Every finding on record at Shirley Chapman Sholom Home East

Based on observation, interview and document review, the facility failed to ensure multi-dose medications were labeled upon opening and discarded in accordance with professional standards for 1 of 2 medications rooms reviewed and 1 of 5 medication carts reviewed for medication storage. Findings include:R92's entry tracking Minimum Data Set (MDS), indicated R92 admitted for short term rehabilitation on 7/16/26. An observation and interview on 7/20/26 at 5:19 p.m., registered nurse (RN)-E was preparing to administer Lispro insulin to R92. When R92's insulin pen was removed, the open date and initials label was blank. RN-E stated all insulin pens were supposed to be dated with the open date, but on the transitional care unit (TCU) residents were not here for very long so it gets missed sometimes. R42's quarterly MDS dated [DATE], indicated R42 had severe cognitive impairment and received hospice services.R25's significant change MDS dated [DATE], indicated R25 had severe cognitive impairment and received hospice services. An observation of the third-floor medication room refrigerator on 7/22/26 at 12:51 p.m., contained two open bottles of liquid Ativan for R42 and two open bottles of liquid Ativan for R25. The bottles of Ativan for R42 and R25 had open date and initial labels; however, they were all blank. All bottles of Ativan for R42 and R25 contained medication and were not full. The bottles had a label that started to discard after 60 days. RN-F verified the bottles and the missing opening dates. RN-F further stated they should be dated when opened and whichever one was older should have been discarded when the newer one opened. RN-F wasn't sure why there were two open bottles and why they were not labeled. An interview on 7/22/26 at 1:01 p.m., licensed practical nurse (LPN)-A had entered the medication room and stated they should be labeled when opened and it was important to know because they are good for only so long. When interviewed on 7/23/26 at 9:21 a.m., RN-B expected insulin pens to be dated when opened.When interviewed on 7/23/26 at 12:09 p.m., the Director of Nursing (DON) stating multiple bottles of opened medications should not be happening. With hospice residents they typically have more than one medication vial in stock, however, staff should be dating them and not opening a new one until needed.A facility policy titled Storage and Expiration Dating of Medications revised 6/30/25, directed staff to follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Furthermore, staff should record the date opened on the primary medication container. If a multidose vial of an injectable medication has been opened, it should be dated and discarded within 28 days unless manufacture guidelines say differently.

Based on observation, interview, document review, the facility failed to ensure a proper sanitization technique was used to obtain food temperatures from ready-to-serve meals from the steam table. This finding had the potential to increase the risk of cross contamination and affect 17 residents who resided on the fourth floor. Findings include: During observation on 7/21/26 at 11:50 a.m., on the fourth floor, dietary aid (DA)-A placed stainless steel trays containing food on the steam table. DA-A washed her hands, put on gloves, got a food thermometer and started to check the food temperatures. DA-A checked the soup temperature first and wiped the thermometer with a napkin, then she checked the steamed vegetables temperature and once again used the same napkin to wipe the thermometer. DA-A stated she always used a napkin to clean the thermometer before she checked the next food item. DA-A stated she was never told to do otherwise. During interview on 7/21/26 at 1:16 p.m., DA-B was cleaning the kitchenette after serving lunch to residents on the second floor. DA-B explained he used a napkin to clean the food thermometer between food items and used a sanitizer solution before he put away the thermometer. During interview on 7/21/26 at 1:57 p.m., culinary services director (CSD) stated she expected the dietary aids will check the food temperature before the food is placed on the steam table. CSD stated the dietary aids needed to check the temperature, write down the temp, wipe off the thermometer with the sanitizing solution, and use a paper towel to dry the thermometer before they checked the next food item. CSD stated they used Ecolab Oasis 146 Multi-Quat Sanitizer diluted following manufacturer's recommendations. CSD stated she had new employees and will need further education.During interview on 7/21/26 at 3:36 p.m., Ecolab district manager (EDM) stated the Ecolab Oasis 146 multi-quat sanitizer was a food surface sanitizer. EDM stated the sanitizer was used to clean tables, and it was also used to wash dishes and silverware. EDM stated if the solution was diluted to sanitize the thermometer it could be safe, but the use of a napkin was concerning because the napkin might be contaminated.During interview on 7/23/26 at 10:52 a.m., director of nursing (DON) stated the expectation was for staff to follow proper sanitization procedures to clean the food thermometers to prevent cross contamination and reduce the risk of foodborne illnesses.Facility's policy titled Food Temperatures: Correct Use of Thermometer dated 10/24/25, indicated all foods were prepared in accordance with the FDA Food code. The policy also indicated the thermometer will be sanitized using a thermometer wipe in between foods of different types to also prevent cross contamination.

Based on observation, interview, and document review, the facility failed to ensure self-administration of medications was assessed and determined to be appropriate for 1 of 1 resident (R9) reviewed for self-administration of medications.Findings include:R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 was cognitively intact and required varying levels of assistance with activities of daily living and mobility. Diagnoses included low blood pressure when standing, heart failure, chronic kidney disease, lung disease, and a pacemaker.R9's Self-Administration of Medications (SAM) assessment dated [DATE], indicated R9 responded No when asked whether he wanted to self-administer medications or treatments.R9's care plan dated 6/26/26, failed to identify interventions related to bedside storage or self-administration of eye medications.R9's medical record, reviewed on 07/21/26, lacked evidence of provider orders for Systane Complete or ketotifen fumarate eye drops or authorization for the medications to be kept at the bedside.During observation on 7/20/26 at 4:03 p.m., two bottles of eye drops, Systane Complete and ketotifen fumarate, were observed unsecured on R9's bedside table. The medications lacked pharmacy prescription labels. During interview at that time, R9 stated the eye drops were not facility medications and reported facility staff administered the eye drops at his request.During observation on 7/21/26 at 8:36 a.m., the two eye drop medications remained on R9's bedside table.During interview on 7/21/26 at 8:54 a.m., registered nurse (RN)-C observed the eye drop medications at R9's bedside and verified they lacked pharmacy prescription labels. RN-C stated the medications may have been brought from home, staff administered them at R9's request, and a SAM assessment was required before medications could be kept in a resident's room. RN-C removed the medications and stated she would notify the unit manager.During interview on 7/21/26 at 9:17 a.m., registered nurse (RN)-D stated staff were required to verify the resident's assessment, provider order, medication, and the rights of medication administration before giving medications.During interview on 7/21/26 at approximately 4:00 p.m., the Director of Nursing (DON) stated residents needed to be able to safely self-administer medications, have a completed assessment, and have a provider's order before keeping medications in their room. The DON stated medications kept in resident rooms required a provider's order and a way to identify the medication. The DON expected staff to remove medications not listed on the Medication Administration Record (MAR) and notify the unit manager.Facility's policy titled Self-Administration of Medications dated 11/2018, indicated residents capable of self-administering medications could keep medications at bedside with a physician's order stating the medication may be kept at bedside for self-administration. The policy required a SAM assessment, identification of bedside medications on the MAR and care plan, and resident education regarding medication use, frequency, storage, and notification of nursing staff when a dose was taken. Nursing staff were required to document self-administration and assess medication effectiveness.

Based on observation, interview and document review, the facility failed to ensure the use of as needed (i.e., PRN) psychotropic medication was limited to 14 days or extended to a certain date with supporting rationale provided by the medical provider for 1 of 5 residents (R8) reviewed for unnecessary medication use. Findings include: R8's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R8 had severe cognitive impairment, received hospice services, and had diagnoses of atrial fibrillation, congestive heart failure, renal failure, Alzheimer's disease, depression and psychotic disorder. R8's medical orders dated 7/22/26, included an order for lorazepam (anti-anxiety medication) 0.5 milligrams (mg) orally every 6 hours as needed (PRN) for anxiety, with a discontinuation date of 9/2026. R8's medical administration records (MAR) indicated R8 did not receive any doses of lorazepam between 3/2026 and 7/2026. R8's medical record lacked supporting rationale for the lorazepam order. During interview on 7/23/26 at 10:07 a.m., requested documentation supporting rationale to the corporate director of clinical services (DCS) stated a psychotropic medication ordered PRN, couldn't be ordered for more than 14 days at the time. DCS stated a doctor needed to do a face-to-face visit and provide a rationale for a psychotropic medication ordered PRN for longer than 14 days. During interview on 7/23/26 at 10:19 a.m., director of nursing (DON) the expectation depended on the situation but initially a psychotropic medication to be used PRN couldn't be ordered for longer than 14 days. After the initial 14 days, the use of the medication needed to be reviewed, and the doctor could re-write the order for an additional 14 days or schedule the medication if necessary. DON added an order for a PRN psychotropic medication should be a red flag for the nurses. Nurses should know the CMS regulations. Facility's policy titled Unnecessary Drugs/Psychotropic Medications dated 3/16/25, indicated the resident will be free from chemical restraints and unnecessary medications. The policy also indicated PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on interview and document review, the facility failed to ensure that a discharge notice was sent to the Office of the State Long-Term Care Ombudsman (OOLTC) for 2 of 2 resident (R87, R89) reviewed for discharge.Findings include: R87 R87's admission Minimum Data Set (MDS) dated [DATE], indicated R87 was cognitively intact and had diagnoses of hepatic encephalopathy (a brain condition caused by severe liver disease), chronic liver failure, cirrhosis (scarring of the liver), systolic congestive heart failure, and chronic kidney disease. R87's face sheet reviewed on 7/23/26, indicated R87 was admitted to the facility on [DATE] and transferred to United hospital on 4/27/26. R87's progress notes dated 4/27/26, indicated R87 had a change in condition. The nurse notified the provider, who ordered transfer to United Hospital for further evaluation. R87 left the facility with paramedics at 10:50 p.m. A facility document titled Monthly Notice to MN Office of Ombudsman for Long-Term Care of Emergency Acute Care Transfers and Discharges dated 5/1/26, failed to include R87's 4/27/26 facility-initiated hospital transfer. During interview on 7/23/26 at approximately 11:00 a.m., the Corporate Director of Clinical Services (DCS) confirmed R87 was transferred from the facility to the hospital on 4/27/26. DCS confirmed the transfer was not listed on the facility's April Ombudsman notification log and should have been included. R89 R89's admission Minimum Data Set (MDS) dated [DATE], indicated R89 had intact cognition with no hallucinations, delusions, or behaviors. R89's Census information dated 4/28/26, indicated that R89 was admitted to the facility on [DATE] and discharged on 4/29/26. R89's progress note dated 4/29/26 at 1:54 p.m., stated that R89 left the facility against medical advice (AMA) around 10:30 a.m. In an email correspondence dated 7/17/26 at 12:33 p.m., the OOLTC stated that no transfer and discharge notices from the facility have been received for approximately two years. The OOLTC identified that the last transfer and discharge notice received from the facility was from May 2024. The facility's Monthly Notice to Minnesota OOLTC of Emergency Acute Care Transfers and Discharges dated 5/1/26, indicated that the ombudsman had been notified of 18 resident hospital transfers during the month of April. The document did not include any record of ombudsman notification of discharges including that of R89. Record of ombudsman notification of R89's discharge was requested and not received. During an interview on 7/22/26 at 1:44 p.m., when notified that record of ombudsman notification of R89's discharge was not found in the Monthly Notice to MN OOLTC of Emergency Acute Care Transfers and Discharges, the Director of Clinical Services (DCS) stated that ombudsman notification of AMA discharges may be kept in a different file and she would provide this if able. The DCS stated that the ombudsman should be notified by the Social Services Director (SSD) of all unplanned discharges, including residents who discharge AMA. The SSD was on vacation during survey and unavailable for interview. During an interview on 7/23/26 at 9:38 a.m., the administrator stated that after reviewing their records, she did not have evidence of ombudsman notification for R89's discharge from the facility. A facility policy titled Transfer and Discharge from the Facility updated 4/5/25, indicated the facility should forward a copy of all discharge notices to the OOLTC and required state agencies.

