Every finding on record at St Benedicts Care Center

Based on observation, interview, and document review, the facility failed to ensure refrigerated food items were properly labeled, dated, and closed after the packaging was opened to prevent cross contamination which had the potential to affect all 45 residents currently residing on the second floor.Findings Include:During observation and interview on 08/03/2026 at 10:28a.m., dietary assistant (DA)-A and surveyor reviewed contents of the Parker's Lane kitchenette on second floor. DA-A verified the following concerns identified in the refrigerator freezer:-one hamburger patty in a plastic bag, left open, undated-one omelet in plastic bag, undated-one French toast in plastic bag, undated-five waffles in plastic bag, left open, undated-multiple pancakes in plastic bags, one bag left open, undated-two macaroni and cheese items wrapped in plastic, undatedDuring observation and interview on 08/03/2026 at 10:38a.m., DA-B and surveyor reviewed contents of the Therapy Suite's kitchenette on second floor. DA-B stated foods in refrigerators and freezers were supposed to be dated. DA-B verified the following concerns identified in refrigerator freezer:-multiple corn dogs in plastic bag, undated-multiple hamburger patties in plastic bag, undated-multiple pancakes in plastic bag, undated-multiple omelets in plastic bag, undated-multiple hot dogs in plastic bag, undated-multiple waffles in plastic bags, one bag left open, undated. DA-B removed waffles in open bag, taped bag closed and returned to freezer. During interview on 8/4/26 at 10:00 a.m. dietary manager (DM)-A indicated all food items should be dated if to be stored for longer than one day. DM-A stated it was important to date items to assure facility was using food first in- first out, and that it could be a potential problem if food items became old. DM-A also stated if bags were left open cross contamination could be possible. The facility policy titled Food Storage dated 5/25, identified sufficient storage facilities would be provided to keep foods safe, wholesome, and appetizing. Frozen foods should be covered, labeled and dated. All foods would be checked to ensure that foods would be consumed by their safe use by dates or discarded.

Based on observation and interview, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was provided to each resident residing in the facility and displayed for residents, visitors, and staff to review. This had the potential to affect all 71 residents currently residing in the facility as well as all staff and visitors.Findings include:During interview on 8/4/26 at 11:23 a.m. R19 stated the [NAME] of Rights was posted on the first floor but did not recall anyone sitting down and going over the bill of rights During observation on 8/4/26 at 11:26 a.m. displayed on first floor across from the kitchen door was the RBOR dated 7/1/07. On 8/4/26 at 11:33 a.m. reviewed facility admission packet, the packet included RROB indicated it was revised 11/28/16, modified 2/1/17. ON 8/4/26 at 11:35 a.m. observed a folder in a clear plastic wall hanger, the folder contained RBOR modified 2/1/17. During interview on 8/5/26 at 11:17 a.m. director of nursing (DON) stated the social service director (SSD) worked with marketing and ordered items needed for the admission packets. DON stated they were not aware the RBOR had been updated. DON stated the admission packet surveyors were provided was the most recent packet. During interview on 8/5/26 at 11:22 a.m. SSD stated they personally did not go over RBOR at admission. SSD stated they were not aware of who was responsible for updating the posters for the RBOR, was not aware if residents had been updated regarding the updated RBOR as they had not been aware there was a change. Policy regarding RBOR was requested, however, none was provided.

Based on observation, interview, and document review, the facility failed to ensure the common use blood glucometer machine was disinfected according to current manufacture's recommendation after resident use for 2 of 2 residents (R85, R21) observed for glucometer use, which had the potential to affect all 5 residents (R85, R21, R82, R84, R12) who resided on the transitional care unit and received blood glucose testing in the facility. In addition, the facility failed to review their Infection Prevention And Control Program (IPCP) at least annually, which could affect all 71 residents who resided in the facility.Findings Include:R85's Order Summary Report dated 8/5/26, identified R85 had diagnoses which included type 2 diabetes mellitus (DMII). R85's orders included glucometer (Gluc) checks before meals and at bedtime. R85's orders also included Novolog insulin inject as per sliding scale (insulin order based on current blood glucose level) subcutaneously (under the skin) with meals for DMII.R33's Order Summary Report dated 8/5/26, identified R33 had diagnoses which included DMII. R33's orders included blood sugar checks before meals and at bedtime. R33's orders also included Free Style Libre 3 Plus Sensor (continuous glucose system sensor) and Novolog insulin, inject 11 unit subcutaneously one time a day before dinner and lunch, and 13 units before breakfast for DMII.R21's Order Summary Report dated 8/5/26, identified R21 had diagnoses which included DMII. R21's orders also included glucose checks before meals and at bedtime. If glucose checks were greater than 300 restart Lantus (insulin) order on HOLD. During observation on 8/3/26 at 3:53 p.m., licensed practical nurse (LPN)-A entered R85's room with a medication cup and a basket with a common use blood glucometer machine and supplies. LPN-A administered R85's pill, then completed a glucometer check for R85. LPN-A placed the glucometer back into the basket, left R85's room then placed the basket on top of the medication cart. LPN-A did not sanitize the glucometer. At 4:03 p.m., LPN-A primed an insulin pen, placed it in the glucometer basket, with the glucometer, then entered R33's room and placed it on the top of the dresser. LPN-A stepped outside of R33's room and applied gown and gloves, then returned to R33's room. LPN-A picked up the basket, placed it on R33's bedside table, administered insulin, then placed R33's insulin pen back into the basket, and placed it on the foot of R33's bed. LPN-A removed the basket from R33's room then returned it to the top of the medication cart. LPN-A removed R33's insulin pen then placed it back into the medication cart drawer. At 4:13 p.m., LPN-A entered R21's room with the glucometer basket and completed a blood glucometer check for R21. LPN-A removed the basket from R21's room and placed the basket back onto the medication cart. LPN-A did not sanitize the glucometer. At 4:16 p.m. LPN-A confirmed she had not sanitized the glucometer after use for R85 or R21. LPN-A indicated she should have sanitized it using the Super Sani-cloths, which were stored on the medication cart. LPN-A indicated her usual practice was to use a Sani-cloth and wipe it all over. When asked if she allowed the glucometer to be kept wet with a cloth, LPN-A indicated she would just wipe it off.The Super Sani-Cloth germicidal disposable wipes label indicated it is a bactericidal, tuberculocidal and virucidal in 2 minutes. Special instructions for cleaning and decontamination against HIV-1, Hepatitis B virus (HBV) and Hepatitis C virus (HCV) of surfaces/objects soiled with blood/body fluids. Cleaning instructions: all blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe. Open, unfold and use first germicidal wipe to remove heavy soil. Contact time: use second germicidal wipe to thoroughly wet surfaces. Allow: to remain wet two minutes, let air dry. Review of the Assure Platinum glucose monitor by Arkray instruction manual suggested cleaning and disinfecting the meter between patient use. The manual indicated cleaning and disinfecting to be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe, (list included: Super Sani-Cloth Germicidal Disposable Wipes). The manual further indicated to follow product label instructions to disinfect the meter. The manual indicated if blood was visibly present on the meter two wipes must be used, one wipe to clean and a second wipe to disinfect. During interview on 8/4/26 at 2:02 p.m., registered nurse infection preventionist (IP)-A indicated her expectation was that the common glucometer would be cleaned between each resident, using the Sani-cloths. IP-A stated the glucometer should be wiped off and kept with a cloth on for about two minutes. IP-A indicated this was important to prevent cross contamination and blood born pathogens. IP-A verified the facility had not had any blood born illnesses. IP-A also confirmed the IPCP had not been reviewed annually and stated she had just become the facility IP in January. IP-A verified the last review date on the policy was 12/23.During interview on 8/4/26 at 2:41 p.m., director of nursing (DON) stated her expectation was that the common use glucometer would be cleaned between residents with a disinfectant wipe. DON indicated this was important to make sure clean and would not contaminate a resident. DON stated she was not aware when IPCP was last reviewed but thought it was reviewed as a team. DON verified IPCP policy last review date was 12/23. DON indicated it was important to review the IPCP for any updated changes.The facility policy titled Obtaining A Fingerstick Glucose Level dated 10/11, identified the purpose of the procedure was to obtain a blood sample to determine the resident's blood glucose level. Supplies included a disinfected blood glucose meter (glucometer). Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.The facility policy titled Cleaning And Disinfection Of Resident-Care Items And Equipment dated 9/22, identified resident-care equipment, including reusable items and durable medical equipment would be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. Reusable items were cleaned and disinfected or sterilized between residents. Reusable resident care equipment was decontaminated and/or sterilized between residents according to manufactures instructions. The facility policy titled Infection Prevention And Control Program, dated 12/23, identified the IPCP was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy identified the infection prevention and control committee was responsible for reviewing and providing feedback on the overall program. The infection prevention and control committee, medical director, director of nursing services, and other key clinical and administrative staff would review the infection control policies at least annually.

Based on interview and document review, the facility failed to provide arrangements for dental care for 1 of 1 resident (R62) reviewed for dental services.Findings include:R62's quarterly Minimum Data Set (MDS) dated [DATE], indicated R62 had moderate cognitive impairment and required staff assistance with activities of daily living (ADLs). R62's care plan revised 6/25/2, indicated R62 had a self-care deficit related to impaired mobility. R62's care plan further indicated they were usually independent with oral care but needed assistance at times. R62's order summary report printed 8/5/26, indicated R62 received a renal diet, level 7 regular texture diet (kidney friendly with normal textures). During interview on 8/3/26 at 11:46 a.m. R62 stated they had no upper teeth and only a couple of teeth on the bottom, R62 stated they had been wanting dentures but have not gotten any, R62 stated this made eating difficult at times. R62's oral/dental assessment form dated 7/23/25, indicated R62 had no upper teeth/dentures and only two teeth on lower and no dentures. The dental care referral recommendations indicated routine dental referral, R62 had non-urgent dental care needs with note to nursing staff question denture for upper and partial for lower. Review of R62's electronic medical record (EMR) failed to identify follow up was completed regarding the question of upper denture and lower partial dentures. During interview on 8/5/26 at 11:43 a.m. licensed practical nurse (LPN)-B stated they were not aware R62 wanted dentures. During interview on 8/5/26 at 12:12 p.m. registered nurse (RN)-A stated R62 had a screening completed at the facility 7/23/25. RN-A stated R62 was previously seen by an outside dental office but had not been seen there since 2004. RN-A stated they had gone to R62 to ask if they wanted to be seen for dentures and R62 had become tearful and wanted to be seen. RN-A stated that typically dental care was not addressed quarterly during care conferences but believed that was something that should be done to ensure residents dental needs were addressed on a regular basis for comfort, dignity, and basic care. Facility Dental Services policy revised 12/2016, indicated routine and emergency dental services was available to meet the resident's oral health services. The policy further indicated routine and emergency dental services were provided to the residents through a contract agreement with a licensed dentist that came to the facility, a referral to personal dentist, referral to community dentist or referral to other health care organizations that provided dental services.

Based on observation, record review, and interview, the facility failed to provide assistance with activities of daily living (ADLs) to 1 of 2 residents (R17) reviewed who was dependent on facility staff for cares.Findings include:R17's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was severely cognitively impaired and dependent on staff for activities of daily living. R17's diagnoses included paraplegia, dementia, anxiety, major depression, and multiple sclerosis. Review of the resident's care plan revealed the resident required assistance with personal hygiene and preferred to be clean shaven. On 08/03/26 at 12:13 p.m., observed R17's face and neck was covered with black and gray whiskers. When asked if having whiskers bothered him, the resident nodded yes. When asked if he preferred to be shaved every day, the resident again nodded yes. On 08/04/26 at 11:22 a.m., observed R17 was sleeping in bed with whiskers remaining on his face and neck. Again at 1:21 p.m. R17 continued to have whiskers on his face and neck. On 08/05/26 at 7:55 a.m. observed R17 continued with black and gray whiskers approximately one-half inch long on his face and neck. On 08/05/26 at 11:37 a.m. nursing assistant (NA)-A stated R17 required total assistance with shaving, did not usually refuse shaving, and preferred to be shaved. NA-A stated the resident was not shaved that morning because his electric razor was broken. On 08/05/26 at 11:43 a.m. licensed practical nurse (LPN)-B stated she had just learned that day the resident's razor was broken and would have to review the documentation. On 08/05/26 at 11:50 a.m. registered nurse (RN)-A stated staff use care guides and the Kardex to identify resident care needs. RN-A stated staff should not document Not Applicable when care was refused and had received education regarding proper documentation. RN-A reviewed R17's Kardex and stated the resident preferred to be shaved in the morning and was to be shaved every morning. She further stated she was unaware the razor was broken until that day and would have expected staff to report the equipment issue when it was discovered. After reviewing the documentation, RN-A stated documentation that indicated R17 had been shaved on 08/03/26 did not appear consistent with the observations and would be investigated as possible inaccurate documentation. On 08/05/26 at 12:54 p.m. director of nursing (DON) stated the expectation was that residents be groomed according to their individual preferences. After reviewing R17's care plan DON confirmed R17 preferred to be clean shaven and staff should document the care that was actually provided. Facility Shaving the Resident policy undated, indicated the purpose was to promote cleanliness and to provide skin care. The policy directed staff to review the residents care plan.

Based on observations, interviews, and document review, the facility failed to ensure a comprehensive care plan was developed and maintained to include focus, goals, and interventions for dialysis for 1 of 2 residents (R1) who had a diagnosis of kidney failure and was receiving dialysis.Findings include:R1's admission minimum data set (MDS) assessment dated [DATE], indicated R1 was cognitively intact, required minimal to moderate assistance with activities of daily living, and had the following diagnoses: acute kidney failure, and renal failure.R1's electronic medical record (EMAR) indicated an order for dialysis every Tuesday, Thursday, and Saturday for hemodialysis.R1's care plan lacked a focus, goal, or intervention specific to R1 receiving dialysis.During interview on 8/5/2026 at 2:34 p.m., registered nurse (RN-A) stated she was familiar with R1 and confirmed R1 received dialysis 3 days per week. RN-A reviewed R1's care plan and confirmed it did not contain information on R1's nephrologist, where she received dialysis treatments, or how to monitor or care for R1's dialysis site. RN-A stated she would expect to see basic information related to dialysis.During interview on 8/5/2026 at 2:58 p.m., Director of Nursing (DON) stated she was familiar with R1 and that she received dialysis. DON confirmed R1's care plan lacked a focus/goal/intervention for R1's specific dialysis treatment. DON stated she expected care plans for residents receiving dialysis treatments to contain at minimum information specific to each resident such as port or fistula access site, care and monitoring instructions for that site, any specific nutritional guidelines or restrictions and dialysis schedule. DON went on to state it would be important for a care plan to include specific dialysis care instructions to ensure R1 received appropriate care to manage her kidney disease and dialysis treatments.

