Every finding on record at Good Samaritan Society - Pipestone

Based on observation, interview and document review, the facility failed to ensure infection control measures were followed during observation of 1 of 1 meal service. This had the potential to affect all 52 residents who dined in the facility.Findings include: Observation on 7/29/26 at 11:29 a.m., identified cook-A completed preparation of the noon meal consisting of chicken with mushroom gravy, noodles, and broccoli. Cook-A was placing the food items onto the steam table when she turned and went to the cabinet, opened the door, removed a saltshaker, and shook salt into her bare hand. After filling the palm of her hand with salt she returned to the stove, where she dumped the salt from her hand into the cooking noodles. When questioned as to her action, she replied she had measured the salt to add to the noodles. She then stated that was how she always did it. Cook-A then set the pot into the sink and prepared a fresh pot of noodles which were placed onto the steam table. As she was pouring the noodles into the steamtable pan several noodles landed on the counter in front of the pan. Cook-A used her bare hand and tossed the noodles from the counter back into the pan of noodles in the steamtable. At no time did cook-A perform hand hygiene in between tasks or put on gloves. Observation on 7/29/26 at 11:42 a.m. identified cook-A washed her hands and returned to the counter across from the steamtable where she picked up a tray containing 2 paper meal slips. She then picked up the slips and identified the resident meals, turned back to the steamtable, picked up 2 plates, and began placing food items onto the plates. She used a large, slotted spoon to scoop noodles onto the plates, then placed the slotted spoon on the side of the steamtable and went around the steamtable to a drawer which she opened with her bare hand. Cook-A then removed a green handle scoop spoon and returned to plating the meal without performing hand hygiene or donning gloves. As she was scooping noodles onto the plate, there were noted to be several noodles were noted to be hanging off the side of the plate. Cook-A then used her bare hand to scoop them back onto the plate. Cook-A then placed the filled plates onto the tray and pushed them into the window for staff to serve to residents in the dining room. Cook-A continued the same process of serving several plates and again used her bare hand to scoop noodles hanging off the side of the plate back onto the plate being served, without performing hand hygiene or putting on gloves. Interview on 7/29/26 at 12:05 p.m. with cook-A reported she had always measured seasonings using her hand and was not aware there was a problem doing it that way. When asked about serving of the noodles and handling them with her bare hands, reported she did not realize she had done that and reported she should have, tossed the noodles that landed on the counter Infront of the steam pan, and used the scoop to position noodles on to plates instead of her hand. Interview on 7/29/26 at 12:15 p.m. with the certified dietary manager (CDM) identified her expectation was for appropriate infection control practices to be followed in the kitchen. She reported she was not aware cook-A used her bare hand to measure spices, and she should have used measuring spoons, not her hand. Touching food with bare hands was not acceptable practice, and she expected staff to use utensils and appropriate hand hygiene practices. She identified anytime staff left the steam table area, staff needed to perform hand hygiene and/or don gloves before returning to serving food after changing tasks. Interview on 7/29/26 at 1:30 p.m., with the infection preventionist (IP) identified her expectation was for all departments to follow appropriate infection control practices by utilizing hand hygiene practices. Review of the 7/14/26, Food Handling-Food and Nutrition policy identified prevention of food related illness to a highly susceptible population in the facility. This was identified as the need for handling of food in a manner to decrease the risk of contamination. Food items were not to be touched using bare hands. Utensils including tissue, spatulas, tongs and single-use gloves were to be utilized when handling food items. Hand hygiene was identified as washing with soap and water and gloves were to be utilized when indicated due to needing to tough a food item.

Based on document review and interview, the facility failed to obtain informed consents including risk and benefit for 1 of 5 residents (R4) reviewed for psychotropic medications.Finding include: R4's comprehensive Minimum Data Set (MDS) dated [DATE] indicated R4 had intact cognition and was admitted on [DATE]. R4 diagnoses included dependence on renal dialysis, type 2 diabetes, and insomnia. R4's current Order Summary Report indicated R4 was currently prescribed clonazepam (anti-anxiety) 1 milligram (mg) tablet by mouth daily every Monday, Wednesday, and Friday. Give on dialysis days started on 04/03/26 and Temazepam (hypnotic) 30 mg by mouth at bedtime started on 04/3/26. R4's medical record lacked evidence of informed consents regarding risk and benefits for any of the above listed medications. The director of nursing (DON) attempted to locate signed consent and was unsuccessful. During an interview on 08/05/2026 9:46 a.m., DON stated, any resident admitted with a psychotropic medication in use needed a consent form signed for that medication on admission day. Facility policy titled Psychotropic Medications- Rehab/Skilled indicated, a consent form must be signed for use of an Antipsychotic medication. The Permission for use of Psychotropic Medications (GSS#478) will be used to obtain consent.

Based on interview and document review, the facility failed to provide the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to 1 of 3 sampled residents (R1) when their Medicare Part A skilled services with days remaining. Findings include: R1's CMS-10123 Notice of Medicare Non-Coverage (NOMNC) form identified R1's services ended on 7/17/26. R1 was not provided with the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) that identified the estimated cost of services if R1 would have chosen to continue with the skilled services on her own. Interview on 8/4/26 at 10:30 a.m., with the director of nursing (DON) identified that she had taken over providing the beneficiary notices after a recent staffing change. The DON stated she did not think that she needed to provide the CMS-10055 notice as R1 had Medicaid pending so she had only provided the CMS-10123 notice. Review of the 5/12/26, Advance Beneficiary Notice of Non-Coverage (ABN) policy identified the ABN informed the beneficiary of potential non-coverage and shift of financial liability for those items or services if Medicare denies the claim. The ABN notice was evidence that the beneficiary had knowledge about the likelihood of Medicare denial, and for purpose of determining financial liability for expenses incurred for services which Medicare does not pay.

Based on observation, interview, and document review, the facility failed to monitor controlled narcotic medications in 1 of 1 emergency kit (E-kit) to prevent potential diversion. Findings include: Observation and interview on 8/5/26 at 2:45 p.m., with trained medication aide (TMA)-A and registered nurse (RN)-A of the 400/500 wing medication room and medication cart identified the E-kit was stored in the medication cart. Inside the locked box was a small plastic E-kit box that housed the controlled narcotic medications. When asked about monitoring the plastic numbered tags that secured the E-kit, RN-A stated the nurses did not monitor the tag of the E-kits daily. The plastic numbered tag was not documented anywhere that would confirm the correct tag remained in place in order to easily identify potential diversion. Both TMA-A and RN-A stated there would be no way to know if someone had opened it and took narcotics out until the nurse accessed the E-kit for medication that was needed. RN-A agreed that the E-kit and E-kit small box with narcotics inside the locked box on the medication cart was not opened on a regular basis so medication could be missing for quite some time before anyone would notice. Review of the E-kit medication list identified that the kit contained controlled narcotic medications of Tramadol 50 mg: 6 tablets, Hydrocodone/APAP 5/325 mg: 6 tablets, Lorazepam 0.5 mg: 6 tables, and Morphine solution 20mg/ml (unknown amount). Interview on 8/5/26 at 3:19 p.m., with director of nursing identified that the staff should have been monitoring the number of the plastic tag on the E-kit and the E-kit located inside the locked box on the medication cart with the narcotics. A policy on monitoring controlled narcotic medications to prevent diversion was requested but not provided.

Based on interview and document review, the facility failed to provide evidence of 1 of 1 required Performance Improvement Project (PIP), which focused on high-risk or problem-prone areas with identified interventions and analysis to track performance to ensure improvement after implementing actions. Findings include: Review of the QAPI meeting minutes provided identified on:9/23/25, the current PIP project was pressure ulcers. The goal was to decrease their percentage to be at or less than 2%. Last year's August report was used for comparison at 4.4%. Actions were to monitor and report monthly and reviewed by wound nurse weekly. There was no mention of what the current rate was, nor how the facility planned to reach their goal, if they were auditing, etc. 12/16/25, QAPI meeting minutes identified pressure ulcers were listed, but not as a PIP , with goal of zero new facility acquired pressure ulcers, with current data listed as 0. The plan was to continue with prevention. The current PIP section was completely blank on the form, so it was unclear if the facility had dropped the current PIP and replaced it with another or had not addressed it at all. 3/30/26, QAPI meeting minutes Appendix IV 2026 Performance Improvement Priorities listed a PIP project for pressure ulcers. The facility was at 10.6%, with national and state comparisons at 5.7% and 6.1% respectively. The target was reported to be at or less than 5.97%, however, there were no actions noted as to how the facility would reach this goal, analysis of current facility practices, or any resident data supplied to identify what was the cause of the increased PU percentage in their facility. 6/26/26, QAPI meeting minutes identified new or worsening pressure ulcers and there was noted to be an increase in pressure ulcers. The current intervention was Great work team! with a goal of NA and 2.3% and current data was listed as 0%. There was a note for short stay residents at 0% but longer stay residents or the facility as a whole was not mentioned. The follow up was listed as ongoing each meeting. No analysis or data was included with the minutes in that section. Further down as another section for pressure ulcers/trends. The goal listed was 6 residents triggered for pressure ulcers, and at 14.6% with an average of 5.7%. The action was to continue with prevention however, there was no identified actions as to how the facility would accomplish their goal. They had another section labeled Current PIP-Pressure Ulcers in their short stay residents at a goal of 0% but current data was also 0%. There was no mention why the facility was separating out their facility into short term or long term stay residents. They listed the current PIP as going well however there was no action to identify what the facility had implemented to reach their goal, or if this was an accurate portrayal of how the facility was doing overall, etc. Interview on 8/5/26 at 3:51 p.m., with the director of nursing (DON) and the administrator identified the DON stated there had been some staff turnover and a new person had started taking care of the minutes and had not put the data in. The committee was reviewing information and having discussion; however, she was unable to show that information was included in the minutes. The DON confirmed the facility PIP project of pressure ulcers had no identified interventions and the facility had no documentation that they had analyzed any data related to the PIP project. The DON was only able to identify that the facility was completing some audits as interventions for reducing long stay pressure ulcers. She stated, We have nothing laid out in a plan such as what were are going to do and how we are going to do that. we need to work on our PIP and documentation of our meetings. Review of the November 2025, QAPI plan identified The Quality Assurance Performance Improvement (QAPI) Plan was designed to outline a comprehensive and data driven QAPI program that focused on improving the outcomes and experiences of those served. The QAPI program was to address the complexity and uniqueness of the care and services provided. The QAPI Committee was responsible to track and trend performance, systematically analyze, prioritize quality deficiencies, develop action plans, and monitor for its effectiveness.