Based on observation, interview and document review, the facility failed to ensure provider orders were followed to put on leg wraps for 1 of 1 resident (R6) reviewed for edema. In addition, the facility failed to ensure effective collaboration between the facility and the hospice agency for 1 of 1 resident (R8) reviewed who received hospice services. Findings include: R6 R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 had intact cognition, had no behaviors and did not reject cares. MDS indicated R6 needed moderate assistance with dressing, putting her shoes on, and showers. R6's Profile form dated 7/23/26, identified diagnoses of essential hypertension, non-rheumatic aortic stenosis, diabetes type II, prosthetic heart valve replacement, morbid obesity, and metabolic encephalopathy. R6's medical orders form dated 7/23/26 included an order to apply leg wraps to bilateral lower extremities; on in the morning and off at night. This order was dated 11/10/25. R6's July treatment medication record (TAR) included the order for leg wraps. During observation and interview on 7/20/26 at 3:25 p.m., R6 was in her room, sitting in her wheelchair. R6 was not wearing the leg wraps, she said she needed help to put them on. R6 said sometimes the staff got busy and didn't wrap her legs. During observation and interview on 7/21/26 at 9:11 a.m., R6 was in her room putting on makeup. R6's leg wraps were on top of her bedside table. R6 stated the staff will help her later to wrap her legs. During interview on 7/21/26 at 10:30 a.m., registered nurse (RN)-G stated he was running behind but would try to wrap R6 legs as soon as possible. During observation on 7/22/26 at 9:05 a.m., R6 was in the dining room and did not have leg wraps on. During observation and interview on 7/22/26 at 12:26 p.m., nurse manager (RN)-H stated the nurses needed to apply leg wraps to resident's legs early in the morning. RN-H stated. If for some reason the nurse on duty got behind with their morning medication pass or other duties, they could let her know as she was willing to support the nurses. RN-H stated the facility needed to follow the doctor's orders and update them as necessary. RN-H verified R6 legs were not wrap, she said she would do it. During interview on 7/23/26 at 10:45 a.m., director of nursing (DON) stated the leg wraps and compression stockings should be applied first thing in the morning. DON stated if the wraps or compression stockings were not applied, the resident's edema could worsen, cause fluid overload, worsened cardiac related symptoms, and possibly have a negative effect on residents' wellbeing. A policy regarding edema and following doctor's orders was requested but none was received. R8 R8's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R8 had severe cognitive impairment, had no behaviors, did not refuse cares, and needed maximal assistance with toileting hygiene and lower extremity dressing. MDS also indicated R8 needed moderate assistance with upper body dressing and was dependent to put on and take off footwear. MDS indicated diagnoses of stroke, a-fib, congestive heart failure, hypertension, Alzheimer's disease, and received hospice services. R8's orders report dated 7/23/26, indicated orders for hospice evaluation and treatment, this order was dated 1/16/26. R8's progress notes between 7/1/26 and 7/21/26 included only one hospice nurse progress note dated 7/16/26. During observation and interview on 7/20/26 at 4:49 p.m., R8 was visiting with one of her daughters. R8 was confused, was able to answer yes/no questions, but after answering the second question she said she didn't want to share any information. R8 appeared to be physically comfortable. Per daughter, R8's didn't trust new people. During interview on 7/21/26 at 9:20 a.m., R8 was in her room, sitting on her wheelchair folding and putting clothes away in her closet. A hospice massage therapist arrived and stayed with the resident for about one hour. During interview on 7/21/26 at 9:28 a.m., RN-G stated he believed the hospice staff visited R8 on Tuesdays. RN-G said the hospice nurses usually talked to him after they visited R8. RN-G stated he knew R8 had a hospice nursing assistant, a nurse, social worker, spiritual worker, massage therapist, and volunteers, but he didn't know when they were scheduled to visit R8. RN-G stated he believed the schedule was on the hospice binder, or in the electronic medical record (EMR). RN-G was unable to find the hospice binder, and the hospice schedule was not on her EMR. During interview on 7/21/26 at 9:32 a.m., RN-H stated R8's hospice information was in front of the resident's hard chart. During document review on 8/21/26 at 9:35 a.m., R8's hard chart had the following hospice documents: a form that identified the medications covered by hospice, a form with the hospice contact information, and a schedule. However, there was not a care plan and/or the current hospice certification. The July hospice schedule indicated the following visits:Spiritual care: 7/14 and 7/28Skilled nursing: 7/8, 7/15, 7/22Massage therapy: 7/8, 7/15, 7/22Volunteer: 7/1, 7/8, 7/15, 7/22HHA (home health aide): 7/2, 7/9, 7/16, 7/23Social worker: 7/17 During interview on 4/21/26 at 9:50 a.m., RN-H verified R8's hard chart didn't include a hospice care plan and/or the hospice certification. RN-H also verified there was only one hospice progress note for the month of July. RN-H stated the hospice manager brought both the care plan and the current certification and she would put it on R8's hard chart. During interview on 7/21/26 at 12:16 p.m., nursing assistant (NA)-C stated she was not sure what hospice did for R8. NA-C stated she had seen volunteers. NA-C stated she had never seen or talked to the hospice nurse or seen the hospice NA. NA-C was not aware if hospice had a schedule and didn't know when they were coming. NA-C added The nurse and the nurse manager should know. I am sure they know. During interview on 7/22/26 at 12:52 p.m., RN-H stated she expected the nurses knew when hospice visited R8. RN-C said she expected the nursing staff to communicate with hospice members before and after their visits and call them to report any changes in condition and to re-order medications. During interview on 7/22/26 at 12:59 p.m., hospice program manager (HPM) stated the hospice program had their own electronic medical record. HPM stated the hospice nurse needed to copy and paste her progress note into R8's EMR after each visit. HPM stated the rest of the team needed to document their visits on the hospice communication book kept in R8's room. HPM verified there was not a hospice certification or care plan until yesterday. HPM stated she was working with management about implementing hospice binders which will be more accessible to the facility's nursing staff. HPM stated the hospice and facility's social workers and nurse managers met on a weekly basis to review changes of condition, but the facility's floor staff was not necessarily aware what hospice did for the hospice patients. During interview on 7/23/26 at 10:31 a.m., director of nursing (DON) stated the facility staff should know what services were provided by hospice. DON stated sometimes the facility's NAs needed to know the services provided by the hospice NA were additional services. DON stated hospice needed to provide a schedule and the resident's hospice care plan to coordinate our resident's cares and to provide continuity of care, we integrate our care plan with hospice. DON stated we will need to do an in-service to educate the staff about where to look for information. DON stated he expected hospice to add their progress notes to the resident's EMR. Facility's policy titled Hospice Care for Nursing Facility Residents- Coordination of services dated 5/23/16, indicated the hospice program ensures that mechanisms are in place to provide for the coordination of all hospice services provided to patients residing in facilities.

Based on observation, interview and document review, the facility failed to ensure fall interventions were implemented for 1 of 3 residents (R90) who were at risk of falls. Findings include:R90's face sheet printed 7/22/26, indicated R90 was recently admitted and had diagnoses of stroke with aphagia (trouble finding words to speak), dementia with mood disturbance, and a history of falling. R90's Comprehensive Nursing assessment dated [DATE], indicated R90 had short and long-term memory problems, had severely impaired cognitive skills for daily decision making, and had a history of falling prior to admission. R90's care plan revised 7/20/26, indicated:-R90 had a self-care deficit with mobility and required assist of 1 staff with a gait belt and four wheeled walker for transfers and mobility.- R90 was at risk for falls related to dementia and wandering. Interventions included keeping bed at transferring height, call light in reach and to ensure R90 wore appropriate footwear. R90's medical record lacked indication R90 did not like or refused grip socks. An observation on 7/20/26 at 11:06 a.m., R90 was sitting on the bed in his room. R90 was barefoot with shoes on the floor near the bed. R90 got up and started walking towards the door. R90 was barefoot and was not using his walker. R90 made it outside into the hallway a few steps and stood there for a short time. Unidentified nursing assistant (NA) rushed from the other side and escorted R90 back to his room. An observation on 7/21/26 at 9:08 a.m., R90 was sleeping in bed. R90 had a transfer belt around him and was wearing socks without grips. An observation on 7/21/26 at 10:07 a.m., R90's family member (FM)-A was with him in the hallway. Unknown physical therapy staff and FM-A were walking with R90 in the hallway. R90 was wearing plain socks without grips and no shoes. An observation on 7/21/26 at 11:52 a.m., R90 was lying in bed sleeping. R90 was wearing plain socks without grips.An interview on 7/20/26 at 3:17 p.m., FM-B stated R90 had recently been admitted to the facility and was so confused. R90 had fallen once, and family was trying to be here as much as possible for support. An interview on 7/21/26 at 3:04 p.m., nursing assistant (NA)-B stated R90 was a fall risk and had had a fall since admission. NA-B stated staff frequently check on R90, ensure call light is in reach, and keep the door open. R90's family recently hired a patient care assistant (PCA) to sit with him. NA-B stated appropriate footwear included grippy socks on when in bed and shoes or grippy socks on when walking. NA-B verified R90 was not wearing grippy socks and stated he should be and went to obtain grip socks from the nurse. An interview on 7/21/26 at 3:26 p.m., licensed practical nurse (LPN)-B stated R90 was a fall risk and most of the time had family or PCA in with him. LPN-B verified one intervention for R90 was to have appropriate footwear on and R90 should have grip socks in place. LPN-B was not aware of any refusals of grip socks.An interview on 7/23/26 at 9:21 p.m., RN-B stated after a resident falls, the interdisciplinary team (IDT) meets to review the fall and collaborate on interventions. RN-B identified appropriate footwear to be griped socks when in bed and grip socks or shoes in place when up walking. RN-B expected staff to be following the care planned interventions for falls and stated grip socks should have been in place for R90. An interview on 7/23/26 at 12:09 p.m., the Director of Nursing (DON) expected fall interventions to be in place and stated R90 should have had the grip socks in place. DON further stated this was important to help prevent falls. A facility policy titled Fall Prevention and Management revised 6/21/21, directed staff to implement interventions according to resident specific risk factors and care plans would indicate the resident specific interventions to prevent falls.

Based on observation, interview and document review, the facility failed to ensure documentation of clinical indications for the continued use of a foley catheter was in place and failed to ensure interventions were in place to prevent urinary tract infections for 1 of 1 residents (R90) reviewed with a catheter. Findings include: R90's face sheet printed 7/22/26, indicated R90 was recently admitted and had diagnoses of stroke with aphagia (trouble finding words to speak), dementia with mood disturbance, urine retention and had a urinary device. R90's Comprehensive Nursing assessment dated [DATE], indicated R90 had short and long-term memory problems, had severely impaired cognitive skills for daily decision making, and was admitted with a foley catheter. R90's hospital Discharge summary dated [DATE], indicated R90 had hematuria (blood in the urine) with urinary retention and required a urology consultation. A foley catheter was placed with a plan to discharge with the catheter and have a trial of void in clinic in 2 weeks as well as a trial of void at the skilled nursing facility next Monday (7/20/26).R90's hospital discharge orders dated 7/16/26, indicated R90 required catheter removal on 7/20/26 with a monitor of post void residual at least twice daily for 24 hours or facility protocol. R90's provider orders dated 7/16/26, indicated the following:-remove foley and perform a trial void on 7/20/26.-R90's catheter required gravity drainage and instructed staff to not loop or kink the tubing so urine can drain, and to keep the drainage bag below the waist. R90's care plan date 7/16/26, indicated R90 had a foley catheter related to neurogenic bladder and was at risk for urinary tract infection (UTI). Interventions included to change foley when needed, keep tubing/bag below the bladder, and ensure tubing was free of kinks.R90's nursing progress note dated 7/20/26 at 9:56 a.m., indicated provider was notified via portal and requested foley removal to be delayed due to resident impulsiveness and self-transferring. R90's nursing progress note dated 7/20/26 at 4:06 p.m., indicated nurse practitioner (NP)-A provided orders to delay trial void until 7/27/26.R90's provider note dated 7/20/26, indicated R90 will need trial void and to continue with foley cares. R90's provider note lacked clinical indication of why catheter removal was delayed. R90's medical record lacked indication R90's family had been involved in decision to delay discontinuation of foley, wanting to keep catheter in place or were educated on risks or benefits. An observation on 7/20/26 at 11:06 a.m., R90 was lying in bed sleeping. There was not a catheter bag hanging from his bed or below his waist to facilitate drainage. An observation on 7/21/26 at 9:08 a.m., R90 was sleeping in bed. R90's catheter tubing was looped and had urine in the tubing. R90's catheter bag was not hanging to gravity and was not below his waist to facilitate drainage. An observation on 7/21/26 at 11:52 a.m., R90 was lying in bed sleeping. R90's catheter bag was attached to his leg. The tubing was looped twice and had urine sitting in the tubing. R90's catheter bag was not hanging below his waist to facilitate drainage.An interview on 7/20/26 at 3:17 p.m., FM-B stated R90 had recently been admitted to the facility and was so confused. R90 was admitted with a catheter. FM-B further stated the catheter was supposed to come out today and was not sure why it was still in. An interview on 7/21/26 at 3:04 p.m., nursing assistant (NA)-B wasn't sure why R90 had a catheter in place. NA-B stated catheter bags should be hanging below the waist and to gravity, so they drain properly. NA-B verified R90's catheter was not hanging below waist and the catheter tubing had loops with urine sitting in the tube. NA-B stated normally catheters were hung from the bed and the tubing should not have loops or kinks however, R90 would play or pull on the tubing, and they wanted to keep it out of sight. An interview on 7/21/26 at 3:26 p.m., registered nurse (RN)-A stated R90 was admitted with the catheter for urine retention. RN-A stated R90's catheter should be below the waist or to gravity and verified R90's orders. RN-A wasn't sure of why the trial void and catheter discontinuation was delayed and would need to speak to the nurse manager. An interview on 7/21/26 at 3:21 p.m., RN-B stated R90 had an incident where R90 had been fidgeting with the catheter that caused some bleeding and required the catheter to be replaced. RN-B stated NP-A had made the decision to keep it for an additional week.An interview on 7/22/26 at 9:24 a.m., NP-A stated R90 was very mobile and that was not a good reason to delay the catheter removal and trial void. However, trying to prevent falls having the catheter may reduce some impulsiveness with getting out of bed to void. NP-A was aware of the incident that required a catheter change for R90 and stated there were no further complications. NP-A stated she instructed nursing R90's trial void had to happen sooner than next week if he was discharging from the facility.A follow up interview on 7/23/26 at 9:21 a.m., RN-B expected staff to ensure interventions were put in place for catheters were implemented, including catheter bags that were hung below the waist to facility gravity drainage. RN-B further stated family of R90 had also requested the catheter to stay in longer, however verified there was no documentation of this or education of risks and benefits of keeping the catheter in.An interview on 7/23/26 at 12:09 p.m., the Director of Nursing (DON) expected staff to ensure interventions were in place to prevent UTI when residents have a catheter. Family requesting to keep the foley in isn't the best reason, however if family wanted to keep the catheter in place, education of risks and benefits should be documented and in place. A facility policy titled Urinary Catheter Care no date, directed staff to check frequently to ensure the catheter tubing is free of kinks and ensure the drainage bag is always positioned lower than the bladder to prevent urine in the tubing/bag to flow back into the bladder. The policy did not address clinical indications or justification needed for catheter use.

Based on observation, interview, and document review, the facility failed to ensure staff followed proper infection prevention and control practices by using the required personal protective equipment (PPE) during Enhanced Barrier Precautions (EBP) for 1 of 1 resident (R11) reviewed for infection control. Findings include: R11's comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated R11 had severe cognitive impairment and was dependent on staff for total body care, bed mobility, and transfers. Diagnoses included chronic heart failure, chronic kidney disease, and nontraumatic intracranial hemorrhage (brain bleed).R11's care plan dated 7/21/26, indicated EBP had been initiated on 6/17/26, due to a pressure wound on the right heel. The care plan instructed staff to wear a gown and gloves during high-contact resident care activities, including dressing, providing hygiene care, and changing briefs.During observation on 7/21/26 at 8:45 a.m., nursing assistant (NA)-A provided personal care to R11 without wearing the required gown. NA-A wore a mask and gloves but failed to don the required gown while providing high-contact care. NA-A repositioned R11 from side to side, performed perineal care, changed the brief and clothing, and completed additional personal care without the required PPE.During an interview on 7/21/26 at 9:23 a.m., NA-A stated she believed R11 was not on EBP, although she knew R11 had an open sore on the heel. NA-A stated resident-specific care information was obtained from the care plan and care sheets. NA-A stated there was no sign on the resident's door, so she believed EBP was not required while providing close-contact care. NA-A further stated there would normally be an EBP sign posted on the door and a PPE supply bin located outside the room. After reviewing the information posted above the foam sanitizer dispenser, NA-A acknowledged there was a sign indicating R11 was on EBP and that a gown and gloves should have been worn while providing personal care, including perineal care, changing the brief, changing clothing, and completing hygiene care.During an interview on 7/22/26 at 8:53 a.m., licensed practical nurse (LPN)-A stated it was important for staff to follow each resident's care plan to provide care within the resident's individualized needs and to reduce the risk of infections and injuries. LPN-A stated the expectation was that staff would universally and consistently don and doff all required PPE for residents on EBP, as ordered, to protect residents and reduce the risk of infection transmission.During an interview on 7/23/26 at 9:37 a.m., the Director of Nursing (DON) stated the expectation was for staff to universally and consistently don and doff PPE in accordance with EBP requirements. The DON stated following EBP was important to protect residents, staff, and the community by reducing potential portals of entry for infection and decreasing the risk of transmission. The DON further stated it was important for staff to follow each resident's care plan. The facility policy titled Isolation - Categories of Transmission-Based Precautions updated 5/29/26, directed staff to implement EBP as an infection prevention and control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) within the facility. The policy indicated EBP required the use of a gown and gloves during high-contact resident care activities. High-contact care activities included dressing, bathing, providing hygiene care, transferring residents, changing linens, changing briefs, and providing device care.

