 30 days or 10% in 180 days, emergence of a new pressure ulcer stage two or higher, or use of a new restraint. The facility policy Notification of Condition dated 7/5/24, identified the nurse would update the resident's care plan, communicate the changes to the rest of the care team and the interdisciplinary team would review the resident with changes in condition to determine if a significant change MDS was needed based on the resident assessment instrument guidelines.

Based on interview and document review, the facility failed to ensure range of motion (ROM) was completed in accordance as care planned from therapy recommendations to prevent the loss of mobility for 1 of 3 residents (R17) reviewed for restorative nursing services. Findings include: R17's Therapy Screening Form dated 9/28/23, identified the physical therapist had reviewed R17's Functional Maintenance Program and ROM. R17 stated stretching felt good and staff were to continue with her current restorative program three times per week. R17's care plan dated 5/24/25, identified R17 had impaired mobility related to multiple sclerosis with a long-term goal to transfer into her wheelchair at least one time daily. Approaches included restorative nursing to assist R17 with ROM to both upper and lower extremities three times weekly. R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 had intact cognition, was dependent on staff with all activities of daily living (ADLs) and was unable to ambulate. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease, anxiety, and chronic pain. R17's Point of Care History for restorative nursing identified the following:June 2025, identified R17 was offered ROM exercises two times per week and not the three times per week ordered by therapy and identified in R17's care plan. July 2025, identified R17 was offered ROM exercises one time per week for three weeks. Two times per week for one week and was not offered any exercise for one week during the month.During interview on 7/30/25, at 12:23 p.m. trained medication aide (TMA)-A stated she mainly worked in restorative nursing as an exercise technician. TMA-A did go to R17's room and offer exercises as care planned, however, R17 would frequently refuse. She thought she offered the exercises more than identified on the point of care history; however, TMA-A did not chart refused or unavailable as often as she should have. The documentation did not reflect the three times per week exercises as ordered and she felt she needed to improve her documentation. When interviewed on 7/30/25, registered nurse (RN)-A, who assisted to coordinate the restorative nursing program, stated a therapist set up the resident exercises and put the instructions in the facility restorative book for the restorative aides to follow. The restorative aide should be offering R17 exercises three times per week and document when R17 refused or was unavailable. When interviewed on 7/30/25, at 1:35 p.m. the director of nursing (DON) stated restorative nursing should offer residents exercises as directed on their plan of care and unavailability or refusals should be documented each time it occurred. During interview on 7/30/25, at 3:13 p.m. R17 stated the staff did not ask her to do exercises very often and there were times when she was asked and refused them. She felt the staff asked her about exercises when she was in the middle of working on her computer games and then she refused. They never offered to come back at a later time, and she never asked them to come back either as they were always so busy. R17 stated staff never offered exercises very often anyway. It would be nice if they offered it daily, but they did not. The most staff came in and offered was one or two times per week. Some weeks they did not offer exercise at all. A policy for restorative nursing was requested, however, none were received.

Based on observation, interview and document review, the facility failed to provide medications as ordered for 1 of 5 residents (R11) reviewed for medication management. Findings include: R11's admission Minimum Data Set (MDS) dated [DATE], identified R11 had moderate impaired cognition and had an indwelling catheter. Diagnoses included cystitis, retention of urine., atrial fibrillation, and peripheral venous insufficiency. R11's Physician Orders dated 6/9/25, included furosemide (a diuretic to treat fluid retention) 40 milligrams (mg) to give for a 3 pound (lb.) weight gain overnight. The medication was to be given once in the morning as needed (PRN) and daily weights were to be obtained once in the mornings to give PRN furosemide, if R11 gained three pounds (lb.) in one day. R11's June 2025 Medication Administration Record (MAR) and corresponding weights were reviewed from 6/1/25 to 6/30/25 and identified the following:On 6/23/25 40 mg of Lasix was given for for a 3 lb. weight gain in a day, however, R11's weight on 6/22/25 was 181.9 lbs. and was 183 lbs. on 6/23, which was a weight gain of only 1 lb. 9 oz.On 6/26/25, 40 mg of Lasix was given for for a 3 lb. weight gain in a day, however, R11's weight on 6/25/25 was 183.9 lbs. and was 184.9 lbs. on 6/26/25, which was 9 oz. gain.R11's July 2025 MAR, and corresponding weights were reviewed from 7/1/25 to 7/30/25 and identified the following:On 7/9/25, 40 mg of Lasix was given for for a five percent weight gain, however, R11's weight had not been recorded the day prior, and it could not be determined if R11 had a 3 lb. weight gain. On 7/29/25, at 6:47 p.m. R11 was observed to have swelling in both lower extremities. During interview on 7/30/25, at 9:14 a.m. registered nurse (RN)-B stated R11 had an order to administer furosemide if R11 had a weight gain of 3 lbs. or more in one day. The nurse was to document the weight on the resident's MAR as well as the administration of the PRN furosemide and its effectiveness. Some of the nurses would also document the weight and administration of the PRN medication in the resident progress notes. RN-B believed the furosemide administered on 6/23/25, 6/26/25 and 7/9/25, were given in error and she would fill out medication error reports for all three of the days. During interview on 7/30/25, at 1:35 p.m. the director of nursing (DON) stated the nurse should have clarified the PRN furosemide order before administering the medication. They had identified it was the same nurse making the medication errors and had educated her on the intent of the order and the process for obtaining and evaluating R11's weights as well when the PRN furosemide was to be administered. On 7/30/25, at 2:45 p.m. a call was attempted to R11's primary physician, however, was not returned. During telephone interview on 7/30/25, at 3:30 p.m. the facility's consultant pharmacist (CP)-C stated although R11 did receive furosemide in error on three occasions it probably was not a significant medication error, especially because R11 did not have an order to receive scheduled regularly scheduled furosemide. It would be more significant if he did receive furosemide scheduled daily and then received additional doses in error because then it could affect some of his lab values such as sodium and potassium or would worry about dehydration. Because he only received it occasionally for weight gain over 3 lbs. the three additional doses spread out throughout the two months would not be clinically significant. The facility policy Medication Management dated 8/8/24, directed nursing staff prior to administration, a medication and dosage schedule on the MAR was to be compared with the medication label. For orders with physician parameters for administration, the nurse was to verify the medication met the ordered parameters (i.e. specific range or values of weight, blood pressure, pulse blood glucose, oxygen saturations, etc.).