Based on interview and document review the facility failed to notify the Ombudsman of transfers and discharges for 1 of 2 residents (R75) reviewed for Ombudsman notification.Findings include:R75's admission Minimum Data Set (MDS) dated [DATE], indicated R75 admitted to the facility 6/11/2026, and had the following diagnoses: anemia, coronary artery disease, diabetes and long-term use of anti-coagulants. R75's medical record identified the following MDS assessments:1) 6/22/2026 Entry Tracking record2) 6/22/26 PPS-Discharge Assessment - Return Not Anticipated Review of the May and June Discharge tracking log failed to identify the Ombudsman had been notified of R75's transfer/discharge out of the facility against medical advice. (AMA) Progress note dated 6/11/2026 at 11:11 p.m., indicated R75 admitted to the facility for rehabilitation after a short hospital stay. Progress note dated 6/12/2026 at 2:24 p.m., indicated R75 left the facility AMA at 2:00 p.m. R75's daughter was present and the primary care provider was updated. Progress note dated 6/12/2026 at 3:56 p.m. indicated a MAARC (Minnesota Adult Abuse Reporting Center) report was filed. During interview on 8/4/2026 at 1:30 p.m., Administrator (Admin) stated the facility did not routinely report residents who left AMA to the Office of the Ombudsman. Admin confirmed the ombudsman wasn't notified when R75 left the facility. Admin stated it was important to notify the ombudsman of resident transfers and discharges to ensure residents were connected to any follow-up services they may need after discharge. A policy regarding Ombudsman notification was requested but not provided.

Based on interview and document review, the facility failed to follow manufacturer's recommendation and facility policy to ensure safe transfers with an EZ Way Smart Lift (mechanical, full body lift) for 1 of 3 resident (R1) reviewed for full body mechanical lift transfers. R1 fell out of the sling and sustained a laceration to his right eyebrow, was sent to the Emergency Department (ED), and required sutures. The facility implemented corrective action prior to the survey; therefore, the deficient practice was issued at past non-compliance.Findings included:R1's admission record dated 12/4/25, indicated R1's diagnoses included palliative care, wild-type transthyretin-related amyloidosis (build-up of abnormal proteins in tissues, such as heart and nerves), chronic kidney disease stage four (severe, irreversible loss of kidney function), and rhabdomyolysis (breakdown of skeletal muscle tissue).R1's care plan dated 12/4/2025, indicated R1 needed a full mechanical lift with assist of two staff for transfers.R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, had no falls, and needed total assistance with transfers.R1's progress note dated 3/29/26 at 11:07 a.m., indicated at 9:14 a.m., staff was informed R1 was on the floor, licensed practical nurse (LPN)-A entered R1's room and R1 was on his right side and had a laceration approximately two inches above right eye.R1's progress note dated 3/29/26 at 12:36 p.m., indicated the ED nurse called the facility and stated R1's eyebrow laceration was deeper than they thought and needed multiple layers of dissolvable sutures due to laceration being the depth of the bone.R1's ED note dated 3/29/26, indicated R1 had a 5.0cm (centimeter) laceration to his right eyebrow after a fall from a mechanical lift. Was given oxycodone 10mg (milligram) and lidocaine-epinephrine (used to numb specific area) injection. R1 required 19 sutures placed in right eyebrow.During an interview on 4/8/26 at 12:12 p.m., nursing assistant (NA)-A stated on 3/29/26, she entered R1's room to assist NA-B with a full body lift transfer. NA-B had already hooked R1's sling to the lift. NA-A stated she did not double check to ensure R1's sling was attached to the lift correctly. NA-A stated that according to the policy she should have double checked the sling straps to ensure they were attached correctly but it, slipped her mind. NA-A stated NA-B lifted R1 with the full body mechanical lift until he was no longer touching his wheelchair. NA-A pulled the wheelchair out from under R1 and R1 fell out of the lift when the right shoulder strap came off the lift. R1 fell on his right side and was bleeding from his right eyebrow.During an interview on 4/8/26 at 1:46 p.m., LPN-A stated on 3/29/26 around 9:00- 9:30 a.m., NA-B alerted LPN-A R1 had fallen and was on the floor. LPN-A went to R1's room and found him on the floor on his right-side bleeding from his right eye. LPN-A sent R1 into the ED.During an interview on 4/8/26 at 1:56 p.m., EZ Way representative stated she was aware of R1's fall from the lift. The expectation would be for staff to follow the instruction manual which included a final check to ensure all four loops were attached sufficiently to the respective hook of the hanger bar on the lift. If staff would have followed the manual and facility policy, R1's fall might have been prevented. During an interview on 4/8/26 at 2:21 p.m., the facility medical director stated if the staff had checked the straps per the policy they would have caught the issue and R1 would not have fallen and gotten injured.During an interview on 4/8/26 at 2:36 p.m., the director of nursing (DON) stated staff did not follow the process put into place and R1 fell from the lift due to the sling not being hooked to the lift correctly. The straps were not checked to ensure they were on the lift correctly by the second staff member.Facility policy, Using a Mechanical Lifting Machine revised 7/2017, indicated staff would attach sling straps according to manufacturer's instructions, would make sure the sling was securely attached to the hooks, before lifting the resident staff would double check the security of the sling attachment, examine all hooks, and would check the stability of the straps.EZ-Way Smart Life Operator's Instructions revised 2/10/2026, directed staff to make a final check of all four loop attachment points to ensure each loop was sufficiently attached to the correct hook of the hanger bar.The facility's corrective actions following this incident were confirmed through observation, interview, and record review of staff completing full body mechanical lift transfers with residents per policy and manufactures instructions, staffs ability to explain expectations of full body mechanical lift transfers, and review of re-education and audits completed with staff.

Based on observation, interview and document review, the facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 1 of 3 residents (R1) reviewed for transfers.Findings include:R1's admission record dated 12/4/25, indicated R1's diagnoses included benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms.R1's care plan dated 3/4/26, indicated R1 had an indwelling foley catheter.R1's order summary report dated 3/4/26, indicated R1 had a foley catheter.During an observation on 4/7/26 at 12:45 p.m., nursing assistant (NA)-C and NA-D entered R1's room to transfer R1 from his wheelchair to another wheelchair for an appointment. R1 did not have signage or supplies for EBPs on his door or in his room. NA-C and NA-D did not have any EBPs (gown and gloves) on during R1's transfer. R1's lift sling was hooked to the full body mechanical lift. NA-C grabbed R1's catheter bag from under his wheelchair and attached it to the sling. R1 was placed in the new wheelchair and NA-D grabbed R1's catheter bag and attached it under the wheelchair.During an interview on 4/7/26 at 1:44 p.m., NA-C stated residents who have wounds or catheters should be on EBPs. R1 did have a foley catheter but NA-C was not sure why R1 was not on EBPs. The unit manager would decide who was on EBPs. NA-C did not wear EBPs when transferring R1 because R1 did not have the signage or supplies on his door and that is how NA-C would have known if someone was on EBPs. During an interview on 4/7/26 at 1:53 p.m., NA-D stated residents with open sores or catheters would have been on EBPs. R1 has a foley catheter. NA-D was not sure why R1 was not on EBPs as the nurse would decide who is placed on EBPs. NA-D did not use EBPs when transferring R1 because there was nothing on the door indicating NA-D needed to use EBPs.During an observation on 4/8/26 at 8:19 a.m., an EBP sign and personal protective equipment (PPE) was observed hanging on the outside of R1 room door.During an interview on 4/8/26 at 9:25 a.m., registered nurse (RN)-A stated R1 had a foley catheter and after clarification, R1 should have been on EBPs and was not until 4/7/26. RN-A stated she was the one responsible for putting signage on the resident's door and equipment outside the resident's room related to use of EBPs.During an interview on 4/8/26 at 2:36 p.m., the director of nursing (DON) stated RN-A would have been responsible for putting R1 on EBPs and was able to determine if a resident needed EBPs by following the facility policy. DON was not sure why R1 was not placed on EBPs prior to 4/7/26.The facility policy titled, Enhanced Barrier Precautions revised 12/2024, indicated EBPs would be applied when a resident had a wound or indwelling medical device. Indwelling medical devices include urinary catheters. Gowns and gloves would be applied when performing high contact resident activities including transfers.

Based on interview and record review, the facility failed to ensure 1 of 1 residents (R27) reviewed for dignity, received services in a dignified manner to promote quality of life when staff failed to respond timely to call light and provide toileting assistance resulting in incontinent episodes and adult son of R27 provided toileting assistance. Findings include: R27's admission minimum data set (MDS) dated [DATE], indicated R27 was cognitively intact, did not reject cares and was dependent on staff assistance for all toileting needs. During an interview on 5/12/25 at 1:49 p.m., R27 stated she needed help to use the bathroom, some call light times exceeded 20 minutes and once over two hours. R27 stated there had been times she became incontinent because of the long wait time. It was embarrassing. R27 stated during a visit with family on Mother's Day (5/11/25) she had turned on her call light and requested help to use the bathroom. Staff came to the room, shut the light off and said they would be right back. When staff had not returned after approximately 5 minutes, R27 turned the light back on. Again, staff came in and shut the light off and said they would be right back. When staff did not return immediately, she was assisted to the bathroom by her adult son. R27 stated it was horrible, he had to pick me up and carry me. My son, not my husband. R27 shook her head and looked away and stated, how would that make you feel? I hated it. R27 stated she was embarrassed and ashamed her son had to help her with such a personal thing. R27 stated her son turned the call light on after transferring her into the bathroom so staff could assist with helping her off the toilet. R27 stated staff came after a couple of minutes and stated they would come back to assist when she was finished. R27 stated she was done about 15 minutes later and pushed for assistance and staff then came to help. Review of call light call logs indicated the following data: 5/11/25 R27's call light was activated at 1:03 p.m. and staff responded within 11 seconds. 5/11/25 R27's call light was activated at 1:06 p.m. and staff responded within 8 seconds. 5/11/25 R27's call light was activated at 1:37 p.m. Staff responded within 1 minute and 24 seconds. 5/11/25 R27's call light was activated at 1:47 p.m. and staff responded within 2 minutes and 16 seconds. 5/11/25 R27's call light was activated at 5:38 p.m. and staff responded after 29 minutes and 16 seconds. During interview on 5/14/25 at 11:32 a.m. Director of Nursing (DON) stated all staff can answer call lights, but primarily they are answered by certified nursing assistants (CNA). DON stated typically call lights were answered right away but it was reasonable to expect a 5-10-minute wait time during busier times of days such as early morning, mealtimes and bedtimes. DON stated she expected staff to check in with residents who use their call light and if multiple lights are on at once, to triage the highest priority lights first, and always return to residents and follow up that their needs are met. DON stated it could be embarrassing for a continent resident to become incontinent as a result of extended wait times and it is important that all residents' needs are met timely to promote dignity and general wellbeing. A policy for dignity was requested but not provided.

Based on interview and document review the facility failed to ensure the care plan included management and monitoring of anticoagulant (blood thinner) therapy for 1 of 5 residents (R1) reviewed for unnecessary medications. Findings include: R1's admission minimum data set (MDS) dated [DATE], indicated R1 was cognitively intact, received anticoagulation medications and had the following diagnoses: A-fibrillation (irregular heartbeat), Acute Embolism and Thrombosis of Deep Veins (blood clots within a blood vessel), and heart failure. R1's order summary report printed 5/14/25 indicated R1 took the following medications: Warfarin 1 mg by mouth one time daily every Friday for A-fib. Warfarin 1.5 mg by mouth one time a day every Monday, Wednesday for A-fib. Warfarin 2 mg one time every Tuesday, Thursday, Saturday and Sunday for A-fib. R1's care plan printed 5/13/25 identified a potential for injury related to history of falls, decreased/impaired mobility, diuretic medications and decline in activities of daily living. R1's care plan lacked evidence of anticoagulant use, increased risk for bleeding, or need for anticoagulant side effect monitoring. During interview on 5/13//25 at 10:13 a.m. registered nurse manager (NM) stated residents on anticoagulant therapy should be monitored for increased bruising, bleeding and staff should be aware of risks associated with these medications. During interview with Director of Nursing on 5/14/25, at 11:32 a.m. Director of Nursing (DON) confirmed R1 was receiving anticoagulant therapy. DON stated residents receiving anticoagulant therapy care plans should include anticoagulant use and instruct staff to monitor for potential side effects including bleeding risks, and an increased risk for bruising. DON confirmed R1's care plan lacked evidence of a focus area related to anticoagulant therapy or monitoring for side effects of anticoagulant therapy. DON stated she expected care plans to include staff instructions for monitoring of side effects related to anticoagulant therapy, completing associated labs as ordered by physicians and updating physicians with any pertinent findings. DON stated this was important because a resident was at a higher risk for complications related to these medications and potential accidents could result in increased bleeding or a resident bleeding out. Facility policy Anticoagulation-Clinical Protocol dated 2018, instructed staff to, Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. The policy instructed staff to monitor for possible complications such as excessive bruising, hematuria (blood in urine), hemoptysis (coughing up blood), or other bleeding and to contact provider before administering next dose of anticoagulant. A care plan policy was requested but not provided.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R21, R25, R28, R53) were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R21's significant change minimum data set (MDS) dated [DATE], indicated hypertension (high blood pressure), peripheral vascular disease (poor blood vessel flow) malnutrition (poor nutrition), and respiratory failure (difficulty breathing). R21 had not received any pneumococcal immunization, and MDS had indicated it had been offered and declined. R25's quarterly minimum data set (MDS) dated [DATE], indicated heart failure (failing heart), hypertension (high blood pressure), and age-related physical debility (reduced physical ability). R25 had not received any pneumococcal immunization, and MDS had indicated it had been offered and declined. R28's quarterly minimum data set (MDS) dated [DATE], indicated coronary artery disease (heart and artery disease), cerebrovascular accident (stroke), Parkinson's disease (involuntary movement), and malnutrition (poor nutrition). R28 had not received any pneumococcal immunization, and MDS had indicated it had been offered and declined. R53's quarterly minimum data set (MDS) dated [DATE], indicated age-related physical debility (reduced physical ability), malnutrition (poor nutrition), and dementia (Poor memory). R53 had not received any pneumococcal immunization, and MDS had indicated it had been offered and declined. R21, R25, R28, and R53's Immunization record indicated that no pneumococcal immunization had been administered, offered, or refused. R21 and R25's Pneumococcal Vaccination Consent Declination indicated refusal and resident dated 7/31/24. Consent Form offered residents and representatives the PPSV23, PCV13, PCV15, and PCV20 immunizations. R28's Pneumococcal Vaccination Consent Declination indicated yes to receiving a pneumococcal vaccination and was dated 7/31/24. Consent Form offered residents and representatives the PPSV23, PCV13, PCV15, and PCV20 immunizations. R53's Pneumococcal Vaccination Consent Declination indicated yes to receiving a pneumococcal vaccination and was dated 11/9/23. Consent Form offered residents and representatives the PPSV23, PCV13, PCV15, and PCV20 immunizations. During an interview on 7/31/24 at 3:57 p.m., director of nursing (DON) stated she is the infection preventionist and the records for R21, R25, R28, and R53 failed to indicate the PCV20 vaccinations had been administered. The DON stated the declinations were just preformed for those residents that day. During an interview on 8/1/24 at 9:16 a.m., DON stated a recent audit had been done for all facility residents, and that it had not been done until 7/31/24. DON stated the vaccinations should have been reviewed earlier and offered. The DON stated it was an issue and was reviewing the facility policy. A facility policy titled Pneumococcal Vaccine, was provided. Policy indicated: Residents will be offered the pneumococcal vaccination and administered, according to CDC recommendations. Facility policy failed to indicate the administration of the PVC15 and PVC20.

