Every finding on record at St Francis Home

Based on observation, interview and document review, the facility failed to ensure staff were completing hand hygiene and using proper personal protective equipment (PPE) according to the Centers for Disease Control (CDC) guidelines for enhanced barrier precautions (EBP) while performing activities of daily living (ADLs) for 1 of 1 residents (R2) observed for EBP.Findings Include:R2's quarterly Minimum Data Set (MD) dated 6/4/26, identified R2 had paraplegia (loss of control of lower part of the body) and multiple sclerosis (an auto immune disease that affects the central nervous system). R2's MDS further identified R2 had an indwelling catheter and colostomy. R2's MDS revealed R2 was dependent on staff for personal hygiene, dressing, and transfers.R2's care plan revised 6/5/26, identified R2 had a history of infections and was on EBP per CDC infection prevention guidelines due to R2's indwelling catheter.R2's room door displayed a sign informing staff that R2 was on EBP. R2's door also provided a hanging cabinet that contained yellow gowns and gloves.Review of the CDC guidance dated 4/2/26, Implementation of PPE use in Nursing Homes to Prevent Spread of Multidrug-resistant organisms (MDRO), EBP are an infection control intervention designated to reduce transmission of resistant organisms that employes targeted gown and glove use during high contact resident care activities.During an interview and observation on 6/9/26 from 9:06 a.m. to 9:34 a.m., NA-A stated staff were going to get R2 up and dressed to go to breakfast. NA-A entered R2s room grabbed a pair of gloves from the hanging cabinet on R2s door and applied them. NA-A grabbed washcloths and towels out of R2s closet. NA-A grabbed the wash basins with supplies to provide personal hygiene for R2. NA-A removed R2's gown, checked R2's colostomy to ensure it was intact. NA-A removed gloves and applied a new pair of gloves. NA-A covered R2 up with a sheet and grabbed a pair of grey sweatpants and gold shirt out of R2's closet. NA-A filled R2's wash basin up and brought it out to the bedside table. NA-A removed R2's pressure relieving boots and two pillows under each side of R2. NA-A placed the washcloth into the basin and wrung it out. NA-A handed R2 the washcloth to wash R2's face and hands. NA-A took wash cloth from R2 placed put it in the basin and handed R2 a towel to dry face and hands. NA-A grabbed the washcloth wrung it out and washed R2's armpits. NA-A put the washcloth in the bag and the floor and dried R2's armpits. NA-A applied deodorant to R2's armpits and the applied R2's shirt. NA-A took another washcloth and placed it in the wash basin. NA-A wrung out the washcloth and washed R2's groin area. NA-A put the washcloth back into the wash basin and dried R2's groin area with a towel. NA-A removed gloves and applied new gloves. NA-A went to the right side of the bed and pulled the lift sheet under R2 to prepare R2 to roll to R2's side. NA-B entered the room to assist NA-A to roll R2 to R2's side. NA-B applied one glove and assisted NA-A to roll R2. NA-A wrung out the washcloth and washed R2's coccyx area. NA-B applied second glove. NA-A put the washcloth into the bag on the floor and dried R2's bottom with a towel. NA-A put the towel into the bag on the floor. NA-A applied barrier cream to R2's bottom. NA-A removed gloves and applied new gloves. NA-B removed gloves. NA-A grabbed R2s sweatpants and put them on R2s legs. NA-A and NA-B rolled R2 from side to side to get R2s pants up and place sling under R2. NA-A went to the bathroom to grab a graduate. NA-A emptied R2's catheter, dumped the urine into the toilet, and rinsed the graduate out. NA-A removed gloves and applied new gloves. NA-B removed one glove, pulled paper out of pocket, wrote urine amount on paper, and placed paper back into pocket. NA-B removed gloves. NA-A tied up bag and the floor and left the room to get the lift. NA-A and NA-B hooked sling up to lift and transported R2 to electric wheelchair. NA-A removed gloves, sanitized hands and left the room with the lift. NA-B sanitized hands, grabbed the bag on the floor and left the room. NA-A returned to R2's room and assisted R2 with combing R2's hair. NA-A made R2s bed and placed a new trashcan liner in bin. R2 left room in electric scooter to go to breakfast. NA-A and NA-B did not wear gowns or sanitize their hand between glove changes.During an interview on 6/9/26 at 9:30 a.m., nursing assistant (NA)-B indicated NA-B was aware R2 was on EBP and NA-B did not wear proper PPE while providing personal cares for R2. NA-B further indicated NA-B did not sanitize hands during glove changes.During an interview on 6/9/26 at 9:36 a.m., NA-A indicated NA-A should have been wearing a gown when NA-A provided personal cares for R2. NA-A stated NA-A was aware R2 was on EBP and staff were supposed to use PPE when providing personal cares. NA-A further stated NA-A did not sanitize hands between glove changes. NA-A indicated NA-A thought about putting a gown on but did not want to stop cares for R2.During an interview on 6/9/26 at 10:33 a.m. registered nurse (RN)-B indicated R2 was on EBP and staff were expected to be putting on gowns, gloves and completing hand hygiene while providing R2's personal cares.During an interview on 6/09/2026 at 10:42 a.m., RN-A indicated RN-A assisted with infection control and had talked to staff about following EBP. RN-A further indicated EBP was discussed at meetings and staff received training on how to follow EBP.During an interview on 6/9/2026 at 10:47 a.m., administrator and vice president (VP) of patient services indicated the importance of EBP was to protect the residents and staff. Administrator and VP of patient services stated they would both expect staff to be compliant and follow EBP when providing personal cares to residents who are on EBP.Facility policy titled Isolation Precautions dated 11/22, identified healthcare personnel will utilize enhanced barrier precautions with all patient care activities to minimize exposure to potential pathogens as recommended by The Centers for Disease Control and Prevention (CDC). EBP was to be used with all residents have wounds and/or indwelling medical devices (urinary catheter).

Based on observation, interview and document review, the facility failed to provide assistance with routine grooming cares which included oral cares for 1 of 2 residents (R34) reviewed for activities of daily living (ADLs) who required assistance with grooming and personal hygiene.Findings Include: R34's quarterly Minimum Data Set (MD) dated 4/28/26, identified R34 had severe cognitive impairment with diagnoses which included: Alzheimer's disease, anxiety and depression. R34's MDS identified R34 was dependent on staff for eating, oral hygiene, personal hygiene, and dressing. R34's care plan revised 5/13/26, identified R34 had self-care performance deficit related to Alzheimer's disease and dementia along with Impaired balance and weakness. R34 required total assistance of one with oral care and had own teeth in good condition. During telephone interview on 6/8/26 at 2:30 p.m., family member (FM)-A indicated they did not think staff routinely brushed R34's teeth. FM-A stated I think they do floss occasionally, but do not brush R34's teeth often enough. During observation on 6/9/26 at 7:06 a.m., nursing assistant (NA)-A was in R34's room attaching a sling for the stand- up lift to R34 while R34 sat on the edge of bed with assistance. At 7:07 a.m., NA-B entered room and assisted NA-A with the stand-up lift for R34, then they assisted R34 to the bathroom. NA-B left the room, then NA-A assisted R34 with washing and drying upper half of body, then applied R34's shirt and deodorant. At 7:16 a.m. NA-B came into R34's room and completed perineal cares, applied new brief and pants. NA-B assisted NA-A to transfer R34 to her wheelchair. NA-B left the room, then NA-A combed R34's hair, and applied perfume. NA-A made R34's bed, bagged up soiled clothing, linen, and garbage. NA-A wheeled R34 out to the common area near the TV. NA-A then sanitized hands. NA-A returned to room and disposed of soiled clothing, linens and garbage in soiled utility room. NA-A did not offer or complete oral cares for R34. At 8:12 a.m. R34 was assisted to the dining room, where staff fed her breakfast. During interview on 6/9/26 at 8:56 a.m., NA-A verified he did not offer to complete R34's oral cares or to brush R34's teeth. NA-A indicated he usually worked pm shift until a few weeks ago and was not used to morning cares. NA-B stated his usual practice was to complete oral cares in the evening. NA-A stated it was important to complete oral cares, so residents did not get cavities. NA-A stated it was difficult to be observed completing cares and most residents had dentures, so he was used to rinsing and applying dentures for residents in morning. During interview on 6/9/26 at 11:04 a.m., registered nurse (RN)-A stated expectation was for oral cares and brushing of teeth to be done with morning and evening cares. RN-A indicated oral cares were important, so residents did not develop infections, and for good oral hygiene. Director of Nursing (DON) was not available for an interview. The facility policy titled Grooming For Residents, undated, identified All residents would receive the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing manifested in part by being fully groomed. Residents who had their own teeth should have their teeth brushed every morning, every evening and as needed (PRN).

Based on interview, observation and document review, the facility failed to provide a comprehensive assessment by therapy for 1 of 3 residents (R3) to ensure the resident received treatment and care in accordance with professional standards of practice.Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], identified R3 had severely impaired cognition with disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject), and no behaviors. R3 had limited range of motion/impairment upper extremity on one side. R3 required substantial/maximal assistance with toileting hygiene, lower body dressing, sit to stand, all transfers, partial/moderate assistance with personal hygiene, and used a motorized wheelchair/scooter for mobility. R3 diagnoses included non-traumatic brain dysfunction, heart failure, arthritis, Alzheimer's Disease, dementia, depression, psychotic disorder, Parkinson (neurological disorders causing movement problems, including slowness, rigidity, tremor, and balance issues). R3 had no falls since entry and re-entry to the facility. Height was 70 inches (5 feet 8 inches) and weight was 228 pounds. R3 was not receiving therapy (physical, occupational, restorative).R3's fall risk assessment dated [DATE], identified no falls in the last 90 days. Cognition status had changed in the past 90 days. R3 was easily distracted with periods of altered perception or awareness of surroundings. Episodes of disorganized speech, restlessness, and periods of lethargy. Mental function varied over the course of the day. Balance was unstable and was only able to stabilize with human assistance. R3's fall risk score was 20 (high risk 16-20). R3's care plan revised last on 3/17/26, identified he was at risk for falls related to festinating gait/balance (described as feeling like stuck in place, when initiating a step or turning) problems secondary to Parkinson's disease, psychoactive drug use, vision/hearing problems. R3 had a self-care deficit with increasing motor difficulty, chronic disease and decreased activity intolerance. Interventions included: -Date initiated 12/27/18, resolved 12/18/25, toilet use: required extensive assist of one. Often takes himself. Will call if incontinent episode.-Date initiated 12/18/25, and resolved: 2/4/26, transfer assist of two with bariatric SUL (stand up lift) (type of lift designed to assist individuals with limited mobility in transitioning from a seated to a standing position safely. Bariatric models are specially engineered to accommodate higher weight capacities, ensure safety, and comfort for larger patients). Sling size XL. Tendency to self-transfer.-Date initiated 2/3/26, fall on 2/1/26, with assisted transfer. No injury. Assist of two for transfer safety. OT referral.-Date initiated 2/4/26 (current), transfer assist of two with Medline SUL. Sling evaluation monthly.-Date initiated 3/5/26 (current), Fall on 2/21/26, with assisted transfer. No injury. Therapy referral. Recommendations: SUL (non-bariatric) assist of two Extra large (XL) sling on red loops. Leg and check straps donned and tightened. Sign posted in room. PT for strengthening. R3 had a self care deficit.Resident care sheet dated 3/5/26, identified R3 was a fall risk and transferred with a regular SUL assist of two and an XL sling.A staff communication report calendar dated 2/2/26 through 2/8/26, identified R3 required assist of two sit-to-stand with bariatric lift (SUL). Follow-up charting. Ensure sling straps were secure with all transfers.On 2/24/26, occupational therapy (OT) evaluation: change to Medline SUL assist of two (frame was different than the other bariatric SUL) less slack in the sling.Interdisciplinary teams (IDT) meeting notes for R3 identified:-On 12/23/26, clarification, R3 bariatric SUL due to illness and stature. -On 2/3/26, fall during transfer with standing lift. No apparent injury. Lift evaluation on weekend (W/E) by maintenance. Re-evaluation by biomed. OT referral on transfer safety. -On 2/24/26, weakness, fall from Medline SUL recent evaluation after last occurrence. Therapy evaluation. Full body lift (FBL) until evaluation. Await therapy recommendations (RECC).Staff education document undated, identified Lift Safety: take seriously can cause injury to resident and/or staff. Ensure proper lift for resident. Legs should be at widest when turning, go slow, and take your time. Lock brakes when hooking up and disconnecting slings, unlock brakes when operating lifts. Once you start lifting with the machine, as the straps are about to get tight, check again to ensure everything is in the correct place. R3's progress notes dated from 12/1/25, through 2/26/26, identified:-On 12/1/26 at 4:37 a.m., R3 required assist of two with SUL for all transfers. He had been able to call for help and express needs. R3 was extremely shaky while he tried to hold onto the SUL and sometimes had hard time properly aligning his legs on the SUL. Reassurance was provided. -On 12/1/25 at 1:25 p.m., with increased tremors, slurred speech, increased hallucinations referred to emergency room (ER) for evaluation. -On 12/1/25 at 2:40 p.m., returned from ER. Elevated kidney functions. FU with primary provider. -On 12/1/25 at 7:20 p.m., R3's upper and lower extremity involuntarily shaking/twitching intermittently. R3 voiced frustration with having to call for help as compared to four days ago when he could go the bathroom by himself. Educated resident for his safety to continue to call for help with transfers and toileting due to unsteadiness caused by shaking/twitching. Words continued to be somewhat garbled and difficult to understand the meaning of what he said. -On 12/4/25 at 5:26 p.m., R3 was sent back to ER at 11:50 a.m. for acute kidney failure. At 5:00 p.m. returned to facility. -On 12/9/25 at 1:54 p.m., urinary tract infection (diagnosed on [DATE]) currently on antibiotic. R3 back to baseline with strength, stands well with the SUL with assist. Tremors have significantly improved as have the complaints of hallucinations. -On 12/11/25 at 2:48 p.m., not currently on restorative therapy. R3 utilized standard wheelchair and ant-roll brakes. -On 12/19/25 at 7:04 p.m., back to ER at 3:10 p.m. and diagnosed with Influenza A and dehydration.-On 1/1/26 at 9:59 a.m., R3 has had a significant decline in health recently. -On 1/1/26 at 11:40 p.m., staff encouraged R3 use of the bathroom due to increased need for assistance with toileting. -On 1/5/26 at 4:26 p.m., Continued to require staff assist of one with toileting, transfers and cares due to some weakness and shakiness. -On 2/1/26 at 3:03 p.m., R3 laid on floor with upper body resting on aide lap. Alert, oriented, and denies pain. Sling loop slid off the stand lift. Aide stated he did not hit head and slowly lowered to the floor. Vitals taken, assessment completed, and full body lift was used with assist of two aides and nurse to sit resident in recliner. No injuries noted upon inspection. -On 2/21/26 at 9:05 a.m., R3 was being transferred off the toilet using the Medline SUL, hooked on correctly, legs gave out could no longer hold himself up any longer. Lift was lowered down and was caught with his arms elevated. Took three staff members to assist him out of the lift. Full body lift obtained with a crisscross lift sheet and assisted off the ground to his recliner. R3 was unable to state what happened. Assessed no injury. -On 2/22/26 at 2:00 p.m., had assisted fall yesterday. No complaints of pain. Has been transferring well with lift. No injuries noted from fall. -On 2/25/26 at 1:19 p.m., R3 has had increased weakness and decline in mobility due to Parkinson's. Required assistance of two staff and SUL for transfers. -On 2/26/26 at 2:40 p.m., discussed with R3 and wife PT evaluation for effective, safe transfer technique. Sign posted in room with reminders about plan specifics. Therapy for strengthening had been initiated.Observed on 3/12/26, located on R3's bathroom door, an undated sign, PT EDUCAUTION: TRANSFER PROCUDURE. Use standing mechanical lift. Assist of X2. Extra large (XL) sling. Place on RED loops when attaching to the lift. Ensure leg strap and check strap are donned and tightened. Educate R3 to hold on to the lift handles at all times.Occupational therapy (OT) evaluation dated 2/4/26, R3 was referred to OT for evaluation for safe transfer/lift implementation. R3's left upper extremity (LUE) fine motor coordination was impaired/limited due to left shoulder pain. He had previously used the standing lift and had an incident where the lift sling let go from the lift. OT observed R3 in the lift that was used during the incident. He did not use the knee blocks of lift due to limited range of motion (ROM) in bilateral knees and pain to support with standing. He was able to extend both knees withstanding as lift brought him up into a standing position. LUE required assistance to move hand to handle. It was noted that the potential for sling straps to be released without physical assist maybe possible when the bilateral upper extremities (BUE) were higher than the lift with this model. The hooks on the lift are approximately 1.0 centimeter (cm) apart. Therapist and rehab aide present R3 with the Medline Standing lift. This lift with the same lift sling was used to test transfer of the resident. The transfer was stopped in various positions to test the possibility of the strap releasing, each time the sling loops stayed intact, and space between lift hooks was less than 1/4 of an inch. R3 and therapist reviewed safety strategies with the lift sling. R3 appeared to be comprehend, and all transfers appeared safe with this lift selection. Clinical impressions: R3 would benefit from a change to midline standing lift due to his height and size. Nursing staff had been notified of recommended change.Physical therapy (PT) evaluation and plan of treatment dated 2/24/26, identified referred for physical therapy secondary to increased difficulty with transfers with patient falling from mechanical lift. R3 had been able to transfer using the standing bariatric mechanical lift and nursing had changed him to a full lift since fall. R3's functional assessment identified left side weakness, left shoulder pain, deficits in proprioception (the ability to sense the orientation, position, and movement of your body), demonstrated fear of anterior weight shift during standing, deficits in standing tolerance and balance, and required total dependence upon staff for transfers.Physical therapy caregiver note dated 2/24/26, Transfers: patient able to transfer safely with standing mechanical lift (non-bariatric) with assist of two. Place sling size XL on red loops when attaching to lift. Ensure leg strap and chest strap are donned and tightened.R3's occupational therapy evaluation and plan of treatment dated 2/24/26, identified he presented with impaired balance, fine motor coordination, groom motor coordination (use of large muscle groups), dexterity, mobility and strength resulting in limitations and/or participation restrictions in the areas of self-care mobility, and general tasks and demands. R3 demonstrated good tolerance to EZ stand lift, no overt signs of risk/decreased safety with mechanical sit-to-stand. He required cuing to not push back on EZ stand (brand of sit-to-stand) and noted decreased left shoulder function.During an interview on 3/1/7/26 at 10:20 a.m., registered nurse (RN)-A stated R3 had a change in condition and was unstable for months from December 2025 to February 2026, acute renal failure, Parkinson's, congestive heart failure, and influenza A. He was unable to stand, nursing judgement was used, and decided the next step was to be moved to a stand up lift. RN-A stated IDT and herself made this decision to transfer R3 with a bariatric SUL (does not have a lower leg strap) without a therapy assessment. The facility did not have access to therapy (OT or PT) from end of 11/25 until 2/3/26. Therapy would have been expected to complete R3's assessment but was not available. In an emergency, the nurse would have made the decision as to the next level the resident would have been moved to, and which lift to be used. Expectation would be for nursing to document the assessment in the progress notes. R3 transferred with the SUL without incident until the fall on 2/1/26, without injury. The care sheet was incorrect, indicated assist of one and should have been two, RN-A unsure how that was determined. A referral to therapy was made on 2/3/26, and R3 was switched to Medline SUL so there was less slack in the sling. R3 was not safe to transfer without hands on assist.During an interview on 3/17/26 at 12:30p.m., physical therapist (PT) and occupational therapist (OT) together. PT stated she had worked at this facility since 2/2/26, contracted through a physical therapy company. PT stated based on how much assistance a resident required with a transfer, a therapy evaluation would be needed to determine which lift would be appropriate and safe. R3 received an assessment from OT on 2/4/26. R3 was changed from the lift he had an incident on 2/1/26, to a midline standing lift due to his height and size. This type of lift would be safer: helped get him over the threshold of the doorways due to his weight of over 230 pounds, made sure he stood up correctly (had weak legs) and therefore would prevent falls and accidents. OT stated R3 required the use of the non-bariatric midline stand lift to be safe. This type of stand lift provided less space, a knee strap which he needed for a safe transfer and allowed him to stand upright better.During an interview on 3/17/26 at 5:20 p.m., administrator stated a therapy assessment should have been completed on a resident prior to the use of the lift for the best interest of the resident, to prevent falls, as well as any type of injury to resident or staff. Therapy would have determined the best and safest route to transfer a resident by assessing ergonomics, size/weight, proper way to lift and transfer a resident from one place to another, not one size fits all. R3 should have been assessed by therapy when his condition changed. Therapy was not available on site at the nursing home however, we had the availability to get therapy (OT/PT) if needed and could have reached out to a sister facility.During an interview on 3/17/26 at 5:30 p.m., director of nursing (DON) stated therapy assessed resident limitations, multiple tool choices for the job and determined the best tool. Therapy (OT/PT) were educated and had the expertise on how to assess the safest way to transfer, whether the resident could bear weight, tolerate it, and take into consideration the body mass index especially when high.Facility policy Fall Prevention Program dated 1/2009, identified falls are not a normal occurrence for the elderly. Falls that do not cause injuries may lead to fear of falling, which in turn may cause the residents to be less active. The goal of this program is to reduce the resident's risk of falling by identifying the elements of deficit and related safety issues by the following methods: -Assessment of the health-related components of falls. -Assessments and modifications of the environmental factors related to falls.-Assessment of Fall risk.-Prevention and rehabilitation. Physical and occupational therapy fall prevention responsibilities included: Assessments of activities of daily living (ADL), balance/endurance and assistive devices /abilities.

