Every finding on record at Johnson Memorial Hospital & Home

Based on observation, interview, and document review, the facility failed to ensure all 9 licensed nurses (registered nurse (RN)-A, RN-C, RN-D, RN-G, RN-I, licensed nurse (LPN)-A, LPN-B, LPN-C, and LPN-D) and all 5 agency licensed nurses (RN-E, RN-J, RN-K, LPN-E, and LPN-F) who administer or had the potential to administer insulin were appropriately trained and deemed competent to facility policy and manufacturer's instructions for insulin administration. This had the potential to affect all residents who recieved insulin. Findings include: Review of the [DATE], report to the facility identified R106 was scheduled to receive 36 units of Basaglar (a long-acting insulin). The staff nurse attempted to document R106's insulin administration on the medical record and realized R106 had actually received 36 units of Fiasp (a short acting insulin), instead. The staff nurse reported the incident to R106's primary provider and was directed to monitor R106 blood sugars. R106's face sheet identified R106 was admitted [DATE] with a diagnosis of diabetes. R106's, February Medication Administration Record identified R106 was to receive 36 units of glargine twice a day for diabetes and Fiasp sliding scale insulin according to blood sugar levels listed as: ,d+[DATE] = 0 units, ,d+[DATE] = 2 units. Staff were to give subcutaneously (fat layer between the skin and muscle) 3 x per day. R106's undated, current care plan identified staff nurses would administer diabetic medication as ordered, monitor/document for side effects and effectiveness of the medication, monitor/document/report as needed signs and symptoms related to low blood sugar levels such as sweating, tremors, confusion, slurred speech. Review of [DATE] Medication Administration Protocol policy identified the facility nursing staff would follow medication rights before, during and after medication administration, as followed: 1) Patient verification 2) Right medication 3) Right dose 4) Right route 5) Right time 6) Right documentation 7) Right reason 8) Right response 9) medication not expired Staff nurses were to ensure medication, such as, insulin would be labeled with an open and discard date, according to manufacturer's instructions. Lastly, staff nurses were to check expiration dates of medications during administration times. Interview on [DATE] at 2:02 p.m., with R106 identified staff nurse informed him he was given the incorrect insulin and was to be monitored throughout the night. R106 stated he did not experience any side effects from the administration of the incorrect insulin. Interview on [DATE] at 5:12 p.m., with the director of nursing (DON) identified there was no formal checklist that would include licensed nurse staff being trained on insulin administration. She had no copies of employee training accessible on file to identify insulin training or competencies had been completed and licensed nurses would be trained on the job alongside other colleagues on the unit by nurse managers. DON stated in services were held at the facility that was directed at insulin administration, however, audits were not completed. Review of [DATE] In-Service Education policy identified continuing education and training for employees would meet regulatory and licensing requirements. New employee was to complete initial training upon hire and annual training was to be completed for all employees based on department needs.

Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 4) 2024 (July 1 - September 30) to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D identified excessively low weekend staffing had triggered. Review of the schedules and staff timecards identified on 7/6/24 registered nurse (RN)-E a contracted nurse had worked a 12-hour shift. RN-E had not clocked in on the facilities system to track hours worked for the PBJ report. On 8/17/24 RN-F, a hospital nurse who worked at the care facility in an on-call basis, had worked an 8-hour shift. Interview on 2/20/25 at 10:05 a.m., with director of nursing (DON) identified that staff punch in with a code, she was not sure how the on-call hospital staff punched in though. She thought the hospital staff punched in the same way they always do and was unsure if the time correctly was allocated to the nursing home hours. She confirmed that RN-E had worked on 7/6/24 and had failed to punch into the facility system so those hours would not have transferred to the PBJ report. She confirmed that the PBJ report was inaccurate related to RN-E not punching into the facility system. Interview on 2/20/25 at 10:15 a.m., with the payroll coordinator revealed he submitted the hours for PBJ however, he did not run any reports to verify there were no inaccuracies. He understood he only needed to review to ensure there was an RN working 8 hours each day. A policy was requested on PBJ reporting however, the DON reported the facility had no policy on PBJ reporting.

Based on interview and document review, the facility failed to implement 1 of 1 facility assessment and ensure the identified number of staff deemed required to provide care and services to residents had been scheduled and maintained on the weekends. Findings include: Review of the 8/8/24, Facility Assessment identified resources needed to provide care and competent support to the residents residing in the facility daily included staffing plan of: 1. Days-weekdays registered nurse (RN) 24 hours, licensed practical nurse/trained medication aide (LPN/TMA) 24-hour, nursing assistant (NA) 45-54 hours, director of nursing/assistant director of nursing (DON/ADON) 16 hours. 2. Days-weekends RN 12 hours, LPN/TMA 12 hours, NA 54 hours 3. Evenings -weekday RN 0 hours, LPN/TMA 16 hours, NA 37-42 hours 4. Evenings-weekend RN 0 hours, LPN/TMA 16 hours, NA 54 hours 5. Nights-weekdays RN 12 hours, LPN/TMA 0 hours, NA 24 hours 6. Nights- weekends RN 12 hours, LPN/TMA 0 hours, NA 32 hours Review of the 6 sampled weekend dates identified on: 1) 7/6/24 day shift RN-12 hours, LPN/TMA 12 hours, NA 44 hours (should have been 54 hours) evening shift- LPN/TMA 12 hours, NA 42 hours (should have been 54 hours), night shift RN 12 hours, NA 24 hours (should have been 32 hours). 2) 7/7/24-day shift RN-12 hours, LPN/TMA 12 hours, NA 47 hours (should have been 54 hours) evening shift LPN/TMA 12 hours, NA 43 hours (should have been 54 hours) night shift RN 12 hours, NA 24 hours (should have been 32 hours). 3) 8/17/24 day shift RN-12 hours, LPN/TMA 17 hours, NA 53 hours, evening shift LPN/TMA 12 hours, NA 35 hours (should have been 54 hours) night shift RN 12 hours, NA 17 hours (should have been 32 hours). 4) 8/18/24 day shift RN-12 hours, LPN/TMA 17 hours, NA 45 hours (should have been 54 hours) evening shift LPN/TMA 12 hours, NA 41 hours (should have been 54 hours) night shift RN 12 hours, NA 25 hours (should have been 32 hours). 5) 9/28/24 day shift RN-12 hours, LPN/TMA 15 hours, NA 58 hours evening shift -LPN/TMA 12 hours, NA 59 hours, night shift RN 12 hours, NA 24 hours (should have been 32 hours). 6) 9/29/24 day shift RN-12 hours, LPN/TMA 12 hours, NA 47 hours (should have been 54 hours) evening shift -LPN/TMA 16 hours, NA 54 hours, night shift RN 12 hours, NA 24 hours (should have been 32 hours). Interview on 2/20/25 at 10:05 a.m., with DON identified the previous interim administrator had determined the staffing needs. Following review of the facility assessment for staffing needs the DON confirmed that the assessment needed to be reviewed and revised as the hours should be the same on weekdays and weekends. The DON agreed that the required staffing hours identified on the facility assessment had not been met on the weekend shifts sampled in quarter 4. There was no additional policy related to staffing provided by the end of the survey.

Based on interview and document review, the facility failed to ensure appropriate oversight by the infection preventionist (IP) and follow up when multiple departments heads consistently failed to report required surveillance data used in tracking employee illness for 33 of 60 (unidentified in the tracking) facility staff and note return to work dates for 3 months reviewed (November 2024 through January 2025). This had the potential to affect all 55 residents at the facility. Findings include: Review of the November 2024, December 2024, and January 2025, staff surveillance identified: 1) November 2024: 8 staff called in sick. 2 with cold symptoms, 2 with nausea, 1 with fever, 1 with a rash, and 1 with a headache. 2 of the 8 staff that called in sick lacked a return to work date. 2) December 2024: 18 staff called in sick. 4 with diarrhea, 7 with cold symptoms, 1 with vomiting, 1 with nausea, 2 with abdominal pain, and 3 with other. 12 of 18 staff who called in sick lacked a return to work date. 3) January 2024: 28 staff called in sick. 4 with diarrhea, 11 with cold symptoms, 5 with vomiting, 1 with a headache, 5 with body aches, and 2 with other. 19 of 28 staff who called in sick lacked a return to work date. There were only departments noted in the report to which them employee worked. No names were noted which would identify potential specific areas or exposure to residents. Interview on 2/19/25 at 1:09 p.m., with the infection preventionist identified she agrees with the above findings. She has had difficulty getting other departments to submit information timely. She provides each department with a form in MS TEAMS (a communication application used for messaging and virtual meetings). Each department was expected to fill out the form and she would then transfer the information to the surveillance log. She identified that she has brought her concerns about the lack of reporting from department heads several times to IDT meetings. Interview on 2/19/25 at 5:17 p.m., with the administrator identified he was aware of the concern by the IP mentioned above, and had discussed those concerns had been discussed at the QAPI (Quality Assurance and Performance Improvement) meeting. He encouraged staff to start providing the information. He would expect the IP to provide retraining to the department heads if they were not providing the correct information and noted the IP should have reached out to the administrator if the concern continued. Review of the facility provided December 2024, Employee Illness Reporting policy identified staff were to report illness to their supervisor, the supervisor was to enter the information into Teams under Employee Illness. The information should include department, staff title, dates ill, nature of illness, return to work date, if seen by a provider, and if testing was completed. The IP was to document and trend the illnesses in an Infection Control Report and the information would be reported to QAPI quarterly. The facility policy lacked any indication the IP should identify who the individual staff that called in with illness to be able to provide accurate over sight and narrow down exposure to residents to be able to comprehensively.

Based on observation, interview, and document review, the facility failed to follow manufacturer's instructions and label insulin pens with an open and discard date for 6 of 6 residents (R7, R23, R28, R29, R51, and R106) sampled insulin pens. Findings include: Observation on [DATE] at 11:37 a.m., with registered nurse (RN)-G, on Prairie Lane hall, reviewed R23's insulin order on Point Click Care (PCC) an online electronic medical record identified R23 was to receive 5 units of Lantus (a long-acting) insulin that was to be given daily at 11:00 a.m. RN-G removed the insulin pen from R23's medication cupboard and read the label. RN-G had sanitized her hands, applied gloves, and administered the insulin. RN-G documented on R23's medication chart in PCC. The label on the insulin pen had an open date of [DATE]. There was no discard date labeled on the insulin pen. Observation on [DATE] at 11:41 a.m., with RN-G, on Prairie Lane Hall, reviewed R29's blood sugar reading from her portable glucometer phone and confirmed R29's blood sugar was 243. RN-G reviewed R29's insulin order identified R29 was to receive Humalog sliding scale insulin from ,d+[DATE]= 4 units, etc. RN-G informed R29 her blood sugar was under 250 and did not require insulin. RN-G opened R29's medication cupboard and removed 2 insulin pens Neither pen had an open or discard date on the label. Both pens were actively in service. Observation on [DATE] at 11:45 a.m., with RN-G, on Prairie Lane Hall, reviewed R28's blood sugar reading from his portable glucometer phone and confirmed R28's blood sugar was 171. RN-G reviewed R28's insulin order identified R28 was to receive Humalog sliding scale insulin ,d+[DATE]= 2 units and informed R28 he was to receive 2 units of insulin. R28 requested the insulin to be placed in his abdomen. RN-G administered the insulin per order. RN-G documented the administration in R28's medical record. R28's Humalog insulin pen had an open or discard date on the label. Further observation on [DATE] at 12:05 p.m., identified the following: 1) R7's lantus insulin pen had no open or discard date on the label. 2) R28's lantus insulin pen had an open date of [DATE] but no discard date and their Humalog insulin pen had no open or discard date on the label. 3) R29's Lantus insulin pen had no open or discard date on the label 4) R51's glargine insulin pen had no open or discard date on the label. 5) R106's Fiasp insulin pen had a open date of [DATE] but no discard date and a glargine insulin pen had no open or discard date on the label. Interview on [DATE] at 12:44 p.m., with RN-A identified staff nurses were to label the insulin pen with an open and discard date once it was removed from the fridge to ensure staff nurses identify when the insulin pen was to expire. Interview on [DATE] at 1:12 p.m., with RN-C identified insulin pens that were not dated appropriately would be discarded and replaced with a new pen from the fridge. She identified it was not appropriate practice for staff nurses to administer insulin to residents without following medication rights and expiration dates of medication before administration. Interview on [DATE] at 5:12 p.m., with the director of nursing (DON) identified she expected staff to follow manufacturer's guidelines identifying staff were to write open and discard dates on insulin pens. Review of [DATE] Medication Administration Protocol policy identified the facility nursing staff would follow medication rights before, during and after medication administration, as followed: 1) Patient verification 2) Right medication 3) Right dose 4) Right route 5) Right time 6) Right documentation 7) Right reason 8) Right response 9) Ensure medication was not expired Staff nurses were to ensure medication, such as, insulin would be labeled with an open and discard date, according to manufacturer's instructions. Lastly, staff nurses were to check expiration dates of medications during administration times.