Based on observation, interview, and record review facility failed to follow infection control protocol for 1 of 1 residents (R21) on contact precautions. Findings include: On 7/29/24 at 2:10 p.m., a sign was observed posted on R21's door that indicated the resident was on contact precautions. The sign had two stop signs, one in each of the upper corners of the sign, and bold upper-case wording Contact precautions everyone must. The sign included instructions to wash hands before entering and when leaving the room, put on gown and gloves before entering the room and remove before exiting the room. Gloves and gowns were in a hanging yellow container on the door next to the sign. A progress noted dated 7/29/24 included the resident was on contact precautions until further notice or update. On 7/31/24 at 8:00 a.m., housekeeper (H)-A was observed in R21's room adjusting a blanket on R21's bed. H-A was wearing only gloves, no gown. H-A swept the floor and exited the room, removing gloves upon exit. On 7/31/24 at 8:02 a.m., H-A stated R21 was only on precautions when she was having personal cares completed. H-A stated since she was only adjusting the blanket and cleaning, she did not have to wear a gown. H-A did confirm R21 had a sign on her door indicating the resident was on contact precautions and did confirm the sign included everyone should wear a gown and gloves. During interview on 7/31/24 at 8:11 a.m., unit manager registered nurse (RN)-A confirmed anyone who has direct contact with the resident or items in the resident's room, such as bedding, should wear a gown and gloves when a resident was on contact precautions. RN-A confirmed gown and gloves should be worn when adjusting a blanket or when providing housekeeping. RN-A confirmed R21 was currently on contact precautions for an unknown rash. During interview on 7/31/24 at 10:05 a.m., director of nursing (DON) stated she expected staff to follow contact precautions signage posted on the door. A gown and gloves were required for contact precautions. DON confirmed a gown and gloves should be worn when providing housekeeping services and when adjusting blankets on residents. Facility policy Isolation - Categories of Transmission-Based Precautions dated September 2022, included contact precautions were implemented for residents with known or suspected infections that could be transmitted with direct contact. Signage would be placed on the resident's door with instructions on the type of precautions. Staff and visitors were to wear a disposable gown when entering the room.

Based on record review and interview the facility failed to ensure the correct advanced directives were documented and stored in the resident's paper chart for 1 of 1 resident (R110) reviewed for advanced directives. Findings include: R110's face sheet dated 7/30/2024, indicated R110's advance directive wishes were Do Not Resuscitate (DNR). R110's current order summary report dated 8/2/24, indicated R110 was a DNR. On 7/29/24 at approximately 2:25 p.m., R110's paper chart included an Advanced Directive Consent (ADC), however it was for Full code, and had another residents name on the form, not R110's. On 7/29/24 at 2:30 p.m., registered nurse (RN)-A stated they would go to the paper chart to verify the residents code status. On 7/29/24 at 2:30 p.m., licensed practical nurse (LPN)-A stated they would go to the paper chart to verify the residents code status. LPN-A retrieved R110's paper chart and stated R110 was a full code. LPN was directed to verify the resident's name on the ADC and LPN-A stated the person was not the same. It was not R110's ADC. On 7/29/24 at 2:39 p.m., the unit manager RN-B stated they expected staff to look at the paper chart for code statuses and if for some reason the ADC was not there, they expected them to refer to point click care (PCC) the resident's electronic health record. RN-B retrieved R110's paper chart, and identified the form for another resident was present in R110's chart, not R110's. On 8/1/24 at 10:28 a.m., the director of nursing (DON) (O)-A stated if their staff needed to verify a code status of a resident they should go to the paper chart. O-A stated their policy was, upon admission to review the residents advance directive wishes, have the physician sign off on the order, put it in the paper chart and update orders and care plans accordingly. The Advance Directive Facility Policy last revised September of 2022, indicated if the resident or the residents representative has executed one or more advance directives, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.

Based on observation, interview, and record review, facility failed to accurately post facility staffing hours with the potential to affect all residents and visitors. Findings include: On 7/30/24 at 9:00 a.m., the staff posting was observed in a public area next to a main set of elevators. Review of daily staff posting and schedules showed a discrepancy between hours worked and hours scheduled. The staff posting did not include all hours scheduled and did not have a category for registered nursing (RN). On 7/30/24 at 12:48 p.m., director of nursing (DON) stated the daily staff posting was completed by herself or a health information specialist during the week and by another staff member over the weekend. The DON stated the schedule would be updated and reprinted if a call in or change occurred. The DON confirmed the daily staff posting did not reflect the staff schedule. The DON confirmed the daily staff posting listed all licensed nursing staff as licensed practical nurses (LPN) and did not differentiate between LPN and RN hours. The staff posting did not indicate an RN scheduled in the building at any time. The DON stated it would be important for the staff posting to accurately represent the staff in the building so residents and visitors would be aware of staffing. During interview on 7/31/24 at 2:20 p.m., the DON stated she had spoken with the software company that the staff posting was printed from and there had been an error in report. The daily staff posting had been incorrect since the software had been utilized. The facility started to use the software on March 22, 2024. Facility policy Posting Direct Care Daily Staffing Numbers dated August 2022, included the number of licenses nurses and number of unlicensed nursing personnel responsible for direct care will be posted within two hours of the beginning of each shift. This posting would include the type (RN, LPN, CAN) and category (licensed or non-licensed) of nursing staff working.

Based on interview and document review, the facility failed to notify the ordering physician of x-ray results, which revealed newly identified fractures, in a timely manner for 1 of 3 residents (R1) reviewed. Findings included: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1's had a diagnosis of severe vascular dementia with anxiety and mood disturbance. R1's Progress Notes revealed the following: -On 7/15/24 @ 12:17 p.m., R1 reported he fell overnight last night in his bathroom, however, was unable to describe the fall, if he was using an assistive device, and how he got up off the floor. R1 reported pain in his ribs on the left side but no skin alterations were noted at the time. Physician updated and staff requested an x-ray for the left side ribs. -On 7/15/24 at 6:01 p.m., R1 reported pain 7 out of 10 and pain got worse with movement. X-ray was obtained and staff were awaiting results. Physician ordered 25 milligrams (MG) Tramadol twice daily and as needed for pain. -On 7/15/24 at 9:43 p.m., X-ray results obtained by fax and were as follows: 1. Subacute mildly displaced fracture to left 9th and 10th ribs. In comparison with prior examination, fractures were not visible on prior study and may be new since prior study. Staff would update R1's daughter via phone and put the x-ray report in the physician's folder. Progress notes lacked evidence of staff notifying physician of x-ray results. On 7/25/24 at 10:55 a.m., licensed practical nurse (LPN)-A stated she was R1's floor nurse on the day R1's x-rays were obtained, and the results were received between 7:30 and 9:00 p.m. LPN-A stated the x-ray results revealed R1 had fractures of his 9th and 10th ribs. LPN-A stated she then notified R1's family by phone, and notified the physician by fax and called the on-call nurse. Further, LPN-A could not recall which nurse she notified. LPN-A stated staff were expected to notify the resident's physician, supervisor, and family right away when staff were aware of a significant injury. On 7/25/24 at 12:20 p.m., registered nurse (RN)-A stated she became aware of R1's x-ray results on the morning of 7/16/24, at approximately 9:00 a.m. when she went searching for the faxed results. RN-A discovered the x-ray results were received the night prior at approximately 9:30 p.m., and R1's floor nurse would have been LPN-A. RN-A stated LPN-A failed to notify R1's physician or the on-call nurse, which would have been the director of nursing (DON). RN-A stated R1's physician and DON were not aware of R1's fractures until RN-A notified them both on the morning of 7/16/24. RN-A stated staff were expected to notify the physician and the on-call nurse immediately when staff become aware of a serious injury. RN-A stated as part of the investigation, staff were educated on importance of following a resident's plan of care specifically regarding toileting and repositioning, but RN-A was not aware of education related to reporting serious injuries timely. On 7/25/24 at 1:18 p.m., DON stated she received a call from RN-A on 7/15/24, in the morning, and RN-A had reported R1 self-reported a fall and had been complaining of increased pain and the physician was notified and ordered x-rays. Further, DON confirmed LPN-A did not notify the physician or the on-call nurse, which would have been the DON, upon receiving R1's x-ray results. DON discovered LPN-A had put the x-ray results on the board for the physician which was for non-emergent things and LPN-A should have immediately called the physician with the x-ray results. In addition, DON stated she was not aware of the delay in notifying the physician or on-call nurse until 7/25/24, and was attempting to interview LPN-A regarding the reasoning as to why LPN-A didn't feel she needed to update the physician when she knew R1 had newly diagnosed fractures. DON stated staff were expected to report serious injury or injuries of unknown as soon as they were aware of an injury. Review of facility policy titled Acute Condition Changes revised 3/18, indicated direct care staff would be trained on recognizing subtle but significant changes in the resident and how to communicate those changes to the nurse. Phone call to the attending or on-call physicians should be made by an adequately prepared nurse who had collected and organized pertinent information, including the resident's current symptoms and status. The nursing staff would contact the physician based on the urgency of the situation. For emergencies, they would call or page the physician and request a prompt response (within approximately one-half hour or less).

Based on interview and document review the facility failed to notify the Office of the State Long-Term Ombudsman of transfers for 1 of 1 resident (R22) reviewed for hospitalization . This had the potential to affect any hospitalized resident. Findings include: Progress note dated 2/18/23 at 3:34 p.m., was titled emergency room transfer note and indicated R22 was sent to the hospital for labored breathing, delayed speech, and weakness. The note indicated the medical doctor (MD) and family were notified and the bed hold was signed. The note lacked documentation of Ombudsman notification. The Notice of Residents/Patient Transfer or Discharge attached to the bed hold policy signed and dated 2/18/23 by R22 lacked information indicating the Ombudsman was notified. Progress note dated 2/19/23 at 3:14 p.m., indicated the resident returned to the facility from St. Cloud Hospital. Progress note dated 2/21/23 at 6:00 p.m., titled emergency room transfer note indicated R22 was sent to the hospital on 2/21/23, for slurred speech and left sided weakness. The note indicated the MD and family were notified and the bed hold was signed but lacked documentation of Ombudsman notification. The Notice of Residents/Patient Transfer or Discharge attached to the bed hold policy signed and dated 2/24/23, by R22 lacked information indicating the Ombudsman was notified. Progress note dated 9/24/23 at 1:55 p.m., indicated R22 returned to the facility at 1:30 p.m. from St. Cloud hospital. On 5/23/23 at 4:34 p.m., the licensed social worker (LSW)-B stated the nurse or health unit coordinator (HUC) were responsible to fax the Ombudsman after every bed hold was signed. They were expected to date and time the bed hold form when it was faxed and put in a progress note. During an interview on 5/24/23 at 9:38 a.m., registered nurse (RN)-A stated when residents were transferred to the hospital, the Ombudsman was notified by fax. RN-A stated staff were to print a fax confirmation page and put it in the chart or document notification of the Ombudsman in the nursing note. During an interview on 5/24/23 at 1:06 p.m., the director of nursing (DON) stated social services were to send a fax to the Ombudsman when residents were transferred to the hospital. The DON stated if it was not documented then it was not done. During an interview on 5/24/23 at 1:24 p.m. social services (SS)-A stated the bed hold procedure included notification of Ombudsman by sending a faxed copy of the resident's transfer discharge form. Staff were to sign off on the bottom of the form when it was completed. Facility policy Discharge-Involuntary Discharge of Resident-Long Term Care/Swing Bed indicates; Before a facility transfers or discharges a resident, the facility will notify the resident and resident's representatives of the transfer or discharge and the reasons for the move in writing in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

Based on interview and document review, the facility failed to ensure allegations of potential abuse were investigated for 1 of 3 residents (R1) who reported an allegation of abuse. Findings include: R1's diagnoses list printed 12/28/22, included spastic diplegic cerebral palsy, unspecified cervical disk degeneration, generalized anxiety disorder, dependent personality disorder, chronic pain syndrome, and major depressive disorder recurrent. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. The MDS also indicated R1 had moderate to severe depression and needed extensive assistance with all activities of daily living (ADL). When interviewed on 12/27/22, at 3:01 p.m. R1 stated on night shift on 11/20/22, a nursing assistant (NA) entered her room, but R1 could not remember which NA it was. R1 stated she had given the NA. a metal emery board and asked her to put it in her drawer across the room. R1 stated the NA threw the emery board in a tomahawk motion and the board flew across the room and fell to floor. R1 stated she became upset at that time. R1 stated the NA then became very angry and stated you called me in for things that were not important. R1 stated that she told NA she needed a brief change because it was wet and had been wet for over two hours. The NA told her she could not do it because there were no other staff to assist her. She was the only aide worked that shift. R1 stated NA told me Your stuff isn't important. R1 stated NA told her You're not important and you are just a disrespectful son of a bitch. R1 stated she started to cry and felt my God Am I ever going to do anything right. R1 stated she felt like she just wanted to kill herself. R1 stated she did feel like what was said was mental abuse and she had reported the incident to licensed social worker (LSW)-A and registered nurse (RN)-A the morning of 12/21/22. A progress note dated 11/21/22, indicated R1 requested to meet with LSW-A and RN-A. R1 shared concerns related to staff and nutrition from over the weekend. Resident stated that she is at the point of suicide. Progress note lacked any details related to staff concern. When interviewed on 12/28/22, at 10:14 a.m. LSW-A stated she remembered meeting with R1 on 12/21/22, there was a discussion about staff concerns, but could not remember the details. After LSW-A was told what R1 reported, LSW-A stated that was what the conversation between LSW-A and R1 involved. LSW-A stated she had not talked with any other staff or residents related to possible abuse. LSW-A stated all she did was report it to LSW-B, her supervisor. When interviewed on 12/28/22, at 11:03 a.m. the director of nursing (DON) stated the IDT, which consisted of LSW-A, social services director, RN-A, and me, met at noon and discussed what R1 reported to LSW-A and RN-A. The DON stated they called the NA in question and asked her side of the story. The DON stated they had not spoken with any other staff or residents. When interviewed on 12/28/22, at 12:27 p.m. the administrator stated his expectation was that complaints that involved mental anguish would be investigated by talking to the vulnerable adult, the accused staff member, other staff members and other residents so the complaint can be investigated thoroughly. A facility policy Vulnerable Adults-Abuse Prevention Policy-Long Term Care last reviewed 8/22, indicated all alleged violations involving abuse would be investigated started when the alleged perpetrator was relieved from duties and placed on administrative leave until completed. Then the resident, staff involved, and witnesses would be interviewed. The policy lacks talking with other residents about concerns with the accused staff member.