Based on observation, interview, and document review, the facility failed to ensure the plan of correction (POC) for the most recent survey of the facility was readily accessible and that the POC for the three preceding years was available upon request. This had the potential to affect all 82 residents residing in the facility as well as family, visitors, and staff.During observation and record review on 7/22/26 at 8:10 a.m., a review of the survey results binder located near the elevators on the first floor of the facility was completed. Although the binder included the survey results from the past three years, the 2024 and 2025 survey results did not include the facility's plan of correction (POC) or indicate that these could be requested from facility staff. During an interview on 7/22/26 at 2:44 p.m., the administrator stated that she was responsible for maintaining the survey results binder. She stated that the POC for the previous three years should be included with the survey results. The administrator confirmed she had reviewed the binder and stated that the POCs for all surveys occurring from 2024 to current were missing from the binder.A request was made for the facility policy regarding the posting of survey results, but this was not provided.

Based on observation, interview, and document review the facility failed to ensure dietary staff was wearing beard guards/restraints when preparing food. This had the potential to affect all 93 residents who reside at the facility and consume food from the kitchen. During observation on 4/16/25 at 10:03 p.m., cook (C)-A had a beard and was preparing roast beef and slicing it on the meat slicer. C-A was not wearing a beard guard/restraint. During observation on 4/16/25 at 10:11 a.m., the culinary manager (CM) had a beard and was stiring a large vat of beef stew. Then he started taking food temperatures and putting the food into an insulated food cart. The CM was not wearing a beard guard/restraint. During interview on 4/16/25 at 10:33 p.m., the CM verified the staff with beards were not wearing beard guards and it had never been an expectation for them to do so. He further verified the facility didn't have any beard guards/restraints available to use, stating if it had been an expectation to wear one he wouldn't have a beard. During interview on 4/16/25 at 2:08 p.m., the administrator stated dietary staff (with beards) were expected to wear beard guards/restraints for infection control purposes. A facility policy regarding beard guards/restraints was requested but not received.

Based on interview and document review, the facility failed to notify the provider of the use of antibiotics concurrent with warfarin, and to obtain a new INR monitoring date for 1 of 2 residents (R76) reviewed for medication administration. Findings include: R76's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, no behaviors, needed partial/moderate assistance for upper and lower body dressing, and substantial/maximal assistance with bed mobility. Diagnoses included hip and knee replacement. R76's medications included an anticoagulant. R76's care plan dated 3/18/25, identified a potential complication: bruising, bleeding, hemorrhage R/T (related to) a dx (diagnosis) of HX (history) of DVT (deep vein thrombosis a type of blood clot) m/b (manifested by) chronic anticoagulation use. Be aware of risk for drug-to-drug interactions. Inspect for signs of bleeding. PT/INR (blood clotting test which checks whether medicine to prevent blood clots is working) per order; report results to MD/NP (medical doctor/nurse practitioner). R76's medication review on 4/16/25 at 7:48 a.m., identified: 1. Bactrim DS (sulfamethoxazole-trimethoprim which is an antibiotic) tablet; 800-160 milligrams oral for seven days for diagnosis of UTI (urinary tract infection) The start date was 4/14/25 and end date was 4/21/25. The order was entered into the electronic medical record (EMR) on 4/14/25 at 3:23 p.m., and verified by 7:06 p.m., by registered nurse (RN)-D. 2. Warfarin tablet; 5 mg; oral; once a day on Sunday, Monday, Tuesday, Thursday, Friday at 8:00 p.m., special instructions: Next INR 4/28/25. The order was entered into the electronic medical record (EMR) on 4/14/25 at 3:19 p.m., and verified by 7:19 p.m., by registered nurse (RN)-D. The order was discontinued on 4/16/25 at 8:57 a.m. 3. Warfarin tablet; 3mg; oral once a day on Wed, Sat at 8:00 p.m., special Instructions: Next INR 4/28/25. R76's progress note by registered nurse (RN)-G, dated 4/14/25 at 3:20 p.m., identified INR 2.4 today. New orders for Warfarin 3mg on Wednesday, Saturday and 5mg AOD [sic]. Recheck INR on 4/28/25. Orders sent to pharmacy and in matrix. The progress note lacked notification to the provider of the antibiotic starting on the same day. R76's provider visit note dated 4/2/25, identifies R76 had difficulties maintaining a therapeutic INR with wall variations; appeared to be very sensitive to warfarin at this moment. INR supra-therapeutic at 10.6 on 3/4/25, treated with vit K (vitamin K, an anticoagulant reversal medication). During an interview on 4/16/25 at 7:48 a.m., licensed practical nurse (LPN)-C stated if a resident taking warfarin was started on an antibiotic, the INR clinic would be notified by nursing via a faxed form so the prescriber could change the INR date or medication dosing. During an interview on 4/16/25 at 7:51 a.m., registered nurse (RN)-E stated she was not sure what to do if a resident on warfarin started on antibiotics and would need to check and find out. During a phone interview with R76's INR clinic on 4/16/25 at 8:05 a.m., INR-RN stated the clinic was not notified R76 had started on an antibiotic on 4/14/25, and Bactrim DS interfered with warfarin and increased the risk of bleeding. Typically, after antibiotics were started, INR clinic would have ordered an INR recheck after being notified, in two to three days instead of waiting until 4/28/25 as identified in R76's current INR re-check orders. During a review of R76's faxes to the INR clinic on 4/16/25 at 8:18 a.m., with LPN-C, it was not identified on the fax to the INR clinic on 4/14/25, that the resident started on an antibiotic. During an interview on 4/16/25 at 8:22 a.m., RN-C stated if a resident on warfarin started on an antibiotic, the nurse taking the antibiotic order would update the INR clinic using a form. During a review of R76's faxes to the INR clinic, it was not identified on the faxes that the resident started on an antibiotic. When asked if waiting until 4/28/25 (13 days) to check the INR was too long if a resident was on warfarin and antibiotics, RN-C stated he was unsure and would need to call the provider and find out. During a follow up interview on 4/16/25 at 10:05 a.m., RN-C stated the nurse taking the antibiotic order should have updated the INR clinic at the time of taking the order or at the latest the next day to ensure the anticoagulant was still working properly. During a follow up interview on 4/16/25 at 10:17 a.m., RN-E sated the INR clinic should be notified so they can change the INR lab date if needed due to risk of elevated INR. During an interview on 4/16/25 at 8:49 a.m., RN-G stated nurses would call and fax the INR clinic upon resident starting an antibiotic concurrent with warfarin, and document in a progress note. During an interview on 4/16/25 at 10:10 a.m., nurse practitioner (NP)-A stated the INR clinic was not updated on 4/14/25, when R76's antibiotics were ordered and started, until today 4/16/25, because the order was still pending in their provider system. Additionally, the facility nurses had not updated the INR clinic, NP-A stated monitoring the INR closely for residents on antibiotics and warfarin was important because the risk of bleeding increases with an elevated INR, which the antibiotics could cause. NP-A stated she put in a new order today for an INR draw tomorrow 4/17/25 instead of 4/28/25. During a phone call on 4/16/25 at 11:30 a.m., RN-D stated she could not remember if she updated the INR clinic when she placed R76's antibiotic order, however, that would be the process she or the charge nurse should have followed. During an interview on 4/16/25 at 1:10 p.m., the director of nursing (DON) stated if a resident on warfarin started on antibiotics, the expectation would be for the nurse to consult with primary physician within 24 hours. During a follow up interview on 4/17/25 at 11:23 a.m., the director of nursing stated if a resident on warfarin started on antibiotics the expectation would be to have an INR lab draw done within three days of starting antibiotics. The DON agreed as soon as the facility gets the antibiotic order for residents on warfarin, the primary physician or INR clinic should be updated in order to ensure the INR lab draw is done in the appropriate time frame. A policy on antibiotics, warfarin and INR lab draw was requested and not provided. The facility policy titled Resident Change in Condition-Notification of Physician/Surrogate Decision Maker dated 3/21, identified significant needs or changes that would require timely notification to the provider included possible adverse drug reactions.

Based on observation, interview, and document review the facility failed to ensure a sanitary and homelike environment for 1 of 1 residents (R48) who had dried tube feeding formula on the base of the tube feeding pole. Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], indicated R48 had moderate cognitive impairment, was dependent on staff for all activities of daily living (ADL), and received 51 percent or greater daily nutrition through a feeding tube. R48's diagnoses included malnutrition, type 2 diabetes, anxiety, and major depressive disorder. R48's care plan dated 3/21/25, indicated R48 had little to no oral intake and relied on tube feeding to meet my nutrient needs. R48's physician orders indicated the following: -Formula Type: ISOSOURCE 1.5, per pump 45 ml/hour continuous gastrostomy. Start date: 11/27/24. - Wipe down pole and pump with damp cloth daily on pm shift. Start date: 10/24/24. R48's medication administration record (MAR) dated 4/1/25 through 4/15/25, indicated received daily continuous tube feedings. During observation on 4/14/25 at 12:41 p.m., R48 lying in bed tube feeding running at 45 cc/hr. Large amount of dried tube feeding formula on the base legs of the pole. During observation on 4/15/25 at 8:17 a.m. R48 lying in bed tube feeding running at 45 cc/hr. Large amount of dried tube feeding formula on the base legs of the pole. During observation and interview on 4/15/25 at 9:22 a.m., nursing assistant (NA)-A and NA-B in to check, change, reposition and perform morning cares with R48. NA-A stated it was the evening shift responsibility to clean the tube feeding poles and agreed R48's pole was dirty with formula and appeared to have not been cleaned recently. During observation and interview on 4/15/25 at 9:30 a.m., registered nurse (RN)-A into R48's room. RN-A confirmed the pole was dirty with dried tube feeding formula and stated it did not appear to have been cleaned last evening as it should have. RN-A further stated if there is spillage at the time the formula bag was spiked, the nurse should wipe it up at that time and not leave it for the evening shift to clean. During interview on 4/15/25 at 11:03 a.m., licensed practical nurse (LPN)-A would expect the tube feeding pole to be clean from visible debris. The pole should be cleaned as ordered or care planned and at the time of a known spillage. During interview on 4/15/25 at 1:41 p.m., director of nursing (DON) stated expectation tube feeding poles were cleaned as ordered and timely after a spill. Facility policy Tube Feedings: Gastrostomy dated 8/2017, indicated tube feeding equipment was to be wiped down daily with a cloth dampened with disinfectant.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 residents (R61) received treatments and services to promote the healing of a pressure ulcer per the comprehensive care plan. Findings include: The State Operations Manual (SOM) revised 2/3/23, defines a pressure ulcer as an area of damaged skin and/or underlying soft tissue normally over a bony prominence or from a device. The injury occurs due to intense or prolonged pressure, or pressure in combination with shear. Other contributing factors include skin temperature and moisture, nutrition, perfusion (the blood flow through tissue), co-morbidities and the condition of the skin and soft tissue. The SOM defines a deep tissue pressure injury (DTPI) as intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mush, boggy, warmer or cooler as compared to adjacent tissue. Furthermore, the SOM adds, this injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extend of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. The SOM defines eschar as dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. R61's significant change Minimum Data Set (MDS) dated [DATE], indicated she did not have intact cognition, received hospice care, and had an unhealed deep tissue injury. The MDS reported she did not exhibit physical or verbal behaviors and did not reject care during the lookback period. The MDS identified diagnoses including non-Alzheimer's dementia (a progressive neurological disorder that impairs a person's memory, thinking, judgment, and behavior), malnutrition and muscle weakness. R61's Care Area Assessment (CAA) dated 3/13/25 for pressure ulcer/injury was triggered because she had a deep tissue injury to her right foot. The CAA reported, pressure ulcer CAA triggered d/t [sic, due to] resident being incontinent of bowel and bladder, need for staff assist for mobility and hygiene, and current has area to foot. Wound care provided per orders. R61's treatment administration record (TAR) dated 4/25 reflected wound orders that included the following: - Prevalon boot to R [sic, right] foot while in bed; ensure foot is floated off mattress, dated 4/14/25. - R [sic, Right] foot (over sesamoid bone) TX [sic, treatment]: 1. Remove mepilex 2. Assess area for any openings/changes/drainage UPDATE provider team/Hospice if noted 3. Apply mepilex 4. Change every 3 days and PRN (as needed), dated 4/14/25. R61's care plan last edited 4/14/25, identified her risk for skin breakdown and indicated she was unable to effectively offload self without staff assistance. The care plan reported the pressure sore to her right foot and directed staff to apply her Prevalon boot (a specialized medical device designed to aid in pressure prevention on by lifting the heel off a surface) while in bed and to administer treatments per provider's order. A skin integrity event dated 3/2/25, identified a DTI or deep tissue injury under R61's right foot that measured 2.8 centimeters (cm) x 3.5cm. The skin integrity event form noted on 3/2/25, a closed blister under resident's right foot, and described the DTI as looks dark purplish. The skin integrity event noted on 4/14/25, the area was noted to measure 2.5cm x 3.2cm 100% hard black eschar, no open area noted, no drainage, surrounding skin is C/D/I [sic, clean/dry/intact]. Upon entry to the patient's room, the patient had their bottom right foot pressed into the mattress. Interventions updated to have Prevalon boot on at all times. During observation on 4/14/25 at 12:14 p.m., R61 was lying in her bed turned towards the wall on her left side. Her heels were not floated off the air mattress. During observation on 4/15/25 at 10:46 a.m., R61 was lying in bed with a rolled-up blanket behind her right shoulder. She was turned towards the wall on her right side with a pillow in-between her knees. Her heels were not floated, she was not wearing a boot on her right foot, and her heels were pressed into the air mattress. She wore gray gripper socks and there was a foam boot in the blue Broda wheelchair next to her television. At 10:42 a.m., registered nurse (RN)-I and nursing assistant (NA)-M entered her shared room and NA-M knocked on R61's wall before entering her side of the room. RN-I told her he was there to exchange her medication patch and give her some oral medications. NA-M verified her heels were not floated when they should have been and confirmed she was not wearing the Prevalon boot that was in the wheelchair as she should have been. NA-M stated the boot was delivered yesterday and said, we can put a pillow to help lift her heels off the bed. RN-I and NA-M lifted her legs together and RN-I removed the right gripper sock, revealing an area to her heel that was dark red-to-dark purple in color. The area was intact and there was no odor or drainage present. There was no dressing in place. RN-I stated it was important to float her heels and keep the Prevalon boot on while she was in bed to help reduce the pressure on her heels. Per interview on 4/17/25 at 10:24 a.m. with the director of nursing (DON), staff were expected to follow a resident's care planned interventions and reposition per the care plan and should update the nurse manager if there are any changes or concerns. Per facility policy titled Skin Integrity Management last updated 8/1/21, it was the policy of Sholom to implement preventative measures; and to provide appropriate treatment modalities for pressure ulcers/injuries according [sic, to] industry standards of care. The policy wrote, based on the identification and assessment of impaired skin integrity, interventions will be implemented and identified on the plan of care.