Based on interview and document review the facility failed to comprehensively assess and identify target behaviors or symptoms and non-pharmacological interventions for scheduled antidepressant and antipsychotic medication to ensure efficacy of the medication for 1 of 5 residents (R32) reviewed for unnecessary medication usage. Findings include: R32's 2/20/25, diagnosis list included generalized anxiety disorder, insomnia, major depressive disorder single episode, and unspecified psychosis not due to a substance or known physiological condition. R32's 1/8/25, quarterly Minimum Data Set (MDS) assessment identified R32's cognition was intact with no behaviors identified. R32 was independent with transfers and eating, R32 required assistance with some personnel cares. R32 had frequent pain that he rated a 3 on scale of 1-10. R32 took a daily antipsychotic, antidepressant, antianxiety, diuretic, hypoglycemic, and opioid. R32's 7/16/24, significant change MDS identified R32 felt down, depressed, or helpless more than half of the days, had trouble falling asleep or staying asleep more than half of the days, and felt tired or had little energy more than half of the days. R32 had trouble concentrating and spoke slowly or felt fidgety or restless nearly every day. R32's Order summary Report identified the following orders: 1. Clonidine HCI 0.1 milligram (MG) three times a day for anxiety. 2. Fluoxetine HCI (Prozac) 80 mg every morning for major depressive disorder single episode. 3. Quetiapine Fumarate (Seroquel) 50 mg at bedtime for unspecified psychosis not due to a substance or known physiological condition. 4. Trazodone HCI 100 mg at bedtime for insomnia. There was no mention of symptoms or target behaviors that the psychoactive medications were prescribed to treat. R32's Anti-Psychotropic Medication Minimum Effective Dose Monitoring assessment identified: 1. Clonidine HCI 0.1 mg three times a day, diagnosis generalized anxiety disorder. Target symptoms reduce anxiety. 2. Fluoxetine HCI (Prozac) 80 mg, diagnosis major depressive disorder single episode. Target symptom was depression 3. Quetiapine Fumarate (Seroquel) 50 mg, diagnosis unspecified psychosis not due to a substance or known physiological condition. Target symptoms to decrease episodes of psychosis. 4. Trazodone HCI 100 mg, diagnosis insomnia, unspecified major depressive disorder single episode. Target symptoms insomnia, depression. There was no identification of specific symptoms that the medication had been ordered to treat. R32's Informed Consent for Psychotropic/Psychoactive Drug Use identified: 1. Clonidine 0.1 mg, diagnosis anxiety, target behaviors, anxiety and depression. 2. Fluoxetine (Prozac) HCI 80 mg, diagnosis major depressive disorder, target behaviors decrease symptoms of depression. 3. Quetiapine Fumarate (Seroquel) 50 mg at bedtime, diagnosis psychosis, target behaviors decrease psychosis episodes, help with sleep 4. Trazodone 100 mg at bedtime, diagnosis insomnia, target behaviors help with sleep. There was no identification of specific target behaviors that the medication had been ordered to treat. R32's undated care plan identified that R32 had depression and would remain free of signs or symptoms of distress, depression, anxiety or sad mood through the review date. Staff were to administer medications as ordered, monitor for side effects and effectiveness. There was no mention of target symptoms that staff were to monitor for effectiveness or any non-pharmacological interventions for target symptoms. R32 used psychotropic medication for a diagnosis of psychosis and would remain free of psychotropic drug related complication through the review date. Staff were to administer psychotropic medications as ordered, monitor for side effects and effectiveness. There was no mention of target symptoms that staff were to monitor for effectiveness or any identified non-pharmacological interventions for target symptoms. Interview on 2/19/25 at 3:39 p.m., with R32 identified he had been in a state of depression for years and his doctor finally talked him into doing something. He reported at first the medication did not seem to help but then he started to see this mental health person and she started him on some other medications that have worked. He reported he took something for anxiety as he feels anxious inside and he takes another medication because he sees things like mice, rats, raccoons, and cats running around in his room. He stated he knows they are not there, and it was not real, but he still seems them. He reported he also sees people standing or sitting in the chair but mostly sitting he stated he has seen his mother many times and once at 4 am he seen the wound nurse sitting in the chair. He revealed he knew the people were not there, and they did not scare him, but he still seen them. He reported sometimes it is just dark shadows that are standing by me or sitting in the chair. He again stated he sees things running around his room a lot, but he knows there was not raccoons in his room. Interview on 2/19/25 at 3:49 p.m., with registered nurse (RN)-C agreed that R32 had no identified specific target symptoms his medications had been ordered to treat identified anywhere she could see. She agreed it would be hard to determine if the medications were effective or not if staff did not know what they were to be treating. She revealed that R32 did isolated to his room mostly, he did have anxiety related to his health conditions, and he did hallucinate at times where he has seen people that were not there. Interview on 2/19/25 at 4:18 p.m., with registered nurse (RN)-B an interim consultant confirmed that the psychopharmacological medication assessment had identified diagnosis but no specific target behaviors or symptoms that the medication was ordered to treat. RN-B revealed his expectation was that each psychoactive medication would have identified target symptoms or behaviors and that should be identified on the care plan. Interview on 2/19/25 at 5:11 p.m. with assistant director of nursing (ADON) registered nurse (RN)-A confirmed she was unable to locate any target behaviors or symptoms that R32's medications had been ordered to treat. Interview on 2/19/25 at 5:15 p.m. with director of nursing (DON) confirmed that there should be identified target behaviors or symptoms for each psychoactive medication ordered. She agreed without the identified target behavior or symptom it would be hard to determine if the medication was effective. Review of February 2025, Psychotropic Drug Monitoring policy identified the primary diagnosis or target behavior must be specified with each psychotropic medication order and would be identified on the medication order as well. The resident care plan would identify the goal of the medication, the medication side effect monitoring, target behaviors, the information that would be used to determine the effectiveness of the medication and reported to the physician. Each psychoactive medication ordered would identify a different target behavior that the medication was ordered to treat.

Based on interview and record review, the facility failed to ensure 1 of 14 residents (R47) care plan was revised to identify that she had an actual elopement event. Findings include: Review of the report to the State Agency (SA) identified on 5/27/24 at 11:10 a.m., R47 was observed by another resident exiting the building without staff knowledge. Once notified, facility staff acted and found R47 approximately 10 feet from the door. R47 had been wearing a WanderGuard bracelet however, staff identified the door did not engage the lock and the alarm did not sound per normal when a resident wore a WanderGuard. R47's 11/22/24, annual Minimum Data Set (MDS) assessment identified her cognition was severely impaired. R47 had diagnoses of Alzheimer's dementia, delirium, and disorientation. R47 was noted to be independent with transfers and required extensive assistance with dressing and hygiene. R47 wore a wander/elopement alarm. R47's care plan identified she was at risk for elopement and had a history of attempts to leave the facility unattended and had impaired safety awareness. R47 wore a wander-guard and staff were to offer pleasant diversion, take R47 out to the courtyard when weather permitted, and check the WanderGuard function every shift. The care plan lacked update or revision following the 5/27/24 elopement to include potential new interventions such as increased supervision etc that was identified by staff. Interview on 2/20/25 at 10:04 a.m., with registered nurse (RN)-D reports they keep an eye on her when she is wandering. She had no knowledge of R47 having successfully eloping from the building on 5/27/24. Interview on 2/20/25 at 10:07 a.m., with nursing assistant (NA)-A identified if R47 is wandering a lot they keep the doors leading off the unit closed. Staff offer snacks or a warm blanket to try and get her to sit for a while and when the weather is nice, they offer to take her out on the courtyard. NA-A had no knowledge of R47's actual elopement event. Interview on 2/20/25 at 11:00 a.m., with director of nursing identified she agreed the facility had ensured they updated the care plan to notify staff of an actual elopement and new interventions to prevent reoccurrence. She agreed that should have been done and was not sure why staff failed to do it. Review of the April 2024, Comprehensive Person-Directed Care Plan and Baseline Care Plan Policy identified revisions to the care plan should be added as the resident's condition changes in order to address current problems.

The facility failed to administer insulin according to physician orders and manufacturers instruction for 1 of 1 (R106) resident who was administered the wrong insulin. Findings include: Review of report to the State Agency on [DATE] at 9:00 p.m., identified R106 was scheduled to receive 36 units of Basaglar (a long-acting insulin). The staff nurse attempted to document R106's insulin administration on the medical record and identified they made an error and R106 had received 36 units of Fiasp (a short acting insulin) instead. The staff nurse reported the incident to R106's primary provider and was directed to monitor R106 blood sugars. R106 face sheet identified they were admitted [DATE] with a diagnoses of Alzheimer's, dementia with psychotic disturbance, depression and diabetes. R106's, February Medication Administration Record identified R106 was to receive 36 units of glargine twice a day for diabetes and Fiasp sliding scale insulin, give ,d+[DATE]= 0 units, ,d+[DATE]= 2 units, give subcutaneously (the fat layer between the skin and muscle) three times a day. R106's undated, current care plan identified staff nurses would administer diabetic medication as ordered, monitor/document side effects and effectiveness of the medication, monitor/document/report as needed, sign and symptoms related to hypoglycemia, such as sweating, tremors, confusion, slurred speech, and refer to podiatrist/foot care nurse to monitor/document foot care needs. Interview on [DATE] at 1:12 p.m., with RN-C identified it was not appropriate practice for staff nurses to administer insulin to residents without following medication rights and expiration dates of medication before administration. RN-C could not recall having demonstrated competency as part of hire or annually. Interview on [DATE] at 2:02 p.m., with R106 identified staff nurse informed him he was given the incorrect insulin and was to be monitored throughout the night. R106 stated he did not experience any side effects from the insulin. Review of [DATE] Medication Administration Protocol policy identified the facility nursing staff would follow medication rights before, during and after medication administration, as followed: 1) Patient verification 2) Right medication 3) Right dose 4) Right route 5) Right time 6) Right documentation 7) Right reason 8) Right response 9) Verify the medication had not expired Interview on [DATE] at 5:12 p.m., with the director of nursing (DON) identified there was no formal checklist that would include licensed nurse staff being deemed competent upon hire or annually on insulin administration. She had no copies of employee training accessible on file to identify insulin training or competencies had been completed and licensed nurses would be trained on the job alongside other colleagues on the unit by nurse managers. DON stated in services were held at the facility that was directed at insulin administration, however, audits were not completed. Review of [DATE] In-Service Education policy identified continuing education and training for employees would meet regulatory and licensing requirements. New employee was to complete initial training upon hire and annual training was to be completed for all employees based on department needs.

Based on interview and document review the facility failed to assess and monitor injuries after a fall, provide pain relieving treatment and physician notification for 1 of 1 resident (R1) who had a fall with a hip fracture that required surgical repair. This resulted in harm when R1's pain was not comprehensively assessed for eight hours after R1 reported and displayed severe pain causing delay in pain relief and medical attention. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include: R1's face sheet dated 1/22/25, identified R1 had diagnoses that included, parkinsonism (neurodegenerative disorder that causes tremors, stiffness, and slow movement), dementia, and Picks Disease (a degenerative brain disease that affects individuals under [AGE] years old). R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was admitted to the facility on [DATE], and had moderate cognitive impairment with no noted behaviors. R1 was dependent on facility staff for eating, toileting, dressing, personal hygiene, bed mobility, transfers, and walking. R1 did not receive scheduled or as needed pain medication and did not have reports of pain during the assessment period. R1's care plan printed on 1/22/25, indicated R1 had a diagnosis of dementia and primary progressive aphasia (language disorder that affects a person's ability to communicate). R1 required two staff assist and mechanical lift for all transfers; two staff assist and walker, gait belt, and wheelchair behind for walking and staff may have to steer the walker. The fall care plan identified R1 is a high risk for falls due to balance problems, poor communication/comprehension, and unaware of safety needs. R1's progress notes titled Late Entry dated 1/15/25 at 5:50 p.m., indicated R1 was found on the floor lying on his back; three staff transferred resident to his wheelchair, brought him to the side of the bed to stand and assisted R1 to bed. The note indicated R1 denied pain but was noted to have a red area on right lower back. R1's record did not address any further monitoring and assessment for injuries as a result of the fall until 1/16/25 at 8:43 a.m. almost 14 hours after the fall occurred. R1's progress notes dated 1/16/25 at 8:43 a.m., indicated the oncoming day shift nursing assistant (NA) was notified by the night shift NA that R1's right leg was hurting. When the NA tried to put his sock on, he jumped and indicated he had pain. R1 was assessed and on-call provider notified and ordered x-rays. R1's progress notes on 1/16/25 at 4:39 p.m., identified R1 was admitted to the hospital due to finding of acute nondisplaced fracture of the proximal femur involving femoral neck and intertrochanteric regions (right hip fracture) and was scheduled for surgery on 1/17/25. R1's emergency department (ED) Provider Note dated 1/16/25, identified R1 was being seen for concerns of right hip pain after an unwitnessed fall out of bed the evening prior. The note further identified R1 was diagnosed with a closed right hip fracture with surgical repair scheduled for 1/17/25. R1's medication administration record (MAR) was reviewed between 1/15/25 through 1/16/25. The MAR identified no additional pain medication was given after his scheduled dose of Tylenol at 5:00 p.m. prior to the fall in which documentation identified R1 did not have any pain. The MAR identified R1 received his regular scheduled dose of Tylenol on 1/16/25, at approximately 8:00 a.m. in which documentation identified pain rating of 5 with no further pain assessment completed. During an interview on 1/21/25 at 2:25 p.m., licensed practical nurse (LPN)-A indicated she worked the evening and night shift on 1/15/25, it was a very busy night. LPN-A was notified by nursing assistant (NA)-A at approximately 7:10 p.m., that R1 had fallen, was agitated, and scooting around on the floor. LPN-A identified she assessed R1, and noted a little bit of redness on the right hip but thought it could have been a rash and did not note any symptoms of pain. NA-A assisted R1 to stand up and put him back to bed. LPN-A was notified on 1/16/25 at approximately 5:00 a.m. that R1 was having pain but did not check on him nor did she give R1 anything for pain. LPN-A stated, I didn't do anything, however she did report to the oncoming shift nurse that R1 had some pain but did not tell them that R1 had fallen the night before, stating, I completely forgot. During an interview on 1/22/25 at 9:35 a.m., NA-B indicated on 1/15/25 she started her shift at 10:30 p.m., typically the on-coming NA's would get report from the prior shift. NA-B explained she did not get report from NA-A, so NA-B had no awareness R1 had fallen earlier that evening. When NA-B did her first check shortly after 10:30 p.m., R1 seemed ok. At 12:30 a.m. while attempting to change R1's incontinent pad, R1 was having pain, he was screaming telling her he was in pain and had facial grimaces, however NA-B indicated an unawareness of where R1's pain was originating from. NA-B stopped what she was doing, then called for NA-A to assist with the repositioning to complete incontinent care. NA-A came to help, however, having a second person did not help alleviate R1's pain; R1 continued to yell out in pain and had facial grimaces. NA-A still had not disclosed to NA-B that R1 had a fall. Immediately after they had finished personal cares, NA-B notified LPN-A by text message that R1 was having pain and requested pain medication. NA-B stated, LPN-A told her No to the pain medication and was not aware if LPN-A had checked on R1 after that. NA-B indicated at approximately 4:30 a.m., R1 was restless and continued to have pain. NA-B again requested NA-A to assist with cares. NA-B stated R1 was making faces like he was in pain again, so she again reported to LPN-A that he was having pain and was told by LPN-A she would pass it on [to the dayshift] in the morning. NA-B indicated R1 was usually smiley and did not have signs that he was pain, so it was a definite change for him. During an interview on 1/22/25 at 12:10 p.m., LPN-B identified she worked the morning shift on 1/16/25 and received morning shift to shift report that R1 did not sleep well the night before. LPN-B further identified later that morning she was notified that R1 was having some pain and that he had pain during the over night shift. LPN-B stated this was the first I heard of his [R1] pain LPN-B assessed R1 and could tell he was in pain, notified the provider, told the NA's not to move him. LPN-B indicated the medical record lacked any of reports of R1's pain, R1's falls the evening prior, or the required paperwork, notifications, and follow up after a resident fall. During an interview on 1/22/25 at 12:20 p.m., the director of nursing (DON) identified that although NA-A and LPN-A were aware and responded to R1's fall on 1/15/25, they did not complete the assessment, notifications, and follow up after the fall. Further identified the facility was made aware of R1's fall by his family who witnessed the fall on the security camera in his room. DON indicated the facility immediately notified the physician when they became aware and completed a thorough investigation. Additionally, the facility provided coaching to staff involved and provided education to all staff on chain of command, documentation, vulnerable adults policy and reporting; shift report process; fall management, documentation, and follow-up. The following facility's corrective actions dated 1/16/25 were verified as implemented prior to the survey: -Assessed and notified provider of R1's change in condition. -The facility completed a thorough investigation that identified the facility falls and notifications policies were not followed. Further identified R1's severe pain was not assessed, monitored or treated. -Provided coaching and corrective action to LPN-A, NA-A, and NA-B -Provided education to all staff on chain of command, documentation, vulnerable adults policy and reporting; shift report process; fall management, documentation, and follow-up. Review of the facility policy Pain Management last revised 7/2023, indicated a pain assessment would be completed for all residents when there is a change of condition, or onset of new unrelieved or persistent pain or when staff assessment shows any indicators of pain, including: non-verbal sounds, vocal complaints, facial expressions, protective body movements or postures. Review of the facility's undated Fall Check List and Monitoring Sheet indicated the following steps: Obtain full set of vitals and document Perform full assessment of elder and document Initiate neuros for suspected head injury or any unwitnessed fall Notify DON of every fall immediately day or night. Notify family/veteran group/hospice (if applicable) and document in PCC on fall report. The DON or registered nurse (RN) on-call only need be notified if there is injury or have concerns Review of the facility policy Notification of Changes in Resident's Condition last revised 11/2019, indicated it is the policy of the facility to inform resident, physician, family/legal representative of an abrupt change in resident condition. The procedure is as follows: Licensed nursing staff will: Assess any changes noted through direct observations Obtain and a complete set of vital signs at the onset of the change and/or at four-hour intervals and /or more often as appropriate/ordered. Obtain any other data necessary for a complete assessment and/or per policy specific to the type of change and/or as ordered by the physician. Notify the resident of the change and assessment findings. Notify the physician of the change and after hours the physician on-call of the change base on the On-Call Physician Policy. If a mess is left continue follow-up every ½ to 4 hours depending on the significance of the change Notify the resident's legal representative and/or designated person of the changes and follow up done by facility and/or physician. Document all assessment data, observations, and notification of resident, family, and physician. Address the change on a temporary care plan for follow through by the next shifts. Follow up should continue as indicated in the policy specific to the change or as order by the physician. The resident, physician, and family should be updated about the resident's status. Update the care plan as needed.