Based on observation, interview and document review, the facility failed to perform hand hygiene for 2 of 5 residents (R20, R29) observed for activities of daily living (ADL's); the facility failed to implement Enhanced Barrier Precautions for 1 of 2 (R9) residents reviewed for pressure ulcers. Findings include: Hand Hygiene: R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 had severe cognitive impairment, and was dependent on staff are all care areas. During an observation on 6/6/24 at 8:16 a.m., nursing assistant (NA)-B and NA-C assisted R20 to transfer from a shower chair to his bed by a full body mechanical lift. R20 was incontinent of bowel (BM). NA-B and NA-C applied clean gloves and cleaned the BM from R20. - At 8:30 a.m., NA-B and NA-C removed their soiled gloves, did not perform hand hygiene, and applied clean gloves. NA-B and NA-C assisted R20 to dress and transferred R20 back into his wheelchair with a full body mechanical lift. - At 8:34 a.m., NA-C continued to wear soiled gloves and reached into R20's bedside drawer to obtain an oral swab. NA-C unwrapped and wetted the swab and moved to clean R20's mouth. NA-C and NA-B stated they did not perform hand hygiene. NA-C stated she should have performed hand hygiene because she was going to put the swab in R20's mouth. R29's quarterly MD dated 5/22/24, identified R29 had mild cognitive impairment and required assistance with ADL's. During an observation on 6/6/24 at 7:29 a.m., NA-A assisted R29 with morning cares while R29 was in bed. R29 was incontinent of BM. NA-A applied clean gloves and cleaned BM from R29. - At 7:31 a.m., NA-A removed the soiled gloves and applied clean gloves. NA-A did not perform hand hygiene. - At 7:39 a.m., NA-A assisted R29 to dress, transferred R29 into his wheelchair and assisted R29 into his bathroom. NA-A did not perform hand hygiene and obtained R29's toothbrush, basin, toothpaste from the 2-drawer bin. R29 took the supplies from NA-A, put toothpaste on his toothbrush while NA-A began to obtain a glass of water for R29. NA-A stated she did not perform hand hygiene and she should have. It's the germs. I was getting stuff to go into his mouth. During an interview on 6/6/24 at 10:58 a.m., registered nurse (RN)-B stated staff were expected to perform hand hygiene when they arrived to work, after and before eating, before and after wearing gloves and before and after resident contact; or whenever going from clean to dirty. RN-B stated staff hands were contaminated, especially after incontinence cares. During an interview on 6/6/24 at 11:03 a.m., the director of nursing (DON) stated staff were expected to perform hand hygiene before and after any patient contact and/or after removing gloves. Staff were expected to absolutely perform hand hygiene prior to oral cares. Hand hygiene was important in infection prevention, whether spreading possible organisms to the residents or staff. Handwashing broke the chain of contamination. The facility Hand Hygiene policy revised 11/10/23, identified hand hygiene practices and expectations for healthcare workers, prevent the transmission of pathogens and aid in the reduction of healthcare associated infections. V. All healthcare workers must perform hand hygiene: A. Before patient contact or contact with the patient's environment. 1. Before entering a patient's room 2. Before touching a patient 3. Before touching any object or furniture in the patient zone B. After patient contact 1. After touching a patient 2. After touching any object or furniture in the patient environment C. Before clean/aseptic procedure D. After body fluid exposure risk E. When moving from a contaminated body site to a clean body site during patient care F'. Before putting on gloves G. After removing gloves or other personal protective equipment. H. Before administering medication. I. Upon arrival and before leaving work. J. After sneezing or coughing. K. Before and after eating. L. After using the restroom. Enhanced Barrier Precautions: R9's quarterly MDS dated [DATE], identified R9 was cognitively intact and had a stage 3 pressure ulcer. R9's care plan revised 5/5/24, identified R9 had impaired skin integrity related to incontinence and was at risk for skin breakdown. Staff were directed to perform weekly wound measurements and documentation. The care plan failed to identify if Enhanced Barrier Precautions (EBP) was implemented for R9. R9's Physician Orders dated 6/1/24, failed to identify if EBP had been ordered for R9. During an observation on 6/6/24 at 11:18 a.m., no EBP signage or personal protective equipment (PPE) were available for R9. Licensed practical nurse (LPN)-A stated R9 did not require EBP because the wound was not infected. LPN-A performed a dressing change to R9's right heel pressure ulcer while wearing gloves but wore no other PPE. During an interview on 6/6/24 at 1:22 p.m., RN-B stated if a resident had a draining wound and/or an indwelling device, the resident would be placed into EBP. RN-A did not realize the CDC guidance included EBP for a chronic open wound. During an interview on 6/6/24 at 2:20 p.m., the DON stated she was aware of the guidance to implement EBP for a resident with draining wounds and/or an indwelling device, but the facility had not interpreted the guidance to implement EBP for R9. The DON stated she did expect staff to follow guidance and she needed to provide more staff education when/where EBP should be implemented. The facility Enhanced Barrier Precautions Standard Work approved 11/7/22, identified Enhanced Barrier Precautions expanded the use of PPE and referred to the use of gown and gloves during high-contact resident care activities that provided opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices were at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions did not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. The Center for Disease Control and Prevention (CDC) Consideration for Use of Enhanced Barrier Precautions (EBP) in Skilled Nursing Facilities dated 6/2021, identified EBP expanded the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multiple Drug Resistant Organisms (MDROs) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices were at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator - Wound care: any skin opening requiring a dressing

Based on observation, interview and document review, the facility failed to perform routine monitoring of a wound to promote healing for 1 of 2 residents (R9) reviewed for wound care. Findings included: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 was cognitively intact and had diagnoses that included Type 2 diabetes. R9 had a stage 3 pressure ulcer. R9's care plan revised 5/5/24, identified R9 had impaired skin integrity related to incontinence, was at risk for skin breakdown and needed assistance with mobility. Staff were directed to perform weekly wound measurements and documentation. R9's physician order dated 6/1/24, identified a dressing change to the right heel. Moist gauze, light gauze and kerlix every other day. Monitor for infection/redness. Special Instructions: Document date changed in results. R9's Wound Management Detail Report dated 12/13/23 through 4/15/24, identified R9 had a stage 3 (affects the top two layers of skin as well as fatty tissue) pressure ulcer to the right heel. The last documented measurement on 4/15/24, was 1.0 centimeters (cm) x 1.5 cm with edges epithelizing flush with wound base; macerated/soft with well-defined wound edges. However, the report failed to identify any measurements from 4/15/24 through 6/6/24 and defining characteristics. During an interview on 6/4/24 at 12:57 p.m., R9 stated she had a pressure ulcer on her right heel because she rubbed her heel on the bed mattress. R9's progress note dated 4/22/24, identified R9's wound was debrided by podiatry. During an observation on 6/6/24 at 11:18 a.m., licensed practical nurse (LPN)-A stated R9 had a pressure ulcer to the right heel. LPN-A performed a dressing change as ordered. Upon removal of the dressing, there was a moderate amount of purulent drainage and measured 2 cm x 1 cm. LPN-A stated there was an additional reddened area surrounding the wound that measured 1.5 cm. - At 11:31 a.m., LPN-A stated wound documentation was entered into R9's chart on bath days. The staff charted in a progress note and there was an observation that was entered as well. During an interview on 6/6/24 at 11:38 a.m., registered nurse (RN)-A stated R9 had a pressure ulcer on her right heel when R9 returned from the hospital on 12/13/23. The facility did have a nurse who was designated to perform wound assessments but left her role in mid-April 2024. After that, not all staff were documenting in the same place. RN-A stated R9's medical record lacked measurements after 4/15/24, and then stated wound monitoring was important to wound healing including preventing infections. During an interview on 6/6/24 at 11:50 a.m., the director of nursing (DON) stated a RN should assess and document wound care. The previous wound nurse left her role mid-April 2024. After that, documentation was not completed consistently with all staff. In observations, there was a wound form for staff to complete, however, the licensed practical nurses did not have access. Because of this, staff did not document the required information such as measurements and description. Wound care documentation was important for tracking of wound condition/healing. A wound care policy was requested but not received.

