Every finding on record at Sholom Home West

Based on interview and document review, the facility failed to ensure the Ombudsman for Long Term Care (OMB - LTC) was notified of resident transfers or discharges for 3 of 5 residents (R73, R139, R141) reviewed for transfers or discharges from the facility. Findings include: R73's comprehensive Minimum Data Set (MDS), dated [DATE], indicated R73 was cognitively intact, and diagnoses included chronic kidney disease, and neuralgia and neuritis (general nerve pain or inflammation). R73's progress note, dated 2/16/26 at 5:43 p.m., indicated R73 was sent to the hospital for blood emesis and loss of consciousness. A subsequent progress note, dated 2/25/26 at 4:05 p.m., indicated R73 was readmitted to the facility on [DATE] at 2:00 p.m. The facility's Monthly Notice to OMB-LTC of Emergency Acute Care Transfers and Discharges, dated February 2026, lacked notice of R73's hospital transfer on 2/16/26. R139's comprehensive MDS, dated [DATE], indicated R139 had moderate cognitive impairment and diagnoses included congestive heart failure (CHF) and rheumatoid arthritis. R139's progress note, dated 2/9/26 at 12:40 a.m., indicated R139 was sent to the hospital for an acute behavioral status change. A subsequent progress note, dated 2/9/26 at 10:19 a.m., indicated R139 was admitted to the hospital for encephalopathy, and the family did not wish to hold the bed. The facility's Monthly Notice to OMB-LTC of Emergency Acute Care Transfers and Discharges, dated February 2026, lacked notice of R139's hospital transfer on 2/9/26. On 3/19/26 at 2:52 p.m., director of nursing (DON) verified the OBM-LTC was not notified of R73's hospital transfer on 2/16/26, and R139's hospital transfer on 2/9/26. DON stated when a resident was transferred to the hospital, a notification was expected to be sent to the ombudsman. Findings Include - R141's Face Sheet (undated) documented the diagnoses of Sepsis due to methicillin susceptible Staphylococcus aureus ( a germ found on people's skin ), pneumonia, acute and subacute infective endocarditis (inflammation of the heart's inner lining). R141's Minimum Data Set (MDS), with a registered nurse signing date of 2/07/26, documented R141 was moderately cognitively impaired and require set up to moderate assistance with all activities of daily living. R141's nurse progress notes on 2/08/26, documentation indicated R141 had eloped from the facility being later found wondering at Target. Family arrived and returned R141 to the facility (this was later investigated by the Minnesota Department of Health - Rapid Response Team). Upon returning to the facility, R141's daughter insisted on taking resident home. R141's provider was contacted, and discharge orders were received. During interview on 3/18/26 at 8:36 a.m., the director of nursing (DON) stated she had received a phone call from the facility on 2/8/26, the family was going to take R141 home AMA (against medical advice). Family was upset about the resident's elopement and concerns over staff monitoring resident's whereabouts. DON stated she and the facility staff were trying to prevent a AMA discharge, due to R141 receiving IV antibiotics and level of care. DON stated the daughter informed the facility she was going to take R141 home and place resident on hospice the following morning. R141 was discharge with family on 2/08/26. In a review of the documented listing, provided by the facility by the months submitted to OMB-LTC, the Month of February 2026 lacked R141's name. During interview on 3/19/26 at 2:19 p.m., the DON stated R141's family requested R141's discharge or they would be taking resident AMA (against medical advice). DON stated she involved the primary physician, who at first was against the discharge. However, after family informed facility / primary of the intentions of enrolling R141 into hospice services the following day, the primary physician gave the orders for discharge. DON stated she didn't want the family taking R141 AMA, and due to the emergent situation, wished to make R141 as safe as possible. DON was unable to explain why R141's name was not listed on the February 2026 listing provided to the LTC-OMB. In review of the facility's policy entitled: Transfer and Discharge from the Facility Policy (updated 4/5/25) documented in the procedure section, the following was documented: 9. Fax notice of transfer discharge form to the ombudsman.

Based on interview and document review, the facility failed to ensure resident records upon discharge were complete and accurate for 1 of 1 resident (R141) reviewed for discharge.Findings Include - R141's Face Sheet (undated) documented the diagnoses of sepsis due to methicillin susceptible staphylococcus aureus ( a germ found on people's skin ), pneumonia, acute and subacute infective endocarditis (inflammation of the heart's inner lining).R141's Minimum Data Set (MDS), with a registered nurse signing date of 2/07/26, documented R141 was moderately cognitively impaired and require set up to moderate assistance with all activities of daily living.R141's nurse progress notes on 2/08/26, indicated R141 had eloped from the facility and was later found wondering at Target. Family arrived and returned R141 to the facility (this was later investigated by the Minnesota Department of Health - Rapid Response Team). Upon returning to the facility, R141's daughter insisted on taking resident home. R141's provider was contacted, and discharge orders were received.R141's electronic medical record, reviewed on 3/18/26, lacked evidence of a recapitulation of stay (a summarization of cares / services performed), documentation of medications sent with and any care instructions which would have been sent home with r141, by the facility on discharge.During interview on 3/18/26 at 8:36 a.m., the director of nursing (DON stated she would look into it, while that information would have been in R141's paper chart. DON stated she had received a phone call from the facility on 2/8/26, family was going to take R141 AMA (against medical advice) being upset about the resident's elopement and concerns over staff monitoring resident's whereabouts. DON stated she and facility staff were trying to prevent a AMA discharge, due to R141 receiving IV antibiotics and level of care. DON stated the daughter informed the facility she was going to take R141 home and place resident on hospice the following morning. DON stated she knew the documents were there. In a follow-up interview on 3/19/26 at 2:35 p.m., DON stated the facility staff were unable to find the requested documents (recapitulation of stay, documentation of medications sent with and any care instructions), after she and the HUC (health unit coordinator) searched R141's paper record and a pile of documents yet to be scanned. DON stated the evening of R141's daughter's request for discharge and family's demand for discharge or would be taking R141 AMA, the facility staff did their best to meet family's demands and contact and process physician's order to meet this request. DON stated she knew the documentation was completed as the requested documents were reviewed with the Rapid Response investigator who investigated R141's elopement days later. DON stated her concern was, during the investigation of the elopement, she may have failed to make copies and the originals may have been given to the Rapid Response investigator. In review of the facility's policy entitled: Transfer and Discharge from the Facility Policy (updated 4/5/25) documented in the procedure section, the following was documented:1. For resident-initiated discharges, the medical record is expected to contain documentation or evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge care plan, and documented discussions with the resident or, if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care. Additionally, the comprehensive care plan will contain the resident's goals for admission and desired outcomes, which should be in alignment with the discharge if it is resident-initiated.

Based on observation, interview and document review, the facility failed to maintain resident equipment cleanliness of intravenous (IV) poles for 1 of 1 resident (R86) reviewed for tube feeding.R86's quarterly Minimum Data Set (MDS) dated [DATE], indicated R86 had severe cognitive impairment and was dependent on assistance from staff for activities of daily living (ADLs). R86 diagnoses included dysphagia (difficulty swallowing food or liquids) following stroke, hypertension, gastrostomy tube (tube into stomach for feeding), hemiplegia (paralysis on one side) and hemiparesis (muscle weakness) following stroke, and encephalopathy (group of conditions that cause brain dysfunction). On 3/17/26 at 8:40 a.m., observed IV pole in R86's room with tube feeding pump attached. The pole, pole legs, and floor below were observed to have tan colored, dried substance that dripped down the pole, covered all five legs with several dried spots on the floor. Follow up observations on 3/18/26 at 10:08 a.m.; 3/18/26 at 1:55 p.m.; 3/19/26 at 8:15 a.m. and 3/19/26 at 1:07 p.m., the IV pole, pole legs and floor below continued to have dried tan colored substance. When interviewed on 3/19/26 at 1:28 p.m., registered nurse (RN)-A stated the poles should be cleaned of any formula spills as soon as it was seen as well as when starting or stopping the feeding for infection control reasons. When interviewed on 3/19/26 at 1:51 p.m., nurse manager (NM)-B stated the pumps and poles should be cleaned whenever it is observed to have anything on them. NM-B stated evening shift should clean the pump and pole when they started the tube feeding, day shift should clean the pump and pole off in the morning when the feeding was stopped. NM-B observed the pole and floor, stated should have been taken care of for cleanliness and infection control purposes. Facility policy Tube Feedings: Gastrostomy revised 8/2017, indicated the IV standard and pump was to wiped down daily with a cloth dampened with disinfectant.

Based on observation, interview, and document review, the facility failed to complete proper disinfection of a blood glucose monitor for 1 of 1 resident (R10) reviewed for glucose monitoring.Findings include: R10's comprehensive Minimum Data Set (MDS), dated [DATE], indicated R10 was cognitively intact, and diagnoses included Parkinson's disease, chronic kidney disease and diabetes. R10's Physician Order Report, dated 2/18/26 - 3/18/26, indicated an order for blood glucose monitoring twice a day for diabetes. During observation and interview on 3/18/26 at 8:26 a.m., registered nurse (RN)-C was observed using an Assure Platinum blood glucose monitor (BGM) to check R10's blood glucose level. After RN-C completed the task and returned to the medication cart with the BGM, RN-C donned gloves, pulled a wipe from a blue-topped canister of PDI Sani-Hands Instant Hand Sanitizing Wipes, wiped the entire BGM with the wipe, and stated she would leave it out to dry. During interview on 3/18/26 at 8:55 a.m., RN-C stated the facility did not use shared blood glucose monitors and each resident had their own. RN-C stated, you can use this one (pointed to the canister of PDI instant hand sanitizing wipes) or you can use the alcohol wipes to sanitize. RN-C stated she was trained to sanitize the BGMs after each use. During interview on 3/18/26 at 2:33 p.m., director of nursing (DON) stated staff were expected to clean and disinfect the BGMs after each use with disinfecting wipes, purple, grey, or orange-topped canisters, and hand wipes were a definite no. DON stated proper disinfection of blood glucose monitors were important for infection control purposes. The Quality Assurance / Quality Control (QA/QC) Reference Manual for the Assure Platinum Blood Glucose Monitoring (BGM) System, provided by the facility on 3/18/26, indicated cleaning and disinfecting the BGM minimized risk of transmitted blood-borne pathogens, and recommended the use of a commercially available EPA-registered disinfectant detergent or germicide wipe. A list of EPA registered disinfectants included Professional disposables International, Inc (PDI)'s Super Sani-Cloth Germicidal Disposable Wipes. The facility's Cleaning of Glucometers policy, updated 8/29/16, indicated to prevent the transmission of blood-borne pathogens glucometers will be cleaned after every use for shared machines and at least weekly if for individual resident and when visibly soiled, with Sani-Cloth wipes (Purple Cap type) and allowed to dry for 2 minutes. Do not use alcohol wipes.

Based on observation, interview, and document review, the facility failed to provide a call light to one of three residents (R2) reviewed for access to call lights when R2 did not have a functioning call light for an unknown number of weeks. Findings Include: R2's Minimum Data Set (MDS) admission assessment dated [DATE], indicated R2 was admitted to the facility on [DATE]. The MDS indicated R2 was continent of bowel and bladder, and independent with toileting. R2's brief interview for mental status (BIMS) was 15 indicating intact cognition. The census report, undated, indicated R2 moved to room [ROOM NUMBER] on 3/7/24. R2's Quarterly Review MDS dated [DATE], indicated R2 was frequently incontinent of bowel and bladder. R2's Significant Change in Status MDS dated [DATE], indicated R2 required moderate assistance with toileting. R2's care plan indicated the call light was to be accessible and within reach whenever the resident was in his room. The facility was unable to provide call light log for R2's room for the last two weeks. The facility was unable to provide maintenance records for R2's call lights for the two weeks leading up to 3/12/25. During an observation on 3/12/25 at 9:30 a.m., R2 did not have a call light within reach. The head of the bed was flush to the wall containing the call light box. The call light box had space for two extension cords on the left and right side of the box. The outlet on the left side of the box had a corded call light inserted appropriately, and the call light was wrapped around his roommate's bed rail. The outlet on the right side of the box did not have a corded call light extending from it. During an observation on 3/12/25 at 2:00 p.m., the interim nurse manager was unable to locate R2's call light. During an interview on 3/12/24 at 9:30 a.m., R2 stated he had not had a call light for several months. R2 stated he had spoken to maintenance about this issue at an unknown time and was told they would have to cut an extra hole in the wall in order to give him a call light. R2 stated the unnamed maintenance employee told him they would not do this and did not offer him a new call light. R2 stated he has been using his roommate's call light since he was told this. R2 stated when he has an incontinent episode at night, he wakes his roommate up and has her press the call light in order to get help from nursing staff. During an interview on 3/12/25 at 12:55 p.m., registered nurse (RN)-A stated if there was an issue with a resident's call light, she would contact their maintenance team to have it fixed immediately. During an interview on 3/12/25 at 1:13 p.m., RN-B stated call lights need to be functioning and within reach of a resident in their room. RN-B stated if a call light is malfunctioning, she can submit a work order or call their maintenance staff. RN-B stated if maintenance is not able to immediately fix the issue, they provide the resident with a bell to contact nursing staff. During an interview on 3/12/25 at 1:41 p.m., RN-C stated if a resident's call light is broken staff should contact maintenance staff. RN-C stated a functioning call light should always be within reach. During an interview on 3/12/25 at 1:46 p.m., nursing assistant (NA)-A stated if a resident's call light is not working he would tell the nurse immediately to have it serviced. NA-A stated if a resident call light is missing, he woud report it to maintenance. NA-A stated a call light should be within reach of a resident. During an interview on 3/12/25 at 1:50 p.m., the interim nurse manager stated every resident gets a call light. The interim nurse manager stated if a call light is not working, they will call maintenance and get it serviced. The interim nurse manager stated they can either temporarily move the resident to a different room with a functioning call light, or give the resident a bell and implement regular rounding until the issue is resolved. The interim nurse manager stated R2 had not informed them there was an issue with his call light. The interim nurse manager stated she would submit a work order immediately. During an interview on 3/12/25 at 2:29 p.m., the interim nurse manager stated R2 has been supplied with a bell, and maintenance was in his room servicing the call light. On 3/12/25 at 3:38 p.m., the director of nursing (DON) stated when she entered R2's room, she only saw one cord coming from the call light box. The DON stated it is her expectation every resident has a functioning call light. During the exit conference on 3/12/25 at 4:10 p.m., the administrator stated R2's call light had been repaired. A facility policy titled Call light dated 5/2017, indicated every resident of the facility must be provided with a functioning accessible call light. The policy stated call lights are always left within reach of the resident. The policy stated call light issues must be reported to maintenance immediately.