Based on interview and document review, the facility failed to follow physician orders for a texture modified diet for 1 of 3 residents (R1) reviewed for diet orders. This resulted in an immediate jeopardy (IJ) for R1 when he was served a regular texture diet and choked while eating, which resulted in R1 requiring emergency department (ED) services and admission to a higher level of care hospital. The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 12/29/25 at 5:00. p.m. when the dietary cook and nursing assistant (NA)-B served R1 with a regular texture tuna fish melt on a bun and sweet potato tots. R1 began to choke, staff performed the Heimlich Maneuver (used on people who can't breathe, speak, or cough because they are choking) three times before R1 was transferred by ambulance to the emergency department (ED), intubated (insertion of a tube into the windpipe to keep the airway open), air flown and admitted to a higher level of care hospital. The administrator and director of nursing (DON) were notified of the IJ on 1/7/26 at 4:46 p.m. The facility implemented corrective action on 12/30/25, prior to the start of the survey and was therefore Past Noncompliance.Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderately impaired cognition, received staff assist with transferring and dressing but was independent with eating and was on a regular texture diet. Diagnoses included epilepsy, chronic obstructive pulmonary disease (COPD), and malignant neoplasm of lower lobe (right lung).R1's Order Summary Report signed on 11/19/25 indicated R1 had a regular diet, regular texture, thick consistency liquids, and 1500 milliliters (ml) fluid restriction.R1's hospital discharge physician order dated 12/26/25, identified R1 was discharged back to the facility following a hospital stay for pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit. Diet order was IDDSI define 5 minced and moist with slightly thick liquids.R1's care plan revised on 12/26/25 identified R1 required slightly thick liquids. Revisions on 1/2/26, identified R1 sat on assistive side of dining room for supervision, cueing, and occasional assistance. R1 was able to feed himself after set-up help. R1 required a therapeutic diet related to pneumonitis due to inhalation of food and vomit evidenced by regular diet, 5 (five) minced and moist texture, slightly thick consistency diet order. Interventions include monitor closely/report signs and symptoms of chewing/swallowing difficulties, coughing, choking, etcetera.R1's Diet Notification Form dated 12/26/25, identified R1's diet was changed to 5 Minced and Moist diet texture; liquids slightly thick fluid consistency, level of supervision was marked as direct supervision and comments indicated R1 was moved to assisted side (of dining room).R1's point of care charting dated 12/29/25 at 6:10 p.m., indicated R1 ate 26-50% of his supper meal.R1's nurse progress noted dated 12/29/25 at 7:00 p.m., by licensed practical nurse (LPN)-A indicated at approximately 5:30 p.m., dietary aid observed resident actively choking and called for the nurse. The resident was removed from the dining room and brought to the nurse's station. The resident was hunched forward in his wheelchair, not breathing, cyanotic, non-responsive to name or sternal rub. Resident's tongue hanging out of mouth with food debris noted around mouth and on clothing. LPN-A performed Heimlich times three while resident seated in wheelchair; after third thrust, the resident coughed and began agonal breathing (gasping and irregular, labored breaths). The resident was transferred by ambulance to the ED at 6:10 p.m. LPN-A documented he verified meal/fluids provided at supper meal were correct according to care plan and that diet orders were followed.R1's ED notes dated 12/29/25 at 7:23 p.m., indicated R1 was there with an airway obstruction and low oxygen saturations. R1 was noted to have copious amounts of solid food removed from R1's mouth and was intubated. ED note dated 12/30/25 at 12:40 a.m., identified chest x-ray noted food bolus; R1 was able to gag up a little bit and several large amounts of food were removed; large pieces of bread as well as a piece of cheese were noted in the substance.The facility's posted guidelines: International Dysphagia Diet Standardization Initiative at www.iddsi.org describes a level 5 Minced and Moist Food for Adults as foods that are:Soft and moist, but with no liquid leaking or dripping from the food.Biting is not required.Minimal chewing required.Lumps of 4 (four) milometers (mm) in size (about the gap between the prongs of a standard dinner fork) Lumps can be mashed with the tongue.Foods can be easily mashed with just a little pressure from a fork.Should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork.No REGULAR DRY Bread due to high choking risk!Example of food to avoid was bread and fruit, vegetable, meat, or other food pieces larger than 4mmx4mmx15mm.The facility's diet spreadsheet alternate menu identified on 12/29/25 the facility was to serve residents with a 5 Minced and Moist (MM5) ordered diet of a ground tuna salad sandwich (MM5), minced sweet potato puffs with ketchup (MM5), pureed blueberry bottom cake (PU4 [pureed]), and milk/beverage. A second diet spreadsheet alternate menu provided by the facility indicated a 5 Minced and Moist texture diet was to receive minced tuna salad (no O/C [onions or celery]) with minced or pureed bread, minced sweet potato puffs with ketchup, pureed blueberry bottom cake, and milk/beverage.When interviewed on 1/6/26 at 3:58 p.m., food service manager (FSM)-A indicated she was not working on 12/29/25 but heard R1 choked on bread and went to the hospital. FSM-A further identified that cook (C)-A moistened the bread but stated R1's diet had recently changed to a minced and moist diet texture and don't believe he [R1] should have had bread.When interviewed on 1/6/26 at 4:15 p.m., the director of nursing (DON) clarified R1's nurse progress notes and stated during her investigation, it was found that LPN-A did not verify that R1's diet texture was correct according to the physician order, but C-A reported to LPN-A, at the time of the incident, it was the correct diet texture. When interviewed on 1/6/26 at 4:27 p.m., LPN-A stated on 12/29/25 at approximately 5:30 p.m., a dietary aide (unknown) pushed R1 out to the nurse's station and he noted R1 to be blue and not breathing. LPN-A performed the Heimlich three or four times, and he coughed up thick clear phlegm and little bits of tuna, called the ambulance and R1 was transferred to the ED. LPN-A stated he did not see what R1 had been served but was told by the dietary R1 had been served a regular bun with tuna.When interviewed on 1/7/26 at 9:40a.m., the registered dietician (RD) identified that she provided consulting services to the facility and had been asked to do some training on 1/8/26 during her normally scheduled visit. The RD stated a 5 minced and moist textured diet should not have been served a bun even if it was soggy. The RD further explained the bread would have to be a gelled bread or a bread that was ground into breadcrumbs, moistened with warm water or milk and put in a sandwich mold to be served as a minced and moist texture. The RD stated that a soggy bun would be moister, but it would not meet the minced criteria of the diet texture so therefore could cause an increased risk of choking if served to a resident.When interviewed on 1/7/26 at 9:53 a.m., C-A we already defined stated he was the cook on 12/29/25 for the evening meal and the menu consisted of tuna melts. C-A further explained the tuna melt was tuna with mayo and pickle relish placed on a hamburger bun and wrapped in tin foil, baked, and put in the steam table. C-A stated that everything tends to get soggy in the steam table, so I know I gave him [R1] a soggy bun. C-A identified his understanding of the minced and moist diet was that a resident could have bread, it just could not be crusty or crispy but then stated, the stuff [information] we had was not up to date. C-A stated he gave R1's plate to nursing assistant (NA)-B and she cut his tuna melt in half, but he could not remember what food R1 was served besides the tuna melt.When interview on 1/7/26 at 1:17 p.m., family member (FM)-A stated R1 was in the hospital because he choked on some food again. FM-A stated R1 was not doing well at all.When interviewed on 1/7/26 at 2:53 p.m., NA-A stated she was working and was in the dining room on 12/29/25 during R1's choking incident. NA-A stated R1 wanted the tuna melt so she handed R1's dietary card to the cook and received a tuna melt on a bun and sweet potato tots, no dessert. NA-A delivered the meal to R1 but did not know R1 had a new diet change as she had not worked with R1 since his most recent hospital return. NA-A stated she was at another table feeding another resident when the dietary aid told her R1 was choking and called the nurse twice with no response so the dietary aide brought R1 to the nurse.When interviewed on 1/7/26 at 2:12 p.m., FSM-B stated she worked on 12/30/25 and assisted with the facility investigation into R1's choking incident on 12/29/25. FSM-B stated she questioned C-A as to what a minced and moist should have had for supper the evening of 12/29/25 and was told they should have been served tuna salad off the bun and beets diced small enough. FSM-B interviewed dietary aide (DA)-A and was told R1 was served tuna melt sandwich on a bun, cut in half and had taken a couple of bites out of each side. FSM-B reapproached C-A and stated, he knew right away what he had done wrong. FSM-B stated the bun could have caused choking very easily; most of the time we go without bread; bread is the worst thing [for the minced and moist diet].When interviewed on 1/7/26 at 2:27 p.m., DA-A stated she was in the dining room at the time of R1's choking incident. DA-A indicated R1 had sweet potato tots and a sandwich on his plate that was half eaten.When interviewed on 1/7/26 at 2:34 p.m., DA-B stated she heard R1 making a weird noise when he was breathing and still took another bit of his sandwich and then started making louder noises and turning gray. DA-B notified NA-B that R1 was choking and took him to the nurse. DA-B stated she looked at R1's plate and it contained cheesy meat between buns and sweet potato tots that looked a little more crisp than usual and further identified R1 had eaten less than half of his meal.During an interview on 1/7/26 at 4:37 p.m., the DON stated it is her expectation of staff that they are aware of and serve the resident's physician order diets and restrictions. It is also her expectation that the nurse or nurse aide that hand the dietary card to the cook acts as a dual check system and any of them can stop the process if they are not sure if the correct diet was served. The DON stated training was started immediately on 12/30/25. The facility policy Texture-Modified Diets- Food and Nutrition Services dated 5/12/2025, identified the purpose was to ensure safe consumption of food/fluids for those residents who have difficulty chewing/swallowing (dysphagia). The definition of a texture-modified diet is a diet specifically prepared to alter the texture or consistency of food to facilitate efficient oral intake. IDDSI terminology will replace NDD (National Dysphagia) diets as the standard of practice for texture modified diets. The past noncompliance immediate jeopardy began on 12/29/25. The immediate jeopardy was removed and the deficient practice was corrected by 12/30/25, after the facility implemented a systemic plan that included the following actions: Education to all staff regarding IDDSI modified texture and physician ordered diets with competencies; a review of dietary policy and procedure; validation of resident diets, care plan updates, audits for all meals to assure those residents on special textured diets received the proper diet texture foods. Verification of the correction action was confirmed by observation, interview, and document review on 1/6/26 and 1/7/26.

Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employee would be able to return to work after an illness, dependent upon their symptoms for 3 of 5 sampled staff (trained medication aide (TMA)-A, nursing assistant (NA)-A, and dietary aide (DA)-B). In addition, the facility failed to ensure 1 of 5 sampled staff (dietary aide) had completed tuberculosis testing (TST) upon hire. This had the potential to affect all 62 residents in the facility. Findings include: Employee Surveillance Review of the December 2024 through April 2025 Monthly Report of Infections in Location- Employees, Children, Family and Visitors logs identified the following columns: 1) Name 2) ID Code 3) Assigned Unit 4) Date of onset 5) Type of Infection 6) Antibiotic Treatment 7) Cautionary Measures 8) Culture Results (if taken). The following randomly selected staff were identified to have absences from work: NA-A, TMA-A, and DA-B. Review of Absence/[NAME] Report sheets and matching timecards from February 2025 to April 2025 identified the following corresponding information: Name, date, time, called in, scheduled shift, reason for absence, illness and symptoms, and return to work date. On: 1) 2/21/25, nursing assistant (NA)-A was noted to have called in sick from work with symptoms of diarrhea (loose watery stool) and vomiting. NA-A returned to work on 2/23/25. There was no mention when or if NA-A symptoms resolved prior to returning to work. 2) 3/14/25, trained medication aide (TMA)-A was noted to have called in sick from work with symptoms of diarrhea and had left early from her shift. TMA-A timecard identified on 3/14/25, TMA-A had worked from 6:30 a.m. to 4:13 p.m. On 3/16/25, she had worked 1 hour and returned to work for a full day (8 hours) on 3/18/25. There was no mention when or if TMA-A symptoms resolved prior to returning to work. 3) 4/29/25, dietary aide (DA)-B was noted to have called in sick from work with symptoms of vomiting and fever. DA-B returned to work on 5/02/25. There was no mention when or if DA-B symptoms resolved prior to returning to work. Interview on 5/19/25 at 3:58 p.m., with director of nursing (DON) and registered nurse (RN)-A identified TMA-A had reported her illness on 3/14/25 had not felt well and left work early on 3/14/25 and again on 3/16/25. The DON identified the Absence/[NAME] report sheets was to track employee illnesses, by the infection preventionist (IP) to identify when employees was eligible to return to work and was not updated, accurately. RN-A identified processes to monitor staff illnesses was not consistent and would need to be evaluated for improvement. Review of May 2024 Employee Health Conditions Reporting and Managing-Infection Control policy identified employees was to communicate with department supervisors, such as the IP, nurse, or DON before returning to work. TB Review of employee health file of DA-A identified DA-A was hired on 3/17/25. DA-A had a baseline TB symptom screening on 3/24/25 and received the first step TST series on 3/14/25. The form lacked evidence of a second TST. Interview on 5/19/25 at 4:11 p.m. with director of nursing (DON) and registered nurse (RN)-A had voiced in agreement that new hires should have TB screening and testing completed upon hire and noted there was no documentation to support DA-A had received a 2nd TB test as required. Review of January 2025 Tuberculosis Control Plan and Screening for Employees, Senior Living, Rehab/Skilled, Home Health, Child Day-Enterprise policy identified new employees was to have a baseline TB screening and testing, prior or upon hire. If, the facility was to provide a two-step Mantoux TST, the first step was to be read within 48 to 72 hours and the second step should be given in 1 to 3 weeks.