Based on interview, observation, record, and manufacturer's instruction review the facility failed to follow manufacturer's instruction for 1 of 3 (R4) residents during a transfer with a stand lift.Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had intact cognition and no behaviors. R4 required substantial/maximum assistance with shower/bathing, upper body dressing, personal hygiene, sit to stand, all transfers, dependent for toileting hygiene and lower body dressing, unable to walk and used a wheelchair for mobility. R4 was occasionally incontinent of bladder and always continent of bowel. R4's diagnoses included debility, cardiovascular conditions, hemiplegia/hemiparesis (weakness or paralysis on one side of the body), muscle spasms, osteoarthritis (protective cartilage that cushions the ends of the bones wears down over time), anxiety, height 62 inches (5 feet 1 inch), weight 238 pounds, body mass index (amount of body fat based on height and weight) 45.0 - 49.9 (over 40 was identified as morbid obesity). She was not receiving therapy (physical, occupational, restorative). No falls since admission. R4's care plan last updated on 1/29/26, identified high risk for falls related to obesity, osteopenia (reduction of bone density), chair bound, past fall, and polypharmacy (several medications taken each day). R4's muscle spasms better managed due to back on routine medications. Staff were directed to stay near but do not need to stay in bathroom. R4 had difficulty with elimination with staff close. R4 had an activity of daily living (ADL) self-care deficit related to hemiplegia and limited range of motion. R4 was unable to walk, and staff were directed to transfers with assist of one and bariatric SUL (stand up lift) (type of lift designed to assist individuals with limited mobility in transitioning from a seated to a standing position safely. Bariatric models are specially engineered to accommodate higher weight capacities, ensure safety, and comfort for larger patients), and assist with toileting and associated hygiene.Resident care sheet dated 3/5/26, identified R4 transferred with a bariatric SUL assist of one and assist of two as needed (PRN) and an XL sling. Additional instructions included, make sure lift legs are spread apart when transferring please.R4's fall risk assessment dated [DATE], identified R4 admitted to facility on 8/22/11, no falls, confined to a chair, required physical assistance to maintain balance while standing. Fall risk score 16 (high risk 16-20). R4's physical therapy (PT) evaluation dated 2/6/26, identified precautions: left hemiplegia, inability to use left hand to functionally hold onto lift, left knee extension lacking 40 degrees from full extension due to pain. She required total dependence with attempts to initiate transfers. R4 was unable to use left upper extremity (LUE) to hold handle for support during transfer but was able to maintain position safely in sling with arm stretched out laterally during transfers and able to use lower extremities to attain partial standing position to allow transfer from wheelchair to toilet. She will benefit from continued PT treatment and further assessment of transfers to ensure safety and recommendations as necessary.During an observation on 3/16/26 at 3:38 p.m., nursing assistant (NA)-A pushed a bariatric SUL into R4's room. R4 sat in her wheelchair. NA-A opened the legs of the lift machine and pushed it in front of the R4's wheelchair. NA-A placed a royal blue trimmed in black sling around R4 and secured the belt closed around R4's waistline. NA-A stood in front of wheelchair while R4 pulled the sling belt strap tight, and hooked red loops to the second metal loop on the lift. NA-A did not engage the lift's brakes. NA-A pushed the lift button, raised R4 out of the wheelchair. R4 held onto the hand grip with only the right hand. R4's left hand/arm was positioned horizontally straight out backwards from her body with thumb pointed down towards the floor. Her body was slightly slouched down, knees bent, butt pushed outwards from her body and appeared to hang from the lift. NA-A pulled the stand lift away from the wheelchair, moved the lever and brought the legs of the lift together, pushed the lift machine into the bathroom, and up to the toilet, pulled down R4's pants, and pushed the lift button to lower R4 onto the toilet. R4's feet remained on lift platform and hooked up to lift machine via leg sling. NA-A instructed R4 to turn on call light when finished. NA-A did not engage lift stand brakes prior to leaving the bathroom and closing the bathroom door. NA-A sanitized hands, exited R4's room and closed the door. Five minutes later, R4 placed call light on and NA-A entered her room. NA-A pushed the lift button to lift R4 off the toilet with the stand lift machine. NA-A did not open the legs of the machine, pulled R4 away from the toilet, completed peri cares with gloves on, and pulled up R4's pants. NA-A pushed pushed the lift out of the bathroom, opened the legs of the lift to clear the wheelchair, and pushed the lift button to lower R4 into her wheelchair. NA-A did not engage the lift's brakes prior to lowering R4 into her wheelchair. NA-A removed the sling loops from the SUL and the transfer belt from R4's waist. NA-A pulled the lift machine away from the wheelchair, placed legs of lift back together, adjusted R4's clothing, sanitized hands and removed the SUL out of R4's room. During the observation, NA-A did not ask R4 if she wanted the brakes on the lift machine and R4 did not ask for the brakes to be engaged.During an interview on 3/12/26 at 11:35 a.m., R4 sat in her room in a motorized wheelchair, well-groomed and stated she lived at facility for 14 years. She required assistance to the bathroom and used a stand lift to transfer. R4 felt some of the new staff lacked knowledge, did not seem to know what to do at times, and transferred her too fast with the stand lift. R4 stated she asked them to slow down many times as she did not want to risk her safety.During an interview on 3/16/26 at 4:45 p.m., NA-A stated she had received education on the SULs, the floor manager demonstrated them for staff. Staff were expected to use the brakes on the SUL before the resident was hooked up to the machine and to keep the brakes engaged while lifting the resident up. It was expected, the brakes were disengaged once staff were ready to move the lift. NA-A stated the brakes should have been engaged prior to lowering R4 onto the toilet, but R4 did not like the brakes engaged. NA-A stated R4 felt, trapped in, when brakes were engaged. NA-A stated it would have been important to use brakes on the SUL as the resident weighs down the machine, the wheels could have moved the machine away from R4 and resulted in an injury or fall. NA-A stated she received education, was told to engage the SUL brakes but did not do that with R4. NA-A stated she previously informed R4 it was important to engage the brakes but R4 still insisted she did not want them on. NA-A stated she used the brakes with all other residents and most likely should have used them while R4 sat in bathroom alone, and remained hooked up to the SUL, in case her feet moved the machine and caused a fall.During an interview on 3/17/26 at 10:20 a.m., registered nurse (RN)-A stated once staff positioned the SUL in front of the resident, they were expected to engage the brakes. The brakes would have helped lock the machine in place to avoid it from sliding side-to-side while the sling loops were being connected. The resident would be lifted off the chair, brakes disengaged and moved to the bathroom. Once resident was positioned in front of the toilet, RN-A expected the brakes were engaged before the resident was lowered onto toilet. If the resident remained connected to the lift machine via sling, RN-A expected the brakes remained engaged. This was important as resident movement could have caused the SUL to move away and may have resulted in an accident/fall. The staff were expected to remain in the room to help prevent an accident. When a resident refused brakes to be engaged on the SUL, RN-A expected staff to educate the resident, safety always overrode the resident's request.During an interview on 3/17/26 at 10:56 a.m., clinical engineering (CE) stated he completed the facility lift inspections annually and as needed. Staff would be expected to have applied the brakes on the SUL after they opened the legs of the machine to go around the chair/recliner and prior to resident being lifted to provide a stationary lift point.During an interview on 3/17/26 at 11:17 a.m., restorative aide (RA) stated mandatory education on facility lifts was provided to the staff yearly, last time was July 2025. The facility has three different types of lifts: standing frame, stand up/PAL (SUL), and the full body lift. All the facility lifts were covered during annual education via verbal, skill labs, observation, and hands on. RA had not reviewed the manufacture's guidelines, but had taught staff the education on the lifts according to what RA learned from previous staff. RA state, he learned as he went. A resident should have been assessed by therapy prior to lift machine use to provide safe transfers. The level of assistance a resident required would vary from resident to resident and was determined by a therapy evaluation. Staff would be expected to use the brakes on a lift during several actions, including when sling and loops were hooked up to the machine, so machine stayed steady, and things did not move around. Then, release the brakes before staff operated the motor and lifted the resident up so that the machine was able to move a bit to adjust to the resident. If a resident was left alone, hooked up to the lift machine such as in the bathroom, the brakes to the lift should have been locked to keep the lift in a safe position, for resident comfort and to avoid resident's feet from hanging down on the floor. If a lift machine was not locked while the resident was still hooked to the lift, accident and/or injury could happen if the resident tried to get off toilet and their feet moved the SUL. Some residents would be ok left alone attached to the lift machine with the brakes on in the bathroom based on their cognition level. R4's cognition was intact and RA trusted R4 to know what she wanted. Staff should have stayed in her room while she was in the bathroom if she allowed.During an interview on 3/17/26 at 1:00 p.m., RN-B stated staff would be expected to have used the brakes on the SUL once the machine was placed in front of the resident. The lift sling would be placed around the resident, attached to the machine, sling belt pulled snug around the abdomen, and slowly lift the resident up. The brakes would be released until the resident was moved to where they wanted to go then brakes were required to be on, especially when lowered down. When a resident remained on the toilet and hooked up to the lift machine, RN-B expected the brakes to remain on so the SUL did not shift or move and pull resident off where they sat. The brakes on the SUL remained on while resident was lifted or lowered to avoid movement of machine and protentional injury to resident or staff.During an interview on 3/17/26 at 5:20 p.m., administrator stated staff were expected to have placed the brakes on the SUL right after it was positioned in front of the resident. The brakes to the SUL must be on while the resident was lifted to have provided stability and traction. Failure to have the brakes on when lifting the resident up could result in the resident falling and getting injured. The only time appropriate to release the breaks on the SUL would be upon movement of the machine going from point A to point B, just like a wheelchair. After a resident was transferred to the toilet and remained attached to lift, the brakes should have been placed on. Failure to do so could have resulted in the lift moving, becoming unstable and placed the resident at risk for falls and/or accidents. During an interview on 3/17/26 at 5:30 p.m., director of nursing (DON) stated she would have expected staff to have applied the brakes on the SUL while a resident was hooked up to the lift, when being lifted or lowered. DON expected the brakes were released to move the machine. DON compared the stand lift to a wheelchair. Without the brakes on, if something moved and created motion, the machine and/or wheelchair would scoot out from under the resident's butt and could have resulted in a fall/accident. Application of the brakes was a must to provide a safe transfer.Alliance Stand Assist Lifts user manual dated 9/2013, identified lift and transfer from seated position.-fit sling as described in fitting stand assist sling. -Push lift towards patient. Open the base of the lift to go around the chair. Apply the brakes in both rear casters. -Position patient's feet on the foot platform and knees against the knee pad. -Attach the sling straps to the hooks. -Have patient's hands holding the handles. -Press the up button on the hand control. -Before the patient's body is lifted from the chair, stop and make sure the sling is secured and patient's knees are against the knee pad. -The patient should be comfortable with the pressure under the arms. If not, adjust the sling and try another loop option to release pressure. -Press the UP button until the patient's body has completely left the chair. -Transfer to another object can be done at this position without the patient attending a full standing position. -Release the brakes, close the base, and pull the lift until the patient's knees are locked in a standing position. -Lower the patient to the object intended.