Based on interview, observation and document review, the facility failed to provide a process by which residents could make their own food selections for meals for 6 of 6 residents (R241, R73, R6, R23, R104, R35) reviewed for food. Findings include: R241's facesheet printed on 1/8/25, included diagnoses of chronic kidney disease and congestive heart failure (heart doesn't pump as it should). R241's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R241 was cognitively intact, had clear speech, could understand and be understood. R241 required supervision for most activities of daily living (ADL) and could eat independently after set-up help. R241's orders dated 12/17/24, indicated a heart healthy diet. R241's care plan dated 12/20/24, indicated R241's preferences would be honored during her stay. Staff responsible for this included nursing and nutritional services. During an interview on 1/6/25 at 3:49 p.m., R241 stated she had been at the facility since 12/17/24, and had not been given a choice of what to eat, adding, if you get started on something, like oatmeal, you get it every day. R241 presented several diet slips and stated, this is what you get -- no options. No weekly menu or alternative menu was visible in R241's room nor was she aware of them. During an interview on 1/7/25 at 9:39 a.m., in the dining room, nursing assistant (NA)-D stated when a resident was admitted , a dietician met with him/her to find out likes/dislikes, and each resident had a diet ordered by a doctor. NA-D presented an electronically generated diet slip with a resident's name, diet order and a list of food items for that meal. NA-D stated if a resident didn't like what they were given, they could tell staff at the time of meal service and request something else. NA-D stated residents did not get a menu ahead of time to make their own food selections. From a window ledge (window looking out into the nurse's station) in the dining room, NA-D obtained a paper week-at-a-glance menu for the current week. Listed for each meal, three times a day, was a main entree and below that another meal option. NA-D also presented a paper Bistro Menu indicating alterative food items for lunch and dinner. NA-D stated she did not know if residents received a copy of either menu. Neither was posted or visible in the dining room for residents. During an interview on 1/7/25 at 10:46 a.m., in the dining room, dietary aide, (DA)-A stated after a meal tray was placed in front of a resident in the dining room, he/she could tell a NA if he/she did not like or want that meal. DA-A stated then the NA would bring the tray back to her, she would discard the food, and obtain what the resident wanted. When asked about an alternative menu, DA-A went to binders on the steam table to look for one and did not find one. DA-A acknowledged there was not a weekly menu or an alternate menu posted in the dining room for residents to see. DA-A stated residents were supposed to have menus in their room and thought her manager took them around to resident rooms. During an interview on 1/7/25 at 1:51 p.m., at the resident council meeting, R104 stated whatever was on their diet slip was what they received at meal time; they did not get an opportunity to select something different ahead of time. R104 stated often, residents didn't even know what the meal was as they did not receive a menu prior to meal services. R104 stated the foods we like and dislike were noted on their diet slips, but that was the extent of their food choices. R104 was not aware of an alternative menu. R35 stated she had heard of an alternate menu but didn't know where to find it. Further, R35 stated it was like scratching off a lottery ticket when staff lifted the cover off their plate of food in the dining room --- meaning the meal was a surprise to them. -- R104: quarterly MDS dated [DATE], indicated intact cognition, clear speech, could understand and be understood, and eat independently after set up help. -- R35: quarterly MDS dated [DATE], indicated intact cognition, clear speech, could understand and be understood, and eat independently after set up help. 44630 R73's significant change MDS assessment dated [DATE], indicated R73 had moderately impaired cognition, no behaviors, required setup or clean-up assistance with eating, and substantial assistance with personal hygiene, utilized a wheelchair, diagnoses included non-Alzheimer's dementia, depression, R73's care plan edited 1/8/24, indicated potential for change in nutrition status related to the need for a therapeutic diet and a BMI (body mass index) that classifies as obese likes egg salad/tuna salad, please offer alternatives at meals if I dislike the daily menu offerings, likes egg salad, tuna salad, PBJ sandwiches on wheat, like to receive less fish at lunch, no rice, no soups with rice/pasta, no orange juice, no bread/rolls with lunch and dinner, provided small portion of starch at lunch and dinner meals would like a salad at lunch and dinner, to receive Mrs Dash and pepper packets with meal, dislike broccoli. On 1/7/25 at 9:08 a.m., R73 stated he did not get a choice of meals and stated he never knew what he was going to eat. R73 stated the facility brings him his meal to his room and it was always a surprise and was not given options and was not aware of menu. On 1/7/25 at 9:46 a.m., NA-E stated residents were not given a choice of food choices, the residents were served food from a generated meal ticked. NA-E stated if the resident did not like what was served the staff would have to call the main kitchen and request another option. NA-E stated there were snacks on the floor however there were not main food options. NA-E stated the menu was expected posted outside the dining room, NA-E was observed outside the second floor north dining room and confirmed a menu was not posted. NA-E stated the residents had lots of complaints regarding food and not liking what was served to them. On 1/7/25 at 10:13 a.m.,, licensed practical nurse (LPN)-A, stated upon admission the dietician assessed residents for preferences, and stated the preferences are entered into the computer and the resident was served food based off those preferences. LPN-A stated there residents were not offered daily choices. 50764 R6's quarterly MDS assessment dated [DATE], indicated R6 had moderately impaired cognition, behavior not directed towards others, required substantial assistance with eating, and substantial assistance with personal hygiene, utilized a wheelchair, diagnoses included renal (kidney) failure, arthritis, and malnutrition. R6's care plan edited 1/2/25, indicated nutrition concern related to inadequate oral intake related to decreased appetite as evidenced by non-significant weight loss. During interview on 1/7/25 at 9:15 a.m., R6 stated staff always brought her tray and dropped it off, she didn't get a choice and would have liked to have some choices. She further stated nobody came to ask what she wanted for meals and she didn't know where she would get a menu. R23's annual MDS assessment date 12/26/24, indicated R23 had intact cognition, no behaviors, required setup assistance for eating, substantial assistance for personal hygiene, utilized a wheelchair, diagnoses included seizure disorder and depression. R23's care plan printed 1/8/25, indicated R23 would maintain her current weight, consume 50% of meals, and will remain able to make needs known through next review date. During interview on 1/8/25 at 10:04 a.m., R23 stated she did not get to choose her meals and would have liked to have had choices. R23 further stated she used to be able to make choices by selecting on a piece of paper but had not done that for over a year. R23 stated she would have liked to choose her meal ahead of time. On 1/8/25 at 10:37 a.m., an interview was conducted with three members of the survey team, the administrator, director of nursing (DON), registered dietician (RD-E), dining services director (DSD)-C, and chef (C)-D regarding food service concerns. C-D was asked to describe the process by which residents made food selections for each meal. C-D stated on admission, the dietician met with residents to determine preferences, likes and dislikes. RD-E stated this information was then entered into meal-tracker software. The administrator stated it weeded out a resident's dislikes and automatically made food substitutions. In addition, RD-E stated residents were asked upon admission if they wanted a weekly menu and bistro menu (alternate menu). During this interview, the group did not describe a process which allowed residents to have a choice in what foods they were served at meals. DSD-C stated menus should be posted in each dining area. The group was informed menus had not been visible in dining rooms or resident rooms, that residents were not aware of an alternate menu, and felt they had no choice in what foods were served to them. Based on interviews from residents and staff, the group was informed of the meal process described to the survey team: a resident at the table in the dining room would receive a plate of food. That would be the first time residents became aware of what their meal would be. At that point, if a resident didn't like that meal, or didn't feel up to eating that meal, he/she would inform staff in the dining room who would remove the plate of food, discard it and either get something else from the steam table or the kitchen. The group was asked if that was accurate, and C-D stated it was. DSD-C stated residents did not select food prior to meal service but were instead given what was electronically printed on their diet slip based upon the menu for that meal, their likes and dislikes. If they wanted something else, dietary staff could make something different for them at that point. DSD-C stated they could not make different meals for that many residents -- they would be short order cooks, and there wasn't time for that - so it worked better to give residents what was on the menu first, then if a resident didn't want that, something else would be made for him/her. A policy on food preferences, how residents select their food/meals, alternate menu was requested. Facility Dining and Food Preferences policy with revised date 10/2022, was received. The policy indicated individual dining, food and beverage preferences were identified for all residents. Dining services director, or designee would interview the resident or resident representative to complete a food preference interview within 72 hours of admission. The purpose would be to identify preferences for dining location, meal times, food and beverage preferences. An individual tray assembly ticket would identify all food items appropriate for the resident based on diet order, allergies, intolerances, and preferences. Upon meal services, any resident with expressed or observed refusal of food would be offered an alternate selection of comparable nutrition value.

Based on interview and document review, the facility failed to hold care conference meetings with the resident and/or their representative to allow the resident and/or representative the opportunity to review and participate in the revision of the care plan for 5 of 5 residents (R14, R105, R6, R74,R97) reviewed for care planning. Findings include: R14's facesheet printed on 1/8/25, included diagnoses of Alzheimer's disease, dementia, depression, chronic kidney disease, diabetes, and congestive heart failure (heart doesn't pump as it should). R14's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R14 was cognitively intact, had clear speech, could understand and be understood. R14 was independent with activities of daily living (ADL) and with ambulation. R14's care plan dated 4/14/23, indicated R14's wishes would be respected, and her wishes would be reviewed at quarterly care conferences. Care plan dated 8/2/24, indicated R14's code status would be reviewed with each care conference. During an interview on 1/7/25 at 2:53 p.m., licensed practical nurse (LPN)-B who was also a nurse manager, stated R14's pain was discussed at her care conference today, as was the condition of her room (cluttered). Upon review of care conference notes in the electronic medical record (EMR), R14's last documented care conference was on 7/25/23 - 18 months prior. During an interview on 1/7/25 at 4:10 p.m., social services (SS)-A looked at R14's care conference notes in the EMR and verified that prior to today's care conference (which had not been documented yet), R14's last care conference had been on 7/25/23. SS-A could not explain why this was, as she had only been employed in her role since August 2024. SS-A was aware prior to her, there had been social workers working in a temporary capacity. During an interview on 1/8/25 at 9:48 a.m., the director of nursing (DON) stated she expected care conferences to be conducted every 90 days (or quarterly). The DON reviewed R14's care conference documentation in the EMR and verified the last documented care conference for R14 was on 7/25/23. The DON was not aware until yesterday (1/7/25), when nurse managers brought it to her attention, that care conferences had not been conducted timely. The DON stated social workers were responsible for scheduling, facilitating and documenting resident care conferences. R105's facesheet printed on 1/8/25, included hemiplegia (weakness or paralysis on one side of the body) following cerebral infarction (stroke), depression and anxiety. R105's quarterly MDS assessment dated [DATE], indicated R105 was cognitively intact, had clear speech, could understand and be understood. R105 needed assistance with ADL's including walking. R105's care plan dated 1/10/24, indicated R105's wishes would be respected, and his wishes reviewed at quarterly care conferences. Care plan dated 6/25/24, indicated R105's code status would be reviewed with each care conference. During an interview on 1/6/25 at 6:46 p.m., R105 mentioned discussing provider visits at a care conference, but could not recall the approximate date. Review of care conference notes in the EMR indicated R105's last care conference had been documented on 5/28/24 - eight months prior. During an interview on 1/7/25 at 4:08 p.m., SS-A stated she just documented R105's care conference note from 9/19/24, today. SS-A said she had been confused about where the care conference note should be documented. During an interview on 1/8/25 at 9:46 a.m., the DON was informed of R105's last two care conference dates - 5/28/24, and 9/19/24, with the notes for 9/19/24, having been documented today. The DON reviewed R105's care conference notes in the EMR and verified the dates as reported. The DON that late entries for documentation should be identified as such. (The 9/19/24, care conference note documented on 1/8/25, did not indicate it was a late entry). The DON stated she expected care conferences to be conducted according to regulation. The DON stated she would discuss with SS-A and report back. During an interview on 1/8/25 at 12:56 p.m., the DON stated she spoke to SS-A and no rationale had been determined as to why care conferences for R14 and R105 had not been conducted. 50764 R6's quarterly MDS assessment dated [DATE], indicated R6 had moderately impaired cognition, behavior not directed towards others, required substantial assistance with eating, and substantial assistance with personal hygiene, utilized a wheelchair, diagnoses included renal (kidney) failure, arthritis, and malnutrition. R6's care plan edited 1/2/25, indicated nutrition concern related to inadequate oral intake related to decreased appetite as evidenced by non-significant weight loss, history of behaviors including yelling out rather than using call light, and frequent requests for therapy services. During interview on 1/6/25 at 12:34 p.m., R6 stated she had not had a recent care conference to make her needs known and could not recall when her last care conference was held. Record review of facility electronic health record (EHR) indicated R6 had a quarterly care conference on 3/8/24 and did not have another care conference until 10/9/24. During interview on 1/8/25 at 12:24 p.m., social services (SS)-C stated she missed R6's care conference around 5/24 or 6/24, and further stated it must have been a busy month. SS-C stated she should have had a care conference for R6 every 90 days. 44630 R74's quarterly MDS assessment dated [DATE], indicated R74 had severe cognitive impairment, required substantial/maximal assistance with activities of daily living (ADL's) and utilized a wheelchair, diagnoses included heart failure, diabetes, depression, and end stage kidney disease. R74's electronic medical record (EMR) indicated the most current care conference was documented on 8/9/24. On 1/6/25 at 7:12 p.m., family member (FM)-A stated R74 had only one care conference she had been aware of, and stated she called social services (SS)-A about four or five times for the last two weeks and left voicemail's asking for a care conference and had not received a phone call back. On 1/7/25 at 9:23 a.m., SS-A stated it was her role to schedule resident care conferences, and care conferences were expected at admission, quarterly and if a resident had a change in condition. SS-A stated she would reach out to the resident's family (representative) via phone call and email with a date and time for the care conference and ensure staff and family were aware. SS-A stated R74's last care conference was 8/9/24, and she placed a phone call to R74's daughter on 11/19/24 to offer a care conference and had not received a call back. SS-A confirmed R74 did not have a care conference quarterly as expected. On 1/7/25 at 10:03 a.m., licensed practical nurse (LPN)-B, known as the nurse manager for second floor north, confirmed R74 had not had a care conference since the documented care conference on 8/9/24. RN-A further stated regular care conferences were important to keep families up to date on how the resident was doing. R97's quarterly MDS assessment dated [DATE], indicated R74 was admitted on [DATE], preferred language was Spanish and needed/wanted an interpreter to communicate with a doctor or health care staff, moderate cognitive impairment, required partial/moderate assistance with toileting hygiene, upper body dressing, personal hygiene, and utilized a wheelchair, diagnoses included dementia, anxiety, and depression. On 1/6/25 at 4:32 p.m., during a interview using a Spanish interpreter (via telephone) R74 stated he does not have care conferences at the facility. On 1/6/25 at 9:35 a.m., SS-A stated she met with R74 frequently and used an interpreter phone and stated she had informal care conferences with R74 and stated she had not had a formal care conference with R74. SS-A stated R74's last documented care conference was 6/8/24 and stated R74 was expected to have had a care conference after that. SS-A stated residents were expected to have care conferences every 90 days and with significant changes. On 1/7/25 at 2:48 p.m., SS-B, known as the director of social services, stated residents were expected care conferences every 90 days, with a significant change in condition, and if requested. SS-B stated residents and families were expected to be invited to the care conferences. SS-B stated she was not aware R74 and R97's care conferences had not been completed every 90 days and expected the care conferences completed and documented in the EMR. On 1/7/25 at 3:28 p.m., the administrator confirmed via email R74 did not have formally documented care conference notes On 1/7/25 at 3:53 p.m., the DON stated the social services arranged care conferences and residents were expected to have a care conference every 90 days and stated she was not aware care conferences were not completed for R74 and R97 every 90 days. Facility policy on Care Conferences was requested and not received.