Based on observation, interview, and document review the facility failed to revise the care plan for 1 of 1 resident (R20) with peripheral edema and diagnosis of cardiomyopathy (disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body). Findings include: R20 was admitted [DATE], with diagnoses of diabetes, implantable cardiac defibrillator, and hypertensive heart disease (disease cause by high blood pressure affecting the heart). R20's 3/29/24 psychosocial note identified she had attended her care conference and nursing had discussed her leg edema with suggestions for management. R20 voiced agreement to try some interventions. R20's 3/21/24 dietary progress note identified her weight had increased 11.2% in the past 30 days. It was noted that some of the increased weight could be related to fluid retention, but it was suspected she was non compliant with her diet restrictions and her feet and ankles were edematous. R20's 3/12/24, nurse practioner (NP) identified she had been contacted on 3/11/24 by nursing staff with concerns regarding R20's lower extremity edema and a 10 pound (lb) weight gain. Treatment was ordered for Lasix 20 milligrams (mg) by mouth (PO) daily (QD) for 3 days. R20's 3/15/24 annual Minimium Data Set (MDS) assessment identified her cognition was intact, and she was independent with activities of daily living (ADL). R20's undated, current care plan identified she suffered from cardiomyopathy, diabetes, heart disease and had an automatic implanted cardioverter-defibrillator ((AICD) electronic device surgically placed in the chest to monitor and correct abnormal heart rhythms). Staff were to monitor vital signs weekly and as needed (PRN). The physician (MD) was to be notified of significant abnormalities and directed to monitor/document/report signs/symptoms of altered cardiac output or ACID malfunction which included dizziness, syncope (brief loss of consciousness), difficulty breathing, pulse below programmed rate and lower than baseline blood pressure. The careplan failed to include any mention or interventions for edema which was also a side effect of heart failure. Observations of R20 from 4/8/24 through 4/10/24 identified she was observed either seated in either her wheelchair or cushioned chair in her room, with her bare feet on the floor. R20's bilateral feet and ankles had 4 + edema and were reddish in color. The only time R20 was observed to have her legs elevated was when she was sleeping in bed and there was not any stockings or wraps noted on her feet or legs. Interview on 4/09/24 at 2:00 p.m. with nursing assistant (NA)-B reported R20 sat with her feet resting on the floor most of the time, and did not wear any support stockings. She reported both her feet and ankles were usually really swollen. Interview on 4/09/24 at 4:32 p.m., with NA-C identified R20 spent most of her time when awake sitting in either her wheel chair of cushioned chair with her feet resting on the floor. She reported she had a foot stool but she was not aware of her using it, and she did not wear any compression stockings or have her legs wrapped that she was aware of. Interview on 4/10/24 at 7:15 a.m. with licensed practical nurse (LPN)-A reviewed R20's medication administration record (MAR) and confirmed R20 was not receiving a diuretic currently. Interview on 4/10/24 at 7:13 a.m. with the director of nursing (DON) reported R20 had been encouraged to elevate her legs, has had medication review with changes and attempts to provide education about her edema, but she refused to wear compression stockings, and was insistent on sitting with her feet on the floor. She reported she had a foot stool by her chair but refused to use it because she was afraid of falling. The DON reported the MD and NP were aware of the foot and ankle edema which she identified as 4+ and had attempted interventions, but she continued to be non-complaint. The DON confirmed the care plan did not address the problem of peripheral edema, a side effect of cardiomyopathy and should be up dated to include edema with interventions for monitoring of edema and weight changes. Review of the April 2023, Comprehensive Person-Directed Care Plan and Baseline Care Plan policy identified the care plan was to be individualized and comprehensive to ensure continuity of care. The care plan was to be reviewed every month (30 days) on each shift by both a licensed nurse and NA. Any revisions were to be shared with the MDS nurse to allow for revision to the MDS. Revisions of both the care plan and MDS were to be completed with a condition change or revised to address current problems.

Based on interview and document review, the facility failed to notify the county (designated state mental health authority (SMHA)) when 1 of 1 resident (R2) had new on-set of mental illness since admission. R2's 2/22/24, annual Minimum Data Set (MDS) assessment identified R2 had diagnosis of delusional disorders, paranoid schizophrenia, obsessive-compulsive disorder, depression, and anxiety. R2's 8/16/10, pre-admission screen (PAS) identified R2 did not have a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders (DSM), current edition. R2's undated, current diagnosis list identified R2 received a new diagnosis of schizophrenia on 10/15/15, obsessive-compulsive disorder on 10/15/15, and a new delusional disorder on 2/29/24. R2's medical record lacked any indication that the county (SMHA) had been notified since the new-onset of R2's mental illnesses. Interview on 4/9/24 at 9:48 a.m., with the social service designee identified he reviews the PAS upon admission but there is no process in place to ensure he is notified if a resident receives a new diagnosis of mental illness. Interview on 4/10/24 at 10:11 a.m., with the administrator identified that she would expect the facility to notify the SMHA authority when a resident receives a new qualifying mental illness diagnosis. She identified the facility process was to discuss new diagnosis at their daily meeting so the social service designee should have been aware of R2's new onset diagnosis. Review of the facility Pre-Admission Screening policy identified the social worker or director of nursing was responsible to contact Senior Linkage when a resident requires a referral for a new PASARR due to a new on-set diagnosis of mental illness.

Based on interview and document review, the facility failed to provide mandatory training on the facility ' s QAPI Program that included the goals and various elements of the program or how the facility intended to implement the program, staff's role in the facility ' s QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility ' s QAPI program. Findings include: Interview on 5/31/23 at 2:57 p.m. with licensed practical nurse (LPN)-B and LPN-C identified neither could recall any annual training provided by the facility on the QAPI program or its components. There were aware of what a performance improvement project (PIP) was, but not identify what PIP the facility was conducting. They also could not specify what QAPI areas or programs the QAPI committee was working on, what activities the QAPI program was monitoring, how they could communicate any concerns they identified to assist the QAPI committee. The facility hosted quarterly skills fairs, however they could not recall any QAPI being discussed at the skills fairs either. Review of sampled staff training identified the following staff had no QAPI training noted as provided on the facility's plan for the following staff reviewed: 1) LPN-B 2) Trained medication aide-(TMA)-A Interview on 5/31/23 at 5:36 p.m., with the staff education coordinator identified she was unaware of the requirement to train staff on all components identified in the QAPI program. Interview on 6/01/23 at 9:27 a.m., with the administrator identified she was unaware the facility needed to provide mandatory training on the facilities QAPI program. Interview on 6/01/23 at 10:31 a.m., with the QAPI coordinator (QC)-A identified she had not provided any training to facility staff regarding the QAPI program. Review of the 2022 Quality Plan policy identified the governing board had the ultimate authority and accountability for the quality of care delivered. The administrator was to provide staff support to the QAPI program and review recommendations made. The administrator was to provide staff support to the QAPI program and review recommendations made through that process. The administrator was to delegate each department to actively participate in the program with objectives to problem identification, implementation of corrective action, and evaluation of the effectiveness of the program through ongoing monitoring and data collection. There was no mention the facility was required to train all staff on activities of the QAPI committee.

Based on interview and document review, the facility failed to ensure data submitted to the QAPI committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 48 residents. Review of the monthly QAPI meetings from May 2022, through April 2023 identified the facility departments were submitting data to be reviewed by the committee. 2 examples of failure to analyze and document that process identified: 1) In June 2022, an aim was identified where all staff would be compliant with personal protective equipment (PPE) use. Quarter (Q)-4 in 2022 identified 90% eyewear rate, Q1 in 2023, 89%, Q2 in 2023 had an 89% audit rate with a goal for 100% compliance. The QAPI committee identified eye protection continued to be an issue. There was no documentation to support the QAPI committee analyzed the data brought forward, how they were going to achieve their compliance, if further education was needed, or if specific staff required retraining etc. 2) Numerous other areas were identified in monthly QAPI meetings, such as labeling of medications identified for Q3 in 2022, which had a 21% efficacy rate. There was no documentation the QAPI committee had analyzed the data to determine why their goal was not being achieved, what barriers were causing the low efficacy rate, or what needed to be done to ensure compliance. There was no indication to support the QAPI committee was analyzing the data brought forth during each month from May 2022 through April 2023 to show how they were going to achieve their compliance, if further education was needed, or for example if only specific staff may have required additional retraining, etc. This remained consistent with all other areas brought forth in each monthly QAPI meeting throughout the past year. Interview on 6/01/23 at 9:27 a.m., with the administrator regarding the QAPI program identified the committee spoke about the elements brought forth to QAPI. She was unaware of any further documentation to support the committee had documented how they analyzed the data brought forth to the QAPI committee for monitoring to ensure they were able to reach their goals, what barriers may be present, or how they would ensure their monitoring over their affected areas were identified to be able to reach their goals for oversight. Interview on 6/01/23 at 10:31 a.m., with the QAPI coordinator (QC)-A identified she had no documentation to support the data brought forth to the QAPI committee was being analyzed to identify how they would achieve compliance. The committee did identify numerous areas where auditing was being completed. For example, with hand hygiene, education had been provided, but there was no documentation to support the QAPI committee had analyzed concerns to see if their education was effective, if continuing education was needed to be provided, or how the facility was going to achieve their perspective department goals. Review of the 2022 Quality Plan policy identified the governing board had the ultimate authority and accountability for the quality of care delivered. The administrator was to provide staff support to the QAPI program and review recommendations made. The administrator was to provide staff support to the QAPI program and review recommendations made through that process. The administrator was to delegate each department to actively participate in the program with objectives to problem identification, implementation of corrective action, and evaluation of the effectiveness of the program through ongoing monitoring and data collection.

Based on interview and document review, the facility failed to ensure 5 of 5 residents (R7, R16, R17, R26, and R45) were appropriately vaccinated against pneumonia upon admission. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 48 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 1) Adults 19-[AGE] years old with specified immunocompromising conditions, staff were to offer and/or provide: a) the PCV-20 at least 1 year after prior PCV-13, b) the PPSV-23 (dose 1) at least 8 weeks after prior PCV-13 and PPSV-23 (dose 2) at least 5 years after first dose of PPSV-23. Staff were to review the pneumococcal vaccine recommendations again when the resident turns [AGE] years old. 2) Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose Review of 5 sampled residents for vaccinations identified: 1) R17 was under 65 with immunocompromising diagnoses and was admitted to the facility in July of 2019. R17 had received the PCV-13 on 11/14/17, prior to her admission. R17 should have been offered and/or provided the PCV-20 at least 1 year after prior PCV13, OR the PPSV-23 (dose 1) at least 8 weeks after prior PCV-13 AND PPSV-23 (dose 2) at least 5 years after first dose of PPSV-23. 2) R16 was over 65 and admitted to the facility in November of 2016. R16 had the PCV-13 on 3/11/16. R16 should have been offered and/or provided the PCV-20 at least 1 year after prior PPSV-23 OR the PCV-15 at least 1 year after prior PPSV-23. 3) R7 was over 65 and was admitted to the facility in September of 2022. R7 had previously received the PCV-13 on 2/20/17. R7 should have been offered and/or provided the PCV-20 at least 1 year after prior PCV-13 OR the PPSV-23 at least 1 year after prior PCV-13. 4) R45 was over 65 and was admitted to the facility in March of 2023. R45 had previously received the PCV-13 on 12/18/16 and the PCV-23 on 9/22/20 (after age 65). R45 should have been offered and/or administered the PCV-20 at least 1 year after prior PCV-13 OR the PPSV-23 at least 1 year after prior PCV-13. 5) R26 was admitted to the facility in February of 2023. R26 had the PCV-13 on 1/27/17. R26 should have been offered and/or provided the PCV-20 at least 1 year after prior PCV-13 OR the PPSV-23 at least 1 year after prior PCV-13. Review of the October, 2022 LTC Resident Vaccination policy related to the pneumococcal vaccine identified: 1) Residents were to be offered a pneumococcal vaccine upon admission. 2) A nurse was to review the resident's admission orders, vaccine history, diagnosis and was to administer either the 13-valent pneumococcal conjugate (Prevnar-13) or the 23-valent pneumococcal polysaccharide vaccine (Pneumovax) as indicated. Staff were then instructed to Please see the CDC algorithm for scenarios and medical conditions at https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf. 3) Residents will be assessed for pneumococcal vaccination annually. 4) Report any unexpected or significant adverse event to the physician and document in the medical record. Interview and LTC Resident Vaccination policy review on 5/31/23 at 9:46 a.m., with the infection preventionist (IP) identified she expected staff to follow the policy as described above. The IP was unaware of updated vaccination schedules per CDC. The IP stated the facility didn't actually give vaccinations here. We require all residents go to the clinic for an annual visit. If the IP or assistant director of nursing (ADON) saw a resident was due for vaccines, they were to remind the clinic. The IP agreed the policy was outdated. The IP agreed since the facility kept no vaccinations onsite, admitting nursing staff staff would not have reviewed the outdated policy and if they had, would have thought the residents vaccines were current according to the policy. She was unaware the facility was required to offer and/or provide the vaccines and not rely on the clinic. Had those residents been offered the updated vaccination per the guidelines, the declinations would have been documented in the medical record. She agreed no declinations were noted. Interview on 5/31/23 at 11:36 a.m., with (RN)-A identified facility had no vaccinations kept at the facility to administer to residents. The facility was to offer vaccines upon admission to see what vaccination was due, then staff were to contact the clinic to notify them a resident needed an appointment to get a vaccine. She agreed the policy as is, was not updated and potentially misleading to staff. Per the policy, she would would have considered the above-mentioned resident's were up-to-date if they received one of the PCV-13 or PCV-23. She agreed they need to be offered upon admission and if a resident was admitted on the weekend, this could not occur as facility staff were unable to send a resident to the clinic as it would be closed. They also wait for a yearly health assessment performed at the clinic for those staff to identify if residents needed further vaccination. She agreed that would delay administration. Interview on 5/31/23 at 1:56 p.m. with the director of nursing (DON) and IP identified the DON agreed the policy was not up-to-date with the CDC guidelines for pneumo-vaccination. She agreed waiting a year for residents to have their annual exam was not following guidance and delaying vaccination. She agreed the facility system needed to be revamped as only some residents were admitted fully vaccinated. The IP identified the pneumo-vaccination changes went into effect last march, however, she didn't have time to update her policy. The IP and DON agreed they had no system to ensure residents were vaccinated appropriately upon admission. Interview on 6/01/23 at 9:27 a.m., with the administrator identified she agreed staff failed to vaccinate residents per the current CDC guidelines. She also agreed it was the facility's responsibility to provide the vaccines and not rely on the adjoining clinic to identify the residents were not either offered the vaccine upon admission or administered the vaccines per the schedule to be fully vaccinated against the pneumococcal virus.