Based on observation, interview, and document review, the facility failed revise the care plan when new physician orders were received for 1 of 3 sampled residents (R55) receiving oxygen therapy upon return from the hospital. Findings include: R55's 3/24/25, admission Minimum Data Set (MDS) assessment identified R55 cognition was intact, R55 had no behaviors. On 5/5/25, the MDS noted she and was receiving oxygen therapy. Observations on 5/19/25 identified at: 1) 8:25 a.m., R55 was noted to be awake lying in her bed. Her oxygen tubing was not applied to her person but was observed lying on the bed next to her. The oxygen concentrator was noted to be on and set to deliver oxygen at 3 liters/minute (L/min). 2) 8:35 a.m., nursing assistant (NA)-B was assisting R55 with morning cares. NA-B ensured R55 had her oxygen on via nasal cannula (NC). NA-B then transferred R55. Following R55's transfer, NA-B switched R55 from her oxygen concentrator set at 3 L/min over to her portable oxygen tank and turned it on. The flow rate was pre-set at 2.5 L/min. 3) 11:06 a.m., of R55 while registered nurse (RN)-B performed a dressing change, identified R55's oxygen flow rate was set at 3 L/min. R55's 3/31/25, hospital discharge summary identified an order for oxygen at 2 L/min. per NC for 1 month. R55's current care plan identified a focus area of oxygen therapy initiated revised on 3/31/25 related to acute respiratory failure with hypoxia (lack of oxygen). R55 was to have no signs or symptoms of poor oxygen absorption through the review date. Staff were to monitor for signs and symptoms of respiratory distress and report to the provider. R55's head of her bed was to be elevated as she tolerated. R55 was to have oxygen at 2 L/min. per NC at rest and overnight to maintain her oxygen saturation above 92%. R55's 4/29/25, hospital discharge summary identified a new physician order was placed for R55 to receive oxygen at 1-2 L/min. per NC during the day, with titrating up to 2 L/min. per NC overnight. Further review of the above-mentioned care plan identified no changes were made when a new order was received to change the oxygen flow rate on 4/29/25. R55's 5/21/25, Order Summary Report (OSR) identified R55 had an order for oxygen to be administered at 2 liters (L) per nasal cannula (NC) at rest and overnight to maintain an oxygen saturation over 92 %, The order summary report identified diagnoses of a history of acute respiratory failure with hypoxia. There was no indication the OSR had been updated to the newer 4/29/25 physician order from the original order placed on 3/31/25, to show the change in flow rate to 1-2 L per min. during the day and 2 L/min at night. R55's May 2025, medication administration record (MAR) identified an order was documented for oxygen to be administered at 2 L/min. via NC at rest and overnight to maintain oxygen saturation above 92%. Staff were to check twice a day at 8:00 a.m. and again at 8:00 p.m Staff documented R55's oxygen saturations levels were identified to be 91% to 96%, however, there was no indication staff were checking the actual flow rate, nor had they verified the MAR with the correct physician order which was changed to 1-2 L during the day and 2 L/min. at night. Further observations on 5/20/25 identified at: 4) 5/20/25 at 8:43 a.m., R55 was noted to be seated at the breakfast table. Her portable oxygen tank was set at flow rate of 3 L/min. 5) 5/20/25 at 9:04 a.m., R55 noted to be in her room. Her oxygen was connected to the oxygen concentrator with the flow rate set at 3 L/min. Observation and interview on 5/20/25 at 10:11 a.m., of R55's oxygen flow rate with RN-C identified R55's oxygen was set at 3 L/min RN-C reviewed the MAR and noted R55's oxygen flow rate was supposed to be at 2 L/min. per NC at rest and during the night. Direct care staff were not allowed to change the flow rate and only switch the oxygen tubing from the concentrator to the portable oxygen tank as needed for transfers. RN-C thought R55's family member messed with the oxygen at times. RN-C made no mention if in knowing R55's family member was known to adjust R55's physician ordered oxygen rate, the family member had been educated by staff not to adjust it, or to alert staff if they noticed R55 had any breathing difficulty requiring oxygen adjustment. RN-C also failed to verify the accuracy of the MAR with the updated physician order for 1-2 L per min during the day and 2 L/min at night that was changed on 4/29/25. Interview and document review on 5/21/25 at 10:31 a.m., with administrator identified her expectation was a resident's oxygen administration orders were to be followed, be consistent in the medical record, and appropriately documented and administered. The administrator reviewed the OSR. She confirmed that OSR (entered by staff) noted R55 was to receive oxygen at 2 L/min. There was no indication the administrator was aware R55's oxygen administration order had been changed on 4/29/25 for 1-2 L/min. via NC during the day and 2 L/min. at night. Review of the 7/8/24, Oxygen Administration policy identified oxygen was to be administered with a physician order. A licensed nurse was to be on duty and responsible for the proper administration of the oxygen for the resident. There was no mention of how staff were to appropriately document the amount of oxygen that was being administered. There was no policy related to care plans provided by the end of survey.

Based on observation, interview, and document review, the facility failed to ensure the correct physician order was followed and appropriately monitored for 1 of 3 sampled residents (R55) recieving oxygen therapy. Findings include: R55's 3/24/25, admission Minimum Data Set (MDS) assessment identified R55 cognition was intact, R55 had no behaviors. On 5/5/25, the MDS noted she and was receiving oxygen therapy. Observations on 5/19/25 identified at: 1) 8:25 a.m., R55 was noted to be awake lying in her bed. Her oxygen tubing was not applied to her person but was observed lying on the bed next to her. The oxygen concentrator was noted to be on and set to deliver oxygen at 3 liters/minute (L/min). 2) 8:35 a.m., nursing assistant (NA)-B was assisting R55 with morning cares. NA-B ensured R55 had her oxygen on via nasal cannula (NC). NA-B then transferred R55. Following R55's transfer, NA-B switched R55 from her oxygen concentrator set at 3 L/min over to her portable oxygen tank and turned it on. The flow rate was pre-set at 2.5 L/min. 3) 11:06 a.m., of R55 while registered nurse (RN)-B performed a dressing change, identified R55's oxygen flow rate was set at 3 L/min. R55's 3/31/25, hospital discharge summary identified an order for oxygen at 2 L/min. per NC for 1 month. R55's current care plan identified a focus area of oxygen therapy initiated revised on 3/31/25 related to acute respiratory failure with hypoxia (lack of oxygen). R55 was to have no signs or symptoms of poor oxygen absorption through the review date. Staff were to monitor for signs and symptoms of respiratory distress and report to the provider. R55's head of her bed was to be elevated as she tolerated. R55 was to have oxygen at 2 L/min. per NC at rest and overnight to maintain her oxygen saturation above 92%. R55's 4/29/25, hospital discharge summary identified a new physician order was placed for R55 to receive oxygen at 1-2 L/min. per NC during the day, with titrating up to 2 L/min. per NC overnight. Further review of the above-mentioned care plan identified no changes were made when a new order was received to change the oxygen flow rate on 4/29/25. R55's 5/21/25, Order Summary Report (OSR) identified R55 had an order for oxygen to be administered at 2 liters (L) per nasal cannula (NC) at rest and overnight to maintain an oxygen saturation over 92 %. , The order summary report identified diagnoses of a history of acute respiratory failure with hypoxia. There was no indication the OSR had been updated to the newer 4/29/25 physician order from the original order placed on 3/31/25, to show the change in flow rate to 1-2 L per min. during the day and 2 L/min at night. R55's May 2025, medication administration record (MAR) identified an order was documented for oxygen to be administered at 2 L/min. via NC at rest and overnight to maintain oxygen saturation above 92%. Staff were to check twice a day at 8:00 a.m. and again at 8:00 p.m Staff documented R55's oxygen saturations levels were identified to be 91% to 96%, however, there was no indication staff were checking the actual flow rate, nor had they verified the MAR with the correct physician order which was changed to 1-2 L during the day and 2 L/min. at night. Further observations on 5/20/25 identified at: 4) 5/20/25 at 8:43 a.m., R55 was noted to be seated at the breakfast table. Her portable oxygen tank was set at flow rate of 3 L/min. 5) 5/20/25 at 9:04 a.m., R55 noted to be in her room. Her oxygen was connected to the oxygen concentrator with the flow rate set at 3 L/min. Observation and interview on 5/20/25 at 10:11 a.m., of R55's oxygen flow rate with RN-C identified R55's oxygen was set at 3 L/min RN-C reviewed the MAR and noted R55's oxygen flow rate was supposed to be at 2 L/min. per NC at rest and during the night. Direct care staff were not allowed to change the flow rate and only switch the oxygen tubing from the concentrator to the portable oxygen tank as needed for transfers. RN-C thought R55's family member messed with the oxygen at times. RN-C made no mention if in knowing R55's family member was known to adjust R55's physician ordered oxygen rate, the family member had been educated by staff not to adjust it, or to alert staff if they noticed R55 had any breathing difficulty requiring oxygen adjustment. RN-C also failed to verify the accuracy of the MAR with the updated physician order for 1-2 L per min during the day and 2 L/min at night that was changed on 4/29/25. Interview and document review on 5/21/25 at 10:31 a.m., with administrator identified her expectation was a resident's oxygen administration orders were to be followed, be consistent in the medical record, and appropriately documented and administered. The administrator reviewed the OSR. She confirmed that OSR (entered by staff) noted R55 was to receive oxygen at 2 L/min. There was no indication the administrator was aware R55's oxygen administration order had been changed on 4/29/25 for 1-2 L/min. via NC during the day and 2 L/min. at night. Review of the 7/8/24, Oxygen Administration policy identified oxygen was to be administered with a physician order. A licensed nurse was to be on duty and responsible for the proper administration of the oxygen for the resident. There was no mention of how staff were to appropriately document the amount of oxygen that was being administered.

