Every finding on record at Prairie View Senior Living

Based on observation, interview, and document review, the facility failed to facility failed to maintain surveillance of staff illness for preventing, monitoring and investigating illnesses to control infections for 1 of 1 infection control program. This had the potential to affect all 41 residents. The facility also failed to appropriately clean, rinse, and air-dry nebulizer apparatuses (mask, cup) after medication administration for 3 of 3 residents (R9, R14 and R21) and ensure 3 of 3 observed stand lifts, located in the 200 and 300 wing were appropriately cleaned between resident use. Findings include: SURVIELLANCE Review of the 2024-2025 Norovirus Information for Long-term Care Facilities, located at, https://www.health.state.mn.us/diseases/foodborne/outbreak/facility/ltcfnorotoolkit.pdf, identified Norovirus is transmitted through a fecal (stool)-oral route with symptoms of diarrhea, vomiting, nausea, abdominal pain, low grade fever, headache, and or body aches. Individuals generally become ill 12-48 hours after exposure (swallowing Norovirus). Infected individuals shed the virus in their stool and contaminate food, surfaces, and objects and can be shed in the stool for several weeks after recovery. Products used to clean Norovirus must say they are effective against Norovirus. Hand sanitizer does not work to kill the virus. Individuals should wash their hands for 20 seconds with soap and water. Individual cases of Norovirus are not reportable to the State, however, possible outbreaks or multiple cases with Norovirus-like symptoms must be reported. Documentation of possible outbreaks was to include: Use the RESIDENT ILLNESS LOG and STAFF ILLNESS LOG to document illnesses among staff and residents/patients: Contact managers of each unit, etc. as necessary to gather illness information. Send both ILLNESS LOGS back to MDH within 2 business days of reporting the suspected outbreak. Epidemiology staff will use this to assess A) which pathogen is causing the outbreak, B) the likely route of transmission, and C) whether additional prevention measures are needed. Gather additional information List activities, events, etc., held during the week prior to the first illness (especially if food was served). Determine when and where there were any vomiting incidents or diarrheal accidents in the facility. If requested by MDH, provide a dietary menu (breakfast, lunch, and dinner). If requested by MDH, provide names and phone numbers for staff and/or residents (in rare cases, MDH may want to conduct interviews). Collect a stool sample from three (3) residents and/or staff and send to MDH Laboratory for analysis (MDH will provide specimen collection kits; the testing is free of charge). If stools from residents or staff were sent to a clinical laboratory, notify MDH of any results. Send both completed ILLNESS LOGS back to MDH between 1 and 2 weeks after the last illness. IMPLEMENT OUTBREAK CONTROL MEASURES: Monitor for resident illness (record on RESIDENT ILLNESS LOG) and when possible, isolate residents while they are ill and for 72 hours after symptoms have stopped. Consider halting new admissions until the outbreak has ended. Exclude actively ill residents from games/activities where touching common items occurs (e.g., checkers, cards). Monitor for staff illness (record on STAFF ILLNESS LOG) and restrict ill staff/volunteers from patient care and food handling duties until 72 hours after their vomiting/diarrhea has ended. Review of the Attendance Slip forms identified columns of: Employee name Shift and date Excuse for calling in Time called in A check box if staff were late (approved with less than 12-hour notice), late (no notice), 2 plus hours late (without notice) and if checked, how late staff were, if they left work early without approval, were a no-show, and who it was completed by. The form had no column to document when symptoms started, when symptoms were resolved, when staff RTW, or if they were cleared using national/ state standards to return to work. Review of May 2026, Attendance Slips identified: NA-B had called in on 5/2/26, with symptoms of nausea and vomiting. Review of NA-B time punch identified NA-B had returned to work on 5/3/26 the next day. NA-A had called in on 5/18/26, with symptoms of vomiting and fever. Review of NA-A time punch identified NA-A had returned to work on 5/19/26 the next day. Interview on 5/19/26 at 4:15 p.m., with the infection preventionist (IP) identified she did not have surveillance for staff illnesses. If staff called in one day for a headache, vomiting, diarrhea, or fever they were allowed to return to work 24 hours after symptoms resolved. For norovirus, the facility just kept track of symptoms and if they were symptomatic and more than one resident or staff was affected, that would constitute an outbreak then she would track that information and keep the resident in their room. She made no mention of how that would affect a staff's RTW. When a staff member called in, the person taking the call would fill out an attendance slip. The attendance slip typically went to the director of nursing (DON). She was unaware that staff should be out for 72 hours with symptoms of potential norovirus per State guidance. She acknowledged that she had not tracked staff illness since January of 2025. Interview on 5/19/26 at 4:28 p.m., with the administrator identified the facility could not require staff to disclose their symptoms or reason for calling in if the staff did not voluntarily provide that information. Interview on 5/20/26 at 11:32 a.m., with nursing assistant (NA)-A identified she had called-in for work on 5/18/26, she had vomited and had a fever Friday night on 5/15/26. She had called in because her stomach still did not feel good. She was unaware of any process for staff when they were ill. She had just called in ill and felt better the next day and assumed she should be able to RTW. She thought there should be some kind of process to ensure the residents do not become ill also. Interview on 5/20/26 at 11:52 a.m., with infection preventionist (IP) identified she reached out to her registered nurse (RN) consultant for the facility and was informed that there was no RTW policy. RTW was dependent on the staff symptoms. If staff had one day of vomiting but felt better the next day, staff would be allowed to RTW. The facility was to track symptoms on the absentee form the facility used. She did not receive the forms; however, she was notified of staff illnesses verbally. Staff are asked to report their symptoms when calling in for a shift, however they were not required to disclose their symptoms if they did not want to. Review of 4/20/26, General Infection Prevention and Control-Surveillance policy identified the infection preventionist would record infection data on the facilities monthly Infection Line Listing/Log in Infection Watch. Infection Control Records would be reviewed, presented, and evaluated by the QAPI Committee quarterly for residents and staff. Review of 4/20/26, Surveillance and Monitoring policy identified the facility would maintain routine surveillance and monitoring of the workplace. The infection preventionist or the director of nursing would be responsible for maintaining the surveillance records. The surveillance record would be evaluated for corrective measures to be taken to prevent a recurrence or similar exposure. The surveillance and monitoring would be reviewed at the QAPI meetings. Review of 4/20/26, Staff with Infections policy identified the facility would evaluate staff with infection to determine if staff may continue providing direct care or services to residents in the facility. Staff with infections would not be permitted to provide direct care until the facility conducted a review of the staff's medical record to determine if the staff may provide direct care in accordance with the established policies. NEBS Observations during initial tour on 5/18/26 beginning at 10:00 a.m., through 11:00 a.m., identified R9, R14, and R21's nebulizers were lying on their bedside tables/ nightstands and had not been disconnected, rinsed and air dried. Additional observation and interview on 5/18/26 at 3:48 p.m. of registered nurse (RN)-A as she proceeded to give R9 her inhaled nebulizer treatment identified R9's medication apparatus was still intact from this morning's administration. RN-A proceeded to hold the nebulizer and pour the nebulizer medication from the ampule in through the mask and into the medication cup. RN-A stated the apparatus should have been disassembled, cleaned and rinsed after each nebulizer administration. She was unsure if this occurred and noted facility policy directs staff to disassemble, clean, and air dry after each medication observation. Review of the May 2026 Medication Administration/Treatment Administration Records (MAR/TAR) identified: R9 had received her 6:00 a.m., nebulizer treatment for formoterol furmate nebulizer treatment solution that morning. R21 had received her ipratropium-albuterol inhaler nebulizer treatment at 7:00 a.m. that morning. Review of the 4/20/26, Respiratory Equipment Cleaning Procedure policy identified after each use, staff were to rinse the mouthpiece and medication cup with water and allow to air dry. MECHANICAL LIFTS Random observations on 5/18/26 from 10:00 a.m., through 6:00 p.m., of the 200 and 300 wing stand lifts identified all 3 lifts were sitting in the hall waiting to be used and had dirt and food-like debris on the pedals. Interview on 5/20/26 at 2:02 p.m. with RN-A identified stand lifts were to be cleaned after each use. Review of the 4/20/26, Nursing Weekly Cleaning task policy identified multiple use items, such as a mechanical lift were to be cleaned and disinfected after each use.

Based on interview and document review, the facility failed to ensure 2 of 8 sampled staff (director of nursing (DON) and nursing assistant (NA)-C) had initial or annual Alzheimer's and dementia training. Findings include: Review of the facility Employee Roster, Job and hire date document identified nursing assistant (NA)-C's had a hire date of 2/23/26. Review of her Alzheimer's Disease or Related Disorder Training identified she had not completed training for an explanation of Alzheimer's disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, or communication skills. Review of the facility Employee Roster, Job and hire date document identified director of nursing (DON) had a hire date of 5/28/24. Review of her Alzheimer's Disease or Related Disorder Training identified she had not completed training for an explanation of Alzheimer's disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, or communication skills. Interview on 5/19/26 at 4:25 p.m., with the administrator identified that 2 of the 8 staff had not completed their Alzheimer's training as required. He would expect the Alzheimer's training to be completed initially and annually as required. Review of the undated, New Hire Requirements for Relias orientation education included dementia care:Understanding the world of dementiaBeing with a person with dementia, listening and speakingBeing with a person with dementia, actions and reactionsAlzheimer's/Dementia verses normal ageingHelping friends and family with dementia carePreventing adverse reactions to dementia careDementia care, performing ADL'sDementia care, challenging behaviors and direct care staffCaregiver stress management Review of the 5/12/26, Facility Assessment identified staffing would be adequate for caring for residents with mental health conditions, history of trauma and dementia. The facilities training program for new and existing staff included dementia management and abuse prevention, effective communication, special needs of residents, and caring for residents who are cognitively impaired. A policy on the facilities Alzheimer's dementia training program for new hires and annual training was requested but not provided.

Based on interview and document review, the facility failed to have documented communication between the facility and hospice per their written agreement and ensure hospice notes were included in the medical record for 1 of 1 sampled hospice resident (R5). Findings include: R5's comprehensive Minimum Data Set (MDS) assessment, accepted on 9/24/25 identified R5 was re-admitted to the facility in September 2024, with diagnoses of dementia, anxiety disorder and had moderately impaired cognition. R5's current, undated care plan identified R5 has a terminal prognosis requiring hospice involvement/palliative care related to his end stage disease process. Comfort, dignity and autonomy was to be maintained at the highest level and was to demonstrate peacefulness and calmness through body language and/or verbalization. Review of R5's electronic medical record (EMR) hospice notes identified R5's R5 had hospice notes, schedules, and care plans captured in the EMR for the following months:February 2025, 9 times.March 2025, 6 times.April 2025, 5 times.May 2025, 1 time.June 2025 through August 2025, no notes were captured.September 2025, 6 times.October 2025 through February 2026, no notes were captured.March 2026, 5 times.April 2026, no notes were captured.May 2026, 7 times. Interview on 5/20/26 at 8:46 a.m., with the hospice nurse (HN)-A identified he or another nurse would come to the facility 2x per week on Tuesdays and Fridays. The facility was supposed to have all documentation form each hospice visit captured in their medical record. He noted very recently he had some issues faxing over the documents, but that had been resolved. Hospice staff always speak to facility staff and give report after each day they visit. He was unsure why the facility didn't have any notes and wasn't aware they were missing any. R5's 5/1/26 current hospice care plan identified he was admitted to hospice for senile degeneration of the brain. R5's hospice visit communication note from the facility identified there was 1 entry in January 2025, made by registered nurse (RN)-A that noted R5 continued to have an ulcer to his left rear calf. Improvement was noted. R5 also had a pressure ulcer to his right heel. Staff were to ask the physician to continue betadine and noted other interventions. There was no mention if this was a recommendation from hospice, or what the communication was that day between hospice and the facility staff. Interview and document review on 5/20/26 at 1:26 p.m., with RN-A identified she would expect the facility to follow the hospice contract made between R5's hospice and the facility. Staff do have verbal communication, but the facility doesn't document that communication. If the staff that received the verbal communication and did not pass along pertinent information, she agreed communication that may be urgent etc. could be lost. She was unaware the hospice notes were not being captured for several months. Hospice was to send the administrator the notes, and he would print them out and give them to staff. She was not aware of anyone else checking to see the facility had received that documentation and agreed they need to follow contract identifying both parties document communication. Review of the current hospice contract between R5's hospice provider and the facility identified hospice, and the facility, were to communicate with one another regularly and as needed. After every communication, each party was to document the communication in its respective clinical records to ensure the needs of hospice patients were met 24 hours per day.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident's (R36) room was maintained in a homelike manner and ensure preventative maintenance was provided to repair numerous chips and scratches in the pain on 2 of 4 walls.Findings include: R36's comprehensive Minimum Data Set (MDS), accepted on 9/5/25, identified R36 was re-admitted to the facility in November 2023, with diagnoses of heart failure, high blood pressure, and arthritis. R36 had intact cognition and had no behaviors noted. Observation on 5/18/25 at 10:25 a.m., of R36 ion her room identified R36 was seated in her chair. R36 was alert and oriented and stated she had been at the facility for a while. R36 had numerous chips on the walls directly behind her chair and on the right side of the bed, approximately 10 to 12 inches on the wall, above the mattress. When asked about the chips and scuffs in the paint, R36 stated they had always been there since she moved in. Interview on 5/20/26 at 1:00 p.m., with the administrator identified the maintenance director (M-D) was out at the moment, but he did use a TELS system that could generate, assign, and track work orders, and could be used to track preventative maintenance. He was unsure if the M-D had a preventative maintenance schedule that included resident rooms, but agreed at a minimum, rooms should be checked yearly for maintenance needs. He noted R36 did like to move her furniture around a lot. Interview on 5/20/26 at 1:38 p.m., with registered nurse (RN)-A identified R36 was known to move things around in her room. RN-A was unaware of the numerous scratches and chips in R36's pain behind her chair and beside her bed on the wall. She was not sure if staff had put in a work ticket but did think the M-D did do environmental rounds. Review of the QAPI meeting minutes from May 2025 through April 2026 identified M-D was present at the QAPI meetings and submitted data for environmental services that included painting as needed in the category of Building Improvements. The action plans were to touch up paint when rooms were empty or as needed. Review of the 4/26/26 Safety Meeting documentation identified facility staff did perform monthly safety rounds; however, there was no mention of specific preventative maintenance checks to ensure resident rooms were maintained in a homelike manner. There was no policy related to preventative maintenance provided by the end of survey.