Based on observation, interview, and document review, the facility failed to have an integrated hospice care plan and educate facility staff on what services hospice was to provide, and what services the facility was to provide under the hospice contractual agreement for 1 of 2 residents (R16). Findings include: R16's 5/1/23, Significant Change, Minimum Data Set (MDS) identified R16's primary diagnoses were heart failure and cancer. R16 was totally dependent for most all cares, had no instances of walking or moving with staff assistance. R16's progress notes identified R16 was admitted to hospice on 4/25/23. Observations on 5/30/23 at 3:44 p.m., and again on 5/31/23 at 2:38 p.m., identified R16 was asleep in bed and made no effort to arouse when her name was called. Interview and document review on 5/31/23 at 2:40 p.m. with licensed practical nurse (LPN)-B identified R16 was having ascites (fluid collects in spaces within your abdomen) prior to her admission to hospice. R16's family had not wanted any extraordinary measures. R16 was being made comfortable with pain medication regularly. Prior to hospice admission, R16 was beginning the dying process and sleeping quite often and exhibited difficulty with staff attempting to arouse her. LPN-B stated she was aware hospice staff were coming to the facility. She thought the hospice aide bathed R16 2 times per week. She had a schedule for the nurse posted on the wall. The schedule taped to the wall in the nursing station listed Wednesdays as [NAME]. There was no indication what hospice nurse was scheduled to come, not delineation if that was the aides schedule. LPN-B then asked another unidentified facility aide staff about the hospice aide schedule. LPN-B was advised R16 had a schedule taped to her bathroom door. Review of the calendar taped to the bathroom door identified the word staff was written in on Tuesdays. When asked how she knew who (hospice or the facility) provided specific delegated cares or what hospice staff was scheduled and at what times they would come to the facility, LPN-B was unaware. If hospice staff failed to come as scheduled, she was sure they would alert the facility. Review of the hospice care plan with LPN-B identified she was unsure where the document was located. After some time, LPN-B located the hospice care plan in R16's paper chart where it noted: 1) The hospice aide was to visit 1 x per week, and only provide bathing and personal cares for 5 additional visits for acute personal care as needed. 2) The hospice nurse was to visit 1 x per week for symptom management with an addition 5 visits as needed for acute symptom management. The advanced care plan portion identified the hospice aide would provide specific cares such as assisting R16 with dressing, bathing, changing her oxygen tubing, provide simple dressing changes, and notifying the hospice nurse if R16 had a change in status , increase in confusion, and skin concerns. The hospice aide was to notify the clinician if vital noted were: 1) Temperature over 100 degrees Fahrenheit, 2) Pulse over 100 beats per minute, 3) Respirations over 25, 4) Blood pressure below 90/60 millimeters of mercury (mm/hg) or above 140/90 mm/hg, 5) Increase in weight over 2 pounds (lbs) per day or over 5 lbs in a week, 6) Oxygen level (SpO2) below 80% with activity or less than 89% at rest. Hospice did note the facility staff would provide cares when the hospice staff was not present and facility staff were to be educated on what to do when hospice staff were not present. Hospice was to document their visits in the facility medical record. LPN-B stated hospice visits were not documented in the facility medical record. Continued interview with LPN-B identified LPN-B reviewed the facility care plan. The facility care plan section for hospice identified R16 had a terminal prognosis related to an abdominal mass, carotid (artery in neck), and had a history of facial cancer. Staff were to: 1) Maintain her comfort by adjusting her Activities of Daily Living (ADL) to compensate for her changing abilities. 2) Consult with the physician (MD) and social services to have hospice care for the resident when in the facility. 3) Observe R16 closely for signs of pain, administer medications as ordered and notify the MD if breakthrough pain occurred. 4) Update hospice for unrelieved pain, a change in status LPN-B was unaware of any specific cares she was to provide except medication administration. She could not recall specific education related to R16's needs while hospice staff were not present. There was no specific delegation as to what days the aide or nurse would provide and what days those staff were scheduled to come to the facility. There was also no identification education was provided to all staff responsible for R16's care while they were at the facility and what cares facility staff were to ensure occurred if not provided by the hospice staff. LPN-B agreed the facility failed to delineate what services they were to provide and what services hospice was to provide per the contractual agreement with hospice. LPN-B agreed she had no specific education provided by hospice per the contractual agreement. Hospice staff were unable to be interviewed during the survey. Review of the November 2022, Hospice Nursing Facility Services agreement identified the facility was to ensure hospice patients were kept comfortable, clean, and well groomed. The facility was to provide services that would be provided by the hospices primary provider in coordination with hospice. The facility was to fully inform the hospice patient what services were to be provided by the facility. The facility was to, in coordination with hospice in developing a plan of care unique to the resident's needs. The facility was to ensure the facility care plan reflected both the hospice care plan and description of facility services to be provided by the facility. Hospice was to provide orientation and ongoing training to facility staff to facilitate safe and effective care.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 dietary personnel (dietary aide (DA)-A) followed appropriate infection control technique while preparing and serving food during 1 of 1 meal service observed. Findings include: Observation on 5/30/23 at 11:59 a.m., of DA-A preparing and serving food in the Prairie Lane kitchenette identified DA-A was observed picking up a hamburger bun for the noon meal with her bare hands. DA-A reached into the bag containing buns with her bare hand, placed the bun on the plate, opened the bun, and grabbed the tong and placed a burger onto the bun. DA-A then proceeded to touch each serving handle as she scooped the rest of the meal items onto the plate then handed the plate to another staff to deliver the meal to R19. DA-A was observed to open a drawer and obtain a serving spoon, then grab another plate without washing her hands and reach into the bag of buns with her same bare hand and place the bun on the plate and open the bun. DA-A continued to touch the serving utensils to add the other food items to the plate before handing the plate off to another staff for delivery to R43. DA-A obtained another plate without stopping to wash her hands and reached into the bag and grabbed another bun with her bare hand, place the bun on the plate, open the bun and add the hamburger, touch each serving handle as she scooped the rest of the food items onto the plate before handing the plate to another staff to deliver to R37. DA-A was then stopped and asked about touching the buns with her bare hands. DA-A reported she could not pull the buns out with a tong but could try. DA-A then revealed that sometimes she wore a glove, and then stated, .I guess I can do that. Interview on 5/30/23 at 2:42 p.m., with food service manager identified DA-A was aware that gloves or utensils should be used when handling food for consumption. She confirmed staff should never be touching resident food and it was her expectation that staff either used gloves or utensils during preparation of a meal plate. Interview on 6/1/23 at 9:11 a.m., with administrator identified her expectation would be that staff would use a utensil or gloved hands to handle food that was to be consumed according to the facility policy. Review of 4/2023, Sanitation & Infection Control - Bare Hand Contact with Food and Use of Plastic Gloves policy identified staff were to use gloves when handling food directly with their hands to prevent contamination of the food being served. Staff could also use barriers like tongs, deli paper or spatulas to prevent contamination and food borne illness. Staff were to use a barrier anytime hands would be touching food directly.

Based on interview and document review, the facility failed to provide medically related social services and/or obtain mental health counseling and notify the provider for 1 of 1 resident (R17) whose family member (R199) was in the process of actively dying. This had the potential to exacerbate R17's already existing anxiety and depression. Findings include: R17 was admitted in July of 2019, with diagnoses of major depressive disorder, post-concussional syndrome, and heart disease, and anxiety disorder. R119's progress notes identified on 4/25/23, R199 was admitted to hospice. The hospice nurse, hospice aide and hospice social worker were to visit weekly. R17's 12/27/21, care conference note identified the physician had encouraged R17 to see a mental health counselor when he last saw her. R17's undated, current care plan identified R17 suffered from depression, insomnia, migraines, diabetes, sleep apnea, and post-concussion syndrome. R17's PHQ-9 (mood assessment) identified she had several days with poor appetite and half or more days with little energy and feeling down. R17 had a history of not taking her medications or doing self-cares when she was at home. R17 had expressed sadness over her health. Staff were to take a calm, unhurried approach when dealing with R17, and allow her time to vent her concerns and feelings. R17 appears anxious in new situations. Staff were to offer calm, slow explanation and reassurance. Staff were also to observe her mood and adjustment to the care center. There was no mention of R17's situation dealing with grief over R199's hospice diagnoses or to offer mental health services. There was no mention social services was to provide 1:1's for coping with the situation. Observation on 5/31/23 at 10:50 a.m., identified R17 was asleep in her room. Interview on 5/31/23 at 10:56 a.m., with licensed practical nurse (LPN)-A identified R199 went on hospice about a week ago. At that time R17 was noted to be more withdrawn, quiet in her room, was sleeping more. R199's hospice was discussed at the morning stand-up meetings (IDT meetings). The social worker (SW)-A attended the meetings daily. LPN-A was not aware if SW-A had visited R17 with the sudden change to R199's health. Staff were to monitor her moods for changes. She was unaware of any other interventions. Mental Health services had been offered before and R17 had declined at that time. To her knowledge, no staff have offered mental health counseling again after R199's new admission to hospice. Interview and R17's progress notes review on 5/31/23 at 11:56 a.m., with registered nurse (RN)-A identified SW-A attended daily stand-up meetings and was aware of R17's family situation. RN-A stated had the SW provided services for R17, there would be a progress note made. She agreed there was no progress note made to indicate SW-A had visited R17. RN-A agreed R17 was at risk for worsening depression and anxiety. RN-A agreed the facility should offer SS and MH in a potential emotional crisis time for this resident. Interview on 5/31/23 at 11:43 a.m., with SW-A identified he was aware of R199's hospice situation and that R17 was her family member. SW-A identified he had not been down to see her, no had he identified R17 needed medically related social services to prevent worsening of her depression and anxiety. R17's 1/16/23, quarterly Minimum Data Set (MDS) progress note identified R17 would be free from discomfort or adverse reactions related to antidepressant therapy through next review. R17 continued to stay in her room most of the time, will come out to meals, and special activities of her choice. R17's 4/5/23, annual MDS identified R17 had feelings of being down, depressed or hopeless 1 day during the look-back period, was noted to be tired or have little energy over half the days reported, and had poor appetite or was noted to be overeating at least half of the days reported during the look-back period. R17 was unavailable for interview as she was dealing with R199's end of life process. Review of the December 2022, Behavioral Health Services policy identified staff were to identify residents with mental and emotional care needs based off of physician orders, diagnoses, and mental health history, and care plan those interventions.

Based on observation, interview, and document review identified the facility failed to revise the care plan for 1 of 1 resident (R17) with known diagnoses of anxiety and depression who was currently in a traumatic life event with her family member who was in the process of actively dying. Findings include: R17 was admitted in July of 2019, with diagnoses of major depressive disorder, post-concussional syndrome, and heart disease, and anxiety disorder. R119's progress notes identified on 4/25/23, R199 was admitted to hospice. The hospice nurse, hospice aide and hospice social worker were to visit weekly. R17's 12/27/21, care conference note identified the physician had encouraged R17 to see a mental health counselor when he last saw her. R17's undated, current care plan identified R17 suffered from depression, insomnia, migraines, diabetes, sleep apnea, and post-concussion syndrome. R17's PHQ-9 (mood assessment) identified she had several days with poor appetite and half or more days with little energy and feeling down. R17 had a history of not taking her medications or doing self-cares when she was at home. R17 had expressed sadness over her health. Staff were to take a calm, unhurried approach when dealing with R17, and allow her time to vent her concerns and feelings. R17 appears anxious in new situations. Staff were to offer calm, slow explanation and reassurance. Staff were also to observe her mood and adjustment to the care center. There was no mention of R17's situation dealing with grief over R199's hospice diagnoses or to offer mental health services. There was no mention social services was to provide 1:1's for coping with the situation. Observation on 5/31/23 at 10:50 a.m., identified R17 was asleep in her room. Interview on 5/31/23 at 10:56 a.m., with licensed practical nurse (LPN)-A identified R199 went on hospice about a week ago. At that time R17 was noted to be more withdrawn, quiet in her room, was sleeping more. R199's hospice was discussed at the morning stand-up meetings (IDT meetings). The social worker (SW)-A attended the meetings daily. LPN-A was not aware if SW-A had visited R17 with the sudden change to R199's health. Staff were to monitor her moods for changes. She was unaware of any other interventions. Mental Health services had been offered before and R17 had declined at that time. To her knowledge, no staff have offered mental health counseling again after R199's new admission to hospice. Interview and R17's progress notes review on 5/31/23 at 11:56 a.m., with registered nurse (RN)-A identified SW-A attended daily stand-up meetings and was aware of R17's family situation. RN-A stated had the SW provided services for R17, there would be a progress note made. She agreed there was no progress note made to indicate SW-A had visited R17. RN-A agreed R17 was at risk for worsening depression and anxiety. RN-A agreed the facility should offer SS and MH in a potential emotional crisis time for this resident. Interview on 5/31/23 at 11:43 a.m., with SW-A identified he was aware of R199's hospice situation and that R17 was her family member. SW-A identified he had not been down to see her, no had he identified R17 needed medically related social services to prevent worsening of her depression and anxiety. R17's 1/16/23, quarterly Minimum Data Set (MDS) progress note identified R17 would be free from discomfort or adverse reactions related to antidepressant therapy through next review. R17 continued to stay in her room most of the time, will come out to meals, and special activities of her choice. R17's 4/5/23, annual MDS identified R17 had feelings of being down, depressed or hopeless 1 day during the look-back period, was noted to be tired or have little energy over half the days reported, and had poor appetite or was noted to be overeating at least half of the days reported during the look-back period. R17 was unavailable for interview as she was dealing with R199's end of life process. Review of the December 2022, Behavioral Health Services policy identified staff were to identify residents with mental and emotional care needs based off of physician orders, diagnoses, and mental health history, and care plan those interventions.

Based on interview, and record review, the facility failed to report potential abuse within 2 hours for 1 of 3 residents (R27. who was identified with a bruise on his abdomen of unknown origin. Findings include: R27'S 4/13/23, quarterly Minimum Data Set (MDS) identified R27 had severe cognitive impairment and required extensive assistance with all cares. R27 had diagnosis of diabetes, high cholesterol, depression, anxiety, and cognitive decline. R27's undated care plan identified R27 is a vulnerable adult due to impaired cognition and memory loss and He needs assistance with activities of daily living (ADL's). R27's progress notes entered on 3/27/23, at 12:45 a.m., identified registered nurse (RN)-C documented she had been notified on 3/26/23 at around 8:30 p.m., that R27 had bruising on his abdomen that extended down the left side. RN-C documented R27's abdomen was distended and R27 reported pain. RN-C had called the on-call physician and R27 was sent to emergency department for further evaluation. R27 had a CT scan completed, with the results showing the injury to have an unknown etiology. R27 received IV fluids and an injection of an antibiotic prior to returning to the facility. RN-C updated the director of nursing (DON) at 10:30 p.m Review of the report to the State Agency (SA) identified it was submitted on 3/27/23 at 2:40 a.m., that a nurse aide reported R27 had a large bruise on his abdomen extending from his umbilicus down to his left side. Upon assessment of the bruise, there was abdominal distention as well as some pain. A smaller bruise localized at center of umbilicus had been reported at an earlier date, but bruising had significantly spread throughout the day. The report further identified staff had reported the concern to the on-call physician and R27 was transported to the emergency department for further evaluation with orders to have a CT scan performed. The facility completed the report to the SA more than 6 hours after the injury was reported to RN-C. Interview on 5/31/23 at 3:06 p.m., with DON identified she had been updated around 10:30 p.m., that a nursing assistant had reported a bruise to RN-C. DON stated I see we have a delay in reporting. DON identified that she would have expected RN-C to complete a State Agency report within 2 hours of notification of the bruise and further revealed that RN-C recognized her error when they spoke after the incident. RN-C was unavailable for interview during the survey. Review of the May 2023, Abuse policy identified the administrator, DON, or designee were to report potential abuse within 2 hours.