Based on observation, interview and document review, the facility failed to ensure grievance forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 4 of 4 residents (R26, R35, R102 and R104) reviewed for grievances. Findings include: On 1/7/25 at 1:37 p.m., a resident council meeting was held with four residents which included R26 R26, R35, R102 and R104. During the resident council meeting, all four residents indicated they were not aware how to file a grievance form. R35 stated she thought there was a form at the front door that could be filled out and turned into a nurse. R35 further stated she did not think the form could be filled out without the help of a nurse. During an observation on 1/7/25 at 4:36 p.m., the 340 wing had a slot for grievance forms but no forms were present. During an observation/Interview on 1/7/25 at 4:43 p.m., registered nurse (RN)-F stated grievance forms are not kept on the 340 wing. RN-F further stated the forms were down stairs and residents could ask for them if they wanted to fill them out. During an interview on 1/8/25 at 8:29 a.m., guest services (GS) stated residents could grab a grievance form (concern form) from the box on the first floor by the guest services desk or they could ask a nurse to grab one for them. GS further stated when the form was filled out the resident could give the grievance form to a nurse to give to social services. GS revealed forms have always been given to her to give to social services. GS states puts them in the social services directors mail box. During an interview on 1/8/25 at 11:45 a.m., social services director (SSD) indicated grievance forms are put into her mailbox or handed to her directly after they are filled out. SSD further indicated a resident would need to hand the paper copy of the grievance form to someone as there was no box or any other additional place the form could be placed anonymously. SSD stated nurses could also take the form and fill it out online on the facilities intranet. SSD further stated online forms were not accessible to residents and/or family representatives. During an interview on 1/8/25 at 12:35 p.m., administrator indicated residents would give the paper grievance form to a nursing staff or social worker. Administrator further indicated a form could be left in the dining room or on the nurses station but there were no boxes for the grievance forms to be submitted anonymously. Review of facility form titled Concern Form, dated 6/22, states when complete, please return this form to Guest Services for Director of Social Services. The facility Grievance policy updated 4/17, lacked documentation grievances could be filed anonymously.

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R24, R25, and R124) received pneumococcal vaccinations based on shared clinical decision-making in accordance with the Center for Disease Control (CDC) recommendations reviewed for immunizations. Findings include: Review of the current CDC recommendations 4/2024, revealed The CDC identified Adults [AGE] years of age or older received the (PPSV23) or (PCV13) at any age and who have not received the Pneumo 20-valent conjugate Vaccine (PCV20) should receive a dose of the PCV20 at least one year after the most recent PPSV23 or PCV13 vaccine. In addition, the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 at age 65 and older, based on shared clinical decision-making with the patient and the provider one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Review of R24's facesheet identified R24, age 83 was admitted to the facility on [DATE]. Review of R24's Minnesota Immunization Information Connection (MIIC) record undated, identified R24 received the PPSV23 on 12/17/2004 and 11/18/2019, and received the PCV13 on 12/15/2014. R24's medical record lacked documentation R24 had been offered or received the PCV20 based on shared clinical decision-making. Review of R25's facesheet identified R25, age 84 was admitted to the facility on [DATE]. Review of R25's MIIC record undated, identified R25 received the PCV13 on 4/11/15. R25's medical record lacked documentation R25 had been offered or received the PCV20 based on shared clinical decision-making. Review of R124's facesheet identified R124, age 83 was admitted to the facility on [DATE]. Review of R124's MIIC record undated, identified R124 received the PCV13 on 11/24/15. R124's medical record lacked documentation R124 had been offered or received the PCV20 based on shared clinical decision-making. During an interview on 1/7/25 at 4:14 p.m., infection preventionist (IP) confirmed the above findings and indicated the facility follows the CDC guidelines for pneumococcal immunizations. Director of nursing (DON) stated her expectations were that residents receive immunizations following the CDC guidelines. The facility Pneumococcal Immunizations, Adult policy dated 5/16/24, the facility will reduce the incident of pneumococcal disease by offering and providing pneumococcal vaccinations to residents. Residents will be offered the pneumococcal vaccinations and administered, according to the MDH and CDC recommended interval for the vaccines, unless contraindicated, already immunized, or the resident and/or responsible party declines the vaccine.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) guidelines by appropriately implementing measures to prevent the spread of infection when the facility failed to ensure personal protective equipment (PPE) was discarded prior to leaving resident rooms (R19 and R1), and failed to follow enhanced barrier precautions (EBP) for 1 of 1 resident (R58) who had an indwelling device present. Findings include: R41's facesheet received 1/7/25, included diagnoses including chronic kidney disease, diabetes mellitus, and dementia. A Event Report for R41 for infection control included a start date of 1/3/25 at 9:09 a.m., indicating on 1/2/25 at 10:09 p.m., R41 had 3 loose stools, poor appetite and was placed on isolation with testing completed for RSV (respiratory syncytial virus) and influenza. R41 was negative for Covid-19. A note dated 1/4/25 at 10:36 p.m., indicated R41 remained in isolation and R41 tested positive for Influenza type A. R1's Resident Face sheet received 1/7/25, included diagnoses of dementia, type 2 diabetes mellitus, and paranoid schizophrenia. R1's progress note dated 1/6/25, included R1 had an emesis and was placed in transmission based precautions (TBP) with Covid-19 test negative and RSV and Influenza tests completed and awaiting results. During observation and interview on 1/6/25 at 12:45 p.m., R19's door was closed with a sign that indicated enhanced respiratory precautions. A stop sign was present that directed please see nurse before you enter the room. PPE cart was present outside the door and a garbage can that had discarded gowns, gloves and masks was outside of the room. R1, 2 doors away from R41's room also had a closed door with a stop sign directing Stop, please remain in your room and an enhanced respiratory precautions sign on the door. PPE was present and a trash bin outside of the room with discarded gowns, gloves and masks. Licensed practice nurse (LPN)-A indicated R19 was diagnosed with Influenza A a few days ago and R1 had an emesis this morning and has been tested for Influenza A, Covid-19 and RSV so both are on isolation currently. On observation 1/7/25 at 9:23 a.m., nursing assistant (NA)-A donned gown, gloves, N95 mask and face shield (PPE) and entered R41's room. Upon exit of the room NA-A was wearing the same PPE she entered room in and doffed her PPE and discarded into wastebasket in hallway next to R41's room. NA-A then donned PPE and entered R1's room and upon exit continued to wear PPE donned prior to entering the room. NA-A doffed her gown, gloves, face mask and face shield after exiting the room and disposed of in garbage can outside of R1's room. On observation 1/8/25 at 7:05 a.m., R1 and R41's garbage cans were no longer outside of their rooms. PPE remained present outside the rooms. On interview 1/8/25 at 10:17 a.m., NA-A indicated she doffs wherever the garbage cans are located. NA-A stated yesterday morning they were outside of the rooms but have since been moved to inside the rooms. On interview 1/7/25 at 3:36 p.m., registered nurse (RN)-B, also identified as infection preventionist and the director of nursing stated garbage cans were expected to be inside the room for EBP and isolation rooms and staff are expected to remove PPE prior to exiting the room. R58's Resident Face Sheet, received on 1/8/25, included diagnoses of dementia, paranoid schizophrenia, type 2 diabetes mellitus, and benign prostatic hyperplasia (non cancerous enlarged prostate) with lower urinary tract symptoms. R58's plan of care last edited 12/13/24, included resident requires enhanced barrier due to indwelling medical device; urinary catheter. Interventions included a sign on residents door to alert staff and visitors regarding EBP and follow CDC recommendations wearing PPE with high-contact resident care activities with gloves and gown to be worn prior to the high contact care activity. On observation and interview 1/8/25 at 8:30 a.m., R58 had an EBP sign outside of his room, along with a cart with PPE present. Registered nurse (RN)-C entered R58's room wearing gloves but did not wear a gown. RN-C checked R58's blood sugar and administered insulin in R58's abdomen, discarded her gloves and performed hand hygiene. R58 then gave oral medications mixed in pudding via a spoon to R58 without gloves on. RN-C then exited the room and performed hand hygiene. RN-C indicated they gown if giving personal cares like bathing, toileting, but did not think it was required to gown for medication administration that was completed. On observation and interview 1/8/25 at 10:45 a.m., NA-B and NA-C entered R58's room with a lift after completing hand hygiene and donning gloves only. The lift harness was placed behind and under R58's legs and R58 was placed in his bed. R58 was rolled side to side with pad changed with scant amount of old stool present. Wipes were used to clean R58's rectal area and new pad was placed. R58 was positioned in his bed with pillow under his lower legs and head of bed elevated at 30 degrees. NA-B and NA-C removed gloves and completed hand hygiene upon exit. NA-B stated they only wear gowns when doing catheter or wound care. NA-B stated gowns are not required for type of care provided and NA-C agreed. On interview 1/8/25 at 10:57 a.m., RN-D, also identified as interim care manager, stated she would expect staff to gown and glove with any direct patient care if the resident is on EBP. On interview 1/8/25 at 1:45 p.m., the DON stated staff are expected to gown and glove for EBP patients when providing high contact direct patient care. The facility Isolation - Categories of Transmission-Based Precautions policy last updated 7/12/22, included: - Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug- resistant organisms (MDROs) in the facility. Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for resident known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (i.e. residents with wounds or indwelling medical devices - Enhanced barrier precautions will be used for residents with indwelling medical devices or wounds who do not otherwise meet the criteria for contact precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. - High-contact resident care activities include: Dressing Bathing/ showering Transferring Providing hygiene: i.e. brushing teeth, combing hair, and shaving Changing linens Changing briefs or assisting with toileting Device care or use: any device fully embedded in the body without components that communicate with the outside i.e. central line, urinary catheter, nephrostomy tubes, feeding tube, tracheostomy/ ventilator. Pacemakers would not be considered an indication for enhanced barrier precautions Wound care: any skin opening requiring a dressing - Contact Precautions: Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident ' s environment. Staff and visitors will wear gloves when entering the room. Gloves will be removed and hand hygiene performed before leaving the room. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on observation, interview and document review the facility failed to provide timely repositioning for 1 of 1 resident (R58) who was dependent upon staff for repositioning and high risk for pressure ulcers. Findings include: R58's facesheet received 1/8/25, included diagnoses of dementia, aphasia (the ability to use or comprehend language is lost or impaired), diabetes mellitus, history of falling and chronic kidney disease. R58's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R58 had severely impaired cognition, and no behaviors. Activities of daily living (ADL's) included R58 uses a wheelchair and is dependent on staff for transfers, bed mobility and locomotion. R58 is able to feed self after setup. R58 has a an unhealed pressure injury that is unstageable with slough and or eschar (dead tissue that impedes healing of wounds) present. R58's Care Area Assessment indicated R58 has an unstageable pressure ulcer on right heel which is covered by slough. R58 has been identified as being at risk for pressure ulcers related to impaired mobility and bowel incontinence. R58 requires assistance with all ADL's. Skin is monitored with daily cares and weekly shower. Wound is improving. R58 has a pressure relieving cushion in his wheelchair and pressure relieving mattress on his bed. R58's Braden Scale for Predicting Pressure Sore Risk dated 10/30/24, had a score of 16 indicating R58 is at risk for skin breakdown. R58's care plan dated 1/6/25, indicated R58 was identified at risk for skin breakdown related to history of right hip and arm fracture, incontinence, and immobility. On 10/2/24, pressure area noted to right heel from hospital stay. Interventions included wound team to assess, apply house lotion as needed to dry skin areas, conduct a skin observation daily by nursing assistants (NA) and weekly by a nurse. Incontinence care every 2-3 hours and as needed. Pressure reducing mattress on bed, cushion in wheelchair, and staff assist of 2 to off load resident every 2 hours. R58 was identified as having an alternation in mobility related to history of right hip and arm fracture and the need for assistance with transfer and locomotion by wheelchair daily. R58 at risk for falls, and impaired skin integrity. Interventions included turn and reposition in bed every 2 hours and as needed with total assist of 2 staff. On observation 1/6/25 at 7:05 p.m., R58 was seated in his Broda chair (positioning wheelchair) in his room watching television. R58 had vascular boots on both lower legs and a cushion in his Broda chair. No air mattress was present on his bed. R58 only laughed when asked how he was doing. No verbal response was received other than that. On observation 1/7/25 at 2:22 p.m., R58 was sitting in his Broda chair in his room watching television. Vascular boots present on both lower legs and chair cushion present. On observation 1/7/25 at 4:15 p.m., R58 continued sitting in his Broda chair in his room watching television. Continuous observation was started at 1/8/25 at 7:11 a.m.: 7:11 a.m. - R58 was dressed for the day had on his vascular boots, was sitting in his Broda chair in room which was slanted back at 10 degrees and was watching television. 7:30 a.m. - registered nurse (RN)-E, and registered nurse (RN)-D completed wound care on R58's heel. Wound is open to air with vascular boots on. Measurements were completed 3.5 x 2.5 cm's with edges lifting and no drainage or redness present. Eschar present. Lotion was applied to both lower legs and feet and heels and vascular boots reapplied. There was no position changes completed on R58. 7:46 a.m. - Wound care completed as above and staff left the room. 7:56 a.m. - R58 remains seated in his Broda chair and no staff entered room. 8:13 a.m. - R58 remains seated in his Broda chair and no staff entered the room. 8:30 a.m. - RN-C entered room and administered insulin, and oral medications. No position changes completed. 8:41 a.m. - NA-B entered room and transported R58 to dining room for breakfast. Did not reposition R58. 8:53 a.m. - R58 remains in dining room waiting for his breakfast. 8:57 a.m. - R58 was served breakfast and fed himself after staff set up his meal. 9:07 a.m. - R58 remains in dining room eating. 9:28 a.m. - NA-B brought R58 back to his room in his Broda chair. Chair remains tipped back at 10 degrees. No position changes or incontinence pad check completed. 9:46 a.m. - No change in position. No staff in room. 9:56 a.m. - No change in position. No staff in room. 10:15 a.m., No change in position. No staff in room. On interview 1/8/25 at 10:23 a.m., NA-B stated R58 should be repositioned every 2-3 hours and he is due at 10:00 a.m. to be repositioned. NA-B confirmed there has been no position changes since putting R58 in his chair around 7:00 a.m. this morning. NA-B indicated she would get assistance to reposition him. On interview and observation 1/8/25 at 10:28 a.m., NA-B and NA-C entered R58's room and using a mechanical lift to transfer R58 to his bed. R58 was rolled side to side and incontinence pad was removed with scant amount of stool present. NA-B and NA-C indicated there is some redness present around rectal area extending outwards, but that is R58's normal. NA-B indicated the purple area on right buttock was a previous pressure ulcer that has heeled. Requested NA-B push on skin and blanchable areas were present on left buttock, with no blanching noted on right buttock. Red area extended up and down 2 inches from the rectal area and outwards approximately 3-4 inches each direction. R58 was positioned with head of bed at 30 degrees and pillow under lower legs. On interview 1/8/25 at 10:57 a.m., RN-D reviewed R58's NA care sheet and stated R58 should be repositioning every 2-3 hours and as needed. RN-D then reviewed R58's plan of care and stated the care plan directs repositioning every 2 hours so they are not matching. RN-D confirmed the care plan is what should be followed and R58 should be repositioned every 2 hours. On interview 1/8/25 at 12:56 p.m., the director of nursing (DON) stated she would expect the NA's to follow the care plan and reposition R58 every 2 hours. The facility Skin Integrity Management policy last updated 4/2/21, included: Identification of Risk: The first step in prevention of pressure ulcer/ injuries is the identification of the resident at risk for developing pressure ulcer/ injuries (any skin impairment caused by pressure i.e. friction, shearing, direct pressure, etc.). This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of interventions. Comprehensive Skin Risk Observation: Risk factors and potential cause(s) will be reviewed, addressed in the analysis and interventions implemented. Examples of risk factors include but are not limited to: Impaired/decreased mobility and decreased functional ability. Based upon the findings of the Comprehensive Skin Risk Observation which includes the Braden Assessment, the consideration of current interventions and resident preferences; a comprehensive analysis will be completed to guide the care plan process. Changes and implementation of interventions will be documented in the care plan. Establish an individualized turning and repositioning schedule if the resident is immobile.