Based on interview and record review the facility failed to notify physician of skin alteration for 1 of 3 (R1) residents reviewed for change of condition. Findings include R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition. R1 had infection to the foot and was receiving application of nonsurgical dressing with ointment/medication to her feet.R1's progress note dated 6/4/25 at 1:30 p.m., indicated R1 was admitted via electric scooter from local hospital with many bruises on arms and an open area left great toe. R1's progress notes dated 6/5/25 at 4:08 a.m., indicated admission skin assessment completed and there were multiple bruises noted on bilateral arms and legs and dressing remained intact to left great toe.R1's record reviewed between 6/5/25 through 6/11/25 revealed although the progress notes identified R1 had developed skin changes to her right foot that included discoloration, a large bump, and a large fluid filled blister, it was not evident the physician was notified of the change until 6/12/25. R1's progress notes included the following: R1's progress notes dated 6/8/25 at 3:32 a.m., indicated on 6/7/25, staff alerted writer the R1 had a large bump on the top of her right foot. The site looked inflamed and black/blue in color. A border was drawn around the edges to monitor for changes in size. R1's progress note dated 6/9/25 at 9:13 a.m., R1's top of right foot was noted to be dark in color with a fluid filled intact blister. R1 reported she had bumped it the other day when she lost her balance but did not fall. Area left open to air and continue to observe. R1's progress notes dated 6/10/25 at 12:11 a.m., indicated the fluid filled blister was extending the border that was drawn on 6/7/25 and measured over the raised area 9.2 centimeters (cm) high x 11.4 cm wide. Remained open to the air. R1's progress notes dated 6/10/25 at 7:24 a.m., indicated R1 had a blister like area on her right foot and cellulitis in left great toe. R1's progress notes dated 6/10/25 at 11:15 a.m., indicated a very large intact blister to top of right foot. Skin very thin and transparent with fluid pool present. Remains open to air at time. Will continue to observe. R1's progress notes dated 6/11/25 at 1:22 p.m., indicated left great toe cellulitis with slow improvement noted. Scant bleeding with dressing removal. Skin remains open. Antibiotics complete. Continue current treatment, see wound flow sheet for further information. Continue to observe.R1's progress notes dated 6/12/25 at 2:54 p.m., indicated R1 was seen by physician on rounds for blister on top of right foot. physician completed sharp debridement to area. Dressed with Adaptec (moist dressing), gauze pad and kerlix. R1 to start doxycycline (an antibiotic) and compression provided with ace wraps.During an interview on 7/18/25 at 10:56 a.m., director of nursing (DON) stated it was her expectation that any skin concerns were brought the physician's attention as soon as possible. The nurse should do an assessment, with measurements, start a treatment and make a progress note.During an interview on 7/18/25 1:30 p.m. MD-A indicated the wound was brought to his attention during rounds on 6/12/25. MD-A further stated the wound could have extended R1's stay at the facility, as there was no evidence of physician notification until 6/12/25. Review of facility policy entitled Weekly Skin Assessment and Documentation Process, dated 1/20/23, identified the following:c.) Notification to Physician1- The nurse who initially identifies the skin alteration, they should utilize the fax forms to notify the physician/nurse practitioner or call and put the new order into the electronic health record.

Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 43 residents. Review of the facilities QAPI minutes from June of 2024 through March of 2025 identified the following: 1. June 2024 minutes identified the facility chose a PIP of pain. The minutes did not include any data collection, analysis, evaluation of the identified concern, or an action plan. 2. July, August, September, October, November, December of 2024 and January, February, March of 2025 QAPI minutes identified the facility chose a PIP of pain but lacked any data collection, analysis or evaluation of the identified concern or an action plan. Interview on 4/15/25 at 4:30 p.m., with the administrator identified the QAPI committee had chosen pain from the facilities CMS Quality measures as their PIP project back in June. He reported they had not developed an action plan. He would expect the committee to follow the PIP process to bring the data to QAPI, discuss the problem, set a measurable goal, developed an action plan, and revisit and adjust the plan as needed until completion. Review of the facility provided October 2024, QAPI Plan identified at least annually, a project that focuses on high risk or problem-prone areas will be addressed thought he QAPI program including PIP development. A minimum of one PIP and a maximum of four PIP's will occur simultaneously. A PIP worksheet which establishes the goals, scope, timing, milestones, and team's roles and responsibilities will be developed for each PIP. The PIP team will be assembled by the QAPI committee. The team will be interdisciplinary with employees representing each job role affected by the project and may include resident and/or family representation, when appropriate. A project lead will be selected and will be responsible for coordinating, organizing and directing the activities of that specific PIP team. The PIP team will identify the information needed to evaluate the problem at hand, supplies required, staff participation, and any equipment needs. The project lead will communicate any identified resources needed. The team will utilize root cause analysis to identify the cause of the problem and any contributing factors. The PIP team will develop an action plan with identified problem statement, causes, goals, interventions, employees responsible, and due dates.

Based on interview and document review, the facility failed to implement thier facility assessment to ensure 1 of 1 licensed practical nurse (LPN)-A and potentially 8 other licensed nurses (registered nurses (RN's) and LPN's) who administered insulin had yearly competencies for safe administration of insulin, and identifcation of complications of low or high blood sugar levels and any actions needed. This had the potential to affect all residents who were diabetic. Finding include: R15's 1/21/25, Significant Change Minimum Data Set (MDS) assessment identified R15 cognition was intact, he had no pain, no behaviors, was on a therapeutic diet, received insulin, anticoagulant, diuretic, hypoglycemic medication daily and was on isolation. R15's diagnosis list identified he had diabetes mellitus type 2, long term use of insulin, heart failure, chronic kidney disease, edema, atrial fibrillation, and hypertension. R15's January 2025, Medication Administration Record identified R15 received insulin Glargine Solution 48 units every morning and evening and Fiasp insulin aspart injection solution 32 units three times a day at 8:00 a.m., noon, and 5:00 p.m R15's medication administration audit report identified documentation on 1/26/25 at: 1) 9:17 a.m., Fiasp insulin 32 units had been administered. 2) 9:18 a.m. insulin Glargine 48 units had been administered. 3) 12:17 p.m. Fiasp insulin 32 units had been administered. R15's 1/26/25 at 1:46 p.m., progress note identified LPN-A documented R15 was given his dinner medication and insulin around 11:45 a.m. Staff brought R15 his dinner at 12:30 p.m. (forty-five minutes later) and found R15 to be sweating and drooling from his mouth. R15 was unable to answer appropriately, blood pressure was 135/86 millimeters/mercury (mm/hg) (normal 120/80 mm/hg), temperature 97.5 Fahrenheit (F) (within normal limits), pulse 80 beats per minute (bpm) (normal), respirations 20 per minute (normal), and oxygen saturation 95% (normal) on room air. The ambulance was called at 1:20 p.m., and R15 left the facility at 1:30 p.m. The progress note lacked identification of what R15's BS was at 12:30 when staff identified his level of conscious changes, or what, if any, interventions had been implemented at the facility. R15's vital signs documentation identified on 1/26/25 at 9:18 a.m., R15's BS was 103 milligrams/deciliter (mm/dL). At 12:22 p.m., R15's BS was 99 mg/dL, and at 1:44 p.m. (after R15 had left the facility), staff recorded R15's BS was 68 mg/dL. It is unknown if this was a late entry. Interview on 4/15/25 at 7:55 a.m., with registered nurse (RN)-B identified she would check the resident blood sugar, if it was low at all she would wait to see what the resident ate before giving fast acting insulin. She was unsure if there was any protocol on what to do or what other nurses did for insulin. Interview on 4/15/25 at 8:31 a.m., with LPN-A identified on 1/26/25, from what she could recall, R15 never usually had a low blood sugar, but it was low that day. R15 ate his meal, but occasionally he would get bucky and not want to come out for his meal right away. She thought perhaps staff likely went to get him, but he would not come out, so they brought him his meal and that was when they found him unable to answer appropriately. Staff then came and got her to go and assess him. R15's blood sugar level and blood pressure had gone down so she sent him to the ED for evaluation. Further interview on 4/16/25 at 7:33 a.m., with LPN-A identified on 1/26/25, the day she sent R15 to the emergency department (ED) she had assessed him, attempted to give him orange juice with sugar in it. She reported she did not use the glucagon gel because she was unsure if he would have been able to swallow that as it was thicker. From what she could recall, she wasn't aware if the facility had glucagon injectable medication and did not report what she had not used that if she had concerns about R15's ability to swallow medication. Review of the June 2023, Fiasp insulin aspart injection 100 units/ml manufacturer instructions identified Fiasp was a rapid-acting human insulin analog indication to improve glycemic control for patients with diabetes mellitus (1). Fiasp insulin was to be given at the start of a meal or within 20 minutes after starting a meal. R15's 1/26/25, emergency department record identified R15 with a history of diabetes, the facility reported that R15 had a BS of 68 and was given 4 packets of sugar while at nursing home. Upon arrival R15 had a BS of 33. R15 had tested positive for influenza on 1/20/25 and had not been eating or drinking well however, and the facility had continued to give him his usual insulin doses. He had been receiving Lantus 48 units twice a day along with NovoLOG 32 units three times a day with meals. R15's 1/30/25, hospital discharge summary identified R15 had been admitted on [DATE] for hypoglycemia, influenza A, and acute renal disease and hypotension secondary to dehydration. Review of the current, undated, American Diabetes Association (ADA) , Severe Hypoglycemia (Severe Low Blood Glucose) article, located at https://diabetes.org/living-with-diabetes/hypoglycemia-low-blood-glucose/severe, identified severe hypoglycemia, which may also be referred to as an insulin reaction or insulin shock, is when your blood glucose (blood sugar) drops dangerously low. If you have severe hypoglycemia, you may become confused, pass out (lose consciousness), or treatments for a low blood glucose aren ' t working. People on blood glucose-reducing medications (insulin) were at risk. Signs and symptoms of severe hypoglycemia were listed as: 1) An altered mental state 2) Fainting or losing consciousness 3) Incredibly weak and unable to help yourself 4) Seizure 5) Coma If left untreated for too long, severe hypoglycemia can lead to brain or organ damage or even death. Glucagon, preferably ready-to-use, should be used to treat severe hypoglycemia. It quickly raises blood glucose levels by causing the liver to release the glucose it stores into your bloodstream. Review of the 12/10/2016, ADA and EASD Joint Statement on Hypoglycemia (low BS) article, located at https://www.diabetesincontrol.com/ada-easd-joint-statement-on-hypoglycemia/, identified 3 stages of low blood sugar: 1) Level 1: A glucose alert value of 70mg/dL. 2) Level 2: A glucose level of 54 mg/dL is sufficiently low to indicate serious, clinically important hypoglycemia. 3) Level 3: Severe hypoglycemia, as defined by the ADA, denotes severe cognitive impairment requiring external assistance for recovery. R15's 5/7/24, signed Prairie View Senior Living Physician Standing Orders identified diabetics: administer glucose gel 15 gram by mouth if resident with hypoglycemia is alert enough to swallow get. Administer the glucagon injection, 1 milligram via intramuscular or subcutaneously for hypoglycemia if resident was unresponsive and has a low blood glucose (BS) level. Call the physician to update and implement further orders as soon as possible. Interview on 4/15/25 at 2:10 p.m., with consulting pharmacist identified no one should be taking insulin more than 30 minutes prior to eating in general. Diabetics even if sick still need to take their insulin however, if the resident was not eating the facility should have reached out to the provider to make sure the insulin dose did not need to be adjusted. Fiasp insulin was a rapid acting insulin and should be given just before eating and staff should follow the manufacturer's instruction for any insulin they are administering. The dispensing pharmacy confirmed that the facility emergency kit (E-kit) contained both glucagon gel and glucagon injections 2 doses of each at the time of the incident. Once the facility used an item out of the E-kit the facility would send a fax and they would replace the item the next delivery day. Interview on 4/15/25 at 2:43 p.m., with director of nursing (DON) identified that fast acting insulin should never be given more than 15 minutes prior to eating. On 1/26/25, LPN-A had attempted to give R15 sugar packets with orange juice prior to breaking into the emergency kit (E-kit). She agreed that R15 should have been given his insulin with his meal and the nurse should have made sure he started to eat. She revealed that insulin was an issue with R15 because if he did not like his insulin order he would seek out another provider and make an appointment and set up a ride independently to have his insulin order changed. Further interview on 4/16/25 at 2:30 p.m., director of nursing (DON) revealed that R15's progress note on 1/26/25, indicated that R15 had been given his insulin 45 minutes prior to being served his meal, resulting in a low blood sugar. R15 took Fiasp insulin which was a rapid acting insulin and should have been given with food confirming that LPN-A did not follow the manufacture instruction and gave R15 the insulin before he ate his meal. She further confirmed that LPN-A did not follow the facility standing order protocol for low blood sugar to administer either glucagon gel or glucagon injection according to standing orders. She reported at the time of the incident, LPN-A stated she had given juice or sugar to R15 related to his low blood sugar instead of the correct procedure outlined in the standing orders. She had re-educated LPN-A at that time and had planned to re-educate all the licensed nurses on using the facility standing order protocol for low blood sugars. She had performed a new competency for LPN-A on 1/27/25, however she could not recall if all nursing staff had received competencies yearly. Review of LPN-A's employee file identified education on insulin administration occurred on 3/10/23, 3/13/23, and 3/20/23. On 4/1/23, LPN-A met the requirements for competency of medication pass. There were no competencies listed for 2024 related to insulin adminisistration or identifying potential complications. On 1/27/25, LPN-A had re-education and met the requirements for competency of insulin administration including checking times insulin should be administered. Interview on 4/16/25 at 3:52 p.m., with the emergency department provider who had who treated R15 on 1/26/25 and treated him previously in the past also identified R15 had received his mealtime insulin before he was given his meal. R15 had not been eating well and when she spoke to the facility nurse, she reported that she re-educated the nurse for R15 who had previous concerns with low blood sugars, that the facility should have used critical thinking and brought him out to dining area to ensure he ate his meal after administering his insulin. She confirmed R15 should not be administered his rapid acting Fiasp insulin without eating his meal, his order was insulin at mealtime which means he gets it with a meal and the facility needs to watch that better. She reported the facility was doing the best they can, but they needed to work on critical thinking skills as some nurses just follow orders and do not question anything. If R15 had not been feeling well and had been eating poorly, the nurse should R15 ate within the required timeframe. Review of the 2/17/25, Blood Glucose Monitoring policy identified the policy notes after checking a resident's blood sugar level, staff were to report critical results and test results outside parameters timely. There was no mention on what staff should look for with diabetic complications, if they should follow insulin manufacturer's guidelines, or what to do if those complications should arise. Review of 8/1/24, Facility Assessment identified 9 licensed nurses were employed at the facility. The facility was to ensure nursing staff were to maintain competencies required to meet the residents needs including pharmacological. Staff were to be trained on procedures and policies consistent with their roles. There was no mention staff should be deemed competent at least yearly, or more often as necessary, according to the roles and duties they provide in order to ensure those competencies were maintained.

Based on observation and interview the facility failed to ensure 1 of 1 nursing assistant (NA-A) entering the food preparation area in the kitchen wore a hair net. Findings include: Observation and interview on 4/14/25 at 12:25 p.m., of NA-A standing in the kitchen food preparation area where the cook was dishing up the meal onto plates. NA-A was standing within 2 feet of the cook dishing up the food onto the plate with no hair net on. NA-A obtained a meal tray and exited the kitchen. When asked about hair nets when in the kitchen NA-A stated, I do not think the nurse aides have to wear one. She denied that she typically goes into the kitchen to retrieve a meal, then reported, the resident was out in the dining room, but then changed their mind and wanted to eat in their room. Interview on 4/14/25 at 12:32 p.m., with dietary manager identified staff were able to enter the kitchen as far as the hand washing sink which was just inside the kitchen door. Any distance after that they need to have the hair net on. She confirmed there should be no staff without hair nets in the kitchen serving area. Interview on 4/16/25 at 2:30 p.m., with director of nursing (DON) identified she would expect that any staff entering the kitchen would be donning a hair net prior to entering the kitchen for any reason. She reported the rule has always been you either put on a hair net or you wait at the door. The facility had no policy related to wearing hair nets in the kitchen however, they provided The Safe Food Handler protocol they followed that identified that hair restraints or hats were required when in the food-prep area. Hair nets or hats kept hair from falling into food and onto food-contact surfaces.