Based on observation, interview and document review the facility failed to ensure safe transfer while utilizing a mechanical lift for 1 of 3 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for R1. The immediate jeopardy began on [DATE], when R1 fell while being transferred in a full body mechanical lift that tipped over during provision of care. The facility failed to identify if the staff were correctly using the lift per manufacturer recommendation when the incident occurred. Additional transfer observations identified manufacturer's guidelines were not followed for safe use. The IJ was identified on [DATE]. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 5:05 p.m. on [DATE]. The IJ was removed on [DATE] at 3:22 p.m., but non-compliance remained at the lower scope and severity level 2, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: R1's Resident Face Sheet identified diagnosis that included chronic pain, depression, obesity and long term use of anticoagulants (blood thinners). R1's annual Minimum Data Set, dated dated dated [DATE], identified intact cognition and indicated he was dependent on staff for transfers. R1's care plan dated [DATE], identified the use of a full body mechanical lift for transfers and lift sling size 2 extra large (XL), updated [DATE]. The care plan identified a fall on [DATE], while in the mechanical lift involving two nursing assistants (NA)'s performing the transfer resulting in bruising and scrapes to the right side of R1's body. The care plan indicated staff were provided education on use of the full body lift and indicated a nurse was to be present in the room during transfers with two NA's performing the transfer to observe for safety and correct use of the lift. The care plan further indicated R1 had trauma induced signs and symptoms of nervousness and anxiety due to a previous fall from the lift. R1's Resident Progress Note dated [DATE], indicated two NA's were assisting R1 with transfer from bed to wheelchair using a full body mechanical lift. One NA was moving R1 from the bed to the chair and attempted to open the legs of the lift and the lift started to tip while R1 was in it. R1 fell with the lift and hit his head on the floor. [DATE], Resident Progress Note indicated the interdisciplinary team reviewed the fall and identified the contributing cause of the fall as; equipment tipped, staff reported R1 adjusted himself while in the lift when the lift was being moved out from under the bed to extend the legs. R1 reported the legs of the split leg sling were not crossed as recommended by the manufacturer because it caused him discomfort. Further root cause analysis indicated staff had used an XL sling and based on R1's current measurements the sling size should have been changed to a 2XL. Interventions to prevent recurrence included removing the lift from service. Facility document titled Mechanical Lift [DATE], Incident and OHFC (office of health facility complaints) Report indicated R1 fell while in full body mechanical lift sling during transfer from bed to his wheelchair. Lift tipped and R1 landed on the floor. Verified R1's weight was within range of the lift, R1's weight increased from 395 pounds to 413 pounds between [DATE], and [DATE], and sling size was updated to 2XL based on the weight gain. A nurse must be in the room for all transfers of R1 until further notice. Staff involved were interviewed. All transfers with the lift must be observed by a nurse to verify competency prior to using a lift without supervision. Lift involved was immediately removed from service and brought to maintenance, not to be used until cleared by maintenance. The incident occurred while staff were transferring R1. Staff were unable to extend the legs of the lift under R1's bed and as staff moved the lift clear of the bed to allow base to be extended, R1 adjusted himself in the lift causing the lift to tip over. R1 landed on his butt on the floor and hit his head on the floor. Staff reported R1 would not allow the straps on the sling to be criss crossed as recommended by the manufacturer. R1 also had an 18 pound weight gain over the past few months and XL sling was no longer appropriate. Reported indicated facility took the following action: Sling size was updated to 2XL based on the weight gain, staff were competency tested on full body mechanical lift and educated prior to working their next shift. Care plan was updated to include three staff present during R1's transfers to include a licensed staff member. Maintenance inspected the lift used during the transfer that resulted in the fall and removed some hair that had been hindering movement in the wheels. During interview on [DATE] at 1:36 p.m., R1 asked, Are you here about the ride I took? I hit my tailbone, it hurt so bad, but they did an X-ray and nothing was broken. R1 stated the staff had lifted him up off the bed and were going to swing the lift over and must have swung it a little too fast because it went over. R1 indicated the wheelchair was between the bed and the closet and said, I was in it [the lift] and when they started turning to put me in the chair, that's when it hit [tipped over]. R1 stated he was scared the last time the lift had tipped during a transfer but said, I'm getting used to it now. R1 stated he was scared it was going to happen again, and it did, indicated he was afraid and said, It will probably be more serious next time. During interview on [DATE] at 1:58 p.m., NA-A stated on [DATE], when the lift had tipped over during R1's transfer, she had been behind the wheelchair while NA-B was running the lift. NA-A said the legs on the lift were closed until it cleared the bed and when NA-B opened the legs the lift started tipping. NA-A stated she had not assisted with the transfer, only stood behind the chair. NA-A further stated the straps of the sling that go between R1's legs had not been crossed as recommended by the manufacturer and said staff had not been doing it for a long time because R1 did not like it that way. NA-A stated since the fall staff now crossed the sling between R1's legs and kept the legs of the lift open during the entire transfer. During interview on [DATE] at 2:06 p.m., registered nurse (RN)-A stated on [DATE], she had been called to R1's room and found him on the ground next to his wheelchair. RN-A said she was told staff had been transferring R1 from his bed to the wheelchair and the lift had tipped. RN-A said staff reported they could not open the legs of the lift while it was under the bed and when they pulled out the lift and tried to open the legs, the lift tipped over. RN-A stated one staff should have been operating the lift and the second staff should have been holding onto the handles of the sling to assist with guiding during the transfer. RN-A stated R1 had a trapeze to assist with movement in bed and the legs were under the bed and interfered with opening the legs of the lift. RN-A said since the incident occurred, staff had received more training and said everyone had been educated and said a nurse was observing transfers in R1's room. RN-A further stated R1 should have been assessed for a new sling during his assessment period in February 2024, and said at that time he may have needed a new sling size. During interview on [DATE] at 2:49 p.m., the lift company's representative stated other than a mechanical issue, the only way a lift could tip over was if the resident's weight was centered on the outside of one of the legs which would cause the lift to become unbalanced. The representative stated debris in the wheels may make the lift harder to push but would not cause it to tip over. The representative indicated using the incorrect sling would only affect comfort but would not affect the balance of the lift and said if the resident was attempting to re-adjust in the sling there was no way they could get enough leverage to get themselves outside the area where the legs are balanced. He added, they trained staff to make turns with the legs open but they should be able to safely turn the lift with the legs closed. The lift representative stated unless something on the lift failed, user error was usually the cause of a lift tipping over and if the lift tipped over it would have been during the maneuvering and a leg getting hung up on something. During interview on [DATE] at 3:37 p.m., NA-B stated she had been assisting with the transfer when the lift tipped over with R1 in it. NA-B stated she had been operating the lift and said as she pulled the lift back it tipped over. NA-B stated she could not fully extend the legs under the bed and when she tried to extend them they got stuck and the lift tipped. During interview on [DATE] at 3:50 p.m., the lift used during the transfer that resulted in R1's fall was observed with maintenance worker (MW)-A. The lift was a Volaro PC 450 Series. MW-A indicated there had been some hair stuck in the wheels and said he had removed some small strands. MW-A stated it had not been a significant amount of hair and said everything else had been in good working condition with no other mechanical concerns identified. During observation and interview on [DATE] at 11:25 a.m., NA-C and NA-D prepared to transfer R1 from his bed to wheelchair using the full body mechanical lift. NA-C moved the bed away from the wall so the legs of the trapeze would not interfere and they hooked the straps of the sling to the mechanical lift. When the lift was raised the battery was observed to be low powered and a sling strap came unhooked from the machine. NA-C stated he visualized the straps after hooking them up but did not pull on the straps to ensure they were secure. NA-C and NA-D secured the strap and completed the transfer. RN-B was present in the room to observe the transfer and did not intervene or question the low power warning or when the strap came undone from the lift. During interview on [DATE] at 12:39 p.m., R1 stated each fall he had from the lift occurred when staff were turning him so he told the staff to eliminate turning the lift when he was in it to avoid more falls. R1 said during the transfer at 11:25 a.m. staff had the sling hooked up right but when it got weight on it, the strap came unhooked and out of his hand as he had been holding onto the straps. R1 stated it was okay this time because he was over the bed, but said it was nerve wracking because the strap could have come off when he was not over the bed and he could have fallen again. During observation on [DATE] at 12:49 p.m., NA-E and NA-B prepared to transfer R1 in the mechanical lift while RN-A observed. R1 verbalized he did not want staff to have to turn the lift whatsoever. The staff placed R1 in his wheelchair with his back to the bed and lifted him straight up and pulled him backward approximately ,d+[DATE] feet, removed the chair and pushed him the same distance back to the bed. During the transfer the lift was moving very slowly and NA-E acknowledged the battery light was red indicating it was not fully charged. RN-A did not intervene during the transfer even though NA-D and NA-B did not follow manufacturers recommendations to move the resident in the lift the shortest