Based on observation, interview and document review, the facility failed to ensure a hand brace and palm protector was used consistently for 1 of 1 resident (R71) reviewed for range of motion (ROM). Findings include: R71's quarterly Minimum Data Set (MDS) dated [DATE], indicated R71 was cognitively intact, had limited ROM with impairment of upper and lower extremities on one side, required substantial/maximal assistance with upper body dressing, and received zero minutes of ROM or splint/brace assistance in the 7 day lookback period. R71's diagnoses included hemiplegia and hemiparesis (weakness/paralysis affecting one side of the body) following a stroke affecting left non-dominant side, type 2 diabetes and lymphedema. R71's care plan dated 3/31/25, indicated R71 had decreased ROM to left upper extremity (LUE) and was at risk for contractures (condition where muscles or tendons become permanently shortened, causing loss of movement). R71's care plan instructed staff to DON [apply] Brace to L Arm @ [at] HS [bedtime] REMOVE in the morning and DON Left Hand Palm Protector in AM and remove at bedtime. R71's OT [occupational therapy] note dated 3/28/25, indicated a functional maintenance program including, Wear left resting hand splnit [sic] during the night and off during the day. R71's provider order dated 6/21/24, indicated don brace to left arm at bedtime and remove in the morning. R71's provider order dated 11/22/24, indicated don left hand palm protector in the morning and remove at bedtime. During observation and interview on 4/14/25 at 1:34 p.m., R71 stated he had left sided weakness and was supposed to be wearing a brace at night, but it was not routinely being placed. R71 was not wearing a brace or palm protector. There were two braces (an old gray one and a new blue one) and a white palm protector on the nightstand. Instructions for how to don the blue one hung on the wall. R71 stated could not apply the brace independently, and staff did not always assist. R71 further stated the palm protector was supposed to be on during the day, but again staff did not regularly assist with applying it. R71 stated not understanding what he was supposed to be doing with the blue brace and that it was fairly new. He used to wear the gray one at night, but has not worn it since the blue one was provided. R71 stated the blue brace had only been applied once when it was first brought in, and has not been applied since. During observation and interview on 4/15/25 at 1:31 p.m., R71 was not wearing the palm protector and stated no one had offered to apply it. During observation on 4/15/25 at 3:01 p.m., R71 sat in the common area in a wheelchair and was not wearing a palm protector. During observation on 4/16/25 at 7:25 a.m., R71 was in bed sleeping and the two braces and one palm protector were on the nightstand as they had been the previous day. During observation and interview on 4/16/25 at 7:44 a.m., licensed practical nurse (LPN)-B in to wake R71 up for a blood glucose check. LPN-B verified R71 was not wearing a brace and stated the evening staff were supposed to apply it. R71 stated no one offered to assist with applying the brace last evening. During observation on 4/16/25 at 8:13 a.m., nursing assistant (NA)-C and NA-C into R71's room to complete morning cares. R71's brief was changed, he was washed and dressed and assisted into a wheelchair. R71 was wheeled into the bathroom and set up for oral cares. R71's left hand was in a fist with tips of fingers pressing into his palm throughout cares and transfer. At 8:38 a.m., R71 was wheeled out to the dining room for breakfast. Neither NA-C nor NA-D offered to apply the palm protector. During observation on 4/16/25 at 8:48 a.m., LPN-B pushed R71 back into his room for an insulin injection and then back out to the dining room for breakfast. LPN-B did not offer to apply the palm protector. During observation on 4/16/25 at 9:28 a.m., NA-D walked by R71's room as R71 called out for assistance. NA-D entered and provided his reaching tool and some books and did not offer to apply the palm protector. During observation on 4/16/25 at 10:29 a.m., R71 was wheeled out to the common area for a group activity. R71 was not wearing a palm protector. During interview on 4/16/25 12:59 PM NA-C stated usually worked day shift and R71 does not always have a brace on in the morning and assumed R71 just took it off during the night. NA-C stated R71 was supposed to have a brace on at night and a palm protector on during the day but could not remember ever seeing the blue brace on. NA-C stated the palm protector was supposed to be donned first thing in the morning. During interview on 4/16/25 at 1:11 p.m., NA-D stated could not remember seeing either the blue brace or the gray brace on in the morning. NA-D stated the evening shift were responsible for applying it. NA-D stated R71 should have the palm protector applied in the morning but will refuse at times. During interview on 4/16/25 at 1:18 p.m., licensed practical nurse (LPN)-B stated the day nurse was responsible for documenting that the brace was off in the morning, but the NAs were the ones who typically removed it. LPN-B stated remembered seeing the blue brace on once right after it was provided, but had not seen it on R71 since then. LPN-B could not recall how long R71 had the blue brace. During interview on 4/16/25 at 1:25 p.m., LPN-A stated R71 should have the palm protector donned every morning to protect his palm from skin breakdown. LPN-A stated R71 should wear the brace at night to prevent further contracture. LPN-A stated would expect staff to apply the brace at night and to reapply it if it was removed for toileting or some other reason. LPN-A stated any refusals should be documented. During interview on 4/16/25 at 2:10 p.m., director of rehab (DOR) stated OT R71 last received OT services about a month ago and it was determined at that time the gray brace was worn out and the new blue one was provided by R71's daughter. DOR stated staff have been educated on how to apply the brace expected R71 was wearing it at night. DOR further stated any refusals should be documented and OT notified so they could reassess. During follow up interview on 4/17/25 at 9:03 a.m., DOR stated R71 had the new blue brace since the end of March when he last worked with OT. During interview on 4/17/25 at 9:48 a.m., director of nursing (DON) stated expectation that the brace and palm protector be applied and removed as ordered and refusals should be documented. DON stated R71's brace was to prevent further ROM decline, and the palm protector was to prevent skin breakdown. Facility policy Splint Management dated 4/30/18, indicated, If a member of the rehabilitation team is recommending a splint, brace or other DME device they will collaborate with nursing to ensure there is clear communication about the wearing schedule and any precautions. The policy further indicated therapy should work with nursing to ensure proper donning/doffing instructions.