Based on observation, interview, and document review, the facility failed accurately reconcile physician orders upon return from the hospital and update the electronic medical record for 1 of 3 sampled residents (R55) receiving oxygen therapy. Findings include: R55's 3/24/25, admission Minimum Data Set (MDS) assessment identified R55 cognition was intact, R55 had no behaviors. On 5/5/25, the MDS noted she and was receiving oxygen therapy. Observations on 5/19/25 identified at: 1) 8:25 a.m., R55 was noted to be awake lying in her bed. Her oxygen tubing was not applied to her person but was observed lying on the bed next to her. The oxygen concentrator was noted to be on and set to deliver oxygen at 3 liters/minute (L/min). 2) 8:35 a.m., nursing assistant (NA)-B was assisting R55 with morning cares. NA-B ensured R55 had her oxygen on via nasal cannula (NC). NA-B then transferred R55. Following R55's transfer, NA-B switched R55 from her oxygen concentrator set at 3 L/min over to her portable oxygen tank and turned it on. The flow rate was pre-set at 2.5 L/min. 3) 11:06 a.m., of R55 while registered nurse (RN)-B performed a dressing change, identified R55's oxygen flow rate was set at 3 L/min. R55's 3/31/25, hospital discharge summary identified an order for oxygen at 2 L/min. per NC for 1 month. R55's current care plan identified a focus area of oxygen therapy initiated revised on 3/31/25 related to acute respiratory failure with hypoxia (lack of oxygen). R55 was to have no signs or symptoms of poor oxygen absorption through the review date. Staff were to monitor for signs and symptoms of respiratory distress and report to the provider. R55's head of her bed was to be elevated as she tolerated. R55 was to have oxygen at 2 L/min. per NC at rest and overnight to maintain her oxygen saturation above 92%. R55's 4/29/25, hospital discharge summary identified a new physician order was placed for R55 to receive oxygen at 1-2 L/min. per NC during the day, with titrating up to 2 L/min. per NC overnight. Further review of the above-mentioned care plan identified no changes were made when a new order was received to change the oxygen flow rate on 4/29/25. R55's 5/21/25, Order Summary Report (OSR) identified R55 had an order for oxygen to be administered at 2 liters (L) per nasal cannula (NC) at rest and overnight to maintain an oxygen saturation over 92 %, The order summary report identified diagnoses of a history of acute respiratory failure with hypoxia. There was no indication the OSR had been updated to the newer 4/29/25 physician order from the original order placed on 3/31/25, to show the change in flow rate to 1-2 L per min. during the day and 2 L/min at night. R55's May 2025, medication administration record (MAR) identified an order was documented for oxygen to be administered at 2 L/min. via NC at rest and overnight to maintain oxygen saturation above 92%. Staff were to check twice a day at 8:00 a.m. and again at 8:00 p.m Staff documented R55's oxygen saturations levels were identified to be 91% to 96%, however, there was no indication staff were checking the actual flow rate, nor had they verified the MAR with the correct physician order which was changed to 1-2 L during the day and 2 L/min. at night. Further observations on 5/20/25 identified at: 4) 5/20/25 at 8:43 a.m., R55 was noted to be seated at the breakfast table. Her portable oxygen tank was set at flow rate of 3 L/min. 5) 5/20/25 at 9:04 a.m., R55 noted to be in her room. Her oxygen was connected to the oxygen concentrator with the flow rate set at 3 L/min. Observation and interview on 5/20/25 at 10:11 a.m., of R55's oxygen flow rate with RN-C identified R55's oxygen was set at 3 L/min RN-C reviewed the MAR and noted R55's oxygen flow rate was supposed to be at 2 L/min. per NC at rest and during the night. Direct care staff were not allowed to change the flow rate and only switch the oxygen tubing from the concentrator to the portable oxygen tank as needed for transfers. RN-C thought R55's family member messed with the oxygen at times. RN-C made no mention if in knowing R55's family member was known to adjust R55's physician ordered oxygen rate, the family member had been educated by staff not to adjust it, or to alert staff if they noticed R55 had any breathing difficulty requiring oxygen adjustment. RN-C also failed to verify the accuracy of the MAR with the updated physician order for 1-2 L per min during the day and 2 L/min at night that was changed on 4/29/25. Interview and document review on 5/21/25 at 10:31 a.m., with administrator identified her expectation was a resident's oxygen administration orders were to be followed, be consistent in the medical record, and appropriately documented and administered. The administrator reviewed the OSR. She confirmed that OSR (entered by staff) noted R55 was to receive oxygen at 2 L/min. There was no indication the administrator was aware R55's oxygen administration order had been changed on 4/29/25 for 1-2 L/min. via NC during the day and 2 L/min. at night. Review of the 7/8/24, Oxygen Administration policy identified oxygen was to be administered with a physician order. A licensed nurse was to be on duty and responsible for the proper administration of the oxygen for the resident. There was no mention of how staff were to appropriately document the amount of oxygen that was being administered. There was no policy related to reconciling physician orders provided by the end of survey.

Based on interview and document review the facility failed to complete a comprehensive assessment for continued use of antibiotics for 1 of 3 sampled residents (R16) reviewed for antibiotic stewardship. Findings include: Review of the current, undated, Centers for Disease Control (CDC): The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use, located at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf, identified facilities should evaluate the clinical signs and symptoms when a resident is first suspected of having an infection. Once the resident is placed on an antibiotic, they should be comprehensively reviewed within 48-72 hours after starting the medication to ensure they have been prescribed an effective medication. This is accomplished by reviewing the resident current symptoms and any laboratory results to identify medication effectiveness. The CDC identifies this process as an antibiotic time-out [ATO]. Review of Monthly Infection Summary reports from December 2024 through March 2025 identified the columns for resident's name, infection date, date symptoms resolved, infection, medication, source of the infection and if the criteria was met. May 2025 infection control log identified R16 had been prescribed Bactrim sulfamethoxazole-trimethoprim (antibiotic medication) 800-160 milligrams (mg) for 7 days for a urinary tract infection (UTI). The onset of the infection occurred on 5/1/25 and had met criteria for the continuation of use. R16's current, undated diagnosis sheet identified R16 had a diagnoses of urinary tract infection (UTI) and sepsis (infection of tissues and organs). R16's, May 2025 Medication Record identified R16 had taken the Bactrim 800-160mg, one tablet twice a day from 5/02/25 to 5/09/25. R16's, progress note identified, on: 1)4/30/25 at 11:06 a.m., identified R16 arrived at the facility from an appointment with orders to start Bactrim medication therapy for UTI. 2)5/02/25 at 19:14 p.m., identified Bactrim was prescribed by R16's physician. 3)5/9/25 at 14:50 p.m., identified R16 had completed the antibiotic therapy with no adverse effects. R16's medical record lacked evidence of an ATO after the initiation of the Bactrim therapy between 48-72 hours after initiation. Interview on 5/19/25 at 3:50 p.m., with director of nursing (DON) identified R16 did not exhibit any signs or symptoms according to McGreer's (infection surveillance tool criteria) the facility normally would use to begin an evaluation for potential infection. Since R16 had shown no signs or symptoms while living at the facility and had only received the medication as a result of a physician outpatient visit at the clinic, the facility had not performed an ATO as would be the normal process. The DON agreed the facility was responsible for ensuring antibiotic stewardship, even if a medication was not initiated or ordered by the facility staff or attending physicians. Review of January 2025 Identification and Reporting of Suspected Infection AL, R/S, LTC, Home Health, Hospice policy identified the nurse manager, or infection preventionist (IP) was to identify infections, collect data related to the infection, record indication of use of antibiotic therapy, and maintain infection surveillance on a continued basis.

Based on interview and document review, the facility failed to ensure 1 of 5 sampled residents (R7) was offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC). Findings include: Review of the current, 10/26/24, Centers for Disease Control (CDC): Pneumococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, identified based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV 21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV 21 if they have received both the PCV13 (but not PCV15, PCV20, or PCV 21) at any age and a PPSV23 at or after the age of [AGE] years old. R7's 5/05/25, 5-day Minimum Data Set (MDS) identified R7 was [AGE] years old and had a diagnoses of diabetes, heart failure and pneumonia. Section O-Special Treatments and Programs identified R7 was reported to be up to date with the pneumococcal vaccine (PCV). R7's current, undated immunization report indicated R7 had received PCV 13 on 3/17/15 and PPSV-23 on 3/17/09. R7's 4/15/25, Vaccine Consent form identified R7 consented for an updated PCV dose. Interview on 5/19/25 at 4:08 p.m., with registered nurse (NA)-A and director of nursing (DON) voiced in agreement that R7 had not received the PCV vaccine after the consent was obtained. Review of November 2024 Immunizations/Vaccinations for Residents, Pneumococcal influenza, COVID-19, Other AL, R/S, LTC, HBS-Enterprise policy identified the facility was to provide residents with the PCV, per Centers for Disease Control and Prevention guidelines.

Based on interview and record review the facility failed to devlop and implement a comprehensive person-centered care plan that addressed resident smoking with safety precautions for 1 of 1 (R29) resident reveiwed for care plan. Findings include: R29's printed face sheet identified an admitted to the facility on [DATE]. R29's 2/16/24, admission Minimum Data Assessment (MDS) , section J identified R29 used tobacco. R29's 2/16/24, progress note identified R6 had been smoking with a family member outside. R29's 2/24/24, Tobacco Assessment identified R29 smoked cigarettes, was not on oxygen, and would smoke 10+ times per day. The Assessment lacked evidence of R29 had been educated on smoking and to safely keep cigarettes or lighter in his possession. Interview on 3/18/24 at 12:49 p.m., with R29 stated he had been a smoker and would smoke outside the facility. R29 stated he would inform the nurse of the location of his lighter and cigarettes stored in his room or at the nursing station. Observation and interview on 3/19/24 at 11:51 a.m., with licensed practical nurse (LPN)-B at the 500 unit medication cart observed R29's 2 packs of cigarettes and a lighter. LPN-B stated R29 would occasionally smoke outside the facility and R29 would let her know if he had cigarettes or a lighter in his room. Interview on 3/19/24 at 11:53 a.m., with LPN-C stated she found R29's lighter in his jacket pocket and had stored it in the medication cart on the 500 unit. Interview on 3/19/24 at 1:29 p.m., with registered nurse (RN)-A addressed R29's missing care plan for smoking on the electronic medical record's (EMR) point click care (PCC) and stated it would need to be completed for him. Interview on 3/19/24 at 1:59 p.m., with RN-B stated R29 had been provided education on smoking prior to his admission. RN-B R29 did not smoke at the facility and R29 would go offsite with family to go smoking. Interview on 3/20/24 at 8:48 a.m., with director of nursing (DON) stated her expectation would be for the facility to have had an individualized care plan tailored for R29's smoking needs prior to R29's admission to the facility. Review of 11/01/23 Care Plan-R/S, LTC, Therapy & Rehab policy identified the facility would modify the care plan to address the needs of the residents and develop the whole person ensuring appropriate services would be provided to the resident under the direction of the interdisciplinary team.