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 resident (R1) was treated in a dignified manner while being provided assistance with bed mobility and locomotion. Finding include: R1 Review of facility reported incident received by the state agency (SA) dated 4/19/23, indicated that alleged perpetrator (AP) stated to R1 you should know better than to slide down in bed. R1 felt like AP was brass and nasty towards her and was not listening to her wants and needs. R1 asked for her call light while AP was leaving and AP stomped back into her room rolling her eyes and tossed the call light at R1 and lightly hit her head. R1 denied any injury. R1's admission Minimum Data Set (MDS) indicated an intact cognition and diagnoses of non-Alzheimer's Disease dementia, muscle weakness, obstructive uropathy (obstruction of urinary flow) and spinal stenosis. R1's MDS further indicated R1 required extensive assistance of two staff for bed mobility, transfers, and toileting. R1 has an indwelling catheter. R1's care plan identified a need for extensive assist of two staff to boost, sit-to-lie and lie-to-sit, revised on 4/17/23. During an interview on 5/2/23, at 12:55 p.m. family member (FM)-B present, R1 stated that AP answered her call light and got after R1 for sliding down in bed. AP adjusted R1 per self and then when R1 asked for call light as AP was walking out the door AP came back and grabbed the call light off of the recliner next to bed and threw it at R1 hitting her in the right temple area. R1 indicated this area with her hand. Denied any pain or bruising,just made her feel like she was a bother. R1 stated that she had also asked AP to have the nurse come to her room but the nurse never came. R1 stated that she felt safe in the facility. During an interview on 5/2/23, at 4:28 p.m. Nurse manager (NM)-B indicated she was made aware of the incident during morning stand up on 4/19/23, at 9:05 a.m. and went to talk with resident. Resident told NM-B about the incident and NM-B called the agency of AP and informed the agency that AP was no longer to work at facility. NM-B went back several times during the week to check in on R1. NM-B had not made an attempt to reach out to the AP. Call was placed to AP on 5/2/23 at 4:45 p.m., but there was no answer or return call received.