Based on observation, interview and document review, the facility failed to ensure medications were administered according to the standard of practice for 8 of 13 residents (R1, R2, R4, R5, R7, R8, R9, R10) reviewed for medication administration. Findings include: R1's physician order summary dated 7/18/24, identified the following medications were ordered: Tylenol 325 milligrams (mg) by mouth give two tablets (650 mg) three times a day. Sucralfate give one gram by mouth two times a day. R2's physician order summary dated 8/15/24, identified the following medications were ordered: Calcium-Vitamin D 600-400 mg-unit by mouth daily. CertaVite Senior multivitamin by mouth daily. Cranberry 500 mg by mouth daily. Dalfampridine Extended Release 12 hour give 10 mg by mouth twice a day. Eliquis 2.5 mg by mouth twice a day. Famotidine 20 mg by mouth daily. Gabapentin 600 mg by mouth three times a day. Iron 325 mg by mouth daily every Monday, Wednesday, Friday. Lasix 20 mg by mouth daily every Monday, Wednesday, Friday. Losartan Potassium-Hydrochlorothiazide 100-12.5 mg by mouth daily. Metformin Extended Release 500 mg give two tabs (1000 mg) by mouth daily. Potassium Chloride Extended Release 10 milliequivalent (meq) by mouth daily every Tuesday, Wednesday, Thursday, Saturday, Sunday. Seroquel 50 mg by mouth twice daily. Tizanidine 4 mg by mouth daily. Toprol Extended Release 25 mg; Give 50 mg daily. R3's physician order summary dated 8/15/24, identified the following medications were ordered: Gabapentin 100 mg by mouth three times a day. Systane Ultra ophthalmic solution 0.4-0.3%; Instill 1 drop in both eyes three times a day. R4's physician order summary dated 9/5/24, identified the following medications were ordered: Benefiber powder; Give 3 teaspoons (tsp) by mouth daily. R5's physician order summary dated 8/28/24, identified the following medications were ordered:. Cholestyramine powder 4 grams (gm) by mouth in the morning for loose stools mix with 4-8 ounce orange juice- given at least one hour post other meds. Allopurinol 100 mg by mouth daily. Apixaban 2.5 mg by mouth twice daily. Aspirin 81 mg by mouth daily. Bumex 1 mg by mouth twice daily. Cipro 500 mg by mouth twice daily. Ferrous Sulfate 325 mg by mouth daily. Gabapentin 600 mg by mouth four times daily. Hydralazine 25 mg by mouth twice daily. Lexapro 20 mg by mouth daily. Losartan 50 mg by mouth daily. Metoprolol 75 mg by mouth twice daily. Multivitamin 1 tab by mouth daily. Rosuvastatin 5 mg by mouth in the morning. Vitamin C 500 mg by mouth twice daily. R6's physician order summary dated 9/10/24, identified the following medications were ordered: Letrozole 2.5 mg by mouth daily in the afternoon. R7's physician order summary dated 9/10/24, identified the following medications were ordered: Tylenol 1000 mg by mouth three times a day. R8's physician order summary dated 8/15/24, identified the following medications were ordered: Tylenol Extra Strength 500 mg; Give 1000 mg by mouth three times a day. R9's physician order summary dated 9/4/24, identified the following medications were ordered: Tramadol 50 mg; Give 25 mg by mouth three times a day. Tylenol 1000 mg by mouth three times a day. R10's physician order summary dated 8/15/24, identified the following medications were ordered: Tylenol 1000 mg by mouth three times a day. Buspirone 30 mg by mouth twice daily. R11's physician order summary dated 9/10/24, identified the following medications were ordered: Cosopt ophthalmic solution 22.3-6.8 mg/milliliter (ml); Instill one drop in right eye three times a day. R12's physician order summary dated 8/28/24, identified the following medications were ordered: Artificial tears ophthalmic solution instill one drop in both eyes three times daily. R13's physician order summary dated 9/4/24, identified the following medications were ordered: Ferrous Sulfate 325 mg by mouth twice daily. During an observation on 9/11/24 at 11:57 a.m., trained medication aide (TMA) stood by the medication cart outside of R1's room. TMA unlocked the cabinet in R1's room, removed Tylenol 325 mg two tabs and Sucralfate one tab and placed medications in a plastic medication cup. TMA locked the cabinet and pushed the cart down the hall and returned the cart near the nurses station. The following were observed on top of the medication cart: -Plastic glass with a white powder substance covering one quarter of the bottom of the glass. -Silver/white colored packet of a powder substance. TMA took plastic glass, the white powder substance, an empty plastic glass, silver/white colored packet and the medications in the plastic medication cup to the dining room. TMA set medication cup with the medications in it on the table in front of R1. R1 took the medications and placed the medication cup down on the table. TMA took the empty medication cup and threw the cup in the garbage by the kitchenette area. TMA entered kitchenette, poured a red colored juice into the glass with the white powder substance, poured orange juice into the empty glass, walked over to R4 and set the glass of red juice on table in front of R4. TMA picked up a straw, stirred the juice and walked over to another table and set the orange juice on the table in front of R5. TMA opened the silver/white colored packet of the powder substance and poured into the orange juice. TMA stirred the juice with a straw and exited the dining room. TMA did not observe R4 or R5 drink the juice in front of them. At 12:04 p.m., TMA walked to the medication cart, filled a glass of water, unlocked the cart and removed a plastic medication cup from the top drawer with an unknown number of medications in it. TMA walked to the conference room and gave R2 the medications in the cup. R2 took the medications and handed the cup back to TMA. TMA returned to the cart, signed out the medications on the computer and signed out Gabapentin in the controlled medication book for R2. TMA proceeded to push the cart to R6's room, unlocked the medication cupboard in R6's room, walked to the bathroom, put on two pairs of gloves, removed Letrozole 2.5 mg from cupboard, placed into plastic medication cup and gave to R6. TMA returned to the cart, sanitized hands and removed two plastic medication cups from the top of the cart. TMA wrote names on the cup and proceeded to R7's medication cupboard, removed Tylenol 500 mg two tabs, placed in cup and left the cup on top of medication cart. TMA moved the cart to the other side of the hall and opened R8's medication cupboard. TMA removed Tylenol 500 mg two tabs, placed in the other cup and placed the cup on the top of the cart. TMA brought cart up to main nurses station, crushed R7's medications, placed R8's medication cup in the top drawer of the cart. At the time, another plastic medication cup with an unknown number of medications in it was observed to be in the top drawer of the medication cart. TMA brought crushed medications in chocolate pudding to R7, R7 took the medications and TMA returned to the cart and sanitized hands. TMA signed out R7's medications on the computer, unlocked the cart, removed R8's medications and delivered to R8 in the dining room. R8 took the medications,TMA returned to the medication cart and signed out R8's medications on the computer. At 12:21 p.m., TMA pushed the cart to R3's room, removed Systane eye drops from R3's medication cupboard and administered the eye drops. TMA then removed Gabapentin 100 mg from the locked drawer on the cart, signed Gabapentin out of the controlled medication book, locked the medication cart, obtained a glass of water and gave medications to R3. TMA returned the cart near the nurses station and went to the other hallway to a different medication cart. TMA removed artificial tears from R12's medication cupboard, entered R12's room, put on gloves and administered eye drops to R12. TMA removed gloves, locked R12's medication cupboard and signed out medication on the computer. TMA proceeded to R13's medication cupboard, removed one iron pill and gave to R13 sitting in the hall. TMA returned to the medication cart and sanitized hands. TMA pushed the medication cart to R9's room, took a plastic medication cup and wrote R9's name on it. TMA removed half a tab of Tramadol from the locked medication drawer, placed in medication cup, signed medication out of controlled medication book, removed Tylenol 500 mg two tabs from R9's medication cupboard, locked the cupboard and placed cup in the top drawer of the cart. TMA pushed the cart to R10's room, unlocked the medication cupboard, placed Tylenol 500 mg two tabs in a plastic medication cup, wrote R10's name on the cup and placed the cup in the top drawer of the cart next to the other cups. TMA pushed the cart to R11's room, unlocked medication cupboard, gave R11 Buspar 15 mg, Tylenol 500 mg (two tabs), Cosopt eye drops, proceeded to lock the cupboard and pushed the cart to the nurses station. TMA removed R9's and R10's cups from the top drawer of the cart, stacked the cups on top of each other and administered the medications to R10 in the dining room. TMA walked to the other dining room and gave R9 the other cup of medications that had her name on it. TMA returned to the cart, sanitized hands and signed medications out of the computer for R9 and R10. TMA walked to the other medication cart, unlocked the cart, removed a plastic cup from the top drawer with an unknown number of medications, locked the cart, brought the cup to the dining room and administered the medications to R5. During an interview on 9/11/24 at 2:16 p.m., TMA stated medications were to be administered according to the five rights; right resident, right medication, right route, right time, right dose and to confirm the medications against the computer orders. TMA stated she attempted to give the residents their medications while in their room however sometimes she did not see them until they were in the dining room and would bring the medications to them there. TMA verified the facility expectations were to sign out medications once given. TMA confirmed she prepared medications in advance and placed them in the top drawer of the medication cart. TMA stated sometimes a resident did not want the medications right away while they were eating or she would put the medications in the drawer of the medication cart until she knew where the resident was. During an interview on 9/11/24 at 2:05 p.m., registered nurse (RN) stated she checked medications three times against the computer orders and ensured the five rights of medication administration were followed before giving a resident medications. RN verified controlled medications were to be signed out of the book only after the resident had received the medication. RN confirmed the facility expectations were to prepare only one resident medications at a time to limit the chance of medication errors. During an interview on 9/11/24 at 2:38 p.m., facility pharmacy consultant (PC) verified the expectation was medications would be prepared and administered to a resident at that time and not prepared ahead of time. PC stated preparing medications ahead of time and administering them later increased the risk for a medication error. During an interview on 9/11/24 at 3:10 p.m., director of nursing (DON) verified expectations of staff were to prepare medications for residents one at a time to prevent medication errors. DON confirmed the facility policy stated medications were not to be prepared ahead of time. Review of the Skills: Medication Administration -General Guidelines policy undated, directed authorized staff to ensure medications were administered as prescribed in accordance with the five rights of medication administration. The policy indicated for staff to take steps to eliminate interruptions and distractions during medication preparation. The policy also directed staff to prepare medications for one patient at a time and to stay with the resident until the resident took each medication completely. Review of the Reconciliation of Controlled Substances policy revised 3/24, identified all controlled substances would be documented in the controlled substance ledger immediately after being administered to the resident.