Based on interview and document review, the facility failed to notify primary care provider of a change in condition and obtain treatment orders for 1 of 1 resident (R15) who developed a new pressure injury. Findings include: R15's 2/27/24, annual Minimum Data Set (MDS) identified R15's cognition was impaired, R15 was dependent on staff for transfers and required substantial assistance with repositioning. R15 had pain and took a pain medication. R15 had 1 unstageable pressure ulcer upon re-entry to the facility and had finished working with occupational and physical therapy at end of January. R15's previous 11/30/23, quarterly MDS identified R15 was at risk of developing pressure ulcers, and he had no unhealed pressure ulcers identified during the assessment period. R15's 3/19/24, printed Diagnosis Report identified chronic kidney disease stage 4, type 2 diabetes mellitus, vascular dementia, pressure ulcer of right heel, unspecified stage, history of stroke, atrial fibrillation, and iron deficiency anemia. R15's 2/27/24, care area assessment (CAA) pressure ulcer/injury worksheet identified as an actual problem. R15 had 1 unstageable pressure ulcer to right heel that was treated with betadine and pressure alleviation. R15 was repositioned every 2 hours and wore a pressure alleviating boot on each foot. R15 would have pressure ulcer status addressed on his care plan to promote healing. R15's 3/18/24, printed care plan identified R15 required 2 staff using a sit to stand lift for transfers once out of bed and a total lift to get into and out of bed. R15 had potential for pressure injury related to limited mobility and staff were to notify the nurse immediately of any new areas of skin breakdown. Staff were to apply lotion to dry skin including feet. R15 was identified on 1/9/24, to have actual impairment to skin integrity related to unstageable ulcer to right heel, staff were to reduce risk of skin impairment by avoiding friction and shear. Staff would monitor skin and reposition R15 every 2 hours. R15's 3/19/24, printed Order Summary Report identified an order on 1/9/24, for a low air loss pressure redistribution mattress and staff were to offload R15's heels with pillows or heel protectors' boots. Interview on 3/19/24 at 9:45 a.m., with licensed practical nurse (LPN)-B who identified she was the facility wound nurse. LPN-B revealed that R15 had developed an area of concern on his right heel at the beginning of December however, the provider along with herself had not been notified of the area until a month later. Once she was notified of R15's heel on 1/2/24, she had sent a facsimile (fax) to the clinic notifying the provider and requested treatment orders. Unfortunately, that same day R15 was sent to the hospital for an unrelated concern and returned to the facility on [DATE]. Interview on 3/19/24 at 10:52 a.m., with nursing assistant (NA)-E identified if staff noted any new skin concerns that they were to report that to the nurse immediately. She was unsure exactly when R15's heel became sore, but he had been wearing the foam boots for quite a while now. Review of the facility Skin Observation form used on the resident bath day each week included an area to document skin condition, medications and/or conditions, treatments, follow up comments, care plan, and/or education provided. Reviewed from 11/25/23 through 1/13/24 which identified the following: 1) The 11/25/23, form identified no skin conditions observed 2) The 12/2/23, form identified posterior right heel, dark brown scabbed area from new slippers, there were no measurements identified. All other sections of the form left blank. 3) The 12/9/23, form identified right heel small purple spot on back of heel, that lined up with back of new slippers. There were no measurements identified. All other sections of the form left blank. 4) The 12/16/23, form identified right heel purple spot that is open to air. There were no measurements identified. All other sections of form left blank. 5) The 12/23/23, form identified right heel small purple area. There were no measurements identified. All other sections of form left blank. 6) The 12/30/23, form identified right heel purple spot and dry skin sloughing off around it, slippers rub on this spot. The area was open to air and resident was wearing gripper socks verses slippers today. There were no measurements identified. All other sections of form left blank. 7) The 1/13/24, form identified right heel purple spot and dry skin sloughing off. There were no measurements identified. All other sections of form left blank. Review of R15's progress notes from 11/30/23 through 1/9/24 lacked identification that the primary provider or the family had been updated on R15's wound that developed on his right heel for a month. On 1/2/24 there was a progress note that the provider had called the facility and requested R15 to be sent to ER for an evaluation following the results of some labs that had been drawn earlier. Progress note on 1/3/24, identified R15's care plan had been updated to reflect the area on his right heel. On 1/9/24 R15 returned to the facility with identified pressure ulcer to right heel with treatment orders and new interventions to wear heel protectors and be repositioned every 2 hours. Interview on 3/19/24 at 1:33 p.m., with nursing assistant (NA)-D identified R15 has had the right heel wound for a couple months now. She reported she believed the area on his heel started as a blister from his new slippers. He now needed to wear the foam boots on both of his feet. She reported that the nurse checks his feet every day. Interview on 3/19/24 at 2:16 p.m., with registered nurse (RN)-A who confirmed R15 had a wound to his right heel that had been identified during a skin audit on 12/2/23 however the wound RN assessment had not been completed until 1/2/24 a month later. She revealed that the nurse should have completed a wound assessment, made a nurses note, and updated the provider. Interview on 3/19/24 at 3:24 p.m., with LPN-B identified weekly she completed a wound data collection and measured wounds in the facility. She identified an RN completed the wound RN assessment portion weekly. LPN-B stated R15 was first noted to have something on his right heel on 12/2/23, and she had not been notified until a month later. The charge nurse was to complete a skin audit on bath day weekly and if any new skin concerns were identified the nurse would notify her and if she was not available, they were to notify the provider. She revealed if she was working, she took care of communicating with the provider and obtaining treatment orders, updating the family, and she also took care of reviewing the care plan for any needed updates. She revealed that initially the area on R15's right heel was identified as a scab and typically the facility would not notify the provider for a scab but rather monitor that. She confirmed that by the next week that the area on R15's right heel had been identified as a dark spot and that should have been communicated with the provider and she should have been notified. She confirmed that there should have been an assessment completed on 12/2/23, when the area presented as a dark brown scabbed area with notification to the provider and treatment orders requested, the nurse also should have notified the family and herself but that had not occurred. Interview on 3/19/24 at 3:33 p.m., with the director of nursing (DON) identified any time a new skin concern was identified the nurse should assess the area and notify the provider and obtain treatment orders. The nurse assessing the new skin concern should act and not wait for the wound nurse. She revealed that the facility had a nursing meeting on 1/9/24 and discussed R15 and his wounds. Review of the facility Wound Data Collection and Wound RN Assessment forms identified the following: 1) On 1/2/24, identified it was an initial data collection of the wound. The wound was not present upon admission or re-admission. The wound on right heel was from friction and measured 2.5 cm length X 4.0 cm width. There was no dressing present, noted eschar with dry thick skin lifting at edges. There was no redness or drainage noted. The wound bed had 100% eschar (necrotic tissue that appears black, brown, or tan). A fax was sent to primary care provider to inform and request treatment. Applied gripper socks instead of slippers to prevent further friction to area. Type of wound, identified as non-pressure (venous, arterial, diabetic, non-traumatic), initial evaluation of wound, eschar dry and appears stable at this time with no sign or symptoms of infection. Wound was debrided. Care plan updated. 2) On 1/9/24, right heel wound measured 4.2 cm length X 3.0 cm width, wound bed 100% eschar. Type of wound, identified as pressure ulcer, unstageable. 3) On 2/6/24, right heel wound measured 3.0 cm X 2.5 cm, wound bed 100% eschar. Type of wound, identified as pressure ulcer, unstageable. 4) On 3/19/24, right heel wound measured 2.5 cm length X 2.0 cm width, wound bed 100% eschar. Type of wound, identified as pressure ulcer, unstageable. Interview on 3/20/24 at 7:35 a.m., with registered nurse (RN)-C identified if a staff reported a new skin concern, she would assess the area, notify the provider, and request treatment. She would notify the family of the finding and the facility wound nurse. Interview on 3/20/24 at 8:35 a.m., with licensed practical nurse (LPN)-A who had completed the skin observation on 12/9/23 and 12/30/23. LPN-A identified if a new skin concern was brought to her attention or she identified a new skin concern the protocol was to assess the area, contact the provider and obtain treatment orders, contact the facility wound nurse and family. LPN-A was unable to recall why she had not followed the facility protocol for new skin concerns or what the circumstance was that R15's provider had not been notified of the new purple area on R15's right heel on 12/9/23. Review 4/26/23, Skin Assessment Pressure Ulcer Prevention and documentation policy identified all residents would be assessed by a registered nurse for their risk of developing pressure ulcers. A skin inspection would be made daily by the direct care staff caring for the resident and report any findings or signs of skin concerns to the licensed nurse. If identified pressure ulcer concern the nurse would assess and document the type of wound or skin damage including measurements and characteristics using the facility wound data collection electronic form. The licensed nurse would notify the provider and obtain treatment orders. The licensed nurse would notify the family of the pressure ulcer, the treatment, and the planned interventions. The dietary department would be notified. The interdisciplinary team would determine any necessary changes needed to the resident's care plan.

Based on observation, interview and document review, the facility failed to properly assess disposing of cigarettes for 1 of 1 resident (R29) reviewed for accidents. Findings include: R29's 2/16/24, admission Minimum Data Assessment (MDS) identified R29 was cognitively intact (able to fully understand) and had a diagnosis of diabetes, end stage renal disease (ESRD), diabetes and anxiety. R55 had supervision related to his activities of daily living and used a wheelchair. R55's Section O of the MDS identified R29 was on dialysis and had oxygen. Observation on 3/19/24 at 2:44 p.m., with R29 in his room in his wheelchair had removed his nasal cannula and turned off his oxygen concentrator. R29 propelled himself in his wheelchair to the nursing station. R29 asked for his cigarettes and lighter and licensed practical nurse (LPN)-C assessed his lungs and checked R29's oxygen saturation. LPN-C gave R29 a lighter and a carton of cigarettes. R29 removed 2 cigarettes and placed the cigarette carton in the trash. R29 held his lighter and cigarettes in his right hand and R29 wheeled himself towards the front entrance of the building. Observation on 3/19/24 at 2:51 p.m., with R29 pressed the handicap button for the front door to open and wheeled himself to the sidewalk near the front entrance. R29 lit a cigarette and the director of nursing (DON) walked to R29 and stated R29 could not light a cigarette in front of the entrance but would need to go towards the end of the sidewalk away from the front door, approximate 15 feet away from the facility. R29 stated he knew the rules, held the ciagrette in his mouth and wheeled himself towards the end of the sidewalk away from the front door. Observation and interview on 3/19/24 at 3:08 p.m., with R29 outside flicked his cigarette ash and observed the cigarette ash on his pants and thighs. R29 stated he does not wear a smoking apron and would not need one. R29 finished both cigarettes and held the buds in his right hand. R29 wheeled himself back towards the entrance of the facility and stopped his wheelchair and stated he could not find the cigarette ash tray. R29 stated he would see the cigarette ash tray near the area he smokes or near the front entrance of the facility. R29 entered the facility and wheeled himself to his room. Observation on 3/19/24 at 03:18 p.m., with R29 in his room had placed his cigarette buds in the trash can. R29 stated when he could not find an ash tray he would throw the cigarette buds in the garbage in his room or in the trash bin near the nursing station. R29 pulled a third cigarette bud out of his shirt pocket and placed it in the trash bin in his room along with the 2 cigarettes buds in his trash can. R29 placed a nebulizer (a device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) mask on his face and turned on the Innispire portable machine located next to his bed. An employee came into R29's room and placed ice water on R29's bedside table. Observation and interview on 3/19/24 at 3:26 p.m., with R29 in his room removed his nebulizer mask and turned off the portable machine. R29 placed his nasal cannula in his nose and turned on his oxygen concentrator which was set at 2 liters. R29 stated when he had finished smoking outside, the nurses do not immediately come to his room and he would place the lighter in his pocket or in the drawer in his room. Interview on 3/19/24 at 3:34 p.m., with LPN-C stated R29 would call her when he comes back from smoking outside and would confiscate the lighter. Observation on 3/19/24 at 3:37 p.m., outside the facility entrance doors confirmed no cigarette ash tray located near R29's smoking area or near the entrance of the facility. Observation and interview on 3/19/24 at 3:43 p.m., with LPN-C stated she removed the cigarette buds and cigarette lighter from R29's room. LPN-C stated she wet the cigarette buds with water and disposed them in the trash at the nursing station. LPN-C showed 3 cigarettes buds in the trash at the nursing station. LPN-C stated it would be a fire safety concern for R29 disposing cigarette buds in the trash at the facility and not in the designated cigarette ash tray. Interview on 3/20/24 at 7:26 a.m., with MD-B stated the facility informed him R29 would go outside to smoke with family and would provide nicotine cessation products for R29 to use while residing in a non-smoking facility. Review of 10/11/2023, Smoking and Tobacco Use-Rehab/Skilled, Outpatient Therapy, Adult Day Services and Assisted living policy identified the facility would notify residents on admission of the facilities smoking location and tobacco use policy. The facility would update care plans as indicated and would ensure smoking precautions would be taken for residents safety at the outdoor designated smoking area.