Based on interview and document review, the facility failed to identify a situation as an alleged violation involving abuse and failed to immediately report this allegation to the State Agency (SA) for 1 of 3 residents (R1) who were evaluated for abuse. Findings include: R1's diagnoses list printed 12/28/22, included spastic diplegic cerebral palsy, unspecified cervical disk degeneration, generalized anxiety disorder, dependent personality disorder, chronic pain syndrome, and major depressive disorder recurrent. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. The MDS also indicated R1 had moderate to severe depression and needed extensive assistance with all activities of daily living (ADL). When interviewed on 12/27/22, at 3:01 p.m. R1 stated on the night shift on 11/20/22, a nursing (NA) assistant entered her room, but R1 could not remember which NA it was. R1 stated she had given the NA. a metal emery board and asked her to put it in her drawer across the room. R1 stated the NA threw the emery board in a tomahawk motion and the board flew across the room and fell to floor. R1 stated she became upset at that time. R1 stated the NA then became very angry and stated, you called me in for things that were not important. R1 stated that she told NA she needed a brief change because it was wet and had been wet for over two hours. The NA told her she could not do it because there were no other staff to assist her. She was the only aide worked that shift. R1 stated NA, told me 'Your stuff isn't important. R1 stated NA told her, You're not important and you are just a disrespectful son of a bitch. R1 stated she started to cry and felt, my God Am I ever going to do anything right. R1 stated she felt like she just wanted to kill herself. R1 stated she did feel like what was said was mental abuse and she had reported the incident to licensed social worker (LSW)-A and registered nurse (RN)-A the morning of 12/21/22. R1's progress note dated 11/21/22, indicated R1 requested to meet with LSW-A and RN-A. R1 shared concerns related to staff and nutrition from over the weekend. Resident stated that she is, at the point of suicide. R1's progress note lacked any details related to staff concern. When interviewed on 12/28/22, at 10:14 a.m. LSW-A stated she remembered meeting with R1 on 12/21/22, there was a discussion about staff concerns, but could not remember the details. After LSW-A was told what R1 reported, LSW-A stated that was what the conversation between LSW-A and R1 involved. LSW-A stated the facility did not report the incident to the SA as possible mental abuse. LSW-A acknowledged R1 had mental anguish but that the mental anguish did not fall to the level of needing to be reported. When interviewed on 12/28/22, at 10:40 a.m. RN-A stated she recalled the meeting she was in with R1 and LSW-A/ RN-A stated R1 reported R1 told them NA told R1 her needs did not matter, were not important and that R1 was a son of a bitch. RN-A acknowledged there was mental anguish, but after meeting with the interdisciplinary team, decided it did not meet the level of needing to be reported. When interviewed on 12/28/22, at 11:03 a.m. the director of nursing (DON) stated that if abuse rose to the level of mental anguish, it should be reported to the SA as possible abuse. The DON stated the IDT, which consisted of LSW-A, social services director, RN-A, and the DON, met at noon and discussed what R1 reported to LSW-A and RN-A. The DON acknowledge R1 had mental anguish, but stated the IDT felt it did not need to be reported. When interviewed on 12/28/22, at 12:27 p.m. the administrator stated his expectation was that complaints that involved mental anguish be reported as possible abuse. A facility policy Vulnerable Adults-Abuse Prevention Policy-Long Term Care last reviewed 8/22, indicated all alleged violations involving abuse would be reported to the SA immediately, but not later than two hours after the allegation was made if the allegation involved abuse. The policy also indicated emotional or psychological abuse was defined as verbal or nonverbal infliction of anguish, pain or distress that resulted in mental or emotional suffering.

Based on interview and document review, the facility failed to revise their pneumococcal vaccine policy to current pneumococcal vaccination guidelines. This failure increased the risk for residents not vaccinated to contract pneumonia. Findings include: Review of a policy titled Pneumococcal Immunization, Long Term Care, dated 06/22, indicated .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 the resident representative declines the vaccine.Definitions.Prevnar - PCV13 - Pneumococcal Conjugate 13 Valent.[MEDICATION(S)] - PPV23 - Pneumococcal Polysaccharide 23.Each resident's eligibility or contraindications to receive the pneumococcal vaccine will be determined by utilizing the attached algorithm. However, the policy lacked the updated CDC guidance: Pneumococcal Vaccination: Summary of Who and When to Vaccinate, effective 01/28/22, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV [Pneumococcal Conjugate Vaccine] 15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV [Pneumococcal Polysaccharide Vaccine] 23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or [CONDITION(S)] . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended . For adults who have received PCV13 but have not completed their F883 recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . During an interview on 06/16/22 at 11:05 AM, the Director of Nursing (DON) stated she was aware of the new CDC guidelines for pneumococcal vaccines and the facility should have identified the new guidance and updated the policies when they were reviewed this year.

Based on observation, interview and document review, the facility failed to comprehensively reassess and develop interventions to prevent reoccurring falls for 3 of 4 residents (R5, R2, R3) reviewed who resided in the Gardens Gate Unit. This resulted in harm for R5 when she sustained a right lower extremity fracture after an unwitnessed fall on 10/21/21, and was admitted to hospital for surgical intervention. Findings Include: R5's admission Minimal Data Set (MDS) dated [DATE], indicated R5 had diagnoses which included stroke, [CONDITION(S)] and no cognitive impairment. Further review of MDS, indicated R5 required limited assistance of one staff member for all activities of daily living (ADLS). R5's care plan dated 7/19/21, indicated R5 was at risk for injury related to impaired mobility, narcotic medication, history of falls, impulsive, does not consistently ask for assistance or use call light, poor safety awareness, self-transfers, self-toilets, self ambulates, and right-side [CONDITION(S)]. Interventions for R5's falls included: auto-lock brakes on wheelchair, call staff for items out of reach, Dycem on wheelchair seat, encourage resident to wear appropriate footwear, monthly pharmacy review, observe for adverse side effects, obtain lab work as indicated, referrals to physical, occupation and speech therapy as indicated, reposition per tissue tolerance, and risk and consequences of not reporting falls discussed on 7/19/21. R5's Fall Risk Evaluation dated 8/27/21, indicated a pattern of falls was the reason for the evaluation and interventions listed as above in care plan in addition to pain management involvement, pressure reduction cushion in wheelchair, scoop mattress on bed, risk and consequences for self-transferring, self- toileting and refusing assistive devices with ambulation in room, refusal of pull ups, and refusal of gripper socks. R5 has had 10 recent falls which resulted in minor injuries and a fracture. The following falls were reviewed and lacked evidence of a post fall root cause analysis and implementation of appropriate interventions to reduce likelihood of future falls. -8/12/21: R5 had an unwitnessed fall from wheelchair while reaching for an item on the floor and no injuries were noted at time of fall. The interdisciplinary team (IDT) reviewed fall on 8/19/21, and no patterns were noted, and no new interventions added following the fall. -8/26/21: R5 had an unwitnessed fall from toilet stating she fell asleep and slipped off. There were no injuries noted. The IDT reviewed the fall on 8/26/21, determined self-transferring to be the pattern for R5's falls and no new interventions were added following the fall. -8/30/21: R5 had an unwitnessed fall outside when she slid out of the wheelchair and sustained an abrasion on her right knee which was cleaned, and a band aide was applied. The IDT reviewed fall on 8/30/21, determined self-transferring to be the pattern for R5's falls and no new interventions were added following the fall. -9/3/21: R5 had an unwitnessed fall while attempting to transfer from wheelchair to her bed. There were no injuries noted at the time of R5's fall. The IDT reviewed the fall on 9/3/21, determined self-transferring to be the pattern and no new interventions were added following the fall. -9/4/21: R5 had an unwitnessed fall in resident's bathroom on 9/4/21, at 7:45 a.m. when she slipped from the wheelchair. R5's wheelchair cushion was removed from wheelchair as it extends beyond wheelchair seat giving resident false sense of security as to where actual seat of wheelchair ends. R5's medical record lacked evidence a post fall assessment was completed following R5's fall on 9/4/21. -9/13/21: R5 had an unwitnessed fall from bed attempting to transfer to the toilet and no injuries were noted. The IDT reviewed the fall on 9/13/21, determined self-transferring to be the pattern and no new interventions were added following the fall. -10/15/21: R5 had an unwitnessed fall in room while attempting to pull pants up and no injuries were noted. Post Fall lacked evidence IDT reviewed fall and no new interventions were added following the fall. -10/17/21: R5 had an unwitnessed fall from bed while attempting to transfer into wheelchair to use the bathroom and R5 reported she hit the back of her head. Post Fall lacked evidence the IDT reviewed the fall, and no new interventions were added following the fall. -10/19/21: R5 had an unwitnessed fall near the bed in her room and no injuries were noted at the time of the fall. Post Fall lacked evidence IDT reviewed the fall and no new interventions were added following the fall. -10/21/21: R5 had an unwitnessed fall in room while attempting to pull up pants and reported discomfort and pain to right knee. R5 was reminded to call for assistance with these tasks and an ice pack was applied to knee and an [MEDICATION(S)] was given related to knee pain. R5's progress note dated 10/21/21, at 11:55 a.m. an order from doctor for an x-ray of right knee for increased pain after fall and direct trauma to right knee. On 10/21/21, at 9:24 p.m. doctor was updated on x-ray results showing R5 had a comminuted distal femoral fracture displaced medially. Further review of R5's progress notes dated 10/22/21, R5 was sent to the orthopedics for evaluation of surgical intervention for right lower extremity fracture. R5 was scheduled to return to the facility on [DATE]. On 11/2/21, at 10:36 a.m. nursing assistant (NA)-A indicated R5 was unstable and super high fall risk and she does not use her call light and will self-transfer all the time. NA-A indicated R5's fall interventions included Dycem to wheelchair, pendant call light, not leaving her on the toilet or during cares, and room changes. On 11/2/21, at 1:47 p.m. NA-B indicated R5 was at risk for falls, however, likes to be independent and will not utilize call light for staff assistance. NA-B indicated interventions included assist with transferring and toileting, room changes, utilizing a reacher and education to use call light. On 11/2/21, at 10:56 a.m. dirctor of nursing (DON) indicated the facility knew R5 was a high fall risk on admission and immediately discussed the risk and consequences of self-transferring on admission with resident. Further, DON indicated R5 was unstable and was known to not consistently call for assistance from staff. DON confirmed R5's record lacked evidence of interventions implemented following R5's 10 most recent falls. R2's significant change MDS dated [DATE], indicated R2 had diagnosis which included [CONDITION(S)] and moderately impaired cognition. Further review of MDS, indicated R2 required total assistance of two staff members for bed mobility, transfers, ambulating in room, toileting, and hygiene. R2's admission Fall Risk Evaluation dated 8/26/21, identified R2 at risk for falls. R2's care plan dated 8/26/21, indicated R2 was at risk for injury related to impaired mobility, history of falls, has limited range of motion to bilateral hands, impulsive, does not consistently ask for help or use call light, poor safety awareness, self-transfers, and self-toilets. Interventions for R2's falls included encourage appropriate footwear, monthly medication regime pharmacy review, observe resident for adverse effects of medications in drug regime; obtain lab work as indicated, referrals to physical, occupational and speech therapy, reposition per tissue tolerance, toileting per elimination plan of care, and risk and consequences of self-transfers discussed on 8/26/21 which include falls, minor injuries, fractures, head injuries, up to and including death. Since admission, R2 has had 4 falls which have resulted in minor injuries. The following falls were reviewed and lacked evidence of a post fall root cause analysis and implementation of appropriate interventions to reduce likelihood of future falls. Review of R2's Post Fall Follow- Up included: -9/9/21: R2 had an unwitnessed fall from bed when she slipped while trying to get up. R2 was not wearing socks and was not using her assistive device. R2 reported she hit her left shoulder and landed on buttocks. Resident also stated she hit her pinkie and ring finger on right hand. Ice pack was given. Further review of Post Fall indicated the IDT met on 9/14/21, determined cognitive loss and [CONDITION(S)] diagnoses were the patterns noted to falls and no new interventions were added following the fall. - 9/18/21: R2 had an unwitnessed fall from her bed while self-transferring. R2 was noted to have a small bump on the left side of her head with a small amount of blood and abrasions were noted to bilateral knees. Further review of Post Fall indicated the IDT met on 9/20/21, determined self-transferring as the pattern noted to R2's falls and no new interventions were added following the fall. - 9/23/21: R2 had an unwitnessed fall from bed when R2 lost her balance while self-transferring. No injuries were noted and R2 was reminded to use call light for assistance. Further review of Post Fall indicated the IDT met on 9/24/21, determined self-transferring as the pattern noted to R2's falls and no new interventions were added following the fall. - 10/9/21: R2 had an unwitnessed fall from bed while self-transferring. R2 reported hitting head slightly. Further review of Post Fall indicated the IDT met on 10/15/21, determined self-transferring as the pattern noted to R2's falls and intervention was try to re-educate R2 on need for staff to assist her with transfers. On 10/29/21, at 12:57 p.m. R2 was observed sitting in her transport wheelchair in the dining room and had a pair of shoes on her feet. Further, at 1:23 p.m. R2 was observed in her room lying in bed on her back, bed was at knee height, wearing TED socks, and a soft touch call light on the right side of her bed. On 11/2/21, at 1:54 p.m. R2 was observed in her room lying on her back in bed, bed was low to the floor and resident had gripper socks on feet. On 10/29/21, at 1:23 p.m. R2 indicated she has had several falls related to trying to pick something up off the floor and losing balance and further stated I am petrified of what can happen to me if I fall face first and land on my face. On 10/29/21, at 2:04 p.m. registered nurse (RN)-A indicated R2 is at risk for falls and will self-transfer. RN-A was not aware if R2 required the use of gripper socks while in bed, however stated during transfers staff were to ensure R2 had transferable shoes on. On 10/29/21, at 2:32 p.m. (NA)-A indicated R2 was impulsive and has fallen related to self-transferring. NA-A indicated R2 had impaired cognition at times. When asked about fall interventions, NA-A checked R2's Kardex and confirmed there were no interventions for falls. In addition, NA-A indicated R2 should have gripper socks on in bed and shoes on when up in wheelchair. On 10/29/21, at 3:01 p.m. registered nurse (RN)-B indicated R2 was noted to self-transfer and her cognition may vary. Further, RN-B indicated R2 was a fall risk and interventions included wearing shoes when she is out of bed, observing for side effects, toileting as requests, moved rooms and that is all I see for her. On 11/1/21, at 9:53 a.m. Director of Nursing (DON) indicated R2 had impaired cognition and she is mobile and gets up and moves around a lot. DON confirmed following the 4 falls there were no interventions documented. On 11/2/21, at 1:47 p.m. NA-B indicated R2 was at risk for falls and interventions included using a transfer belt while transferring, assist of two staff for transferring, always lower the bed to the floor and wear gripper socks due to R3 self-transferring. R3's quarterly MDS dated [DATE], indicated R3 had diagnosis which included dementia and severely impaired cognition. Further review of MDS, indicated R3 required supervision with set up only for most ADLs and limited assist of one staff member for dressing and hygiene. R3's Fall Risk Evaluation dated 12/1/20, identified R3 for being at risk for falls. R3's care plan dated 11/18/19, indicated R3 was at risk for injury related to impaired mobility, impaired cognition, diabetic with fluctuating blood sugars, history of falls, impulsive, does not consistently ask for assistance or use call light, and poor safety awareness. Interventions for R3's falls included: encourage resident to wear appropriate footwear, monthly medication pharmacy review, observe resident for adverse effects of medication, obtain lab work as indicated, referral to physical, occupational and speech therapies as indicated, reposition per tissue tolerance, toileting per elimination plan of care, risk and consequences of self-transfers discussed on 11/18/19, and offer assistance with transfers and ambulation on overnight 7/20/20. R3 has had two recent falls which resulted in minor injuries. The following falls were reviewed and lacked evidence of a post fall root cause analysis and implementation of appropriate interventions to reduce likelihood of future falls. Review of R3's Post Fall Follow- Up included: - 10/23/21: R3 had an unwitnessed fall in his room from the recliner. On 10/29/21, the post fall follow up was not completed and there was no root cause analysis or new interventions added following the fall. -10/24/21: On 10/29/21, R3's electronic medical record lacked evidence a post fall follow up was completed for R3's fall that occurred on 10/24/21. R3's progress notes were reviewed: -10/24/21: Fall occurred on 10/23/21, at 6:15 p.m. when R3 fell by his recliner while he attempted to ambulate to the restroom. R3 was noted to sustain a skin tear on left elbow and [MEDICATION(S)] was applied. Progress note lacked evidence an intervention was added following R3's fall. -10/24/21: Fall occurred on 10/24/21, at 7:15 p.m. when R3 fell near his recliner and R3 indicated he stood to boost himself back in his recliner and slid out. Further, R3 reports discomfort in ribs on right side. Progress note lack evidence an intervention was added following R3's fall. On 10/29/21, at 1:40 p.m. R3 was observed sitting in his room in his recliner. R3 had on shoes and walker was next to recliner. On 10/29/21, at 1:23 p.m. RN-A indicated R3 generally has a level of confusion. RN-A indicated she was aware of a recent fall however was not aware of any interventions implemented other than making sure he is being checked on and needs are being met. On 10/29/21, at 1:40 p.m. R3 stated that he has not had any falls at the facility. On 10/29/21, at 2:32 p.m. NA-A indicated R3 was not a fall risk, however was aware of a recent fall and confirmed there were no interventions in place on R3's Kardex other than offering assistance as needed for transfers. On 10/29/21, at 3:01 p.m. RN-B indicated R3 was at risk for falls and interventions included in R3's care plan was encouraging to wear appropriate shoe, offering assistance with transfers overnight shift, monitoring medications, therapy referrals and mostly assisting him when he asks for assistance. RN-B confirmed R3's record lacked evidence of interventions added following two recent falls. Following R3's fall on 10/23/21 the post fall is not completed and further stated there are a couple of residents that have not been completed and there was not a post fall completed following R3's fall on 10/24/21. In addition, RN-B stated looks like both had to do with the recliner. So, it looks like we need to take a look at his recliner. There were no interventions added for either of those. On 11/1/21, at 9:53 a.m. DON indicated R3 had cognitive impairments and is a fall risk. DON confirmed that R3's record lacked evidence of implementation of interventions following his two recent falls. Further, DON indicated the reports lack documentation on what caused R3 to fall. On 11/1/21, at 9:53 a.m. DON indicated staff were expected to follow the fall policy and determine a root cause to implement an appropriate intervention. Further, DON stated there had been leadership changes for the Garden Gate unit that may be a contributing factor to the lack of documentation on the post fall assessments. In addition, DON stated it is not clearly and concisely documented. I am disappointed and seeing an opportunity to improve. On 11/2/21, at 3:35 p.m. Administrator indicated the facility's fall policy was to implement an intervention following a fall as soon after the fall as possible and the IDT will meet weekly regarding all falls on the unit. Review of facility policy titled Falls- Long Term Care revised 8/21, indicated Based on evaluations and current data, the interdisciplinary team will collaborate to identify and implement appropriate interventions related to the resident's specific risk factors and factors contributing to resident's fall history in attempt to prevent the resident from falling, reduce the occurrence of falls and/or minimize complications from falling. Further review of facility policy indicated the staff will monitor and document the resident's response to interventions intended to reduce falling or the risks of falling and if the interventions have been successful in preventing falls the staff will continue the interventions, however if the falls occur despite initial interventions, staff will implement additional or different interventions as applicable or may indicate why the current approach remains relevant.