Based on observation, interview, and document review, the facility failed to comprehensively assess, discuss risks and benefits, obtain informed consent and attempt alternatives prior to use of bed rails for 9 of 12 residents (R11, R14, R3, R19, R6, R7, R16, R22, R188 ) reviewed who were observed to have bed rails raised while in bed. Findings include: R11 R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had severe cognitive impairment with diagnoses which included diabetes mellitus, anxiety and depression. R11's MDS identified R11 required supervision and touching assistance to roll left and right and substantial/maximal assistance for bed to chair transfer. R11's Safety assessment dated [DATE], identified R11 had cognitive impairment, adaptive devices for bed included positioning rail times two on bed, no risk for entrapment identified, and used adaptive devices with prompting. R11's care plan revised 4/23/24, identified R11 had self care deficit and required assistance for transfers and had a half positioning rail to aid in bed mobility. R11's medical record lacked a comprehensive bed rail assessment, including discussion of risks versus benefits, informed consent and attempted alternatives prior to bed rail use. During an observation on 7/17/24 at 7:06 a.m., R11 was lying on back in bed, eyes closed, covered with bed linen. R11 had one half bed rail raised on the side of bed facing the doorway. No movement noted. At 8:23 a.m., R11 remained in bed, bed rail continued to be raised, eyes closed and no movement noted. At 8:45 a.m., R11 was lying on back in bed, eyes open, no movement noted and bed rail remained raised. During an interview on 7/17/24 at 9:53 a.m., registered nurse (RN)-A indicated she was not aware R11 used a bed rail as R11 required two staff to transfer her and did not have much strength in her shoulder. RN-A stated she would refer to R11's care plan to determine if R11 used a bed rail. R14 R14's quarterly MDS dated [DATE], identified R14 had severe cognitive impairment and diagnoses which included: dementia, depression and diabetes mellitus. Indicated R14 required substantial/maximal assistance to roll left and right and for bed to chair transfers. R14's Safety assessment dated [DATE], identified R11 had cognitive impairment, adaptive devices for bed included positioning rail times one on bed, no risk for entrapment identified, and was aware of risk versus benefit of adaptive devices. R14's Safety assessment and medical record lacked documentation of who was informed of risk versus benefits. R14's care plan revised 5/3/24, identified R14 had self-care deficit related to dementia and mobility deficit and required stand by assistance with transfers, assistance for bed mobility and had a left side positioning rail to aide in mobility as needed (PRN). R14's medical record lacked a comprehensive bed rail assessment and attempted alternatives used prior to bed rail use. During an interview on 7/16/24 at 3:20 p.m. licensed practical nurse (LPN)-A indicated bed rails were used mostly so residents did not fall out of bed. In addition, the bed rails were used for residents to hold when they transferred out of bed. LPN-A stated R14 used her bed rail when she transferred out of bed. LPN-A stated bed rails would have been identified on the Resident Care Sheet for that resident. LPN-A reviewed the Prairie Meadow certified nursing assistant (CNA) Resident Care Sheet Side A form, updated 7/12/24, and confirmed the care sheet did not include bed rail use for R14. Review of Prairie Meadow CNA Resident Care Sheet Side A form, updated 7/12/24, lacked identification of bed rails or instructions for their use for R14, R11, R19, R6, R7, R16, R22, and R188. During an observation on 7/17/24 at 7:02 a.m., R14 was lying in bed, eyes closed, while holding a nebulizer to her mouth. R14 had half bed rails raised up on both sides of her bed. At 7:11 a.m. NA-A was in R14's room, standing next to her bed and asked R14 if she wanted to get up. R14 indicated she wanted to sleep in. R14's bed rail on the side towards the door was down when NA-A put it back into the raised position and then exited R14's room. During an interview on 7/17/24 at 7:14 a.m., NA-A indicated R14's rails were up sometimes. NA-A stated she had lowered R14's bed rail while she was in there and then raised it back up. NA-A indicated it was usually not identified on the Resident Care Sheet form to use bed rails however, when residents were in bed, staff usually raised their bed rails and NA-A was unsure of the reason why staff raised the rails. During an observation on 7/17/24 at 8:11 a.m., R14 remained in bed with eyes closed and covered with bedding. R14 had a bed rail up on the side by the wall and the bed rail towards the door lowered. During an interview on 7/17/24 at 7:37 a.m. NA-B stated bed rails were raised while residents were in bed to prevent them from falling out of bed. NA-B reviewed the Prairie Meadow CNA Resident Care Sheet form she carried and stated most residents did not have bed rails listed however, NA-B stated she raised most of the residents' bed rails while in bed to keep them safe. During a phone interview on 7/17/24 at 12:28 p.m., family member (FM)-A stated he was aware R14 had a new bed and had bed rails raised on the bed. FM-A indicated the facility staff had not discussed why R14 used bed rails and confirmed they had not discussed the risks versus benefits of using the bed rails. 45844 R3 R3's quarterly MDS dated [DATE], identified R3 had moderate cognitive impairment and diagnoses which included heart failure, hypertension (elevated blood pressure), and End Stage Renal Disease. Identified R3 required limited assistance for activities of daily living (ADL's) which included toileting, transfer and bed mobility. Prairie Meadow CNA Resident Care Sheet Side B form, updated 6/28/24, lacked instructions for R3's bed rail use. R3's care plan revised 5/2/24, identified R3 required staff assistance to transfer and reposition in bed and used bilateral positioning rails in bed to assist in self repositioning. R3's Safety assessment dated [DATE], identified R11 did not require any adaptive devices for the bed. R3's medical record lacked a comprehensive bed rail assessment, including discussion of risks versus benefits, informed consent and attempted alternatives prior to bed rail use. During an observation on 7/17/24 at 7:16 a.m., R3 was lying in bed, had one half bed rail raised on side of bed facing the doorway. NA-B entered R3's room to assist R3 with ADL's. R3 sat up in bed per self without using the bed rail. NA-B placed a walker in front of R3 which R3 used to stand up and walk into the bathroom. During an interview on 7/17/24 at 7:20 a.m., NA-B stated the bed rail on R3's bed was used to keep R3 from rolling out of bed. NA-B indicated she was unsure if R3 ever used the bed rail for positioning. R19 R19's quarterly MDS dated [DATE], identified R19 had severe cognitive impairment and diagnoses which included non traumatic brain dysfunction, dementia, and hypertension. R3 required extensive assistance for ADL's which included toileting, transfer, and bed mobility. Prairie Meadow CNA Resident Care Sheet Side A form, updated 7/12/24, lacked instructions for R3's bed rail use. R19's care plan revised 5/3/24, identified R19 required staff assistance to transfer and reposition in bed and was to use positioning rails in bed as needed. R19's Safety assessment dated [DATE], identified R19 had cognitive impairment, adaptive devices for bed included positioning rail times two (X 2) on bed, no risk for entrapment identified. Assessment lacked any indication R19 was able to use the bed rails independently. R19's medical record lacked a comprehensive bed rail assessment, including discussion of risks versus benefits, informed consent and attempted alternatives prior to bed rail use. During an observation on 7/17/24 at 8:43 a.m., R19 was lying in bed had one half bed rail was raised on side of bed facing the doorway. NA-B and NA-F entered R19's room to assist her out of bed. NA-F assisted R19 to a sitting position by placing one hand behind R19's back and the other under R19's legs and turned and lifted her to a sitting position on the edge of the bed. NA-F placed a transfer belt around R19's waist and NA-F and NA- B pivot transferred R19 into her wheelchair. During an interview on 7/17/24 at 8:48 a.m., NA-B stated the bed rail on R19's bed was supposed to be for R19 to assist with repositioning however, R19 was only able to use the rail on her good days and most days R19 was not able to use the rail at all. NA-B stated the usual practice was to leave R19's bed rail up whether she was able to use it or not. During a phone interview on 7/17/24 at 11:35 a.m., FM-B stated the facility had not informed her R19 had received a new bed with bed rails. In addition, FM-B stated the facility had not discussed benefits versus risk with her prior to R19 using the bed with bed rails. During a phone interview on 7/17/24 at 12:23 p.m., FM-C stated the facility had not informed her R3 had received a new bed with bed rails. In addition, FM-B stated the facility had not discussed benefits versus risk with her prior to R3 using the bed with bed rails. 49620 R6 R6's admission MDS dated [DATE], identified R6 had moderately impaired cognition and required extensive assistance with bed mobility and transfers. R6's diagnoses included dementia with psychotic disturbance, heart failure, compression fractures of vertebrae (bones in the spinal column). The MDS did not identify use of bed rails. R6's care plan revised 6/19/24, indicated R6 had confusion at times. R6's care plan revised 7/11/24, indicated R6 was at risk for falls related to mobility deficit, pain, incontinence and history of falls. R6's care plan revised 7/16/24, did not include bed rails. R6's safety assessment dated [DATE], indicated bilateral positioning rails. R6's electronic health record (EHR) lacked a comprehensive bed rail assessment, including discussion of risks versus benefits, informed consent and attempted alternatives prior to bed rail use. During an observation on 7/17/24 at 7:06 a.m., R6 was laying in bed, one half bed rail raised on side of bed towards doorway. During an interview on 7/16/24 at 11:45 a.m., NA-D stated the bed rail was always up on R6's bed to prevent R6 from falling out of bed. NA-D stated the bed rails were up on many residents' beds in the facility, just in case to prevent them from falling out of bed. R7 R7's quarterly MDS dated [DATE], identified R7 had severe impaired cognition and required extensive assistance with bed mobility and transfers. R7's diagnoses included multiple sclerosis, psychotic disorder with delusions and hallucinations, depression, anxiety. The MDS did not identify use of bed rails. R7's care plan revised 2/21/19, indicated R7 was a risk for falls related to poor balance, impulsive and poor decision making. R7's care plan revised 4/15/24, indicated staff assist as needed with bed mobility. Bilateral positioning rails as needed. Stand up lift and assist of one staff for transfers. R7's safety assessment dated [DATE], indicated bilateral positioning rails as needed. R7's EHR lacked a comprehensive bed rail assessment, including discussion of risks versus benefits, informed consent and attempted alternatives prior to bed rail use. During an observation on 7/16/24 at 8:51 a.m., R7 was laying in bed, one half bed rail were raised on both sides of the bed. R16 R16's quarterly MDS dated [DATE], identified R16 had moderately impaired cognition and required extensive assistance of two staff with bed mobility and total dependence of two staff and a hoyer lift for transfers. R16's diagnoses included multiple sclerosis, depression, paraplegia, obesity. The MDS did not identify use of side rails. R16's care plan problem revised 7/24/19, indicated R16 could appear to remember at times but may not and had two appointed guardians. R16's care plan problem revised 6/22/20, indicated R16 was at risk for falls related to diagnoses and medication regimen. R16's care plan problem revised 3/7/19, indicated two staff assist with bed mobility, bariatric bed due to height and stature. Bilateral positioning rails as needed. Hoyer lift and two staff assist for transfers. R16's safety assessment dated [DATE], indicated bilateral positioning rails. R16's EHR lacked a comprehensive bed rail assessment, including discussion of risks versus benefits, informed consent and attempted alternatives prior to bed rail use. During an observation on 7/17/24 at 7:06 a.m., R16 was laying in bed, the bed rails were raised on both sides of the bed. R22 R22's quarterly MDS dated [DATE], identified R22 had severe impaired cognition and required extensive assistance with bed mobility and transfers. R22's diagnoses included Alzheimer's dementia, anxiety, chronic obstructive pulmonary disease, heart failure, muscle weakness. The MDS did not identify use of side rails. R22's care plan problem revised 8/24/23, indicated R22 had impaired cognition function, impaired thought processes and impaired decision making. R22's care plan problem revised 11/14/23, indicated R22 was high risk for falls related to confusion, gait and balance problems and was unaware of safety needs and a history of self transfers. R22's care plan problem revised 11/7/23, indicated staff assist as needed with bed mobility, R22 turns self at times. Positioning rails as needed. Stand up lift and assist of one staff for transfers. R22's safety assessment dated [DATE], indicated no positioning rails. R22's EHR lacked a comprehensive bed rail assessment, including discussion of risks versus benefits, informed consent and attempted alternatives prior to bed rail use. During an observation on 7/17/24 at 7:05 a.m., R22 was laying in bed, one half bed rail was raised on the bed facing the doorway. R188 R188's face sheet identified admission on 7/11/24. R188's admission MDS dated [DATE] was in progress. R188's diagnoses included orthopedic aftercare following removal of internal fixation device, depression, fibromyalgia (disorder causing widespread pain, fatigue, sleep problems and cognitive difficulties). R188's baseline care plan dated 7/11/24, indicated R188 had a history of falls and required no setup or physical help from staff for bed mobility, one person assist for transfers, no bed rails indicated. R188's safety assessment dated [DATE], was not completed. R188's EHR lacked a comprehensive bed rail assessment, including discussion of risks versus benefits, informed consent and attempted alternatives prior to bed rail use. During an observation on 7/17/24 at 7:04 a.m., R188 was laying in bed, one half bed rail was raised on the bed facing the doorway. During an interview on 7/17/24 at 11:38 a.m., R188 verified the facility had not discussed the use of the bed rail or the benefits versus risk with her prior to using the bed rail. During an interview on 7/17/24 at 11:39 a.m., family member (FM)-D stated the facility staff had not discussed why R188 used bed rails, and confirmed they had not discussed the risks versus benefits of using the bed rail. During an interview on 7/17/24 at 10:20 a.m. unit manager RN-B indicated the facility received new resident beds within the last year and she had conversations with the sales representative regarding the safety of the beds. The representatives assured them residents would not be at risk for entrapment and the bed rails were regulatory sized for long term care use. RN-B stated the bed rails were not used to prevent falls, only for positioning purposes. RN-B indicated it was difficult to monitor if and when the bed rails had been raised by staff since all of the beds had the rails attached. RN-B confirmed they had not had discussions on the use of the bed rails with all residents or resident representatives, or received consents for the use of the bed rails as they had not considered them side rails; they were only used for positioning. In addition, RN-B confirmed they had not documented on any alternatives attempted prior to the use of bed rails. RN-B reviewed the Prairie Meadow CNA Resident Care Sheets for both side A and B, each of the residents' medical records including the Safety Assessments and care plans, for the residents identified and confirmed the above findings. RN-B clarified that if a safety assessment identified the resident used adaptive devices with prompting, that it should have only been when staff were present. RN-B clarified if the bed rails were care planned as needed (PRN) , it could have been interpreted differently, as each resident's needs were very individualized. During an interview on 7/17/24 at 12:52 p.m., director of nursing (DON) stated the facility had not completed any assessments of bed rail use since the facility had considered them positioning bars and not bed rails. In addition, DON confirmed the facility had not discussed risk versus benefits or obtained informed consent from residents or resident representatives prior to using the bed rails. DON indicated her expectation was that a comprehensive assessment, benefits verses risks and informed consent would have been completed as well as attempting alternatives prior to implementing the bed rails. DON stated she would have expected staff to update the resident care sheets and ensure that care plans were being followed. The facility policy titled Bed Rails reviewed 2/24, identified its purpose was to determine if resident use of bed rail use was safe and appropriate. The policy included upon admission, readmission, or change of condition, residents would be screened to determine the need for special equipment or accessories (bed rails, for example.) Staff would assess the resident to identify appropriate alternatives and assess for risk of entrapment, review the risks and benefits with resident and representative, obtain informed consent, and obtain a physician order, prior to installing bed rails. Staff would update the resident's care plan to reflect the use of the bed rails.

Based on observation, interview and document review, food and drinks were not served in a sanitary and clean manner for residents observed during dining observations in both dining rooms. This deficient practice had the potential to affect all residents who ate their meals in the dining rooms. Findings include: During an observation on 7/15/24 at 11:47 a.m., cook (C)-A began to set up the steam table in the A wing dining room. At 11:53 a.m., C-A began serving the lunch meal which included sloppy joes on a bun with gloves on. Each resident had a dietary card in a plastic sleeve in a binder. C-A would flip the pages with her right hand, then remove a bun with her left hand, open the buns with both gloved hands, then place them on the plates. C-A continued to touch the dietary cards, then the buns with her right hand, until all residents were served in the dining room. C-A did not sanitize hands or apply new gloves after touching each resident's dietary card in the binder. During an observation on 7/15/24 at 12:00 p.m., C-A was serving the B wing dining room. C-A again wore gloves, opened the binder, and touched each dietary card with her right hand, flipping each page open, then would open the buns with both hands and place on each resident's plate. C-A did not sanitize hands or apply new gloves after touching each resident's dietary card in the binder. During an observation on 7/16/24 at 12:01 p.m., nursing assistant (NA)-C served drinks to residents in the A wing dining room. NA-C held the glasses touching the rims with her bare hands. In addition, NA-B served drinks with bare hands and touched the rims of the glasses while filling them from the drink cart. NA-C filled a coffee cup in the kitchenette, held the cup with her fingers touching the rim of the cup, rubbed the rim of the cup with her finger, then proceeded to fill another coffee cup while touching the rim of that coffee cup. NA-B served a glass of chocolate milk after she touched the rim of the glass, filled a glass of juice, held the glass with her hand over the top of it touching the rim and then set it on the table for the resident. During an interview on 7/16/24 at 2:19 p.m., NA-B indicated she was not aware she had been touching the rims of the glasses prior to serving drinks to the residents. NA-B indicated it was important not to touch the rims of the glasses to prevent cross contamination. During an interview on 7/16/24 at 2:22 p.m., NA-C stated glasses should have been held at the bottom while serving drinks. NA-C indicated she was not aware she had been touching the rims of the glasses and cups while pouring drinks and serving them. NA-C stated it was important to not touch the rim of the glasses or cups to prevent cross contamination. During a telephone interview on 7/16/24 at 2:10 p.m., C-A confirmed she had touched the buns after touching the dietary cards and verified she should not have since she did not know what could have been on the dietary cards. C-A stated the binders with the resident's dietary cards were kept in the kitchenettes and were available to all staff for review of each resident's diet. C-A indicated gloves should have been worn when handling foods, like buns, and stated they had a process, that one gloved hand would touch the food and the other hand would touch the dietary cards. C-A indicated she could have also used a butter knife to flip the dietary card pages. C-A indicated it was important not to touch the cards, then the foods, since bacteria and left over foods could have been left on the dietary cards. During an interview on 7/16/24 at 2:30 p.m., dietary manager (DM)-A indicated her expectation was staff were to use a utensil or gloved hand when touching foods. DM-A stated she had instructed staff not to touch the dietary cards and food products with the same hand. DM-A stated this practice was important to prevent cross contamination. In addition, DM-A stated nursing staff should not have been touching the rims of the glasses when serving dinks for the same reason. During an interview on 7/16/24 at 2:40 p.m., director of nursing (DON) confirmed staff should not touch the rims of the resident's glasses or cups, since their hands could have been soiled and could lead to cross-contamination. The facility policy titled Food & Nutrition Services revised 4/22, identified its purpose was to ensure the service of safe food to all patients, residents, staff and visitors. The policy identified food would be served onto clean dishes with clean utensils and sanitary techniques. Hands would not touch the food unless properly covered with clean disposable glove. Gloves would be worn anytime employee would handle food that would not be later cooked, including bread. Gloves would be removed/changed anytime they became contaminated.

Based on observation, interview and document review, the facility failed to implement donning/doffing of personal protective equipment (PPE) practices for 2 of 2 residents (R9 and R32) and to ensure PPE was readily available for use to prevent the spread of infection for 1 of 2 residents (R9) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance dated 4/1/24, Implementation of PPE use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R9 R9's annual Minimum Data Set (MDS) dated [DATE], identified R9 had moderate cognitive impairment and diagnoses which included heart failure, dementia, and arthritis. Identified R9 required extensive assistance for activities of daily living (ADL's) which included toileting, transfer, and dressing. Indicated for activities of daily living (ADL's) which included toileting, transfer, and dressing. Indicated. Indicated R9 had a pressure ulcer. R9's care plan revised 6/17/24, indicated R9 had a stage two pressure injury on her right buttock. (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising). Care plan instructed staff to reposition resident every two hours and to provide treatments ordered per the medical doctor (MD). R9's weekly wound assessment dated [DATE], identified R9 had an open wound on her left buttock that measured one centimeter (cm) in length and 1.3 cm in width. Assessment identified that a Duoderm dressing was applied to R9's left buttock. During an observation on 7/15/24 at 11:27 a.m., there was an organizer on the front of R9's door to her room that contained gowns, masks, and gloves. There was no sign on the door or in the immediate area that identified R9 was on EBP. During an observation on 7/16/24 at 9:10 a.m., nursing assistant (NA)- E entered R9's room wearing no PPE and assisted R9 to transfer into her recliner by placing her right hand on R9's back as R9 stood up and guided R9 into the recliner. R9 stated she wanted to get back in her wheelchair so NA-E proceeded to place her right hand on R9's back as R9 stood up and guided R9 back into the recliner. During an interview on 7/16/24 at 2:44 p.m., NA-E verified she had not worn any PPE when she transferred R9 into her recliner. NA-E stated she only wore a gown and gloves when completing ADL's or toileting R9. NA-E stated she was unaware she should have worn a gown and gloves while transferring R9 into the recliner. R32's significant change MDS dated [DATE], identified R32 had moderate cognitive impairment and diagnoses which included history of neoplasm of the skin (skin cancer), anxiety, and depression. Identified R9 required extensive assistance for ADL's which included toileting, transfer, and dressing. R32's care plan revised 4/11/24, indicated R32 had a lesion to left ear removed. Care plan directed staff to monitor skin daily with care. Care plan lacked any indication of a dressing being used. R32's weekly wound assessment dated [DATE], identified R32 had an open area on his left ear that measured two cm in length and 0.8 cm in width and 0.8 cm in depth from an excision of a squamous cell carcinoma lesion (a type of cancer that starts as a growth of cells on the skin) that dehisced (a partial or total separation of previously approximated wound edges, due to a failure of proper wound healing.). Assessment identified that an Allevyn dressing was used to protect wound and prevent R32 from picking at the wound. During an observation on 7/15/24 at 12:09 a.m., there was no PPE located near R32's room for staff to wear while providing care for R32. During an observation on 7/16/24 at 9:30 a.m., registered nurse (RN)-B entered R32's room, applied gloves on her hands and proceeded to sit down next to R32 on the bed. RN-B peeled back the dressing to R32's left ear to assess R32's wound which contained a small amount of serosanguinous (thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells) drainage and RN-B replaced the dressing. RN-B did not wear a gown in the above observation. During an interview on 7/16/24 at 2:49 p.m., RN-B verified she had not worn a gown while assessing R32's wound to his left ear earlier that day. RN-B verified R32's wound was from an area of skin cancer which was surgically removed and then dehisced. RN-B stated the wound had been open since 7/11/24, however, EBP were only implemented a few hours ago. RN-B stated her expectation was EBP should have been implemented on 7/11/24, for R32. RN-B indicated the expectation was that all staff follow EBP while caring for R9 and R32 to prevent the spread of infection. During an observation on 7/17/24 at 7:29 a.m., NA-A entered R32's bathroom and applied only gloves, assisted R32 off the toilet, pulled up R32's pants and walked along side of R32 to his bed. NA-A removed her gloves and washed her hands. NA-A did not wear a gown. During an interview on 7/17/24 at 7:31 a.m., NA-A stated her usual process was to only wear gloves while caring for R32. NA-A stated the sign and PPE were new on the door and she was not aware she needed to wear a gown and gloves while toileting R32. During an interview on 7/17/24 at 12:44 p.m., director of nursing (DON) verified R9 and R32 had open wounds with dressings and required EBP. DON stated her expectation was that staff would have followed EBP per CDC guidelines to prevent the spread of infection. Review of a facility policy dated 2/10/24, identified the facility would implement enhanced barrier precautions for prevention of transmission of multidrug-resistant organisms. identified EBP employs targeted gown and glove use during high contact resident care activities. Indicated the facility would make gowns and gloves available immediately near or outside of the resident's room; PPE for enhanced barrier precautions was necessary when performing high-contact care activities.