Based on observation, interview and document review, the facility failed to ensure a resident's preferred activities for individual entertainment were offered for 1 of 1 resident (R97) reviewed for activities. Findings include: R97's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R74 was admitted on [DATE], preferred language was Spanish and needed/wanted an interpreter to communicate with a doctor or health care staff, moderate cognitive impairment, required partial/moderate assistance with toileting hygiene, upper body dressing, personal hygiene, and utilized a wheelchair, diagnoses included dementia, anxiety, and depression and no rejection of care. R97's annual MDS assessment dated [DATE], indicated it was somewhat important to participate in favorite activities, listen to music, and to go outside and get fresh air when the weather is good. R97's progress note dated 9/16/23 at 1:05 p.m., therapeutic recreation (TR)-A indicated R97 often fatigued/sleeping, pleasant and sometimes interested in snack being distributed, but prefers to stay close to his room/bed, isn't interested in group programming. R97's care plan dated 12/5/24, indicated R97 was able to self-ambulate, enjoys walking, visits from friends, going outside when weather is nice, weakness: confusion, language barrier (Spanish speaking), will invite or ask Spanish speaking TR (therapeutic recreation) to invite to programs of interest, will respect right to refuse programming, The record lacked documentation of activities R97 was offered, participated or refused. On 1/6/25 at 4:32 p.m., during an interview with R97 and the assistance of the Language line, R97 stated he spoke Spanish, and did not understand English. R97 was lying in bed with the television on in Spanish. R97 stated he did not understand the staff who did not speak Spanish. R97 stated he felt like a bird in a cage and stated the facility did not provide him activities, and just sits in his room all day and watched TV. R97 stated he wished there were activities to do and people to talk with. R97 stated he doesn't get to do activities often, because he speaks Spanish. On 1/7/25 at 10:00 a.m., licensed practical nurse (LPN)-C stated R97s spoke and understood only Spanish. LPN-C stated R97 did not attend activities. On 1/7/25 at 10:20 a.m., LPN-B stated TR staff were expected to offer and invite R97 to activities and was unaware if R97 attended activities. LPN-B stated the facility did not offer activities in Spanish and confirmed R97 spoke and understood only Spanish. On 1/7/25 at 11:11 a.m., TR-B known as the director of TR, stated an activity interest and preference was expected for all residents and confirmed prior to today (1/7/25), an individualized preference for activities was not completed for R97. TR-B confirmed there was not documentation R97 had refused or was offered activities. TR-B stated residents were assessed for their activity preferences quarterly, annually, and with significant changes. TR-B stated expectation of therapeutic recreation staff to communicate with R97 using the interpreter phone and offer R97 activities based off preferences. On 1/7/25 at 11:25 a.m., R97 was in bed sleeping. On 1/7/25 at 2:06 p.m., R97 was self propelling in wheelchair in the hallway and had a ice cream cup in his hand. On 1/7/25 at 11:35 a.m., TR-A and TR-C, stated the facility had planned activities for all residents. TR-C confirmed R97 was not asked daily to attend activities, and was not sure when the last time R97 was asked to attend an activity. TR-A and TR-C confirmed the facility did not have any activities offered in Spanish and stated a reason R97 may not attend activities could be because of the language barrier. TR-C confirmed activities were expected documented in the EMR and stated R97 had no activities documented or refused. TR-A and TR-C were not able to identify how R97's preferences were assessed for one-to-one visits given that she was known to not attend group activities or how individualized activities were being offered. On 1/7/25 at 2:42 p.m., social services (SS)-B, known as the director of social services, stated TR staff were expected to invite R97 to activities daily and would expect the facility to implement activities and programs specific to each resident and have Spanish speaking activities individualized for R97. On 1/7/25 at 3:53 p.m., the director of nursing (DON) stated TR staff were expected to offer activities to all residents daily and documenting refusals in the EMR. On 1/8/25 at 8:12 a.m., the administrator indicated she was unable to find documentation about R97's activities beyond the information on the MDS. The facility Life Enrichment Activities policy dated 10/18/22, indicated: Life Enrichment systems and programs are designed to serve the total person and incorporate ALL disciplines. Resident engagement is grounded in honoring the person and their individual purpose through all the wellness dimensions: spiritual, social, physical, intellectual, environmental, emotional and vocational. Meaningful activities are designed to promote life-skills, quality of life and to encourage involvement. Residents participate in self-care, structured recreational programming, and leisure activities. A member of the Recreation team completes a Resident Assessment by interviewing the resident, family or significant other regarding the residents leisure activities , cultural needs, values and choices. The assessor will seek to understand the residents past roles in order to incorporate them into the present daily life. Provide a variety of engaging resident programs designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community Incorporate resident preferences into the calendar Identify based on assessment barriers or preferences related to group size variety based on resident needs provide resource for independent resident interests and hobbies incorporate referrals to the Interdisciplinary team (spiritual care, fitness, culinary, volunteers) Assist as assessed with development of calendar participation(daily, weekly and/or monthly) Identify individual program needs: rooms/set up/supplies/dietary & volunteer requests Encouraging resident participation Personal invites as appropriate

Based on interview and document review the facility failed to complete a level II preadmission screening and resident review (PASARR) for 1 of 2 residents (R95) reviewed with a new mental illness diagnosis. Findings include: R95's facesheet printed on 1/8/25, indicated R95's original admitted was 12/16/22, and diagnoses at the time of admission included malnutrition, failure to thrive, anxiety, and repeated falls. Further review of the diagnosis listed on face sheet, indicated R95 was diagnosed with delusional disorders, major depressive disorder, and borderline personality disorder on 7/16/24. R95's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R95 had moderately impaired cognition, felt depressed half or more of the days and felt bad about himself nearly every day. R95's current physician orders printed 1/8/25, included risperidone 0.5mg tablet at bedtime for delusional disorders and citalopram 20mg tablet daily for psychosis. Record review of R95's PASARR screen completed on 8/31/23, indicated negative level 1 screening, level 2 screening not needed at time. Record review indicated R95 had new mental health diagnoses on 7/16/24 with no PASARR screen completed with the new diagnoses. During interview on 1/8/25 at 12:45 p.m., social services (SS)-C stated R95 did not have a PASARR completed at the time of new mental health diagnoses and was not sure who was supposed to complete that, but it should have been done. During interview on 1/8/25 at 12:49 p.m., administrator stated there was a gap in the system for having new PASARR screenings completed and the admissions team took care of making sure residents had a preadmission screening at the time of admission, but a process was lacking for ensuring a new one was completed with a new mental health diagnosis. The facility PASRR Screening policy dated 5/23/18, directed Sholom will comply with DHS regulations regarding screening and necessary updates for persons with developmental or intellectual disorders and those with mental illness. The policy further stated reasons people who have not previously been identified as needing Level II Resident Review includes the addition of or significant increase in antipsychotic or psychotropic medications.

Based on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for change in condition. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 had intact cognition, and a diagnosis of congestive heart failure (CHF, when the heart is unable to pump enough blood to provide the body with the blood and oxygen it needs). R1's Physician Orders dated 11/22/24 included: Daily weights with special instructions: Call for weight gain three pounds or greater in 24 hours or five pounds in one week. Furosemide (diuretic) tablet 40 milligrams (mg) once a day. R1's care plan dated 11/27/24, indicated R1 had atherosclerotic heart disease with staff interventions to assess and monitor R1's weight, and to notify the provider immediately if R1 had weight increase of 3 pounds (Ibs) per day or five pounds per week. On 11/22/24 at p.m., R1's electronic medical record (EMR) indicated R1's weight was 249 Ibs at admission. On 11/27/24 at 11:43 a.m., R1's EMR indicated R1's weight was 253 Ibs (a weight gain of 4 lbs in five days). On 11/27/24 at 11:26 a.m. a progress note indicated R1 reported she felt her weight was trending back up again as her ankles were getting puffy. The note also indicated R1 had orders in place for daily weights, and to notify the provider if R1 experienced a weight gain of three pounds or greater a day, or five pounds in one week. On 11/28/24 at 6 p.m., R1's EMR indicated R1's weight was 265 Ibs (a weight gain of 16 lbs in six days). On 11/28/24 at 11:33 a.m. lacked evidence of notifying the provider of R1's 16 lb weight increase. On 11/29/24 at 5:08 p.m. a progress note indicated R1 was sent to the hospital for congestive heart failure (CHF) exacerbation. On 12/5/24 at 1:45 p.m., R1 stated she was at the facility for one week and gained 21 Ibs. She was not breathing well and had swelling in her lower legs. On 11/29/24, she talked with her provider and asked to be sent to the hospital. When she arrived at the hospital, her weight was 269 Ibs. On 12/5/24 at 2:20 p.m., licensed practical nurse (LPN)-A stated she expected nurses to assess and monitor for edema, shortness of breath (SOB), and weight gain for patients diagnosed with congestive heart failure (CHF), and notify the provider if there was a change in condition. LPN-A stated she could not find any documentation about R1's weight increase being reported to the provider. On 12/5/24 at 4:11 p.m., nurse practitioner (NP)-A stated the nursing staff did not notify her about R1's weight increase. She was at the facility on 11/29/24 when R1 and her family raised concerns about R1's weight increase and breathing issues. Upon assessment, R1 was retaining a lot of fluid, so she sent her to the hospital for further evaluation. On 12/5/24 at 4:15 p.m., RN-B stated when she obtained R1's weight of 265 Ibs on 11/28/24, she assessed R1 to rule out SOB, but did not notify the provider. She was planning to reweigh R1 and notify the provider, but got busy and forgot to follow up. The facility policy Resident Change in Condition-Notification of Physician/Surrogate Decision Maker revised 3/21 directed the primary physician or nurse practitioner and the resident's designated surrogate decision maker will be notified of a significant change in the resident's physical, mental, or psychosocial status.