Based on interview, document review, and video review, the facility failed to ensure an environment free of abuse for 1 of 1 resident (R2) who experienced an incident of physical and sexual abuse by staff. The survey resulted in an immediate jeopardy (IJ) that began on 5/3/21, when 2 nursing assistants in the facility lobby NA-A and NA-B made inappropriate sexual gestures, slapped, and kissed R2, and took photos and video of R2 during the incident. The administrator and director of nursing (DON) were notified of the IJ on 5/7/21 at 3:35 p.m. Findings include: Review of the 5/4/21 at 4:29 p.m., report filed to the State Agency (SA) identified the maintenence supervisor (MS) reviewed the 5/3/21 video footage on the facility surveillance camera. The camera was located at the Prairie Lane entrance. Video footage identified between 7:00 p.m. and 7:30 p.m., R2 was sitting on the couch in the lounge next to the entrance with two NAs. 1 NA was dancing in a sexually provocative manner involving thrusting hip movements and a low, squatting stance (twerking) in front of R2 and pulled up her shirt exposing her lower back. The other NA slapped the twerking NA on the bottom. One of the NAs sat on R2's lap and also had kissed R2 on the lips. Both NAs also took photos of R2 with their mobile devices, and were reported to have thrown foam balls at R2. One ball made contact with R2's head, bounced off and hit the window. Both NAs were suspended pending further investigation. Review of the 5/5/21, Internal Investigation Form identified on 5/4/21 at between 8:00 a.m. and 8:30 a.m., the MS was viewing the surveillance camera footage from 5/3/21, and discovered NA-A and NA-B engaging in inappropriate behavior with R2 near the Prairie Lane entrance between 7:00 p.m. and 7:20 p.m. At 9:00 a.m., the MS met with the human resources director (HRD). The MS identified he was reviewing surveillance camera footage and observed NA-A and NA-B twerking in front of R2 several times while recording their actions on their personal phones. NA-B kissed R2 on the lips while NA-A took photos and both nursing assistants were laughing. NA-A and NA-B also shot nerf balls at R2, and sat on her lap. At 10:00 a.m., the HRD notified the assistant director of nursing (ADON) of the incident and planned to meet after the video was downloaded to a flash drive. At 11:00 a.m., the administrator was notified of the incident. At 3:00 p.m., the HRD met with the administrator and ADON to view the video. At 3:20 p.m., Both NAs were placed on suspension pending investigation of the incident. Between 5/4/21, and 5/5/21, 3 staff and 4 residents who worked with NA-A and NA-B on the day the incident occurred were interviewed. Staff identified NA-A and NA-B had performance issues of not performing cares and following care plans. The residents interviewed had no concerns. No additional interviews from staff or residents were conducted. The investigation report did not identify whether education of all staff or any additional actions were taken by the facility to prevent further abuse. Review of the 5/3/21, facility surveillance camera footage identified between 7:00 p.m. and 7:20 p.m., R2 was seen sitting on a couch in the lounge next to the entrance of the Prairie Lane unit. R2 was wearing a white sweatshirt and staff were wearing blue scrubs. NA-A was seated in the window ledge next to the couch, while using a mobile device. NA-B was seated next to R2 on the right side of the couch. NA-A rose from the window ledge and sat on the arm of the couch next to R2. R2 batted her right hand towards NA-A. NA-A stood and turned her back side towards R2. NA-A was standing to the left side of R2 and pointed the mobile device towards NA-B and R2. NA-B continued to be seated on the couch. R2 turned towards NA-B, NA-B leaned into R2 and kissed her on the lips.Both NA-A and NA-B laughed boisterously. NA-B rocked backwards on the couch, clapped her hands and continued to rock back and forth and laugh. At the same time, NA-A threw her head back while laughing and viewing her mobile device. NA-B stood and walked towards NA-A. Both looked at NA-A's mobile device and continued to laugh. R2 remained seated on the couch. NA-B walked to R2, stood in front of her, turned and wiggled her bottom in front of R2. NA-B then bent forward with her bottom at R2's face level and began twerking. NA-A from the couch stood next to NA-B and slapped NA-A on the bottom while she twerked in front of R2. NA-A sat down on the right side of the couch next to R2 and looked at her mobile device. NA-B stood in front of R2 while looking at her mobile device. The image on NA-A's device was visible on the footage and identified an image of a lady in a white sweatshirt, in a seated position and a staff person dressed in blue bent over in front of the person, presumed to be R2 in the white sweatshirt. NA-A put her right leg over R2's lap and leaned into R2 with her mobile device. NA-B lay on the left arm of the couch near R2. NA-A's right arm reached towards the level of R2's face. R2's hand became visible as she raised her hand to swat NA-A's hand out away. R2 continued to swat at NA-A. R2 slapped NA-A's left shoulder. NA-A's torso leaned away from R2. NA-A turned to face R2 when R2 attempted to swat at NA-A again, NA-A placed her hand on R2's hand then made two quick slaps towards R2's face. It could not be determined if NA-A made contact with R2. R2 attempted to stand several times. Both aids distanced themselves from R2. R2 maintained a semi-seated position at the couch. Observation on 5/6/21 at 9:33 a.m., with R2 identified R2 was sitting in her recliner in her room, R2 was calm, alert, and had no signs of injury on her face or hands. R2's 3/25/21, Significant Change Minimum Data Set (MDS) identified her cognition was moderately impaired. R2 was assessed as having no rejection of care and had wandered during the observation period. R2 required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. R2 required supervision for moving on and off the unit and walking in her room and in corridors. R2 had no impairment in her upper and lower extremities. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's 5/6/21, care plan identified R2 had dementia with short-term memory loss. R2 was anxious in new situations and became upset when unable to remember information. R2 had periods of disorganized thinking and delusional thoughts, and required assistance to maintain her safety. R2's behaviors included delusional beliefs about returning home, family, refusal of assistance with toileting, changing clothes, bathing, packing clothes and personal items to go home, and wandering. Interventions included to use a calm unhurried approach, re-approach R2 when agitated, explain all cares, follow her routine closely, provide one-to-one support in new situations, and ensure R2 was safe and separated from any residents she was fearful of. Interview on 5/6/21 at 3:00 p.m., with the administrator verified she was notified of the incident by the human resources director (HRD) on 5/4/21 at 11:00 a.m. The morning of 5/4/21, the MS was viewing video surveillance from a request to check R2's WanderGuard function. The MS discovered video footage of NA-A and NA-B being physically and sexually inappropriate with R2. The MS notified the HRM of the situation. The administrator contacted director of nursing (DON) and assistant director of nursing (ADON) were also contacted. R2 was interviewed on 5/4/21, but was unable to recall the event from 5/3/21. The administrator verified the ADON submitted the report on 5/4/21 at 4:28 p.m. The afternoon of 5/4/21, NA-A and NA-B were contacted and notified they were suspended pending the investigation. Neither NA worked after 5/3/21. The facility scheduled appointments with NA-A and NA-B. NA-B met with the administrator, DON, and HRD. NA-B denied any involvement in the situation, even after she was told there was video footage of the incident. At the conclusion of the meeting, NA-B was given termination notice. NA-A texted the facility her resignation, and never met with management. The HRM began interviewing staff and residents to identify whether other residents had similar interactions. The interviews concluded the incident was isolated. The adminstrator indicated she felt the event was unfortunate, and was two teenagers who had not followed the rules. On 5/6/21, the DON and administrator met with staff who had not been available to meet on 5/5/21. The administrator indicated education was not provided regarding cell phone use or abuse during the meeting. Interview on 5/6/21 at 4:00 p.m., with the HRD identified on 5/4/21 at 8:30 a.m., the MS contacted the HRD regarding what he found the video surveillance camera. The video identified NA-A and NA-B acting inappropriately towards R2 at Prairie Lane entrance. The NAs were observed twerking, sitting on R2's lap, kissing her on the lips and shooting foam balls at R2 from a [NAME] toy from the activity department. At 11:00 a.m., the administrator was notified of the incident. The HRD interviewed staff and residents. No concerns regarding abuse were identified however, staff reported concerns NA-A and NA-B were noted to have previously not provided cares to residents. Both NA-A and NA-B were placed on suspension following the allegation, and an appointment was set up to meet with NA-A and NA-B on 5/5/21. On 5/5/21, at 3:30 p.m., NA-B came to the facility to meet with the HR, the administrator, and the DON. During the meeting, NA-B denied using her cell phone, taking photos or videos. NA-B denied twerking and shooting green balls at R2, however she identified NA-A had shot green foam balls at R2. When informed the incident was on the surveillance camera. NA-B identified she had not kept any of the photos of video from the personal phone. The HRD provided NA-B a termination notice. NA-A texted the HRD to cancel her meeting and later texted the HRD her resignation. A termination letter was mailed to NA-A on 5/6/21. The ADON and the social worker (SW) reported the incident to the SA. The HDR identified she worked for both the long-term care (LTC) facility and the hospital. The HRD received annual vulnerable adult training through computer-based training, however she had not been trained to the facility's polices and procedures for abuse and neglect. The administrator was notified of the incident at 11:00 a.m. on 5/4/21. She confirmed the incident was not reported to the administrator or law enforcement immediately. Interview on 5/6/21 at 4:59 p.m., with licensed practical nurse (LPN)-D identified she had worked with NA-A and had concerns with NA-A's work performance in the past. She indicated she had concerns with NA-A not providing care to a resident and had reported her concerns to the DON. She was unsure of any time frames for reporting allegations of abuse. Interview on 5/7/21 at 9:00 a.m., with the MS identified on 5/4/21, he received a work request to find out if R2's WanderGuard was malfunctioning. Around 8:00 a.m., he began to reviewing surveillance camera footage. As he was forwarding through footage on high speed, and had seen two twerking, sitting on R2's lap, shooting foam balls at R2, kissing R2 on the lips, and taking photos and video during the interaction. The MS contacted the HR around 8:30 a.m., to schedule a meeting with her after his morning meeting with the other maintenance staff. He had not notified the DON because she was out of the facility. The MS confirmed he had not notified the administrator. He felt the HRD would know what to do. The MS identified he worked for both the nursing home and hospital. The maintenance department had annual abuse training through computer-based training. He had not been trained specifically to abuse policies and procedures of the nursing home as it related to reporting abuse directly to the facility. Interview on 5/6/21 at 4:39 p.m., with the DON identified she was made aware of the incident on 5/5/21. The DON met with staff to see if they had observed anything out of the ordinary. The staff who worked the evening shift on 5/3/21, were also interviewed to identify whether there were any concerns. No abuse training was provided following the incident. All staff were expected to report to the DON or admiistrator any allegation of abuse within 2 hours. Review of the abuse neglect policy was reviewed with the DON and she agreed the incident on 5/3/21, fit the description of abuse and should have been reported to the reported to administrator and the SA within two hours. Charge nurses also had the ability to report allegations of abuse to SA. The DON identified in the situation with R2, the MS was the initial reporter and had reported the incident to the HRD. On 5/7/21, attempts to contact both NA-A and NA-B via telephone for interview were done, but unsuccessful. Review of NA-A's employee records identified a hire date of 8/25/20 and was terminated on 5/5/21 for the above incident. No corrective actions prior to 5/3/21 were included in NA-A's employee file. Review of NA-B's employee records identified a hire date of January 2021 and was terminated on 5/5/21 for the above incident. No corrective actions prior to 5/3/21 were included in NA-B's employee file. Interview on 5/7/21 at 9:26 a.m., with the medical director identified he was notified of the incident on 5/6/21, while doing rounds at the facility. He had not viewed the video of the incident. He identified the facility should have notified him before 5/6/21. He was not familiar with the facility's abuse policies, but was aware all allegations of abuse were to be reported to the SA within two hours. The medical director was not provided a timeline of events, investigation information, whether staff were immediately educated. He identified the actions of NA-A and NA-B were elderly abuse and he expected the facility to identify, report, identify, and correct any allegations of abuse and any breaks in compliance in accordance with the facility abuse policies and regulations. Review of the February 2021, Cell Phone Use policy identified cameras and camera phones were prohibited in the workplace unless for business purposes. Signed consent on the official consent form must be on file from any employee, patient, or visitor whose photo is taken. Employees who violated the policy were subject to disciplinary action up to and including termination. Review of the October 2020, Care Center Abuse Prevention Plan prohibited phsyical, sexual, mental abuse and included photos or video of residents. A mandated reporter was to report any suspicion or observed incident of abuse immediately to the DON. If the DON was absent, allegations were to be reported to a designee. If reporter was unable to report the allegation verbally to the DON, ADON, or the charge nurse immediately, they were to report the allegation directly to the administrator. The incident was to be reported to the SA immediately. Reports suspected of a crime were to be reported to law enforcement. Review of the facility's July 2018, Appendix C-Decision Guide for Incident Reporting policy identified staff were to immediately report allegations of abuse and to report any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property to the administrator and designated SA immediately, but not later than two hours after the allegation is made if the allegation involved abuse. The IJ was removed on 5/10/21 at 1:10 p.m., when it could be verified by interview and document review the facility took steps to remove the immediacy by revising policies and procedures and educating staff about reporting abuse neglect and to restrict use of cell phones while in patient care areas and while on duty. Non-compliance remained at a severity of D, isolated, with the potential for actual harm that was not immediate jeopardy.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for COVID-19 surveillance, quarantine and cohorting to prevent or minimize the transmission of COVID-19 when 1 of 53 residents (R5) tested positive for COVID-19, 1 resident was symptomatic with known exposure to R6 (R5), and 1 resident had an inconclusive test (R8). The facility's failures resulted in an immediate jeopardy (IJ) situation for all remaining residents. The immediate jeopardy began on 10/9/20, when a lack of surveillance and implementation of infection control measures put all 50 residents at risk for COVID-19. The administrator was notified of the immediate jeopardy on 10/9/20 at 5:08 p.m. The immediate jeopardy was removed on 10/11/20 at 10:54 a.m., but noncompliance remained at the lower scope and severity level F, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During interview on 10/7/20 at 1:10 p.m., with the facility's infection preventionist (ICP), the ICP identified the facility was notified one resident R6 tested positive for COVID-19 at approximately 11:00 a.m. that day. The ICP reported the facility had completed their point prevalence testing on 10/5/20. R6 shared a room with her spouse R5. The facility plan at that time was to keep both R6 and R5 in their room together and implement isolation precautions. Review of the residents' electronic medical records (EMR)s identified the following: R6's nurses notes and bowel records identified on 10/5/20, R6 complained of feeling sluggish as of late. R6's only documented screening for potential COVID that day was temperature and oxygen saturation level (SpO2). Staff failed to document or notify the ICP or director of nursing (DON) of R6's malaise as a potential sign and symptom (s/s) of COVID-19. On 10/7/20 at 3:15 p.m., R6's family member was notified of R6's positive COVID-19 results. Staff documented she had no signs and symptoms besides the diarrhea and headache which staff indicated was normal for R6. R6's bowel records identified staff had not documented any diarrhea like bowel movements from 9/28/20 to 10/8/20. There was no documentation to support staff had notified the medical provider of R6's s/s, nor documented R6's symptoms of headache and diarrhea in the medical record. The staff had only recorded temperature (T) and oxygen saturation (SpO2) in all resident screenings. During observation on 10/8/20 at 9:02 a.m., R6 had a sign on her door (respiratory precaution) with a table outside the room with directions for donning PPE. There was also a sign in sheet to enter R6's room with date and time, and a box of masks on the table. There was a box of face shields on the floor next to the room. The door to R6's room had a rack hanging on it with PPE supplies including gowns and gloves. R5, the husband to R6, was observed to have a room next to R6. There were no identified precautions on R5's door and no designated supplies outside of his room. During interview on 10/9/20 at 7:45 a.m., housekeeper (HSKP)-A identified R6 was the only resident on precautions on the River Road wing. HSKP-A stated rooms where residents were isolated, were the rooms they cleaned last, using a bleach mixture. Housekeeping staff must gown when going in and put on an additional mask. R5's nurses notes identified on 9/27/20 at 1:14 p.m., R5 had two incontinent stools, one diarrhea. R5's bowel documentation identified during the day shift on 10/6/20, R5 had loose stools/diarrhea. The nurses' notes indicated on 10/8/20, R5 again experienced diarrhea. There was no documentation in R5's medical record that R5 had been placed on precautions when he exhibited these symptoms consistent with COVID. During observation on 10/8/20 at 9:19 a.m., nursing assistant (NA)-A entered R5's room with a mask and eye goggles on, staff put on gloves once in R5's room. R6 came to her door peeked her head out around the corner into R5's room and asked staff, Are you getting him up? let him sleep longer. NA-A turned and walked to R6 meeting her at the door and R6 handed staff her meal slip, NA-A who was wearing gloves took the slip from R6 and returned into R5's room. NA-A came back out of R5's room and tucked the meal slip under her arm as she remove her gloves and used hand sanitizer. NA-A proceed to the dining room area and placed R6's meal slip on the counter. NA-B was then observed to pick up meal slip, and moved R6's slip into the basket with the other meal slips. During observation on 10/8/20 at 10:42 a.m., R5 was up in his recliner, with his room door open. There was no sign to indicate whether R5 required precautions. On 10/8/20 at 11:52 a.m., R5 was observed sitting in the dining room at a table wearing a mask. NA-A delivered R5 his noon meal, assisted him to remove his mask and set it on the table. NA-A assisted R5 with his clothing protector and cut his meat. On 10/9/20 at 9:16 a.m., R5 was observed sitting at the dining room table with his mask off drinking coffee. A staff wearing a surgical mask was observed sitting next to R5, assisting him to cut up his breakfast. During observation on 10/9/20 at 9:34 a.m., NA-B walked with R5 with his walker back to his room. NA-B assisted R5 into his recliner and gave him the call light. NA-B left the room and the door remained open. NA-B proceeded down the hall without using hand sanitizer after exiting R5's room. During observation on 10/9/20 at 11:33 a.m., NA-B walked R5 back to his room after lunch. NA-B had no gown or gloves on while assisting R5 however, R5 had a mask on. During observation on 10/9/20 at 12:43 p.m., there was still no any signage placed on R5's door indicating precautions, nor were PPE supplies set up. During observation and interview on 10/9/20 at 11:23 a.m., NA-B entered R5's room without putting on gloves or a gown, to tell him it was time for dinner. NA-B assisted R5 to stand up and walk to the dining room with his walker. There were other resident in the dining room. NA-D stated there were a total of thirteen residents who eat in the dining room (R23, R40, R42, R45, R46, R7, R47, R49, R50, R5, R52, R54, R55). When interviewed on 10/9/20 at 11:28 a.m., RN-A stated R5 had diarrhea so they were now completing a rapid COVID test and would implement quarantined to his room. RN-A stated she was first notified of R5's diarrhea symptoms today around 11:00 a.m., and at that time had discussed the situation with the assistant director of nursing (ADON) and MD (Medical Doctor)-B who had instructed to test and isolate R5. RN-A stated the ICP (infection control preventionist) had confirmed it was okay for him to leave his room even after his wife tested COVID positive two days prior. RN-A stated R5 should have been isolated at the same time as his wife on 10/7/20, when positive results came in. During the interview, RN-A stated R5 was not in his room, and instructed NA-B to return to the dining room to bring R5 back to his room. RN-A also stated RN-B had reported the diarrhea to her as she had seen the information on the nursing report sheet about R5 having a large loose incontinent stool the day before which was abnormal for R5. RN-A was unaware of any other resident having an inconclusive test result, stating R6 had been the only resident on isolation and now R5 was being placed on isolation too. During interview on 10/9/20 at 12:48 p.m., RN-B stated she found that R5 had experienced a large loose incontinent stool yesterday, when reading the report book this morning around 9:30 a.m. RN-B stated she had notified RN-A, but was unsure of what time, because she'd been busy and was unable to find RN-A right away. RN-B stated, We discussed (R5's) symptom and his exposure, then (RN-A) went to talk to (R5's) MD-B at the attached hospital. RN-B confirmed she was the nurse on duty the day before, and stated she was unaware of R5's loose stool as it had not been reported to her. RN-B stated the NA should have reported R5's loose stool, and would have been expected to report for anyone with any type of new symptoms. RN-B confirmed the ICP had been asked if R5 was able to come out of his room after his wife tested positive for COVID-19, and stated staff had been instructed that it was okay for R5 to leave his room. RN-B confirmed as the nurse there is not a specific place to chart if a resident was screened for symptoms, such as they do with screening staff. RN-B said for the residents, they only document temperatures and oxygen saturations. RN-B stated R6 was being monitored once a day just like all other residents in the facility. R8's record indicated R8 had inconclusive test results for COVID dated 10/7/20. R8's progress note from 10/10/20 at 4:40 p.m., revealed ICP notified writer of inclusive COVID results. R8 was placed on droplet precautions until another COVID test could be performed on 10/12/20. There was no prior documentation in the progress notes regarding inconclusive results or need for precautions between 10/7/20 and 10/10/20. On 10/11/20 at 9:17 a.m., a progress note identified R8 remained on precautions for inconclusive COVID results. R8 had no s/s of COVID observed. During interview with licensed practical nurse (LPN)-A on 10/7/20 at 3:00 p.m., LPN-A stated resident screening consisted of documenting the resident's temperature and SpO2 (oxygen saturation) only. LPN-A stated staff were to observe for any other symptoms, and would document any symptoms in the resident's progress notes. She stated there was no check list of symptoms to review with the resident. LPN-A was unaware of policy or procedure identifying Centers for Disease Control (CDC) current symptoms of COVID-19. During interview on 10/7/20 at 3:13 p.m., RN-A stated nursing staff were responsible for resident screenings. RN-A stated nurses were to record and document residents' SpO2 and temperatures each morning. If a resident would have any s/s, the nurse should make a progress note identifying what those s/s are. RN-A also stated staff charted by exception, and did not routinely monitor the nursing assistant notes such as bowel records. She stated the expectation was nurse aides were to report s/s information to the nurse for further evaluation. During interview on 10/8/20 at 10:00 a.m., the ICP identified R8's COVID results had come back inconclusive, and the facility would place her on isolation since she was in a room next to R6. During an observation on 10/8/20 at 10:40 a.m., R8 was sitting up in her recliner, her door was open and there was no sign indicating required precautions. Review of infection control surveillance identified monthly logs identified resident's name, room, infection type, onset, s/s, cultures with results, antibiotic usage and classification check boxes for McGreer's, resident in facility less than 48 hours, not infection, and community or health care acquired field, followed by date resolved and precautions implemented. Data from April 2020 to current included: 1. April 2020, R56 had s/s coughing, wheezing, no T, and was COVID neg. R56 was placed on droplet precautions but it's unclear how long. R45's s/s identified she had head congestion. R45 was not documented as being placed on precautions. R57 s/s were having had a chest x-ray (CXR), increased white blood cell count and right hand swelling. R57 was placed on an antibiotic. There was no correlation for the CXR to identify if R57 had s/s of [MEDICAL CONDITION] activity or required IC (infection control) precautions. R48 had loose stools. R16 had vomiting x 3. There was no indication R57 or R16 were placed on any isolation precautions for potential COVID s/s. 2. May 2020, R3 had documented fever with s/s of urinary tract infection [MEDICAL CONDITION]. R3 was not documented as being placed on precautions for potential COVID s/s. R1 had documented fever, cough with negative COVID test results. R1 had been placed on droplet precaution at that time. R14 had documented GI bleed, norovirus, low sodium and hemoglobin. R14 had been placed on contact precaution. That was the last entry for any residents being placed on precautions. 3. June 2020, R1 s/s of RLL(right lower lobe) pneumonia, was placed on an antibiotic. R1 was not documented as being placed on precautions for potential COVID s/s. R43 had documented fever, was not documented as being placed on precautions for potential COVID s/s. R5 was identified on the line list as onset date of 6/26/20, with no documentation of what R5's s/s were or a resolved date. 4. July 2020, R59 s/s T 100.4, crackles new admit. R59 was not documented as being placed on precautions for potential COVID s/s. R60 had s/s of coughing. R60 was not documented as being placed on precautions. R3 had s/s of chills and fever. R3 was placed on antibiotic. R3 was not documented as being placed on precautions. R58 had s/s of decreased SpO2, LLL (left lower lobe) crackles. R58 was not documented as being placed of precautions. 5. August 2020, R43 s/s of pneumonia, SOB (shortness of breath), low SpO2. R43 was not documented as being placed on precaution for potential COVID s/s. R58 had documented s/s of low SpO2, SOB, and decline. R58 was not documented as being placed on precautions for potential COVID s/s. R26 had s/s documented including fever and UTI/mixed growth, which did not meet criteria. R26 was not documented as being placed on precautions for potential COVID s/s. 6. September 2020, R26 had s/s of fever and diarrhea. R26 had documented [DIAGNOSES REDACTED] and there was no documentation to indicate whether R26 had been placed on precautions. 7. October 2020, R6 documented COVID positive test date 10/5/20, contact precaution until 10/14/20, and had no symptoms documented at that time. Review of the Quality Assurance Performance Improvement (QAPI), quarterly summarized infection control surveillance reports identified total number of infections, number of healthcare acquired infections (HAI), and type of infection. In: 1. April 2020, identified total number of infections as one, HAI infections one, urinary tract infection without catheter as one, shingles as one. The monthly report contained numbers data but lacked any type of summary. 2. May 2020, identified total infections three, HAI infection as three, urinary tract infection with out catheter as one, upper respiratory tract infection as one, gastrointestinal infection as one. The monthly report contained numbers data but lacked any type of summary. 3. June 2020, identified total infection of two, HAI infections two, urinary tract infection without catheter as one, lower respiratory infection as one. The monthly report contained numbers data but lacked any type of summary. 4. July 2020, identified total infections as four, HAI infections as four, urinary tract infection without catheter as three, lower respiratory infection as one. The monthly report contained numbers data but lacked any type of summary. 5. August 2020, identified total infections three, HAI infections as three, urinary tract infection without catheter as two,[MEDICAL CONDITION] as two, lower respiratory infection as one. The monthly summary identified two urinary cultures came back with proteus (proteus mirabilis, a gram-negative bacterium) and plan will be to watch for a trend. 6. September 2020, identified total infections three, HAI infection as three, urinary tract infections without catheter as one, gastrointestinal as one, lower respiratory infection as one. The monthly summary identified two more urine cultures came back with proteus, met with environmental services staff about contact time and cleaning bathrooms. Verified cleaning solutions used are appropriate. PPE audits were increased, hand hygiene also was emphasized with staff. There was no mention QAPI had been alerted to [MEDICAL CONDITION] activity after May 2020 for suspect COVID symptoms. During interview on 10/8/20 at 8:52 a.m., LPN-B stated resident screenings were completed once a day in the morning. LPN-B stated the screenings consisted of checking the resident's oxygen saturation and temperature with that being documented in the resident's medical record on the computer. LPN-B identified other symptoms of COVID-19 included shortness of breath or anything that was out of ordinary for that resident. During interview on 10/8/20 at 1:12 p.m., with the ICP, the ICP stated the nurse monitors the resident's T and SpO2 reporting anything out of the ordinary to the medical provider. Further, she stated staff update the ICP if a resident had any other symptoms. The ICP stated staff completing the screening should be asking the resident and/or staff if there are other symptoms of COVID and document that. Further, she verified there was no formal guidance for staff to refer to on current CDC symptoms of COVID-19 available for them to refer to. During follow up interview with the ICP on 10/9/20 at 8:50 a.m., the ICP stated the facility started to document staff screenings in their computer system in September 2020. The ICP said for staff who are on leave because of COVID symptoms, or exposure, the staff symptoms had not been documented but a risk assessment had been completed. R48 stated during interview on 10/9/20 at 9:38 a.m., that staff come in and check her temperature each day but she does not recall anyone asking her any questions about how she feels. R48 stated, They just check my temperature and tell me it is good. During interview on 10/9/20 at 9:45 a.m., trained medication aid (TMA)-A stated if a resident had signs and symptoms of COVID, the nurse would be notified and the resident would be isolated to their room until tested . RN-A stated during interview on 10/9/20 at 10:13 a.m, that residents are screened each morning. They get their T and SpO2 checked and documented each morning. If they would have other symptoms such as diarrhea, cough, or a temperature greater than 100.4, a complete assessment would be done and we would implement standing orders, keep resident in their room and update the provider. The ICP confirmed during interview on 10/9/20 at 1:45 p.m., she was responsible to determine if a resident would need to go on isolation. She stated the charge nurse would contact her and they would discuss the situation and make the determination. For a resident to come off of precautions that determination is made by the medical provider. New admissions are kept in isolation for 14 days unless they are admitted from the facility's attached hospital. Hospital returns from our attached hospital do not require a fourteen day quarantine. If a resident came from an outside hospital they would need to be tested for COVID before coming, if they had symptoms of cough,or fever greater than 100.F, we would contact the provider and they would be put on isolation. The ICP was unaware of what the resident screening process consisted of each day, she reported she does not review the resident screening information and was unsure what data staff were using for screening. The ICP stated she was verbally informed at interdisciplinary team meetings (IDT) of resident illnesses. The ICP had not routinely reviewed resident progress notes as a way of auditing information, but stated the verbal information presented at IDT meetings would be added to her surveillance form. The ICP confirmed if an illness was not reported at IDT or directly, she would be unaware of any potential s/s of COVID. She stated she had been bombarded now for a few months and had not completely filled out the surveillance forms. The ICP agreed [MEDICAL CONDITION] activity, especially COVID symptoms, was missing. She revealed if she had not been so busy changing policies and doing other things she would be reviewing the surveillance information daily but at this time she was only reviewing it 1 x month. She stated she does not review any ongoing surveillance for residents as that would be each nurse's responsibility. The ICP verified R5 had been isolated as of 10/9/20, and agreed R5should have been isolated on precautions right away when his wife, R6, had tested positive for COVID. When interviewed on 10/9/20 at 3:08 p.m., MD-A confirmed R5 should have been isolated with droplet precautions implemented for his high risk exposure alone, and especially when he had symptoms. MD-A stated residents like R8, with an inconclusive test result, should also be treated like a positive COVID patient until that person can be retested , and precaution should be in place. MD-A stated he would expect the facility to follow the Centers for Disease Control (CDC) guidelines for COVID. During interview on 10/9/20 at 3:43 p.m., the administrator (A) stated she expected residents to be screened each day in the same manner as staff, including a T check, and assessing and asking questions about symptoms and documenting either the presence or absence of those symptoms. The administrator stated if a resident had a symptom, management was to be notified right away. She stated, on 10/8/20, management was updated R5 had diarrhea with a known exposure to R6, so he was tested and will be quarantined until his results come back. Our process may not be as hard wired as it should be as this is our first positive case in the facility. Further, she verified they have one person who is the ICP, who is also the lab person between the hospital and care center. There is room to grow. I would expect isolation and precautions to have occurred immediately for (R6) and (R5). The administrator also stated R5's need for assistance with eating was the reason he had been out in dining room however, she confirmed he should not have been out of his room. The administrator confirmed both R5 and R6 should have been isolated with droplet precautions immediately, and said the resident with inconclusive test results should be retest and be monitored for symptoms. Staff should assume a person with inconclusive results to be positive until a negative test result, then we need to change our process and that involves our medical director. Interview on 10/9/20 at 4:52 p.m., with director of nursing (DON) identified she was unsure why staff did not implement PPE and isolation for R5 right away after R6 had been confirmed positive with COVID since they shared a room together. Review of the facility's August 2020, Communicable Disease Surveillance and Reporting Policy, identified the purpose was to establish a procedure for reporting, monitoring, analyzing and controlling disease. The policy focused on reporting to the Minnesota Department of Health by phone, mail or fax and what to report and when. The policy lacked information on how surveillance would be documented, who would document, how tracking and trending would be completed, or if interventions would be implemented to control an outbreak of identified illness. There was no direction on how often data of illnesses would be documented or reviewed. Review of facility's Infection Control Committee Function/Structure Policy dated 8/2020, identified the committee met quarterly and provided oversite with organizing, planning, monitoring and maintaining elements of the infection control program. The ICP will be the chairperson of the committee and the surveillance officer responsible for preparing, reviewing, implementing, monitoring, and reporting to the committee. Review of the facility's COVID-19 policy dated 10/2020, identified staff were to minimize exposures and promptly identify residents with clinical features and risks, and adhere to standard, contact and droplet precautions. The policy further indicated staff were to place residents with known or suspected COVID (with symptoms) in their room with door closed initiate contact/droplet precautions and limit only essential personnel to the room with appropriate PPE and respiratory protection. The policy lacked identification staff would complete daily resident screening which included temperature, oxygen saturation and interview/assessment to determine any signs or symptoms of COVID-19 with findings documented. Review of the facility's October 2020, COVID-19 Screening Policy identified residents enter through a designated entrance. Screening included fever and respiratory symptoms (cough, shortness of breath). If patient's temperature exceeds 100.4 or has a combination of any symptoms listed, they will be asked to exit the building and be seen curbside respiratory clinic. The policy did not include the most up to date information from CDC guidance, the policy did not include direction for screening of residents of the long term care facility. The IJ was removed on 10/11/20 at 10:54 a.m., when it could be verified by observation, interview and document review, the facility had implemented all necessary TBP, reviewed and revised policies and procedures, implemented thorough monitoring of resident signs and symptoms of COVID-19, educated the nursing department on current CDC guidance and reporting signs and symptoms, and had updated surveillance processes for daily review by ICP, DON or a designee, with consult with an on-call provider if indicated for direction.