Based on interview and record review, the facility failed to ensure resident was reassessed for continued as needed (PRN) antipsychotic medication (xanax and buspirone (buspar)) had been re-evaluated every 14 days to ensure the appropriateness of continued use for 1 of 2 residents (R55) reviewed for unnecessary medications. Findings include: R55's, face sheet identified a diagnosis of acute respiratory failure with hypercapnia (too much carbon dioxide in the body), chronic obstructive pulomanry disease (COPD), anxiety, and chronic kidney disease. R55's 2/23/24, admission Minimum Data Assessment (MDS) identified she had moderately impaired cognition and had no behaviors. R55 had took antidepressants and had oxygen. R55's 3/11/24, Order Summary Report identified the following medications, buspar (buspirone used to treat anxiety disorders) 5 milligram (mg) by mouth every 8 hours as needed (PRN) with a start date of 2/27/24 with an end date of 3/18/24, past 14 day period. R55 had PRN xanax (alprazolam treats anxiety and panic disorders) 0.25mg by mouth every 24 hours with start date of 2/19/24 with no end date. R55's February 2024, Medication Administration Record (MAR) identified R55 received 2 doses of PRN buspar and 3 doses of PRN xanax that month. R55's March 2024, MAR identified R55 received 20 doses of PRN buspar and 5 doses of PRN xanax that month. Interview on 3/19/24 at 11:29 a.m., with R55 stated she did not need her PRN medications every day. R55 stated her PRN medications helped her when she had difficulty breathing. R55 stated she did not take her PRN medication at home prior to her hospitalization and had taken the (prn) medication since her admission to the nursing home. Interview on 3/19/24 at 11:43 a.m., with medical doctor (MD)-A stated R55 had been issued xanax prescriptions over a period of time, before her admission to the facility, but had not taken them consistently. MD-A stated R55's anxiety medications had been modified and she had no plan to remove the PRN medication and directed nursing staff to continue the administration of R55's PRN medications as indicated. Interview on 3/19/24 at 1:36 p.m., with registered nurse (RN)-A stated R55 had active orders for buspar and xanax to be used PRN related to her anxiety. RN-A agreed R55's xanax and buspar PRN orders should have been addressed and had a stop date on R55's PRN medications prior to the end of the 14 day period. Interview on 3/20/24 at 7:26 a.m., with medical doctor (MD)-B stated the process of PRN medications written for residents should be addressed by the provider of how they would want to issue the continuation of PRN medication usage at the facility. MD-B stated the medical providers should have a clinical rationale to extend psychotropic medications over a 14 day period, in addition, documentation to include weaning of psychotropic medications. Interview on 3/20/24 at 8:44 a.m., with director of nursing (DON) stated her expectation would be for the facility to address the need for gradual dose reduction (GDR) for residents on psychotropic medications to the medical providers and had been difficult to implement. Review of December 2023 Psychotropic medications Rehab/Skilled identified the facility would be free from unnecessary drugs including duplicate drug therapy, and excessive duration of the medication. A registered nurse would complete the initial antipsychotic medication assessment and the abnormal involuntary movement scale assessment and would implement mood and behavior documentation to monitor the effects of the medicaiton. The provider would document a rationale in the residents' medical record and indicate the duration for the PRN order if the PRN order should be extended beyond 14 days. The document further identified all PRN anti-psychotic medications were to be limited to 14 days.

Based on interview and document review, the facility failed to notify the county (designated state mental health authority) when 2 of 2 residents (R2 and R23) when the preadmission screen had not identified a current mental health diagnosis upon admission or had new on-set of mental illness. Finding include: R2's 4/12/22, admission Minimum Data Set (MDS) assessment identified a current diagnosis of schizophrenia. R2's undated care plan identified a a communication problem and the use of an antipsychotic medication related to schizophrenia, disorganized thinking and flight of ideas with an intervention to monitor and document changes. R2's 3/12/22, Pre-Admission screening (PAS), did not identify a diagnosis of schizophrenia and did not indicate the need for a level II PASARR to be completed. Interview on 4/12/23 at 11:00 a.m., Senior Linkage Pre-Admission Screening Specialist confirmed R2's diagnosis of schizophrenia was not identified on the initial PAS. He agreed that if the diagnosis had been included, a level II PASARR would have been required prior to admission to determine need for services. R23's 1/23/23, annual MDS assessment identified a diagnosis of depression and schizoaffective disorder. R23's electronic health record identified a diagnosis of schizoaffective disorder with an effective date of 1/25/2018. R23's 10/19/16 PAS did not identify a diagnosis of schizoaffective disorder and did not indicate the need for a level II PASARR to be completed. Interview on 4/11/23, at 5:32 p.m., RN-B identified the facility relied on the hospital to initiate the PAS prior to admission. She revealed the facility does not have a process or policy in place to review the PAS for accuracy when the facility receives them or a process for communication with the county authority when a new diagnosis has been identified.

Based on interview and document review the facility failed to comprehensively assess and identify target behaviors and non-pharmacological interventions for scheduled anti-anxiety medication for 1 of 5 residents (R23) reviewed for unnecessary medication usage. Findings include: R23's admission record identified an admitted [DATE], with diagnoses of fracture of left fibula, fracture left tibula, chronic kidney disease, generalized anxiety disorder, major depressive disorder, iron deficiency anemia, atrial fibrillation, gout, hypothyroidism, muscle spasm, and type 2 diabetes mellitus. R23's 3/13/23, significant change Minimum Data Set (MDS) assessment identified R23 had moderately impaired cognition, felt tired or had little energy 2-6 days during the 7 day assessment period, required extensive assistance of 2 staff for cares, and had an indwelling catheter. R32 was on continuous oxygen. R32 took a daily diuretic, antibiotic, anti-depressant, and an anti-anxiety medication. R23's 3/23/23, Care Area Assessment identified psychotropic drug use as an actual problem and R23 received anti-depressant and anti-anxiety medication daily per physician orders. R32 had diagnoses of depression per physician and the care plan would address psychotropic drug use to avoid complications and for symptom relief. There was no mention of target behaviors for either the anti-depressant nor the anti-anxiety medication as to why they were prescribed or what the medication would be relieving. R23's care plan identified on 8/9/21, R23 was on an anti-anxiety medication related to anxiety disorder. R23 would be free from discomfort or adverse reactions related to anti-anxiety medication use. Staff were to monitor and document side effects and effectiveness however, the care plan lacked any identified target behaviors to monitor for effectiveness. The care plan further lacked any identified non-pharmalogical interventions that could be tried if R23 was anxious. R23's 4/13/23, printed Order Summary Report identified R23 was prescribed Paxil 20 milligrams (mg) every day for general anxiety disorder and Ativan 1 mg three times a day for general anxiety disorder neither medication identified a target behavior it was prescribed to treat. Interview on 4/12/23 at 11:38 a.m., with licensed social worker (LSW) identified if a resident had behaviors she would be responsible for that section on the MDS assessment and would be the one responsible for putting that information on the care plan. She confirmed there were no identified target behaviors for R23's anti-anxiety medication on the care plan or the medication administration record and it would be hard to determine if the medication was effective or not if the reason for the medication was unknown. She further confirmed there were no identified non-pharmacological intervention on the care plan for staff to implement if R23 was displaying anxiety. Interview on 4/13/23 at 11:00 a.m., with interim director of nursing (IDON) agreed without documented target behaviors it would be hard to determine if the psychoactive medication was effective or not. Review of 12/9/22, Psychotropic Medications policy identified when a medication is warranted the nurse will contact the physician and describe the behavior and attempted interventions. The staff should monitor for effectiveness and potential adverse consequences of prescribed psychotropic medications. The reduction committee will review the need for the psychotropic medications by evaluating the resident's target symptoms and the effect of the medication.

Based on observation, interview, and document review, the facility failed to ensure a glucometer was appropriately disinfected between use during 1 of 3 observations of blood glucose testing. Findings include: Observation and interview on 4/11/23 at 11:36 a.m., with registered nurse (RN)-A during a blood glucose (aka blood sugar(BS)) check for resident R14. RN-A took the glucose meter from the drawer of the medication cart, and explained to R14 she wanted to check her blood glucose (aka blood sugar (BS). RN-A inserted the test strip into the meter. She then cleansed R14's finger and lanced her finger and applied the blood sample to the strip. Following obtaining R14's BS, RN-A took a purple packaged Sani-cloth from the drawer of the medication cart and preceded to wipe the surface of the meter several times. She reported she needed to wipe the surface for 30 seconds to allow for disinfection. This was the usual procedure she used to disinfect the glucometer. RN-A reported she had been instructed by staff to wipe the glucometer with the Sani-cloth and place on a paper towel and allow to dry for 2-3 minutes. She was not aware of the manufacture's instructions for the glucometer to remain wet for 2 minutes with the disinfectant, to ensure disinfection was achieved. Interview on 4/12/23 at 5:30 p.m., with the director of nursing (DON) reported her expectation for staff to follow the facility policy and the manufacture's recommendations for disinfection of the glucometer following completion of a blood glucose test. The DON provided documentation of Blood Glucose Monitoring education provided to nursing staff on 3/24/23. RN-A's signature was present on the document as having been in attendance. Review of the Super Sani-cloth instructions for use, located at https://pdihc.com/wp-content/uploads/2018/08/Super-Sani-Cloth-IFU-0821-UPDATE_05168539.pdf, identified staff were to allow the surface to allow the treated surface to remain wet for 2 minutes and then allow to air dry. Review of the 9/22/22, facility policy Blood Glucose Monitoring, Disinfecting and Cleaning identified meters were to be cleaned and disinfected after each use whether it was facility use glucometer or assigned to a specific resident. The policy directed staff to follow the specific instructions for each meter. For cleaning and disinfecting staff were to use a wipe from the container and follow the instructions on the label for cleaning and disinfecting.