Based on interview and record review, the facility failed to comprehensively assess and monitor edema for 2 of 2 (R1, R3) residents reviewed with lower extremity edema. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was admitted on [DATE] and had diagnoses including traumatic ischemia of muscle (inadequate blood supply to muscles), benign neoplasm of meninges (brain tumor), multiple sclerosis, history of COVID-19, and muscle weakness. R1 required supervisory assistance with transfers, moderate assistance with mobility in bed and standing up, and maximal assistance with lower body dressing and putting on or taking off footwear. R1's Admission/Readmission Full Body Observation skin assessment dated [DATE], noted a dry scab on R1's left outer ankle and did not note any other skin conditions on R1's legs. A progress note dated 1/24/24, indicated R1 had bilateral (both) lower extremity (BLE) edema (swelling caused by fluid in the body's tissues). The progress note did not identify the extent of edema. R1's orders included an order dated 1/24/24, to take vital signs and weights per facility protocol. A progress note dated 1/29/24 by a Registered Dietician (RD), indicated R1 had a usual body weight of 179 pounds (lbs.) with a current body weight of 179.4 lbs on 1/28/24, 197.4 lbs. on 1/27/24, and 183 lbs. on 1/24/24. Hospital weights prior to admission were 187 lbs. and 188 lbs. BLE edema per nursing progress notes was noted with a plan to continue to monitor intakes, weights, and skin integrity. A progress note dated 1/31/24, indicated R1 refused a shower and skin check. It did not indicate if R1 also refused to be weighed. A progress note dated 2/9/24, by an RD, indicated R1's current body weight was 176.2 lbs. [on 2/7/24], resident previously noted a usual body weight of 179 lbs. but today noted she weighed 156 lbs. at home. R1 had a history of BLE edema and her intakes, weights, and skin integrity would continue to be monitored. A progress note dated 2/10/24, indicated R1 refused a shower, skin check, and weight check. A progress note dated 2/16/24, by nurse manager licensed practical nurse (LPN)-A, noted R1 had edema in both legs measured as 2+ on the left leg and 3+ on the right leg (edema that is pitting leaves a dimple after being pressed on and is measured by depth of indention from 1+ being the shallowest to 4+ being the deepest) with three fluid filled blisters on the right leg and was not on a diuretic (medication to help reduce excessive fluid build-up). Family and the provider were updated, orders for wound dressing obtained, R1 was referred to the wound care team to be seen the following week, dietary was notified for nutritional support to promote wound healing, and it was planned to put a recliner in R1's room to promote elevation of legs. R1's physician orders included an order dated 2/16/24, to assess wound dressing integrity and surrounding skin daily and redress as needed, and to alert provider to unrelieved pain, negative changes in wound, or signs or symptoms of infection daily. An order dated 2/17/24 instructed to apply Tubigrips (elastic tubular compression bandage) in the morning and remove at bedtime for R1's BLE edema and to encourage elevation of BLE. A progress note dated 2/17/24, indicated R1's bilateral lower legs are edematous. No further assessment or description of the edema was documented. A progress note dated 2/18/24, indicated R1's left leg was swollen, and the fluid blisters were oozing. No further assessment or description of the edema was documented. A progress note dated 2/19/24, indicated R1's left leg was oozing and R2 refused to elevate her legs at night. No further assessment or description of the edema was documented. A progress note dated 2/19/24 by a RD, indicated R1's current body weight was 176 lbs. [on 2/17/24] and R1 had BLE edema. No further assessment or description of the edema was noted. R1's care plan included a focus on potential for alteration in skin integrity with an intervention created 2/19/24 to encourage elevation of BLE due to edema. An Advanced Health Institute wound care note dated 2/21/24, indicated R1 had increased edema in BLE and had serous (fluid-filled) blisters were open wounds on the right leg. Wound Management entries created by LPN-A on 2/21/24 detailed three right shin blisters and one left ankle ulcer but did not include assessment or description of the BLE edema. A progress note dated 2/22/24, indicated R1 was transferred to the hospital for a change in condition at 2:30 p.m. related to increased leg pain and abnormal vital signs per provider order. Vital signs recorded in the vital signs section of R1's electronic health record included: - 183 lbs on admission on 1/24/24 - 197.4 lbs on 1/27/24 [presumed erroneous entry intended to be 179.4 lbs.] - 179.4 lbs on 1/28/24 - 179.4 lbs on 1/29/24 - 179.6 lbs on 1/30/24 - 179.4 lbs on 2/1/24 - 175.6 lbs on 2/5/24 - 176.2 lbs on 2/7/24 - 176 lbs on 2/17/24 An admission vital signs flow sheet from Methodist Hospital included R1's first charted weight at the hospital as 195 lbs. on 2/23/24 at 12:36 p.m. This was 19 lbs. more than R1's last recorded weight at the facility of 176 lbs. on 2/17/24. In an interview on 3/4/24 at 1:07 p.m., LPN-A stated R1 had edema in her legs that was weeping (leaking fluid through the skin) which LPN-A assessed in a progress note dated 2/16/24. LPN-A stated that progress note from 2/18/24 just said R1's leg was swollen and the progress note from 2/19 just said the left leg was oozing. The notes did not include further assessment such as a 1+ to 4+ measurement of the depth of the edema. LPN-A noted R1 then had an initial visit with the wound care team on 2/21/24. LPN-A stated there's not any assessment of the edema after the 16th, I can't find any. LPN-A noted that for someone with edema, her expectation would be that nurses assess the edema daily and complete a full observation by removing any dressings or clothing, checking for pitting, weeping, and redness because there could be infection. LPN-A stated to monitor edema, staff check for pitting from 1+ to 4+ and check the tension of the skin. If a resident has edema, nurses should do a full body assessment including listening to lung sounds and getting a set of vital signs. LPN-A noted for someone with edema, she would expect them to be getting weighed. LPN-A confirmed R1's last weights were on 2/5/24, 2/7/24, and 2/17/24 and R1 was not a resident whose weight was taken daily, R1 did not have congestive heart failure as a diagnosis so she was not weighed daily. LPN-A stated the first time R1's edema was noticed was on 2/16/24 and there wasn't a full assessment of the edema from then until she was seen by the wound care team on 2/21/24. LPN-A stated that based on the documentation entered after her note on 2/16/24, staff would not be able to monitor R1's edema to ascertain if it was worsening. R3's face sheet printed 3/5/24 indicated R3 was admitted on [DATE] and had diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), nutritional anemia, bullous disorder (a skin condition causing large fluid-filled blisters), erythema intertrigo (an inflammatory skin condition causing redness and rash), candidiasis (fungal infection) of skin and nails, and mild cognitive impairment. A new admission nursing progress note dated 11/15/23, indicated R3 had 3+ BLE edema. R3's Physical Therapy Evaluation & Plan of Treatment dated 11/17/23, noted that R3 required maximum assist with mobility in bed and moderate assist with transfers. R3's new admission provider note dated 11/17/23, indicated R3 had swollen legs with lymphedema (swelling caused by build-up of fluid in tissues related to dysfunction of the body's lymphatic system) wraps as well as blisters reported by nursing staff. Assessment noted edema of both right and left lower legs (note did not identify extent of edema), blister on both ankles, a couple of open areas on the skin, and legs wet with serous drainage. R3 was noted to have lymphedema. R3's diagnoses did not include CHF at this time. An Initial Nutritional Assessment note dated 11/17/23 by an RD, indicated fluctuations in R3's weight were anticipated secondary to the present of 3+ BLE edema. R3's care plan included a problem of potential for altered cardiovascular status related to diagnoses of hypertension, atrial fibrillation (irregular heartbeat), hyperlipidemia (high cholesterol), and past medical history with an intervention dated 11/26/23 to assess and monitor for signs of cardiac decompensation, [cardiac] diet as ordered, and monitor weight and updated provider as needed. A provider note dated 12/7/23, indicated R3 was seen for follow up on a chest x-ray completed on 12/1/23 due to weight gain and shortness of breath reported by facility staff. The x-ray showed a pattern of CHF with pleural effusions (fluid build-up around the lungs), took a three day course of Lasix (a diuretic), and was then started on a different diuretic, torsemide, for the ongoing edema which was improved. The plan for the lymphedema and CHF were to continue taking torsemide daily, elevate legs above heart level, and use lymphedema wraps managed by occupational therapy. A provider note dated 12/19/23, indicated staff encouraged R3 to elevate her legs during the day but R3 did not always comply. R3 had an order for lymphedema wraps but refused them at the time. A provider note dated 1/9/24, indicated R3 was seen at the request of staff for open areas on BLE. R3 had blisters on her legs last week that had opened, had lymphedema, and did not like to elevate her legs but was encouraged by staff to do so daily. The plan included daily wound care by nursing and a visit with the wound care provider later that week. A occupational therapy (OT) note dated 2/22/24, identified OT had been managing R3's lymphedema wraps and were assessing/monitoring edema. Note indicated OT's lymphedema treatments were put on hold because R3 required wound care and the last girth measurements of R3's legs were obtained on 1/9/24; right lower extremity was 242.3 centimeters (cm) and left lower extremity was 245.5 cm. In review of R3's record it was not evident R3's edema was consistently monitored and assessed after 1/9/24. An Advanced Health Institute wound care note dated 1/10/24, indicated R3 had a left shin wound secondary to lymphedema and continued to have 2+ pitting edema bilaterally. An Advanced Health Institute wound care note dated 2/7/24, indicated 3+ swelling on BLE and bilateral wounds secondary to lymphedema and weeping with improvement over the last week. An Advanced Health Institute wound care note dated 2/14/24, indicated 2+ swelling on BLE and bilateral wounds secondary to lymphedema and weeping with the edema significantly lessened over the last two weeks. A Comprehensive Nutritional assessment dated [DATE], indicated R3 had lower extremity edema and leg wounds, but did not include further description or assessment of the edema. A progress note dated 2/19/24 by LPN-A, indicated R3's BLE were extremely swollen on both upper thigh and lower shin areas. It did not include further description or assessment of the edema. An Advanced Health Institute wound care note dated 2/21/24, indicated R3 continued to have bilateral wounds secondary to lymphedema and weeping with 2+ swelling on BLE, new blisters, and new suspicion of bullous pemphigoid (a type of skin disease that causes large fluid-filled blisters, part of a category of conditions called immuno-bullous diseases) diagnosis. A progress note dated 2/22/24, indicated R3 was transferred to the hospital for a change in condition related to blisters, vomiting, and diarrhea. A Hospital Medicine Progress Note dated 2/23/24, indicated R3 was diagnosed with immuno-bullous skin disease. A progress note dated 2/28/24 indicated R3 was readmitted to the facility from the hospital. In an interview on 3/4/24 at 12:55 p.m., R3 stated she was not doing well because of her blisters and was recently in the hospital but didn't know why. R3 stated she did not do anything for the swelling in her legs but could see when they were more swollen. R3 did not know if staff did anything about the swelling and did not know if staff measured her legs but knew staff looked at her skin on shower days. In an interview on 3/4/24 at 1:07 p.m., LPN-A stated R3 had CHF, lymphedema, and the new immuno-bullous skin disease. LPN-A noted that treatment had included wound care team, occupational therapy, dietary, and referral to dermatology with treatments and interventions adjusted over the course of R3's admission and overall improvement of the edema. LPN-A stated R3 was on daily weights and her weights had been stable, LPN-A noted she wanted to keep track of weights for residents with CHF. LPN-A confirmed that a person's edema can increase without a corresponding change in weight. In regard to R3's edema, LPN-A stated it is something R3 was admitted with, there hasn't been tracking of it, and a result of the edema was the water blisters. LPN-A noted that her nursing staff are visually assessing R3's edema, but have not put it in progress notes. In an interview on 3/4/24 at 1:57 p.m., registered nurse (RN)-A stated nurses assess edema daily and document in a progress note. RN-A noted an edema assessment includes daily weights, checking the color and firmness of the skin, measuring for pitting edema from 1+ to 4+, and assessing wounds if present. RN-A stated she did not know how to assess edema if it was not pitting edema. RN-A stated nurses can tell if edema is getting worse based on weight increases, if pitting edema becomes deeper, or if the edema is visibly increased. RN-A noted that most of the time nursing staff do daily weights for residents with edema or congestive heart failure and nurses can do daily weights using nursing judgement. In an interview on 3/4/24 at 2:13 p.m., RN-B stated for a resident with edema, a nurse needs to look at it and know the size of the edema and that this is measured by pushing on the edema and rating it for pitting edema. RN-B stated nurses need to assess to know if the edema is getting better or worse or has changed, like if it is pitting or weeping less. RN-B stated edema should be assessed daily and assessment information put in a progress note. RN-B stated that the description of edema as swollen is not comprehensive and doesn't indicate the size of the edema because swollen can mean different sizes and doesn't provide enough information to identify change in the edema. In an interview on 3/4/24 at 2:35 p.m., director of nursing (DON)-A stated nurses should assess edema while providing treatments, cares, and services per a resident's treatment schedule or per facility policy. DON-A stated that if a resident used Tubigrips, nurses would be assessing the resident's edema when they take them on and off every day. DON-A stated that per nursing standards of professional practice, an edema assessment should include the severity of the edema, like checking the pitting of the edema; for R1 this would include lower extremity temperature and color, if the edema is pitting or not, and measurement of the severity of the pitting of the edema using the 1+ to 4+ scale. DON-A stated R1 was monitored throughout her stay but did not know where everyone documents edema assessment and had not looked through R1's whole record. DON-A stated the wound care nurse practitioner saw R1 on 2/21/24 and assessed her, but thought she was seen before then. DON-A noted that LPN-A assessed R1's edema on 2/16/24 and updated the nurse practitioner and believed the nurse practitioner should have some kind of note or something and we just don't have it. DON-A stated it would have been helpful if LPN-A and nursing staff had documented that R3 refused assessment or why they didn't assess R3's pitting edema and nursing staff should attempt and document an assessment or attempted assessment. DON-A stated I don't think her [R3] notes are updated. They are monitoring her, maybe not spelling out the edema, but in their [nursing staff] minds they are monitoring her. Additional notes for R1 and R3 not included in the electronic medical record as of 3/4/24 were requested, but none were received. Facility policy titled Skin Integrity Management dated 11/13/22, included: Non-pressure skin impairment/ injury: 1.When a resident presents with an area of skin impairment and/or skin injury the nurse will do the following: - Assess the area including measurements, description of area impaired, pain, cause of the injury - Immediately initiate first aide - If the injury is related to suspected abuse or unexplainable notify the administrator immediately - Notify the nurse practitioner/ physician - Obtain a treatment order - Initiate monitoring of the area until healed - Notify the family and/or resident representative - Create an event in Matrix - Document area of concern within the resident medical record - Update care plan with interventions to prevent reoccurrence.

Based on observation, interview, and document review, the facility failed to provide a dignified dining experience for 1 of 1 resident (R28) observed for dignity. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated R28 had severe cognitive impairment and received assistance with all activities of daily living (ADL's). R28 is independent with eating after meal is set-up. During continuous observation on 9/19/2023, at 5:14 p.m. R28 was sitting on four-wheeled walker at a table in the middle of the dining room with three other residents. At 5:21 p.m. staff attempted to redirect R28 to her assigned table, R28 pushed staff away. At 5:22 p.m. another staff attempted to redirect R28, R28 shook her head, made a scowled face and pushed staff away. At 5:24 p.m. staff approached R28 with a sanitizing hand wipe, R28. At 5:31 p.m. another staff approached R28 to attempt to redirect R28 to assigned seat, R28 pushed staff away again. At 5:36 p.m. program manager (PM) approached R28 to attempt to redirect R28 to assigned seat, R28 pointed at PM and then at chair. At 5:52 p.m. staff took R28's food tray and brought it to R28's assigned seat assignment and tried to get R28 to go to that location. Staff showed dietary ticket to R28 and pointed at her tray. R28 grabbed the ticket and tore it up. At 5:55 p.m. PM approached R28 and asked R28 if she needed to use the toilet with R28 shaking head no. R28 made a scowled face towards PM and pointed for PM to go away. At 5:56 p.m. PM retrieved R28 dentures and brought them to R28 in the dining room and handed them to R28. R28 grabbed dentures and put them in mouth. At 5:58 p.m., R28's food tray remained uncovered, at R28's assigned seat, while R28 remained sitting at table with staff assisting other residents. At 5:59 p.m., R28 was pointing to another resident's food. PM stated, yours is over there and pointed to the food sitting on empty table. At 6:02 p.m., staff applied a plate cover to R28's food tray. At 6:07 p.m., R28 looked over at table, where her food was sitting, and shook her head. Staff brought R28's food to R28. R28 pushed food away. Staff brought food tray back to the empty table. R28's care plan dated 9/5/23, included if R28 sits in the wrong seat in the dining room that staff should ask R28 once to move to her assigned seat and if R28 refuses, staff are not to seat another resident within R28's arm reach. On 9/21/23 at 10:42 a.m., PM stated R28 will sit in different spots in the dining room during meals. When R28 sits in another location, staff are to offer her food and attempt to assist R28 to her assigned location, at least once. If R28 is resistive, staff would move other residents and let R28 calm down for awhile before reapproaching. PM confirmed that R28 was approached (during meal on 9/19/23) by several staff in a short time, likely agitating R28. On 9/21/23, at 9:59 a.m. registered nurse manager (RN)-B stated R28 is resistive to redirection. When R28 doesn't want to move, she will not move. If R28 gets in the dining room and sits in a seat other than her assigned seat, staff are to offer R28 to move once and then would adjust the other residents to keep them out of R28's reach so R28 would not be able to take food out of their trays. RN-B stated that during the meal on 9/19/23, R28 was offered food initially by staff who then took food to R28's assigned table after R28 refused. RN-B did not comment when asked why care plan was not being followed as staff were continually reapproaching resident to move. A Quality of Life-Dignity policy was requested but was not provided.