Based on observation, interview and document review, the facility failed to implement measures to prevent falls for 1 of 5 residents (R1) who used an electric lift chair. R1 sustained actual harm when she fell out of the electric lift reclining chair sustaining multiple fractures. Findings include: R1's 8/5/20, Minimum Data Set (MDS) assessment identified she had [DIAGNOSES REDACTED]. She required extensive assist of 2 staff to transfer, toilet and to assist with bed mobility. The MDS indicated R1 was unsteady with positional changes and required staff assist to steady her, and indicated R1 had not had any falls in the prior 3 months. R1's 9/29/20, care plan identified she required extensive assist of 1-2 staff and an EZ-Stand (mechanical sit to stand lift) for transfers. On 9/28/20 the care plan had been updated to include use of a lift chair. Per the care plan, R1 had been determined to be unsafe to use the lift chair independently. Care plan interventions had been revised to indicate staff were to place the remote in the side pocket of the chair. R1's lift chair safety assessment 11/8/19, identified she was unable to sit upright unsupported, reach for the power control, manipulate the power control. She was unable to stand without physical assistance and required the use of an assistive device. The assessment indicated R1 was cognitively impaired and unable to operate the lift chair even when given cues and concluded that R1 required total staff assistance to operate the lift chair. An incident report from 9/25/20 at 4:39 p.m., identified R1 was found on the floor next to her recliner with a large cut on her forehead and was bleeding from the nose. She was having pain and vital signs were unable to be obtained. Staff transferred her onto a backboard and a gurney and she was taken to the emergency room (ER) of the hospital. The incident report indicated R1 had been sitting on the remote for the recliner chair causing it to raise up and she fell out of the chair. Review of the 9/25/20, radiology reports identified R1 had sustained a left humeral neck fracture with impaction and mild offset angulation, and trimalleolar fracture which included right distal fibula, with medial and posterior tibial malleolar fractures. Review of the 9/25/20, emergency room notes identified R1 had a Y shaped laceration to the forehead, with the area measuring 3.4 centimeters (cm) and the shortest measuring 1.5 cm. The area was sutured with 9 stitches. The notes also indicated R1 was noted to have fractures of the distal fibula, medial and posterior malleolar, trimalleolar fracture with no significant dislocation and a posterior splint with ace wraps had been applied. R1 had a [MEDICAL CONDITION] neck of the left arm with mild offset, impaction and angulation and was placed in a sling to immobilize the left shoulder. She had then been admitted to the hospital for adjustment of pain medications. The notes indicated R1 had been brought to the ER after being found lying on the floor of her room. The staff had stated they believed the lift chair remote had been stuck underneath the resident in the chair, and ended up raising the chair to the point that either she attempted to self transfer or she fell forward out of the chair landing on her face, at which time she had cried out for help. Upon arrival to the ER R1 was complaining of severe pain to the left shoulder, right hip and right ankle. The ER notes indicated she had obvious deformity to the left shoulder and right ankle, had a 3.4 cm x 1.5 laceration to the forehead, and had a [MEDICAL CONDITION] ankle and humeral neck (arm). R1 was admitted to the hospital and [MEDICATION NAME] (a narcotic pain medication) had been initiated. A computerized tomgraphy (CT) scan of the head was obtained and surgical interventions were not pursued due to her comorbidities. Review of the hospital progress notes identified the following: 1. 9/26/20, R1 had continuing pain that was not controlled and the pain medication was increased. 2. 9/27/20, R1 continued to have pain that was not controlled especially when staff were providing cares and pain medication was changed to [MEDICATION NAME] (another narcotic pain medication). She had acute [MEDICAL CONDITION] 3. 9/28/20, R1 had [MEDICAL CONDITION] since admission. Suspect occult (GI) blood loss, however even if R1 had occult bleeding she was not a surgical candidate. Staff would continue to try to get her pain under control with a possible move back to the facility on [DATE]. Review of the 9/29/20, hospital discharge summary identified R1 also likely had a significant concussion. She had a general decline in her mental status with increasing lethargy and somnolence. She had a decrease in her hemoglobin. As her condition worsened she developed progressive [MEDICAL CONDITION] (kidney function decrease). Discussion was held with family, given her age and comorbidities, hospice was agreed upon and she was admitted to hospice and returned to the nursing home. R1's progress notes on 9/29/20 2:00 p.m., hospice registered nurse (RN) visit made to admit to routine hospice cares. R1 had been resting in bed. Eyes were open and she sucked at sponge when mouth was moistened. [MEDICATION NAME] (a narcotic pain medication) was ordered for pain to be given prior to repositioning for pain control. R1's progress note 9/29/20 at 2:37 p.m., identified that she returned from the hospital at 1:00 p.m. and was transferred into her bed. She responded to her name. Multiple bruises were noted to right arm, left arm and face from incident on 9/25/20. She had a sling to her left shoulder and a cast to the right lower leg. R1 grimaced and moaned when repositioned. She was resting quietly in her room at 2:00 p.m. At 2:15 p.m. she was noted no respirations or pulse. The assistant director of nursing (ADON) was interviewed 10/6/20 at 12:57 p.m., the ADON stated the lift recliner had not been addressed on R1's care plan at the time of the incident. However, following the incident it had been added, and all other resident's with lift chairs had their care plans reviewed to assure they were accurate with the most current lift chair assessment. In addition, the ADON stated all chair remotes were marked with tape to indicate who was able to safely use the chairs and who was not. An undated staff note identified that lift chair remotes had been marked with colored tape. The different colors were intended to ensure all staff were able to identify if a resident should have help using their lift chair or if they could use it independently. Red tape indicated staff were to stop and assist the resident, and to place the remote out of reach in the side pocket or behind the chair, or if needed to unplug the chair. Yellow tape indicated the staff were to use caution and supervise the resident while using the chair and to place the remote out of reach if they were not using it safely. Green tape indicated the resident was safe to use the lift chair remote independently and no assist was needed. When interviewed on 10/6/20 at 1:16 p.m., licensed practical nurse (LPN)-A identified she had been alerted to R1's room by staff. Upon entering the room, she said R1 was on the floor and the RN and nursing assistants were attempting to stop the bleeding from R1's forehead. LPN-A stated they attempted to perform vital signs but R1 was too uncomfortable. They then transferred R1 to a backboard and to a gurney, and she was quickly brought to the attached ER. After transferring her to the ER, LPN-A stated she noted the lift chair to be approximately halfway elevated. LPN-A stated they though R1 had the chair remote to the side of her in the cushion in the chair, and when she had shifted her weight had landed on it causing the lift chair to elevate, and resulting in a fall out of the chair. LPN-A stated due to R1's dementia, she would not have been able to safely operate the remote. LPN-A further stated lift chair assessments were completed by the rehab nursing assistant and were reviewed and placed on the care plan by the RN. LPN-A said if she had questions regarding safe use of the lift chair she would have referred to the care plan. If she were to note a change in a resident's abilities, she would notify therapy to evaluate. Nursing assistant (NA)-A stated during interview on 10/6/20 at 1:49 p.m., that on 9/25/20 at approximately 12:30 p.m., he had assisted R1 into her recliner after her meal. NA-A said he believed he'd placed the lift chair remote in the side pocket of the chair, but was uncertain. He said he had placed the call light on R1's chest. He left the room with R1 in a reclining position. NA-A stated, prior to the supper meal he was called to the room to assist. R1 was on the floor and after the nurse assessed her, he assisted to get her onto the gurney to go to the ER. NA-A said if a resident was not to use a lift chair without assistance it would be noted in their chart. He stated if he was unsure, he would check their Kardex. NA-A stated he had worked daily since the incident and was unaware of any changes that had been implemented to prevent reoccurrence. He was unaware of tape being placed on the remotes and did not know what it meant. During interview on 10/6/20 at 12:38 p.m., NA-C stated there was now tape on the remotes for resident lift chairs to identify assistance required. Red meant stop, and to put the remote behind the chair or in the side pocket; Green meant it was ok to use independently; and NA-C stated she was unaware what the yellow tape indicated. During interview on 10/6/20 at 2:01 p.m., NA-B stated she was called into R1's room to assist the day of the fall. The RN and physical therapy assistant (PTA) were in the room. R1 was lying face down on the floor and complained of pain in her shoulder. LPN-A asked NA-B to assist, and NA-B put pressure on the gauze applied to R1's [MEDICAL CONDITION]. She then assisted in transferring R1 onto a backboard and onto the gurney to go to ER. NA-B stated R1's recliner was in the corner of the room, and was elevated to about halfway up and the remote was dangling from the arm of the chair. NA-B stated lift chair assessments were performed on admit, annually, and with significant changes in condition. If unaware of residents' safety with the use of a lift chair, staff could view the care plan and NA's were able to view that on the Kardex. NA-B said R1's assessment was current and she was determined to be unsafe with use of the lift chair. NA-B was unaware that information was not care planned. NA-B further identified she had implemented the tape system with the remotes. All remotes were to be marked with red, yellow, or green tape so staff would be aware of whether or not a resident was safe to use the lift chair remote. Green means they are safe, yellow they are safe only with supervision, and red the resident is unsafe to use the lift chair remote and staff are to place it out of sight. NA-B stated the information was given to the nursing staff to discuss in shift to shift report. The information was also placed in a communication note in the electronic charting system. There is no documentation to support all staff were educated on the new process. Interview on 10/6/20 at 2:14 p.m., with the physical therapy assistant (PTA) identified she had been walking down the hall on the day of R1's fall, when she heard help me, entered R1's room and noted her to be face down on the floor between the recliner and her bed. PTA stated she immediately called for nursing help. PTA confirmed R1's lift chair was elevated approximately half way up and the remote was hanging out of the chair and R1 appeared to have rolled out of the chair to the right. RN-A stated during interview on 10/7/20 at 8:56 a.m., on the day of R1's incident she had been in the hall and heard someone yell for help. She entered R1's room and noted her to be face down on the floor and angled a little to the right. The lift chair was about halfway up and she believed the remote to be wedged between the cushion and the side of the chair. She was unaware of what R1's lift chair assessment or care plan identified but stated lift chair assessments were done annually. When she checked R1's care plan after the incident, she verified there was no information in the care plan regarding the lift chair. R1 was not someone who had used the remote in the past and that is why RN-A believed her to have sat on it causing it to lift up. Interview on 10/9/20 at 9:18 a.m., ADON identified after R1's fall it was noted that the care plan did not identify that R1 used a lift chair or that she was unsafe according to her assessment. She created a list of all residents with lift chairs and reviewed to assure care plans were accurate to the lift chair assessment. Education the staff note regarding the color coded tape on the chair remotes was given to the nurses to pass on in report and were placed in the report books. A note was also placed in point click care to notify staff. There was no system in place to assure all staff were educated on this system. No audits had been initiated to assure the process was effective and tape was on the remotes. Review of the facility's September 2020 Lift Chair policy, verified use of lift chairs were to be evaluated by an RN or OT (occupational therapist) for safety. If determined unsafe, the interdisciplinary team was to develop interventions for safety while the chair remained in a resident's room. Results of assessments were to be documented on the resident's care plan.