possible distance nor did RN-A suggest the battery be replaced when staff identified it was low. During the transfer R1 stated, I don't want to fall on my head again. During interview on [DATE] at 12:58 p.m., RN-A stated the competency checklist indicated if the lift battery was low staff were supposed to stop and change it before transferring the resident. RN-A said she had not intervened because she did not want to step on their toes. During interview on [DATE] at 1:02 p.m., NA-E stated she had received competency testing after R1's last fall on [DATE]. NA-E said she was aware the checklist said to change the battery if it was reading low but she did not want to stop the transfer to change it. NA-E said if the battery would have died she would have called for help. During interview on [DATE] at 3:11 p.m., the director of nursing (DON) stated the reason they had implemented having a third person in the room during R1's transfers was to ensure his safety by adding another set of eyes. The DON stated if the third person identified something staff were not doing correctly she would have expected them to intervene. The DON indicated if the battery was low, staff should have lowered R1 back down and got a new battery. Volaro Series 4 Lift Operator's Manual dated ,d+[DATE] included the following Safety Notes: - the Volaro lift is designed for patient transfer only. Using the lift for transport can create an unsafe patient handling situation. - legs must be fully extended in the wide position when lifting a patient or resident. - Make sure all four loops from the sling are properly nested in the bottom of the hooks before lifting or transferring the resident. Also make sure all four retainer springs are functioning correctly. Volaro PC450 General Procedure Guide for Training indicated: - Have assistant stand on opposite side of bed to assist with transfer. - Position wheelchair at foot of bed. - Make sure power pac indicator does not indicate a low power pac. (if so, replace) - Make sure the correct sized sling is to be applied. - Check that the legs are in the widest position, where applicable. If base position must remain in narrow position, make sure the lift area between the bed and chair are clear of any obstacles. Widen once clear from bed. - Attach straps on the sling with strap nesting in the bottom of the hook. Remember with a divided leg sling, the straps at the thigh area must be criss crossed before lifting. - As you begin to left the resident from the bed, once there is tension on the straps check to make sure all four loops are still nested in the bottom of the hooks before lifting. The immediate jeopardy that began on [DATE], was removed on [DATE], when the facility implemented the following actions which were verified through interview and observation. - R1's bed will be moved away from trapeze for transfers with mechanical lift. - The wheelchair will be placed at the end of the bed to allow minimal movement of the lift. - Straps will be checked to make sure all four strap loops are nested in hooks. - Therapy evaluation for safe and appropriate transfer process. - Retrain all staff who use Full Body Mechanical Lift to ensure proper use of Lift for R1 along with return demonstration for all staff working and for oncoming staff prior to their next scheduled shift. - Observe a minimum of one transfer for each resident using a full body lift. If concerns/issues are identified observation will be repeated. - Any resident with significant change in weight, physical ability, cognitive ability will have therapy evaluate for safe and appropriate transfer process. - Maintenance inspection of the hooks on all mechanical lifts. - Mechanical lift competency will include section of if no for staff observing to enter actions to correct staff with just in time education. - DON, or designee, will utilize all steps of the competency steps in checklist for competency testing, per manufacturers recommendations, using return demonstration of all staff using mechanical lift in both the operator and assist position prior to their next shift. - DON, or designee, will competency test with return demonstration, per manufacturers recommendations, all licensed staff for supervision of staff using a mechanical lift. - All staff will have education and knowledge verification on troubleshooting items. - Review and revise Mechanical Lift Standard Work as needed per policy.

Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 4 of 5 residents (R14, R20, R27, R34) reviewed for immunizations. Findings include: R14's quarterly MDS dated [DATE], identified R14 was admitted to the facility on [DATE], was [AGE] years old and identified a diagnosis of diabetes. R14's Preventative Health Care immunization record undated, identified R14 received the PPSV23 on 10/6/04 and 20/20/19. R14's EHR did not include evidence R14 or R14's representative received education regarding pneumococcal vaccine booster and there was no indication R14 was offered the pneumococcal vaccine per CDC guidance. R20's quarterly MDS dated [DATE], identified R20 was admitted to the facility on [DATE], was [AGE] years old and identified diagnoses of hypertension and dementia. R20's Preventative Health Care immunization record undated, identified R20 received the Pneumococcal conjugate vaccine (PCV13) on 10/27/15, and a PPSV23 on 11/16/21. R20's EHR did not include evidence R20 or R20's representative received education regarding pneumococcal vaccine booster and there was no indication R20 was offered the pneumococcal vaccine per CDC guidance. R27's significant change Minimum Data Set (MDS) dated [DATE], identified R27 was admitted to the facility on [DATE], was [AGE] years old, and included diagnoses of heart failure, hypertension and diabetes. R27's Preventative Health Care immunization record undated, identified R27 received the pneumococcal polysaccharide vaccine (PPSV23) on 11/29/04. R27's EHR did not include evidence R27 or R27's representative received education regarding pneumococcal vaccine booster and there was no indication R27 was offered the pneumococcal vaccine per CDC guidance. R34's quarterly MDS dated [DATE], identified R34 was admitted to the facility on [DATE], was [AGE] years old and and included diagnoses of hypertension and diabetes. R34's Preventative Health Care immunization record undated, identified R34 refused pneumococcal vaccination on 3/7/23. R34's EHR did not include evidence R34 or R34's representative declination for pneumococcal vaccine nor received education regarding pneumococcal vaccine. Additionally, R34's EHR lacked evidence R34 was offered or received education regarding influenza vaccine. During an interview on 8/16/23 at 4:05 p.m. director of nursing (DON) stated she was responsible for the facility's infection prevention program, before taking the DON position. The facility works with a local pharmacy to provide immunizations for the residents and were aware of pneumococcal vaccination recommendation changes; however, had reviewed immunization records for new admissions only. The plan was to offer immunizations in the fall during the influenza immunization clinic. The DON stated immunizations were important for the prevention of communicable disease transmission. The facility provided Vaccine Information Statement (VIS) Pneumococcal Conjugate Vaccine dated 5/12/23, and Pneumococcal Conjugate Vaccine (PCV13) dated 10/30/19, identified education regarding the need for PPSV23 and Prevnar 13. The facility policy SNF Vaccination of Residents - Influenza, Pneumococcal and COVID-19 undated, instructed staff to review vaccination history for all residents at the time of admission and to document in the preventative health section of the EMR. Additionally, the policy directed staff to administer pneumonia vaccines as appropriate. However, the policy did not provide staff direction upon resident or resident's representative vaccine declination.

Based on observation, interview and document review, the facility failed to follow care planned interventions to prevent falls for 1 of 1 residents (R27) reviewed for falls. Findings include: R27's significant change Minimum Data Set (MDS) dated [DATE], identified R27 had severe cognitive impairment and required extensive assistance to total dependence for all care areas. Diagnoses included dementia and a history of falling. R27's falls Care Area Assessment (CAA) dated 7/17/23, identified R27 was a high fall risk and balance concerns. R27's contributing factors included: advanced age, impulsiveness, forgetfulness, R27 did not think that he needed help, cancer, urinary catheter, multiple falls reported prior to admit to facility with compression fractures and since admit he had continued to have multiple falls, one with fracture to hip that was most recent this summer, and taking an antidepressant and a diuretic. This placed R27 at risk for more falls, minor or serious injury, and possible need for re-hospitalization . R27's care plan dated 6/12/23, included interventions of fall mat at bedside (keep bed at knee height) and also for the bed to be at knee height rather than to the floor due to cathether bag touching floor. During an observation on 8/15/23 at 12:44 p.m. R27 was lying in bed with the bed in the lowest position. On 8/17/23 at 7:57 a.m., R27 was observed lying in bed. R27's room was darkened but R27 was clearly visible from the hallway. R27's bed was in the lowest position with a mat on the floor next the bed. R27 was curled up on his left side, facing the hallway. On 8/17/23 at 8:23 a.m., nursing assistant (NA)-B entered R27's room and stated R27's bed should not be in the low position and pointed to a piece of tape that was taped to the wall near R27's headboard. NA-B then raised R27's bed so that it was equal in level to the tape. On 8/17/23 at 8:36 a.m., licensed practical nurse (LPN)-A entered R27's room to assist NA-B with cares. LPN-A stated R27's bed not being at the correct care planned height could increase R27's risk for falls. During an interview on 8/17/23 at 10:30 a.m., the director of nursing (DON) stated R27's care plan was updated after his fall with major injury in June 2023. Saff placed tape near the headboards of all residents' beds for staff to have a quick reference at what height the bed should be to lessen confusion. As always, the staff should follow the care plan and leadership was trying to break staff going by memory or verbal report. Staff should always ask if they are not sure or use the care plan that is posted in every resident's closet. The facility policy Fall and Fall with Injury Risk Assessment, Prevention and Management for Hospital and Ambulatory Settings reviewed 5/3/23, identified the facility's guiding principle was that all residents were at risk for falls. Universal Fall Precautions/Low Risk Interventions always applied to every resident. The registered nurse would use the fall risk assessment and risk for injury screeening tools to individualize the resident's care plan to reduce the risk of falls and/or fall-related injuries. The tools would be used to the assist the RN in the selection of appropriate risk reduction interventions to implement.