Based on observation and interview the facility failed to ensure only authorized personnel entered 1 of 1 medication storage room. Findings include: Observation and interview on 4/16/25 at 8:24 a.m. of licensed practical nurse (LPN)-A wheeled R8 into the medication storage room adjacent to the dining room. LPN-A donned gloves and primed Humulin Kwik pen with 2 units. LPN-A identified R8's blood sugar was 171 and then dialed up 20 units of insulin for administration. LPN-A administered the insulin in R8's left abdomen and discarded the insulin needle in the sharp's container and removed her gloves. LPN-A then wheeled R8 back out to the dining room table. LPN-A reported that typically she did not give insulin in the medication room however R8 had gotten out the dining room before she caught her to give her insulin. She also revealed that there were typically 2 licensed nurses on duty during the daytime hours and today she was the only licensed nurse on duty with a trained medication aide (TMA) so she had to give all the insulins in the facility so that was why she gave the insulin in the medication room. Interview on 4/16/25 at 8:30 a.m., with the assistant director of nursing (ADON)/infection control nurse identified that if a resident needed insulin that she had taken them into the medication room to provide privacy before. Interview on 4/16/25 at 2:30 p.m., with the director of nursing (DON) identified that she was unaware nurses had been taking residents into the medication room to administer insulin. She agreed that would be an infection control concern and a medication storage concern if the nurse had to run out for some reason like an emergency, the resident could potentially get left unattended. The DON was surprised to hear more than one nurse had brought a resident into the medication room to administer insulin. Review of the undated, Medication Storage in the Facility policy identified the medication supply was only accessible to licensed nursing personnel, staff members lawfully authorized to administer medications, or the pharmacy personnel.

Based on interview and document review the facility failed to ensure 1 of 1 resident (R15) rapid acting insulin injection was administered according to the manufactures instructions. Finding include: R15's 1/21/25, Significant Change Minimum Data Set (MDS) assessment identified R15 cognition was intact, he had no pain, no behaviors, was on a therapeutic diet, received insulin, anticoagulant, diuretic, hypoglycemic medication daily and was on isolation. R15's diagnosis list identified he had diabetes mellitus type 2, long term use of insulin, heart failure, chronic kidney disease, edema, atrial fibrillation, and hypertension. R15's January 2025, Medication Administration Record identified R15 received insulin Glargine Solution 48 units every morning and evening and Fiasp insulin aspart injection solution 32 units three times a day at 8:00 a.m., noon, and 5:00 p.m R15's medication administration audit report identified documentation on 1/26/25 at: 1) 9:17 a.m., Fiasp insulin 32 units had been administered. 2) 9:18 a.m. insulin Glargine 48 units had been administered. 3) 12:17 p.m. Fiasp insulin 32 units had been administered. R15's 1/26/25 at 1:46 p.m., progress note identified LPN-A documented R15 was given his dinner medication and insulin around 11:45 a.m. Staff brought R15 his dinner at 12:30 p.m. (forty-five minutes later) and found R15 to be sweating and drooling from his mouth. R15 was unable to answer appropriately, blood pressure was 135/86 millimeters/mercury (mm/hg) (normal 120/80 mm/hg), temperature 97.5 Fahrenheit (F) (within normal limits), pulse 80 beats per minute (bpm) (normal), respirations 20 per minute (normal), and oxygen saturation 95% (normal) on room air. The ambulance was called at 1:20 p.m., and R15 left the facility at 1:30 p.m. The progress note lacked identification of what R15's BS was at 12:30 when staff identified his level of conscious changes, or what, if any, interventions had been implemented at the facility. R15's vital signs documentation identified on 1/26/25 at 9:18 a.m., R15's BS was 103 milligrams/deciliter (mm/dL). At 12:22 p.m., R15's BS was 99 mg/dL, and at 1:44 p.m. (after R15 had left the facility), staff recorded R15's BS was 68 mg/dL. It is unknown if this was a late entry. Interview on 4/15/25 at 7:55 a.m., with registered nurse (RN)-B identified she would check the resident blood sugar, if it was low at all she would wait to see what the resident ate before giving fast acting insulin. She was unsure if there was any protocol on what to do or what other nurses did for insulin. Interview on 4/15/25 at 8:31 a.m., with LPN-A identified on 1/26/25, from what she could recall, R15 never usually had a low blood sugar, but it was low that day. R15 ate his meal, but occasionally he would get bucky and not want to come out for his meal right away. She thought perhaps staff likely went to get him, but he would not come out, so they brought him his meal and that was when they found him unable to answer appropriately. Staff then came and got her to go and assess him. R15's blood sugar level and blood pressure had gone down so she sent him to the ED for evaluation. Further interview on 4/16/25 at 7:33 a.m., with LPN-A identified on 1/26/25, the day she sent R15 to the emergency department (ED) she had assessed him, attempted to give him orange juice with sugar in it. She reported she did not use the glucagon gel because she was unsure if he would have been able to swallow that as it was thicker. From what she could recall, she wasn't aware if the facility had glucagon injectable medication and did not report what she had not used that if she had concerns about R15's ability to swallow medication. Review of the June 2023, Fiasp insulin aspart injection 100 units/ml manufacturer instructions identified Fiasp was a rapid-acting human insulin analog indication to improve glycemic control for patients with diabetes mellitus (1). Fiasp insulin was to be given at the start of a meal or within 20 minutes after starting a meal. R15's 1/26/25, emergency department record identified R15 with a history of diabetes, the facility reported that R15 had a BS of 68 and was given 4 packets of sugar while at nursing home. Upon arrival R15 had a BS of 33. R15 had tested positive for influenza on 1/20/25 and had not been eating or drinking well however, and the facility had continued to give him his usual insulin doses. He had been receiving Lantus 48 units twice a day along with NovoLOG 32 units three times a day with meals. R15's 1/30/25, hospital discharge summary identified R15 had been admitted on [DATE] for hypoglycemia, influenza A, and acute renal disease and hypotension secondary to dehydration. Review of the current, undated, American Diabetes Association (ADA) , Severe Hypoglycemia (Severe Low Blood Glucose) article, located at https://diabetes.org/living-with-diabetes/hypoglycemia-low-blood-glucose/severe, identified severe hypoglycemia, which may also be referred to as an insulin reaction or insulin shock, is when your blood glucose (blood sugar) drops dangerously low. If you have severe hypoglycemia, you may become confused, pass out (lose consciousness), or treatments for a low blood glucose aren ' t working. People on blood glucose-reducing medications (insulin) were at risk. Signs and symptoms of severe hypoglycemia were listed as: 1) An altered mental state 2) Fainting or losing consciousness 3) Incredibly weak and unable to help yourself 4) Seizure 5) Coma If left untreated for too long, severe hypoglycemia can lead to brain or organ damage or even death. Glucagon, preferably ready-to-use, should be used to treat severe hypoglycemia. It quickly raises blood glucose levels by causing the liver to release the glucose it stores into your bloodstream. Review of the 12/10/2016, ADA and EASD Joint Statement on Hypoglycemia (low BS) article, located at https://www.diabetesincontrol.com/ada-easd-joint-statement-on-hypoglycemia/, identified 3 stages of low blood sugar: 1) Level 1: A glucose alert value of 70mg/dL. 2) Level 2: A glucose level of 54 mg/dL is sufficiently low to indicate serious, clinically important hypoglycemia. 3) Level 3: Severe hypoglycemia, as defined by the ADA, denotes severe cognitive impairment requiring external assistance for recovery. R15's 5/7/24, signed Prairie View Senior Living Physician Standing Orders identified diabetics: administer glucose gel 15 gram by mouth if resident with hypoglycemia is alert enough to swallow get. Administer the glucagon injection, 1 milligram via intramuscular or subcutaneously for hypoglycemia if resident was unresponsive and has a low blood glucose (BS) level. Call the physician to update and implement further orders as soon as possible. Interview on 4/15/25 at 2:10 p.m., with consulting pharmacist identified no one should be taking insulin more than 30 minutes prior to eating in general. Diabetics even if sick still need to take their insulin however, if the resident was not eating the facility should have reached out to the provider to make sure the insulin dose did not need to be adjusted. Fiasp insulin was a rapid acting insulin and should be given just before eating and staff should follow the manufacturer's instruction for any insulin they are administering. The dispensing pharmacy confirmed that the facility emergency kit (E-kit) contained both glucagon gel and glucagon injections 2 doses of each at the time of the incident. Once the facility used an item out of the E-kit the facility would send a fax and they would replace the item the next delivery day. Interview on 4/15/25 at 2:43 p.m., with director of nursing (DON) identified that fast acting insulin should never be given more than 15 minutes prior to eating. On 1/26/25, LPN-A had attempted to give R15 sugar packets with orange juice prior to breaking into the emergency kit (E-kit). She agreed that R15 should have been given his insulin with his meal and the nurse should have made sure he started to eat. She revealed that insulin was an issue with R15 because if he did not like his insulin order he would seek out another provider and make an appointment and set up a ride independently to have his insulin order changed. Further interview on 4/16/25 at 2:30 p.m., director of nursing (DON) revealed that R15's progress note on 1/26/25, indicated that R15 had been given his insulin 45 minutes prior to being served his meal, resulting in a low blood sugar. R15 took Fiasp insulin which was a rapid acting insulin and should have been given with food confirming that LPN-A did not follow the manufacture instruction and gave R15 the insulin before he ate his meal. She further confirmed that LPN-A did not follow the facility standing order protocol for low blood sugar to administer either glucagon gel or glucagon injection according to standing orders. She reported at the time of the incident, LPN-A stated she had given juice or sugar to R15 related to his low blood sugar instead of the correct procedure outlined in the standing orders. She had re-educated LPN-A at that time and had planned to re-educate all the licensed nurses on using the facility standing order protocol for low blood sugars. She had performed a new competency for LPN-A on 1/27/25, however she could not recall if all nursing staff had received competencies yearly. Review of LPN-A's employee file identified education on insulin administration occurred on 3/10/23, 3/13/23, and 3/20/23. On 4/1/23, LPN-A met the requirements for competency of medication pass. There were no competencies listed for 2024 related to insulin adminisistration or identifying potential complications. On 1/27/25, LPN-A had re-education and met the requirements for competency of insulin administration including checking times insulin should be administered. Interview on 4/16/25 at 3:52 p.m., with the emergency department provider who had who treated R15 on 1/26/25 and treated him previously in the past also identified R15 had received his mealtime insulin before he was given his meal. R15 had not been eating well and when she spoke to the facility nurse, she reported that she re-educated the nurse for R15 who had previous concerns with low blood sugars, that the facility should have used critical thinking and brought him out to dining area to ensure he ate his meal after administering his insulin. She confirmed R15 should not be administered his rapid acting Fiasp insulin without eating his meal, his order was insulin at mealtime which means he gets it with a meal and the facility needs to watch that better. She reported the facility was doing the best they can, but they needed to work on critical thinking skills as some nurses just follow orders and do not question anything. If R15 had not been feeling well and had been eating poorly, the nurse should R15 ate within the required timeframe. Review of the 2/17/25, Blood Glucose Monitoring policy identified the policy notes after checking a resident's blood sugar level, staff were to report critical results and test results outside parameters timely. There was no mention on what staff should look for with diabetic complications, if they should follow insulin manufacturer's guidelines, or what to do if those complications should arise. Review of 8/1/24, Facility Assessment identified 9 licensed nurses were employed at the facility. The facility was to ensure nursing staff were to maintain competencies required to meet the residents needs including pharmacological. Staff were to be trained on procedures and policies consistent with their roles. There was no mention staff should be deemed competent at least yearly, or more often as necessary, according to the roles and duties they provide in order to ensure those competencies were maintained. There was no policy related to following manufacture instruction provided by end of survey.

Based on observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 2 of 12 sampled residents (R13 and R14). Findings include: R13 was admitted [DATE]. R13's undated, current diagnosis list identified R13 received a diagnosis of bipolar disorder 11/05/24. R13's 3/03/25, Level II PASARR had indicated R13 had meet criteria for severe mental illness. R13's 3/28/25, Significant change Minimum Data Set (MDS) identified R13 was moderately, cognitively impaired and had a diagnoses of anxiety, bipolar disease and dementia. R13 had little interest or pleasure in doing things, never to 1 day and felt down, depressed or hopeless 2 to 6 days. R13 was dependent with ADLS and required substantial maximal assist with transfers. R13 had taken antipsychotics, antianxiety and antidepressant on a routine basis. Section A 1500 PASARR: resident been evaluated by [NAME] II PASARR and determined to have a serious mental illness and/or mental retardation, or a related condition was marked no. Interview on 4/15/25 at 12:56 p.m., with Registered nurse (RN)-A identified the Level II (PASARR) was missed and would have to modify the entry error and update the correct data on R13's MDS. Interview on 4/16/25 at 8:49 a.m., with the director of nursing and assistant director of nursing voiced in agreement they would expect the MDS entry to be coded accurately. Interview on 4/16/25 at 9:12 a.m., with the administrator would expect residents MDS submission to be accurate. He identified the facility did not have a policy for MDS but used the RAI manual for guidance. Review of the Resident Assessment Instrument (RAI) manual identify residents MDS submissions must be accurate during the look back period, in accordance with standards of clinical practice and documentation. 39988 R14's 3/31/25, significant change Minimum Data Set (MDS) assessment identified R14 had severe cognitive impairments, and he was dependent on staff for cares. The assessment identified he did not have a prognosis that may result in a life expectancy of less than 6 months, and he was not on hospice. R14's prior significant change MDS dated [DATE] and his quarterly MDS dated [DATE] both identified he was on hospice. R14's medical record identified an order on 11/29/24 for hospice services. Medical record further identified R14 had been admitted to [NAME] at Home Hospice on 12/3/24. R14's 12/4/24, care plan identified terminal prognosis requiring hospice services. R14's comfort would be maintained. Staff were to adjust provisions of cares to compensate changing abilities. Assess coping strategies and respect wishes. Staff were to contact [NAME] Hospice with concerns or question. Encourage support systems of friends and family. There were multiple other interventions identified for comfort and coordination of care with hospice. On 4/16/25 at 12:51 p.m., an attempt was made to contact the regional clinical reimbursement specialist that was identified as the staff completing R14's MDS assessments. A voice mail was left to return call with no response. Interview on 4/16/25 at 2:30 p.m., with director of nursing (DON) identified she would expect that the MDS assessment accurately reflected the resident status. She confirmed that R14's significant change MDS lacked identification of hospice.