Based on observation, interview, and document review, the facility failed to fully assess and follow up on weight loss and meal intakes for 1 of 2 resident (R73) reviewed for nutrition. Findings include: R73's Optional State Assessment (OSA) dated 3/17/25, indicated intact cognition, required supervision and set up support with eating. R73's admission Minimum Data Set (MDS) dated [DATE], indicated R73 had an impairment in range of motion on one side of the upper extremity, required supervision with eating, did not have a swallowing disorder, was 63 inches and weighed 146 pounds, had no or unknown weight loss or gain in the past 6 months, and had the following diagnoses: displaced comminuted fracture of the shaft of the right humerus (right arm), urinary tract infection, age related macular degeneration, other disorders of electrolyte and fluid balance, hearing loss, and history of malignant neoplasm of the large intestine. R73's Nutrition Care Area Assessment (CAA) dated 3/17/25, indicated R73 had functional problems that affected the ability to eat that included limitation in range of motion, inability to perform self care or mobility without significant physical assistance, and a recent decline in functional abilities. Further, weight loss was not warranted unless recommended by the physician and weight maintenance was R73's goal of care. R73's Dehydration/Fluid Maintenance CAA dated 3/17/25, indicated R73 had a urinary tract infection (UTI) and a fracture of the right arm that predisposed R73 to limitations in maintaining normal fluid balance. R73's care plan dated 3/11/25, indicated R73 was at nutrition/hydration risk related to humerus fracture, e-coli infection, macular degeneration, neoplasm of the large intestine, and partial guided assist during meal times. R73's goal was to maintain her current body weight of 146 pounds plus or minus 3% with intakes of meals and supplements averaging over 50% while rehabbing. Interventions included providing three meals and snacks, offer ensure, refer to the registered dietician as needed, and provide partial/guided assistance during meal times. R73's care plan dated 3/20/25, indicated R73 was at risk for dehydration related to advanced age, impaired mobility, and diagnosis of a urinary tract infection. Interventions included assessing risk factors for dehydration including poor by mouth intake, diuretic use, infection, or electrolyte imbalance, and assist with fluids as needed. R73's care plan dated 3/20/25, indicated R73 had an alteration in self-care ability due to impaired mobility due to non weight bearing on the right arm due to a humerus fracture. Interventions included assist of set up. Assist of 1 as needed. R73's Comprehensive Nutritional Assessment form dated 3/17/25, indicated R73 was on a regular diet and thin liquids, was 63 inches tall and weighed 146 pounds. R73's goal body weight was 146 pounds plus or minus 3%. Further, the form indicated it was not known if R73 had a 5% or more weight loss or gain in the last month or a 10% gain or loss in the last 6 months, and R73 required partial guided assist with feeding during meals and intake met 26 to 75% of estimated needs. The note further indicated R73's intakes varied averaging anywhere between 26 to 75% and did not take breakfast and in order to ensure needs were met the dietician recommended Ensure plus twice a day between meals. R73's weight was 146 which was consistent with the hospital weight of 145 pounds on 3/7/25. The form indicated the weight should be based on the most recent measure in the last 30 days. Further the dietician would continue to monitor weights and intake patterns and would reassess when or if medically necessary. The assessment had an area to document food preferences, likes and dislikes, religious/cultural/ethnic food needs and the area was left undocumented. R73's Census form indicated, R73 was on hospital leave on 4/6/25, and returned on 4/8/25. R73 had the following physician orders: 4/8/25, regular diet. 4/8/25, complete vital signs including weight every week on bath day. 4/8/25, document dinner intake daily on the evening shift. 4/8/25, offer a bedtime snack every day at bedtime. 4/9/25, document breakfast intake daily. 4/9/25, document lunch daily. 4/9/25, fracture/circulatory: fall with right humeral fracture, non-operative, using a sling on the right upper extremity. 4/12/25, functional maintenance program walk with assist of 1 and a gait belt/hand hold; non weight bearing to the right arm. Offer to come out to meals. Walk up to 25 feet to and from meals. Document any refusals via progress notes with meals at 8:00 a.m., 12:00 p.m., and 5:00 p.m. 4/16/25, Ensure Plus three times a day after meals if by mouth intake is less than 50% for weight loss and record amounts consumed. 4/16/25, Offer snacks three times a day to improve by mouth intake and meet nutritional needs at 10:00 a.m., 2:00 p.m., and 8:00 p.m. R73 had the following physician orders that had been discontinued: Starting on 3/11/25, and discontinued on 3/11/25, complete every week on bath day vital signs including weight. Starting on 3/11/25, and discontinued on 4/6/25, non-weight bearing of the right upper extremity. Starting on 3/11/25, and discontinued on 4/6/25, offer a bedtime snack daily. Starting on 3/11/25, and discontinued on 4/6/25, resident to be in [NAME] brace at all times. Starting on 3/11/25 and discontinued on 3/12/25, admission weight. Starting on 3/11/25, and discontinued on 4/6/25, regular diet. Starting 3/11/25, and discontinued on 4/6/2025, document dinner intake daily. Starting on 3/12/25, and discontinued on 4/6/25, document lunch intake daily. Starting on 3/12/25, and discontinued on 4/6/25, document breakfast intake daily. Starting on 3/17/25, and discontinued on 4/6/25, Ensure Plus twice a day. The Ensure Plus had not been reordered when R73 returned from the hospital on 4/8/25. Later, on 4/16/25, the dietician ordered Ensure Plus three times a day after meals if by mouth intake was less than 50% for weight loss. Starting on 4/8/25, and discontinued on 4/9/25, admission weight. R73's medication administration record (MAR) dated 3/16/25, through 4/15/25, indicated R73 refused Ensure Plus on 3/21/25, 3/23/25, 3/31/25. The Ensure Plus was discontinued 4/6/25, when R73 went to the hospital. R73's MAR dated 3/16/25, through 4/15/25, indicated R73 refused a bedtime snack on 3/22/25, 3/23/25, 3/26/25, 3/31/25, 4/1/25, 4/3/25, 4/5/25, 4/8/25, 4/9/25, 4/11/25, 4/12/25, 4/13/25, 4/14/25. R73's Weight Records form from 3/11/25, to 4/15/25, indicated the following weights: On 3/11/25, R73 was 146 pounds. On 3/18/25, R73 was 139.8 pounds. On 3/25/25, R73 was 136.6 pounds. The weight was highlighted in red with an orange triangle containing an exclamation point in the center of the triangle next to the weight. On 4/1/25, R73 was 128.4 pounds. The weight was highlighted in red with an orange triangle containing an exclamation point in the center of the triangle next to the weight. On 4/4/25, R73 was 130.1 pounds. The weight was highlighted in red with an orange triangle containing an exclamation point in the center of the triangle next to the weight. On 4/8/25, R73 was 125.6 pounds. The weight was highlighted in red with an orange triangle containing an exclamation point in the center of the triangle next to the weight. On 4/9/25, R73 was 125.6 pounds. The weight was highlighted in red with an orange triangle containing an exclamation point in the center of the triangle next to the weight. On 4/10/25, R73 was 126 pounds. The weight was highlighted in red with an orange triangle containing an exclamation point in the center of the triangle next to the weight. R73 lost 20 pounds or 13.5% of her body weight from 3/11/25, to 4/10/25. R73's Breakfast meal intake form from 3/11/25, to 4/15/25, indicated 15 of 36 daily entries were documented. R73 did not have any breakfast 14 times and ate 26 to 50% one time. R73's Lunch meal intake form from 3/11/25, to 4/15/25, indicated 16 of 36 daily entries were documented. R73 ate 26 to 50% of lunch 5 times, 51 to 75% of lunch 6 times, and 76 to 100% of lunch 5 times. Lunch intakes were documented one time after 4/9/25. R73's Dinner meal intake form dated 3/11/25, to 4/15/25, indicated 20 of 36 daily entries were documented. R73 did not have dinner one time, ate 1 to 25% 1 time, ate 26 to 50% 3 times, 51 to 75% 5 times, and 76 to 100% of dinner 10 times. Dinner intakes were not documented after 4/9/25. R73's A.M. Snack intake form from 3/11/25, to 4/15/25, lacked documentation a snack was provided. R73's P.M. Snack intake form from 3/11/25, to 4/15/25, lacked documentation a snack was provided. R73's Bedtime Snack intake form from 3/11/25, to 4/15/25, lacked documentation a snack was provided. R73's nutritional progress note dated 3/17/25 at 10:00 a.m., indicated R73 was on a regular diet and thin liquids and did not take breakfast according to charted data and recommended Ensure twice a day between meals. Further the dietician would monitor weight and intakes and would reassess when and if medically necessary. The note lacked information on R73's likes and dislikes. R73's progress notes were reviewed from 3/11/25, and lacked information the dietician or physician was notified of R73's weight loss prior to 4/16/25. R73's progress note dated 3/27/25 at 10:33 a.m., indicated family decided not to pursue hospice per recommendations from the cardiologist. R73's progress notes dated 4/10/25 at 8:31 p.m., indicated R73 ate independently after set-up assist. A progress note dated 4/16/25 at 11:14 a.m., was added following conversation with licensed practical nurse (LPN)-A that indicated dietician (D)-D placed an order to offer nutritional supplement (Ensure Plus) three times a day after meals if meal intakes were less than 50% and snack orders were placed between meals three times a day. A progress note dated 4/16/25 at 1:03 p.m., was added following conversation with LPN-A that indicated LPN-A updated nurse practitioner (NP) on R73's weight change and will continue with weekly weights, additionally the provider was aware of the Ensure order placed if having less than 50% of a meal. A progress note dated 4/17/25 at 10:40 a.m., indicated D-D spoke with R73's son who reported R73 was not a big eater and was raised eating meat and potatoes. Prior to fall would graze throughout the day and eat one meal which was often a lean cuisine. Further, R73 did not like to receive large portions due to disliking food waste and being overwhelmed and small portions would be included on the meal ticket. R73's history and physical dated 3/7/25, indicated R73 fell at home and sustained a right humerus fracture and had moderate dehydration. R73's history and physical dated 4/6/25, indicated R73 was admitted to the hospital with acute encephalopathy. R73's hospital discharge summary dated 4/8/25, indicated R73 had acute encephalopathy and a urinary tract infection. R73's transitional care unit (TCU) physician progress note dated 3/18/25, indicated R73's hospital weight on 3/7/25, was 145 pounds and R73's admission to the facility weight on 3/11/25, was 146 pounds. R73's TCU nurse practitioner (NP) progress note dated 3/19/25, indicated R73 had a well appetite, and had +1 to 2 edema to the right upper extremity. Further, the note indicated no nursing concerns were reported. The note contained R73's admission weight of 146 and TCU vital signs including a weight of 139.8 on 3/18/25. The note lacked information the weight loss was evaluated or addressed. R73's TCU NP progress note dated 3/24/25, indicated R73's appetite has been fair and would like to work on diet and had +1 edema to the right upper extremity. Further, the note indicated no nursing concerns were reported. The note contained R73's admission weight of 146 and TCU vital signs including a weight of 139.8 on 3/18/25. The note lacked information the weight loss was evaluated or addressed. R73's TCU NP progress note dated 3/26/25, indicated R73's appetite was good. R73's right upper extremity had +1 edema. Further, the note indicated no nursing concerns were reported. The note contained R73's admission weight of 146 and TCU vital signs including a weight of 136.6 on 3/25/25. The note lacked information the weight loss was evaluated or addressed. R73's TCU NP progress note dated 3/31/25, indicated R73 stated her appetite was good and was not interested in hospice and had trace to +1 edema to the right upper extremity. Further, the note indicated no nursing concerns were reported. The note contained R73's admission weight of 146 and TCU vital signs including a weight of 136.6 on 3/25/25. The note lacked information the weight loss was evaluated or addressed. During interview and observation on 4/14/25 at 12:04 p.m., R73 was in bed and stated she fell a few weeks ago and broke her arm pointing to her right arm which was under the covers and stated she still had that thing on her arm. During observation on 4/15/25 at 11:45 a.m., staff delivered resident's meal and R73 was sleeping in bed. R73 had a plate with 3 cookies and a bottle of ensure. The Ensure was unopened. The aide offered the ensure and R73 did not want any at that time. The aide set the Ensure back down and did not open the Ensure. During interview on 4/16/25 at 9:34 a.m., registered nurse (RN)-A stated staff looked at the care plan to know what cares a resident required and stated resident refusals were documented in a progress note along with the reason why. RN-A stated staff weighed residents in the a.m. and nursing would follow up with the dietician if a resident had a drop in their weight and stated most providers would be updated if a resident had a drop of more than 2 pounds and nursing would complete an assessment and call the provider. RN-A stated sometimes the provider will ask for a reweigh. Further, RN-A stated if there were no orders to follow up, a loss of two or more pounds in a day was concerning and would be documented in a progress note whenever the provider was updated. RN-A stated he expected staff document a resident's intake with every meal. RN-A stated R73 was initially admitted in the TCU because she had fallen and fractured her arm and stated R73 was not a big eater, and had not eaten well since she came to the facility and presumed R73 was losing weight. RN-A viewed R73's weights and stated the weights in red indicated a drop in weight and further stated R73 was in the hospital and came to the long term care floor on 4/8/25, and verified R73 lost weight, but was sick and went to the hospital and stated some of the weights were recorded when R73 was in the TCU. RN-A reviewed R73's progress notes and verified there were no notes indicating the physician was updated on the weight changes. RN-A stated R73 required stand by assist with meals, stated R73 had a cast when first arriving, but had a big drop in weight from when she first came into the facility. RN-A stated it would be important to update the physician on the weights because it was a significant weight drop and if someone dropped that much weight they don't have the stamina to do therapy and other things they are supposed to do. RN-A viewed R73's paper chart and verified the chart lacked documentation of the physician being updated. RN-A stated R73's weights prior to 4/8/25, were from R73's previous admission, on 3/11/25, and R73 readmitted to long term care on 4/8/25, and her weight was 125.6 and on 4/10/25 was 126. During interview on 4/16/25 at 10:34 a.m., licensed practical nurse (LPN)-A stated if a resident had a significant change in weight or 5% or 10%, they worked with the dietician and looked at intakes and whether supplements could be added, and if staff had a conversation, the dietician would complete an assessment and would place an order for Ensure in between meals. Further, if a resident had a significant change in weight, the physician was notified. LPN-A viewed R73's weights under Vital Signs in the electronic medical record (EMR) and stated R73 admitted to long term care on 4/8/25, and since her admission, the weight was consistent of 125.6 and went from the TCU to the hospital and had not yet had a care conference and further stated he would have expected staff update the provider. LPN-A viewed R73's intakes and verified R73's intakes were not consistently documented and stated it was important to see trends and compare weights. LPN-A verified the dietician had not completed an additional assessment since 3/17/25. Further LPN-A stated hospice was discussed with R73's son and R73 had a urinary tract infection and was unclear on R73's baseline and R73 plateaued and then rebounded, and the family was not ready for hospice. LPN-A stated dietician (D)-D was working remotely and would send D-D a message. During interview on 4/16/25 at 10:51 a.m., D-C stated she covered the TCU and resident's nutritional status was assessed with in their ARD (assessment reference date) for the MDS to assess how a resident was eating, their usual weight, whether they experienced weight changes. D-C stated residents were weighed weekly and the dietician reviewed charts and nurses notify the dieticians if a resident lost weight and the dietician interviews the resident to obtain their perspective and implements interventions to prevent further weight loss. If a resident had a weight loss of 5%, D-C expects nursing staff to follow up and sometimes weights may be inaccurate and dieticians will ask for a re-weigh. Further, D-C stated if a resident initially admitted and they had a history of weights from the TCU, went to the hospital a few days and then readmitted would go by the history of weights for determining weight loss and expected staff to document most meals unless a resident was out for an appointment. D-C stated she had been off for several months and the facility utilized a consultant dietician while R73 was in the TCU, who was no longer at the facility. D-C verified R73's admission weight was 146 on 3/11/25, and expected staff notify the dieticians of R73's weight changes and verified the weights in red indicated a 5% change in weight and was important to notify the dieticians to try to intervene before the weight loss was significant. D-C reviewed R73's nutritional assessment and verified R73's goal was to maintain her weight within 3% and verified the assessment did not include R73's likes or dislikes and verified likes and dislikes was also not documented on the care plan and further stated R73's likes and dislikes was not documented in the progress notes either. During interview on 4/16/25 at 11:59 a.m., D-D stated he had not been updated from nursing regarding R73's weights and thought it may have been due to the transition of R73 being in the TCU, then transferred to long term care following hospitalization . D-D also stated he was not aware of R73's appetites and reviewed them after talking to LPN-A today and added snacks three times a day, and supplements if R73 ate less than 50%. D-D stated staff should have updated him after identifying the initial 5% change in weight because interventions could have been implemented more proactively and was important for better outcomes and stated he expected staff document intakes after every meal because he would have a better idea how meal intakes were and gave a better picture of what they were collectively seeing and added it was difficult to predict if weight changes were from poor appetite or a comorbid condition. During interview on 4/16/25 at 12:41 p.m., the director of nursing (DON) stated the dietician ran weight reports monthly and nursing completed weekly weights and if a weight triggered for a 5% weight loss, nursing consulted with a dietician and would conduct a deeper dive such as checking a re-weight and would go from there as far as notifying the provider. The DON further stated when a weight entered was in red under Vital Signs in the EMR, it indicated a 5% change. The DON further stated R73 was on the TCU and moved to long term care and also had a consultant dietician who was overseeing R73 at the time and stated the provider documented admit weights and current weights in the progress notes. When asked if the physician addressed the weight loss, the DON stated she would have to look into that and further stated she would have expected staff update the dietician and stated she expected staff to document in the record if they update anyone. Further the DON stated meal intakes should be documented after every meal daily. Requested polices on weight monitoring and follow up, meal intake monitoring, nutrition and physician notification. During interview on 4/16/25 at 1:05 p.m., the DON stated she spoke with the provider and the nurse manager discussed intake and appetites and there were no concerns and if there was, would complete a dietician consult and further stated R73 had a swollen arm upon admission and stated some of the weight was from the swelling and further stated she expected staff document intakes and update the dietician. During interview on 4/16/25 at 1:19 p.m., the DON stated LPN-C documented several of R73's weights and spoke with R73's son regarding weights and discussed the weights were due to R73's arm, however, the DON agreed the information should have been documented. The medical record lacked information these conversations occurred. During interview on 4/16/25 at 2:41 p.m., the DON stated R73's NP went into the Allina system and found a baseline weight before R73's hospitalization that indicated R73 was 133 pounds and provided an encounter visit note dated 11/8/23. The DON agreed the nursing facilities record lacked documentation or coordination for determining R73's weight loss. A policy, Weights, dated 2/23/21, indicated weights were monitored to track significant weight changes related to nutritional status. Residents requiring more frequent weights, related to fluid imbalances, will be weighed per physician order or clinical judgement and monitored by nursing services. Clinical Nutrition Services (CNS) will notify nursing if a re-weigh is needed for a monthly weight. Resident intakes will be monitored per recommendations. All residents will be weighed and documented in the electronic health record. CNS and the resident's physician will be promptly notified of significant weight change. A significant weight change is 5% change in 30 days, 7.5% change in 90 days, and 10% change in 180 days. A policy, Resident Change in Condition-Notification of Physician/Surrogate Decision Maker, dated 3/2021, indicated the primary physician or nurse practitioner and the resident's designated surrogate decision maker will be notified of a resident's acute illness, serious injury, accident, or death. Physicians may establish specific parameters for notification beyond this. Notification will be made in the event of a significant change in the resident's physical, mental, or psycho social status. Documentation in the medical record will include all information given to the physician, name of the physician, time of contact, responses to concerns and new orders received, name of surrogate decision maker that was notified.

Based on observation, interview, and document review the facility failed to ensure a feeding tube tubing and nutrition bag were labeled according to professional standards to avoid the possibility of feeding tube complications and or related infections for 1 of 1 residents (R48). Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], indicated R48 had moderate cognitive impairment, was dependent on staff for all activities of daily living (ADL), and received 51 percent or greater daily nutrition through a feeding tube. R48's diagnoses included malnutrition, type 2 diabetes, anxiety, and major depressive disorder. R48's care plan dated 3/21/25, indicated R48 had little to no oral intake and relied on tube feeding to meet my nutrient needs. R48's physician order dated 11/27/24, indicated, Formula Type: ISOSOURCE 1.5, per pump 45 ml/hour continuous gastrostomy. R48's medication administration record (MAR) dated 4/1/25 through 4/15/25, indicated received daily continuous tube feedings. R48's nutrition assessment dated [DATE], indicated R48, Continues to tolerate continuous feeding, through very rarely [or at all] accepts food by mouth. During observation on 4/14/25 at 12:41 p.m., R48 was lying in bed with tube feeding running at 45 cc/hr. Neither the tube feeding tubing, nor the bag of formula had any indication of a start date or time. During observation on 4/15/25 at 8:17 a.m., R48 was lying in bed with tube feeding running at 45 cc/hr. Neither the tube feeding tubing, nor the bag of formula had any indication of a start date or time. During observation on 4/15/25 at 9:22 a.m., R48's tube feeding bag and tubing were unlabeled. R48's bedside table and nightstand each contained a pre-printed label indicating, Kangaroo enteral use only. The date and time were blank on both labels and the backing had not been removed to be affixed to the bag and/or tubing. During observation and interview on 4/15/25 at 9:30 a.m., registered nurse (RN)-A confirmed R48's tube feeding bag and tubing was not labeled with the start date and time as they should have been. During interview on 4/15/25 at 11:03 a.m., licensed practical nurse (LPN)-A would expect the tube feeding bag and tubing to be labeled with the date and time every 24 hours when the bag was hung and the tubing changed. During interview on 4/15/25 at 1:41 p.m., director of nursing (DON) stated expectation for tube feeding bag and tubing to be changed every 24 hours and labeled with the date and time of change. Facility policy Tube Feedings: Gastrostomy dated 8/2017, indicated, The bag/container is to be changed daily on the 11-7 shift.