Based on observation, interview and document review, the facility failed to ensure proper catheter care was provided to prevent infection for 1 of 3 residents (R27) reviewed for catheter. Findings include: R27's significant change Minimum Data Set (MDS) dated [DATE], identified R27 had severe cognitive impairment and utilized an indwelling urinary catheter. Diagnoses included dementia, diabetes and cancer. R27's care plan dated 6/12/23, identified R27 used an indwelling urinary catheter due to obstructive uropathy (a condition of excess urine accumulation in kidney(s) that causes swelling of kidneys). Staff were directed to empty R27's catheter bag each shift and as needed. Record output total and appearance. During an observation on 8/17/23 at 7:57 a.m. R27 was lying in bed with his uncovered catheter bag lying on the floor. At 8:23 a.m., nursing assistant (NA)-B entered R27's room and stated R27's catheter bag should not be lying on the floor without a protective barrier such a bag cover. - At 8:13 a.m., NA-A applied a gown and gloves and gathered supplies to perform catheter care for R27. - At 8:27 a.m., NA-B picked up R32's catheter bag, placed paper towels on the floor and attempted to open the drainage port. However, NA-B stated she was unable to open the port and stated she needed the nurses' assistance. - At 8:30 a.m., NA-B opened an alcohol swab but laid it on it R32's bed. - At 8:32 a.m. licensed practical nurse (LPN)-A entered R32's room to assist NA-B. LPN-B applied a gown and gloves, then demonstrated the opening of the drainage port to NA-A. However, neither LPN-A nor NA-A cleaned the drainage port with the alcohol swab prior to opening the port. - At 8:35 a.m., once the catheter bag was empty, NA-B closed the drainage port and cleaned the port with the alcohol swab. NA-B then placed the catheter bag into a linen cover and hung the catheter bag from the bottom of R32's bed. placed cath bag in a linen cover. During an interview with NA-B and licensed practical nurse (LPN)-A on 8/17/23 at 8:36 a.m., NA-B stated an uncovered catheter bag lying on the floor increased the risk of infection. Additionally, a catheter drainage port should be cleaned prior to opening to prevent infection. During an interview on 8/17/23 at 10:30 a.m. the director of nursing (DON) stated R27's catheter bag and cares should be done in a manner to prevent the transmission of infection. The facility policy Catheter Associated Urinary Tract Infection (CAUTI) Prevention last reviewed 5/22/23, directed staff to use standard precautions when handling a urinary catheter and/or urine collection system. This included hand hygiene before and after catheter cares or manipulation/emptying of the urinary collection system and donning clean exam gloves prior to catheter care or emptying the urine collection system. However, the policy did not address where the catheter bag should be kept and/or to keep the catheter bag off the floor.

Based on observation, interview, and document review, the facility failed to assess respiratory status and determine efficacy of oxygen therapy for 1 of 1 residents (R27) reviewed for respiratory services. Findings include: R27's significant change Minimum Data Set (MDS) dated [DATE], identified R27 had a severe cognitive impairment. The MDS did not identify R27 exhibited shortness of breath nor that R27 used oxygen. Diagnoses included heart disease, hypertension and diabetes. R27's physician order dated 3/6/23, Oxygen 2L via nasal cannula (NC) as needed (PRN). Special instructions: per standing orders R27's care plan dated 6/12/23, identified R27 had acute shortness likely due to interstitial lung disease. R27 evidenced of shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring, or when he takes of oxygen), shortness of breath or trouble breathing when sitting at rest if not wearing oxygen, and shortness of breath or trouble breathing when lying flat. Staff were directed to ensure: - R27's head of bed was to be elevated in increase oxygenation. Encourage upright position with dyspnea (shortness of breath). Encourage rest, semi-recumbent in bed or chair. Mobility assistance to assist with shortness of breath. - Identify other diagnoses and activities that may exacerbate symptoms of shortness of breath and the interventions utilized to decrease symptoms of shortness of breath. R27 had a history of a heart attack. - Treatment orders for symptom management included oxygen at 2 liters (L) as needed (PRN). During an observation on 8/15/23 at 5:39 p.m., R27 was sitting in his wheelchair in the common area with oxygen on at 2L per nc. During on observation on 8/15/23 at 7:39 p.m., nursing assistant (NA)-A, after assisting with bedtime cares, placed R27's nc into R27's nares and turned on his concentrator to 2L. During an observation on 8/16/23 at 1:50 p.m., R27 was lying in bed with oxygen on at 2L per nc. During an interview on 8/16/23 at 2:08 p.m., NA-I stated R27 always wore his oxygen at 2L per nc. During an interview on 8/16/23 at 2:28 p.m., NA-J stated R27 did not wear his oxygen during his bath but did at all other times. During an interview on 8/16/23 at 3:01 p.m. licensed practical nurse (LPN)-B stated R27's oxygen order was a standing order. Staff could apply it when R27 asked for it or was short of breath. The administration of oxygen should be documented on the MAR and staff should obtain an oxygen saturation and a general condition which should be documented as well. Upon review of R27's MAR, LPN-B stated it was not documented that R27 was receiving oxygen. LPN-B confirmed she was the nurse responsible for R27's medication administration that day, but stated she was unaware R27 was receiving oxygen. LPN-B stated she did not apply his nc and was unaware of who did. R27's Medication Administration Records identified the following: - June 2023 MAR identified R27 did not use oxygen. - July 2023 MAR identified R27 did not use oxygen. - August 2023 MAR identified R27 did not use oxygen between 8/1/12 and 8/17/23. The medical record from June 2023 through August 2023 lacked any assessment related to R27's respirtatorty status. During an interview on 8/16/23 at 3:17 p.m. registered nurse (RN)-A stated she was the charge nurse that day. Upon review of R27's physician's orders, stated R27's oxygen order was a standing order that should be updated by the physician. RN-A stated staff should always document administration of oxygen because it assisted staff and R27's physician to recognize a change of condition or worsening. During an interview on 8/16/23 at 3:37 p.m., the director of nursing (DON) stated staff were expected to document administration of oxygen as well as document resident condition to warrant the administration. The facility policy Oxygen Administration dated 3/2023, directed staff to review provider order for administration of oxygen and appropriate flow rate. Document use of oxygen and saturation monitoring per physician's order in the treatment record.

Based on interview and document review, the facility failed to accurately code the hospice status on the Minimum Data Set (MDS) for 1 of 1 residents (R28) reviewed hospice services. Findings include: R28's quarterly MDS dated [DATE], identified R28 had diagnoses that included chronic kidney disease, hypertensive heart disease, and legal blindness. The MDS failed to identify R28 received hospice care in section O- Special Treatments and Programs. R28's care plan dated 7/24/23, identified R28 received hospice services due to end stage heart failure. During an interview on 8/16/23 at 3:28 p.m., registered nurse (RN)-A stated she missed entering R28's hospice services and had been on hospice services for awhile. During an interview on 8/16/23 at 4:03 p.m. the director of nursing (DON) stated R28 was on hospice for some time. The DON stated MDS assessment accuracy was important because it drove payment, staffing needs and was basis for everything long term care related. The facility policy Minimum Data Set revised 6/14/21, identified the MDS was a minimum set of screening and assessment elements, including common definitions and coding categories, needed to comprehensively assess an individual nursing home resident to provide the facility with the information necessary to develop a care plan and to provide appropriate care and services for each resident and to modify the care lan and care/services based on resident status. Staff were directed to refer to the Resident Assessment Instrument (RAI) manual for further instructions, definitions and guidance.