Based on interview and document review, the facility failed to initiate timely cardio-pulmonary resuscitation (CPR) in accordance with resident wishes and physician orders [REDACTED]. This deficient practice resulted in an immediate jeopardy (IJ) when R1 was found with absent pulse and respirations, timely CPR was not initiated, and R1 died . The IJ began on [DATE], when R1 was found with an absent pulse and respirations, timely CPR was not initiated, and R1 died . The administrator and director of nursing (DON) were made aware of the incident on [DATE], and immediately initiated corrective actions. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 1:00 p.m. The facility implemented corrective action on [DATE], prior to the onsite investigation, and the deficiency is being issued at past non-compliance. Findings include: R1's Admission Record printed [DATE], indicated R1's [DIAGNOSES REDACTED]. R1's admission Care Area Assessment (CAA) dated [DATE], indicated R1 had moderately impaired cognition. R1's Advance Directive Consent Form dated [DATE], directed staff to perform CPR if R1 went into [MEDICAL CONDITION] or respiratory arrest. The document was signed by R1. The Facility Investigation of alleged neglect dated [DATE], indicated registered nurse (RN)-B found R1 with no pulse, no breathing, and eyes open with no response. RN-B notified licensed practical nurse (LPN)-A and RN-A of R1's passing. RN-A asked if RN-B had checked R1's code status. RN-B revealed she had not checked R1's code status. R1's code status was confirmed as full code. CPR was then initiated. The medical director was notified and an order to discontinue efforts and call the time of death was received. Although CPR was initiated, there was a delay of approximately eight minutes. The facility interviewed staff regarding the incident. RN-B was interviewed and placed on suspension for the investigation. The facility initiated education for all staff regarding the Code Blue Response. During interview on [DATE], at 1:38 p.m RN-A was interviewed regarding R1's passing and stated at approximately 9:30 a.m. on [DATE], RN-B came to RN-A and stated R1 had passed away. RN-A asked what R1's code status was and RN-B did not know what R1's code status was. RN-A and RN-B went to the area where the paper charts were and found R1 was a full code (will allow all interventions needed to get their heart started). The physician was on speaker phone with LPN-A doing a telehealth rounding session and the physician directed to do ten compressions for R1 and check for a pulse, and if no response do not continue. RN-A stated about 9:45 a.m. they went to R1's room and performed ten compressions, R1 had no pulse, and efforts were halted. RN-A stated there was no code blue (an emergency situation announced in an institution in which a patient is in cardiopulmonary arrest, requiring a team of providers to rush to the specific location and begin immediate resuscitative efforts) called for R1. RN-A stated RN-B was taken off the floor, talked to by the director of nursing (DON), and has not been back to the unit. RN-A stated the facility started asking staff what they would do if they found an unresponsive person on [DATE]. RN-A stated staff from the day shift received education and as the evening shift came in to work they received education on what to do when you would find an unresponsive person in the facility. RN-A stated you check the resident's code status in the paper chart or have someone look for you. RN-A stated staff had to sign a sheet that indicated they had read the policy and what the expectation of the facility was for an unresponsive person. During interview on [DATE], at 3:20 p.m. nursing assistant (NA)-A was interviewed regarding the passing of R1. NA-A stated that morning R1 was up for breakfast at 8:00 a.m. in the dining room. R1 ate breakfast and did not mention any discomfort. NA-A stated R1 was assisted to bed after breakfast, about 9:00 a.m. NA-A further stated later in the morning, unsure of the time, RN-B called over the walkie talkie that help was needed in R1's room. NA-A stated R1 was laying on right side with a pillow behind the back. NA-A stated RN-B thought R1 had passed away. RN-B went to get the vital machine and there was no blood pressure, no oximetry (measure the oxygen level of the blood). NA-A stated R1 was grayish in color. NA-A stated NA-A went to get RN-A and RN-A was on a telephone conference. RN-B went to get someone else. NA-A never went back into R1's room until R1 was prepared for viewing by the family. On [DATE], at 3:59 p.m. the DON was interviewed and stated RN-A had come to see her after she had a missed call from RN-A. The DON went on to state that RN-A told her there was a problem, that R1 had coded, was a full code and CPR was not immediately initiated. The DON stated the administrator was also informed of the incident at this time. The DON stated they started the investigation immediately, obtained written statements from those involved, and that following interview and obtaining a written statement, RN-B was suspended. The DON stated they had initiated whole house education on how to response to an unresponsive resident, what they would do when a resident is found unresponsive, and what the expectation is. The DON stated staff working during the day shift on [DATE], were asked to read and sign they understood the facility process for a resident that is found unresponsive that included the following, to call for assistance and have someone check the code status for the resident and if a full code, staff would call a code blue and proceed with CPR. If the resident was DNR (do not resuscitate) then staff were to follow the process of expiration. The DON stated a code blue is called to get more staff to the location quickly and for assistance. The DON stated the evening shift on [DATE], was educated on this same process as they came in to work and the rest of the staff continued to be educated when they came for their shift. The DON stated this education was completed by the nurse managers on the unit when the staff entered the facility. The DON stated, on the day of the incident, a code blue was not called for R1 and CPR should have been initiated. On [DATE], at 4:10 p.m. LPN-A was interviewed and stated on the day of the incident of [DATE], she was talking with the physician when RN-B came into the area and stated R1 was cool to the touch and had passed away. RN-B left the area to find RN-A. Then RN-A and RN-B came to the area and checked on R1's code status. R1's code status was listed as full code. LPN-A stated the physician told them to try CPR. LPN-A was not sure of the exact time. When asked about what she would do if a resident was found unresponsive, LPN-A stated it does not matter if the resident is cold you do CPR until called (time of death) by the physician. LPN-A stated our policy indicates if unresponsive, check the paper chart for code status, if full code, call code blue and start CPR. LPN-A stated others could call 911 while CPR compressions are started until emergency management system (EMS) would come and take over the compressions. During a telephone interview on [DATE], at 10:18 a.m. RN-B stated on [DATE], the day of the incident, RN-B entered R1's room at 9:35 a.m. to administer medication. R1 was in bed. RN-B stated R1 did not respond to the greeting from RN-B, that R1's eyes were open, no blinking, and R1's color was gray. RN-B stated the covers were lowered and RN-B placed a hand on R1's chest to see if R1 was breathing and checked R1's right wrist for a pulse. R1's finger tips were a blue, purple color, and that R1's hands and arms were cool to the touch. RN-B stated she called over the walkie talkie for a NA to assist. RN-B went to get the vital machine and did a blood pressure (BP) on the right upper arm and there was no reading obtained. RN-B stated at 9:38 a.m. she went to RN-A's office and they were in a meeting and then talked to LPN-A about what the process was for residents that passed away. At 9:40 a.m. RN-A came out of the office and RN-B stated R1 had passed away. RN-A had asked what R1's code status was. RN-B stated that R1's code status was not checked and they both proceeded to the paper chart where R1 was determined to be a full code. The physician was on the phone and could hear the conversation and told them to do ten chest compressions and check for a pulse and if there was no pulse, to call it. RN-B stated this direction was followed and the time RN-B was 9:42 a.m. RN-B stated following R1's death, she had not done any charting of the incident. RN-B had not called a code blue for R1. RN-B stated, I did not check (R1's) code status and I do not know why I did not check code status. RN-B stated RN-B had CPR certification and was current. RN-B stated she assumed R1 was a DNR/DNI (do not resuscitate/intubate). RN-B stated she was sent home while the investigation was pending. On [DATE], at 11:33 a.m. family member (FM)-A was interviewed and stated R1 was treated well and had no concerns that were shared about the facility. FM-A stated the facility called and stated R1 was found by the nurse and had passed away. FM-A stated the facility did not help R1 and that is why he passed away. The facility implemented corrective action to prevent recurrence by [DATE]. On [DATE], the facility started to educate all licensed nursing staff and unlicensed staff on the Code Blue Response for finding a resident unresponsive. Staff are to immediately check the resident's code status in the paper chart. If DNR, (do not resuscitate) no further action is required. If full code, immediately initiate CPR. 95% of staff were trained prior to survey on [DATE], with a plan in place to retrain the remaining staff prior to working. In addition, staff were interviewed and were able to correctly verbalize understanding of the established CPR policy and procedure. The facility policy Code Blue Response, undated, indicated if a resident is witnessed to become unresponsive or is found unresponsive and is without a pulse or respiration, you must immediately call for assistance and check the paper chart to confirm the resident's code status preference. If the resident code status is indicated Do Not Resuscitate (DNR) no further intervention is required. If the resident has indicated a wish for Resuscitate/full code immediately initiate CPR.