Based on observation, interview and record review the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 resident (R23) reviewed for respiratory care. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had severe cognitive impairment, was dependent on staff for all activities of daily living (ADL), and required continuous oxygen therapy. R23's diagnoses included acute respiratory failure with hypoxia (low oxygen levels in tissues), Alzheimer's disease, dementia, and congestive heart failure. R23's care plan dated 4/4/25, indicated R23's diagnoses of Acute respiratory failure but failed to provide guidance for monitoring respiratory status or oxygen therapy. R23's physician orders dated 3/20/25, indicated the following: -Discard and replace oxygen tubing weekly - Sun 11-7 shift. -Discard and replace oxygen humidifier/bubbler weekly. R23's treatment administration record (TAR) dated 4/1/25 through 4/15/25, indicated, Discard and replace oxygen tubing weekly-Sun 11-7 shift. R23's TAR documentation indicated this was completed on 4/6 and 4/13. R23's TAR further indicated, Discard and replace oxygen humidifier/bubbler weekly. R23's TAR documentation indicated this was completed on 4/6 and 4/13. During observation on 4/14/25 at 12:38 p.m., R23 was not in room. The oxygen concentrator was on with an active bubbler. The O2 tubing attached to the oxygen concentrator was labeled with 4/7. The bubbler was not labeled. During observation on 4/14/25 at 1:13 p.m., R23 was in room after lunch sitting in wheelchair. R23 was receiving oxygen therapy via nasal cannula attached to a portable O2 tank. The tubing was not dated. The O2 tubing attached to the oxygen concentrator was labeled with 4/7. The bubbler was not labeled. During observation and interview on 4/15/25 at 9:51 a.m., nursing assistant (NA)-B stated nursing was responsible for oxygen tubing changes and bubbler weekly and confirmed R23's concentrator tubing was labeled 4/7 indicating the tubing was last changed 4/7. NA-B confirmed R23's portable O2 tubing and bubbler were not labeled with a date of last change. During observation and interview 4/15/25 on 10:06 a.m., registered nurse (RN)-A stated the oxygen tubing and bubbler were supposed to be changed weekly on both the concentrator and any portable unit if different tubing is used. RN-A stated the tubing was changed every Sunday. RN-A confirmed R23's tubing on the concentrator was labeled 4/7 and the tubing on the portable tank was not labeled. During interview on 4/15/25 at 11:03 a.m., licensed practical nurse (LPN)-A stated would expect oxygen tubing and bubbler to be changed and discarded weekly and labeled with the date of change. During interview on 4/15/25 at 1:40 p.m., director of nursing (DON) stated expectation for oxygen therapy equipment to be maintained as ordered. The tubing and bubbler should be changed weekly and the labeled with the date of change. Facility policy Oxygen Therapy dated 4/2018, indicated, Oxygen therapy will be provided per physician's order. The policy further instructed, Cannulas and tubing will be replaced at least weekly.

Based on observation, interview and document review the facility failed to ensure the recommended personal protective equipment (PPE) was utilized during high-contact cares for 2 of 3 residents (R48 and R53) reviewed for enhanced barrier precautions (EBP). Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, no behaviors or rejection of care, dependent on staff for dressing, hygiene, bathing and rolling left to right in bed. Had an indwelling catheter, feeding tube, was at risk for pressure ulcers but had none during the lookback period. Diagnoses included malnutrition, neurogenic bladder, diabetes, and dementia. R48's care plan dated 1/30/25, identified EBP were in place due to indwelling medical devices of urinary catheter and feeding tube. Goals included remain free of infection and prevent the spread of MDROs (multidrug-resistant organisms) within the community. Approaches included sign on resident's door to alert staff and visitors of EBP. PPE per CDC (Centers for Disease Control) recommendations during high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care; and any skin opening requiring a dressing. Staff were directed to wear gloves and gown prior to the high-contact care activity. During an observation on 4/14/25 at 5:32 p.m., licensed practical nurse (LPN)-B prepared R48's evening gastric tube (GT which is a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) medications at the medication cart. R48 prepared each medication by crushing and putting into an individual medication cup. During an observation and interview on 4/14/25 at 5:50 p.m., LPN-B walked past the EBP sign on R48's door, entered R48's room, and explained cares. LPN-B put on gloves, took R48's blood pressure, pulse and temperature. LPN-B did not put on a gown prior to high contact cares. LPN-B then removed gloves, put new gloves on, brought a towel from the bathroom and laid it on R48's abdomen near the GT site. LPN-B used her stethoscope from around her neck to listen to R48's bowel sounds, put the stethoscope back around her neck without cleaning. LPN-B administered the medications into R48's GT one at a time followed by ordered water flushes. At 6:04 p.m., after being prompted, LPN-B reviewed R48's care plan for EBP, and stated gown and gloves were only needed for catheter care, even though the care plan specified for GT care and high contact care. LPN-B continued to provide cares to R48 without a gown on. LPN-B put new gloves on, uncovered R48's lower legs from her blankets. unvelcroed foam boots from both lower extremities, lifted up R48's feet one at a time to apply a topical medication. LPN-B's scrubs came in direct contact with R48's bed, linens and boots during these cares. After exiting R48's room on 4/14/25 at 6:08 p.m., LPN-B was prompted to observe the EBP signage outside R48's room that directs staff to wear EBP PPE for GT cares. LPN-B stated the gown was only needed for catheter cares. During an interview on 4/15/25 at 8:55 a.m., LPN-C also stated EBP PPE of gown and gloves was not needed for GT medication administration, only if contact with wounds or catheter. During an interview on 4/15/25 at 12:52 p.m., registered nurse (RN)-B stated EBP PPE was required for residents with GT medications and cares, and direct contact. 49617 R53's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had short- and long-term memory problems and had severely impaired cognitive skills for daily decision making. The MDS indicated she was dependent on staff for toileting and personal hygiene and received 51% or more of her total calories and 501 cubic centimeter (cc, approximately one milliliter, mL) or more of her daily fluid intake from a feeding tube (a tube surgically inserted into the stomach to provide supplemental caloric intake). The MDS identified diagnoses of malnutrition, heart failure, dementia (a progressive neurological disorder that impairs a person's memory, thinking, judgment, and behavior). R53's Care Area Assessment (CAA) dated 12/19/24, triggered for tube feeding due to her inability to orally meet her nutritional needs. The CAA reported possible complications of tube feedings include: infections to G/J tube site ., where G/J tube referred to R53's gastrojejunostomy tube (a feeding tube going from the stomach into the small intestine with two access ports; the gastric or 'G' port; and the jejunal or 'J' port). The CAA and directed staff to monitor for signs and symptoms of complications and/or intolerance. R53's care plan dated 10/2/24, indicated she needed EBP because of her feeding tube and directed staff to follow the Center for Disease Control (CDC) recommendations during high-contact resident care activities, including providing hygiene, changing briefs or assisting with toileting. Her care plan guided staff to don gloves and gown prior to the high contact care activity. Per observation on 4/14/25 at 2:11 p.m., there was a sign posted on R53's door that indicated EBP were in place and PPE of gown and gloves were required for high-contact cares. During observation on 4/15/25 at 3:04 p.m., nursing assistant (NA)-E knocked on R53's door, entered and asked her if would be okay if she checked her brief. R53 nodded her head up and down but did not open her eyes. NA-F entered the room with bed linens, towels, and a hospital gown and donned a pair of gloves in the bathroom but did not wear a gown. NA-E stated the room was not stocked with any incontinence briefs and exited the room. NA-F put a plastic bag on the floor next to the bedside. NA-E returned at 3:07 p.m. with incontinence briefs and NA-F stated R53 needed a larger size. NA-E performed hand hygiene before leaving the room again. At 3:09 p.m., NA-E entered the room and performed hand hygiene in the bathroom. NA-E donned a pair of gloves but did not wear a gown. NA-F stood at R53's bedside and explained they were going to check and change her incontinence brief while NA-E pulled the shades over the windows in her room. The NA-E and NA-F pulled her pants down, then unfastened the tabs on the incontinence brief. NA-F held R53's hand when she started to say, no no no, and NA-F talked to her about going outside. NA-F offered her a stuffed animal from her bedside table and her behavior was calm as NA-E wiped her front perineal area with a washcloth. When NA-E finished wiping her front, they asked R53 if she could help turn herself onto her side, and she grabbed onto her grab bar and pulled herself onto her side with the NAs assistance. NA-E removed the old incontinence brief, wiped her backside from front to back with a washcloth, then dried in the same manner. NA-E grabbed the clean bed linen, tucked the old bed linen underneath R53, then rolled and tucked the clean bed linen under her and doffed the soiled gloves, revealing another pair of gloves underneath. NA-E continued working and tucked the clean incontinence brief under R53 and asked her to turn over the linens and brief onto her other side. The NAs assisted her to turn herself over and NA-F pulled the bed linen and clean brief through. NA-F fastened the tabs on the brief while NA-E discarded the soiled brief and linens. The NAs doffed their gloves and performed hand hygiene in the bathroom. During interview on 4/15/25 at 3:31 p.m., NA-E was initially unsure why R53 was on EBP, stating, I don't think she's on isolation, I don't think she has any sickness. NA-E read the EBP signage on R53's door and stated she was on EBP because of her feeding tube and confirmed the NAs should have worn a gown and gloves during their check and change cares to prevent the spread of infection. Per interview on 4/17/25 at 10:01 a.m. with the director of nursing (DON), acting as the facility's interim infection preventionist (IP), staff were educated on EBP and were expected to follow precautions in place. The DON acknowledged staff's struggle with understanding high-contact resident care activities and advised donning appropriate PPE first before entering the resident's room. Per facility policy titled Isolation - Categories of Transmission-Based Precautions last updated 7/12/22, when a resident is placed on transmission-based precautions, appropriate notification would be placed on the room entrance door and on the front of the chart, so personnel and visitors were aware of the need for and the type of precaution. The policy indicated the signage should inform staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. The policy wrote EBP involves the use of gown and gloves during high-contact resident care activities for residents known to be colonized or infected with multidrug-resistant organisms (MDROs) and those at an increased risk of MDRO acquisition (for example, residents with indwelling medical devices or wounds). The policy identified high-contact resident care activities to include dressing, bathing/showering, transferring, providing hygiene (brushing teeth, combing hair, shaving), changing linens, changing briefs or assisting with toileting, device care or use, and/or wound care. The policy indicated EBP are focused on the use of gown and gloves during such high-contact resident care activities because they have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare worker, even if blood and fluid exposure is not anticipated.

Based on interview and document review, the facility failed to review and revise the care plan with current interventions for the care of a new catheter and enhanced barrier precautions (EBP) for 1 of 1 residents (R2) reviewed. Findings include: R2's physician order dated 9/10/24, indicated R1 required a foley catheter related to diagnosis of urinary retention due to neurogenic bladder. R2's progress note dated 9/10/24, indicated R2 had returned to the facility following hospitalization . R2 was admitted to the hospital for septic shock due to bacteremia (blood stream infection) caused by an infected kidney stone. R2 came back to the facility with a foley catheter. R2's care plan revised on 9/20/24, indicated R2 had an actual alteration in elimination related to impaired mobility, overactive bladder exhibited by frequently incontinent of bowel and bladder. R2 had a diagnosis of neurogenic bladder and was at risk for skin breakdown and urinary tract infection (UTI). Further, R2's care plan directed staff to offer toileting at start of shift, every two to three hours and as needed, complete bladder assessment quarterly or with significant change, encourage adequate fluid intake every shift, incontinence care as needed, observe condition to perineal area with incontinence care, observe for signs and symptoms of UTI, toilet with assist of two staff. However, R2's care plan lacked evidence of R2 requiring a catheter or EBP and interventions in place to direct staff on how to manage R2's catheter. During an observation on 9/24/24 at 3:59 p.m., nursing assistant (NA)-A and NA-B applied a surgical mask and entered R2's room. R2 was noted to be lying in bed and a catheter bag was noted to be hanging on the side of the bed in a blue privacy bag. NA-A and NA-B applied gloves to assist R1 with incontinent cares. NA-A grabbed a canister from R2's bathroom and emptied R2's catheter while holding the canister. NA-A then placed the canister containing urine on the carpeted floor and NA-A wiped the open end of the catheter tubing and catheter bag using an incontinent wipe. NA-A then grabbed the canister, emptied the urine into the toilet, and removed the soiled gloves. NA-A and NA-B assisted R2 from bed to her wheelchair using a mechanical lift. NA-A and NA-B then exited R2's room. NA-A and NA-B did not wear a gown while assisting R2 with high contact cares. On 9/25/24 at 12:56 p.m., NA-C stated R2 required total assistance by staff for activities of daily living (ADL), was incontinent of bowel, and had a catheter that was placed about a week ago. NA-C confirmed R2 did not require the use of EBP, as there was no sign posted outside of R2's door. Further, NA-C stated if a resident required EBP a sign would have been posted outside the resident's door directing staff on what personal protective equipment (PPE) needed to be used, which would be kept in the cubby outside the resident's door. NA-C stated the resident's care plan and nursing care guide sheets would have also identified what each resident required. On 9 /25/24 at 3:08 p.m., licensed practical nurse (LPN)-A stated R2 returned to the facility from the hospital with a catheter. LPN-A confirmed R2 was not on EBP as the interdisciplinary team (IDT) must have missed implementing EBP upon returning from the hospital and LPN-A had not revised R2's care plan. On 9/25/24 at 3:28 p.m., director of nursing (DON) stated staff would know if a resident required EBP by a sign posted outside each resident's room, and DON was unsure if EBP were expected to be identified in a resident's care plan. Review of facility policy titled Care Plan Policy and Procedure revised 11/22, indicated the care plan was to be changed and updated as the care changes for the resident and as the resident changes occurred it would be updated in the electronic medical record and was to always be current. Further, policy directed staff to list all care to be provided for the problem listed and the care must be necessary and appropriate to accomplish the goal stated. As well as communicate vital information to all staff providing direct resident care, list of infection control measures, list of safety measures, approaches to maintain resident's customary routine and list of preventative measures.