Based on observation, interview and document review, the facility failed to evaluate and analyze hazards following a resident fall from a Hoyer lift resulting in a laceration to the elbow and hematoma on the head. A second, near miss incident occurred one week later for the same resident (R1) using the same lift. This resulted in an immediate jeopardy for R1. The immediate jeopardy began on 5/9/23, when R1 fell from the Hoyer lift during provision of care. The facility failed to thoroughly investigate and identify if the staff were correctly using the lift per manufacturer recommendation when the incident occurred. The IJ was identified on 5/19/23. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 12:34 p.m. on 5/19/23. The IJ was removed on 5/22/23, but non-compliance remained at the lower scope and severity level 2, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set, dated dated dated [DATE], identified intact cognition and indicated he required total assistance from two staff for transfers. R1's care plan dated 4/26/23, identified decreased independence and the need for assistance with activities of daily living due to limited mobility. The care plan directed staff to use a full body mechanical lift to perform transfers. R1's facility Progress Notes identified the following: -5/9/23, recorded as a late entry on 5/22/23, at 1:03 a.m. following surveyor inquiry, indicated R1 was on his left side on the floor. The mechanical lift tipped as he was being transferred. R1 had a small open area on his left elbow, Steri-strips applied and a small bump on the back of his head. The lift was removed from use at that time. The progress note was written by licensed practical nurse (LPN)-A. -5/9/23, recorded as a late entry on 5/16/23, writer arrived in room and R1 was on the floor on his side. R1 had fallen when the lift tipped. R1 was checked for injuries, had a cut on his left elbow and a small bump on the back of his head. Lift removed from use. -5/10/23, recorded as a late entry on 5/16/23, interdisciplinary team review identified contributing cause of the fall: mechanical lift tipped during transfer. Staff and resident interviewed and confirmed correct use of equipment. Maintenance found the latching mechanism for the lift legs did not catch as it should. Part ordered to fix. The lift was removed from service to have maintenance assess/fix. -5/17/23, recorded as a late entry on 5/21/23, following surveyor inquiry: Near miss fall: nursing assistant (NA) reported to nursing staff that mechanical lift was making odd noises as staff was using machine to lift resident from bed. NA reported lifting arm of machine appears off center as well. NA reported that resident was laid back down in bed and a different lift was used to safely transfer R1. Nursing instructed NA to put lift out of service to prevent further use. A handwritten note by NA-A indicated on 5/9/23, while lifting R1 in the mechanical lift, on the way to the commode the lift tipped over and R1 fell hitting his head on the commode and his elbow on the floor. NA-A wrote she was trying to pull the wheelchair back as another staff lifted him up and was attempting to pull the lift back before turning it toward the commode. NA-A wrote R1 was hooked up correctly and was not moving around. NA-A wrote, R1 was not moving around, the hoyer [mechanical lift] tipped from his weight. I believe [R1] should not be using that type of hoyer machine and should switch to the other we have been using since. A facility document titled, EH (Essentia Health) SNF (skilled nursing facility) Vulnerable Adult (VA) Template dated 5/15/23, indicated on 5/9/23, R1 fell due to a lift tipping over. The document indicated maintenance was involved due to equipment involvement and indicated R1 did not feel safe using any of the lifts. The document indicated all staff involved in the incident should be interviewed as well as staff who normally work with the resident and determine if education, coaching or corrective action needed to be implemented. The document further indicated all staff would be educated on use of lifts and potential issues. An e-mail dated 5/22/23, from registered nurse (RN)-A to the administrator and the DON identified the following: below completed 5/10/23 - 5/14/23. - R1 reported staff helped him get in the lift sling as they usually did. They had the commode to the side and as they were going from the wheelchair to the commode, NA-B was lifting him up, the legs were wide like they usually do and when he was moving toward the commode, it just tipped over. R1 stated it surprised all of them and said he was on his left side with the lift on his right side. R1 said his elbow hurt at first and he could tell he bumped his head. - NA-B reported they needed to transfer R1 to the commode. NA-B said she opened the legs of the lift and lifted R1 up. NA-B reported all seemed to be going well and when she was moving the lift so she could get R1 on the commode the lift tipped, landing partially on R1. NA-B said they helped get the lift off R1 and called for the nurse. - NA-A reported while lifting R1 in the mechanical lift, on the way to the commode the lift tipped over and R1 fell hitting his head on the commode and his elbow on the floor. NA-A said he was hooked up correctly and the legs were open. NA-A said R1 had not been moving around and said she believed the lift tipped due to R1's weight. An e-mail dated 5/22/23, indicated maintenance noted the locking mechanism on the legs of the lift were worn and likely caused the lift to tip as the legs would have closed during the transfer. During observation and interview on 5/18/23, at 1:14 p.m. R1 was seated outside the dining room in a standard wheelchair. R1 stated on 5/9/23, two staff were transferring him from the wheelchair to the commode. R1 said when they went to move sideways, one leg turned in and we swiveled a little and we all went down. R1 stated they were in a tangled heap with the lift between them. R1 said he got a cut on his elbow and a big bump on the back of his head. R1 said he had a few aches and pains from the fall. R1 stated, Yesterday the same thing happened, I didn't fall, we caught it in time. R1 said staff started lifting him and turning and said as the lift was raised it kind of turned to one side. R1 said when the staff tried to turn, the lift over balanced. R1 said staff went and got another lift to complete the transfer. R1 said three staff were assisting him, NA-C, NA-B, who was assisting on 5/9/23, when the lift tipped over, and a third NA. R1 said when the first incident occurred, he was seated in his wheelchair next to the second bed when staff started to push him in the lift toward where the commode was sitting, then it happened. At 3:55 p.m. R1 described the position of the wheelchair and the commode in the room at the time of the fall. R1 said he was seated in the wheelchair between the two beds and said the commode was in the pathway near the bathroom (approximately 8 feet away). R1 said the staff were pushing the lift to the commode and when they started to make the turn the lift tipped over. R1 confirmed he was not interviewed by the facility following the second incident on 5/17/23. During interview on 5/18/23, at 1:29 p.m. NA-C stated the previous day R1 was hooked up to the mechanical lift and said three NAs were present including herself. NA-C said they started to lift R1 and as soon as she lifted him up, the lift tipped. NA-C stated the head of R1's bed was upright and that was the only thing that kept him from falling. NA-C stated they lowered R1 back to the bed and went and got a different lift. NA-C stated she had not received any training on lifts following the incident on 5/9/23, and said she was only told to use three staff. NA-C confirmed the lift used was lift number six and confirmed it was the same lift used during the fall on 5/9/23. NA-C stated she had reported the incident to the nurse on the floor. During interview on 5/18/23, at 1:34 p.m. NA-D stated she was aware of the incident involving R1 falling from the lift. NA-D said she had not received any training following the incident and said all the lifts in the facility could be used for any resident who required the use of a lift. During interview on 5/18/23, at 2:07 p.m. LPN-A said he was called to R1's room after the fall on 5/9/23. LPN-A stated according to the NAs, the lift tipped over and R1 landed on the floor. LPN-A said R1 had a cut on his elbow and a bump on his head. LPN-A said the lift was taken out of R1's room and a different lift was used to get him up off the floor. LPN-A said the lift had not been removed from the floor and said there was nothing wrong with the lift, R1 was too heavy for it. LPN-A said after the incident staff were told to be more careful when using the lifts. During interview on 5/18/23, at 1:38 p.m. the DON stated she had received a text message the evening of 5/9/23, that R1 had fallen out of the lift. The DON said staff removed the lift from the floor right away and confirmed the lift was lift number six. The DON stated maintenance took the lift and inspected it and determined the mechanism that secured the legs was not working and if something bumped the leg during a transfer the leg could close. The DON stated the lift was repaired and tested and put back into use however, the DON indicated the lift had not been tested to ensure worked correctly. The DON said on 5/17/23, staff said the lift was loud when using it so she and maintenance again removed it from the floor. On 5/18/23, at 1:49 p.m. the maintenance worker (MW) stated all the mechanical lifts received routine inspections each month to include checking bolts, breaks, controls, pivots, etc. The MW said after R1 fell , he identified the lift used during the transfer had a manual bar that opened and closed the legs and the notches were worn. The MW said the parts were