Based on observation, interview, and document review, the facility failed to provide restorative walking program as ordered for 1 of 1 residents (R42) reviewed for range of motion (ROM). Findings include: R42's admission Minimum Data Set (MDS) dated [DATE], indicated R42 was cognitively intact. R42 was totally dependent with transfers and had not walked during assessment period. R42's face sheet created 9/21/23 indicated diagnosis of left side weakness following cerebral infarction, also known as a stroke. Physical therapy discharge summary dated 8/25/23, indicated R42 was to transfer with EZ stand lift, which was a mechanical lift to assist the resident to go from sitting to standing, and was started on a restorative ambulation program. Staff had been trained. R42 was to walk twice a day for 10 feet along hallway rail with assistance and wheelchair following. R42's medication administration record dated August 2023 and September 2023 indicated walking task was not completed due to condition, not able to walk and not safe to walk. Walking task was not completed on all 24 of 24 days ordered. Nursing progress note dated 8/29/23 indicated resident was not safe to walk at this time. Staff tried and R42 was unable to walk. On 9/18/23 at 6:51 p.m., R42 stated he was not walked in the hallway with staff since discharged from physical therapy. R42 stated he wanted to walk. On 9/20/23 at 4:11 p.m., nursing assistant (NA)-A stated physical therapy provided training three times on R42's walking program. R42 was unable to support own weight and needed an EZ stand lift for transfers and standing. NA-A was not comfortable walking R42. NA-A reported concerns to floor nurse and unit manager nurse. NA-A stated not wanting to put R42 at risk for fall or injury with walking when not safe. On 9/20/23 at 1:04 p.m., physical therapist (PT)-A stated a walking program was developed for R42 and staff were trained. R42 was then discharged from physical therapy. PT-A received an email from nurse manager relaying staff did not feel comfortable walking with R42 and did not feel it was appropriate. No additional follow up or evaluation was completed by physical therapy or nursing. Director of nursing and floor nurse manager were unavailable for interview. Facility policy Restorative Nursing and Functional Maintenance July 2017, indicated therapy would assess and make program recommendations, nursing team would update care plan, nursing would perform program per recommendations. Changes in the resident's status were to be reported to nursing. In the absence of therapy involvement, nursing would assess and make recommendations. The resident care plan would be updated and revised as needed.

Based on observation, document, and interviews, the facility failed to promote dignity of its residents when a resident's family member found TikTok videos made by a nurse who was working in the facility and wearing her employee badge. The nurse created and posted social media videos on TikTok that disrespected residents of the facility who were prescribed medications for psychiatric illness and/or neurological illness. Findings include: Upon interview on 10/11/22, at 9:52 a.m. A resident's family member (FM)-A provided TikTok videos made by a facility licensed practical nurse (LPN)-A that FM-A found disturbing. FM-A reported having seen the videos solidified her concerns that the resident could be overdosed with his [CONDITION(S)] medications causing FM-A anxiety about what occurs at the facility. FM-A identified licensed practical nurse (LPN)-A as the resident's main nurse working on either the evening or night shift. Upon observation of TikTok video 0512 undated, LPN-A was shown filming herself. LPN-A's name and the facility name are identifiable on her nametag in this video. The initial caption on in the video read Best part of nursing and When he chased you in the unit swearing to kill you. The background on the screen was LPN-A smiling. The caption changed to a male nursing manikin laying in a comatose state with his eye shut, mouth open wearing a hospital gown and the caption read Then gets knocked out. The next segment is back to LPN-A with her hand next to her face making a claw with her hand and saying [NAME] followed by giggling with the caption After a dose of [MEDICATION(S)]. LPN-A is giggling/laughing throughout the video. Throughout the video behind LPN-A were facility charts and a facility white board that were visual. The video is 13 seconds long. Upon observation of TikTok video 7244, undated showed LPN-A seated at a nursing station in the facility. LPN-A's name badge and facility charts are visible. The initial caption read Why I can't be a stay-at-home mom no matter how much I love it. The next caption showed LPN-A seated and dancing with her arms to a Rod Wave song titled Rags2Riches with the caption reading After family sends you to a [NAME] country all the living generation of your ancestors depend on your paycheck. The video then showed pictures of the facility hallways. The hallway was empty. In the next segment, LPN-A is standing up dancing in place with arm, and torso movements. The caption read This type of bullshit is what makes [MEDICATION(S)] of living. The lyrics to the song played throughout the video were, I give out daps and them hugs, wasn't no one's for me. Cause that type of[OBSCENITY]don't faze a player uh, this type of[OBSCENITY]is what makes a hater. When you got it out of mud, yeah? Ran it up yeah The video is 17 seconds in length. Upon observation of TikTok video 4386, undated, showed LPN-A seated at a nurse's station at the facility eating a chip. The caption read Just when you done with the 20th person then the [MEDICATION(S)] wears off your first patient. A loud screaming sound is heard. LPN-A throws her potato chip, she looks off the to the right, gives a look of dismay to the camera and adjusts her eye goggles with her index finger. The video is 11 seconds in length. Upon observation of TikTok video 8487, undated, showed a photo of medications in a medication cup. The initial caption was Can you keep a secret and the caption Med pass tips for new nurses in Mental care. The video showed the medications being crushed together and poured into a drink of boost (nutritional supplement) and showed the crushed medications poured into chocolate ice cream. The video ends with an unidentified health care worker placing her index finger over her lips making the shhhh sound. The song titled Secret by The Pierces placed during the video. The lyrics were, I've got a secret can you keep it? Swear, this one you'll save better lock it in your pocket taking this one to the grave. If I show you, then I know you won't tell what I said. The video is 18 seconds in length. Upon interview on 10/12/22, at 2:45 p.m. LPN-A verified she had social accounts for Facebook, Twitter, TikTok, and Instagram. She reported posting on one of her social media accounts about three years ago of a video taken at the facility showing a table of food provided by the facility for a celebration. When asked about any video posting about medications from the facility during work, she the recalled posting videos and those videos were not authorized by the facility and their intentions were to be a form of education for new nurses on how to give medications. She verified she was aware of the facility policy of social media, HIPPA, and resident privacy. Upon interview on 10/14/22, at 2:32 p.m. the Administrator stated that the facility identified who the staff was in the TikTok videos. She reported LPN-A was interviewed by the facility and admitted to posting videos in 2020, during the Covid-19 pandemic. The Administrator stated LPN-A mentioned during the interview that posting videos was how she coped with having to work through the pandemic. A facility policy, titled, Media dated 1/22/18, indicated if staff is to identify their affiliation with the facility, the media activities should be consistent with the facilities high standards of professional conduct. If staff communicates in the public internet about the facility or facility related matters, they should disclose their connection at the facility with their role at the facility. Staff is to ensure that social media does not interfere with work and staff is not to access social media unless authorized for business purposes. Employees can be appropriately disciplined and/or sued by the facility or commentary, cyber bullying, content, videos, or images that are defamatory, pornographic, propriety, harassing, libelous or can create a hostile work environment. Hidden video or still photography equipment is strictly prohibited. A facility policy titled, Abuse Prohibition/Vulnerable Adult Protection/Abuse Prevention plan dated 7/31/22, indicated mental abuse included humiliation, harassment, and threats of aversion, punishment, intimidate, fear, shame, agitation, or deprivation. This would include but is not limited to photographs and recordings using any type of equipment and keeping or distributing them through multimedia messages or social media networks.

Based on observation and interview, the facility failed to ensure outdated food items were not available for resident consumption. This had the potential to affect 88 of 89 residents who received food from the facility. Findings include: During an observation on [DATE], at 12:04 p.m. four Gold's horseradish and beets containers were found in a cooler. The best used by dates of these containers were [DATE]. During an observation on [DATE], at 12:20 p.m. three packs of Passover vanilla pudding were found with expiration date ,d+[DATE]. Kitchen staff removed the expired pudding and threw it away. During an observation on [DATE], at the expired Gold's Horseradish and Beets with expiration date of [DATE] and [NAME] herring fillets had not removed from the cooler. Due to the large container of the herring fillets, the expired date was not able to be visualized. When interviewed on [DATE], at 12:05 p.m. kitchen manager (KM)-A verified the horseradish and beets were expired. KM-A also stated, the fish [herring] down there are expired too. KM-A acknowledged staff do not check these items enough and they are used for special occasions. When interviewed on [DATE], at 12:21 p.m. Dietary Aide (DA)-A verified the Passover vanilla pudding was expired. When interviewed on [DATE], at 11:20 a.m. cook (C)- A stated the expiration dates were checked by the person who stocks. The C-A also stated this person rotated items and made sure everything was dated. When interviewed on [DATE], at 12:04 p.m. DA-A stated food was delivered twice a week. Expiration dates were checked and items rotated to the front of the shelf on delivery days. DA-A further stated the Passover food found to be expired was ordered twice a year and was only used during Passover. When interviewed on [DATE], at 1:31 p.m. CD stated the kitchen uses the first in, first out system and there was not a formal bases for checking for expired foods. CD further explained there may be expired food in the coolers and it was the responsibility of everyone who removed food from the cooler to check the dates. CD stated it was her expectation to have food removed when it is outdated and expired foods should not be in coolers for months. A facility policy titled Food Storage dated 2021, indicated all stock must be rotated with each new order received.

Based on observation, interview and document review, the facility failed to maintain confidentiality of medical information for 1 of 1 (R241) residents observed to have a sign indicating vaccination status on their bedroom door. Findings include: R241's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/21, at 5:33 p.m. a sign was observed taped to the outside of 241's room door which informed, This Resident is on Precautions. Observation (single use N95 mask, eye protection, gown + gloves). 14 days from move in, ER visit, hospital/TCU stay for UNVACCINATED resident/tenants. When interviewed on 7/13/21 at 8:33 a.m. registered nurse (RN)-A stated the, Precautions sign is used for residents who are unvaccinated and under a 14-day observation period. The sign is used to inform staff a resident is not vaccinated. RN-A added no conversation occurred with the resident or the resident's representative regarding having the vaccination status displayed on the door where it can be observed publicly. When interviewed on 7/15/21, at 10:44 a.m. infection preventionist (IP) stated the sign observed on R241's door was not a standard sign and did violate the resident's right to privacy due to the information it contained. The facility policy titled, Dignity, created 12/2014 included, It is the policy of Sholom that residents are cared for in a manner and in an environment that promotes maintenance and/or enhancement of each resident's quality of life. Sholom is committed to an atmosphere that humanizes and individualizes each resident and their experiences.