Based on interview and document review, the facility failed to notify the Office of the Ombudsman of transfers and discharge for 2 of 5 residents (R29 and R39) reviewed for hospitalizations and/or discharges. Findings include: R29's 3/16/25, discharge return anticipated Minimum Data Set (MDS) assessment identified an unplanned discharge to general hospital. 3/19/25 an entry tracking record was completed. R39's 2/3/25, discharge return not anticipated MDS identified he returned to home/community. Review of the February and March 2025 Monthly Notice to Office of Ombudsman for Long-Term Care of Emergency Acute Care Transfer and Discharges form identified that neither R29 nor R39 were on the list of resident who had been discharged . Interview on 4/16/25 at 9:20 a.m., with social service designee (SSD) identified she notified the ombudsman monthly of any hospital discharges. She did not notify the ombudsman of any other types of discharges. She reported that the nurse took care of ombudsman notification if a resident discharged to home or anther facility. She confirmed that R29's hospital discharge did not get reported to the ombudsman. She identified that there had been a agency staff working that shift and did not fill out the Emergency Notice of Transfer/Discharge, Notice of Bed Hold Policy and Return form so she was unaware of the hospital discharge and the need to notify the Ombudsman. Interview on 4/16/25 at 11:43 a.m., with assistant director of nursing (ADON) identified that as far as she was aware the SSD notified the ombudsman of all discharges. Interview on 4/16/25 at 2:30 p.m., with director of nursing (DON) identified that the prior Minimum Data Set (MDS) nurse who was no longer employed at the facility, had been completing some discharge notices to the Ombudsman while the SSD notified the ombudsman of hospital discharges. She confirmed since the MDS nurse left, some discharge notices had not been made. The MDS nurse that left completed a lot of tasks and the facility was still figuring out what she had been taking care of and what needed to be re-assigned. The SSD worked on discharge planning and already completed the hospital discharge notices to the Ombudsman and could probably take over ensuring the Ombudsman was notified of all discharges. Review of the 10/22/21, Notice of Transfer or Discharge Process policy identified the Office of the State Long-Term Care Ombudsman would be notified of discharges monthly.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 medication room was not used for resident insulin administration and/or blood glucose checks, in order to prevent potential cross-contamination. Observation and interview on 4/16/25 at 8:24 a.m. of licensed practical nurse (LPN)-A wheeled R8 into the medication storage room adjacent to the dining room. LPN-A donned gloves and primed Humulin Kwik pen with 2 units. LPN-A identified R8's blood sugar was 171 and then dialed up 20 units of insulin for administration. LPN-A administered the insulin in R8's left abdomen and discarded the insulin needle in the sharp's container and removed her gloves. LPN-A then wheeled R8 back out to the dining room table. LPN-A reported that typically she did not give insulin in the medication room however R8 had gotten out the dining room before she caught her to give her insulin. She also revealed that there were typically 2 licensed nurses on duty during the daytime hours and today she was the only licensed nurse on duty with a trained medication aide (TMA) so she had to give all the insulins in the facility so that was why she gave the insulin in the medication room. Interview on 4/16/25 at 8:30 a.m., with the assistant director of nursing (ADON)/infection control nurse identified that if a resident needed insulin that she had taken them into the medication room to provide privacy before. Interview on 4/16/25 at 2:30 p.m., with the director of nursing (DON) identified that she was unaware nurses had been taking residents into the medication room to administer insulin. She agreed that would be an infection control concern and posed a likelihood of cross-contamination. The DON was surprised to hear more than one nurse had brought a resident into the medication room to administer insulin. Review of 6/21/21, General guild lines for infection control identified facility would maintain a sanitary environment by adhering to infection control practices. The infection preventionist and/or the director of nurses would be responsible for the facility infection control procedures. The charge nurse would be responsible to carry out functions of infection control. Infection control practices are necessary to prevent or control the spread of infections. Review of 2/1/25, Medication Storage in the Facility policy identified the medication storage areas are to be kept clean and only authorized personnel should be in the medication storage area.

Based on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day for 3 of 12 days reviewed. This had the potential to affect all 44 residents. Findings include: Review of random nursing staff schedules and time punches for 7/24/24, /25/24, 8/11/24, 8/12/24, 8/16/24, 8/17/24, 8/18/24, 9/7/24, 9/8/24, 9/14/24, 9/15/24, and 9/16/24 identified: 1) On 8/16/24, registered nurse (RN)-A had punched in for work for 3.2 hours. The facility lacked evidence that any other RN had worked that day. 2) On 8/17/24, RN-B had punched in for work for 3.9 hours. The facility lacked evidence that any other RN had worked that day. 3) On 8/18/24, the facility lacked evidence that an RN had worked that day. Interview on 9/18/24 at 12:38 p.m., with business office manager identified she review RN coverage each payroll. She confirmed that RN-A had only worked 3.2 hours on 8/16/24 and revealed that no other RN had worked that she could tell. A follow up interview at 1:16 p.m., with business office manager revealed that RN-C had also worked on 8/16/24 for 2.7 hours but there still had not been 8 consecutive hours worked. On 8/17/24, RN-B had only worked a couple hours and had called in for work on 8/18/24. She confirmed there had been no RN replacement for RN-B. She further identified that the administrator had reached out to the corporate office and was told that the facility was to get 4 free days of no RN coverage per quarter in order for the Provider Based Jornal (PBJ) to trigger RN coverage as a concern. Per phone call during exit on 9/18/24 at approximately 1:35 p.m., with administrator identified per his understanding according to their corporate office, the facility had 4 days each a quarter that they did not have to meet the RN hourly coverage according to the PBJ regulation. No policy related to RN coverage or staffing was provided by the end of the survey. Review of the Sufficient and Competent Nurse Staffing Review pathway, located in the Surveyor Resources Folder at https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes, identified Note: The rule of 4 or more days is used for the purposes of the PBJ Staffing Data Report. The expectation of CMS is that the survey team would consider issuing a citation when a minimum of one day is identified to not meet the nurse staffing requirement for both a Registered Nurse and Licensed nursing staff.

Based on observation, interview and document review, the facility failed follow manufacturer's safety instructions for safe transfers for 1 of 2 residents (R4) who was not transferred with the appropriate mechanical lift sling. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], indicated severe cognitive impairment with the diagnoses of aphasia, dementia, anxiety, and depression. R4 had physical and verbal behaviors toward others, and rejection of cares one to three days during the look back period. R4 had impairment to one side of upper extremity and used a wheelchair. R4 was dependent for all his activities of daily living (ADLs) except for dressing of upper body, which required partial assist. R4 did not walk. R4's ADL care related to transfers dated 12/7/23, directed staff to use two staff assistance to transfer with mechanical lift. R4's care plan did not identify the size and type of sling R4 required. During an observation on 7/30/24 at 12:17 p.m., R4 had returned from hospital and was sitting in wheelchair on Guldmann ceiling lift sling that the hospital had used to transfer R4 to his chair to return to the facility. R4's room was not observed to have a ceiling lift. Nursing assistants (NA's) brought a Volaro total body lift into R4's room. NA-T and NA-K hooked the Guldmann sling to the Volaro lift. NA's lifted R4 into the air, they did not stop the lift to check the tension of the sling straps and transferred R4 from wheelchair to the bed. NA-T and NA-K stated they were not aware the Guldmann sling was not approved by Valaro manufacturer to use with Valaro lifts. Interview on 7/30/24 at 3:31 p.m., Administrator stated that NA-T and NA-K informed him that I watched the transfer of R4 with the wrong sling and Administrator stated he re-educated the staff they should have changed the sling out to the Volaro sling as the Guldmann sling was not compatible to use with the Volaro lift. During an interview on 7/30/24 at 4:07 p.m., Valaro lift representative (LR)-A stated the manufacturer would not recommend the use of any other sling with the Volaro total body lift. LR-A stated he would have advised the staff to change out the sling with a Volaro sling prior to the transfer to ensure safety. During a clarification interview on 8/7/24 at 2:24 p.m., administrator stated they did not have a policy regarding transferring resident but use the competencies to verify correct usage of mechanical lifts. Valaro Operator's manual included Use only Volaro slings and accessories designed for use with the Volaro lift models

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R6, R10, and R11) were appropriately vaccinated against pneumonia and offered updated vaccinations and/or additional vaccinations when identified or upon admission. Furthermore, the facility failed to have a method or system to ensure the facility offered or provided any initial or updated vaccines to residents per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 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 e) Received PCV-13 at Any Age AND PPSV-23 AFTER Age [AGE] years: aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. R6 was under age 65 and was admitted to the facility in July of 2023. R6 had received a PCV 13 on 4/21/17, prior to her admission. R6 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 upon admission. R11 was age 79 and admitted to the facility in January 2018. R11 received the PCV-13 on 8/2/18. R11 should have been offered and/or provided the PCV-20 at least 1 year after prior PCV-13. R10 was age 81 and admitted to the facility in November 2021, R10 received the PCV-13 on 9/30/15. R10 received the PPSV-23 on 12/28/11. R10 should have been offered and/or provided the PCV-20 at least 1 year after prior vaccination. Interview on 1/30/24 at 2:33 p.m., with infection preventionist identified she uses a CDC online tool to determine if a resident is due for a vaccination. She identified that for the above-mentioned residents the tool indicated their vaccinations were complete. In the recommendation box on the tool it also identified staff were to use shared clinical decision-making to decide whether to administer one dose of the PCV-20 at least 5 years after the last pneumococcal vaccine. There was no indication staff had contacted the providers to see if the PCV-20 should be offered. Review of the 10/5/23 LTC pneumococcal vaccination policy identified: 1) All residents will be provided with the opportunity and encouraged to receive pneumococcal vaccinations. 2) On admission each resident will be questioned regarding history of receiving the pneumococcal vaccinations and staff were to offer vaccinations each year if a resident was eligible. 3) The director of nursing/designee was to be responsible for following up with the physician's office when questions arose.

Based on document review and interview, the facility failed to ensure 1 of 1 required member (infection preventionist) and/or their designee attended the quarterly Quality Assurance Performance Improvement (QAPI) meetings. Findings include: Review of the quarterly QAPI meeting attendance forms for February 2023, May 2023, August 2023, and November 2023, identified the facility infection preventionist was not present at the meetings however, her name and title of ADON/Infection preventionist was listed as a member of the committee. Interview on 1/31/24 at 1:18 p.m., with registered nurse (RN)-C who was also the infection preventionist identified the reason she did not attend the QAPI meetings was that they were held on Wednesdays, and she was scheduled to work as the charge nurse and complete wound rounds. Interview on 1/31/24 at 3:45 p.m., with administrator identified he was unaware the infection preventionist was required to attend the QAPI meetings. He revealed he knew the director of nursing (DON) was required and thought the DON could relay the infection control information at the meetings. He revealed he had already started to adjust the infection preventionist schedule for her to attend the meetings. Review of the October 2018, Quality Assurance and Process Improvement Plan identified the executive director and executive leadership team appointed the QAPI committee member which included 2 non-licensed employees. The QAPI committee would consist of the director of nursing, the medical director, the executive director, the infection control, and prevention officer, and 2 additional employees.

Based on interview and document review, the facility failed to ensure an allegation of misappropriation of a resident's money was reported to the State Agency (SA) in a timely manner for 1 of 2 residents (R11) reviewed. Findings include: R11's 11/14/23, quarterly Minimum Data Set (MDS) assessment identified his cognition was intact and he required some assistance from staff with toileting, dressing, and personal hygiene. R11 had diagnosis of dementia, and non-compliance and used a wheelchair or walker for mobility. Interview on 1/29/23 at 10:21 a.m., R11 identified he was missing $330.00. He identified that he had reported the missing money and stated, they said they would investigate but it never happened He was not certain of the dates that the money had went missing, but it had been during the last few months. Interview on 1/30/24 at 1:36 p.m., with the administrator identified when money or something of value is reported missing and they are unable to locate the missing item, they file a report to the SA and complete an internal investigation. The administrator identified he did not report R11's allegation of missing money because R11 would not answer his questions. He also identified the facility did not complete a grievance because R11 would not cooperate with an investigation. Additional interview on 1/31/24 at 10:00 a.m., administrator identified he did not believe this allegation of missing money should be reported because suspicion of a crime is defined by a 'fact and he had no facts, only mere suspicion which is not reportable. He stated, I have a police officer here and I have talked to him about this and he agrees with me he is willing to come down and explain the definition of suspicion vs mere suspicion to you. Review of a facility provided summary of their investigation identified that on 12/29/23 at 3:00 p.m., R11 had given nursing assistant (NA-A) $130.00 in the form of a tip, when the social service designee (SSD) attempted to return the money R11 reported to her that he had been missing about $330.00 over the last 6 months. R11 wanted to know what the facility was going to do about it. The summary identified that the SSD attempted to ask R11 some questions about the allegation of missing money but R11 would not speak to her. The SSD reported the allegation of missing money to the administrator at 10:00 a.m., both the administrator and SSD went back to R11's room to speak with him about the missing money but R11 was angry, and he told the administrator to get out of his room. The administrator identified in the summary that he had called R11's brother and asked if he had given R11 any money, the brother said no. R11 had not mentioned any missing money to him. He identified that he was not certain if R11 had any money. The summary identified that staff working on 12/29/23, did not know of R11 having money. The facility reported R11 did not mention to any other staff that he was missing money and identified that they are not reporting the allegation of missing money because they are not able to determine if R11 had any money, because R11 became angry, refused to be interviewed, and had not reported the missing money to the facility. Interview on 1/30/24 at 2:28 p.m., with NA-A identified R11 had given her a tip in the amount of $130.00 and she turned it in to the nurse. She stated He had been to the casino and won a lot of money, I heard that from other staff NA-A identified that she and other staff were aware that R11 frequently went on outings with his brother to the casino and he had just been there the previous weekend. Later interview on 1/31/24 at 8:08 a.m., with R11 reported he gave NA-(A) the $130.00 tip because she needed a winter coat. He did not want that money back, but he did want the money that was stolen from him. He stated, I had about $300.00 stolen from me over 2 different times He identified that the first time was from his billfold that was in the top drawer of his dresser. The second time was again from his billfold but this time it had been in the top drawer of his nightstand. R11 identified that he goes to the casino with his brother, sometimes he wins and that is where the money came from. Review of the 10/19/2022, Vulnerable Adult policy identified the facility would report allegations of misappropriation of resident property that is not reasonably explained, immediately (as soon as possible) after discovery of the incident.