Based on observation, interview, and document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 2 of 4 hallways observed for linen transportation. In addition, the facility failed to ensure proper hand hygiene and glove use was implemented during food preparation in 1 of 2 kitchenettes observed for food prep. Findings include: Review of Centers for Disease Control (CDC )guidance , Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. Further, CDC guidance Handwashing: A Health Habit in the kitchen dated 7/18/22, identified handwashing was one of the most important things that could be done to prevent food poisoning. LAUNDRY During an observation on 8/7/23 at 1:51 p.m., laundry aide (LA)-A exited the laundry room into the Prairie [NAME] Lane hallway pushing an uncovered cart which contained clean personal laundry that consisted of pants and shirts on hangers. Proceeded down the hallway, removed laundry from the uncovered cart and placed it in R1's closet. LA-A walked back into the hallway, removed laundry from the uncovered cart and placed it in R9's closet. Returned to the hallway, removed laundry from the uncovered cart and placed it in R3's closet. Returned to the hallway, removed more laundry from the uncovered cart and placed it in R29's closet. LA-A then placed the empty cart back back in the laundry room. During an interview on 8/7/23 at 1:59 p.m., LA-A confirmed the personal laundry she delivered had not been covered. Indicated her usual practice was to place personal items in a dignity bag and all other laundry was delivered to each resident room uncovered. She stated she was unaware of any expectations of laundry being covered during delivery to residents. During an observation on 8/8/23 at 2:06 p.m., LA-A brought out an uncovered cart from the laundry room into the Lady slipper Lane hallway which contained personal laundry that included pants and shirts hung on hangers. Proceeded down the hallway, removed laundry from the uncovered cart and placed it into R4's closet. Walked back into the hallway, removed laundry from the uncovered cart and placed it in R2's closet. Returned to the hallway, removed a garment dignity bag from the cart, brought the garment dignity bag into R19's room and placed the garments from inside the bag into R19's dresser drawer. LA-A brought the garment dignity bag back out into the hallway and placed it back on the clean laundry cart. Removed laundry from the uncovered cart and placed it in R4's closet. Returned to the hallway, removed laundry from the uncovered cart and placed it into R8's closet. LA-A returned to the hallway, removed laundry from the uncovered cart and placed it in R28's closet. HAND HYGIENE During an observation of Prairie Meadows Kitchenette on 8/7/23 at 5:12 p.m., nursing assistant (NA)-A removed two slices of bread from a bread bag using bare hands, grabbed a knife and placed peanut butter and jelly on the bread while touching the bread with bare hands. NA-A had not been observed to perform hand hygiene first. NA-A picked up the peanut butter and jelly sandwich with his bare hands, placed it on a plate and delivered it to R19. During an interview on 8/7/23 at 5:24 p.m., NA-A confirmed he had not performed hand hygiene prior to making a peanut butter and jelly sandwich for R19 while using his bare hands. Indicated the expectation was to perform hand hygiene prior to food preparation and to use gloves or tongs while removing bread from the bag. During an interview on 8/8/23 at 10:20 a.m., infection preventionist (IP) indicated she had seen laundry delivered uncovered. Stated her expectation was staff would cover laundry while being delivered. Indicated dignity bags should not have been brought into a resident's room due to the potential to spread infection. In addition, IP stated her expectation was for staff to wash their hands prior to food preparation and to wear gloves during food preparation to prevent the spread of infection. During an interview on 8/8/23 at 12:23 p.m., director of nursing (DON) stated her expectation was staff would wash their hands prior to food preparation and wear gloves when touching food to prevent the spread of infection. In addition, indicated her expectation was staff would cover laundry when it was delivered per CDC guidelines. Facility policy titled Infection Prevention/ Linen Handling reviewed 2/9/23, indicated cart covers should have been in place and used at all times to protect clean linen from contamination. Facility policy titled Household Kitchen Food Safety Practices reviewed 8/22, indicated all nursing staff would have been trained to understand basic food safety practices that must be followed while at work. Instructed staff to always wash hands prior to serving food and to always wear gloves when directly handling food the resident would have been eating.

Based on observation, interview and document review the facility failed to provide assistance with changing of soiled clothing for 1 of 3 residents (R8) who was dependent on facility staff for activities of daily living (ADL's). Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated R8 had moderate impaired cognition and had diagnoses which included heart failure, renal insufficiency and dementia. Identified R8 required extensive assistance of two staff with bed mobility, transfers, toileting, personal hygiene, dressing and had no behavior concerns. Review of R8's annual Care Area Assessment (CAA) dated 4/18/23, indicated R8 had moderate impairment and required staff assistance for ADL's. R8's care plan revised on 7/27/23, indicated R8 had self care performance deficits related to easily fatigued, shortness of breath with minimal exertion, unable to bear weight and joint pain. The care plan identified R8 required one to two staff assistance with dressing and ADL's. During an observation on 8/6/23 at 11:20 a.m., R8 was seated in his wheel chair. - at 12:31 p.m., R8 continued to be seated in his wheelchair in the dining room with other residents and was done eating his lunch which consisted of roast beef, mashed potatoes and gravy. R8 had a large brown spot on his chest of his gray shirt where he had dropped mashed potatoes and gravy while eating. - at 12:41 p.m., R8 was seated in his wheel chair in his room watching TV and continued to have a large brown spot on the chest area of his shirt. - at 4:18 p.m., R8 was in bed resting, when nursing assistant (NA)-B and NA-C assisted R8 into his wheel chair. NA-C exited R8's room and continued down the hallway to assist other residents. NA-A wheeled R8 out of his room and down the hallway towards the dining room area when R8 indicated he wanted to stay in his room. R8 continued to have a brown spot on the chest area of his gray shirt. NA-A turned R8 around in his wheel chair, brought him back to his room, gave him the call light, placed his bedside table next to him and left the room. NA-A and NA-C were not observed to offer or change R8's soiled shirt. - at 5:29 p.m., R8 was in the dining room for supper which consisted of [NAME] dean sausage and egg skillet. Nursing staff assisted R8 to eat and he continued to have the same soiled gray shirt on. - at 6:42 p.m., R8 was seated in his wheel chair in his room watching TV and continued to have a large brown spot on the chest area of his shirt and several pieces of potatoes, sausage and eggs were present all over his lap from supper. - at 7:14 p.m. R8 remained the same. - at 7:26 p.m. R8 remained the same and staff were not observed to offer or change R8's soiled clothing. During an interview on 8/7/23 at 3:05 p.m., NA-A stated R8 required staff assistance with his ADL's which included dressing due to his weak arm. During an interview on 8/7/23 at 3:17 p.m., registered nurse (RN)-A confirmed the above findings and indicated R8 required staff assistance with dressing and ADL's. Stated her expectations of staff were to make sure the resident's clothes were changed when soiled or dirty and to follow the care plan as written. During an interview on 8/7/23 at 5:15 p.m., the director of nursing (DON) confirmed the above findings and indicated R8 required staff assistance with all of his ADL's which included dressing. Indicated she would expect staff to make sure the resident's clothes were clean and to change their clothes when they were soiled or dirty. Stated it was not dignified or appropriate to wear dirty clothes and she would expect staff to follow the care plan. Review of the facility policy titled, Apparel and Dressing of Residents date 5/2010, indicated resident's will be cared for in a manner which enhances each resident's quality of life with regard to personal appearance. The policy further indicated resident's clothes would be clean and in good repair.

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R1, R3, and R29 ) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Current CDC recommendations 3/15/2023, revealed the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 was received at age 65 and older, based on shared clinical decision-making, should receive one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Indicated adults 19-[AGE] years old with chronic health conditions that have received only the PCV 13 should receive one dose of PCV20 or PCV15 at least one year after the last pneumococcal vaccine. Review of R1's facesheet, identified R1, age 91 was admitted to the facility on [DATE]. Review of R1's Minnesota Immunization Information Connection (MIIC) undated, identified R1 had received Pneumo- PCV13 on 2/4/2016, and the PPSV23 on 4/10/2001. R1's medical record lacked documentation R1 had been offered or received the PCV20 vaccine. Review of R 3's facesheet, identified R3, age 82 was admitted to the facility on [DATE]. Review of R3's MIIC undated, identified R7 had received Pneumo- PCV 13 on 2/25/2016, and PPSV23 on 5/15/2008. R3's medical record lacked documentation R3 had been offered or received the PCV20 vaccine. Review of R29's facesheet, identified R29, age 56 was admitted to the facility on [DATE], and had a diagnosis of Diabetes Mellitus (DM). Review of R29's MIIC undated, identified R29 had received PPSV23 on 6/14/2011. R29's medical record lacked documentation R29 had been offered or received the PCV20 or PCV15. During an interview on 8/8/23 at 10:20 a.m., infection preventionist (IP) confirmed R1, R3, and R29 had not been been offered or received the pneumococcal vaccinations as recommended by the CDC. IP stated the expectation was the facility would offer or administer all vaccinations per CDC recommendations. During an interview on 8/8/23 at director of nursing (DON) stated they had been planning to offer and administer the new pneumococcal vaccines to all residents who had not yet received them. DON confirmed R1, R3, and R29 had not been offered or received the pneumococcal vaccines as recommended by the CDC. Facility policy titled Pneumococcal Vaccine reviewed 7/22, indicated facility was committed to protecting it's residents against invasive bacteremia disease through vaccination with the pneumococcal polysaccharide vaccine. Directed staff to determine appropriateness of vaccine using the pneumococcal vaccine sheet to ensure the appropriate vaccine was administered. .

Based on interview and document review, the facility failed to ensure the surety bond contained sufficient funds to insure and protect the resident's trust funds reviewed for personal funds. This deficient practice had the potential to affect all 28 residents who had personal funds with the facility. Findings include: Review of the Travelers Casualty and Surety Company of America bond dated June 2, 2008, revealed the sum of the bond was not to exceed 20,000 dollars. On 8/07/23 1:58 p.m., the resident's personal funds accounts was reviewed with the patient financial representative (PFR). The PFR provided and confirmed a list of 28 residents had accounts and the total amount of the residents' accounts was in the amount of 49,483.96 dollars. During an interview on 8/8/23 10:50 a.m., the administrator and assistant administrator confirmed the surety bond was for 20,000 dollars. The administrator indicated his understanding was the surety bond covered each resident for 20,000 dollars and felt the facility had more than enough coverage for the resident's personal funds. During an interview on 8/8/23 at 12:09 p.m., the insurance specialist stated the total amount the surety bond would cover was 20,000 dollars for all resident accounts and verified it was not 20,000 dollars per resident. During a follow-up interview on 8/8/23 at 12:55 p.m., the adminstartor confirmed the surety bond did not cover the total amount of 49,483.96 dollars and indicated he would need to increase the surety bond amount for resident's personal funds. On 8/8/23, a policy regarding surety bond was requested however one was not provided.

Based on interview and document review, the facility failed to immediately report, no later than 2 hours, an allegation of abuse to the State Agency (SA) for 1 of 1 residents (R1) reviewed for abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .), and [CONDITION(S)]. The MDS indicated R1 was cognitively intact and required extensive assistance with activities of daily living (ADL's) which included: bed mobility, transfers, and toileting. R1's care plan dated 9/12/22, revealed R1 was a vulnerable adult and was vulnerable to abuse related to R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care pan directed staff to keep R1 separated from identified perpetrators of harm. The facility SA report dated 11/13/22, at 1:33 p.m. indicated R1 stated nursing assistant (NA-A) cursed at R1 under his breath when he entered R1's room to answer the call light. The report identified NA-A was reassigned to work on side A since R1 resided on side B of the facility. During an interview on 11/21/22, at 9:41 a.m. R1 stated on the evening of 11/12/22, NA-A entered his room to answer his call light and NA-A cursed at R1 under his breath. R1 indicated he reported the incident to NA-B on the morning of 11/13/22. During a telephone interview on 11/21/22, at 1:23 p.m. NA-B indicated on 11/13/22, at 10:00 a.m. R1 stated NA-A had cursed at R1 under his breath the prior evening while answering R1's call light. NA-B stated she had reported the allegation of abuse to registered nurse (RN)-A at 10:00 a.m. on 11/13/22. During an interview on 11/21/22, at 1:32 p.m. RN-A stated on 11/13/22, at 10:00 a.m. NA-B approached her and reported the allegation of abuse. RN-A indicated she had spoken to R1 and R1 informed her NA-A hollered at him. RN-A stated she was not certain what time she had reported the allegation of abuse to RN-B who then reported the allegation of abuse to the SA. During an interview on 11/21/22, at 1:43 p.m. RN-B stated on 11/13/22, around 10:00 a.m. R1 reported to NA-B that NA-A had cussed at R1 under his breath. RN-B confirmed she had been made aware of the allegation of abuse around 12:30 or 1:00 p.m. on 11/13/22. RN-B stated she had filed the report shortly after learning about the allegation of abuse. RN -B confirmed the report had been submitted to the SA late and not within the two hour time frame. During an interview on 11/22/22, at 9:15 a.m. director of nursing (DON) confirmed she had been notified of the allegation of abuse on 11/13/22, and had been in contact with RN-B however was uncertain of the time the initial allegation of abuse had been reported to NA-B. DON stated her expectation was for staff to report any allegation of abuse to the SA immediately but no later than two hours. During a telephone interview on 11/22/22, at 2:13 p.m. administrator indicated he had been notified of the allegation of abuse on 11/13/22, immediately when RN-B became aware of the allegation of abuse. Administrator stated he was unsure why the allegation of abuse was not reported within the two hours. Administrator indicated he felt the allegation of abuse was reported in a timely manner to the SA. A facility policy dated 7/15/22, titled Vulnerable Adult Abuse And Neglect Reporting defined a vulnerable adult as any person [AGE] years or older who is a resident or inpatient of a facility. The policy further defined abuse as use of repeated malicious oral, written, or gestured language toward a vulnerable adult are the treatment which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. The policy indicated that any allegation of abuse would have been reported immediately as soon as possible , but no longer than two hours after the initial knowledge of the incident that occurred had been received.