Based on interview, and document review the facility failed to ensure proper assessment and notification of the primary care provider following a fall for 1 of 4 residents (R1) reviewed for change of condition following a fall, which resulted in death. This resulted in an immediate jeopardy. The immediate jeopardy (IJ) began on [DATE], at 11:30 p.m. when R1 had an unwitnessed fall in her room. Neuro checks were initiated, but were not followed per facility policy. During the 12:30 a.m. neuro check, R1 had a change of condition which included increased drowsiness and sluggish pupils. R1's provider was not notified of R1's change of condition, and no further assessments were completed. R1 subsequently died . The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 3:13 p.m The IJ was issued at past non-compliance due to corrective actions taken by the facility. On [DATE], the facility provided training to all licensed and unlicensed staff on neuro checks, assessments, change in condition, falls, and notification of change. Findings include: R1's Face Sheet printed on [DATE], indicated R1's [DIAGNOSES REDACTED]. anticoagulants (medicines that prevent the blood from clotting as quickly or as effectively as normal). R1's care plan dated [DATE], indicated R1 was at risk for falls. The care plan directed staff to place call light within reach and answer promptly, remind resident to ask for assistance with transfers and ambulation as appropriate, and observe for changes in cognition. R1's Provider Orders for Life-Sustaining Treatment (POLST) dated [DATE], indicated R1 wanted CPR performed if patient had no pulse and was not breathing. R1's Observation Detail List dated [DATE], at 9:01 p.m. indicated R1 had no history of multiple falls, had a decline in functional status, required assist with elimination, and was not steady, but able to stabilize without human assistance for moving seated to standing, moving on and off toilet, and surface to surface transfers. On [DATE], R1 was seen by nurse practitioner (NP)-A. R1's orders at that time included [MEDICATION NAME] (blood thinner) two milligrams (mg) take mg on Monday, Wednesday, and Friday, and 1 mg Tuesday, Thursday. Saturday, and Sunday. On [DATE], at 12:11 a.m. a progress note (edited at 5:43 a.m. with more data available) indicated R1 had been discovered sitting on the floor next to her bed at 11:30 p.m The progress note indicated she was trying to get up, she was extremely confused, agitated, was unaware of where she was, could only say she was getting out of the pool. The note further indicated R1 was not able to be reoriented, neuro checks were started, and she had no signs of head trauma. The progress note indicated R1 was lifted back into bed with the assist of two staff and a mechanical lift. NP-A was notified by a message left on voice mail. The noted further indicated 30 minute checks were done, and R1 was breathing and more alert at 12 a.m. and able to answer questions. On [DATE], R1's Neurological Assessment Flowsheet indicated R1's first neuro check was at 11:30 p.m. R1's level of consciousness was alert, pupils were equal and responsive to light, equal hand grasps and moves all extremities, and appropriate pain response. On [DATE], at 12:00 a.m. there was no change documented in the checklist. At 12:30 a.m. R1's level of consciousness was documented as drowsy, pupils as sluggish, equal hand grasps and moves all extremities, and appropriate pain response. R1's medical record lacked indication R1's primary care provider was notified of this change in condition. No further neuro checks were completed on R1. There was no plan for ongoing monitoring of R1, despite the change in her neurological status. On [DATE], at 3:36 a.m. a progress note written by licensed practical nurse (LPN)-A indicated R1 was found at 2:30 a.m. and resident wasn't breathing. No pulse, no heart beat, called 2N nurse and brought the crash cart to resident's room. Started CPR right away, resident was still warm to the touch. Other nurse from upstairs called 911 right away. They came and took over CPR from me. Preformed (sic) CPR for 25 min. then they came and told me that they called it (pronounced R1 dead). Son was called before and after. Son was told of our aforts (sic) to bring her back. Also that she had fallen at 11:30 pm. On [DATE], at 10:01 a.m. R1's family member (FM)-A was interviewed. FM-A stated he would have expected staff to follow their procedures after a resident fall. FM-A was aware that R1 was on blood thinners, and would have expected the facility to complete neuro checks if there was a possibility of a head injury. -at 10:52 a.m. LPN-C was interviewed. LPN-C stated she was the nurse on call on [DATE], through [DATE], until 6:00 a.m. LPN-C stated she was not called about R1's fall. LPN-C stated if a fall is unwitnessed and the resident cannot say for certain if they hit their head, neuro checks should be started. LPN-C also stated if there was a change in a resident's condition, she should also have been notified. -at 11:10 a.m. the NP-A was interviewed. NP-A stated she was not notified of R1's change of condition at 12:30 a.m. on [DATE]. NP-A stated a resident's change of condition would warrant a call and she would expect the facility to follow their policies and procedures. -at 12:31 p.m. the administrator and the director of nursing (DON) were interviewed. The DON stated LPN-A did not complete the skill area Change of Condition/Focused Assessment during her orientation. The DON stated this should have been completed. -at 1:53 p.m. LPN-A was interviewed. LPN-A stated after R1 fell she did half hour checks on R1. LPN-A stated she should have completed neuro checks every 15 minutes. LPN-A stated if someone was sleeping and you woke them to do a neuro check there is no real reaction to their eyes. LPN-A stated she would expect someone to have a sluggish reaction to light shined in their eyes. LPN-A stated her training for neuro checks was quite a bit, but was stated it was because she had been a nurse for [AGE] years. LPN-A stated sluggish pupils is a bad sign. LPN-A stated she knew she should have been completing neuro checks every 15 minutes for the first hour, then every 30 minutes for the next hour, but did not do this because she was too busy. When asked if she called the on call nurse, the DON, or other nurses in the building for help she responded with no. LPN-A verified R1 had a sluggish pupil reaction and was drowsy at 12:30 a.m. and that she did not notify R1's medical provider. -at 2:40 p.m. nursing assistant (NA)-A was interviewed. NA-A stated she was called to the unit to assist R1 to the commode sometime between 11:00 p.m. and 12:00 a.m. on [DATE], through [DATE]. R1 transferred to the commode with an assist of two. NA-A stated R1 seemed quite weak, seemed in pain, and was not able to stay seated upright without assistance. On [DATE], at 8:53 a.m. the DON was interviewed. The DON stated she would expect staff to follow the facility policy after a resident falls, she would expect staff to call the on-call nurse for help if she was not able to follow through because she to busy to complete needed assessments, and she would have expected LPN-A to call the on-call physician for sluggish pupils and drowsiness. LPN-A's Employee Corrective Action Form dated [DATE], indicated the facility elected to terminate employment as performance did not meet their standards of practice. The facility policy Fall Prevention and Management updated [DATE], directed staff following a fall, if the resident is not able to state if they hit their head to do the following: perform neuro checks per neuro check policy and form and to alert the physician or NP with any changes. The facility policy Neurological Assessment revision date ,[DATE], directed staff to complete a neurological assessment for unwitnessed falls, if the resident is not competent to recall if they hit their head and there is no evidence of head trauma. The frequency of neuro checks was as follows: every 15 minutes times one hour, every 30 minutes times one hour, every one hour times two hours, every four hours times 20 hours to cover 24 hours. Then day two and day three once a shift. The policy also indicated symptoms of closed head injury are often not immediately apparent. Pupil size and reaction to light is often a late sign of increased intracranial pressure. The policy further directed, The physician will be notified of changes in physical and mental states including head trauma and neurological symptoms. Changes found in follow-up assessments will be communicated to the physician. The facility policy Resident Change in Condition-Notification of Physician/Surrogate Decision Maker dated ,[DATE], directed staff to notify physician immediately for, Falls with any suspected serious injury, i.e. fracture, incidents involving trauma to the head, i.e. hematoma, lacerations, recurrent falls, any other symptom (using nursing judgement) that is causing discomfort or that may jeopardize health and/or safety. Education provided to licensed and unlicensed staff included staff were educated as of [DATE]. Training included fall policy review and fall education, interventions for high fall-risk patients, neurological assessment policy, neurological assessment form revision, reporting to the administrator, change of condition, fall education work flow review, interdisciplinary team (IDT) review process. The training was verified through interviews with staff about education relating to falls, neurological changes, and updating providers.

Based on interview, observation and document review, the facility failed to ensure the advanced health care directive (AHCD) and the POLST (Physician Ordered Life Sustaining Treatment) for 1 of 1 resident (R49) had the same code status identified, according to R49's wishes. The facility failed to ensure a system to identify a resident's POLST to initiate cardio-pulmonary resuscitation (CPR) was accurate in the event breathing and pulse ceased for R49 who wanted CPR initiated. This resulted in an immediate jeopardy (IJ) situation placing the resident at risk for death in the event their heart stopped beating, and their breathing ceased. The Immediate jeopardy which began on [DATE], at 4:30 p.m. when R49's wishes for CPR would not have been honored due to descrepancies between the POLST and AHCD. Review of R49's record identified a do not resuscitate (DNR) status POLST dated [DATE], which was placed directly in front of an AHCD, dated [DATE], which identified to initiate CPR. Interview with R49 acknowledged her wishes to be resuscitated in the event of a cardio-pulmonary arrest, as directed on her AHCD. Because of the descrepencies identified and innaccurate POLST in front of the most recently signed AHCD, R49 was at risk to not receive CPR and expire, in the event that breathing ceased. The administrator was notified of the immediate jeopardy on [DATE], at 4:30 p.m. While the Immediate Jeopardy was removed, non-compliance remained at the lower scope and severity of a D. Findings Include: R49's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R49's quarterly Minimum Data Set (MDS) dated [DATE], indicated R49 had intact cognition and did not display any behaviors. Review of R49's medical record included two documents which addressed code status: A POLST signed by the physician on [DATE], and an AHCD signed and dated by R49, and notarized [DATE]. The POLST had the box Do Not Attempt Resuscitation/DNR (Allow Natural Death) checked and the AHCD had the box checked for I want Cardio-pulmonary resuscitation [CPR] attempted unless my doctor determines any of the following: I have an incurable illness or injury and am dying; or I have no reasonable chance of survival if my heart or breathing stops; or I have little chance of long-term survival if my heart or breathing stops and the process of resuscitation would cause significant suffering. Although the most current AHCD, dated [DATE], identified CPR, the POLST directly in front of the AHCD was dated [DATE] and had not been replaced and/or updated to address CPR as identified on the AHCD dated [DATE]. In addition, the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2 N (north)-Nursing Worksheet-Wing 5, updated [DATE], identified R49's code status as DNR. On [DATE], at 2:00 p.m. during interview, R49 stated, I want to be full code but there are conditions to it. R49 indicated all the information was in the Advanced Health Care Directive and stated that all of her children had a copy of her wishes. On [DATE], at 2:11 p.m. when registered nurse (RN)-D was asked where a resident's code status was located, RN-D stated it was found on the POLST towards the front of the chart. When asked how she would know the code status or advanced directive for any of the resident(s) in case of an emergency, RN-D stated, We would have to come back to the desk to pull the chart and open it to the POLST. On [DATE], at 2:13 p.m. RN-E was asked where the code status for a resident would be located, RN-E stated, It is either in the computer or in the chart. RN-E indicated the POLST was located within the first few pages of the chart. When RN-E was asked if nurses carried any type of nursing sheets with the resident's code status, RN-E stated, I am not sure if they have it on this floor but there are care sheets that do have code status on them. On [DATE], at 2:55 p.m. the director of nursing (DON) indicated that the code status for residents could be found in the paper chart and were scanned into the electronic chart. DON also stated, Code status could also be found in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per policy is go to the chart or Matrix [electronic chart], but not to a cheat sheet. When the DON was asked who was responsible to update the code status of the residents, DON stated social services was responsible for obtaining residents wishes in regards to advanced directives and POLST upon admission. DON also indicated if a resident was to provide an AHCD after admission then social services would review it and would update the POLST and have the provider sign a new POLST. When asked what the process was if someone was readmitted from the hospital and there were changes made to the code status, the DON indicated that, we would start a new POLST and get a telephone order from the physician so that we can make the changes and have social services review it with the resident. When asked how often code status was reviewed with residents, the DON indicated it was always reviewed at care conferences by the social services. On [DATE] at 3:21 p.m. during a second interview and observation, R49 stated, I want CPR [Cardiopulmonary Resuscitation]. When R49 was shown the AHCD dated [DATE], and the POLST signed by the physician on [DATE], R49 was observed to point to the POLST and state, This one was first written when I first came from the hospital and I was not thinking clearly. When asked if she were to be found on the floor not breathing, R49 stated, I want CPR, but I don't want blood transfusion or tube feedings. R49 explained that all of her children had a copy of the AHCD that identified her wishes of CPR. On [DATE], at 3:29 p.m. licensed practical nurse (LPN)-G was asked which document, POLST or AHCD, she would use to identify a residents code status, LPN-G stated, I would use the POLST because usually they are the most recent. When shown R49's AHCD was dated [DATE], with the box for CPR checked and the POLST dated [DATE], with DNR checked, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what staff were supposed to do if family member handed them an AHCD, LPN-G stated, It should be reviewed with social services prior to being filed in chart. On [DATE], at 3:35 p.m. when asked how often residents' code status were reviewed, social service director stated, We verbally go over them at the care conferences and review with what we have on file. Social services director indicated there were care conference notes in the electronic record regarding code status. When social services director was asked how the code status and AHCD were reviewed with residents during care conferences she indicated the staff went over it briefly and if a resident had concerns then they would have further discussion. The social services director did not identify how and what exact documents were reviewed. On [DATE], at 7:45 a.m. family member (FM)-D was called, but was not available. Surveyor left a message and asked FM-D to call back. -At 7:52 a.m. FM-E was called, but was not available however surveyor left a message requested FM-E to call back. On [DATE], at 10:51 a.m. surveyor received phone call from FM-E who indicated that family was present at R49's recent care conferences. FM-E stated, At first [R49] did not want CPR when she arrived to the facility, but then she started feeling better and wanted CPR. FM-E stated all along since R49 had felt better she had wanted CPR performed in case she was found unresponsive and also she had selected specific treatments which were outlined in the AHCD. When asked what verbiage was used to discuss the code status at the care conferences, FM-E stated, There is a newer social worker that asked and stated they were required to ask about code status and she specifically asked about [R49's] wishes of DNR status. FM-E could not recall the specific date of the care conference, however stated R49 clearly responded to the question by stating, No, I want to have CPR performed. FM-E stated she thought this had been resolved. FM-E indicated R49 had an AHCD filled out around the time R49 wanted full code status. FM-E stated that recently R49 had changed her code status and no longer wanted CPR or an AED (Automated External Defibrillator) used. FM-E stated that up until the last week or so, R49 had always wanted CPR to be performed and thought this had been outlined in the POLST and AHCD. When asked if FM-E was given a second copy of an AHCD, FM-E stated that recently, on Saturday [DATE] (following survey), R49 gave her an AHCD that had a page removed and new page replacing it in the original document that was dated and notarized [DATE]. They just added a sheet to the one form that was already there. FM-E further stated R49 asked to have copies made and given to all her siblings, so that all siblings were now aware of her (R49) not wanting CPR. FM-E stated, All I know is when she [R49] first got there [to the facility] she did not want to be resuscitated and then she got better, and wanted CPR, then recently changed her mind to DNR. Review of the Sholom Health Care Directives, POLST policy, updated on [DATE], under the procedure section indicated the resident, resident representative, family and/or responsible party is informed of Sholom Healthcare Directives and POLST Policy through information included in the admission packet. This information is also available at all times throughout the resident's stay. 2. Consideration of an Advanced Directive/other treatment options can be initiated at any time. 3. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Advanced Directives/POLST will be completed within 72 hours or as soon as possible. Social Services will be responsible for completion of the form. At any time the form can be updated to reflect any changes requested and a corresponding physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. The original document will be sent to the physician to be signed and a copy placed in the medical record until the original has been returned. 7. If a resident or designee is unable to determine the wishes for code status, the facility will follow the order received from the discharging facility. In the absence of an order the resident will be considered Full Code or full resuscitative measures will be provided in absence of a DNR/DNI designation. 9. The Advanced Directives/other treatments options- physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These forms, once signed by the medical provider will be placed in the Resuscitation section of the Electronic Medical Record and copied onto the golden-rod card stock and placed in front of the paper chart. 11. If the Advanced Directive/other treatment option is rescinded by the physician, resident or appropriate decision maker, write across the form Rescinded by whom (reason and circumstances), the date, time with the staff signature and file in the medical record. The immediate jeopardy that began on [DATE], at 4:30 p.m. was removed on [DATE], at 10:38 a.m. when the facility interviewed R49 and acknowledged her desire for CPR as identified on the AHCD, dated [DATE]. Full code was confirmed and on [DATE], at 9:49 a.m. R49 had a new POLST reflecting her wishes to be full code that now matched the AHCD. The health care power of attorney was contacted to confirm agreement, and the primary care physician was contacted. In addition, the facility completed a whole house chart audit [DATE] to compare AHCD to the POLST and to the current order for other residents. The facility policy and advanced directives/POLST was reviewed and resident's care plan was updated. All licensed staff on duty at the time of immediate jeopardy were educated on Healthcare directive, POLST policy, specifically related to when a change for a new advance directive was initiated. Licensed staff, social workers and health unit coordinators would be educated immediately prior to the start of their shifts. Facility staff reported that if someone wanted to change their code status a new POLST would be signed by the resident and doctor, and on the old one would write rescind with a line through it, then date and time it. The non-compliance remained at the lower scope and severity level of a D because the facility had not identified descrepencies in R49's Healthcare directive and POLST, in the case of an emergency. In addition, the facility failed to have a system in place to assure and verify the POLST and Healthcare directive were accurate when reviewed during audits and during routine care conferences.