Based on interview and document review the facility failed to perform a thorough investigation in a timely manner following allegations of potential misappropriation of residents' property for 2 of 2 residents (R11 and R17). Findings include: R11's 11/14/23, quarterly Minimum Data Set (MDS) assessment identified his cognition was intact and he required some assistance from staff with toileting, dressing, and personal hygiene. R11 had diagnosis of dementia, and non-compliance and used a wheelchair or walker for mobility. Interview on 1/29/23 at 10:21 a.m., R11 identified he was missing $330.00. He identified that he had reported the missing money and stated, they said they would investigate but it never happened He was not certain of the dates that the money had went missing, but it had been during the last few months. Interview on 1/30/24 at 1:36 p.m., with the administrator identified when money or something of value is reported missing and they are unable to locate the missing item, they file a report to the SA and complete an internal investigation. The administrator identified he did not report R11's allegation of missing money because R11 would not answer his questions. He also identified the facility did not complete a grievance because R11 would not cooperate with an investigation. Additional interview on 1/31/24 at 10:00 a.m., administrator identified he did not believe this allegation of missing money should be reported because suspicion of a crime is defined by a 'fact and he had no facts, only mere suspicion which is not reportable. He stated, I have a police officer here and I have talked to him about this and he agrees with me he is willing to come down and explain the definition of suspicion vs mere suspicion to you. Review of a facility provided summary of their investigation identified that on 12/29/23 at 3:00 p.m., R11 had given nursing assistant (NA-A) $130.00 in the form of a tip, when the social service designee (SSD) attempted to return the money R11 reported to her that he had been missing about $330.00 over the last 6 months. R11 wanted to know what the facility was going to do about it. The summary identified that the SSD attempted to ask R11 some questions about the allegation of missing money but R11 would not speak to her. The SSD reported the allegation of missing money to the administrator at 10:00 a.m., both the administrator and SSD went back to R11's room to speak with him about the missing money but R11 was angry, and he told the administrator to get out of his room. The administrator identified in the summary that he had called R11's brother and asked if he had given R11 any money, the brother said no. R11 had not mentioned any missing money to him. He identified that he was not certain if R11 had any money. The summary identified that staff working on 12/29/23, did not know of R11 having money. The facility reported R11 did not mention to any other staff that he was missing money and identified that they are not reporting the allegation of missing money because they are not able to determine if R11 had any money, because R11 became angry, refused to be interviewed, and had not reported the missing money to the facility. Interview on 1/30/24 at 2:28 p.m., with NA-A identified R11 had given her a tip in the amount of $130.00 and she turned it in to the nurse. She stated He had been to the casino and won a lot of money, I heard that from other staff NA-A identified that she and other staff were aware that R11 frequently went on outings with his brother to the casino and he had just been there the previous weekend. Later interview on 1/31/24 at 8:08 a.m., with R11 reported he gave NA-(A) the $130.00 tip because she needed a winter coat. He did not want that money back, but he did want the money that was stolen from him. He stated, I had about $300.00 stolen from me over 2 different times He identified that the first time was from his billfold that was in the top drawer of his dresser. The second time was again from his billfold but this time it had been in the top drawer of his nightstand. R11 identified that he goes to the casino with his brother, sometimes he wins and that is where the money came from. 49336 R17's admission Minimum Data Set (MDS) dated [DATE], identified her cognition was moderately impaired and had a diagnosis of dementia, anxiety, and depression. Review of 12/19/23, report to the State Agency (SA) identified R17 stated she was missing $100.00 that her son left her in her top drawer. The facility spoke to family members (FM)-E and FM-D, who identified FM-E had brought $100.00 in twenty-dollar bills to the facility. When he had returned a week later, the money was gone. FM-E reported he assumed staff had placed it in the facility safe and did not report it missing. The administrator searched the facility safe and the money was not there. With permission from R17 the administrator searched her room. While searching the room, R17 reported she thought her husband had taken the money home with him. The facility was unable to reach the husband for interview. The facility had interviewed 12 staff who denied knowing the money was in R17's room or taking any money from R17's room and had notified local law enforcement. Review of the undated, facility investigation notes identified the facility had spoken to several staff, however, there was no indication the facility had conducted a thorough investigation and interviewed other residents and/or families about potential missing money. 12/19/23 progress note entered at 10:27 a.m., the social service designee (SSD) identified R17 reported to facility staff she was missing $100.00. SSD identified she was unable to verify how R17 obtained the money. Interview on 1/30/24 at 9:59 a.m., with law enforcement (PD) stated he was in contact with the facility administrator and their investigation was ongoing. Interview on 1/30/23 at 10:03 a.m., with FM-E and FM-D identified FM-D had brought in $100.00 to the facility for R17. FM-D left the money on R17's dresser so she could get her hair done. FM-D was not certain what happened to the money and had made the decision that going forward neither FM-E and FM-D would not leave any cash with R17 at the facility. Interview on 1/30/24 at 12:29 p.m., with the administrator identified could not provide copies of staff investigations from the incident, because they were not completed as part of a thorough investigation. Interview on 1/30/24 at 4:06 p.m., with director of nursing (DON) identified no other residents in the facility had related reports of missing money since 2021. The DON was not routinely involved with investigations at the facility as they were conducted by the administrator. Interview on 1/30/24 at 4:25 p.m., with administrator identified he had completed a staff group interview he asked them if they took the money out of R17's room. The administrator identified that he later confirmed a family member had in-fact brought in 5 twenty-dollar bills but had not reported it right away when he discovered it was missing. He identified 2 weeks had passed by the time the facility was made aware, therefore the facility was unable to identify a perpetrator. There was no indication the administrator met with staff individually or residents and/or their families to identify the pervasiveness of the issue, nor if staff had knowledge or suspicions of other staff they may not have wanted to state publicly in a group setting. Review of 10/19/22, Vulnerable Adult policy identified the facility was to identify, intervene, and correct situations in which abuse, neglect, mistreatment and/or misappropriation of resident property may occur. The Internal Reporting Procedure identified the Supervisor, DON, or administrator would immediately conduct an internal investigation of the reported incident and may include interviews from staff, residents and witnesses. There was no indication the facility had specific steps on how to conduct a thorough investigation, who was to be responsible for those steps, or how they would determine they had interviewed other residents and their families, checked with other residents and their lock boxes to ensure their monies were still accounted for, or interviewed staff privately to identify their knowledge of the situation etc

Based on interview and document review, the facility's current administration failed to ensure proper oversight nursing staff licensure. This deficient practice resulted in a licensed practical nurse (LPN) working scheduled shifts with administrations knowledge under an expired licensed. Findings include: Review of license practical nurse (LPN)-A employee file revealed an expired licensed as of [DATE]. Review of facility schedule revealed LPN-A was currently scheduled to be working and had been scheduled since [DATE]. During an interview on [DATE] at 5:05 p.m. LPN-A stated nursing license had expired on [DATE], and forgot to renew them. LPN-A confirmed she had worked from [DATE], until [DATE], as a licensed nurse without a current license. LPN-A also stated the director of nursing (DON) called her on [DATE], and informed her to renew her nursing license. LPN-A verified on [DATE], she had paid the $106 fee to renew nursing license, and on [DATE], the DON called and asked why her nursing license was still expired. LPN-A stated called the Minnesota Board of Nursing (MNBON) on [DATE], and was informed she was required to provide proof of continuing education units (CEU's), verify employment and hours worked, and pay a fine of $170 for working as a LPN without a current license. LPN-A stated she had understood once the renewal fee of $106 had been paid on [DATE], her nursing license would have been reinstated, but had not received confirmation from the MNBON or checked for verification on the website. LPN-A stated she was allowed to work at the facility as a licensed practical nurse and charge nurse, completed nursing duties such as medication administration, insulin injections, nursing assessment and all other nursing duties from [DATE], through [DATE]. LPN-A stated she had received a phone call from the administrator on [DATE], discussed the situation, and agreed should have been off work until my nursing license were reinstated. During an interview on [DATE] at 11:19 a.m. DON stated the facility was expected to have provided nursing coverage 24 hours a day with a nurse that had current licensure to ensure proper care of the residents. DON stated nursing staff would not be allowed to work when they had an expired nursing license. DON verified had been her responsibility to assure all nursing staff had current nursing license and was aware on date of hire LPN-A's nursing license expiration date was [DATE]. DON indicted they later realized, not sure of date, LPN-A nurse's licensed had expired on [DATE]. DON stated on [DATE], they called LPN-A and informed her she needed to renew her nursing license, and assisted her with the cost. DON received verification through her credit card it was paid and assumed LPN-A nursing license was renewed, however did not check the MNBON website. DON stated she returned to work the following Monday on [DATE], checked the MNBON website, and LPN-A's nursing license was listed as inactive so they assisted LPN-A to submit the required documents. DON verified LPN-A worked at the facility as a LPN from [DATE], through [DATE], without current nursing license. DON stated LPN-A was allowed to work as a TMA on [DATE], approximately 3 ,d+[DATE] hours then taken off the schedule until [DATE]. During an interview on [DATE] at 12:33 p.m. administrator stated had been on vacation [DATE], through [DATE], but was made aware of LPN-A's expired nursing license on [DATE]. Administrator verified the DON was made aware of LPN-A's expired nursing license on either [DATE], or [DATE]. Administrator indicated he had worked on licensure tracking on [DATE], and a TMA had reported to him that day also LPN-A had been working with an expired nursing license. Administrator stated licensed nurses are not allowed to work until nursing license were renewed. Administrator indicated LPN-A was allowed to work on [DATE], [DATE], [DATE], and [DATE], after DON indicated she had received confirmation the license renewal was received. Administrator verified he had not received confirmation of the renewal prior to going on vacation on [DATE]. Administrator indicated facility was required by Centers for Medicare and Medicaid Services (CMS) to have provided a licensed nurse with a current nursing license on every shift. Administrator stated the DON was responsible to have kept track of the licensed staff and expiration dates of each licensure. Administrator also stated would have expected DON to have notified him right away of this incident rather than wait. MNBON statues dated 2022, revealed every licensed practical nurse must maintain with the board a current registration for practice and renewed at regular intervals established by the board by rule. Any licensed person who failed to register within the period shall not be entitled to practice nursing in the state as a licensed practical nurse. A person whose registration had lapsed desiring to resume practice shall make application for registration , submit satisfactory evidence of compliance with the procedures and requirements established by the board, and pay the registration fee for the current period to the board. A penalty fee shall be required from a person who practiced nursing without current registration. Facility document titled Director of Nursing Services-Skilled Nursing Facility Essential Job Functions dated 2018, identified assist with hiring nursing staff and retain quality staff to carry out nursing care and services. Facility document titled Executive Director/Administration Essential Job Functions dated 2019, identified the administrator was expected to oversee and conduct regular rounds to monitor deliver of nursing care, monitor Human Resources to ensure compliance with employment laws, company policies, and to ensure practices maintain high morale, staff retention, including effective communication, prompt problem resolution, and a proactive work environment.

Based on interview and document review, the facility failed to identify and act upon an emergent change of condition (COC) for 1 of 1 resident (R36) who had significant changes in her health. The facilities failure to get immediate emergent medical evaluation resulted in delayed treatment for severe sepsis (life threatening infection) resulting in serious harm. R36 died that afternoon in the hospital as a result of her infection. The IJ began on [DATE], when the facility failed to appropriately identify and intervene when an emergent COC occurred for R36 whose health had dramatically declined. The facility administrator and director of nursing (DON) were notified of the IJ on [DATE] at 2:26 p.m The IJ was removed on [DATE] at 11:29 a.m., but non-compliance remained at the lower scope and severity of D: ISOLATED, the potential for more than minimal harm that is not immediate jeopardy. Findings include: R36 was admitted to the facility on [DATE], from a regional hospital after having had a fall with fracture with diagnoses of congestive heart failure with a recent history of acute respiratory failure (life threatening emergency requiring medication and potential breathing treatment), and recent pelvic fracture. R36's admission note dated [DATE], identified R36's vital signs were all within normal limits upon admission. They were as follows: blood pressure (BP) ,d+[DATE] millimeters of mercury (mm/hg) pulse (P) 71 beats per minute (bpm), temperature (T) 97.7 degrees Fahrenheit and her respiratory rate (RR) was 20 breaths per min (bpm). R36's progress notes and accompanying vital signs identified from [DATE] to [DATE], R36 had no signs of declining health until a progress note was made on [DATE] at 2:08 a.m., when licensed practical nurse (LPN)-B identified R36 was noted to have been uncomfortable all night. This writer noted mottling [web-like pattern on the skin appearing red, bluish, or purple, signaling poor circulation] and nail beds bluish [also a sign of low oxygen. R36 had been on the bed pan once, was continent of urine, but staff noted she had scant amounts. Staff noted they had checked her RR at 1:15 a.m. and noticed the beginning of a decline. R36 had a RR of 36 with audible wheezing. Staff then administered an Albuterol inhaler. LPN-B then noted R36's respirations had increased over the last two hours. Her RR was 44 and her SpO2 had dropped to 77% (dangerously low oxygen saturation (SpO2) normal is 95 to 100%)on room air. LPN-B administered oxygen at 2 liters (L) per minute. Will continue to monitor . LPN-B lacked noting at [DATE] at 2:08 a.m. progress note that R36 also had a slight fever of 99.3 F, and her blood pressure had decreased from her normal to 112 /56 mmHg. There was no indication LPN-B identified the emergent decline in R36's overall health status or called emergency medical services (EMS or 911) or called the hospital's on-call physician who was located across the street in the local hospital emergency room (ER). R36's progress note dated [DATE], identified staff had reportedly re-checked R36's SpO2 at 3:15 a.m., while she was on 2 L of oxygen. R36's SpO2 was 97% at that time. There is no documentation to support this was an accurate reading as it was not included in the vital sign charting, or if a physical assessment had been performed by the nurse to check for RR, skin changes to show continued lack of oxygen, or if her RR had decreased from 44. Review of R36 progress notes lacked any other updated information until 8:04 a.m., 5 hours later when LPN-B noted Resident very hypoxic this morning. O2 81% at 4 liters. Nail beds dark blue .ambulance called to send her to [regional hospital] per [R36's] request. Staff noted the ambulance arrived at 7:00 a.m., and it was discovered by EMS, R36's BP had dropped to 80's over 40's (seriously low BP. Normal is 120's over 80's). At that time, the determination was made to take R36 to the local ER across the street for emergency treatment. The last note made on [DATE] at 1:15 p.m. identified the local hospital called the facility to inform them R36 had been admitted with a diagnosis of sepsis (serious and often life threatening whole body infection). Interview on [DATE] at 1:48 p.m. with the director of nursing (DON) and the regional nurse consultant (RNC) identified both were unaware of the COC that occurred with R36 prior to her emergency transfer and subsequent hospitalization . The RNC stated would do random audits on medical records to identify problems or concerns with care if she had been made aware. The DON was unaware of the situation as she had been on vacation at the time the incident occurred. Both noted the facility had no policy or procedure or had professional references for nursing to follow with regards to identifying a COC or an emergent situation. Both agreed the incident was an emergency and at minimum, LPN-B should have called the on-call MD across the street at the local hospital if she was unsure how to proceed, but because R36 showed such a drastic decline in her health, EMS should have been called right away at 2:08 a.m Both agreed LPN-B failed to perform appropriate assessments, identify and emergent situation, and timely intervene on R36's behalf. Interview on [DATE] at 4:46 p.m., with physician's assistant (PA)-B identified he was the on-call provider on [DATE] when R36 was brought to the ER at the local hospital. When R36 arrived, he had very limited information on her condition as the facility failed to call the ER and give any status update. R36 had low oxygen levels, was hypotensive (low blood pressure) and she looked like she was crumping (slang for a major decline). The ER did a complete examination , oxygenated her and identified R36 had sepsis due to a previously unidentified urinary tract infection . R36 was a do not resuscitate (DNR) so they tried giving her fluids to increase her BP. R36's family member came and it was decided to approach palliative care. R36 was given a broadband antibiotic. R36 did recover slightly, however, her condition continued to worsen and R36 passed away later that day. PA-B expected LPN-B or any other nursing staff at the facility should have called theER on -call service at minimum to ask questions on a non-emergent basis. However, had he received a call, he would have instructed them to immediately call 911. The IJ was removed on [DATE] at 11:29 a.m., when it could be verified through staff interviews and document review, the facility had created a policy and procedure specific to a resident' COC, had purchased nursing reference book, and had educated all nurses, including LPN-B prior to their next shift, and had a process for all staff to be re-educated for those not currently working.