Based on interview and document review, the facility failed to complete a thorough investigation to assure residents were safe, following an allegation of abuse, for 1 of 1 residents (R1) investigated for abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), and [CONDITION(S)]. The MDS indicated R1 was cognitively intact and required extensive assistance with activities of daily living (ADL's) which included, bed mobility, transfers, and toileting. R1's care plan dated 9/12/22, revealed R1 was a vulnerable adult and was vulnerable to abuse related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan directed staff to keep R1 separated from identified perpetrators of harm. The facility five day State Agency (SA) report dated 11/16//22, at 1:40 p.m. identified R1 stated nursing assistant (NA)-A cursed at R1 under his breath when he entered R1's room to answer the call light. The report indicated NA-A was reassigned to work on side A since R1 lived on side B of the facility. The report identified the investigation had been completed on 11/15/22. During an interview on 11/21/22, at 1:43 p.m. registered nurse (RN)-B stated she spoke with NA-A at 2:00 p.m. on 11/13/22, regarding the allegation of abuse. RN-B confirmed NA-A was allowed to return to work without direct supervision on 11/13/22, due to staffing needs, while the facility was still in the process of investigating the allegation. RN-B stated NA-A had been scheduled to work on side A since R1 resided on side B. During an interview on 11/21/22, at 2:30 p.m. NA-A indicated on 11/13/22, RN-B spoke with him regarding the allegation of abuse. NA-A confirmed he had never been removed from the schedule and was allowed to return to work without direct supervision on 11/13/22. NA-A stated he had been reassigned to work on side A since R1 lived on side B in the facility. During an interview on 11/22/22, at 9:15 a.m. director of nursing (DON) confirmed NA-A had been allowed to work without direct supervision while the investigation was still in process due to staffing needs. DON verified the investigation had been completed a few days later on 11/15/22. DON stated her expectation would have been all residents would have been protected while the facility was still in the process of investigating the allegation of abuse. During a telephone interview on 11/22/22, at 2:13 p.m. the administrator confirmed NA-A had been allowed to work unsupervised while the facility was still in the process of completing the investigation. The administrator stated he felt the protection plan was adequate since NA-A was reassigned to work on the opposite side where R1 resided. A facility policy dated 7/12/22, titled Appendix B- Long Term Care indicated if the vulnerable adult report involved an employee,the investigation team would determine the corrective action regarding the employee. The policy further indicated to prevent further potential abuse while the investigation was in process , at the discretion of the administrator/designee, staff may be put on suspension or probation during the investigation. .

Based on observation, interview, and document review, the facility failed to ensure dignity by removing facial hair for 1 of 3 residents (R31) who were dependent on staff for assistance with grooming and personal hygiene. Findings Include: R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's MDS further identified R31 required total assistance for personal hygiene, and extensive assistance with dressing and transfer assistance. R31's activities of daily living Care Area Assessment (CAA) dated 11/5/21, identified R31 required total assistance with grooming and bathing. R31's care plan revised 7/26/22, identified R31 had an activity of daily living (ADL) self-care performance deficit and required staff assistance to ensure personal needs were met due to poor follow through and insight related to Alzheimer's disease. R31's interventions included assistance of 1 for personal hygiene. On 9/6/22, at 1:00 p.m. R31 was sitting in her wheelchair in her room, dressed in street clothes with her door open. R31 had 5-6 approximately 0.5 to 0.7 centimeter (cm) long white course facial hairs above the right side of her mouth, and one approximately 2 cm long white hair on the center of her neck and a few approximately 0.3 to 0.5 white hairs scattered on her cheeks. At 5:26 p.m. R31 was in the dining room sitting with other residents and a staff member. R31 continued to have facial hair present. On 9/7/21, at 10:46 a.m. R31 was in the common sitting area with 2 other residents. R31 was dressed in street clothes and continued to have 5-6 approximately 0.5 to 0.7 centimeter (cm) long white course facial hairs above the right side of her mouth, and one approximately 2 cm long white hair on the center of her neck and a few approximately 0.3 to 0.5 white hairs scattered on her cheeks. On 9/7/22, at 2:28 p.m. during interview nursing assistant (NA)-B indicated R31 required staff to pretty much do everything for her now. NA-B stated R31 had a razor in her room, her usual practice was to remove facial hair every time she would see it. NA-B stated she had not removed R31's facial hair that morning, because she had not noticed any. NA-B indicated when R31 first moved the facility, she would tell staff she needed her facial hair removed and that R31 liked to have it removed, so they continued to assist her with this. On 9/7/22, at 2:36 p.m. registered nurse (RN)-A and surveyor observed R31 while she was lying in her bed. RN-A confirmed R31 had facial hair present. After RN-A left R31's room, she informed surveyor that staff were supposed to remove R31's facial hair by shaving during her morning cares. RN-A indicated it was important to assist R31 with facial hair removal as this was a dignity issue, and she expected the facial hair to be removed. RN-A indicated she would not want facial hair on her face. On 9/7/22, at 3:03 p.m. during a phone interview family member (FM)-A confirmed R31 liked to have her facial hair removed. FM-A indicated R31 had been obsessed over removing facial hair and always had a tweezers. FM-A again stated R31 would like to have her facial hair removed and it was important to her. On 9/8/22, at 7:19 a.m. NA-C and NA-D assisted R31 with morning cares. R31 continued to have facial hairs present. At 7:37 a.m. NA-C brought R31 into the bathroom then began to remove R31's facial hair with an electric razor that was in her bathroom. On 9/8/22, at 10:43 a.m. during interview director of nursing (DON) stated she had been made aware of R31's facial hair. DON indicated her expectation was that staff would shave R31 to remove her facial hair when it was present during morning cares. DON confirmed removing R31's facial hair was important for R31's dignity. DON also confirmed if residents were unable to tell staff they wanted facial hair removed it was the staff's responsibility to assist them. The facility policy titled Grooming Of Residents, undated, identified all residents would receive the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being manifested in part by being fully groomed. The policy procedures included shaving of women on Tuesdays and Fridays with their AM cares or as needed (PRN). The facility policy titled Shaving Male And Female Residents last reviewed 11/21, identified the policy was to improve the self-worth, dignity and well-being of each resident. The procedures for shaving female residents included shaving should be completed daily with AM cares and as needed.

Based on observation, interview, and document review, the facility failed to ensure three years of survey results were readily accessible for residents or visitors. This had the potential to affect all 38 residents currently residing in the facility and any visitors. Findings include: During an observation on 9/6/22, at 4:50 p.m The facility survey results were located in a folder on a bulletin board approximately three feet from the ground. The last survey results noted in the folder were from an abbreviated survey dated 5/14/20. A sign on the folder indicated the last three years of survey results were available upon request. In review of survey results from 7/19 to present the facility lacked survey results completed from 10/1/20, to 5/10/22. - 10/1/20, an abbreviated survey was completed - 10/19/21, an abbreviated survey was completed. - 6/21/22, an offsite revisit was completed. - 5/13/21, an abbreviated survey was completed - 12/14/21, an abbreviated survey was completed. - 1/20/22 an abbreviated survey was completed. - 7/1/22 an offsite visit was completed. - 5/10/22 an abbreviated survey was completed. During an observation on 9/7/22, at 8:42 a.m. the survey results in the folder on the bulleting board remained the same. During an interview on 9/8/22, at 11:30 a.m. director of nursing( DON) confirmed the survey results after 5/14/20, were not included in the folder on the bulleting board and were not readily accessible for the residents or visitors to review. DON stated her expectation was the folder would have been kept up to date. A policy on posting survey results was requested however, one was not provided.

Based on interview and document review, the facility failed to thoroughly investigate an allegation of staff to resident abuse for 1 of 2 residents (R5) reviewed for allegations of abuse. In addition, the facility failed to protect the resident and report to the State Agency (SA) the results of the investigation within 5 working days for 1 of 1 allegations of abuse reviewed. Findings Include: R5's quarterly MDS dated [DATE], identified R5 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MDS identified she did not walk and required extensive assistance with transfers, toileting and personal hygiene. R5's MDS identified she had no [CONDITION(S)], behaviors or hallucinations. R5's care plan revised, 4/27/22, identified R5 had an activities of daily living (ADL) self-care performance deficit due to poor follow through/insight related to Alzheimer's disease and dementia. R5's care plan interventions included to identify what staff were going to do before starting cares and to offer reassurance throughout cares. R5's interventions instructed staff to enlist additional staff assistance when needed, and R5 had perceived staff could be rushed or rough with cares at times. R5's interventions included assistance of one staff for personal hygiene, toilet use and transfer. Review of R5's progress notes dated 1/1/22, to 5/10/22, identified the following: -1/18/22, at 9:27 a.m. certified nursing assistant (CNA) went to do cares that morning and when CNA had R5 hooked up to the stand up lift, she noticed her balance was not steady. CNA placed her hand to the back of R5's head for support and R5 stated you slapped me. CNA apologized and reassured R5 she had placed her hand behind her head for support. Family member was updated. CNA was able to complete cares without any further concerns expressed from R5. Review of R5's Individual Grievance/Complaint Investigation Report form dated 1/18/22, instructed readers to refer to attached progress note from 1/18/22, at 9:27 a.m. R5's form identified licensed practical nurse (LPN)-A stated nursing assistant (NA)-C informed her R5 alleged NA-C had hurt her and NA-C denied the allegation. (LPN)-A notified R5's family member who had expressed no concerns. Registered nurse case manager (CM)-B was aware of the situation and assessed R5's back of her head on 1/18/22, at 10:42 a.m. and no injury was noted. The grievance form identified NA-C, LPN-A and R5 were interviewed. The facility's documentation lacked information to support a thorough investigation had been completed such as: protection of the resident by removing the alleged perpetrator from the facility during the investigation, completing further resident and staff interviews to ensure no other allegations existed and had not completed a 5 day investigation report to the SA. On 5/10/22, at 9:33 a.m. NA-C indicated she had been assisting R5 with cares by herself when R5 made the allegation of abuse. NA-C stated she informed R5 she had not hit her, completed R5's cares and assisted her out of her room. NA-C indicated she reported the allegation to LPN-A right away. NA-C stated she was not aware of what had been done with the allegation once it had been reported. On 5/10/22, at 9:53 a.m. during a telephone interview LPN-A confirmed NA-C had informed her R5 reported she hit her. LPN-A indicated she had informed the charge nurse CM-B immediately. LPN-A stated she believed the allegation was not accurate however the facility should have investigated it to see determine if it was true. LPN-A stated she had interviewed R5 after the allegation had been made however she could not recall what R5 had said. On 5/10/22, at 1:15 p.m. CM-B reviewed the grievance form and confirmed R5 reported NA-C had slapped her. CM-B indicated LPN-A had assessed R5 right away, determined no harm had been done and CM-B reported the allegation to the licensed social worker. During a follow-up interview on 5/10/22, at 2:43 p.m. CM-B confirmed R5's statement which alleged she had been hit by NA-C was an allegation of abuse. CM-B explained she had checked R5 for injury after the allegation had been made and interviewed NA-C and LPN-A. CM-B confirmed a thorough investigation had not been completed due to the timing of the assessment of R5 and timely interviews of the two staff involved. On 5/10/22, at 2:26 p.m. director of nursing (DON) stated when R5 had made allegations of abuse staff were expected to take them seriously however indicated R5 had delusions. DON confirmed R5 had not made false accusations in the past of staff hitting or slapping her. DON stated LPN-A and CM-B had assessed and interviewed R5 after the allegation had been made. DON confirmed R5's report of being slapped by staff was an allegation of abuse. DON stated the staff handled the and would have expected staff to file a VA report if R5 had a red mark or repeated the allegation when interviewed. DON stated she believed filing a grievance form was appropriate in this situation in place of reporting the allegation to the SA since the facility still had a paper trail and had spoken to the family directly. DON confirmed the facility had not reported the allegation of abuse to the SA. On 5/10/22, at 1:34 p.m. administrator stated he expected staff to report allegations of abuse to the SA and to him. Administrator confirmed he had not been notified of the allegation of abuse made by R5 and verified the report had not been made to the SA. On 5/10/22, at 2:26 p.m. director of nursing (DON) confirmed R5's statement you hit me was an allegation of abuse. DON stated LPN-A and CM-B had assessed and interviewed R5 and R5 had not repeated the allegation. DON indicated since R5 never made the statement again, she believed the staff handled the allegation appropriately. On 5/10/22, at 3:05 p.m. during exit interview, administrator confirmed the facility had not thoroughly investigated R5's allegation of abuse. The facility policy titled Vulnerable Adult Abuse And Neglect Reporting dated 7/6/21, identified abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. The facility attached Appendix B-Long Term Care (Nursing Home), undated identified an investigation included the charge nurse or DON would conduct a physical examination of any alleged victim(s) immediately. The appendix also identified the investigation may include interviewing all persons associated with the situation, residents who had the potential to have had similar situations, medical records and physical assessment. The appendix further identified if the vulnerable adult report involved an employee, the investigation team would determine the corrective action regarding the employee and to prevent further potential abuse while the investigation was in process, staff may be placed on suspension or probation during the investigation and the outcome of the investigation would determine retention of termination of the involved staff.

Based on interview and document review, the facility failed to ensure incidents of potential abuse were immediately reported to the State Agency (SA), no later than 2 hours after knowledge of the allegation when the event that caused the allegation involved abuse, for 2 of 2 residents (R2, R5) reviewed for allegations of potential abuse. Findings Include: R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS indicated R2 required extensive assistance with transfers, toileting, personal hygiene and physical help with bathing from two staff. R2's care plan revised 4/20/22, identified R2 had a self-care deficit related to generalized weakness and deconditioning due to recent illness and cancer diagnosis. R2's care plan interventions included assistance of two staff with all personal hygiene and bathing assistance. R2's care plan identified R2 was vulnerable to abuse due to various diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R2's SA report submitted 4/19/22, at 12:11 p.m. identified the allegation of abuse had occurred 4/19/22, at 10:15 a.m. The description of the allegation identified at 8:45 a.m., nursing assistant (NA)-A and NA-B had reported R2 refused her bath and NA-A stated R2 had reported she had tried to drown her last week. At 10:15 a.m. R2 informed the nurse on duty she did not feel safe and believed NA-A would harm her. The facility SA report identified the allegation of physical abuse occurred on 4/19/22, at 8:45 a.m. The SA report was submitted by the facility on 4/19/22, at 12:11 p.m., three hours and 26 minutes after the allegation was made. On 5/10/22, at 10:13 a.m. NA-A indicated R2 expressed a concern on 4/19/22, about the bath she had received the week before. NA-A stated when staff attempted to prepare R2 for her bath, she refused the bath and informed NA-A she had tried to drown her during her bath the week before. NA-A indicated she had reported the allegation to registered nurse clinical manager (CM)-A within 15 to 20 minutes after R2 made the allegation. NA-A stated CM-A and the facility licensed social worker (LSW)-A spoke to R2 and NA-A was sent home. On 5/10/22, at 10:27 a.m. R2 indicated staff treated her with respect and dignity for the most part however R2 identified she had one incident awhile back which occurred during her bath. R2 stated the staff member who provided the bath was very rude to her. On 5/10/22, at 10:56 a.m. registered nurse (RN)-A confirmed R2 was able to make her needs known. RN-A stated two staff were used to perform R2's cares, because she thought some false accusations had been made at one time. On 5/10/22, at 12:58 p.m. CM-A confirmed NA-A and NA-B had informed her R2 had made an allegation NA-A had attempted to drown her during her bath the week before. CM-A confirmed she had reported the allegation late to the administrator and to the SA as she was busy and believed R2 needed some time before CM-A interviewed her. CM-A stated the usual process of reporting an allegation of abuse was to contact the administrator right away, file a report to the SA, complete an incident report and remove the staff from the schedule they had been identified as an alleged perpetrator. CM-A indicated R2 had episodes of confusion and had made allegations in the past which were unsubstantiated. R5 R5's quarterly MDS dated [DATE], identified R5 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MDS identified she did not walk and required extensive assistance with transfers, toileting and personal hygiene. R5's MDS indicated she no [CONDITION(S)], behaviors or hallucinations. R5's care plan revised, 4/27/22, identified R5 had an activities of daily living (ADL) self-care performance deficit due to poor follow through/insight related to Alzheimer's disease and dementia. R5's care plan interventions included to identify what staff were going to do before starting cares and to offer reassurance throughout cares. R5's interventions instructed staff to enlist additional staff assistance when needed and R5 had perceived staff could be rushed or rough with cares at times. R5's interventions included assistance of one staff for personal hygiene, toilet use and transfers. R5's care plan identified R5 was vulnerable to abuse due to age, related cognitive decline and diagnoses. Review of R5's progress notes dated 1/1/22, to 5/10/22, identified the following: -1/18/22, at 9:27 a.m. certified nursing assistant (CNA) after CNA had R5 hooked up to the stand up lift while providing morning cares, she noticed R5's balance was not steady. CNA placed her hand to the back of R5's head for support and R5 stated you slapped me. CNA apologized and reassured R5 she had placed her hand behind her head for support. Family member was updated. CNA was able to complete cares without any further concerns expressed by R5. Review of R5's Individual Grievance/Complaint Investigation Report form dated 1/18/22, instructed readers to refer to attached progress note from 1/18/22, at 9:27 a.m. R5's form identified licensed practical nurse (LPN)-A stated NA-C informed her R5 alleged NA-C had hurt her and NA-C denied the allegation. LPN-A notified R5's family member who had expressed no concerns. CM-B was aware of the situation and assessed R5's back of her head on 1/18/22, at 10:42 a.m. and no injury was observed. The facility lacked documentation the administrator had been notified about the allegation and the allegation had been reported to the SA. On 5/10/22, at 9:33 a.m. NA-C indicated she had been assisting R5 with cares by herself when R5 made the allegation of abuse. NA-C stated she informed R5 she had not hit her, completed R5's cares and assisted her out of her room. NA-C indicated she reported the allegation to LPN-A right away. On 5/10/22, at 9:53 a.m. during a telephone interview LPN-A confirmed NA-C had informed her R5 stated she hit her. LPN-A indicated she had informed the charge nurse CM-B immediately. LPN-A stated she believed the allegation was not accurate however the facility should have reported it. On 5/10/22, at 1:15 p.m. CM-B indicated the usual process for handling allegations of abuse included reporting to the administrator right away, the director, family, resident and communicating to the IDT team. CM-B reviewed the grievance form and confirmed R5 reported NA-C had slapped her. CM-B indicated LPN-A had assessed R5 right away, determined no harm had been done and reported the allegation to the licensed social worker. During a follow-up interview on 5/10/22, at 2:43 p.m. CM-B confirmed R5's statement which alleged she had been hit by NA-C was an allegation of abuse. CM-B confirmed the allegation of abuse had not been reported to the administrator or reported to the SA due to the timing of it. CM-B explained she believed since the allegation had been reported to her right away, she was able to speak to LPN-A and NA-C right away and had checked R5 immediately for injury and as a result, she had not reported it. On 5/10/22, at 2:26 p.m. director of nursing (DON) stated when R5 had made allegations staff were expected to take them seriously however indicated R5 had delusions. DON confirmed R5 had not made false accusations in the past of staff hitting or slapping her. DON stated LPN-A and CM-B had assessed and interviewed R5 after the allegation had been made. DON confirmed R5's report of being slapped by staff was an allegation of abuse and would have expected staff to file a VA report if R5 had a red mark or repeated the allegation when interviewed. DON stated she believed filing a grievance form was appropriate in this situation in place of reporting the allegation to the SA since the facility still had a paper trail and had spoken to the family directly. DON confirmed the facility had not reported the allegation of abuse to the SA. On 5/10/22, at 1:34 p.m. administrator stated he expected staff to report allegations of abuse to the SA and to him. Administrator confirmed he had not been notified of the allegation of abuse made by R5 and verified the report had not been made to the SA. The facility policy titled Vulnerable Adult Abuse And Neglect Reporting dated 7/6/21, identified abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. The facility attached Appendix B-Long Term Care (Nursing Home), undated identified if a situation of suspected maltreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . If the information gathered indicated a vulnerable adult report may be necessary, the Administrator on-call was notified immediately by telephone. The report must be filed no later than two (2) hours after discovery of the incident including abuse. The appendix also identified if the initial information supported the need for a Vulnerable Adult report to be submitted to the Office Of Healthcare Facility Complaints (OHFC), then the reporter would file a report immediately but no later that 2 hours after the concern had been identified. The Administrator or the Administrative designee (Administrator on-call) was to be notified immediately prior to filing the OHFC report. The facility policy titled Patient/Resident/Client (Non-Hippa Privacy) Grievance, dated 5/12/21, identified when applicable, a vulnerable adult and/or elder justice report would be filed with the appropriate agency. The policy instructed to see Vulnerable Adult Reporting Policy and Procedure.