Based on interview and document review, the facility failed to ensure residents wishes regarding code status were accurately reflected throughout medical records for 4 of 94 residents (R25, R41, R86, R349). The facility staff also lacked a consistent process on where to find the code status. This failure resulted in an immediate jeopardy (IJ) for R25, R41, R86, R349, when their medical records failed to identify the residents' wishes accurately. The IJ began on [DATE], when R25's providers order for life sustaining treatment (POLST) signed by provider indicated do not resuscitate (DNR) with selective treatment. However, the physician orders dated [DATE], indicated full code. The code status was not reflected consistently in R25, R86, R41, and R349's medical record. The IJ was identified on [DATE]. The corporate director of clinical services and the director of nursing (DON) were notified of the IJ on [DATE], at 10:58 a.m. The IJ was removed on [DATE], but noncompliance remained at the lower scope and severity level of E-patterned scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R25's quarterly MDS dated [DATE], indicated R25 had mild cognitive impairment and required limited assistance for most ADLs. R25's care plan dated [DATE], R25's care plan lacked reference to advanced directives or code status. R25's physician order dated [DATE], indicated full code. R25's POLST signed by provider on [DATE], indicated DNR with selective treatment. R25's POLST indicated documentation of discussion with Other Surrogate and was signed by R25's spouse (R41). During interview on [DATE], at 6:43 p.m. R41 stated R25 would not want CPR initiated if found unresponsive. R86's admission Minimum Data Set (MDS), dated [DATE], indicated R86 has severe cognitive impairment. R86's care plan dated [DATE], lacked reference to advanced directives or code status. R86's hospital discharge summary dated [DATE], indicated Treatment Options as DNR. R86's physician orders dated [DATE], indicated code status DNR. R86's POLST was not dated and was left blank with no choice of full code or DNR and no resident or physician signature. The facility's 24-hour Nurse Report Sheet (not dated) indicated R86 code status was DNR/do not intubate (DNI). During interview on [DATE], at 6:03 p.m. licensed practical nurse (LPN)-D stated he verified code status for residents by looking at the POLST in the resident's paper chart, the code status would also be found on the resident's face sheet in the electronic health record (EHR). LPN-D stated he would automatically go to the paper chart for the POLST and provide treatment according to what was indicated on the POLST because in an emergency scrolling through the EHR would take too long. LPN-D indicated a blank POLST means the residents code status is automatically considered a Full Code/ cardiopulmonary resuscitation (CPR). LPN-D confirmed R86 had a blank POLST in his paper chart and stated he would initiate CPR if R86 was found unresponsive. During interview on [DATE], at 6:08 p.m. registered nurse (RN)-D stated the code status for residents was verified by looking at the 24-hour nurse report form they carry with them which lists each resident's code status. RN-D verified on the 24-hour nurse report sheet R86's code status was DNR/DNI, and she would not initiate CPR if R86 was found unresponsive. During interview on [DATE], at 6:19 p.m. family member (FM)-B stated she has been the main interpreter for R86 and did not recall any discussion regarding R86's code status with the facility. FM-B stated she believed R86 would want CPR, but not be hooked up to machines. During interview on [DATE], 7:00 p.m. LPN-E indicated on admission the code status is determined by what is listed on the resident's hospital discharge summary and having the resident and/or responsible party verify code status by completing the POLST. Once code status has been determined it would be entered in EHR under orders, and the POLST is placed in medical record. LPN-E confirmed that R86's hospital discharge summary and orders in EHR indicated his code status was DNR. She confirmed that R86 had a blank POLST and stated that a blank POLST does not mean the resident is an automatic full code/CPR. LPN-E also confirmed R86's code status was listed as a DNR/DNI on the nurse 24-hour report form and indicated that code statuses were not to be listed on the 24-hour nurse report form as it is not consistently updated and may not be accurate. LPN-E stated she would not initiate CPR if R86 was found unresponsive due to the EHR had the code status as DNR. 42584 R41's significant change MDS dated [DATE], indicated R41 was cognitively intact and required minimal assistance for most ADLs. R41's care plan dated [DATE], R41's care plan lacked reference to advanced directives or code status. R41's physician order dated [DATE], indicated full code. R41's POLST signed by provider and R41 on [DATE], indicated DNR with selective treatment. R41's Associated Clinic of Psychology (ACP) note dated [DATE], indicated, [R41] said he is glad to be alive .not ready to die. R41's nurse practitioner (NP) note dated [DATE], indicated, Advanced Directives: Full Code. During interview on [DATE], at 6:43 p.m. R41 stated he would want CPR initiated if found unresponsive. During interview on [DATE], at 6:46 p.m. licensed practical nurse (LPN)-A stated a resident's code status could be found in the hard chart on the paper POLST or on the resident's face sheet in the EHR (electronic health record). LPN-A stated scrolling through the face sheet could take too long, therefore would go straight to the resident's hard chart for the POLST and provide treatment according to what was indicated on the POLST. LPN-A confirmed R41's POLST indicated DNR and stated she would not initiate CPR if R41 was found unresponsive. During interview on [DATE], at 6:59 p.m. LPN-B stated code status could be found on the resident's face sheet and the orders in the EHR and on the POLST in the hard chart. LPN-B stated staff should reference the most convenient location to determine code status when a resident was found unresponsive. LPN-B stated if discrepancies noted, staff should go by the most current date between the face sheet, orders in the EHR, and POLST. LPN-B confirmed R41's order in the EHR indicated R41 was a full code as of [DATE], and the POLST indicated DNR and dated [DATE] and therefore, R41 should be considered DNR, and CPR would not be initiated. 48109 R349's admission Minimum Data Set (MDS), dated [DATE], indicated R349 was cognitively intact. R349's provider order, dated [DATE], indicated a full code (to provide cardiopulmonary resuscitation) status. R349's care plan, dated [DATE], lacked direction for code status. An undated facility worksheet, entitled 24-hour Nurse Report Sheet, indicated R349 was a full code status. R349's Physician Order for Life-Sustaining Treatment (POLST) form indicated a Do Not Resuscitate (DNR) status. During an interview on [DATE], at 7:13 p.m. R349 stated he completed a POLST on [DATE] to declare his DNR status. During an interview on [DATE], at 7:26 p.m. RN-D verified R349's POLST form, signed by R349, indicated a DNR status while the provider orders indicated a full code status. In an emergency, RN-D stated she would look at the 24-hour Nurse Report Sheet for code status. During an interview on [DATE], at 8:55 a.m. the director of nursing (DON) stated a resident's admission orders indicated resident's code status. The admitting nurse would verify the code status with resident and/or responsible party by filling out a POLST form and entering the orders into Matrix (electronic health record). In an emergency, the DON stated her expectation was the code status indicated on the POLST and in the electronic health record (EHR) would match so it wouldn't matter where staff looked. DON also stated a resident's code status should never be listed on the 24-hour Nurse Report Sheet and wasn't aware that some were currently listed there. In the case of a blank POLST, the DON stated she didn't know what the policy was regarding whether CPR would be performed by default and would need to review facility policy. In the case of a discrepancy between the POLST and Matrix, the DON stated she would expect staff to follow policies and procedures to get clarification. Further, the DON stated code status was reviewed with resident care conferences and a clear code status was important to ensure the resident's wishes were upheld. The facility's policy Health Care Directives, POLST updated on [DATE], indicated facility will respect and follow the advanced directive of the resident, with standard medical practices. Policy lacked evidence of where the staff should find the residents code status. The IJ was removed on [DATE], at 11:30 a.m. when the facility developed and implemented a systemic removal plan which was verified by interview and document review, which included an audit of all resident's code status to ensure residents have matching code status order, POLST and Advanced Directive. The facility also reviewed and updated their Health Care Directive Policy and Procedure, which outlined the implementation of code status and where the staff would locate the code status. All licensed nurses, social services and therapy staff were trained immediately or prior to their next scheduled shift regarding the updated Health Care Directive Policy and how to answer questions or concerns regarding resident code status. All new admissions and readmissions to the facility will have the order, POLST, or Resident Determination of Medical Wishes and Advance Directive match to align with the residents wishes.

Based on interview, and document review the facility failed to protect 1 of 1 resident (R3) from resident to resident sexual abuse when R3 had an incident of sexual touch without consent occurred. The facility failed to report the abuse and implement interventions to prevent further abuse, as a result a second incident of sexual touch occurring one day later. This resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/16/22, when R4's hand was rubbing R3's thigh and R4's hand went up R3's thigh and began tugging on R3's shirt as though wanting to go under the shirt. Facility staff failed to report the incident of sexual abuse and no interventions or protections were put into place to prevention further abuse. On 3/17/22, a second incident of sexual abuse occurred when R4's hand was observed by staff under R3's shirt. The Chief Operating Officer (COO), the Corporate Director of Clinical Services and administrator intern were notified of the IJ on 3/30/22, at 2:38 p.m. The facility had implemented corrective action to prevent recurrence by 3/19/22, prior to the start of the survey therefore the deficiency is being cited as past non-compliance. Findings include: R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the MDS identified R3 had severely impaired cognition and was dependent of staff for all activities of daily living (ADL's) including mobility using a wheelchair in and out of the unit. R3's psychosocial well-being care plan dated 2/28/22, identified R3 was a vulnerable adult and needed assistance to remain safe within the community and was vulnerable to abuse from others. The care plan directed staff, You will report and investigate any allegations of suspected abuse, neglect, or exploitation. R4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the MDS indicated R4 had moderately impaired cognition. R4's cognitive loss/dementia care plan dated 10/26/2021, identified R4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan directed staff to provide redirection. During review of a facility reported incident (FRI) dated 3/17/22 revealed R3 was observed seated on the wheelchair outside of the Beauty Salon when R4 approached R3 and staff observed R4's hand under R3's shirt. The staff immediately intervened and removed R3. At this time nursing assistant (NA)-A made note of this encounter and she notified nurse manager immediately, and then the administrator was updated. The report also indicated R3 was confused at baseline and was unable to provide consent for this encounter and the immediate interventions included putting R4 on 1:1 for staff to always monitor his where about's and a psych referral was made for both residents involved. In addition, when interviewed R4 indicated he was adjusting R3's shirt and did not feel that he was acting inappropriately. In addition, after the incident on 3/17/22, during the investigation when staff were asked if they had noted any inappropriate touching, or behaviors between R4 and R3, NA-B acknowledged on the evening of 3/16//22, R4 was observed putting his hand up R3's shirt. NA-B stated she separated the residents immediately at that time and thought she reported the incident to the nurse. During interview on 3/30/22, at 10:45 a.m. NA-B stated on 3/16/22, she was down the hallway putting residents to bed and R4 had been going up and down the hallway. NA-A stated when she approached R3 and R4 she observed R4's hand was on R3's thigh rubbing and R4's hand went up R3's thigh and was tugging R3's shirt. NA-B stated R4 was yanking and pulling on the hem of the shirt as though wanting to go under but R4's fingers were visible and there was no skin-to-skin contact. NA-B stated she turned R4 around, took R3 to get her ready for bed and reported to the nurse as she thought it was suspicious because R3 had her eyes closed at the time. NA-B stated she had reported the incident to the nurse to make sure he had documented it. NA-B also stated she had not thought of reporting to the supervisor because she had been told to report to the nurse she was working with. During interview on 3/30/22, at 10:35 a.m. the Corporate director of clinical services stated staff was supposed to have reported the first incident to ensure R3 was provided protection from R4 and the second incident was avoidable. She stated education had been initiated and completed for all the staff on abuse and a referral had been completed for R4 to be transferred to a all male facility and R4 was waiting to be transferred once things were in place. During interview on 3/30/22, at 2:38 p.m. COO stated she had been updated about the investigation and she would have expected the staff to reach out to the administrator when they had seen observations or suspected any verbal interaction which was not appropriate, then the administrator was supposed to follow through by investigating and making sure the resident was protected. During interview on 3/30/22, at 5:00 p.m. R3's Family (FM)-C stated in R3's intact cognition, R3 would be appalled if she was touched by someone without consent. FM-C stated the facility had informed him of the incident which happened on 3/17/22, and later had called him to inform him there had been another incident which had come to light when staff was being interviewed which had been observed on 3/16/22. The facility Abuse Prohibition-Vulnerable Adult Protection / Abuse Prevention Plan revised 9/16/21, directed staff it was the responsibility of all employees to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown etiology, theft or misappropriation of resident property to facility management immediately. In addition, the policy directed administrative strategies were to be developed to protecting the rights and well-being of residents and staff to reinforce protection for the resident. The immediate jeopardy began on 3/16/22, when the facility failed to implement immediately interventions to protect R3 from repeated occurrence of sexual touch without consent. The immediate jeopardy deficient practice was corrected by 3/19/22. Following the incidents on 3/17/22, the facility completed interviews for both staff and residents about observing or experiencing inappropriate touch or made to feel uncomfortable respectively; both R3 and R4 got referrals and were seen by psych; all staff education was completed on vulnerable adult policies and procedures, reporting abuse responsibility and examples of abuse, R4 was moved to a different unit in the facility and was put on 1:1 for staff to monitor his whereabouts and NA-B was written up and was provided education. In addition, verification of corrective action was confirmed by the interviews with a multiple staff and facility Abuse Prohibition-Vulnerable Adult Protection/Abuse Prevention Plan policy was reviewed.