Based on observation, interview and document review, the facility failed to ensure residents were free from sexual abuse for 1 of 4 residents (R1) reviewed. Nursing assistant (NA)-C sexually abused R1 during a two week period. Facility staff failed to immediately report, and the facility failed to provide immediate protections, when they became aware of the abuse, resulting in an immediate jeopardy (IJ) situation. The IJ began on 2/28/19, when staff had knowledge NA-C had sexually abused R1 and failed to immediately report the abuse. The administrator and director of nursing (DON) were notified of the IJ on 3/6/19, at 12:55 p.m. The IJ was removed on 3/6/19 at 5:23 p.m., but noncompliance remained at the lower scope and severity level of G, isolated, actual harm, since R1 suffered psychological harm as a result of the sexual abuse. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 as cognitively intact. R1 had no delusions or hallucinations. R1 had no physical or verbal behavioral symptoms. R1 required extensive staff assistance with bed mobility, transfers, dressing, and toilet use. The MDS identified [DIAGNOSES REDACTED]. R1's anti-anxiety medication evaluation form dated 12/21/18, indicated [REDACTED]. R1's MD (medical doctor) note dated 1/7/19, indicated R1 had been recently seen by her usual psychiatrist, had underlying depression with anxiety which was exacerbated by her need for long term care placement, and inability to return home. Further the note indicated R1 was stable on medication but continued to require psychotherapy as well. The note further indicated a combination of medications were required to maintain control of her depression and anxiety, and to maintain her quality of life. R1's care plan, revised 3/4/19 included the following: -initiated 2/23/19 [DIAGNOSES REDACTED]. History of crying/tearfulness related to not being able to return home and family dynamics. Can become fixated/obsessed and ruminate regarding certain subject matters or people. Has displayed paranoid behavior (i.e. calling family an excessive number of times if unable to reach them and accusing spouse of having an affair.) -initiated 3/3/19: 2 people present at all times to help with toileting, dressing, bathing, peri care and catheter cares. Revised on 3/4/19 to 2 female care givers. Excerpts from R1's Progress Notes between 2/6/19 and 2/27/19, identified R1 had a fixation and was ruminating about a male nursing assistant: -2/6/19: R1 asking staff about a certain nursing assistant (unidentified) 5 times. I think he blocked me on Facebook. Why wouldn't he respond to my friend request. Where has he been at? R1 told staff aren't allowed to add patients on social media. R1 was not very receptive to this. -2/13/19: R1 has been obsessing over night aide for some time now. R1 stated there is someone here that is trying to keep him away from me. Someone is making it hard for me here. I just know it. -2/16/19: R1 requested help using white pages. R1 attempting to find aides number that she has been fixating on. Staff communicated this behavior was inappropriate and would not help with it. -2/20/19: Licensed practical nurse (LPN)-B met with R1 to go over patient care giver boundaries regarding a nursing assistant (unidentified) she has been displaying obsessive tendencies towards. R1 informed inappropriate to try and add caregivers on social media, attempt to look up their phone number, ask other staff to look up their phone number. R1 was not receptive to this re-education. R1 stated who is trying to keep him from me? Someone is out to get me. What do they think I am trying to molest him? -2/22/19: R1 asked if NA-C was working, but just could not come to her room. I said I wasn't going to answer her about that. R1 stated someone is going to get into trouble over this and that she will make sure of it. Asked house nurse to speak with R1. After House nurse spoke to R1, R1 continued to press her call light. R1 stated she was going to call a lawyer. R1 stated .no one can keep (NA-C) away from her, she will make sure of this. R1 stated .no one can keep them apart, then corrected herself, saying-keep him from talking to me. -2/22/19: R1 asked why nurse is only allowing the female nursing assistant to answer her call light. R1 asked to speak with house charge nurse. House charge nurse told R1 the other nursing assistant (unidentified) will not be coming into her room anymore, and additional questions can be answered by management on the day shift. -2/23/19: Social worker (SW)-B, NA-C and R1 met together as a follow-up to previous discussion regarding professional boundaries and caregiver roles. R1 was reassured that any nursing staff member can assist her with care needs. R1 acknowledged that she has her favorites. R1 smiling, laughing and in good spirits later that day. -2/27/19: 4:54 a.m. Call light answered by registered nurse (RN)-F. R1 asked Where is he? referring to male staff working this unit tonight. Informed aide was busy and would see her at breakfast. R1 began crying stating SW-B was in her with him and he made sound like it was all my fault. Asked what was her fault. R1 would not answer. Asked if there was anything she could do for R1. R1 stated you won't help me. R1 stated I'm sorry for whatever I did to him I just want him to explain everything. RN-F told R1 she was unaware of what was going on and was there to help her if R1 needed help. R1 began to cry. When asked if having pain R1 stated yeah in my heart. why did he do that to me. I just want him to come in and explain everything to me. RN-F informed R1 the staff was somewhere else helping other people and she could help her. R1 did not answer. RN-F left the room. RN-F answered the call light a few minutes later. R1 still crying. R1 asked RN-F to walkie the other staff (unidentified). RN-F stated the other staff was in another room helping another patient. RN-F left the room. A few minutes later RN-F responded again to the call light. R1 continued to cry. I just want to know why he wants to hurt me. When asked how male staff was hurting R1, R1 stated he said that he would come in here tonight and explain everything to me. RN-F told R1 that this needs to be addressed with (SW-B) as RN-F was not aware of what was going on. R1 continued to cry I just want him not to hurt me. RN-F again asked how he was hurting her. R1 stated I need him to come talk with me. -2/27/19 at 5:37 a.m. Administered Lorazapam (anti-anxiety medication) 0.5 mg. Given due to anxiety and worrying about male staff member not visiting her. -2/27/19 at 5:47 a.m. registered nurse (RN)-G went into room to talk to R1. Continues to make statements such as why does he have to hurt me? Why does he always lie? and everyone here is a liar. Offered and accepted Lorazapam. RN-G told R1 that he isn't trying to hurt you and that she can talk to him at breakfast. R1 responded with He won't tell me why he wants to hurt me if others are listening. An email from NA-C to social worker (SW)-B dated 2/27/19 at 10:17 a.m., was provided and indicated: last night We had more trouble with (R1) . R1 was using her call light several times. The note indicated when other staff answered the call light R1 was asking for NA-C to come in, saying we don't help her and asking for an explanation. The email also indicated NA-C had at that time asked to be moved to another unit. NA-C's [MEDICATION NAME] sheet report 2/4/19-3/1/19 identifies NA-C worked 2/26/19 from 11:08 p.m. to 2/27/19 at 7:45 a.m. Although progress notes from 2/6/19 to 2/27/19, indicated the facility was aware R1 had a fixation on NA-C and was perseverating about NA-C, the facility failed to conduct a thorough investigation into the concerns, and did not remove or reassign NA-C to a different work area until NA-C requested to be transferred to another unit on 2/27/19. During an interview on 3/7/19, at 9:46 a.m. NA-B stated R1 was super obsessed with (NA-C) every day for about 2 weeks. NA-B stated one day when R1 was talking about NA-C she thought it would be appropriate to question R1, Did (NA-C) do anything. NA-B said R1 had initially paused and stated, I shouldn't say. NA-B further stated R1 was acting different, but stated she just kept talking with R1. NA-B said R1 finally told her NA-C had told R1 he'd gotten a hard on in the shower thinking about her, and had commented something about a bra or making a bra. NA-B stated she'd taken R1 to the beauty shop following her shower and had immediately reported the allegation to registered nurse (RN)-D and RN-E. NA-B stated about an hour after R1 had returned from the beauty shop, NA-B was told by the director of safety and environmental services (DSES) R1 had denied the allegation. NA-B stated she had gone into R1's room with DSES and R1 had continued to deny the allegation. NA-B stated NA-D worked on the night shift a lot with nursing assistant NA-C so she'd called NA-D regarding her suspicions of NA-C. NA-B said she'd had a feeling nothing was going to be done since R1 had denied making the allegation, so she'd told NA-D to keep her eyes open. The facility's Vulnerable Adult report submitted 2/27/19 at 1:14 p.m., indicated: (NA-B) reports that while working with (R1) she stated '(NA-C) said he had a hard on in the shower thinking about her' she said he said he wanted to make her a 'bra' and that he touched her breast once. The report indicated NA-C had been placed on administrative leave pending an investigation. During an interview with the director of nursing (DON), Social worker (SW)-B, and administrator at 2:39 p.m. on 3/5/19, SW-B stated in mid (MONTH) multiple staff were reporting R1 was attempting to befriend them on Facebook. SW-B stated she had educated R1 on the role of the caregiver, and had reviewed personal and caregiver boundaries. SW-B stated R1 understood the boundary conversation of not attempting to befriend staff on Facebook, but did not agree with it. SW-B also stated the DON, administrator and herself had met to discuss potential concerns related to NA-C because they had received information R1 was continuously asking for NA-C and was asking for NA-C's phone number. SW-B said some staff were directing NA-C not to go into R1's room, because R1 was constantly asking for him and R1 was asking why NA-C wouldn't come into her room. SW-B stated she'd also spoken with NA-C on 2/22/19, and that the two of them (SW-B and NA-C) had planned on talking with R1 on 2/23/19 about boundaries. SW-B said she'd directed NA-C not to go into R1's room unless it was an emergency until the meeting. SW-B said on 2/23/19, she and NA-C had met with R1 and that the focus was on boundary issues, and providing R1 with assurance that all nursing assistants could meet her needs and provide care. SW-B said they'd also discussed R1 not asking to befriend staff on Facebook. SW-B stated it was a very casual conversation and stated R1 had not appeared scared or uncomfortable. SW-B stated she checked in with R1 on 2/24/19, at which time R1 had not identified any other concerns. SW-B further stated on 2/27/19, she'd received an email from NA-C asking to work on another unit due to R1 constantly asking for him. SW-B added that approximately 11:30 a.m. NA-B had reported sexual abuse allegations and SW-B said the administrator was notified of the allegation which was the first report of alleged abuse reported to the administrator. However, when R1 was interviewed she had denied the allegations. SW-B said the allegations of abuse were reported to the state. The DON stated she had called NA-C, and placed NA-C on administrative leave pending a Vulnerable Adult report and investigation. The DON said the police had been called and had interviewed R1, who denied the allegations. In addition, the DON said R1's family was notified of the allegation, and staff interviewed other female residents who reported no concerns. The DON said she'd also reviewed their surveillance video, and NA-C had not entered R1's room the night of 2/26/19. The DON also stated she'd spoken on the phone with NA-C a second time, and he'd denied the allegations. As a result, NA-C was taken off administrative leave and was allowed back to work on a different unit of the facility for the night shift of 2/27/19. The DON stated the nursing assistants were supposed to immediately report allegations of abuse to the clinical coordinator, shift leader, or floor nurse, and those individuals were to immediately contact the RN on call or DON. The DON stated she would then immediately notify the administrator by phone or email. A Computer Assisted Dispatch police document indicated the police had received a call on 2/27/19 at 3:40 p.m., and had arrived at the facility at 3:54 p.m The police narrative report included, It was reported through staff that (R1) my (sic) have had her breast touched by employee (NA-C). When speaking with (R1) she denied that (NA-C) ever touched her or made inappropriate comments about having an erection. At this time there is no rerson (sic) for concern. An untitled document in the facility's internal investigation folder indicated a staff (unidentified) indicated on 2/28/18, (untimed) after R1 returned from an appointment with family, staff (unidentified), family, and SW-B had spoken with R1. When asked if she could remember what shed told NA-B, R1 stated yes, I told her he touched my breast but added, it was not in a sexual way. When asked about the comment she'd made about how NA-C got sexually aroused thinking about her in the shower R1 responded, yes he did say that. However, R1 stated she didn't want to get NA-C into trouble. During an interview on 3/6/19 at 11:20 a.m., SW-B stated on 2/28/19 at around 2:00 p.m., R1, R1's family, and RN-D met per family's request to clarify what had been said and where things were at. SW-B stated R1 had denied touching of any kind. When asked about NA-C touching her breast, R1 had stated her breast was touched in the process of completing cares, but had admitted NA-C had told her he got a hard on in the shower thinking of her. SW-B stated she, along with RN-D, updated the administrator with what was said in the meeting. SW-B stated we as a group, we decided to call NA-C and ask him if the allegation was true. It was decided if NA-C denied the allegation, NA-C would be permitted to continue to work, If NA-C admitted to the allegation, the administrator was to be updated. SW-B further stated RN-D had called and spoken to NA-C on 2/28/19, shortly after the meeting. SW-B stated she'd listened to the conversation and NA-C had denied the allegations. SW-B acknowledged because of that, NA-C was not removed from the schedule. Although R1 had reported during the 2/28/19, meeting that NA-C had stated he'd gotten a hard on in the shower thinking of R1, NA-C continued to work unsupervised, returning to work for the night shift 2/28/19. Additional interviews with staff who frequently worked with NA-C during the night were not completed prior to allowing NA-C to return to work unsupervised. During an interview on 3/5/19 at 3:28 p.m., NA-D stated she normally worked the night shift and frequently worked with NA-C. NA-D stated she'd heard R1 had a history of [REDACTED]. NA-D stated it had started the same way with NA-C, R1 was always asking for NA-C. Over about 2 months it increased in frequency to every night and R1 had begun to demand to see NA-C. NA-D stated although she was told NA-C could assist with R1, she had spoken with NA-C and told NA-C not to go into R1's room because R1 was obsessed with him. NA-D stated NA-C had agreed, but kept going into R1's room saying he felt bad for R1. NA-D stated 2/22/19 was the worst. R1 was constantly on her light asking for NA-C. NA-D said she'd told R1 that only NA-D and the nurse were answering her light and R1 had said she was going to call the police if she was not allowed to see NA-C. The house charge came and spoke with R1. NA-D said on 2/27/19, NA-B called NA-D and would not give details, but told NA-D that something happened between R1 and NA-C that grossed her out. NA-D stated she knew she was scheduled to work with NA-C that night, so she messaged NA-C to call her. NA-D stated NA-C had met her and they talked. NA-D stated NA-C was panicked saying R1 was flirting with him. NA-D stated NA-C denied that anything happened between he and R1, but had told her R1 had tried to grab his butt in the past. NA-D stated she was aware NA-C and R1 talked on messenger is the past. NA-D said NA-C had told her he had not communicated on messenger with R1 in awhile, but the night of 2/27/19, R1 had requested assistance with her phone and NA-D saw recent messages between NA-C and R1. NA-D stated it bothered her NA-C had told her earlier that day he had not communicated with R1 in a while. NA-D stated she'd left the faciity on [DATE] at 7:30 a.m. and had text NA-C to call her. NA-D stated NA-C called her at 10:00 a.m. on 2/28/19, and they spoke on the phone until noon. NA-D stated she kept asking NA-C what he'd done. NA-D stated NA-C had started to cry. NA-D stated NA-C had told her he had sexual contact with R1 that included touching of one another's genitals. NA-D stated, At first he made it seem like it was one night, then said it happened over 2 weeks. NA-D stated NA-C had told her it started with flirting and her (R1) trying to touch his butt, but had told her the second week it went way, way too far. NA-D stated she was distressed by the call. NA-D stated she knew she had 24 hours to report the incident to the supervisor, but had no intention of waiting that long. NA-D stated she called the house supervisor, licensed practical nurse (LPN)-A on 3/1/19, at around 1:45 a.m. and went to the facility around 2:30 a.m. to report the abuse to LPN-A. Although NA-C had admitted the sexual relationship he'd entered into with R1 to NA-D on 2/28/19 at approximately 10:00 a.m., NA-D did not immediately report the incident to the supervisor until the early hours of the next day (approximately 14 and 1/2 hours) after becoming aware of the abuse. NA-D stated she has since been re-educated on reporting to the supervisor immediately. NA-C's [MEDICATION NAME] sheet report 2/4/19-3/1/19 identifies NA-C started work on 2/28/19 at 10:51 p.m. with no punch out time recorded. During an interview on 3/6/19, at 8:30 a.m. with the DON and administrator, when asked about the conversation with SW-B and RN-D following the meeting with family, the administrator stated she could not remember what information was discussed. The administrator stated as far as she could remember R1 had denied the allegation. The DON stated LPN-A called her on 3/1/19 at 2:54 a.m. LPN-A stated NA-D was at the facility reporting NA-C had confessed to the abuse. The DON directed LPN-A to remove NA-C from the floor and place him in a room away from residents and to call the police. The DON notified the administrator of the allegation. The DON stated she arrived at the facility on 3/1/19, just after 4:00 a.m. The police were interviewing NA-D. NA-C left the facility with the police. The DON stated NA-D was called later that day and put on administrative leave for failure to report abuse immediately. The police returned that afternoon and interviewed R1. NA-C had confessed to the police. R1 was not sent to the hospital for a sexual assault examination. NA-C's employment was terminated on 3/1/19. A member from Champlain services has met with R1 everyday since 3/1/19. The on-call physician was notified of the incident on 3/2/19. The Administrator stated on 3/1/19, all staff working were educated about the responsibilities of immediately reporting. Another education meeting was held on 3/4/19 at 2:00 p.m The DON added those staff working who went to the meeting were provided education. The administrator stated there was no documentation of those who attended the re-education meeting. The DON stated all staff were sent an email to complete the vulnerable adult training online, which includes reporting requirements, by 3/11/19. The facility lacked documentation of which employee's were re-educated on vulnerable adults and reporting after the incident. The police report dated 3/4/19 indicated on 3/1/19 the police took a statement from NA-C. NA-C stated the touching began approximately mid-February and lasted about 2 weeks. NA-C stated R1 touched his genitals and NA-C touched R1's breast. NA-C stated the contact escalated during the second week The police spoke with R1. R1 stated that approximately 2-3 weeks ago, R1 and NA-C engaged in sexual touching of each others genitals. R1 stated the conduct occurred in her room at the facility. NA-C was charged with Criminal abuse-sexual-caregiver/staff-vulnerable adult-sexual contact/penetration. During an interview on 3/5/19, at 2:12 p.m., R1 stated (NA-C) was the most gentle person in here. (NA-C) did not make me do anything I did not want to do. R1 continued to respond to questions, talking with no eye contact and her eyes closed. R1 stated (NA-C) touched me between, down there. R1 stated NA-C asked her If I ever had it in the back or if I ever have been with a woman. R1 stated she touched NA-C's once with just skin otherwise over NA-C's scrubs. R1 went on to say NA-C asked me to have oral sex which R1 stated she did. R1 began to cry. R1 stated NA-C gave her his phone number because NA-C thought R1 was to go home and wanted to keep in touch. I wish I could call him and tell him I am sorry, he wanted to be a nurse. Oh I miss him. R1 stated she did not have a relationship with NA-C prior to admission to the facility. A 3/4/19 physician note indicated medical doctor (MD)-D saw R1. Unfortunately, (R1) was involved in a incident this past week at this facility which involved inappropriate sexual behavior which resulted in legal action for a staff member. (R1) is quite bothered by this and had a lengthy conversation with both her chaplain as well as her counselor today as well as multiple staff members. (R1) continues to perseverate about calling this individual and simply wanting to state 'I'm sorry'. During an interview on 3/6/19, at 5:15 p.m. licensed psychologist (LP)-E stated he had seen R1 approximately weekly for 6 months due to family issues. LP-E stated he visited with R1 on 3/5/19. LP-E stated R1 did indicate what was done was inappropriate and had established a strong attachment to NA-C. LP-E stated there is always a tendency for the victim to develop a strong attachment to the abuser. Sometimes victims want to run away and sometimes run towards it. LP-E stated R1 is a person who has a strong need for closeness an a lot of times when perpetrators are involved, the perpetrator tends to gravitate to people with this personality. LP-E stated he feels R1 may have been blind-sided and may have mixed feelings. I think (R1) is conflicted in many ways and when conflicts arise (R1) does not know how to solve them. LP-E stated with NA-C he feels R1 was looking for someone that was supportive. These type of perpetrators pick these people out like radar searching for who they can victimize. I don't think she did consent. When interviewed on 3/5/19 at 1:15 p.m. licensed practical nurse (LPN)-B stated she would report any abuse immediately to her supervisor and she receives vulnerable adult (VA) training yearly, and needs to complete an online VA training by next Monday. On 3/5/19, at 1:20 p.m. trained medication aide (TMA)-D stated she receives training annually for vulnerable adult training (VA). TMA-D stated she would report abuse to her supervisor immediately. TMA-D stated she needs to complete an online VA training by next Monday, the 11th. During an interview on 3/5/19, at 1:27 p.m. nursing assistant (NA)-I reported he is new and received his training when he was hired at orientation. NA-I stated he would report any abuse to a resident immediately to his supervisor. NA-I stated he is supposed to complete an online training for VA, but has not had a chance yet to do it. When interviewed on 3/5/19, at 1:40 p.m. neighborhood coordinator (NC)-G stated she just recently had the VA training at a meeting because of what happened. NC-G stated she would report abuse immediately to her supervisor. NC-G stated all employees get training annually for VA. Some staff that did not go to the meeting have to do an online training. During an interview on 3/5/19, at 1:45 p.m. NA-E stated she receives yearly vulnerable adult training, which includes reporting. NA-E stated she would report suspected abuse immediately to her supervisor. Stated she was told yesterday to complete online training on abuse, but has yet to complete the training. During an interview on 3/5/19, at 1:55 p.m. NA-J stated she received the VA training upon hire and yearly. She went on to say it is an online course and everyone has to have it done by next Monday. NA-J stated if she knew about a resident being abused or witnessed it she would report it to her supervisor right away. During an interview on 3/5/19, at 2:15 p.m. social worker (SW)-A stated she just received the training at a meeting recently and is trained yearly. SW stated she would report any abuse immediately to her supervisor. The facility's policy Vulnerable Adults-Abuse Prevention Policy-Long Term Care, approved on 2/2019. Residents will be protected against abuse under the vulnerable adult policy. Abuse definition indicated Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse included verbal, sexual, physical and mental. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual assault is non-consensual sexual contact of any type with a resident. All employees, contracted employees, students, and volunteers will report alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property immediately to the administrator of the facility and/or their delegated designee. Upon identification of suspected abuse and/or neglect, provide for the immediate safety of the resident. Means of providing protection may include, but are not limited to: a. Moving resident to another room or unit. b. Provide 1:1 monitoring as necessary. c. Suspend suspected employee(s) pending outcome of the investigation. d. Implement discharge process immediately if the resident is a danger to self and/or to others. e. Ongoing Social Service involvement for support to the resident and family. All employees and volunteers receive annual in-service training on understanding their legal responsibilities regarding the Vulnerable Adult act and upon hire with new employee general orientation. The immediate jeopardy that began on 2/28/19, and was identified on 3/6/19 at 12:55 p.m., was removed on 3/6/19 at 5:23 p.m., when it could be verified by interview and document review, the facility had reviewed and revised policies related to protecting residents during investigations by removing the alleged perpetrator from their duties and placing them on administrative leave until the completion of the investigation; had re-educated RN-D and SW-B about the requirements for reporting allegations of abuse and initiating a comprehensive investigation, and had established a process that all staff would be educated regarding their responsibilities for looking for and reporting allegations of abuse, prior to the start of their next shift. On 3/11/19, via email, the facility provided additional information to demonstrate efforts they had made to provide Vulnerable Adult training to their staff prior to the on-site survey. However, as indicated above, several staff who were working were interviewed during the survey and stated they had not yet completed the assigned training. Additional information provided via email from the facility on 3/11/19: -On 3/1/19, 12 clinical coordinators, 10 department managers, and 7 social workers were informed of the role of a mandated reporter and the importance of reporting immediately. -On 3/1/19 online employee education module was assigned for all employees that must be completed by 3/11/19. -On 3/1/19, at 3:30 p.m. a mandatory meeting was held with approximately 52 employees in attendance based on facility video, and were educated on the VA policy and the importance of immediately reporting. -On 3/1/19, the administrator was on site and provided education on their role as a mandated reporter and the importance of immediately reporting for 8 nurses coming onto their overnight shift at 10:00 p.m. and 8 nursing assistants coming onto their shift at 11:00 p.m -On 3/4/19 at 2:00 p.m. a mandatory meeting was held for approximately 68 employees based on a count from facility video camera and received education on the VA policy and the importance of immediately reporting. -The email lacked documentation as to how many staff were working when staff were retrained on 3/1/19 and 3/4/19. -The email lacked documentation as to any staff re-education over the weekend 3/2/19 and 3/3/19. -The email lacked documentation as to any staff re-education from 3/4/19 night shift until the immediate jeopardy was called on 3/6/19 at 12:55 p.m.