Based on observation, interview, and document review, the facility failed to appropriately assess, monitor, and intervene when 1 of 1 resident (R1) with known increasing physical behaviors caused by dementia, physically abused 5 of 35 residents (R2, R3, R5, R6 and 1 unknown resident) resulting in skin tears, a lacerated lip, and 2 puncture wounds caused by biting. R1 was also at risk for abuse when 1 of 1 resident (R4) threatened to harm R1 with his oxygen tank. This resulted in an immediate jeopardy (IJ). The IJ began on 5/9/21, when R1 had physically assaulted R3 by grabbing R3's arm and pinching her and the facility failed to assess R1's dementia and behaviors and develop interventions to manage behaviors and prevent further resident to resident altercations. The facility's administrator and director of nursing (DON) were notified of the IJ on 7/23/21 at 2:52 p.m. The IJ was removed on 7/26/21 at 11:00 a.m Non-compliance remained at the lower scope and severity of E (pattern), no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's 6/17/21, quarterly Minimum Data Set (MDS) identified R1 had severely impaired cognition and was independent with walking throughout the facility. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her 12/24/20, Care Area Assessments identified R1 triggered for behaviors, mood, and this was to be addressed in her care plan. R1's current, undated care plan identified R1 was able to ambulate independently in the facility with use of a walker and needed cueing and reminders to use her walker. R1 had cognitive loss and dementia. Staff were to administer her medication as ordered and observe for side effects and effectiveness. Staff were to notify the doctor (MD)-A for mental health and medication adjustments. Staff were to cue and supervise as needed. R1 was noted to wander frequently into other resident's rooms. Staff were to redirect R1 as they are made aware or discover that occurring. R1 was identified as being dependent on staff for activities. R1 was noted to have a history of traveling with her spouse to all states and overseas, played cards, watched high school sporting events, and was active with walking, riding bike, bowling, church, baking, sewing, crotchet and played clarinet. R1's current preferences included reading, visiting with others, attending church, playing bingo and card games, attend outings, shopping, being outdoors and do independent religious devotions. Staff were to encourage exercise and activity games, reminisce in topics form her years of being a homemaker. She preferred to watch TV stations and shows like old time dancing on the pioneer channel. R1 was noted to use anti-psychotic medication, anti-depressant medication, and anti-anxiety medication. Interventions for those medications were: R1 was to be free of drug related complications. Staff were to attempt non-pharmacological interventions of golf or football on the facility's iPad, offer cooking magazines, and sweet treats and observe for effectiveness. Staff were also to observe and record R1's target behaviors and symptoms and document per facility protocol. Staff were to consult with pharmacy and the MD when considering a dosage reduction, monitor for medication side effects and complications from medication complications and offer behavior health consults as needed. There was no mention staff had identified R1 had physical behaviors of abuse towards others and was also at risk for abuse. Observation on 7/22/21 at 10:10 a.m. identified R1 was actively participating in kick-ball in the day room. R1 appeared to be engaged in the activity and was seen moving from sitting to standing at a very fast rate. Observation and interview on 7/22/21 at 12:20 p.m. with R1 in the dining room identified she was seated at a table with 4 other residents and 1 staff. R1 was unable to answer basic questions like how is your food?. R1 would only repeat Someone stole my clothes. R1 ate quietly and was easily redirected by staff when she appeared to be wanting to leave. Review of R1's progress notes revealed the following. On: 1) 5/9/21 at 7:15 p.m., R1 was busy walking around prior to supper and in a good mood. She then sat at the dinner table and dozed off, so staff assisted her to her room. She was a little irritated but was willing to get washed up. R1 then got up and started walking in her room and walked into a wall R1 refused to open her eyes when asked. Despite staff noted being calm and taking their time with R1, she became physically aggressive. R1 began kicking and hitting, pinching, grabbing wrists, and ripping a staff's glasses off their face. Staff then left R1 in a safe manner. R1 was noted to have stayed in her room about 10 minutes, then was seen wandering room to room. R1 got a phone call and staff were able to sit her in the hallway where she was able to talk on the phone. A later note at 9:00 p.m., staff documented R1 was in a weird position in a chair in the hall. R3 wheeled herself around R1. R1 then dropped the phone and grabbed R3's arm and began pinching her. R1 eventually let go and the other [unknown] resident came to the nurses station to report the incident. R1 was then put on 15 min checks. 2) 5/10/21 at 1:59 p.m., staff documented R1 came out to the day room and had reached out to touch another resident's (R4) oxygen tank. R4 said he was going to hit her over the head with the oxygen tank if she touched it. Staff intervened and moved the resident away from the area. 3) 5/24/21 at 10:38 p.m., R1 was noted to be entering other resident rooms and went into R2's room and her unidentified roommate at that time. R2 and the unidentified resident became upset. R1 began to scream. Staff were kicked and punched by R1 trying to remove R1 from R2's room. Once staff got R1 into her room, she kicked staff again and told them to get the hell out. R1 was noted to sit in her room and when she was rechecked on, she was much calmer. 4) 6/3/21 at 11:08 p.m., staff noted at around 4:20 that day, R1 began yelling, screaming, and telling staff and residents they were fired, calling police, banging on the entrance door, picking up her walker, shoving walker into staff, exit seeking, and dragging chairs. Staff documented environmental or situational events were R1 was in the dining room. She was easily directed when staff observed her attempting to push another resident in a wheelchair. Staff toileted R1 then set her down in a wheelchair. She appeared to be calm then suddenly she became upset and angry. Details of behavior included the above observations as well as getting a skin tear while she hit staff members picking up her walker as if she was going to attempt to throw it and kicking at anyone who came near. R1's family member (FM)-A was called and arrived at the facility. R1 continued her behaviors directed at her son and was not noted as calm for another 30 minutes. Interventions listed were toileting, walking, 1:1, monitor, re-approach by another staff, remove other residents, redirect visitors to another door, escort to a different environment, have supper in her room. And her son to provide 1:1. 5) 6/8/21 at 11:51 a.m., staff documented R1 received a rectal suppository that morning which was known to upset R1 and escalate her behaviors. An unknown nurse aide (NA) was trying to toilet R1 when R1 began hitting the NA. R1 hit the unidentified staff in the face, and kicked and squeezed staff in an unknown location on on the NA's body. 6) 6/15/21 at 10:29 p.m., R1 was documented to have been screaming during evening cares, pinching staff's upper arms resulting in bruising to staff. Interventions tried were walking with R1, toileting, and providing 1:1 were effective for short periods of time, then restless and wandering started up again. 7) 6/17/21 at 11:34 a.m., the social services designee (SSD) documented a Vulnerable Adult (VA) note indicating a VA assessment was completed and inaccurately included No history of abuse towards others or self noted. 8) 6/18/21 at 12:45 p.m., R1 was observed dropping her pants in the tub room. Staff attempted to stop her. R1 hit and kicked at them. One staff member was noted to have been punched in the shoulder. 9) 6/18/21 at 11:40 p.m., R1 removed her shirt in the dining room. When staff attempted to put R1's shirt back on, she became aggressive and started hitting the NA's. R1 also accidentally hit another resident in the back that was close by. Staff documented they felt she never meant to intentionally hit another resident. When staff assisted R1 to her room, she continued to swing at staff. R1 taken to her room and laid down to bed. 10) 6/21/21, at 1:01 p.m. R1 hitting, kicking, punching and trying to bite staff and moving furniture around in the dayroom. R1 was unable to be redirected. R1 was sent to emergency room to rule out outstanding medical reasons. Further review of R1's progress notes revealed the following. On: 1) 6/24/21 at 10:22 p.m., staff noted they received a call from the ER. R1 was returning to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No physical behaviors were reported. The facility received orders for an as needed (PRN) [MEDICATION(S)] (anti-psychotic) injection as well as a PRN dose of [MEDICATION(S)] to be given in addition to her scheduled dose. 2) 6/26/21 at 9:54 a.m., staff documented R1 was toileted when she screamed, blocked, kicked, and scratched staff. During this episode, R1 bumped the right side of her head on the doorway. No redness or bruising was noted. 3) 6/26/21 at 12:07 p.m., R1 was using profanity at staff, grabbing another unidentified resident's shirt and would not let go. She repeatedly hollered while twisting staff's fingers, kicking, and had bumped her knee on a table while attempting to kick staff. R1 was angry with an unknown cause. R1 was noted prior to the event to be sitting by the nurses station when she began yelling at other unidentified residents. When staff intervened, they were able to get R1's grip released on the other unidentified resident. Staff removed other residents away. This occurred during the entirety of the lunch hour. After yelling, R1 was wandering around the dining room and sat by another resident who removed themselves away from her. Interventions noted were for staff to approach R1 with a smile, attempt to talk, offer sweets, attempt to toilet, redirect her, attempt to remove her from the area, monitor her and other residents' safety, remove other residents away, and approach by other staff members. Staff noted all interventions were ineffective until R1 calmed down but did note it was best to leave in a safe manner and monitor. 4) 6/28/21 at 6:10 p.m., staff documented R1 was restless and wandering into other residents' rooms, telling staff to get away, attempting to sit in random areas, pick items off the floor that were not present, and punched staff in the stomach when staff tapped R1 on the shoulder when they noticed she was not wearing socks or shoes while wandering. Staff interventions attempted were to guide her to the bathroom, offer to wash her up, assist her when taking her clothes off, leave her in a safe manner then re-approach or re-approach with a different staff member, walk with her, and bring her walker to her. Staff noted none of the interventions were effective for long periods. 5) 6/28/21 at 11:33 p.m., staff noted they administered a PRN [MEDICATION(S)] as R1 was demonstrating behaviors of reaching for items on the floor, almost falling, restless, agitated, uncooperative. Staff also noted she was wandering and going into another resident's room. Staff reoriented her to time, offered toileting, sweet treats. 6) 7/1/21 at 11: 24 p.m., staff documented they found R1 on another (unidentified) resident's bed. Staff took her back to her room. R1 became upset. R1 punched staff in the nose. Later when resident had a fall, resident also kicked and pinched staff. R1's blood pressure was taken and recorded to be low. FM-A was notified and opted for R1 to be seen in the clinic the next day, 1:1 supervision for safety. 7) 7/3/21 at 11:36 a.m., R1 returned from a brief admission to the hospital for heart concerns. Staff documented Almost immediately upon her return, [R1] became combative. R1 was stripping her clothes off wanting to put different ones on. R1 became mad because she wanted her original clothing. Staff noted she settled down and laid down. At an unknown time, R5 put his call light on. R1 was trying to lie down with him. 3 staff were required to get R1 out of R5's room. R1 was hitting, punching, attempting to bite staff and tried to sit down. R1 was held up by staff when trying to sit down and put into a wheelchair. Staff took R1 to her room where she finally laid down and fell asleep. Staff noted they did not wake her for lunch. 8) 7/5/21 at 10:35 p.m.,behavior note staff documented earlier that day at 4:14 p.m., prior to R1's second fall, she was observed smacking another resident (unknown identity) on his back as she was pushing him into his room. When staff attempted to redirect R1, she was feisty and uncooperative. A male resident (unknown) reported R1 bit his shoulder. Staff confirmed circular shaped teeth marks. 9) 7/6/21 at 12:59 p.m., staff documented Behavior Note. R1 was found walking down the north hallway naked except for a T-shirt. R1 was redirected back to her room and was dressed. R1 slept for a while, then got up, walked to kitchen, pulled her pants down and urinated on the kitchen floor. Staff then intervened and toileted R1. She was noted to later be going into other residents rooms but settled down and ate her lunch and was currently eating. 10) 7/16/21 at 10:22 p.m. staff noted R1 had scratched and hit another resident (R2). Staff contacted the on-call MD to request an increase to R1's [MEDICATION(S)]. The on-call MD agreed. 11) 7/17/21 at 1:40 p.m., staff documented R1 was in the dining room for lunch when she began wandering and trying to take other residents' water glasses so she could brush her teeth. Staff got other resident's waters away from her, but she was hitting and kicking at staff as they did it. Staff noted they were finally able to calm her down and she is currently in bed sleeping. 12) 7/19/21 at 10:51 p.m., R1 was wandering to different hallways, attempting to go into other resident's rooms, repeatedly stated she was tired or needed to sit. When staff offered her a chair she would get up and wander again. R1 had crying behaviors when staff provided brief 1:1, toileting, and walking. R1's Behavioral Committee (BC) Notes identified the behavioral management team had documented twice on R1's behaviors and accuracy of her care plan. Notes are as follows: 1) 6/3/21 at 8:56 a.m., staff documented they performed an evaluation of R1's behaviors. Psychoactive medications were ordered and in-use. The committee recommended a psychiatry (psych) consult. R1's care plan was reported to be reviewed and updated. R1's dementia was noted to be progressing. R1 had an overall decline. No mention was made that staff identified R1's physical behaviors and lack of supervision when those behaviors occurred or had identified the care plan lacked interventions specific to her physical aggression. 2) 7/1/21 at 12:12 p.m., staff documented they performed an evaluation of R1's behaviors. Psych meds were ordered and in-use. Recommendations were made for a psych consultation. The care plan was noted to be reviewed and updated. R1's progress notes, identified multiple notes between 5/9/21 and 7/23/21 of incidents of physical behaviors and abuse perpetrated on the above-mentioned residents by R1. The notes lacked further indicated R1's behaviors had been reassessed and interventions implemented as R1's behaviors continued after 5/9/21. Interview on 7/22/21 at 10:46 a.m. with the social services designee (SSD) identified R1 had resided at the facility prior to her employment in October, 2020. R1 has steadily declined in her cognition due to her dementia. The SSD was not at the facility on 7/16/21 when the incident between R1 and R2 occurred. On Monday, 7/19/21, she followed up with R1. R1 would be restless and wander, once in a while she would pop into other resident rooms. Earlier this month, the SSD reported she spoke with FM-A and explored options for R1's potential placement in other facilities in a locked memory care. R1 saw a psychologist weekly (MD-A), at the clinic across the street. If staff start to see R1's behaviors ramping up, staff are to call for an ambulance to transfer to the regional hospital in Marshall to seek placement in an inpatient behavioral health facility. Staff have requested to have R1's medication adjusted. When this occurred, she would mellow a little. The SSD stated 1:1 were the best to do. When it came to non-pharmacological interventions, she left that up to the interim director of nursing (IDON). The SSD stated she thought wandering was more of the issue. When R1 wanders, she feels it is her space and her room. Staff try to redirect if they see her wandering. Interview on 7/22/21 at 2:02 p.m. with registered nurse (RN)-A and licensed practical nurse (LPN)-A identified when R1 exhibited behaviors she would get restless and have wandering behaviors and would often go into other residents' rooms. Staff attempt to distract her. Nurses do not assign anyone to increase her supervision when she exhibits restlessness or immediately prior to her physical behaviors. We just know her and everyone helps. If nurses are busy and the nurse aides (NA) are busy, the kitchen helps watch her as well. They have no plan or method care planned to identify specific interventions on her care plan to prevent potential future incidents from occurring. We do what we can. Neither RN-A or LPN-A were aware R1 had increased mental health visits with MD-A. The facility has previously requested to increase her medications to see if that helps. Interview and document review on 07/22/21 at 2:32 with the IDON identified she was aware of R1's physical aggression and abuse towards other residents. Staff do behavior rounds monthly and have a behavior committee meeting. The IDON agreed R1's behaviors have escalated since 5/9/21. The facility plan to prevent further physical abuse to residents and staff from R1 was to call the ambulance and send R1 to Marshall hospital for her mental health exam as that is the only way the facility can get R1 admitted to a behavioral health inpatient program. The IDON stated she felt the facility had interventions care planned to manage her behaviors. Staff were to offer R1 an iPad with football or golf on it, cooking magazines, or offer her sweets. The IDON stated if R1 was agitated staff were to do 1:1 supervision. Staff often lead her to her room, but they can anger her even more. The facility has tried a lot of things but nothing worked for very long. the IDON stated she felt staff were providing appropriate supervision and they had gotten her psych medications increased to see if that helped with R1's behaviors. R1 was now seeing MD-A weekly since the 7/16/21 incident when R1 assaulted R2. Review of R1's mental health provider (MD-A)'s progress notes revealed the following: 1) R1 was seen on 5/10/21 after she had assaulted R3 on 5/9/21. MD-A identified R1 came to the clinic for a 3 month follow-up after initially being referred by the facility for behaviors of agitation with dementia and poor sleep. R1 was not counseling with anyone and never has. MD-A stated R1 had previous medication of [MEDICATION(S)] which was causing unstable gait and was of no help for behaviors or her sleep. MD-A reviewed R1's history of past medications R1 had tried. R1 was noted to be in a good mood. MD-A was aware R1 scratched R3. Evidently this is the only incident that happened in the past 3 months. Follow-up in 3 months and to call MD-A if there were problems before that time. 2) 7/14/21, MD-A identified R1 was seen for a 2 month follow-up. MD-A documented R1 had been urinating in various places in the facility. R1 had no prior mental health hospitalization s. The note inaccurately listed No psychiatric consults ever. R1's medications were once again discussed. MD-A identified R1's [MEDICATION(S)] was increased due to her aggressive behavior. MD-A and FM-A discussed cutting back R1's morning dose of [MEDICATION(S)] to see if she can be awake a little bit more in the mornings and try to eat as she has lost a couple pounds in the past couple of days. MD-A noted R1 was deteriorating more since spring and adjusted medications and to follow up in 2 weeks, and call if problems before that time. There was no indication MD-A was aware of the increased physical aggression R1 was exhibiting, nor if she had been asked to assist the facility in identifying if non-pharmacological interventions were appropriate. MD-A was unavailable for interview at the time of the survey. Interview on 7/23/21 at 10:54 a.m. with FM-A identified he was aware of R1's recent incident with R2. R1 had scratched R2. R1 had a recent mental decline. He attended a care conference on 7/20/21. Everyone sees escalating behaviors and these occurred more since Memorial day, 2021. Facility staff told him if there is another altercation, she will be sent to ER then to inpatient psych on a behavioral health unit. Interview on 7/23/21 at 11:45 a.m. with trained medication aide (TMA)-A identified staff would often try to redirect R1 when she had behaviors. Staff were to leave her in a safe space. Interventions included to have her watch golf on the iPad. When asked how staff communicate interventions they had tried she stated We try to pass it along if anything works. The facility had tried to put up banners across other residents rooms to deter R1. That did not work. R1 was very into her appearance in the past so they try and braid her hair or put it up in a bun. TMA-A identified R1's wandering always preceded her physical behaviors .but her wandering would not necessarily start them. If she exhibited behaviors, staff were to stay with her until they think she is calm. There was no set time to directly monitor her. Interview and document review on 7/23/21 at 12:41 p.m. with the administrator identified he agreed R1's care plan lacked appropriate interventions and supervision required and made no mention of R1's physical behaviors or that she was also at risk for abuse herself. Interview and document review on 7/23/21 at 2:00 p.m. with the MDS coordinator (MDS-A) identified she was the sole staff responsible to update care plans in the facility. MDS-A stated she also worked on the floor providing direct care and often provided direct care or medication administration to R1. She agreed the care plan made no mention of R1's physical behaviors and lacked interventions and appropriate supervision required to prevent future incidents of abuse, and failed to identify R1 was at risk of potential abuse from others. Interview on 7/26/21 at 11:54 a.m., with MD-B identified he would see residents at the facility if he was their primary care physician. he was not R1's physician. MD-B was unaware of R1's physical behaviors. He was the medical director as the facility needs a doctor to attend QAPI. those meeting are just generalized. We really don't dig into or analyze issues. MD-B reported he had little involvement with the facility. He was not able to recall if R1 was discussed at the June meeting, but stated he attended. The facility had a psych provider for behavioral health issues to deal with those residents. Review of the January 2020, VA policy identified abuse was the willful infliction of injury resulting in physical harm, pain, or mental anguish. Willful means the individual must have acted deliberately in their actions. All resident-to-resident altercations were reportable to the SA. The facility was to have systems in place to identify residents who were at risk for abusing other residents. During the shift the allegation of abuse occurred, staff were to report to their supervisor. the supervisor was to immediately report to the administrator and DON. An immediate investigation was to begin and include interviews, environmental reviews, behavior reviews, and medication reviews. Abuse prevention was to include assessment of the resident's environment and adequate staffing and supervision of staff to identify inappropriate behaviors. Residents were to be continually assessed, care planned, and monitored in order to identify needs and behaviors. Review of the Mood and behavior Rounds Guideline policy identified mood and behavior rounds were specific meetings with staff that were to provide care dedicated to the knowledge of the resident. Meetings were to be conducted routinely and each resident reviewed monthly. Staff were to have discussion regarding prior observations of resident behavior, assess non pharmacological interventions and determine appropriate interventions. Staff were to discuss potential triggers for behaviors and review the medical record for adverse effects of medications such as falls, weight loss, to determine if the medication and/or dosage was appropriate. The resident's care plan was to be reviewed to determine if all areas on the care plan were appropriate. At the end of the evaluation, the committee was to determine an action plan and further follow-up. There was no policy specific to dementia care provided at the time of the survey. The IJ was removed when it could be verified staff had assessed R1 and implemented appropriate interventions for when R1 would become physically aggressive. Staff were to provide 1:1 supervision when R1 was identified as wandering or had behaviors to ensure behaviors had not escalated. Staff were educated to the interventions and R1's care plan was updated.