Based on interview and document review, the facility failed to implement their policy to initiate cardio-pulmonary resuscitation (CPR) for 1 of 16 residents (R1) who had requested to be a full code status, meaning the resident wanted life-saving interventions implemented. The deficiency was identified as past non compliance and issued at Immediate Jeopardy (IJ). The IJ began on [DATE], when the facility failed to provide CPR for R1 after R1 became unresponsive during care and her heart stopped. However, the facility had implemented corrective action to prevent recurrence by [DATE]. The facility had conducted a root cause analysis with the resident's physician, corrective action was proivded to the licensed nurse involved, each resident's chart was reviewed to verify code status. In addition, facility policies had been reviewed for adequacy. Staff education had also been implemented to ensure each shift of staff understood the facility's policies, and drills were established for staff to verify appropriate response. Findings include: The American Heart Association's (YEAR) guidelines for cardio-pulmonary resuscitation indicated while the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION] (lack of pulse), there were a few exceptions where withholding CPR would be considered appropriate: -Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril. -Obvious clinical signs of irreversible death (e.g., rigor mortis (stiffening of muscles), dependent lividity (pooling of blood in the lowest lying part of the body due to gravity), decapitation (separation of the head from the body), transection (cut across body causing body separation), decomposition (decay of the body). -a valid advanced directive, Provider Orders for Life-Sustaining Treatment (POLST), or order indicating do not attempt resuscitation R1's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R1 had no cognitive impairment, required extensive assistance with activities of daily living (ADLs), and received physical therapy to help regain strength and mobility. R1's discharge goal was identified to return to an independent living center. R1's [DIAGNOSES REDACTED]. R1's [DATE], physician orders [REDACTED]. Review of R1's [DATE], POLST (physician orders [REDACTED]. Follow these orders until order changes. These medical orders are based on the patient's current medical condition and preferences . The POLST was signed by R1 and her primary physician [DATE]. Review of R1's progress notes dated [DATE], included (1) Shortly before 4:00 a.m., nursing assistant (NA)- A answered R1's call light. R1 was assisted to the bathroom. While voiding, her speech became garbled. NA-A identified R1's speech returned to normal moments later. R1 then stood up and walked towards her bed and stated, I am so sorry. R1 became limp and NA-A lowered her to the floor. NA-A called for help. When licensed practical nurse (LPN)-A arrived R1's lips were blue and she was foaming at the mouth, was totally limp and unresponsive. R1 was not breathing and had no pulse. (2) No activation of the emergency medical services (EMS) was initiated, and no resuscitative measures were attempted. R1 was pronounced dead at 4:05 a.m. when an unidentified RN, who was working at the adjacent hospital, came from the hospital and verified R1 was pulseless and without breath. (3) Family, the director of nursing (DON) and the physician on call were notified and R1's body was released to the funeral home. Family member (FM)-B was interviewed on [DATE], at 1:33 p.m. with regard to the incident on [DATE], at 4:00 a.m She indicated she had received a telephone call at 4:40 a.m. from FM-A of the death of R1. FM-B denied any knowledge of R1 having any history of cardiac issues. At the time of admission to the facility she was having some shortness of breath, (SOB) but her physician felt it was due to her anxiety. R1 was not having difficulty with her health and was progressing with her therapies and gaining strength. R1 made her wishes previously known to family, and advised them she hade wanted CPR in an emergency. FM-B had arrived at the facility that a.m., shortly after R1 passed away. LPN-A entered R1's room stating she was sorry for their loss, revealing We did not perform CPR on (R1) . we didn't even attempt it. In addition, FM-B stated an unknown resident, who knew R1 well, had reported to FM-B he had visited with R1 the night before and she was doing very well. FM-B also said the resident had told FM-B, he had been awake when the incident occurred and had seen NA-A walking with R1 from the bathroom. He reported R1 fell to the floor with her back against the bed and had heard staff say, She is coding. FM-B said the resident had told FM-B he saw no CPR performed. RN-A was interviewed on [DATE], at 2:55 p.m. and stated she works primarily evenings and nights with the usual staffing pattern consisting of 1 licensed charge nurse for the building and four NAs. RN-A stated she was aware of R1's CPR status. A resident's CPR status is able to be identified by the listing at the top of the resident profile, and outside every resident door based on the sticker beside each resident's nameplate. RN-A stated she was not aware there was a POLST' placed in the closet in each individual resident's room. RN-B was interviewed on [DATE], at 3:11 p.m. and stated she attended monthly care conferences. RN-B stated Advance Directives/POLST documentation was reviewed at every care conference to ensure it remained accurate. RN-B stated in the circumstance where a resident is not cognitively able to voice choices with regard to resuscitative measures, the paperwork is sent to the responsible party for review and signature. Upon receipt, CPR status was documented in the electronic medical record (EMR), resident profile, and on the outside of the room nameplate via a red or green colored sticker. In an emergency, staff would quickly check the name plate on the door frame, or the computer if it was close to the room. In addition, RN-B verified only licensed staff were certified in CPR. NA-C and NA-D were interviewed on [DATE], at 3:32 p.m. and confirmed they were not certified in CPR at the facility, but that only licensed nursing staff were certified. They stated, if a resident became unresponsive they would immediately notify the nurse and stay with the patient until the licensed staff arrived. Both NAs stated residents' code status is listed in the Kardex which is available via the communication phones that staff carry. The NAs stated they could also ask the nurse what the resident's status was and in the instance of a new resident, or a change, it would be communicated verbally at the time of shift report. LPN-B was interviewed on [DATE], at 3:40 p.m. and verified she primarily worked charge for 12 hour day shifts. LPN-B said if a resident became unresponsive, she would lower to the floor, check for breathing, initiate CPR based on assessment and code status, and activate EMS. If the resident had a no code status ( DNR/DNI) she would assess the patient, notify the MD, family and determine their wishes. When asked how she would determine a resident's code status, LPN-B stated a colored Star are located on door and green= CPR and Red = No CPR. In addition they also include code status on PCC profile and in paper chart. LPN-B said she would first check the identified sticker on the door in an emergency. The POLST is competed with admission and the code status is also in the physician's orders [REDACTED]. The director of nursing (DON) was interviewed on [DATE], at 3:54 p.m. and verified only licensed staff were certified for CPR and use of the AED (automated external defibrillator) located in the main entrance/lobby of the facility. The DON verified signage on use of the device is clearly posted on the wall beside the AED. Her expectation was staff were to follow facility policies and procedures in the event of an emergency. In the instance of the absence of breathing and pulse, if the resident was listed as wanting CPR, staff would activate the EMS system and initiate CPR. In addition the occurrence of an incident requiring activation of the EMS should have had an incident report completed and submitted according to facility policy. FM-A was interviewed on [DATE], at 7:44 p.m FM-A indicated R1 had been admitted for strengthening and mobility following a leg fracture. FM-A said prior to her leg fracture, R1 lived in a home setting and was independent with her activities of daily living. FM-A stated R1 had progressed from requiring 1 person standby assist for ambulation, and had graduated with therapies to the ability to be independent in her room and standby assist for ambulation in the hall, was alert and oriented, able to make her own decisions and directed her care. FM-A said R1's goal was to be discharged back to her residence within the month of June. FM-A said she had received a telephone call on [DATE], at 4:39 a.m. from LPN-A who informed her R1 had been assisted to the bathroom by a NA and had started speaking incoherently, but her garbled speech resolved quickly and staff escorted R2 back to bed. LPN-A advised FM-A they had lowered R1 to the floor. R1's lips turned blue and she was dead. FM-A stated LPN-A had offered condolences and told her the DON had been notified. FM-A further reported that family members had gone to the facility on [DATE] to collect R1's belongings. FM-A was shown a document that FM-C had retrieved from the closet door. That document was a POLST which indicated R1 wanted CPR-and/or full medical treatment. FM-A said she had not been informed that CPR hadn't been initiated. FM-A said she'd returned to the facility on [DATE], where she was approached by LPN-A who had said she was sorry. LPN-A confirmed to FM-A, R1's lips turned blue. FM-A said LPN-A had told her she hadn't initiated CPR because she didn't feel it would do any good. FM-A knew her mother wanted CPR and asked LPN-A if that had changed. LPN-A replied. LPN-A reported to FM-A, R1 was in fact still CPR status but it wouldn't have saved her in LPN-A's opinion. FM-A stated on [DATE], at approximately 11:00 a.m. she had requested a meeting with the DON to discuss questions she had related to R1's death. FM-A proceeded to repeat the information LPN-B had told her on [DATE], with regard to the sequence of events which had taken place on [DATE]. FM-A stated she told the DON, LPN-A told her she had not initiated CPR because she hadn't felt it would do any good. FM-A stated she had then asked if the DON if she had been aware of the rational that LPN-A stated as the reason for not initiating resuscitative measures for R1, to which the DON replied, yes. FM-A said she had then asked why no one had said anything to her or anyone in the family about this. FM-A said the DON had told her the medical director (MD) had reviewed R1's medical record following the incident. Per FM-A's request a meeting was arranged for [DATE], at 12:00 noon. At the time of the meeting, FM-A said she'd requested FM-C be included in the meeting via telephone. FM-A reported FM-C had asked why CPR was not administered and the medical director had replied he was sorry, and stated maybe the nurse froze. FM-A said the MD also reported having reviewed R1's medical record, and had reported R1 had experienced previous episodes of unresponsiveness while at the nursing home. MD then asked if either FM was aware of R1 having any of these (syncopal) episodes while at home, to which both FM-A and FM-C had responded their mom would get dizzy, but they had no recollection of any spells of unresponsiveness. LPN-A was interviewed on [DATE], at 10:37 a.m. and verified she had worked at the faciltiy 5 years on the over night shift. LPN-A said she had a current CPR certification which included use of the AED, but she had not ever had to perform CPR or attempt to utilize the AED. LPN-A then described the location of the AED in the main lobby area which included directions on the use of the device posted on the wall beside the unit. LPN-A was asked to review the sequence of events with regard to R1. On the night of [DATE]: (1) Staffing on the night of [DATE] was herself as the charge nurse and 2 NAs. 2.) Around 4:00 a.m. she was toileting another resident when she received a text from NA-A that R1 was on the floor. She messaged the NA back she would come when finished toileting the resident she was with. There was no sense of urgency in the text message she received. 3.) LPN-A proceeded to R1's room and observed R1 lying on the floor on her left side with a pillow beneath her head. NA-A and NA-B were standing in the room looking at R1. LPN-A stated the NAs thought R1 was having a behavioral episode. 4.) LPN-A stated she'd bent over R1 and attempted a sternal rub, to which R1 usually responded by regaining orientation with her past history of syncopal episodes at the facility. R1 opened her eyes and was breathing through her mouth. R1 was not verbally responsive and her skin color was pale. LPN-A noted R1 had some foam around her mouth. 5.) LPN-A attempted to sit R1 upright, and her head fell forward and she had no muscle tone. LPN-A looked at the 2 NA's and stated, she's dead. 6.) LPN-A checked for a heart rate and didn't find a pulse, so she went to retrieve a stethoscope and contacted the RN on duty at the hospital. LPN-A failed to begin CPR as outlined in the policy. She returned to R1's room, listened for a heart beat, and did not find one. 7.) The hospital RN was called. When she arrived, she verified there were no signs of life for R1. 8.) LPN-A began the appropriate notifications to family, physician and management. Further interview with LPN-A identified she was aware of R1's code status, but stated it had been approximately ,[DATE] minutes from the time she was notified via text message to the time she arrived at R1's side. When asked why she hadn't initiated CPR or initiated EMS when R1 had a full code status, LPN-A stated she was gone too long. LPN-A was aware of the faciltiy policy which included the signs of irreversible death which included rigor mortis and coldness. She confirmed neither of these conditions were present when she'd arrived at R1's bedside. NA-B was interviewed on [DATE], at 12:11 p.m. and indicated she had been employed since (MONTH) (YEAR), and commonly worked the night shift. NA-B had been on duty the night of [DATE] and was assisting a resident in a different room when she received a page that help was needed in R1's room. Upon her arrival at R1's room, she observed R1 on the floor and NA-A was telling her to get up. There was no response from R1. She had foam around her mouth. NA-B instructed NA-A to call the nurse and had proceeded to turn R1 onto her side to assist with opening her airway. LPN-A responded to the room, and turned R1 onto her back, LPN-A was rubbing R1's sternal area NA-B had been advised to call the adjoining hospital and get a nurse over here. NA-B said LPN-A left the room and went to call the hospital nurse. NA-A and NA-B were left in attendance with R1 and no resuscitative measures were implemented as only licensed staff were allowed to perform CPR. NA-B stated the hospital RN responded, assessed R1 and stated she was gone. NA-B stated she was not currently certified in CPR, but had asked NA-A what R1's code status was. NA-A responded she was unaware. NA-B instructed NA-A to go look on the door. NA-A did and reported to NA-B CPR was indicated. LPN-A then entered the room, looked at R1 lying on the floor and commented she is a full code. Neither the EMS or CPR were initiated following R1's emergency by any staff. The facility Administrator was interviewed on [DATE], at 12:45 p.m She indicated she had been notified of R1's death via text at 9:54 a.m. by the DON. R1 was to have been a full code. On [DATE] she received a phone call with a follow up email notifying her of a plan for a family meeting. The administrator stated her expectation was that care and services would be provided according to the facility policies and standards of nursing practice. The EMS system should have been activated at the time of the incident. Following discussion with the DON it was decided the incident should be reported. The incident which occurred on [DATE], was first reported to the State Agency [DATE]. The medical director (MD) was interviewed on [DATE] at 1:00 p.m,. and confirmed his expectation a resident whose POLST/Advance Directive indicated a full code status should receive necessary lifesaving treatment. MD stated following this incident, there had been discussion with staff, the best chance scenario would have been to initate CPR, and obtain and utilize the AED. The MD indicated without those measures, there would be no chance of survival. The MD was aware of some syncopal episodes fro R1, but there was nothing in her medical history that would indicate R1 was at risk for sudden death. He said he had not learned about the incident until the following day and it had been disappointing to hear. MD stated, If CPR had been initiated, it would have been (R1's) best chance. He had told R1's family there was no excuse for what had happened. It was a mistake, and we are doing our best to insure it never happens again. Review of the facility's (MONTH) (YEAR), CPR/CODE Status policy , the facility policy included: To provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED]. Further, the policy indicated the care center was to have at least one staff member on duty at all times, who is trained in single rescuer adult CPR and who has completed the initial training, or a refresher course, within the previous two years. The policy indicated CPR certification would be obtained through training that included hands-on practice and in-person skills assessment. A staff member, properly trained in CPR, will be available immediately to provide basic life support to residents requiring emergency, prior to the arrival of EMS and subject to accepted professional guidelines, the resident's advance directives, and physician orders. Review of the facility's professional guidelines from The American Heart Association (AHA)included: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of EMS in accordance with the resident's advance directives and any related physician order, such as code status, or in the absence of advance directives or a DNR order. The past non-compliance that began on [DATE], was verified during the ,[DATE]-[DATE] onsite visit to have been corrected by [DATE]. Verification of corrective action was confirmed by interview with a variety of nursing staff, interview with the medical director, review of progress notes, and documentation of staff training. In addition, facility policies were reviewed and audits had been scheduled.