Based on observation, interview and document review, the facility failed to provide a preventative maintenance program for the bathing tubs and chairs according to manufacturer's recommendations; failed to comprehensively investigate a fall from a bath chair for 1 of 1 residents (R7); and failed to put into place preventative measures following the fall. This practice resulted in a risk for serious harm, injury or death to 104 out of 155 residents who received baths in the facility. Findings include: The immediate jeopardy began on 3/9/17, when R7 sustained a fall while in the tub chair. Following the incident, the facility failed to comprehensively assess the fall, failed to implement interventions to include nursing assistant re-education, and failed to implement a preventative maintenance program for the tubs per manufacturer's recommendations. The administrator, via telephone, the assistant director of nursing (ADON) and unit manager registered nurse (RN)-C, were notified of the immediate jeopardy at 5:42 p.m. on 3/30/17. The immediate jeopardy was removed on 3/31/17, at 3:38 p.m. but noncompliance remained at the lower scope and severity level of a pattern, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy (Level E). R7's annual Minimum Data Set ((MDS) dated [DATE], indicated R7 had short term memory impairment, but intact long term memory. The MDS indicated R7 had no behaviors, and required extensive assistance with transfers. The MDS identified R7 required physical help in part in bathing. The MDS further identified [DIAGNOSES REDACTED]. R7's care plan dated 1/17/17, indicated R7 had a self-care deficit related to Parkinson's disease with fluctuations in participation ability, resting tremors, and decreased hearing. The care plan indicated R7 needed assistance of one staff to bathe, and assistance of two staff and a standing lift to transfer. R7's progress notes indicated the following: - On 3/9/17, at 7:55 a.m. R7 had a fall at 6:15 a.m. in the tub room. Resident received tub bath. When RCA (facility nursing assistant) was using tub chair to remove resident from tub mechanical failure occurred and resident was lowered to ground as the tub chair separated from the base. Injuries: skin tear to right hip and right shoulder measures 0.2 x 0.2 cm (centimeters). Intervention/care provided: assessed for injuries, vitals BP (blood pressure) 140/80, RR (respiration rate) 20, sats (oxygen saturation percent) 92% on RA (room air), T (temperature) 95.5, HR (heart rate) 79. Use of FML (full mechanical lift) to w/c (wheelchair). - On 3/9/17, at 9:25 a.m. Resident experienced a fall out of tub chair d/t (do to) mechanical failure. This incident is not suspicious in nature. Resident's P(NAME) (plan of care) was being followed at time of fall. Resident was lowered to the ground by staff and did not experience any significant injury or head strike. Resident does not have any c/o (complaints of) pain. Staff immediately deemed tub room out of use and maintenance contacted. After review, this incident is not deemed a VA (vulnerable adult) reportable event. R7's Fall Report dated 3/9/17, revised on 3/17/17, indicated, Resident was given a bath. When he was taken out of the tub chair an unknown issue occurred with equipment and the tub chair tilted backwards off the track and the resident fell backwards to floor - staff member was with resident and lowered to ground as best possible and no head strike occurred. MD (medical doctor) updated via fax. Injuries noted were abrasion to right scapula (shoulder blade) and right trochanter (hip) and resident was alert. No predisposing environmental, physiological or situation factors indicated. The report indicated, Tub chair possible mechanical issue. An interview dated 3/9/17, with nursing assistant (NA)-H included on the fall report indicated, I gave resident a bath. When taking him out of the tub I pulled the chair forward on the track and heard the click. I stepped on the pedal to release the track from the tub and the chair tipped backwards and fell off the track. I lowered him to the ground the best I could and he did not hit his head. A note on the Fall Report dated 3/10/17, from RN-C indicated, Resident received tub bath. When RCA was using tub chair to remove resident from tub mechanical failure occurred and resident was lowered to ground as the tub chair separated from the base. R7's Post Fall Follow Up dated 3/9/17, indicated R7 had a fall on 3/9/17, at 6:15 a.m. R7 was sitting on the tub chair lying on the floor on his back in a seated position. The follow up indicated there was Mechanical failure of equipment. No new interventions identified. Tub chair out of order until maintenance assessed. The Post Fall Follow Up indicated an interdisciplinary team (IDT) reviewed the incident on 3/14/17 (5 days later), however, did not include the IDT notes, what mechanical failures occurred, or what was done to prevent an incident from occurring again. On 3/29/17, at 8:07 a.m. R7 was interviewed and stated he fell from the tub chair when the track or connection was not tight and came apart. R7 stated that he did not receive any serious injury, but his bottom hurt that day. R7 stated he had continued to use the tub for bathing, without fear. R7 stated he didn't know what exactly happened, or what the facility did to fix the situation. On 3/29/17, at 8:58 a.m. the second floor north tub room was observed with nursing assistant (NA)-F. An Apollo 6000 tub and chair system was in place. NA-F demonstrated how the tub system worked. NA-F stated the tub chair was locked onto the base (which also acted as a scale) with a primary safety lever. After the resident was seated on the chair, belts were used to secure the resident to the chair; with one belt around the resident's waist and one belt around the resident's torso. The end of the tub was opened, the chair along with the base was secured to the tub with a locking pin at the bottom of the tub, with a foot pedal to engage the lock. Metal rails were on both sides of the tub and the back of chair base, and NA-F stated the rails needed to be lined up. When the rails were lined up, the primary safety lever was released, the chair was released from the base, and it glided on the rails into the tub. The chair was then secured to a buckle in the tub, so the chair did not move. The base was then released with the foot pedal, moved away from the tub, and the door would be closed. Staff would then fill the tub with water. NA-F stated after the bath was finished, the tub was drained, and the door at the end of the tub was opened. Once the rails were lined up, the base was locked into placed, the security buckle on the back of the chair was released. The chair would then slide into place over the base, and it would click into place. The base was then released from the tub. NA-F stated the chair could fall if it was not completely on top of the base before releasing the base from the tub, or if the rails were not lined up properly. NA-F stated she had heard R7 had a fall from the bath chair, but was not sure what happened. NA-F stated there had not been any education about the tub system following R7's fall. On 3/29/17, at 2:30 p.m. NA-G was interviewed and stated she had heard about R7's fall a few days following the fall. NA-G stated she heard the chair malfunctioned and R7 fell backwards from the tub chair. NA-G stated it was important to hear a click before removing the base from the tub. NA-G stated when she was hired she was trained in how to use the tub. NA-G stated there was no follow up on education following the incident with R7. On 3/30/17, at 8:35 a.m. the director of maintenance (DM) stated he thought there was a work order put in for a tub on 2/8/17, but the order was pretty vague. DM stated a maintenance worker adjusted the rails the chair slides onto and adjusted a screw. DM stated that there was not a maintenance slip filled out following the incident with R7, but he had received an immediate phone call, and he found issues with the secondary safety on the chair. DM stated he made the needed adjustments the chair, and was confident that was the solution. DM stated that no follow up inspections had been made to the tub chair system on second floor north. DM further stated the facility relied on maintenance slips or phone calls if there were issues with the tubs or the chairs. DM stated following the incident, the maintenance department checked on all the facility's tubs and tub chairs. DM stated a work order was submitted on 3/19/17, regarding the second floor north tub chair scale. A maintenance worker fixed the scale on 3/20/17, and also ensured the chair was in working order. DM further stated along with mechanical errors, human error could have occurred, but it was hard to tell. DM also stated the facility had no preventative maintenance schedule to inspect the tubs and tub chairs prior to the incident on 3/9/17, and the facility had not implemented a system for preventative maintenance following the incident. DM stated only when the maintenance department was alerted to a potential issue with the tubs or tub chairs, do they get looked at. DM stated he verbally told someone that the issue had been resolved but was not sure who he told. On 3/30/17, at 8:51 a.m. during follow up observation of the second floor tub system with DM, DM pointed out the secondary safety was bent on both sides of the chair. The secondary safety was a U-shaped metal bracket attached to the base of the chair on the rail assembly system. If the primary locking lever was not engaged, and the chair was sliding back off, the base would come in contact with metal pieces that hung off the end of the rails on both sides of the chair, preventing the chair from falling off the base. DM stated there was not anything wrong with the primary lever when inspected on 3/9/17, and that should have locked the chair in place. DM added the secondary safety was there in case the primary locking lever failed. After walking through potential scenarios of how the chair could have fallen off the base, DM stated that the base had to have been released from the chair, the primary safety lever was not engaged, and the secondary U- shaped brackets were bent causing the chair to fall backwards off the base. The DM stated he did not walk through any possible scenarios with the nursing staff, he just assumed the secondary safety failed. DM stated no thought was put into the primary locking lever. The DM further stated if it was human error by not engaging the lock, or if it was engaged, then how did the primary locking lever fail? The DM further stated the incident was not thoroughly investigated. The DM provided the following Maintenance Work Order forms: - 2/7/17, second floor north tub room. Location of repairs needed: Tub chair does not go on correctly. Off track? Work completed on 2/8/17. Type of repairs made: Tightened screw and adjusted rail. -3/19/17, second floor north tub room. Location of repairs needed: Tub chair scale not weighing correctly. Work completed on 3/20/17. Type of repairs made: Recalibrated scale. The work order did not identify checking the function of the chair or locking systems. The Safety and Health Committee Meeting Minutes from 1/12/17, 2/9/17, and 3/9/17, did not address any concerns with the tub systems, nor were any concerns brought up regarding the tub systems. However, R7 had fallen that morning while be transferred out of the tub. On 3/30/17, at 9:20 a.m. registered nurse (RN)-C was interviewed and stated on the morning of 3/9/17, following R7's fall from the tub chair, she was notified via telephone by RN-E about the incident. RN-C stated RN-E followed up with maintenance, and it sounded like there was something bent on the secondary safety that caused the chair to tip backwards. RN-C further stated that RN-E reported to her NA-H had re-enacted her steps, regarding the fall with R7, and demonstrated them to RN-E. RN-C stated she believed NA-H did everything right, and there was no indication of possible human error. RN-C stated the assistant director of nursing (ADON) was also notified of the incident. On 3/30/17, at 1:32 p.m. NA-L stated some staff do not get the base lined up with the track correctly, and they would call for assistance to push the chair off the base into the tub. NA-L further stated the chairs have stoppers (secondary locking system) that prevent the chair from going any further if the rails are not lined up. On 3/30/17, at 1:33 p.m. the ADON was interviewed and stated the incident was reported to her when it occurred. The ADON stated she thought it was a mechanical error as soon as she entered the tub room. Maintenance was called, and a sign was placed for the staff not to use the tub. The ADON stated she did not think human error was involved by the look of the chair, and NA-H's explanation of what happened. The ADON stated no further investigation was completed to determine if the fall was a result of human error or if the primary locking system failed. The ADON stated there should have been further investigation into the cause of the fall. The ADON further stated she thought mechanical issues were the reason for the fall. The ADON stated the incident was not reported to the administrator, or the State Agency (SA) as a possible VA incident, as the fall was witnessed by staff. The ADON stated there was no conversation with the DM after his review of the chair see why the primary lock did not keep the chair in place over the base. The ADON stated she was not sure what was reviewed in the IDT review, and she was unaware if all possible sceneries had been covered to implement interventions to prevent another incident. The ADON stated she was not aware of any other incidents regarding falls from the tub chairs. The ADON stated that she had no further information regarding the incident. The ADON stated in hind sight a more complete investigation should have been completed, and the incident should have been reported immediately to the administrator and the SA. The ADON also stated following the incident, no education had been given to the nursing assistants, and no preventative maintenance program on the tubs and tub chairs had been implemented. The ADON stated nursing assistants were trained on the tub function upon hire, but were not trained on the various tub systems in the facility. The DON further stated the third floor tub was not being used, as it leaked. On 3/30/17, at 1:59 p.m. NA-H was interviewed via telephone. NA-H stated she was the NA who had given R7 his bath on 3/9/17. NA-H stated she was not sure how to explain what happened when R7 fell . NA-H stated R7 had finished his bath, she slid the chair out of the tub onto the scale (chair base) and heard the click indicating the chair was in position over the base. NA-H stated she used the foot pedal to release the base from the tub, and when she started to move the base with the chair on it, R7 started falling backwards towards the floor. NA-H stated she was 99 percent sure she heard the click but was not 100 percent sure as she gave a lot of baths. On 3/30/17, at 2:15 p.m. licensed practical nurse (LPN)-A stated the third floor nursing assistants often needed to get help from a second person when putting a resident into and out of the tub. LPN-B stated the second person was needed to hold the base in place when the rails did not line up so the base did not separate from the tub. On 3/30/17, at 2:19 p.m. DM stated he thought there were six Apollo tubs in the facility that worked the same way as the tub on second floor north. DM stated when the second floor north tub chair was fixed, new parts were not ordered and he bent the U-shaped metal brackets back into place so the secondary lock system would lock. The DM stated that the Apollo 6000 model tubs had been in the facility since 2003, and there had never been preventative maintenance preformed on the tubs by the maintenance department. DM further stated that the facility did not contract with any other company to do routine inspection or maintenance on the tubs or tub chairs. On 3/30/17, at 2:20 p.m. NA-I demonstrated the third floor tub system. NA-I stated if the chair does not not get pulled far enough forward onto the base, it could by-pass the secondary locking system and fall off the base backwards. On 3/30/17, at 2:29 p.m. DM observed the third floor tub room. DM stated he was not sure why staff were not using the tub, as he did not have a work order for it. The DM stated that the leak to the tub had been fixed previously. DM demonstrated if staff put too much pressure on the front of the tub chair when moving it, the back of the chair can come off the rails, and by-pass the secondary locking system. The DM further stated it should never take two people to move a resident from the base to the tub and vice versa, and staff should stop immediately if they are having issues and contact the maintenance department. On 3/30/17, at 4:56 p.m. DM stated in the last year he had been called a few times about the tub rails not lining up, and the rails were adjusted. DM further stated there was no written record of maintenance phone calls that are received and followed up on. On 3/31/17, at 8:38 a.m. a technical representative (TR)-A for Apollo bathing systems was interviewed via telephone. TR-A stated he was familiar with the Apollo 6000 tub system. TR-A stated it is recommended the facility perform routine inspections on the tub system per the manufacturer's recommendations at intervals of monthly, quarterly and yearly. TR-A stated each facility is given a checklist on what needed to be inspected and when. TR-A further stated routine maintenance was essential to prevent part failure; and a facility not performing maintenance per manufacturer's recommendation was running a high risk of a resident falling and possibly sustaining serious injury. TR-A stated in the event the primary locking lever failed, or if by user error it was not engaged, the secondary locking system was in place to prevent a resident from falling. TR-A stated during normal operation of the chair, the U-shaped metal brackets on the rail system would not bend on their own. If the secondary system had been maintained properly, it should have prevented a resident from falling. TR-A stated the facility was responsible for checking the rails, primary and secondary locking systems monthly, along with the pin that locks the base to the tub. TR-A stated the facility needed to contact Apollo in the event of a resident fall from an Apollo bathing system, It was extremely important as the company tracks adverse events. TR-A further stated the company could help the facility investigate what had occurred. TR-A stated the facility had not reported the incident to Apollo, and if a tub chair was repaired without following manufacturer's recommendations, the chair would not be safe to continue using. On 3/31/17, at 12:26 p.m. the director of education (DE)-A was interviewed and stated nursing assistants and licensed staff are given training about disinfecting the tubs upon hire, while in the classroom setting. DE-A stated nursing assistants are assigned a preceptor when hired, and the preceptors train the nursing assistants on how to use the tub system on the unit they are working on. DE-A stated the preceptors do not go through any special orientation or preceptor program. DE-A stated nursing assistants were expected to utilize the manufacturer's instructions for the tub systems that were posted in each tub room. DE-A stated if a nursing assistant floated to a different unit they were expected to have someone show them how to utilize the tub system if it was a different tub than what they were trained to use. DE-A further stated the education department was not contacted following the incident on 3/9/17, to ensure nursing assistants were using the tub systems accurately. DE-A stated since being alerted to potential education issues regarding the tub systems, the facility was working on a new process of using the manufacturer's checklist for training, with a return demonstration. The DE-A stated the tub system should be treated like a mechanical lift. DE-A further stated the ADON and nurse unit managers were doing training each nursing assistant in the tub rooms at the beginning of their shifts, and had started this morning. On 3/31/17, at 2:30 p.m. TR-B stated he had been called today by the facility to ensure that the Apollo bathing systems were in safe working order. TR-B stated he would look at all tubs and fix or replace what was needed per administration approval. TR-B stated facility maintenance staff were responsible to maintain the bathing systems. TR-B stated when a nursing assistant trains another nursing assistant on how to use the tub system, they may miss details. TR-B further explained the click staff listen for (so they know the chair is locked over the base) can be heard without the chair fully locking into place. TR-B stated listening for the click was not a substitution for a visual verification that the chair was locked into place. The tub system on second floor north was observed with TR-B and DM. TR-B demonstrated how you can still hear a click when positioning the chair over the base without fully locking it. TR-B inspected the chair, then stated it was okay to bend the U-shaped metal bracket into place; this does not alter the strength. DM stated human error should be negated because there were a few missing screws on the chair at the time of the incident on 3/9/17. After a brief overview, TR-B stated he thought the chair was safe to use, but recommended some upgraded safety enhancements to the primary lock lever. TR-B stated he would complete a thorough inspection of all the facility tubs. On 3/31/17, at 3:15 p.m. the interim administrator stated TR-B and the DM actually sat on the tub chair and noted the primary locking lever was not in working condition, and was not safe for use. The administrator assured all defects found on all bathing systems would be fixed before use. A tub system training curriculum was requested and not provided. A preventative maintenance program policy was requested and not provided. The undated manufacturer guide Apollo Bathing System Series 6000 Owner's Manual and Operator's Guide included information on operation, installation instructions, operation remedy, level glide transfer, and rada valve. The guide informed Improper adjustment of the Patient Transfer System or failure to lock patient chair onto carrier could allow patients to drop to the floor resulting in serious injury. Before moving carrier, check to be sure patient chair is locked to carrier and will not accidentally roll off carrier. Warning! Patient carrier could drop if rails are loose or transfer chair wheels are not aligned with rails. Inspect chair fastener screws periodically to insure they remain tight during use (Refer to maintenance schedule). The guide signed and initialed on 3/03, included Recommended Maintenance Schedule Carriers and Scales to include preventative maintenance on the following items at the following intervals: - Docking Pin Setting to receiver every three months - Carrier Locks (should freely work) monthly - Carrier Rail Alignment (align to tub rails) monthly - Chair Release Lever monthly - Castor Lock every three months - Safety Straps and Buckles monthly - Chair Mounting Bolts (wheels, arms, etc.) every six months - Bottom Chair retaining Tabs (All fasteners tight) monthly - Chair Wheel Bearings every 12 months The facility Fall Management policy dated 8/15, directed The staff will identify interventions related to the resident/ patient's specific risks and causes to try to prevent the resident/ patient from falling and try to minimize complications from falling. Staff will identify and implement relevant interventions as applicable to try to minimize serious consequences of falling. The Clinical Nurse Manager and /or designee will ensure Post Fall Analysis-Resident Worksheet is completed with input from the unit's fall team. The immediate jeopardy that began on 3/9/17, was removed on 3/31/17, at 3:38 p.m., when the facility: - Implemented a facility preventative maintenance program for the tub systems per manufacturer's recommendations, and contacted Apollo technicians to inspect the tub systems and were on site 3/31/17. - Comprehensively completed an investigation regarding the incident with R7 on 3/9/17. Two tub systems were taken out of use pending manufacturer inspection. Licensed staff in charge received education related to incident reports and investigations. - Nursing assistants were being educated on the process of reporting equipment needing to be serviced. Nursing assistants are being required to perform a return demonstration on how to use the tub system at the beginning of their shifts, and at a skills fair on 4/4/17. - Audits of the preventative maintenance program will be turned in to the administrator and reviewed at the quality assurance meeting. The noncompliance remained at the lower scope and severity level of a pattern, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy (Level E), as all staff training had not been completed, and Apollo representative had not inspected all the Apollo tubs for safety nor completed any repairs that may have been needed for safe functioning. On 3/31/17, from 1:50 p.m. to 2:15 p.m. nursing assistants were interviewed and verified they had been re-educated on the tub systems, they provided a return demonstration, and were educated on notifying maintenance of potential concerns with the tub systems.