ordered and replaced. The MW said the whole machine had been checked out and was put back on the floor. MW said he became aware on 5/18/23, there was a problem with the lifting part and said the lift was an older lift. During interview on 5/18/23, at 2:31 p.m. RN-A stated after the fall on 5/9/23, she contacted both of the NAs involved to ask what happened. RN-A said the NAs said R1 was hooked up, they started lifting him up and when bringing him over to the next surface the lift tipped over. RN-A stated NA-B told her she did not know what had happened so the lift was sent to maintenance to inspect it and see if something needed to be fixed. RN-A said maintenance looked at the lift and said the only way it could have tipped over was if the legs closed so he replaced the parts. RN-A stated she had not been aware there was a second incident with lift number six until this morning, so the lift was again put out of service this morning (5/18/23). RN-A stated an LPN reported to her that staff were transferring R1 and the lift was making some noise so they lowered him back down, unhooked him and used a different lift. RN-A stated she had not spoken to the staff involved. The DON was present and stated staff told her the lift had been making a weird noise during the incident on 5/17/23, but did not remember who had told her. The DON stated she had not asked R1 about the incident. When asked about staff education following the two incidents, the DON said for a couple of shifts the nurses had watched transfers but said there was no documentation. The DON said she was planning to do staff education at the next staff meeting in June. The DON further stated there was no evidence NA-As concern about R1's safety when using lift number six had been addressed. RN-A and the DON stated they felt the issue had been addressed when maintenance replaced the part on the lift. Despite facility's documented interviews with staff involved in the lift incidents detailing the incorrect use of the lift (transporting resident in lift), the facility failed to identify concern, interview resident for more details and contact Hoyer Lift manufacturer following lift failures. On 5/19/23, at 10:24 a.m. the facility's customer service representative (CSR) for the Volaro lifts used in the facility was interviewed. The CSR stated typically when they heard of a lift tipping, it was due to the legs being closed or if the lift was positioned too close to the bed and staff turned and pushed the resident, the weight would start to pull the lift over especially if the resident was too heavy. The CSR stated the lifts were not designed to transport any distance, only surface to surface and if staff transported a resident too far in the lift it could create a situation. On 5/19/23, at 10:59 a.m. NA-F stated when transferring a resident in the mechanical lift she would bring the chair or commode to the resident. NA-F stated she would not transport a resident more than 5 feet in the lift. The Volaro 4 Series Operators Manual, safety notes indicated The Volaro lift is designed for patient lift only. Using the lift for transport can create an unsafe patient handling situation. Facility policy, Fall Standard Work, undated, indicated the following: Review Devices in use/involved in fall and determine if location of device played a factor, if device was used by resident/staff properly, ensure device is working properly and if any adjustments need to be made involve maintenance staff or therapy staff as appropriate. The immediate jeopardy that began on 5/9/23, was removed on 5/22/23, when the facility identified and assessed all residents who utilized a mechanical lift for safety, completed a thorough analysis of the incidents on 5/9/23 and 5/17/23, completed an inspection of all lifts in the facility and completed training with staff to include return demonstration of the correct use of mechanical lifts and implemented a plan to educate all staff prior to working with the lifts.

Based on interview and document review, the facility failed to report allegations of abuse to the state agency (SA) as required; provide resident protection during investigation for 4 of 4 residents (R3, R4 R2, R1) reviewed for allegations of staff to resident abuse. This resulted in an immediate jeopardy (IJ) situation for R3, R4 R2, R1 who all had allegations of abuse by the same nursing assistant and the facility failed to provide protection from ongoing abuse and had the potential to all residents residing in the facility. The IJ began on 3/7/21, when it was reported nursing assistant (NA)-A and NA-B used profanity and called R3 names, this was not reported to the SA and the residents were not provided immediate protection from further abuse. On 3/8/21, it was reported by staff that NA-A and NA-B were in R2 and R4's room swearing, making inappropriate jokes and being rough with R2 and R4 in the room; this allegation was not reported and the residents were not provided immediate protection from further abuse. On 4/5/21, a staff member reported NA-A told R2 to shut the F*** up, this allegation was not reported and the residents were not provided immediate protection from further abuse. Along with another grievance on 4/5/21, where a resident had concerns about how he was treated by NA-A. On 6/18/21, staff members reported NA-A made inappropriate comments to and about R1 during cares, this allegation was not reported timely and again the residents were not provided protection from further abuse. The administrator and director of nursing (DON) were informed of the IJ on 7/12/21, at 4:45 p.m. The IJ was removed on 7/15/21, at 10:55 a.m. but noncompliance remained at the lower scope and severity level of F, widespread with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: a) First Incident 3/7/21. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had intact cognition and required supervision to complete activities of daily living (ADL)'S. R3's care plan dated 4/20/21, identified a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A Resident Grievance Form dated 3/7/21, indicated registered nurse (RN)-A received a complaint from a staff member of staff being mean, using profanity and calling R3 a name. The form indicated R3 reported similar information to day shift NA's and remained consistent when interviewed by RN-A. The grievance further indicated a night shift licensed practical nurse (LPN) reported the complaint and R3's family member (FM) called and reported R3 had told her similar concerns. Immediate action by nurse indicated she interviewed R3 and sent messages to NA-A and NA-B asking for their input. Correlating text messages between RN-A and NA-A identified the following: - A documented interview dated 3/7/21, at 7:09 a.m. identified RN-A stated to NA-A, Hey. We have had a resident c/o [complain of] this morning about the 2 small thin girls who were in her room last night being mean and using horrible language and called her a [OBSCENITY] . Please let me know ASAP if something happened, obviously this is unacceptable and we need to investigate the complaint further. Thanks. A second message indicated LPN also reported that before he left the same resident had complained about the girls working that night. - Another interview identified NA-A stated to RN-A; I would like to know who because I have been watching my language since I got talked to about it. The grievance was signed by the social services director (SSD)-A and the DON and indicated R3 agreed with the resolution, however, no resolution was identified. The allegation was not reported to the SA, nor were measures to protect the residents identified and implemented. During interview on 7/12/21, at 12:11 a.m. RN-A stated the incident on 3/7/21, occurred on a weekend. The incident was reported to RN-A and she wrote up a grievance report. RN-A stated R3 had complained about the two girls swearing on the overnight shift and said there were only two girls working (NA-A and NA-B). RN-A interviewed R3 right away and R3 reported that the NA's had called her a B****. RN-A stated, I suppose it could be considered verbal abuse. Further, RN-A had reported the incident to the DON that morning. b) Second Incident 3/8/21. R4's quarterly MDS dated [DATE], indicated R4 had severe cognitive impairment and required total assistance from staff for ADL's. R4's care plan dated 5/19/21, identified impaired cognition and impaired mobility and directed staff to assist with ADL's. A Resident Grievance Form dated 3/8/21, indicated NA-C reported to the DON via a handwritten note the following: I want to inform you about the incidents that happened this weekend. On Saturday night 3/6, [NA-A and NA-B] were in [R4 and R3]'s room while I was helping them get ready for bed. Both girls were making inappropriate jokes, swearing and being rough with both residents. The form indicated the DON had spoken with R3 and R3 stated he did not hear anything. R4 did not remember the incident and did not comment. The grievance was signed by SSD-A and the DON and indicated R3 agreed with the resolution, however, no resolution was identified. The allegation was not reported to the SA, nor were measures to protect the residents identified or implemented. c) Third Incident 4/5/21. A Resident Grievance Form dated 4/5/21, indicated NA-D reported via e-mail to the DON and the administrator on 4/5/21, at 11:39 p.m. I am sorry to be sending you this e-mail so late in the evening but I just got home from the facility working my scheduled shift from 2:00 p.m. until 11:30 p.m. and I can't sleep with what happened between another staff and a resident. NA-A and NA-D had gone into R3 and R4's room to assist them with p.m. cares and get into bed for the night. During the cares R3 had made some comments to NA-A. NA-D indicated not remembering all of the details but shortly after NA-A told R3 to shut the F*** up. Then while assisting