Based on observation, interview and document review, the facility failed to ensure resident wishes for Do Not Resuscitate (DNR) or cardiopulmonary resuscitation (CPR) were performed for 1 of 1 (R1) resident whose Provider Orders for Life Sustaining Treatment (POLST) identified DNR and CPR was performed when resident was found unresponsive and as a result R1 was resuscitated, sent to the Emergency Department (ED) by Ambulance and sustained fractured ribs. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], at 12:45 p.m., when R1 was found unresponsive and LPN-A initiated CPR without confirming R1's code status, which was documented as DNR. Additionally, the responding facility staff also failed to identify R1's code status and assisted with CPR until Emergency Services arrived and they were instructed to stop because R1 was showing signs of life. The IJ was removed, and the deficient practice was corrected on [DATE], prior to the start of the survey and therefore is being issued at Past Noncompliance. Findings include: A Nursing Home Initial Report (NHIR) sent to the State Agency on [DATE] indicated, at approximate 12:50 p.m. resident was found unresponsive. Nurse initiated CPR and had staff call Ambulance. Upon verification on MN POLST, it was determined resident was DNR and CPR was stopped. Resident was moving arm/had pulse and was sent to the hospital at 1:15 p.m. R1's Face Sheet/Admission Record dated [DATE], documented R1 was admitted to the facility on [DATE] with diagnosis's of generalized [CONDITION(S)] and epileptic syndromes, [CONDITION(S)] with alcoholic polyneuropathy, history of [CONDITION(S)], cerebral infarction without residual deficits, alcoholic polyneuropathy, and Advanced Directive - MN POLST: do not attempt resuscitation/DNR which indicated if patient had no pulse and was not breathing, allow natural death. During an interview on [DATE], at 12:48 p.m. RN-C stated as the admission coordinator, part of the admission process is to complete the POLST. The POLST is reviewed with the resident and/or resident representative to ensure their end-of-life wishes are documented. When the POLST form is completed the physician signs to make it an order and she ensures the order is entered in PointClickCare (PCC). In R1's case, his POLST was DNR. Document review of R1's completed POLST signed by R1 and R1's primary care physician dated [DATE], directed Do Not Attempt Resuscitation / DNR (Allow Natural Death), Comfort-Focused Treatment (Allow Natural Death), and that R1 was the responsible party who made the DNR decision with his primary care physician. Document review of PCC electronic medical record dated [DATE], documented physician order: MN POLST: COMFORT-Focused Treatment (Allow Natural Death). Patient prefers no transfer to hospital for life-sustaining treatments. During an interview on [DATE], at 1:30 p.m. director of nursing (DON) stated, when a code blue (resident in a medical crisis and/or possible cardiac or respiratory arrest) is announced, all available staff will respond to the identified resident room or location. Typically, the nurse who is calling the code blue will announce it is STAT (immediate response requested) and will assume the nurse leader of the medical situation. When a code blue is initiated, staff will use the Emergency Response Drills (CPR) form to document key components with a timeline of resident care. The Emergency Response Drills (CPR) form, found on top of the crash cart, identifies the questions of, Code Status Requested by and Code Status Verified by, and is initialed and time documented by the scribe. DON stated an Emergency Response Drills (CPR) form was not completed for R1's medical emergency and should have been. DOC further stated, if the form was used, the question of code status would have been verified. DON stated, we own this; R1 was DNR, and CPR was performed to a successful resuscitation and should not have been. During an interview on [DATE], at 10:26 a.m. R1's sister (FM)-A stated the family is very upset and angry with the facility because they did not follow R1's DNR wishes. FM-A indicated that R1 had clearly directed he did not want to be resuscitated if his heart stopped and the facility performed CPR anyway. Additionally, FM-A stated R1 reported to her that he has broken ribs from the facility performing CPR and he is in a lot of pain and R1 further reported he is very angry the facility performed CPR on him because is wishes were in the event he died , he was not to be resuscitated. Adding, He wanted to die but now he is in the hospital and trying to die again. FM-A informed surveyor she was traveling to visit R1 and if was strong enough to talk with the surveyor, they would call. No call was received from R1. During an interview on [DATE], at 1:49 p.m. FM-B stated the family and R1 were very angry with the facility, adding the facility knew R1 was DNR, but they performed CPR and now R1 will have ambulance and hospital bills. During an interview on [DATE], at 12:20 p.m. LPN-B stated resident DNR status is updated/reviewed on all residents every night, and a new master copy is kept in the POLST binder at each nurses station. Staff do not rely on memory or use a cheat sheet because a resident's DNR status may change. In the event of an emergency, the fastest way to know the most current DNR status is for staff to review the POLST binder. During an interview on [DATE], at 12:34 p.m. LPN-C stated the POLST status is updated/reviewed on all residents by the overnight staff and a new master copy is kept in a binder at each nurses station. If there are any changes in POLST status, the overnight staff share this information during the morning end of shift report. It is also shared at each end of shift report each day. The fastest way to know the POLST status of a resident is not to look in PCC, but to review the POLST binder. R1's room is next door to the first nurses station so it would have been found quickly. During an interview on [DATE], at 2:50 p.m. LPN-A stated on [DATE], at approximately 12:45 p.m. she was assessing R1 due to a non-injury fall. LPN-A observed R1's oxygen saturation was declining, his level of consciousness was decreasing, and he was not responding to verbal questions. LPN-A left R1's room to locate an oxygen concentrator and upon returning she observed R1 sitting in his wheelchair, but his upper body was laying on the bed. LPN-A lifted R1's head up and observed that his lips were blue, he was drooling, and had pale facial color. LPN-A stated she tried to obtain a radial pulse and could not find one, and R1 was not breathing. LPN-A radioed for help and started chest compressions while R1 was sitting in his wheelchair. When staff arrived, she directed NA-A to call 911. R1 is a large man so when enough staff arrived, they slid him to the floor and LPN-A resumed CPR. LPN-A stated, no one asked R1's code status and that she did not think of it. LPN-A directed the [NAME] AED+PLUS automated external defibrillator (AED) be placed. The AED audio command directed no shock advised and to start compressions. Approximately five minutes later the ambulance emergency medical technicians (EMT) arrived and instructed staff to stop compressions because R1 was moving. EMT's inquired R1's code status and LPN-A stated she did not know. LPN-A left R1's room, entered R1's medical record in PCC and discovered R1 was DNR. LPN-A stated she did not follow the procedure for verifying code status before starting CPR. During an interview on [DATE], at 9:01 a.m. RN-A stated she heard LPN-A call for help over the walkie and quickly responded to R1's room. RN-A observed LPN-A attempting to perform CPR while R1 was sitting in his wheelchair. Once enough staff responded to R1's room, they slid R1 out of the wheelchair to the floor. LPN-A restarted CPR. RN-A noted R1 was totally incontinent of bowel and bladder. An unknown nursing assistant ran to get the Ambu Bag Resuscitator (Ambu Bag) and AED. After a few minutes of CPR, R1 made a gasping sound. When CPR was stopped, the AED verbally directed that no shock advised and to start compression. When EMT's arrived, they directed staff to stop CPR because R1 was moving. EMT's inquired R1's code status and LPN-A stated she did not know. RN-A indicated there was no scribe during the code and that she assumed the code status was checked before CPR was initiated. When LPN-A returned to R1's room, she reported R1 was DNR. LPN-A confirmed she received re-education on the facility policies following the incident with R1 and was able to provided the surveyor steps she would take in the event she found a resident unresponsive in the future that were consistent to the policy. During an interview on [DATE], at 2:47 p.m. RN-B stated hearing a call for help and to bring the Crash Cart to R1's room. When entering R1's room, LPN-A was doing chest compressions and RN-A was placing AED defibrillator pads on R1's chest. RN-B heard the AED audio command instruct for chest compressions to be deeper and no shock advised. RN-B replaced LPN-A for chest compressions and at that time EMT's arrived. EMT's quickly directed to stop compressions due to R1 moving his arms. EMT's asked the code status of R1 and LPN-A stated she did not know. RN-B indicated she assumed the code status was checked before CPR was initiated. LPN-A left R1's room and upon returning, reported R1 was DNR. RN-B confirmed she received re-education on the facility policies following the incident with R1 and was able to provided the surveyor steps she would take in the event she found a resident unresponsive in the future that were consistent to the policy. During an interview on [DATE], at 9:24 a.m. nursing assistant (NA)-A stated hearing a call for help in R1's room and upon entering R1's room, observed LPN-A performing a sternum rub to assess if R1 would respond. R1 did not respond and with the staff who just entered R1's room, they slid R1 from his wheelchair to the floor. LPN-A directed NA-A to call 911 for an ambulance and LPN-A restarted CPR. When NA-A returned to R1's room, RN-A had the Ambu Bag and AED. RN-A and LPN-A attached the AED defibrillator pads to R1's chest and the audio command directed, no shock and to start compressions. NA-A stated CPR had been ongoing for approximately five minutes when the EMT's arrived. EMT's directed staff to stop compressions because R1 was moving his arms. EMT's inquired R1's code status, and LPN-A stated she did not know. LPN-A left R1's room and upon return reported R1 was DNR. NA-A stated, at no time did anyone reviving R1 ask what his code status was. EMT's transported R1 to the local hospital. NA-A confirmed he received re-education on the facility policies following the incident with R1 and was able to provided the surveyor steps he would take in the event he found a resident unresponsive in the future that were consistent to the policy. The Past Noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed, and the deficient practice was corrected on [DATE], after the facility mandated all nursing staff attend educational presentations on, Group In-Service - Nursing Services Department, CPR/AED Policy/Code Status and the facility policy Cardiopulmonary Resuscitation (CPR) Certification Requirements dated [DATE], and Group In-Service - Nursing Services Department, Emergency Response Drills (CPR) dated [DATE], to reeducate nursing staff on ensuring the code status is identified before CPR is initiated on a resident. Education documentation for facility staff was reviewed by surveyor and interviews were conducted to ensure competency related to detection, response and reporting while onsite.