Based on observation, interview and document review, the facility failed to comprehensively re-assess residents' skin integrity to ensure residents received the necessary treatment and services to promote healing and/or prevent new sores from developing for 4 of 5 residents (R24, R3, R28, R116) reviewed for pressure ulcers. This resulted in actual harm for R24 and R3 who developed multiple stage II pressure ulcers (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). Findings include: During interview on 8/8/16 at 3:50 p.m., registered nurse (RN)-B stated R24 did not have a pressure ulcer. On 8/9/16, at 7:44 a.m., R24 was interviewed and stated he had pain. He stated the pain he had a sore on his buttocks which caused him pain. During an observation on 8/11/16, at 8:41 a.m. nursing assistant (NA)-Q toileted R24. R24's right and left ischial tuberosities were noted to be reddened and excoriated (an ischial tuberosity is a bony swelling on the buttocks that bears the weight of the body while sitting). There were five open areas observed which each measured approximately one centimeter (cm) x one cm. The areas of redness were noted to be approximately four inches x two inches on the left side and approximately two inches x one inch on the right. R24's Care Area Assessment (CAA) dated 4/6/16, indicated R24 was at risk for pressure ulcers due to the need for extensive assist with bed mobility and incontinence. A quarterly Minimum Data Set ((MDS) dated [DATE], indicated R24 was cognitively intact, occasionally incontinent of bladder, frequently incontinent of bowel and required extensive assistance for bed mobility, toileting and transfers. R24's care plan dated 7/26/16, indicated the resident experienced incontinence and interventions directed staff to apply a barrier cream to the resident ' s perineal area after each incontinent episode, and to observe the condition of R24 ' s skin. The care plan further identified R24 had a risk for alteration in skin integrity and directed staff to observe for changes in skin, to report changes to the licensed staff, and for the licensed staff to conduct a weekly skin assessment. R24's Treatment Flowsheet from 8/1/16 through 8/12/16, indicated the following interventions were to be implemented: Reposition patient every two hours in order to displace weight on sacral/coccyx area; Skin assessment weekly on bath day; Apply barrier ointment to sacral coccyx area twice daily with cares. A review of a facility document titled Weekly Skin Checklist for August 2016, indicated R24 had an open area to his right shin on 8/6/16. The Weekly Skin Checklist did not identify any alteration to the skin on his buttocks. When reviewed, the Weekly Skin Checklist for July 2016 had void of any documentation for the entire month. A review of the Nurse's Progress Note late entry dated 8/12/16, indicated R3 has stage 2 ulcers (multiple open areas on right and left buttocks). Family notified of pressure ulcers. A facility document titled 2 North Plan of Care (NA worksheet) undated, indicated R24 had a history of [REDACTED]. During an interview on 8/11/16 at 8:18 a.m., nursing assistant (NA)-Q stated R24 complained of pain in his bottom and stated he gets rashes on it. NA-Q stated the resident has stated it gets better, then worse. NA-Q stated she would update the nurse when R24's bottom was noted to have sores on it. NA-Q was asked if RN-B was aware of the open areas and NA-Q replied, He should have been aware of it. During an interview on 8/11/16 at 8:54 a.m., RN-B stated he was not aware R24 had an alteration to the skin on his bottom. He stated the nurses should be performing weekly skin checks for R24 and should be reporting anything that had not been noted on a previous assessment. However, there was no evidence the weekly skin assessments had been conducted during the month of July. During an interview on 8/11/16, at 12:29 p.m. the director of nursing (DON) stated weekly skin checks should have been completed for R24 and stated RN-B should have been aware of the pressure ulcers to R24's bottom as RN-B was the nurse manager on the unit. During a follow up interview with R24 on 8/11/16 at 2:42 p.m., R24 stated he'd had sores on his bottom on and off for a year. During a subsequent interview with RN-B on 8/11/16 at 2:57 p.m., RN-B described R24's bottom as breakdown of left buttock, moving to the right. RN-B stated the areas looked like they had started as chafing and then the skin had been sheared off. RN-A stated during interview on 8/9/16 at 7:12 a.m., that she was unaware of any alterations to R3's skin but that she would look at it. At 7:28 a.m., RN-A reported to the surveyor that she had looked R3's skin, and had observed an open area on his right buttock. RN-A described the area as a stage I pressure ulcer (non-blanchable [DIAGNOSES REDACTED] of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, [MEDICAL CONDITION], induration, or hardness may also be indicators). During an observation on 8/11/16 at 7:23 a.m., licensed practical nurse (LPN)-A and RN-A completed a dressing change to R3's buttocks. R3's right and left ischial tuberosities were observed to be red and excoriated with three separate open areas. RN-A described the area as having lots of redness and three stage II pressure ulcers. LPN-A stated the wound had gotten bigger since the last time she'd done the dressing change and now required a larger dressing than it had previously. A review of Nurses' Progress Notes from 2/12/16 through 8/11/16, identified R3 had a history of [REDACTED]. The notes indicated R3 had a stage II pressure ulcer on 2/23/16. R3's annual MDS dated [DATE], indicated he was cognitively intact, required extensive assistance for bed mobility, transfers and toileting and was frequently incontinent of bowel and bladder. A CAA dated 6/30/16, indicated R3 had a high risk for pressure ulcer due to a history of pressure ulcers. R3's care plan dated 8/5/16, identified a problem area of impaired mobility, and interventions included for staff to assist with bed mobility, transfers and toileting. R3's care plan had been updated on 8/11/16, to include identification of an open area to his left buttock measuring 1.5 cm (centimeters) x 1.5 cm. Although the observation on 8/11/16 at 7:23 a.m. had identified three open areas, a Nurses' Progress Note dated 8/11/16, indicated a message had been left for the nurse practitioner regarding: two open areas (1.2 cm x 1.2 cm) on resident's left buttock. A review of R3's Physician order [REDACTED]. A Weekly Skin Checklist dated 7/27/16, identified an open area on R3's left buttock. While the Physician order [REDACTED]. During an interview on 8/10/16 at 1:01 p.m., LPN-A stated she was aware of the open area to R3's buttocks. She stated the nurse practitioner saw him in July and found the area. LPN-A further stated R3 had experienced problems with the skin on his bottom in the past. During an interview on 8/11/16, at 7:02 a.m., two days after RN-A was made aware of the pressure ulcer on R3's buttock, RN-A stated she had not assessed the wound yet. She stated, I think the nurses do the assessments daily. However, review of the record reflected there had been no assessment to measure and monitor R3's pressure ulcers. During an interview on 8/11/16 at 12:19 p.m., the DON stated when a skin concern was identified an incident report should be filled out and the care plan should be updated. She stated RN-A was responsible for implementing the process and stated weekly skin assessments would have been expected to be completed since the initial area had been discovered by the nurse practitioner on 7/14/16. R28's quarterly MDS dated [DATE], indicated she was moderately cognitively impaired, frequently incontinent of bowel and bladder and required extensive assistance of two staff for bed mobility, toileting and transfers. R28's care plan dated 7/31/16, indicated she required assistance using a mechanical stand to transfer related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The care plan further identified a pressure ulcer to R28's right buttocks and directed staff to monitor weekly, reposition with pillows and provide a pressure relieving cushion in wheel chair. A facility document titled 2 North-Plan of Care undated, directed staff to be diligent with turning and repositioning but did not identify a frequency. Prior to inquiry by surveyor, the care plan reflected every hour repositioning based on tissue tolerance tests. A Nursing Progress Noted dated 7/29/16, indicated R28 had a stage II pressure ulcer present on her right buttock. During continuous observation on 8/10/16 from 8:06 a.m.-10:07 a.m., R28 remained seated in the wheelchair without repositioning. At 8:06 a.m. on 8/10/16, R28 was seated in a standard wheel chair with a cushion on the seat. At 8:58 a.m., R28 remained seated in the wheel chair in the dining room. At 9:26 a.m., staff escorted R28 to her room where she remained seated in her chair without repositioning. At 10:07 a.m. R28 remained in the wheelchair. NA-Q was interviewed at 10:15 a.m. on 8/10/16. NA-Q stated she knew to reposition R28 every two hours and stated she thought the resident had last been repositioned about 8:30 a.m. However, R28 was seated in the dining room at 8:30 a.m. and had not been repositioned. At 10:24 a.m., NA-Q stated R28 had left for the beauty shop and had still not been repositioned. At that time, R28 had been in her wheel chair for two hours and 18 minutes without repositioning. At 11:05 a.m., NA-Q stated she had taken R28 to the bathroom after she returned from the beauty shop but did not specify an exact time. During an interview on 8/10/16, at 10:11 a.m., registered nurse (RN)-B stated another staff completed the assessments and the care plans and he updated the care sheets (the 2 North -Plan of Care). RN-B stated if the care plan directed staff to reposition R28 every hour it should be reflected on the care sheet and staff should be repositioning her every hour. During an interview on 8/11/16 at 12:26 p.m., the DON stated R28 should have been repositioned every hour as directed by the care plan. She further indicated the care sheets should indicate a frequency to guide the nursing assistants. R116 was observed on 8/10/16, at 6:53 a.m. lying in bed on her right side, eyes closed and a pillow behind her back. Two Posey sleeves (provide comfortable protection for fragile or sensitive skin that may bruise or tear easily) were observed on top of the night stand. At 6:56 a.m. NA-U was observed to enter R116's room. NA-U stated she was going to get R116 dressed but then said she would leave R116 and would be back in 45 minutes. At 7:14 a.m. NA-U was overheard reviewing the assignment sheet with NA-A outside R116's room. When interviewed at that time, and asked about when R116 had last received care, NA-A stated she was not a regular staff on the unit but would be getting R116 up shortly. NA-A stated because she did not know residents in the unit she would follow their care plans. At 7:19 a.m. NA-A was observed go to R116's room with linens. She stated she was not getting R116 up yet, but was just getting what she would need ready. At that time, NA-A did not reposition the resident. At 7:27 a.m. R116 was observed to be asleep on the bed wearing the arm sleeves on both arms still lying on her back, positioned to her right side. At 8:29 a.m. LPN-A stated she had informed NA-A that R116 was supposed to be repositioned every hour. When asked when the resident had been last repositioned, LPN-A stated she had gotten to the unit at 6:30 a.m. but did not know when R116 had last been repositioned. LPN-A stated R116 had an open area which was improving however, the area was a recurring one in the same area. At 8:32 a.m. both NA-A and LPN-A were observed to provide pericare and repositioning for R116. During the observation R116's bottom appeared red and non-blanchable. The area on the tail of the coccyx was observed covered with a thick layer of cream. LPN-A wiped the area and a scab was observed. LPN-A stated the bottom was red and non-blanchable because R116's skin was so fragile. LPN-A also verified R116 was supposed to be wearing a left heel boot which was not on. At 8:36 a.m., NA-A stated LPN-A had informed her R116 was supposed to be repositioned hourly however when she'd looked at the NA assignment sheet, it indicated R116 was to be repositioned every one to two hours, and because she had been pulled from another unit later into the shift she had not been told when R116 had been repositioned last. R116 went one hour and 39 minutes without being repositioned. At 8:45 a.m. on 8/10/16, LPN-A verified the resident was supposed to wear the Posey sleeves at all times. LPN-A stated it was not on the treatment sheet but that she was going to add it. On 8/10/16 at 8:50 a.m., RN-A reviewed R116's care plan and verified R116's care plan indicated staff were to reposition her side to side hourly when in bed. However, the care plan was contradictory as it also directed staff to reposition the resident every one to two hours. RN-A verified the Posey sleeves were supposed to be on at all times. RN-A stated she would expect staff to follow the resident's plan of care. On 8/10/16, R116 was observed from 8:52 a.m. to 9:18 a.m. R116's cares were observed provided by NA-A and NA-U who turned R116 from the left to the right but never placed a pillow behind the resident. On 8/10/16 at 10:36 a.m., LPN-A stated she had reviewed the NA group Plan of Care sheet and had noticed both the one to two hours and every hour for repositioning. LPN-A stated she was going to make sure it was updated to reflect the hourly repositioning schedule as this was confusing and misleading for staff. At 10:42 a.m. LPN-A stated R116 had an open area that was pressure related as it was the same area where it had healed before. LPN-A stated the area was a stage II which was healing well. On 8/12/16 at 7:20 a.m., R116 was observed seated in a Broda chair in front of the dining room door. R116 was noted to have blue boots on both feet however, did not have a pillow placed on the foot rest. At 7:30 a.m. RN-A verified their was no pillow in place on the foot rest. R116's annual MDS dated [DATE], identified the resident's [DIAGNOSES REDACTED]. The MDS also indicated R116 had severely impaired cognition and required extensive to total dependence of one to two staff for all activities of daily living which included bed mobility, toilet use and transfers. In addition the MDS indicated R116 was at risk for pressure ulcers, but had no unhealed pressure areas at the time of the assessment. R116's pressure ulcer CAA dated 5/31/16, indicated the resident was at risk for pressure ulcers related to impaired mobility, dementia and bowel incontinence. The CAA directed staff to assist R116 with turning and repositioning and to observe skin daily during cares. R116's care plan dated 7/8/16, indicated she was at risk for alteration in skin integrity related to dementia, incontinence of bowel and bladder, dependency with ADLs, poor nutritional intake, and being chair fast. The care plan further indicated R116 had a history of [REDACTED]. Care plan interventions included: Place pillow on foot rest when resident is in BRODA chair, elevate lower extremities when in bed above level of heart. Turn side to side hourly while in bed, use pillows to protect bony prominences when repositioning, Repositioning hourly while in BRODA chair (specialized wheelchair), Posey sleeves upper extremities (Full arm) and derma-savers to lower extremities at all times, remove at bedtime to apply lotion, then reapply. Heel blue boots on both feet when lying in bed and sitting up daily on all three shifts . During review of the Event Reports assessments and the Interdisciplinary team notes (IDT) the following were revealed: -A Weekly Summary dated 7/7/16, indicated resident required physical extensive assistance of staff with bed mobility and repositioning. -Skin Integrity Events -- Pressure Sore/Stasis Ulcer/Arterial dated 8/1/16, indicated R116 had a stage II- partial thickness loss of skin layers that presents clinically as an abrasion blister, or shallow crater. The open area was on the left buttocks and measured 1.5 centimeters (cm) by 1.0 cm. The assessment indicated resident had history of pressure ulcer and directed interventions included but not limited to turning and repositioning and use of pressure relieving devices in chair and bed. -Interdisciplinary note (IDT) note dated 8/4/16, indicated resident pressure open area on right bottom measured 1/4 cm x 1/8 cm, washed with normal saline (NS), patted dry, barrier cream applied to area. On 8/12/16, at 7:36 a.m. DON stated she would expect staff to have repositioned R116 timely in accordance with the care plan. A facility policy titled Prevention and treatment of [REDACTED]. The policy further directed staff to initiate weekly wound monitoring to include onset of skin condition, location of wound, stage of wound, length, width, depth and wound characteristics.