R4, told him in an upset tone that she was sick of both residents being mean to her when she was only trying to help them. NA-D wrote, I'm bringing this to your attention because as a mandated reported it's my responsibility to notify you regarding a vulnerable adult being mistreated with verbal attacks. The e-mail further identified several other staff members who had witnessed similar actions by NA-A. The grievance was signed by the SSD-B and the DON and indicated R3 agreed with the resolution, however, no resolution was identified. The allegation was not reported to the SA, nor were measures to protect the residents identified or implemented. d) Fourth Incident 4/5/21. R2's quarterly MDS dated [DATE], indicated R2 had moderate cognitive impairment and required extensive assistance from two staff for ADL's. R2's care plan dated 5/13/21, identified impaired mobility related to weakness and pain and directed staff to assist with bed mobility and transfers. R2's progress note dated 3/7/21, indicated R2 complained of pain and when asked what staff could do he began yelling at staff. Later R2 indicated he had not slept all night and when questioned why he did not say anything replied, because everyone gets sassy with me if I do. A second Resident Grievance Form dated 4/5/21, identified R2 stated there was inappropriate verbal comments and behaviors from NA-A. The interview with R2 stated he was not sure if NA-A swore of not but stated NA-A pushes their buttons. Interviews with a staff member identified NA-A was short and rude with residents. During interview on 7/12/21, at 11:39 a.m. R2 stated NA-A was short tempered and had a bad mouth. R2 stated NA-A used the F word and said I didn't like her mouth and she was so impatient. R2 stated Oh, she's got a bad mouth, but I didn't want to make any trouble. c) Fifth Incident 6/18/21. R1's significant change MDS dated [DATE], identified severe cognitive impairment and required assistance of two staff for ADL's and was incontinent of bowel and bladder. R1's care plan dated 7/6/21, identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Resident Grievance Form dated 6/18/21, indicated LPN-A and NA-E reported NA-A using inappropriate language. The form indicated on Saturday 6/19/21, a text message was sent from RN-B to the DON and indicated: FYI, issues with [NA-A] again last night. [LPN-A] has statements from two NA's who witnessed her behavior and form under my door to review concerns about [NA-A] working tonight. An untitled undated document indicated during the evening of 6/18/21, NA-E and NA-F were assisting R1 to wash up for the evening. R1 had been incontinent and staff called NA-A to assist. NA-A entered the room and stood by the door and stated Eeww .do I really need to help, this F****** stinks so bad. While providing care NA-A stated R1 stinks like[OBSCENITY]all the time, and why do you have so much F****** poop on you, this is ridiculous. NA-A also told R1, shut the F*** up, you're not in F****** pain. LPN-A moved NA-A to a different wing of the building. During a meeting on 6/19/21, NA-A denied using foul language and requested to work on another wing and stated she was burnt out from the South wing. The report indicated NA-A was terminated on 6/25/21. During interview on 7/12/21, at 11:16 a.m. the DON stated prior to the incident on 6/18/21, there had been previous concerns about NA-A. The DON identified the allegation by another staff member regarding R2 and R4 and stated R2 had not taken offense to it. The DON stated R2 knew NA-A was in trouble and tried to cover for her. NA-A had been educated about her swearing and was told if it continued she would be terminated. The DON took care of the issue in a grievance form and R2 wasn't worried about it. The incidents were not reported to the SA but knew it was important and that's why a grievance report was filed. The DON stated after the incident regarding R1, the LPN on duty moved NA-A to another unit and LPN-A had not notified her or the administrator but notified the oncoming RN the next morning. Further, LPN-A should have notified the DON right away and then would have sent NA-A home and notified the administrator. The DON stated she started the grievance process on 6/21/21, because she was notified the grievance had been placed under her door and she was supposed to investigate it. During interview on 7/12/21, at 11:49 a.m. RN-B stated the morning following the incident with NA-A and R1, LPN-A reported there were some issues and she had written up NA-A and put it under the DON's door. RN-B stated she contacted the DON and told her their had been some issues and NA-A was removed from the schedule. RN-B stated she did not remember if she had been told the specific information about the incident but felt like it was something the DON needed to know about. RN-B stated LPN-A told her whatever NA-A had said to R1 made the other two NA's so upset they were in tears. RN-B was aware of previous concerns with NA-A about her behaviors and not being appropriate. When interviewed on 7/12/21, at 12:24 p.m. the DON stated the incident with R3 was not reported to the SA as it was handled as a grievance. The DON had not thought about it as a reportable incident but stated, it is abuse, I took it seriously, that's why a grievance was completed. The DON stated each of the incidents identified as grievances should have been reported to the SA and said she thought they were covering it by filing a grievance. On 7/12/21, at 1:35 p.m. the administrator and DON were interviewed. The administrator stated the incidents handled as grievances fit the definition of abuse and should have been reported and investigated. The administrator was not immediately notified about the events but generally would ask if the resident was safe and then put the staff member on another wing or out the door. The DON stated staff were not provided any extra supervision or suspended during any of the instances. Further, the facility had not completed any audits on resident cares to ensure safe cares. The DON stated following the last incident involving R1, NA-A had been suspended the next day and with the other incidents she had spoken with the residents. The DON stated there was no documented proof NA-B used inappropriate language with any of the residents. Further, the DON stated she had not interviewed other residents or staff to determine if ay other residents had been subjected to verbal abuse by NA-A or NA-B. On 7/13/21, at 8:37 a.m. LPN-B stated NA-A had an attitude since she started working at the facility. LPN-B stated NA-A swore all the time and was disrespectful to the residents and said she did a lot of on the spot education but it did not work. LPN-B stated she had reported it to the DON hoping she would do something about it. LPN-B stated multiple residents had complained about NA-A. On 7/14/21, at 1:53 a.m. LPN-A stated when the incident occurred between NA-A and R1, she was the one first aware of the incident and wrote it up. LPN-A stated did not get the full story initially but NA-E and NA-F told her what happened. LPN-A stated she did not know exactly what to do but should have reported it to the DON right away. LPN-A only had concerns about NA-A and NA-B using inappropriate language. LPN-A had witnessed NA-A using inappropriate language prior to the incident with R1 but did not think it had been directed at a specific resident. LPN-A did not have any concerns about NA-B as the last time she had heard anything was about a year ago. On 7/15/21, at 10:34 a.m. the administrator stated he relied on his leader in specific areas to stay abreast of policies and procedures and tried not to get too in depth with the details. Once something happened he was involved in terms of investigating, reporting and follow up. The administrator acknowledged he was not consistently notified immediately when incidents occurred in the facility. The facility Essentia Health Fosston Vulnerable Adult Policy and Procedure dated June 2017, indicated Essentia Health Fosston should establish and enforce an ongoing abuse prevention plan. The plan should contain an assessment of the physical plant, environment and it's population identifying factors which may encourage or permit abuse and a statement of specific measures to be taken to minimize the risk of abuse. The policy identified Immediate as: as soon as possible, but no later than 24 hours from the time initial knowledge that the incident occurred has been received. The policy indicated for long term care an electronic submission to the SA must be completed within 24 hours of the incident. - Section IV, Protection of Patient During Investigation indicated all patients, residents and clients will be protected from harm during the investigation. The policy lacked a procedure or steps to be taken to protect residents. - Section V, Reporting of Incident, Investigation and Facility Response to the Results Of the Investigation indicated reports would be made immediately to the director of long term care. The policy directed once a report was made internally, a team will convene to conduct the internal investigation. The internal team should interview staff involved in the incident, decide if a safety plan was needed and gather information related to past incidents by the alleged perpetrator. The policy did not include interviews with other staff or residents who may have knowledge of abuse. The IJ was removed on 7/15/21, at 10:55 a.m. when it could be verified through interview and document review the facility had updated their policy on reporting and protecting residents with allegations of abuse; completed a thorough investigation to ensure no other residents had abuse concerns, which included resident interviews and skin assessments of those residents that could not be interviewed; and ensured all staff were educated on the new abuse policy and expectations.