Based on observation, interview and document review, the facility failed to identify signs and symptoms of COVID to ensure implementation of transmission-based precautions (TBP) for 3 of 6 residents (R3, R4, R5) in accordance with Centers for Disease Control (CDC) guidelines to prevent or minimize COVID-19 transmission; failed to ensure staff appropriately implemented use of personal protective equipment (PPE) while transporting 1 of 1 readmitted resident (R1) who was COVID positive; and failed to review and revise infection control policies annually. The facility's failures resulted in an immediate jeopardy (IJ) situation for 18 COVID negative residents residing in the facility. The IJ began on 12/5/20, when the facility failed to identify symptoms of COVID-19 and immediately implement TBP and quarantine. The administrator and director of nursing (DON) were notified of the IJ on 12/29/20 at 3:34 p.m. The IJ was removed on 12/30/20, but non-compliance remained at the scope and severity of E, a pattern with potential for harm that is not immediate jeopardy. Findings include: SCREENING/ TBP R3's progress notes identified from 12/5/20, through 12/15/20, R5 experienced daily documented diarrhea stools. On 12/6/20, progress notes indicated R3 was unresponsive to questions. Her eyes were open, but not following movement, and she had right-sided facial droop. R3 was sent to the ED for evaluation and was diagnosed with [REDACTED]. There was no mention whether a COVID test was conducted. On 12/15/20, R3 was noted by staff to be feeling quite warm and the progres note indicated the resident wasn't herself. R5 was assessed and found to have a T of 100.5 degrees F and and SpO2 92%. R3 was described as lethargic and quiet. A RAPID COVID test identified R3 was positive for COVID-19 at which time the resident was placed on isolation with TBP implemented. There was no documentation to support whether TBP had been immediately implemented when diarrhea, a symptom of COVID, was identified on 12/5/20. R5's progress notes identified on 12/12/20, R5 had diarrhea. R5's daily COVID screening documentation from 12/12/20 identified R5 had no signs or symptoms that day. On 12/13/20, R5 had been found seated in his wheelchair, leaning to the right, and had right sided weakness. The progress notes indicated staff had assessed R5 who was found to have a temperature (T) of 100.3 degrees Fahrenheit (F) and an oxygen saturation level (SpO2) of 92% (normal 95-100%). The progress notes indicated R5 was then transferred to the emergency department (ED) where he was diagnosed with [REDACTED]. R5 returned to the facility on [DATE] at 12:41 p.m., and was admitted to the COVID designated wing with TBP in place. There was no evidence TBP were implemented on 12/12/20 when the resident first exhibited diarrhea, a potential symptom of COVID-19. R4's progress notes identified on 12/16/20, R4 had complained of indigestion and a headache. On 12/17/20, the notes indicated R4 again complained of not feeling well, had aching legs and was feeling dizzy. Review of the documented COVID symptom screen from 12/16/20, did not identify R4's headache or gastrointestinal symptom of indigestion as symptoms of COVID-19. R4 tested positive for COVID on 12/18/20 at which time TBP were initated. Review of the facility's Infection Control Surveillance identified none of the symptoms for R3, R4 or R5 were included in the IC surveillance when first identified by staff. PPE During observation and interview on 12/28/20 at 12:05 p.m., R1 was seen entering the main entrance of the facility transported by an unknown hospital staff wearing full PPE. Registered nurse (RN)-A was notified of R1's arrival from the ED (emergency department). RN-A, who was wearing only a mask and eye protection, left her medication cart to greet R1. RN-A did not sanitize her hands, apply gloves, or apply a gown prior to meeting R1 in the facility's entryway. RN-A placed a hand on R1's shoulder, spoke to her, and transported R1 across the common area to the entrance of the designated COVID-19 unit. RN-A opened the COVID-19 unit door with her un-gloved hands, spoke to an unidentified staff person inside who was wearing full PPE, and left R1 in the care of the staff in the COVID unit. RN-A returned to the medication cart and without performing hand hygiene, began handling medication administration supplies including a multi-resident use applesauce container used for med pass. RN-A then handled a multi-resident use use blood glucose monitor, step away from the medication cart and entered the medication room, touching the refrigerator and treatment cart with her hands before the surveyor intervened. During interview at 12:10 p.m. on 12/28/20, RN-A stated she had not realized her breaches in infection control (IC) procedures. RN-A stated she was not aware of the surfaces she had contacted with her unwashed hands, and identified she would have continued with putting items away and gone about administering medication to the remaining 18 residents not on the COVID unit. RN-A also verified she was aware R1 was positive for COVID-19. When interviewed on 12/28/20 at 11:12 a.m., the director of nursing (DON) verified RN-A's actions were not consistent with appropriate IC measures. The DON verified RN-A should have used full PPE while transporting a COVID positive resident. During interview on 12/28/20, at 1:45 p.m. licensed practical nurse (LPN)-A stated staff completed screening of residents on both the day and evening shifts which included: Temperature (T), SpO2, and a COVID questionnaire. LPN-A stated when a resident was found to have signs/symptoms (S/S) of COVID, the DON or the assistant DON (ADON) would be updated and would provide direction as to whether staff were to continue to monitor symptoms or request a RAPID test be completed. LPN-A further stated when a resident had a change in behavior or cognition then they were usually tested . LPN-A stated she was unaware diarrhea was a potential sign or symptom of COVID-19. During interview on 12/28/20 at 2:01 p.m., registered nurse (RN)-A stated she was aware of symptoms of COVID-19 and was aware diarrhea was a potential sign of COVID. However, RN-A said she would first attempt to treat a resident's symptoms with the facilty's standing orders and if effective, would continue to monitor. RN-A said TBP were not immediately implemented when a resident had signs of COVID-19 including diarrrhea. In addition, RN-A stated a RAPID COVID test would also be an option if the nurse felt it was indicated. RN-A stated residents were not placed on TBP unless they had a COVID positive test, or the resident had positive signs or symptoms of COVID that were not relieved by applicable standing orders. When interviewed on 12/28/20 at 2:20 p.m., the administrator and DON stated the facility did not have a specific policy on isolation guidelines, but followed the Centers for Disease Control (CDC) guidelines. In addition, the DON stated the facility would contact the corporate clinical team, and the provider, dependent on the individual S/S. If a RAPID test was indicated, only a positive test would result in TBP otherwise staff would refer to the direction of the clinical team and standing orders. The DON identified a resident who developed GI symptoms of nausea, vomiting, or diarrhea, would be assessed to determine if this was abnormal for that resident. During interview on 12/28/20 at 3:33 p.m., nurse consultant (NC)-A verified the policy directed staff to place a resident on TBP following development of new or abnormal signs or symptoms, including respiratory symptoms, GI symptoms, or an elevated T over 100.0 F. NC-A stated the plan of treatment was to be individualized with the resident remaining on TBP until a negative test result was received along with resolution of signs or symptoms of COVID. During interview on 12/28/20, at 4:05 p.m. the facility's medical director (MD) stated he had not been informed of the facility's outbreak until two days after it was identified. MD stated his expectation was to be notified at the time of a single presumptive or positive occurrence via telephone, not by fax. MD stated the facility was considered to be behind in their response to the COVID outbreak, and verified any abnormal sign or symptom associated with COVID should have resulted in immediate implementation of isolation with TBP with testing for COVID being completed. The MD stated the facility should not have waited to determine if signs or symptoms resolved or medication was effective per previous standing orders prior to implementing isolation and TBP. The facility's infection preventionist (IP) stated during interview on 12/29/20, at 11:06 a.m. COVID symptom screens were to be completed by the charge nurse on duty, and any abnormal signs or symptoms were to be reported to the DON and an assessment completed. The IP stated if a resident had diarrhea, staff were to assess and consider testing prior to intervention of isolation or TBP. During a subsequent interview at 1:45 p.m. that same day, the IP stated they would now begin notifying the provider at onset of any sign or symptom of COVID-19. A resident would then be placed on TBP and assessed for need to be placed in the observation area. When the NC was interviewed at 3:00 p.m. on 12/30/20, she stated the facility had a corporate policy detailing implementation of TBP with procedures to follow, but verified the above residents should have been put into TBP and weren't. Review of the facility's September 2017 policy, Guideline for Standard and TBP for Communicable Diseases and Other Conditions identified TBP categories followed CDC guidelines. The policy indicated TBP were assigned if there was strong evidence for person-to-person transmission via droplet or contact precautions. Although COVID was listed under infectious conditions, the type of precautions required, the duration of those precautions, and the comments section were left blank. Review of the facility's 9/16/17 policy, Practice Guideline and Procedure: PPE, Selection and Use identified staff were to receive training on isolation policies and procedures for recognizing when a resident had a communicable disease. The policy indicated staff were to wear PPE including a gown and gloves for all interactions that may involve contact with a resident or their environment, and identified hand hygiene was important. Review of the facility's 9/2/20 policy, Accura Testing Process, identified the facility was supposed to test any resident who presents with any single sign or symptom of COVID-19. The policy identified signs or symptoms as including: fever/chills, repeated shaking with chills, new loss of taste or smell, diarrhea, congestion/runny nose, muscle or body ache, sore throat, nausea/vomiting, fatigue, shortness of breath, coughing, difficulty breathing, and temperature greater than 100.0 F. The policy further identified when a resident's test results were negative but the resident was symptomatic, the resident should go to the observation wing for a minimum of 10 days. The policy also indicated before a resident could discharge from the observation wing, the nurse would need to get clearance by the Clinical Quality Team. The IJ which began on 12/5/20, was removed on 12/30/20 at 4:00 p.m., when it could be verified by observation, interview and document review the facility had re-educated staff to identify COVID signs or symptoms, had inititaed surveillance documentation, and had initiated isolation and TBP for residents at onset of symptoms of COVID-19. In addition, the facility implemented audits of handwashing, transportation of residents, and a screening process was set up for ongoing monitoring of compliance.