Based on interview and document review, the facility failed to initiate cardiopulmonary resuscitation (CPR) in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an immediate jeopardy (IJ) situation. The IJ began on [DATE], at approximately 5:40 a.m. when the facility failed to provide CPR for R1 after R1 was found unresponsive without a pulse or respirations, and CPR was not initiated. The Chief Operating Officer, the Corporate Director of Clinical Services and administrator intern were notified of the IJ on [DATE], at 2:18 p.m. The facility had implemented corrective action to prevent recurrence by [DATE], therefore the deficiency is being cited as past non-compliance. Findings include: R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the MDS identified R1 had intact cognition. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Provider Orders for Life-Sustaining Treatment (POLST) signed by R1 and the nurse practitioner on [DATE], indicated R1's wishes were to Attempt Resuscitation and Full Treatment including life support measures in the intensive care unit. R1's progress note dated [DATE], at 7:24 a.m. by licensed practical nurse (LPN)-A indicated at 5:00 a.m. staff had been to resident room and had noted R1 was sleeping. Then at 5:40 a.m. Writer entered to see patient had leg over edge of the bed, urine in the urinal. Patient had no resp [respirations], No BP [blood pressure], No signs of life. Lips cyanotic, skin mottled and cool to touch. Shook patient with no change. Verified by another licensed [lic] staff and supervisor of patient's passing. The note did not indicate CPR was initiated. Resident's record verified resident was a full code. During interview on [DATE], at 9:51 a.m. LPN-A stated nursing assistant (NA)-A had completed resident round checks between 4:30 a.m. and 5:00 a.m. and she had reported R1 was asleep. LPN-A then stated when she entered R1's room at 5:30 a.m. to check R1's oxygen saturation she found R1 was unresponsive, had no respirations, no pulse, had no signs of life, was mottling in the upper arms and lips were blue. LPN-A acknowledged she did not review R1's POLST until she was calling the physician on-call and that was when she found out R1 was a Full code. LPN-A also acknowledged she did not initiate CPR but instead declared R1 was dead. LPN-A stated she informed LPN-B R1 had passed away and there was no discussion of CPR being initiated but instead she and LPN-B put R1's leg, that had been hanging on the edge of bed, up and that was it. LPN-A stated she was supposed to look at the POLST if she found a resident unresponsive first, then was supposed to follow the facility protocol which she did not follow. During interview on [DATE], at 12:35 p.m. the Corporate Director of Clinical Services stated her expectation was the nurse should have followed the policy and procedure to initiate CPR as this was what was on the resident POLST. She then stated following the incident the facility had immediately initiated training for all nurses and therapy staff. In addition, the Corporate Director of Clinical Services stated LPN-A was terminated. During interview on [DATE], at 10:45 family member (FM)-A stated although R1 had medical issues, he was looking forward to discharging from the facility to the community. FM-A also stated R1 was coherent and able to make decisions about his health and still wanted to be alive. During interview on [DATE], at 6:43 a.m. LPN-B stated she had worked the night shift on [DATE], to [DATE], when R1 was found unresponsive. LPN-B stated LPN-A had approached her as she assisted another resident to the bathroom and had asked her to hurry and at the time she asked what was going on and that was when LPN-A stated to her R1 had passed away. LPN-B then stated NA-C and LPN-A went into R1's room and observed one of the legs was hanging on the edge of the bed. LPN-B stated she assisted LPN-A to reposition R1 to the middle of the bed and at this time she also checked R1's pulse and did not feel anything and she did not say anything to LPN-A. LPN-B stated she then reminded LPN-A to call to report to the supervisor all three staff left R1's room. LPN-B stated she did not ask LPN-A R1's code status because she thought because LPN-A was the assigned nurse she was well aware of R1's wishes. LPN-B stated since the incident she had received training that if a resident was unresponsive, they were supposed to first check the resident POLST and code status, then initiate CPR and call 911. During interview on [DATE], at 6:54 a.m. LPN-C night building supervisor stated LPN-A had called to report R1 had passed on and she had asked LPN-A if she needed any assistance and if she had made the necessary calls and LPN-A had stated she had. LPN-C also stated LPN-A had called her a second time and told me R1 was a full code and she again asked her if she needed any assistance and LPN-A told her no. LPN-C stated when a resident was found unresponsive, first of all we have to check the POLST and if they are a full code we are to call *79 and to call the code blue and start CPR and when staff start running we tell them what to assist with the procedure. We are to start CPR and call 911 and to get them out of here. LPN-C stated since the incident she had received in-service on CPR protocols. LPN-C further stated We are to read the POLST out of the chart and then take the necessary actions. The facility's CPR policy dated [DATE], directed staff working at the facility to their best of their ability to respect the wishes of residents and follow the procedure listed below for the initiation of CPR or Do Not Resuscitate (DNR) orders for each resident, if obtained. The American Heart Association (AHA) publishes guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). The AHA urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. If a resident experiences a cardiac or respiratory arrest facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives and any related physician order, such as code status, or in the absence of advance directives or a DNR order. The immediate jeopardy began on [DATE], when the facility failed to implement their policy, and the resident's directive, related to CPR for R1. The immediate jeopardy was removed and the deficient practice corrected by [DATE], when the facility had implemented a systemic plan of correction that included re-educating the facility's licensed nursing and therapy staff regarding the facility's CPR policy and what staff are supposed to do when they found a resident unresponsive which included checking the POLST, initiate CPR immediately and call 911; an audit of charts for other residents who had passed away was completed to ensure the staff had followed the residents wishes. In addition, LPN-A was terminated. Verification of corrective action was confirmed by the interviews with a variety of nursing and therapy staff and facility CPR policy was reviewed.

Based on interview and document review, the facility failed to ensure the safety of 1 of 3 residents (R1) reviewed for accidents. R1 was harmed when she fell /rolled out of bed and sustained a fractured right hip requiring surgical repair. However, the facility implemented corrective action on 8/10/20, therefore the deficiency is being cited at past non-compliance. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], included, severe cognitive impairment with a [DIAGNOSES REDACTED]. The MDS indicated R1 had not fallen in the last quarter. R1's mobility care plan dated 1/28/20 directed staff to utilize a full mechanical lift with 2 assistants for transfers. R1's falls care plan, dated 12/9/19, identified a risk for falling related to not being aware of safety needs and directed staff to use a bed that goes to the floor with a mat along side of the bed. R1's Safety Events-Falls reports dated 10/25/20 through 3/12/20, indicated R1 had fallen or rolled out of bed thirteen times. R1's progress note dated 8/4/20, at 2:51 p.m. indicated nursing assistant (NA)-A reported R1 was on the floor at 9:20 a.m. R1 was observed, Lying on her back with legs stretched towards the foot of the bed and her head an inch beneath the night stand. R1 was able to move upper extremities and the right leg, however, Resident put her hand on her left hip and moaned in pain. Care Specialist reported that she was getting Resident ready for a shower, took the floor mat off the floor and went to get the hoyer lift (full body mechanical lift). Coming in with the lift, she witnessed Resident rolled from the bed to the floor hitting her left side. Resident unable to verbalize what happened due to dx (diagnosis) of dementia. Alert with confusion. Resident's Bp's (blood pressure) ranged from 128/58 and increased to 185/100 (normal under 120/80). Resident denies dizziness and writer took BP every 15-30 mins. R1's progress note dated 8/4/20, at 1:15 p.m. included, X-ray result identified an acute [MEDICAL CONDITION]. R1 was transported by paramedics to the hospital for surgical repair of the left hip. R1's post fall investigation dated 8/4/20, included the bed was 17 inches off the floor, but the mat was not on the floor to cushion any fall as directed in R1's care plan. R1's interdisciplinary team review, dated 8/6/20, indicated all staff had been re-educated to follow the care plan specific to each resident. An Education for Following the POC (plan of care), showed nursing staff were being re-trained on following the resident individual plan of care. The education sign in was started on 8/4/20, and continued prior to the start of each shift until all staff were trained 8/10/20. The specific direction was while providing care If a hi-low bed and /or fall mat are to be in place and not to leave the resident in bed unattended without these things in place for any amount of time. Nurses and nursing assistants were interviewed on 8/11/20, and verified they had received the training prior to starting their shift. A facility audit form dated 8/10/20, indicated the facility began routine audits on the placement of floor mats for all residents who required them. When interviewed on 8/11/20 at 1:30 p.m. the director of nursing (DON) verified All staff were trained prior to the start of each shift for following the plan of care and fall mat was to be in place and the audits began on 8/10/20, and would continue to ensure fall mats were in place as care planned. A facility policy titled, Fall Prevention and Management, updated 1/29/19, read Upon admission, quarterly, annually and with significant change all residents will be assessed for their risk for falls. All falls will be investigated and new interventions put in place and care planned.

Based on observation, record review, policy review, and staff interview, the facility failed to ensure that residents received the necessary care and services to identify pressure ulcers, promote healing and prevent further development of pressure ulcers for 2 of 2 residents (R7, R96) with pressure ulcers. The failure to provide the necessary care and services resulted in actual harm for R7. Findings include: R7 was admitted to the facility's transitional care unit on [DATE], with [DIAGNOSES REDACTED]. R7 was identified being at risk for the development of pressure ulcers, lacked a comprehensive assessment which identified and addressed all pertinent risk factors for skin breakdown and subsequently developed a stage II pressure ulcer (damage to the skin extending into, but no deeper than, the dermis) after admission to the facility. R7 was lying in her bed on [DATE], from 8:40 a.m. until 10:34 a.m. when the licensed practical nurse-C (LPN-C) and a care specialist (CS-C) used the draw sheet to lift and reposition the resident into the center of the bed. CS-C indicated she had been in earlier around 8:00 a.m., and repositioned resident with pillows. The initial minimum data set ((MDS) dated [DATE], indicated the resident needed extensive assist from staff for all bed mobility and transfers. The MDS indicated the resident was at risk for development of a pressure ulcer and that a Stage II pressure ulcer was noted on [DATE]. There was no further indication of any other stageable or untraceable pressure ulcer. A review of the admission body assessment dated [DATE], indicated the resident had multiple ecchymotic bruises on legs, arms, back and buttocks. The assessment indicated the resident did not have any pressure sores. However, R7 did have a sore that was closed on the left ankle. The first week Skin Risk Assessment checklist (a scale for prediction of pressure sore risk) dated [DATE], indicated the resident had a score of 16 (which indicated at risk). It listed [DIAGNOSES REDACTED]. The skin risk assessment did not identify or address other pertinent risk factors including the resident's [DIAGNOSES REDACTED]. The assessment indicated skin treatments included other preventive or protective skin care. There was no further Braden (a tool to assess the risk for developing pressure ulcers) conducted on the resident until nearly two weeks later when the resident returned from the hospital on [DATE]. The Tissue Tolerance Observation dated [DATE], indicated there were no current skin integrity concerns. For the lying observation, completed on [DATE], no skin concerns were noted, and results indicated the resident should be turned and repositioned while lying every one hour. The sitting observation was completed on [DATE], and indicated there were current skin integrity concerns and an open area on the buttocks and redness was noted. The results indicated the resident had redness after one hour and recommended the resident be turned and repositioned every one hour while sitting. There was no indication or documentation indicated why the sitting portion of the tissue tolerance observation was not completed until six days after admission. A review of the wound flow sheet dated [DATE], indicated the resident had a Stage II pressure ulcer on the left buttocks that measured three centimeters (cm) x one cm. R7 was hospitalized from ,[DATE]-[DATE], with a [DIAGNOSES REDACTED]. An Admission Body Assessment was completed on [DATE], that indicated resident had a darken area on heel that resident stated was from a fall at home(prior to the first admission of [DATE]) and the open area on coccyx had increased in size. R7 had two open areas on left lateral leg new since readmitted from hospital. Staging was not identified. A Skin Risk Assessment with Braden Scale was completed on [DATE], that identified clinical risk factors including cardiovascular disease, diabetes, [MEDICAL CONDITION] and other (fractured pelvis). The assessment did not identify the [DIAGNOSES REDACTED]. However, the assessment identified the resident at moderate risk for skin breakdown. The assessment identified the resident as having a stage IV pressure ulcer (an ulcer that was deep and could possibly extend into the muscle or bone) the location not identified. There was no indication in the medical record that another tissue tolerance was completed. A nursing note dated [DATE], at 10:10 a.m. indicated a skin check was done with numerous bruises in varying sizes, and open areas on coccyx and left lateral lower leg. Further nursing notes on [DATE], indicated the open area on coccyx had increased in size to eight cm x eight cm. There were two lacerated type open areas on the left lateral lower leg and a bruise was noted on the left heel that resident had indicated was related to a fall at home. A nursing note dated [DATE], indicated the resident was turned and repositioned every two hours. The High Risk For Skin Breakdown handwritten care plan, dated [DATE], indicated the resident was high risk for impaired skin integrity and identified the Braden score of 16. The left buttock (identified as stage II) site and left heel were identified in the problem statement. The plan indicated resident was to be repositioned every two hours and as needed. Other interventions and reviews were noted on the working care plan that indicated a specialty air mattress and dietary support. However, these interventions were all added after the resident had skin breakdown. The current care plan, updated [DATE], indicated the resident was to be turned and repositioned every two hours and as needed with total assist of one - two staff when in bed. R7 went for two hours and 34 minutes without being repositioned on [DATE]. A review of the wound flow sheet dated [DATE], indicated the resident had a Stage II pressure ulcer on the left buttocks that measured three cm x one cm. On [DATE], the wound flow sheet identified it as being on the coccyx and measured eight cm x eight cm. On [DATE], the wound was measured which indicated there were now three open areas on the buttocks/coccyx area which measured : 2.6 cm x 1.5 cm, 2.6 x 1 cm, and 0.8 cm x .05. On the [DATE], the Wound Flow Sheet identified the left heel ulcer as an unstageable pressure ulcer due to declining status condition. On [DATE], the Wound Flow Sheet identified the coccyx with multiple open areas due to end stage [MEDICAL CONDITION]/decline in condition. The three wounds measured three cm x two cm, two cm x three cm and one cm x one cm. The open areas had increased in size. The facility's policy and procedure for Skin and Wound Care Protocol revised ,[DATE], was provided by the director of nursing (DON) on [DATE], at 10:00 a.m. The policy indicated the Braden Scale will be used to identify residents at risk for potential impairment in skin integrity and the result of the Braden Scale score will be used as part of the foundation for the skin care and other risk factors and contributing [DIAGNOSES REDACTED]. The policy lacked mention of the use of the tissue tolerance observation. The DON was interviewed on [DATE], at 12:30 p.m. regarding the initial skin assessment. The DON agreed the tissue tolerance observation indicated the resident should have been repositioned every hour based on that observation and that the care plan had instructed staff to turn and reposition the resident every two hours. The DON was not sure why the observation was not completed sooner than six days after the resident was admitted and indicated the tissue tolerance observations are to be completed on the first shift of an admission/readmission. The DON verified another tissue tolerance observation was not completed until after the [DATE] hospitalization . R96 developed a pressure ulcer while at the facility and the facility did not comprehensively assess that resident for pressure ulcer development risk. R96 was admitted [DATE], with [DIAGNOSES REDACTED]. The resident's condition gradually declined and the resident expired at the facility on [DATE]. The initial Minimum (MDS) data set [DATE], describes the resident as having two, stage two pressure ulcers. No documentation regarding assessment of the resident's skin integrity after pressure relief was found in the record. Documentation of that assessment information was requested of the facility DON on [DATE]. No reference to tissue tolerance testing was found in the facility's " Skin & Wound Care Protocol " policy, revised ,[DATE]. Record review on [DATE], revealed an "Admission Body Assessment" dated [DATE], showing that the resident had no pressure ulcer upon admission. A "Skin Integrity Events-Pressure Sore/Stasis Ulcer/Arterial" form in the record showed two, stage two pressure ulcers were identified on [DATE], that measured at two x one cm and two x 0.7 cm. At 12:05 p.m. on [DATE], the DON stated that she could not locate any documentation that a tissue tolerance assessment had been completed for that resident. When interviewed at 2:45 p.m. on [DATE], the DON stated that tissue tolerance assessment is part of the skin risk assessment routine at the facility, and she provided a checklist showing "Initiate Tissue Tolerance (on paper)" was to be completed the first shift after a resident's admission.