Based on interview and document review, the facility failed to thoroughly investigate an allegation of staff to resident abuse for 1 of 3 residents (R1) reviewed for allegations of abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 as cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R1 had no behaviors and required extensive assistance with bed mobility, dressing, toileting and personal hygiene. The MDS indicated R1 required total assistance with transfers and supervision with eating. A facility incident report dated 3/18/21, at 11:30 a.m. completed by registered nurse (RN)-B identified R1 stated licensed practical nurse (LPN)-A took her snack mix away from her and stated that is enough for you, you know your sugars have been way too high all week. LPN-A stated to nursing assistant (NA)-A she is diabetic do not give her any more. R1 stated it was cruel. R1 indicated she requested assistance to be repositioned and LPN-A positioned herself in front of her, pointed her finger at her, and stated that is enough of that. R1 stated it brought me to tears. Immediate action taken by RN-B was an interview completed on 3/18/21, at 11:38 a.m. with NA-A. NA-A indicated she witnessed LPN-A slide the bag of snack mix away from R1 and in a gruff voice stated you need to quit eating that you have had enough sweets, your sugars were sky high today. Review of Incident Report # 3, submitted to the state agency (SA) on 3/18/21, at 12:22 p.m. indicated R1 stated the incident occurred on 3/17/21, and reported the incident to RN-A on 3/18/21. R1 stated LPN-A grabbed her snack from her and told her that she had enough sweets for the day due to her high blood sugars. R1 indicated she hollered out for help in the parlor and LPN-A approached in front of her and pointed her finger while stating now that is enough of that. Review of Investigation Status Report identified the investigation was submitted on 3/23/21, at 10:34 a.m. The facility sent out education to staff to be mindful of allowing residents to exercise their rights on 3/18/21. Education was provided to NA-A regarding whenever she felt uneasy during an interaction she had witnessed or believed a staff member was rough in tone to let the charge nurse, resident care coordinator, social services, or the director of nursing (DON) know immediately so follow up can occur. The report lacked documentation of attempts made by the facility to interview other residents or additional staff that worked on the same unit where R1 resided. During an interview on 5/12/21, at 3:05 p.m. LPN-A verified RN-B contacted her by telephone on 3/18/21, and completed a brief interview regarding the incident on 3/17/21. LPN-A stated she was removed from work on 3/18/21, and allowed to return to work on 3/23/21. During an interview on 5/12/21, at 3:30 p.m. NA-A indicated during an incident on 3/17/21, she witnessed LPN-A state roughly and loudly to R1 you should not be eating any more of that (party mix). NA-A stated R1 had told her in private she better not eat this or that because LPN-A would yell at her. NA-A indicated the staff received reminders regarding resident rights via email and at shift huddles, however stated she had not received any education or training regarding the situation. During an interview on 5/13/21, at 8:40 a.m. RN-B identified interviews were completed with R1, LPN-A and NA-A. RN-B also stated the facility social worker (SW) proceeded with the investigation and RN-B was not aware of any other interviews that had been completed. During an interview on 5/13/21, at 11:15 a.m. SW confirmed the incident on 3/17/21, would possibly be considered emotional or mental abuse. SW stated the staff nurse involved was removed from the schedule until a thorough investigation had been completed. SW stated the staff nurse was allowed to return to work on a different unit for a designated period of time. SW confirmed two staff and R1 were interviewed during the investigation and verified no other staff or residents had been interviewed. The facility had not thoroughly investigated the allegation of staff to resident abuse due to no additional residents or staff on that floor had been interviewed about potential abuse or resident cares being provided by staff to prevent re-occurrence. During an interview on 5/13/21, at 12:10 p.m. DON identified R1 stated she felt disrespected during the incident on 3/17/21, and therefore the allegation had been filed as mental and emotional abuse. LPN-A had been taken off of R1's unit where she resided for at least 30 days to give each other a break. DON confirmed no interviews were completed with any other residents and verified the facility missed this step in the investigative process. DON stated the investigative interviews were typically approached as a team which included the DON and charge nurses assisting however, the interviews were usually completed by the SW. Facility policy titled CHI (Catholic Health Initiatives) St. [NAME] Health Appendix B - Long Term Care: (Nursing Home) revised last 7/2019, identified investigation may include, but not limited to: interviewing all persons associated with the situation.

Based on observation, interview and record review the facility failed to ensure interventions were implemented to reduce the risk of falls for 1 of 3 residents (R1) who were investigated for falls. R1 fell from her recliner when the facility failed to unplug her recliner and keep the recliner control out of reach, which resulted in a [MEDICAL CONDITION]. The facility had implemented corrective action 7/26/20, so the deficient practice is being issued at past non-compliance. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], identified R1 was cognitively intact and had [DIAGNOSES REDACTED]. R1's MDS identified she required total assistance with transfers, and extensive assistance with bed mobility, dressing and personal hygiene and had functional limitation in range of motion with impairment on one side of her upper and lower extremities. Further, R1's MDS identified R1's balance during surface to surface transfer was not steady and was only able to stabilize with human assistance and identified R1 had no history of falls. R1's Fall Care Area Assessment (CAA) dated 6/20/20, identified R1 had potential for falls and had difficulty maintaining sitting balance and impaired balance with transfers. The CAA identified R1 had agitation behavior, and cognitive impairment and indicated falls would be addressed in her care plan. R1's care plan, revised 7/29/20, identified she was at risk of falls due to confusion. R1's care plan listed various interventions which included total assistance of 2 staff with a full body lift(FBL), signs present as reminder and recliner to be unplugged when staff not assisting and in use. The facility Riverwalk CNA (certified nursing assistant) Care Sheet Side A, updated 7/24/20, identified R1 required FBL with assistance X 2. The care sheet instructed staff to unplug recliner when in use and bed control was to be out of reach and placed behind headboard. On 7/29/20, at 9:13 a.m. R1 was seated in her wheelchair in her room, dressed in street clothes. Nursing assistant (NA)-A and licensed practical nurse (LPN)-A were in her room, wearing gown, gloves, mask and eye protection. They assisted R1 using the full body lift to raise her up from the wheelchair to the bed. NA-A and LPN-A then assisted R1 by checking for incontinence and positioning her in bed. R1's bed control was placed on the far right side of R1's head board. A sign was on the wall above the bed which instructed staff to keep bed control out of reach, staff only, and another sign on the wall which instructed staff to unplug chair when R1 was in it. R1's recliner was on the opposite side of the room not plugged in. At 12:01 p.m. R1 was in her wheelchair in her room, door slightly ajar, with her bedside table in front of her, eating her meal with her call light next to her. R1's Fall assessment dated [DATE], identified R1 had no history of falls. R1's fall assessment identified R1 required assistance with elimination, was confined to a chair, was unable to attempt balance without physical help, had 2 or more health conditions and received 3 or more medications which put R1 at high risk for falls. R1's Safety assessment dated [DATE], identified risk factors to include impairment in ADLs and dependence on a care provider. Safety interventions included gripper socks when in bed and non-slip footwear when out of bed. The assessment identified R1 had no history of falls and used a beriatric bed. Review of R1's Progress notes 7/20/20, to 7/21/20, included the following: -7/20/20, at 1:43 p.m. R1 found on floor lying on her left side in front of her recliner. The recliner was in full upright position. R1 indicated she was trying to lift her head up so she could breath easier. R1 stated she hit her head on the wheelchair. Transferred to bed, and once in bed R1 indicated she had left hip pain with movement. Intervention; Recliner to be unplugged at all times when R1 occupied it. -7/20/20, at 8:00 p.m. complained of left hip pain, controlled with pain medication. R1 had no shortening of left limb and no rotation of left foot. R1 flaccid on left side to due left [MEDICAL CONDITION] stroke. -7/21/20, at 5:07 a.m. complained of pain in both left and right hips first part of the night and was given [MEDICATION NAME] (pain medication). R1 stated pain was mostly relieved and had been well since 1:00 a.m. -7/21/20, at 8:53 a.m. in extreme pain of left hip. R1 agreed to be seen at emergency room and was transferred to emergency room at 7:30 a.m. for further assessment. -7/21/20, at 11:01 a.m. emergency room nurse alerted nurse at 10:15 a.m. that R1 had been taken by ambulance at 9:45 a.m. to hospital in Fargo due to left [MEDICAL CONDITION]. R1's hospital discharge summary dated 7/24/20, identified R1 was at emergency department to hospital admission from 7/21/20, to 7/24/20 and listed R1 slipped from her chair and landed on her left back, then complained of left hip pain since then, and x-ray showed a femoral neck [MEDICAL CONDITION] hip. The summary identified R1 had a closed left [MEDICAL CONDITION], with surgical procedure of hemiarthroplasty. R1's untitled Incident Report dated 7/20, indicated NAR went to nurses station to alert nurse that R1 was found on floor lying on her left side in front of her recliner. The recliner was in full upright position. R1 indicated she was trying to lift her head up so she could breath easier. R1 stated she hit her head on the wheelchair. Transferred to bed, and once in bed R1 indicated she had left hip pain with movement. Immediate action included notifying administration and VA filed due to not following the care plan. Injury post incident was a left trochanter (hip) fracture. On 7/21/20, R1 assessed in emergency room for left hip pain, left femoral neck fracture identified per x-ray. Predisposing factors included confused and high anxiety, constantly yelling out, hitting objects against objects and moving around. The facility investigation dated 7/23/20, indicated R1 had fallen out of the chair when she kept pushing the control too much and R1 felt the fall was her fault. R1's care plan was updated, as prior to it only stated to keep remote out of reach for safety and did not accurately include directions for unplugging the recliner when in use as posted signage and the care sheet directed. R1 had stated her left hip hurt, but always hurt, but now was really hurting worse with pressure on it in bed. The report indicated a sign had been present in R1's room which listed please unplug chair when resident is in use. The investigation identified the nurse had spoken with trained medication aide (TMA)-A and NA-B who had assisted R1 to the recliner. TMA-A reported she did not pay attention to the sign posted to unplug the chair in her room and reported she had last seen the remote in the pocket of the recliner. TMA-A had been educated to review signs and double check resident care sheet prior to leaving room. NA-B indicated he was not aware he was supposed to unplug R1's recliner. NA-B was educated to follow each resident's care sheet and double check care sheet prior to leaving room. The investigation further included a nurse reviewed in morning report the importance of looking for signs in rooms and to double check the resident care sheets. On 7/21/20, a reminder had been also placed in the facility communication book to unplug R1's chair. The investigation further identified the director of nursing (DON) had sent a reminder to all facility staff which directed all staff providing direct patient care were required to carry and utilize resident care sheets throughout their shift. The communication also directed unit managers to remind staff at the beginning of shift to ensure all staff had the care sheets with them. R1's care plan was updated to unplug recliner when in use to reflect the interventions listed on R1's care sheets. Also, the report identified DON completed a spot check of NA-B on 7/21/20, at 11:00 a.m. to assure he had his care sheet on him. On 7/29/20, at 11:35 a.m. during phone interview family member (FM)-A indicated he had been informed of R1's fall in which R1 had grabbed the control for the recliner, and the chair bent forward. FM-A indicated R1 went to Fargo for surgery. FM-A indicated he felt it was an accident, and would like to know what the facility was doing moving forward to prevent R1 from falling again. On 7/29/20, at 10:02 a.m. NA-A indicated today was the first day she had worked with R1. NA-A indicated she carried the care sheet, and indicated the form had all instructions needed to care for the residents. NA-A indicated they had a huddle meeting every morning at 9:45 a.m. and indicated during the meeting they went over any changes on the individual resident care sheets. On 7/29/20, at 11:37 a.m. trained medication aide (TMA)-A confirmed she had assisted with R1's transfer into her recliner the day she fell . TMA-A indicated about an hour later R1 was on the floor. TMA-A confirmed she had not unplugged the recliner. TMA-A indicated she thought the sign was on R1's wall instructing them to unplug the recliner when she was in it, the day she fell . TMA-A indicated licensed practical nurse (LPN)-B provided her education after the fall to follow the care plans and to watch for signs on the wall. On 7/29/20, at 12:01 p.m. R1 confirmed she had fallen out the recliner. R1 indicated she was trying to adjust her head in the recliner. R1 indicated she had used the control and was unable to stop it, then she fell out and hit her head on the wheelchair. R1 indicated she had not used the recliner since the fall. On 7/29/20, at 12:05 p.m. LPN-A indicated she was aware R1 had fallen out of her recliner when she used the control to try to lift her head up. LPN-A indicated it was in R1's care plan that she cannot be in the recliner with the control prior to the fall, but was unsure if the recliner was to be unplugged when in use. LPN-A indicated she also was not sure if R1's sign was on the wall prior to her fall, but indicated they had spoken about R1's interventions since the fall. On 7/29/20, at 1:23 p.m. registered nurse clinical coordinator (CC)-A confirmed R1 had intermittent confusion. CC-A confirmed R1 fell from her recliner when she had gotten the recliner remote with her right hand and the chair raised up and she fell . CC-A confirmed it was identified R1 had a fracture the next day. CC-A confirmed staff had not followed R1's care sheet and care plan when R1 fell from the recliner. CC-A indicated she understood the remote for the recliner was put in the side pocket of her recliner, within reach for R1. CC-A indicated staff reviewed R1's interventions after the fall during the huddle meetings, which all staff attended for their units including; licensed and unlicensed staff, social services and activities. CC-A reviewed the huddle report sheet documentation and verified after R1's fall, the huddle report included to remember bed controls and to unplug the chair for R1. CC-A indicated she felt there was some confusion between the care plan and care sheets since the care sheet instructed staff to unplug R1's recliner the time of the fall, and the care plan instructed staff to keep the recliner control out of reach. CC-A confirmed she would expect the staff to follow the care sheets. CC-A confirmed R1 was confused and anxious intermittently and felt that was the reason for unplugging the recliner. On 7/29/20, at 2:03 p.m. NA-C she was aware R1 had fallen out of her chair. NA-C indicated R1 was very anxious and on her call light often. NA-C indicated when she worked on the floor she carried her CNA Care Sheet and it told her everything to care for the residents. NA-C indicated they had daily huddle meetings and at that time they provided reports on the residents. On 7/29/20,at 2:07 p.m. NA-D indicated before R1 fell , she was anxious and would use the call light every 5 minutes. NA-D indicated R1 fiddled with the call light, and R1 was unaware if she was even using it to call someone at times. NA-D indicated they were provided education to prevent falls often, which included R1 and staff discussed R1's fall interventions every morning in report, and also reviewed any changes. On 7/29/20, at 2:37 p.m. NA-F indicated staff were supposed to unplug R1's recliner when she was in it. NA-F indicated R1 would fiddle with her bed control and recliner control. NA-F indicated staff were now supposed to also put R1's bed control out of reach. NA-F indicated staff used the care sheets to know how to take care of the residents. NA-F removed her care sheet from her pocket and reviewed with surveyor R1's instructions to unplug her recliner when in use, and to keep her bed control out of reach and behind the head board. NA-F indicated during their daily huddle meetings, they reviewed how to specifically take care of residents, like unplug R1's chair. On 7/29/20, at 2:46 p.m. registered nurse (RN)-A indicated R1 had a lot of anxiety with intermittent confusion. RN-A indicated she thought on the day of R1's fall, the remote had been placed on her right side, and confirmed R1 had function on her right side. RN-A indicated putting R1's recliner remote in the pocket on the right side of the recliner was not out of her reach. RN-A indicated the facility had been educating staff about using their care sheets, reviewing them at huddle reports and R1's interventions were on their white board. RN-A indicated the care coordinators were responsible to make sure the nursing staff carried their care sheets at the beginning of their shifts. RN-A confirmed she would expect the nursing staff to follow their care sheets. RN-A indicated if there were any changes to the care sheets, these were discussed at the beginning of every shift until they were updated on the care sheets weekly. On 8/3/20, at 8:23 a.m. during phone interview, DON confirmed the day of R1's fall, staff had not followed R1's care plan, which resulted in R1's [MEDICAL CONDITION]. DON indicated TMA-A and NA-B had transferred R1 into R1's recliner, and NA-B had placed the recliner remote in the pocket of the recliner, and the recliner was left plugged in. R1 had then used the remote, raised herself up, then fell out of the recliner. DON confirmed R1 had a sign posted in her room at the time of the fall, which instructed staff to unplug the recliner when R1 was in it. DON confirmed at the time of R1's fall, the CNA care sheet had instructed staff to unplug R1's recliner. DON indicated immediately after the fall, education was provided to TMA-A and NA-B about always being visual for signs in the room, and follow the care sheets. DON indicated she sent an e-mail out to all staff to look at the care sheets, and if questions to ask their nurse. The e-mail titled Care Sheets, dated 7/21/20, to all facility staff included a reminder that all staff providing direct patient care must carry and utilize resident care sheets throughout their shift. The e-mail further indicated if they had questions to ask their unit leader or supervisor. The e-mail also instructed unit supervisors to ensure all staff had them at the beginning of their shift, before report started. The facility's untitled communication form dated 7/20/20, to 7/26/20, identified as used in huddle meetings with all staff included instructions to be given daily for R 1 to unplug recliner and bed control out of reach at all times. An untitled memo, signed by CC-B on 7/31/20, indicated after DON sent e-mail on 7/21/20, Prairie Meadows neighborhood added it to the huddle board for all shifts to review for one week, discussed this at daily huddle for one week. The memo also identified the Unit Leader checklist was updated to include staff have their care sheets at the beginning of shift and the care sheets are reviewed and updated every Friday. If changes were made during the week, these were written on the care sheet, highlighted and discussed at reports. The memo identified spot checks were being done by licensed staff to ensure staff had their care sheets with them. The facility policy titled Fall Prevention revised 3/19, identified the purpose was to to identify patients at risk for falls, initiate interventions to prevent falls and thus reduce the risk of injury due to falls. The policy further identified that prevention of falls was the responsibility of all personnel and if the patient was found to be at high risk for falls, the fall protocol would be initiated. The policy indicated patients would be checked per individualized plan of care and signage would be placed in patient rooms to educate and inform patient, family and visitors of safety precautions as necessary. Staff would receive education on falls at orientation and as needed to ensure understanding the importance of injury prevention. The past non-compliance that began on 7/20/20, was verified during the 7/29/20, to 8/3/20 onsite visit and was corrected by the facility on 7/26/20 when DON e-mailed all staff a reminder that all staff providing direct patient care must carry and utilize resident care sheets throughout their shift. Throughout the following several days, education was provided to all staff through report meetings, communication board and change in nursing checklists to assure all staff had their care sheets. The verification of corrective action was confirmed by interview with a variety of nursing staff, resident and observation of residents who were at risk of falls, in addition to documentation of education provided to the nursing staff.