Based on interview and document review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 7 residents reviewed, (R1), when staff failed to follow the care plan and attempted to transfer R1 alone with no gait belt. This resulted in actual harm when R1 fell to the floor and sustained a left femur fracture that required surgical intervention. R1 died eleven days after the fall. Findings include: R1's admission Minimum Data Set (MDS) dated (MONTH) 6, (YEAR), indicated R1 was moderately cognitively impaired, and required two staff assistance for transferring and toileting. R1's physical therapy initial assessment dated (MONTH) 31, (YEAR), indicated R1 required two staff assistance with a front wheeled walker to ambulate, and two staff assistance to transfer. R1's care plan dated (MONTH) 31, (YEAR), indicated R1 required two staff assistance and a front wheeled walker to ambulate to and from the bathroom, and two staff assistance to use the toilet. R1's morse fall scale dated (MONTH) 6, (YEAR), indicated R1 was a low fall risk. Review of nursing assistant (NA)-J personnel file indicated NA-J cleared a background check on (MONTH) 13, (YEAR), and began her employment with the facility on (MONTH) 14, (YEAR). Review of NA-J's position description signed by NA-J on (MONTH) 14, (YEAR), indicated NA-J understood the job requirements including the use of gait belts and utilizing daily assignment sheets and care plans daily to know the most recent care guidelines for assigned residents. NA-J's team member general orientation checklist signed by NA-J on (MONTH) 14, (YEAR), indicated acknowledgment and understanding of the Elder Justice Act. NA-J signed the acknowledgement of receipt and understanding of the employer's employee handbook on (MONTH) 14, (YEAR). R1's physician progress notes [REDACTED]. A facility fax sent to the physician dated (MONTH) 7, (YEAR), indicated R1 slid to the bathroom floor and bumped her head. Neurological checks were started, and R1 had no injuries other than a scrape the size of a nickel on the upper left arm. R1's nursing progress note dated (MONTH) 7, (YEAR), at 11:14 p.m., indicated licensed practical nurse (LPN)-E was called to R1's room due to a fall in the bathroom. R1 was on the bathroom floor with her head against the far door and feet straight out with shoes and socks on but no gait belt on. NA-J stated R1 reached for the assist bars but missed and slid to the floor bumping her head on the far closed door. LPN-E completed range of motion on all four extremities and R1 had no complaints of pain. R1 had a smaller than a nickel size scrape on her upper left arm. The skin was missing from the wound. NA-J was educated on R1's care plan that directed the resident required a gait belt and two person assistance. R1 was assisted to bed with the total lift. R1's resident incident report dated (MONTH) 7, (YEAR), at 11:30 p.m., indicated when R1 attempted to stand from the toilet, R1 missed the assist bar, slid to the floor, and bumped her head on the door. The care plan was not followed as R1 had no gait belt on, and only one NA was assisting the resident and not two according to the plan of care. R1's nursing progress note dated (MONTH) 8, (YEAR), at 5:12 a.m., indicated R1 had no pain symptoms noted. R1's nursing progress note dated (MONTH) 8, (YEAR), at 10:24 a.m., indicated R1 had severe pain and was unable to transfer or complete therapy. R1's left knee was swollen and the kneecap appeared to be dislocated. R1 was sent to the clinic for further evaluation. R1's nursing progress note dated (MONTH) 8, (YEAR), at 2:02 p.m., indicated R1 had a left femur fracture and was being transferred to the hospital. R1's incident report updated on (MONTH) 8, (YEAR), indicated R1 had no initial injury; however, the following morning R1's left knee was swollen and R1 had difficulty transferring. R1 was transferred to the clinic and was discovered to have a left femur fracture. R1 was transferred to the hospital for surgical repair. R1's clinic progress notes dated (MONTH) 8, (YEAR), indicated R1's x-rays revealed a closed [MEDICAL CONDITION] end of the left femur, and R1 was placed in a knee immobilizer. A consult was made to the orthopedic surgeon who recommended surgery. Family gave consent and R1 was transferred to the hospital. R1's hospital records dated (MONTH) 8, (YEAR), indicated the physician had a long discussion with R1 and her family regarding R1's medical problems. A mutual decision was reached that therapy should consist of comfort measures to maximize R1's welfare and minimize R1's suffering. The physician discussed R1's code status with the family and the possible need of intubation to get R1 through the operation, and R1's family consented to the operation. R1 tolerated the surgical repair of her left femur fracture. R1's nursing progress note dated (MONTH) 14, (YEAR), at 2:32 p.m., indicated R1 returned to the facility and was alert, awake, and oriented. R1 had two surgical incisions on the left knee. R1 denied having any pain. A facility investigation report summary dated (MONTH) 14, (YEAR), at 2:24 p.m., indicated it was determined R1's fall was not the direct fault of NA-J, but more a breakdown of facility practice and orientation of new hires. The investigation indicated it was expected all NA's carry the resident care plans on them at all times. NA-J was reinstated to work, but as a result of R1's fall, NA-J received a final written warning for not following the resident care plan which resulted in resident injury. A facility notice of discipline dated and signed by NA-J on (MONTH) 14, (YEAR), indicated NA-J received a final written warning for failure to follow facility safety rules as well as not carrying required resident care plan. NA-J's corrective action plan indicated NA-J would receive education on the requirement of carrying the resident care plan and facility safety rules. R1's nursing progress note dated (MONTH) 16, (YEAR), at 10:05 a.m., indicated R1 received a physician's orders [REDACTED]. R1's nursing progress note dated (MONTH) 16, (YEAR), at 1:19 p.m., indicated R1's pain score was 2.0 on a scale of ,[DATE], indicating mild pain indicators. R1's nursing progress note dated (MONTH) 16, (YEAR), at 4:26 p.m., indicated R1 was resting in bed with family at bedside. Family requested an emergency admission to hospice care due to a decline in R1's health. R1's skin was pale, was not verbalizing, was unable to swallow well, and the resident appeared restless at times. Hospice was contacted. R1's nursing progress note dated (MONTH) 16, (YEAR), at 6:36 p.m., indicated R1 received physician's orders [REDACTED]. R1's nursing progress note dated (MONTH) 16, (YEAR), at 8:52 p.m., indicated R1 was resting quietly in bed after receiving a dose of [MEDICATION NAME]. R1's nursing progress note dated (MONTH) 17, (YEAR), at 12:56 a.m., indicated R1 received [MEDICATION NAME] and [MEDICATION NAME] for restlessness as R1's family did not feel R1 was comfortable. R1's nursing progress note dated (MONTH) 17, (YEAR), at 2:05 a.m., indicated R1 was less restless with [MEDICATION NAME] rather than [MEDICATION NAME], and oxygen was started due to R1's low oxygen saturation level. R1's hospice nursing progress note dated (MONTH) 17, (YEAR), at 1:02 p.m., indicated R1 was admitted to hospice with [DIAGNOSES REDACTED]. R1 was communicating and out of bed 24 hours ago, however, now R1 was unresponsive and in an active phase of passing. R1's nursing progress note dated (MONTH) 17, (YEAR), at 11:43 p.m., indicated R1 was alert to voice and able to understand cues. Family remained at bedside and felt R1 was comfortable. R1's nursing progress note dated (MONTH) 18, (YEAR), at 4:58 a.m., indicated R1 had been given Tylenol and [MEDICATION NAME], and R1 had pain moans with turning. R1 was alert to verbal cues and smiled when asked to smile. Family remained at R1's bedside. R1's nursing progress note dated (MONTH) 18, (YEAR), at 7:44 p.m., indicated family remained at bedside as R1's condition continued to decline. [MEDICATION NAME] had been given every two to three hours for general discomfort. R1 was having periods of apnea. R1's nursing progress note dated (MONTH) 18, (YEAR), at 10:56 p.m., indicated at 10:10 p.m. LPN-E assessed R1 and determined R1 had died . Family remained at R1's bedside. R1's death certificate dated (MONTH) 18, (YEAR), indicated R1's cause of death was natural due to [MEDICAL CONDITION] as a result of multi system organ failure. When interviewed on (MONTH) 19, (YEAR), at 12:20 p.m., trained medication aide (TMA)-G stated staff are expected to use a gait belt with residents that require staff assistance for transfers or ambulating. Staff are routinely reminded and expected to always carry the resident care plans in their pockets. When interviewed on (MONTH) 19, (YEAR), at 12:35 p.m., TMA-H stated R1 needs two staff and a gait belt with every transfer, and two staff, a gait belt, and walker when ambulating R1 to and from the toilet. When interviewed on (MONTH) 19, (YEAR), at 2:00 p.m., registered nurse (RN)-D stated R1 has always required two staff assistance with transfers. When interviewed on (MONTH) 19, (YEAR), at 4:10 p.m., NA-J stated the night R1 fell was her first assignment to night shift since she was hired three weeks earlier. NA-J stated after the night shift received the change of shift report, NA-J and NA-K went to R1's room to assist R1 to the toilet and provide cares. NA-J stated NA-K did not put a gait belt on R1 when NA-K stood R1 up and hung on to the top of R1's pants while R1 pushed the walker to the bathroom. NA-J walked along the other side of R1, but did not touch R1. Once R1 was on the toilet NA-K left the room, so NA-J thought R1 required only one staff assistance. NA-J stated all residents require the use of a gait belt, but since NA-K did not use one NA-J thought she did not need to use one. When R1 was done on the toilet NA-J put the walker in front of R1 and told R1 to grab the bar on the wall in front of the toilet, and NA-J assisted R1 to a standing position. NA-J stated initially R1 was standing fine while hanging onto the grab bar, and then suddenly R1 fell sideways landing on her right hip with her legs between the walker and the toilet. NA-J called on the radio for LPN-E who completed an assessment on R1, while NA-J went to get NA-K. R1 had no complaints of pain after the fall or when staff assisted R1 to bed. NA-J stated at the beginning of the shift she told NA-K she was only familiar with half of the residents. NA-J stated she did not know R1 required two staff assistance, and she was never told about the resident care plans and never saw the other NA's carry them on the evening shift. NA-J stated she completed orientation paperwork with administration, and received training on the floor by other NA's. NA-J stated after R1 fell she was suspended for three days, and received additional training when she returned to work. NA-J had been checked by nurses to ensure she used the resident care plans. When interviewed on (MONTH) 19, (YEAR), at 5:00 p.m. TMA-I stated when she worked with NA-J on an evening shift, NA-J used a gait belt and carried a care plan. When interviewed on (MONTH) 20, (YEAR), at 11:30 a.m., family member (FM)-R stated after R1's fall, FM-R was told staff had used the gait belt to assist R1 to the toilet. Once R1 was on the toilet, staff removed the gait belt to change R1 into her nightgown, and staff forgot to put the gait belt back on R1. One NA left the room to answer a call light, and R1 fell when the remaining NA attempted to transfer R1 alone with no gait belt. R1 told FM-R when R1 tried to stand up from the toilet, R1's hand slipped off the grab bar across from the toilet and R1 fell to the bathroom floor. FM-R stated six days after surgery R1 was doing well and returned to the facility. Two days later R1 started to decline, and was referred for hospice services. Two days after that R1 died . When interviewed on (MONTH) 20, (YEAR), at 5:15 p.m., LPN-E stated R1 required two staff assistance with the gait belt to transfer, and two staff assistance with gait belt and walker to ambulate to the toilet. The night R1 fell , LPN-E was called to R1's room and found R1 lying on the bathroom floor without a gait belt on, and only NA-J was present in the room. R1 was lying on her back with her legs straight and her head up against the bathroom door. LPN-E completed an assessment and found a skin tear on R1's upper left arm. LPN-E checked R1's range of motion and R1 did not complain of any pain. Staff assisted R1 back to bed where LPN-E checked R1's range of motion again, and R1 still had no complaints of pain. R1 told LPN-E she hit her head during the fall, so LPN-E initiated neurological checks on R1. LPN-E monitored R1 throughout the remainder of the night, and R1 had no complaints of pain. The next morning R1 complained of pain and was sent to the clinic for further evaluation, and R1 was found to have a fractured left femur. When R1 returned to the facility following surgical repair of the fracture, R1 decompensated quickly and died a few days later. NA-J told LPN-E as she was turning to assist R1 to transfer; R1 reached for the grab bar across from the toilet and fell to the bathroom floor. NA-J told LPN-E she was orientating and did not know what she was suppose to do. LPN-E stated NA-J had been working other shifts prior to working the night shift. NA-K stated herself and NA-J had walked R1 to the bathroom with the gait belt and R1's walker. Once in the bathroom the gait belt was removed to prepare R1 for bed. LPN-E stated the care plans are always available in the drawer at the nurses station, and LPN-E expects NA's to know what is in the care plan and to carry the care plan with them when working. LPN-E stated when she responded to R1's room after the fall the gait belt was hanging on the back of the resident's room door where it is stored in between uses, and staff would have to step out of the bathroom to reach the gait belt. LPN-E stated she would have expected the gait belt to be on the seat of R1's wheelchair, or lying on R1's bed if staff had been utilizing it when transferring R1 to the toilet. When interviewed on (MONTH) 20, (YEAR), at 2:20 p.m., NA-K stated R1 required two staff and a gait belt to transfer, and two staff with a gait belt and walker to ambulate. The night R1 fell , NA-K and NA-J transferred R1 to the toilet with the gait belt and walker. NA-K removed the gait belt and hung it on the back of R1's room door. NA-K dressed R1 for bed, gave R1 a washcloth and call light, and left R1's room to answer another resident's call light. While NA-K was in another resident's room, NA-J informed NA-K that R1 had fallen. When NA-K returned to R1's room, NA-K saw R1 lying on the floor in the bathroom and LPN-E was assessing R1 for injuries. R1 was moving her legs, did not have any pain and was assisted back to bed. NA-K stated after R1's fall, NA-K checked on R1 throughout the night and R1 never complained of pain. NA-K stated the care plans are kept in a drawer at the nurses' station and everyone is expected to carry the care plan. NA-K stated at the beginning of the shift NA-K asked NA-J if she needed to be refreshed on anything, and NA-J said no. NA-K did not know if NA-J had a care plan the night R1 fell . When interviewed on (MONTH) 27, (YEAR), at 8:00 a.m., NA-L stated when toileting a resident the gait belt is left on except when staff are changing the resident's clothes. If a resident needed their clothing changed, staff removed the gait belt, change the resident's clothes, and put the gait belt back on before assisting the resident off the toilet. When the gait belt is removed while the resident is on the toilet, staff put the gait belt on the walker or grab bar to keep it close by while assisting the resident. When staff are done with the gait belt, it is hung on the back of the resident's room door for storage. When interviewed on (MONTH) 8, (YEAR), at 3:15 p.m., the director of nursing (DON) stated all staff are expected to follow the resident's care plan, and if staff have any questions they are expected to ask the charge nurse, MDS nurse, or the DON. R1 had always required two staff assistance to transfer and ambulate, and R1 never attempted to transfer alone. The DON stated when NA-J was hired on (MONTH) 14, (YEAR), NA-J received facility training, and orientation to the floor including the residents and the residents' care plans. NA-J told the DON when R1 was transferred to the toilet, NA-K was the primary person walking R1 to the bathroom and NA-J was just walking beside R1. NA-J told the DON since NA-K left the room while R1 was on the toilet; NA-J thought it was all right to transfer R1 with just one staff. NA-J then attempted to transfer R1 alone and R1 fell . The DON stated she would expect staff to follow the care plan and use a gait belt and two staff assistance to transfer R1. When interviewed on (MONTH) 14, (YEAR), at 8:30 a.m., the physician assistant (PA)-A, stated he consulted with the orthopedic surgeon regarding the best treatment for [REDACTED]. It was determined surgery to repair the femur fracture was the best option to provide R1 palliative care. PA-A stated R1's health history was more fragile than medical records indicated, and the fracture was traumatic for R1's body. At the time of R1's femur fracture R1 was no longer in good condition, and that affected R1's body's ability to handle the impact the fracture and surgical repair had on R1's system. The facility Fall Risk and Fall Prevention Guidelines revised (MONTH) (YEAR), indicated the purpose was to ensure adequate interventions are in place to decrease, limit and prevent resident falls and ensure resident safety while maintaining their dignity and highest practical level of abilities. The interventions section of the guidelines indicated the goal of the Morse Fall Scale (MFS) is to identify why a resident is at risk for falls. Focusing on the areas of risk identified by the MFS will help to recognize specific interventions to prevent future falls. Included in the interventions were listing all interventions on the care plan and the nursing assistant assignment sheet. Assistive devices such as transfer bar, drop seat, pummel cushion, walker, gait belt, bolstered mattress, and measuring bed height to ensure bed is at appropriate level for the resident. It is the responsibility of the DNS and/or delegate to monitor these preventative measures to assure they are in place. The facility Practice Guideline and Procedure: VA Policy revised (MONTH) 30, 2013, indicated the facility supportsZero Tolerance for resident abuse, neglect, mistreatment and/or misappropriation of resident property. The policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.