Based on observations, interviews, and documentation review, the facility failed to provide emergency care, including resuscitation attempts, for 1 of 1 resident (R1). When R1 became unresponsive and his/her pulse stopped, staff did not initiate emergency care even though staff were attending to R1 from the time s/he had a pulse to when s/he no longer had a pulse. R1 died . No cardiopulmonary resuscitation (CPR) was initiated in accordance with R1's advance directives. Findings include:During the facility entrance on [DATE] at 8:31 a.m., Employee B/administration stated part of the admission process is to discuss and complete the Advanced Directive consent form with the resident. The facility tour was conducted on [DATE] at 8:41 a.m. with Employee A/administrator and revealed the facility has two short stay units where residents receive nursing care and rehabilitative services to return home to the community. The short stay units are equipped with emergency care crash carts. The north short stay unit has 24 beds. The south short stay unit has 20 beds. The medical records for R1 was reviewed. The physician orders and care plan dated ,[DATE] for R1 with an admission date of [DATE] revealed R1 was admitted to the north short stay unit following hospitalization for a pacemaker placement. The Advanced Directive Consent Form, signed by R1 and dated [DATE] was signed by the physician on [DATE], indicated R1's preference was to be resuscitated in the event his/her heart or breathing stopped. Review of the Clinical Monitoring Record dated ,[DATE] revealed R1 complained of dizziness at least six times during a 10 day facility stay. The physician documentation dated [DATE] noted the patient had some lightheadedness and was admitted to the facility following pacemaker implantation for rapid [MEDICAL CONDITION]. Progress notes dated [DATE] at 12:42 p.m. revealed the patient was going to the dining room at 12 noon, became dizzy and had a pulse present. R1 died . Staff verified the time of R1's death was 12:10 p.m. An interview with registered nurse (RN)-G was conducted on [DATE] at 3:16 p.m. RN-G said on [DATE] at lunchtime R1 came into the dining room and told RN-G s/he was dizzy and sat in a dining room chair. RN-G said R1 became unresponsive but had a pulse and was breathing when she began to immediately assess R1. RN-G called licensed practical nurse (LPN)/E to take over care for R1. RN-G left the dining room to begin calling the physician, emergency transport, and family. LPN-E, licensed practical nurse (LPN)/F, and an unknown nursing assistant transported R1 back to his/her room by dragging the dining room chair s/he sat in. LPN-E came to the nursing station where RN-G was at approximately 12:10 p.m. and said R1 had no pulse. RN-G told LPN- E it was too late to initiate CPR. RN- G said there was no witness to the resident's last breath, even though staff were with R1 during this time so no CPR was started. An interview was conducted with LPN-E, on [DATE] at 12:42 p.m. LPN-E stated she was in the hall at the medication cart when RN-G called her to the dining room on [DATE] at approximately 12:00 noon to 12:05 p.m. R1 was sitting in a dining room chair and was unresponsive. LPN- E stated R1 was in the dining room at that time. R1 had a radial pulse, was breathing, and sneezing. LPN- E was unable to obtain R1's blood pressure in the dining room. LPN-E and unknown nursing assistants, transported R1 to his/her room. Staff were trying to decide how to transfer R1 into bed when LPN-E checked R1 and found no apical pulse. LPN-E ran to get the crash cart and notify RN-G that R1 had no pulse. LPN F was in the room with R1. At least one nurse was with R1 the whole time from the dining room to his/her room when LPN-E found no pulse. When LPN-E went to get the crash cart she saw RN-G and informed RN-G that R1 had no pulse. RN-G told LPN-E it was too late to do CPR. Emergency medical care or CPR was not initiated. The time frame from R1 found with a pulse to no pulse was no more than 10 minutes. The resident died . An interview was conducted with LPN-F on [DATE] at 1:38 p.m. LPN- F stated on [DATE] at approximately 12:00 noon she went to the dining room to check on residents. LPN-E and a nursing assistant (unknown) were with R1 trying to move R1 out of the dining room. LPN-F checked R1's radial pulse, which was present and fast. LPN-F assisted to transport R1 to his/her room and held R1's head to keep her airway open during the transport to R1's room. After R1 to his/her room, LPN-E, LPN-F and the nursing assistant tried to decide how to transfer R1 out of the chair. LPN-E checked R1's pulse. LPN-F was unsure of the details until RN-G came to R1's room (unknown time). When RN-G came into the room, she told the nurses not to do CPR as the last breath was not witnessed. Emergency medical care and CPR was not initiated. LPN-F stated the nurses should have been assessing more continuously, put R1 on the floor, started CPR, and called a code. This was not done. An interview was conducted with Physician H on [DATE] at 9:06 a.m. R1's code status was full code. Physician H stated CPR was not initiated by staff. Physician H stated staff should have initiated CPR. Review of the facility policy and procedure for Advanced Directives, last revised ,[DATE], noted on Advance Directive Consent Form, "Full cardiopulmonary resuscitation (CPR) is....performed in an attempt to revive a resident who's gone into a witnessed [MEDICAL CONDITION] (heart stops beating) or witnessed respiratory arrest (breathing stops)....In the event of an unwitnessed cardiac or respiratory arrest cardiopulmonary resuscitation will not be initiated." The facility policy and procedure failed to note the criteria for not starting CPR according to the American Heart Association. This criteria states: " ....Therefore, it is recommended that all patients in [MEDICAL CONDITION] receive resuscitation unless The patient has a valid DNAR order. The patient has signs of irreversible death: rigor mortis, decapitation, or dependent lividity. No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy for such conditions as progressive septic or cardiogenic shock. Withholding attempts to resuscitate in the delivery room is appropriate for newly born infants with....." R1 met none of the exceptions listed above.