Based on observation, interview and document review, the facility failed to conduct adequate assessment, provide appropriate supervision, or an assistive device to prevent a fall for 1 of 3 residents (R1). R1 self-transferred without her walker or appropriate supervision resulting in a fall with [MEDICAL CONDITION]. Findings include: Facility incident report records indicated R1 fell on [DATE] at 6:58 p.m., and later complained of pain resulting in a trip to the Emergency Department (ED) for evaluation where R1 was diagnosed with [REDACTED]. R1's 1/5/21 at 6:58 p.m., Risk Management report identified R1 was found on the floor with her legs in front of her and a blanket folded under her left leg. The report further indicated R1's walker was tipped over and faced away from the resident. R1's wheelchair was near the wall on the opposite side of the room. When interviewed, R1 stated she got out of her recliner and was attempting to go to bed when she lost her balance and fell backwards. The resident said she took her blanket from the walker and tucked it under her leg while she waited for staff to come and soften things. The report indicated R1 had impaired memory, confusion, weakness and used a walker. In addition, the report identified R1 had a suspected fracture. R1's 11/13/20, quarterly Minimum Data Set (MDS) identified R1 had moderately impaired cognition, poor memory, poor decision-making ability, difficulty understanding others, and altered levels of consciousness. The MDS indicated R1 required extensive assistance of 1 staff for bed mobility, transfers, toileting, dressing, and walked with an assistive device in her room, in corridors, and on and off the unit. Further, the MDS indicated R1 was dependent on staff to pick objects off the floor, required a walker for transfers and walking, and used a wheelchair for mobility. R1's current diagnose report identified [DIAGNOSES REDACTED]. R1's 1/12/20, care plan identified R1 had moderate cognitive impairment, impaired decision making, memory and safety awareness. The care plan also indicated R1 had poor vision, had difficulty expressing herself, and had difficulty understanding others. R1 would attempt to ambulate, transfer and toilet herself without staff assistance. She was known to rummage and hoard items in her room and would enter other resident rooms as part of her behaviors. R1 was a fall risk due to a history of multiple falls, confusion, and self-transfer attempts. R1 was incontinent of urine. R1 required use of a gait belt, front wheeled walker, wheelchair, and assistance of one staff to transfer, walk, toilet. R1's interventions included to ensure use of proper footwear, use gripper socks while in bed, and for staff to ensure adequate lighting. Staff were to assist R1 to the toilet every two to three hours. When R1 wandered, staff were to redirect, use simple cues, remind her to ask for assistance, and use a grabber to retrieve items off the floor. R1 was encouraged to visit with others in the day room to prevent self-transferring in her room. R1's walker was to be removed from her room when not in use for walking to prevent potential unassisted transfers. R1's wheelchair was to be placed next to her bed when not in use. Staff were to monitor R1 for changes in gait and consult physical therapy (PT) and occupational therapy (OT) when changes were identified. On 1/11/20, after she fell and fractured her hip, R1's care plan was updated to keep excess blankets and other environmental hazards in her closet and out-of-sight. Staff were to ensure R1's wheelchair was in a safe position while she rummaged and were to remind her to refrain from hanging blankets on her walker. The care plan revised 1/11/20, indicated R1 was no longer safe to operate her electric recliner. During interview on 1/12/21 at 2:57 p.m., registered nurse (RN)-A stated she had worked the day shift on the day R1 fell . RN-A stated R1 was her normal self during the day and had anxiety in the afternoon, which was normal for her. She further stated that evening, R1 was tired wanted to lie down but had attempted several times to get up and walk. Staff provided one to one interaction with her and kept her in the area by the nurses' station. RN-A stated she was in shift report at the time R1 fell and had not seen R1 between supper and the time of the fall. Around 7:00 p.m. RN-A was called to R1's room and assisted with R1's initial fall assessment. RN-A said R1 was on the floor facing the head of her bed with her legs straight in front of her. She had a blanket under her left leg by her knee. RN-A stated she was unsure how R1 would have gotten a blanket. RN-A said she thought R1 must have gotten the blanket before she fell . RN-A said R1 was unable to recall how she'd gotten the blanket and said R1 was not a good historian. R1 complained of pain in an area above her sacrum and identified it was because she sat on the floor too long. RN-A added that R1 had stated she knew she should have waited for help. After R1 was assessed, and no injury found, R1 was transferred from the floor to the bed with no complaints of pain during the transfer and denied pain while lying in bed. Further interview with RN-A identified during R1's post-fall huddle, discussion of the event identified nurse aide (NA)-A had observed R1 in her recliner prior to her fall and had been there since after the evening meal. RN-A stated she was unsure who assisted R1 to the recliner, but when she (RN-A) entered R1's room to assess her after her fall, it appeared R1 had gotten up from the recliner and attempted to walk towards her bed. RN-A said the recliner footrest was observed up 10 degrees (slightly opened). RN-A was not sure if R1 had used the recliner control to adjust the chair prior to self-transferring. R1's walker was tipped over facing the opposite of R1. R1's wheelchair was way behind her, parked on the other side of room against the wall next to her TV. R1's bed was on the farthest wall and R1 was on the floor by her dresser in front of her bed. RN-A also stated it appeared the blankets from R1's bed had been moved. RN- A further clarified R1 had a history of [REDACTED]. RN-A said R1 liked to stack items such as blankets on her walker and liked to rummage in her closet. She sometimes thought people were stealing items in her room, and she tried to hide things so they would not be stolen, and would forget where she placed them. RN-A said the recliner footrest was not used for R1 because R1 had a history of [REDACTED]. RN-A was unsure if R1 was able to use the controls on the recliner due to her cognition. She was also unsure whether the wheelchair was supposed to be within R1's reach while she was in the recliner. After her last fall on 12/21/20, R1 was supposed to use the wheelchair most of the time. Prior to R1's recent fall, R1 was supposed to have assistance of 1 staff to transfer and walk. When interviewed on 1/12/21 at 4:12 p.m., NA-B stated she'd worked the evening shift the day R1 fell . R1 was still in the dining room at 6:00 p.m. After supper she assisted other residents before she took her employee supper break. NA-B was unsure who assisted R1 back to her room, and said when R1 fell , she (NA-B) was on break. After she returned from break, R1 was in her bed saying, help me and she wanted to get up. NA-B said she offered R1 assistance to the toilet, and when she attempted to move R1's legs out of the bed R1 screamed in pain. NA-B said she called the nurse to R1's room because R1 had pain in her knee area, and R1 was sent to the hospital. NA-B said R1's interventions to prevent falls were to keep her door open while she was awake. R1 went to bed early and was known to sit in her recliner frequently after supper. R1 was supposed to have 1 staff assist her to transfer and walk, but R1 was busy and hard to keep an eye on, and R1 was to have the wheelchair by her bed for safety. NA-B stated cares during the evenings were busy and staff were in and out of rooms a lot providing care to all residents. Staff tried to check on residents as they pass by the rooms. NA-B said R1 frequently wanted to walk, and use to walk all day and verbalize she wanted to go home. NA-B stated R1 was able to get up from her recliner independently without help and would walk in her room without staff assistance. In addition, NA-B said R 1 would rarely use the call light for assistance. During interview on 1/12/21 at 1:50 p.m., NA-C identified she generally provided cares for R1 on the weekends. NA-C stated R1 was known to be confused and forgetful, and before the fall R1 required assistance of 1 staff to walk. Staff were to assist her to the toilet every 2 to 3 hours. R1 had frequent urges to use the bathroom and never called for help. She had a history of [REDACTED]. R1 continued to require assistance of 1 staff, a walker, and her gait belt to safely transfer. If R1 wanted to sit in her recliner, staff needed to check on her frequently because she didn't sit there very long. When R1 was witnessed to be restless and would not remain seated in her recliner, staff would bring her to the area by the nurse's desk for closer observation. R1 was not receptive to activities that she would have to do on her own. R1 mostly wandered when she was restless. R1 usually only sat in the recliner in her room for about an hour and staff were to never put her feet up in the recliner because she would not remember to put her feet down. NA-C was unsure if R1 had an electric recliner and said R1 never had her feet up on her recliner that she was aware of. Staff were to have R1's wheelchair by her bed, away from her chair. She was unsure if R1's walker was to be beside her or across the room away from her to prevent her from potentially self-transferring. NA-D stated during interview on 1/12/21 at 3:47 p.m., that R1 was confused but easily redirected. NA-D said R1 often thought people were stealing from her, so she hid things. R1 self-transferred often and would do so at any time of the day from her wheelchair to bed, or bed to wheelchair. R1 was requesting to lie down more frequently and staff would catch her attempting to self-transfer. Staff provided verbal cues for R1 to call for help. She was supposed to be assisted with 1 staff, a gait belt, and her front wheeled walker. She was able to get up and around her room by herself. Sometimes she tried to get to her walker. NA-D stated she knew R1 would use her over the bed table to attempt to get around her room if her walker was unavailable. Further, NA-D said R1 had Sundowner's and would not consistently use the call light. When interviewed on 1/12/21 at 4:51 p.m., NA-A stated R1 was found lying by the foot of the bed, facing towards her recliner across the room. NA-A said R1 had no pain initially and stated she tried to get to her walker. The walker was observed positioned toward the end of the bed. NA-A said prior to the fall, she had assisted R1 to go the bathroom, change into pajamas, and transferred her to her recliner. NA-A said she'd reclined the recliner all the way back adding, R1usually sat in her recliner. She seemed really tired that day when I put her in the recliner. I was surprised she got up. She was a person who was independent a few months ago but now needed to have staff to help. At the time of the fall, R1's wheelchair was parked in the corner of her room, and the walker was placed towards the end of her bed. Both items were away from R1. NA-A stated R1's walker was still at the end of the bed at the time of the fall. NA-A also stated she'd given R1 her blue snowflake blanket when she was in the recliner. She was noted to have grabbed the blanket from the end of her bed. It was found under her knee after she fell . NA-A was unsure how long R1 laid on the floor after the fall. NA-A was in another resident room when dietary staff found R1. NA-A was unsure what staff would have checked on her. NA-A said R1 fell about a half hour after she cared for R1. R1 was supposed to be checked every 2-3 hours for bathroom. NA-A was unsure if R1 was to be checked on more frequently or if she needed to be supervised at times she wasn't in direct sight of staff to ensure her safety. When interviewed on 1/12/21 at 5:12 p.m., occupational therapist (OT)-A identified R1 had physical therapy (PT) ordered on [DATE], due to a general decline, and R1 had a history of [REDACTED]. OT-A was aware R1 would continue to transfer without assistance but advised staff check her more often and provide assistance whenever possible. She stated R1 had a history of [REDACTED]. Prior to this last fall, R1 was able to get up on her own without staff assistance. She was able to use her walker for transfers and walking. She was even also able to rummage and pick things up off the floor. PT and OT were involved in exercises for strengthening. OT-A said nursing had placed R1's wheelchair by her bed as an intervention to potentially deter her from self-transferring and R1 should have had her walker within reach while in her recliner, in case she attempted to self-transfer. R1 had used her walker for a long time and would look for her walker if it was out of reach or out of sight. She was supposed to use it to pivot transfer. She also had a bag on the walker that contained her personal items such as her toothbrush and other personal items. PT-A stated during interview on 1/13/21 at 9:29 a.m., R1 was walking on her own prior to her fall. R1 attempted to carry items with her walker at times. She was not able to remember cues or previous education for walker safety. R1 had the ability to get out of her recliner, bed or wheelchair independently. Due to her history of falls, she required staff assistance with a gait belt for safety. R1 made poor choices and had not always remembered to use her walker. PT-A would always put R1's walker within reach however, had never formally directed staff to keep R1's walker within her reach when she was left unsupervised in her room. RN-C stated during interview on 1/13/21 at 1:57 p.m., R1's interventions for fall safety included to place her walker away from her to see if R1 would call for help. RN-B said during interview on 1/13/21 at 2:29 p.m., she was the case manager for R1. R1 was able to rise from sitting to standing without staff assistance prior to her fall on 1/5/21. However, RN-B said R1 was inconsistent with performing sit to stand safely. R1's care plan prior to her fall was for R1 to use a walker to ambulate with a gait belt and assistance of 1 staff. There was no mention R1 was to have her walker within reach prior to her fall in case she attempted to self-transfer. There was discussion after her fall when she fractured her hip whether she should have her walker within reach. There was no consensus among staff as to whether it would make her safer. PT and OT were to have evaluated R1 for safe walker use after her return from the hospital. Staff later decided to keep R1's walker away from her to prevent her attempts to self-transfer. There was no mention how staff were to monitor to see if the measure was effective or could place R1 at higher risk for falls. RN-B stated she thought it would be safer to keep R1's walker near her in her recliner to maintain safety if she attempted to self-transfer. There was no mention how staff were to supervise R1 after she was left alone in her room at night prior to bed in an effort to prevent falls. The Director of Nursing (DON) stated during interview on 1/13/21 at 2:15 p.m., she could not answer whether R1's walker was to be within R1's reach while in her recliner. The DON stated staff were attempting to implement interventions to maintain R1's safety following her falls. She declined comment regarding whether it would be safer for R1 to use her walker without supervision, or to keep the walker out of R1's sight. The medical director was interviewed on 1/14/21 at 9:06 a.m., and stated if PT and OT determined R1 required use of a walker to maintain safety during transfers and walking, the device should have been kept within reach. He further clarified any resident who doesn't call or wait for staff assistance, who used assistive devices for ambulating and transferring, should have their equipment within reach to provide the safest scenario possible. The medical director stated staff should have assessed whether or not R1 was able to be alone in her room without direct supervision, knowing she had a history of [REDACTED]. Review of the facility's 6/24/20, Fall Prevention and Management Rehab/Skilled policy, identified before falls occur residents were to be assessed for any fall risk. Interventions were to be care planned and personalized and communicated to all staff to prevent a fall before it occurred, using the 24-hour Report, care plan, Kardex, and during any daily stand-up meetings and fall committee meetings. Any identified environmental or device referral needs were also to be communicated to the appropriate departments such as PT or OT. After falls occurred and interventions implemented, staff were to continue to monitor the effectiveness of interventions and adjust interventions as needed.