Based on interview and document review the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident (R1) who required such emergency care and had a full code status of CPR. CPR was not initiated, which resulted in an immediate jeopardy situation and R1's death. In addition, the facility policies and practices did not reflect current standards of practice for CPR which placed 7 of 7 residents (R2, R3, R4, R5, R6, R7, R8) whose code status' were identified as full code CPR placing these residents at immediate risk in the event their heart stopped and breathing ceased. The immediate jeopardy began on [DATE], at 12:30 a.m. when it was identified the facility failed to provide CPR to R1, when he was found on the floor with no pulse, respirations and blood noted under his head and died . In addition, the facility policy identified and was verified through mutliple interviews the facility would only implement CPR if an arrest was witnessed despite the resident wishes to have CPR initiated which placed 7 of 7 residents (R2, R3, R4, R5, R6, R7, R8) at immediate risk in the event their heart stopped and breathing ceased. The director of nursing, administrator and vice president were notified of the immediate jeopardy at 5:09 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], at 4:38 p.m. but noncompliance remained at the lower pattern scope and severity level E, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], identified R1 was cognitively intact and had [DIAGNOSES REDACTED]. R1's MDS further identified R1 required extensive assistance with bathing, dressing, hygiene and locomotion on and off the unit. R1's baseline care plan, unsigned and undated, identified R1 was admitted [DATE], and required physical assistance with hygiene, toilet use, dressing and bathing. R1's care plan further identified he was alert and cognitively intact. R1's care plan failed to identify advanced directives or code status. R1's physician orders [REDACTED].>Review of R1's progress notes dated [DATE], to [DATE], identified the following: -[DATE], social services documentation identified no health care directives made, full code status -[DATE], 12:30 a.m. R1 found on floor with no respirations or pulse. R1's pupils rolled back, fixed and dilated and R1's skin cool and cyanotic. R1 had gash to back of head with small pool of blood noted. Administrator and emergency room medical doctor updated of unexpected death. R1's progress note failed to identify CPR had been initiated on [DATE], following the American Heart Association's recommendations when a residents's wishes are identified as full code status. R1's emergency room physician (ERP)-A progress note dated [DATE], identified R1 was cool with mottled skin and no CPR was initiated to R1 due to lividity and cold to touch, pronounced dead at 1:00 a.m. and he was notified by the facility at 12:50 a.m. (R1 had been found with no respirations or pulse at 12:30 a.m. and no CPR was initiated.) On [DATE], at 8:40 a.m. LPN-C indicated she would not initiate CPR for a resident who was full code if their eyes were fixed and dilated and their skin was cold. On [DATE], at 8:52 a.m. resident care coordinator (RCC)-A indicated the usual facility practice was to complete CPR if a resident was a full code and it was a witnessed event. RCC-A confirmed if a resident was found and had no signs of life, no respirations and no pulse, CPR would not be initiated, even if the resident was full code. RCC-A indicated that was explained to the residents at each care conference. RCC-A again confirmed the only time CPR would be initiated was during a witnessed event. On [DATE], at 10:54 a.m. licensed social worker (LSW)-A indicated she discussed residents code status at care conferences. LSW-A indicated she told residents and resident representatives that if a resident was full code, in the event nursing staff saw the resident going into [MEDICAL CONDITION], or their heart stopped, the staff would start CPR, send them to the emergency department and notify the family. LSW-A indicated she would tell them if it was not witnessed, and their heart had already stopped, the facility staff would not start CPR. LSW-A confirmed she informed the residents if they were found when their heart had already stopped, the licensed staff would not start CPR. On [DATE], at 11:43 a.m. registered nurse (RN)-C indicated she understood the facility policy was to do CPR if the event was witnessed. RN-C indicated she did not believe CPR would be initiated if the event was not witnessed, and indicated she could not be sure how long the person had been down. RN-C confirmed the usual facility practice was not to do CPR if the event was not witnessed or if a resident had an order for [REDACTED].>On [DATE], at 12:49 p.m LPN-D indicated on [DATE], she had been notified by RN-E, who was not working at the time, R1 was on the floor. LPN-D and RN-E ran down to R1's room, as RN-E brought the vitals pole. (device on wheels with blood pressure cuff and other equipment). LPN-D indicated when she entered the room she saw R1 was cyanotic and his pupils were fixed and dilated and his arms were cool to the touch. LPN-D indicated staff did not perform CPR for R1. LPN-D indicated they called the administrator and the emergency room physician, who then came over and assessed him. LPN-D indicated staff moved R1 from the floor to the bed prior to the physician's arrival. LPN-D indicated if they witnessed a resident stop breathing, staff would start CPR and call 911. If a resident was found unresponsive, staff would check for signs of life, do a sternal rub, check pupils and listen for a heart rate. During a follow up interview, on [DATE], at 2:25 p.m. LPN-D indicated when she assessed R1 on the floor, she checked immediately for a pulse and respirations. LPN-D indicated his lips and finger nails were cyanotic in color and his arms and hands were cool to the touch. LPN-D indicated she had not checked any areas for lividity (reddish to bluish-purple discoloration of the skin due to the settling and pooling of blood following death) LPN-D indicated she had asked her charge nurse, who also indicated they would not initiate CPR because R1 had no pulse or respirations and his eyes were fixed and dilated. On [DATE], at 2:00 p.m. the facility medical director (MD)-A confirmed he would expect CPR to be performed for a resident who was full code unless they found them with obvious signs that they had expired. MD-A indicated signs a resdient had obviously expired would included rigor mortis or pooling of the blood noted in the dependent skin when it is picked up. MD-A indicated he was not sure when the last time he had reviewed the facility policy for code status and indicated he was not sure if the facility had written criteria to determine if a resident was expired. MD-A indicated he had received a verbal report from the facility staff that R1 was found on the floor dead, and that he was dead awhile, but indicated he had not asked for any details. On [DATE], at 2:41 p.m RN-E indicated at the time of the incident, she had been off work with no walkie talkie, and was returning to the facility with food for the staff. RN-E indicated she had witnessed R1 lying on his floor with blood behind his head when she walked by R1's room and ran to the office to notify LPN-D. She grabbed some of the nursing assistants coming out of a room along the way. RN-E stated she followed LPN-D with the vitals pole, and indicated LPN-D came out of R1's room and stated he was gone, called the charge nurse and within a minute the charge nurse arrived. RN-E indicated R1 was lying on his side with his eyes closed, blood behind his head and was only wearing jogger style pants and regular socks. RN-E indicated R1 was not breathing, his skin was waxy, but not mottled and he was limp. RN-E indicated R1's skin did become mottled in color eventually, after he was in bed, at the time the emergency room physician assessed him. RN-E indicated she would initiate CPR for a resident who was full code if she saw the resident go down and found no pulse. RN-E stated she would check to determine if a resident was responsive or not, was not breathing, had no pulse and his eyes were fixed and dilated. RN-E indicated if the resident had no pulse, was not breathing and his eyes were fixed and dilated, she would not perform CPR. On [DATE], at 3:50 p.m. director of nursing (DON) indicated residents wishes for code level status were discussed on admission and at every care conference. DON confirmed she would expect CPR to be performed for a resident who had full code status if they saw a resident go down in front of them and had a cardiac event. DON indicated if the staff came across a resident who was clinically deceased , CPR woud not be initiated. DON indicated she would expect staff to check for pulse, respirations and the resident's pupils to determine if they should inititate CPR. DON confirmed the Code Blue 100 policy dated ,[DATE], was the current policy for CPR guidelines and indicated she would expect the staff to follow the policy. She indicated she was not aware of the current the American Heart Associations recommendations. DON confirmed the facility had 7 current residents who's code status' were full CPR which included R2, R3, R4, R5, R6, R7, and R8. R2's admission MDS dated [DATE], identified R2 was cognitively intact and had [DIAGNOSES REDACTED]. R2's Order Summary Report signed by physician [DATE], included an order for [REDACTED]. R3's admission MDS dated [DATE], identified R3 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. R3's Order Summary Report signed by physician [DATE], included an order for [REDACTED]. R4's quarterly MDS dated [DATE], identified R4 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. R4's Order Summary Report signed by physician [DATE], included an order for [REDACTED]. R5's admission MDS dated [DATE], identified R5 was cognitively intact and had [DIAGNOSES REDACTED]. R5's Order Summary Report signed by physician [DATE], included an order for [REDACTED]. R6's significant change MDS dated [DATE], identified R6 was cognitively intact and had [DIAGNOSES REDACTED]. R6's Order Summary Report signed by physician [DATE], included an order for [REDACTED]. R7's significant change MDS dated [DATE], identified R7 was moderately cognitively impaired and had [DIAGNOSES REDACTED]. R7's Order Summary Report signed by physician [DATE], included an order for [REDACTED]. R8's quarterly MDS dated [DATE], identified R8 was cognitively intact and had [DIAGNOSES REDACTED]. R8's Order Summary Report signed by physician [DATE], included an order for [REDACTED]. On [DATE], at 3:22 p.m. during a telephone interview R1's primary care physician (PCP)-A indicated he had contacted the facility to determine what had happened to R1. PCP-A indicated he had not asked the facility if they had performed CPR. PCP-A indicated he would of expected the staff to follow the American Heart Association guidelines and perform CPR for R1. The American Heart Association current guidelines dated (YEAR), identified: The American Heart Association urged all potential rescuers to initiate CPR unless a valid DNR order was in place; obvious clinical signs of irreversible death (e.g., rigor mortis (stiffening of the joints and muscles of a body a few hours after death, usually [MEDICATION NAME] from one to four days), dependent lividity (pooling of the blood causing purple or red skin discoloration), decapitation (head detached from body), transection (body cut in half), or decomposition (the body is is a state of rotting or decay)) are present; or initiating CPR could cause injury or peril to the rescuer. The facility policy titled Code Blue 100, revised ,[DATE], identified CPR would be performed if a resident indicated their wishes for resuscitation-Yes, and have some response when assessment criteria was performed. CPR would not be performed when the resident indicated their wishes for resuscitation-No, residents who had been assessed by the licensed nurse as clinically deceased and residents who had no response when assessment criteria was performed. The facility policy further identified the licensed staff would determine the need to CPR based on assement criteria which include: absence or respirations, absence of heart beat, pupils fixed and dilated, and no response to painful stimuli, sternal rub or corneal reflex. The facility policy failed to include the American Heart Associations recommendations for CPR. The immediate jeopardy that began on [DATE], at 12:30 a.m., was removed on [DATE], at 4:38 p.m., when the facility revised the policy titled Code 100, to include the American Heart Association recommendations when to complete CPR, trained the licensed staff of the new policy and procedure in person in the facility and by phone or mail for those who were not present. All licensed staff were required to complete the training and understanding of the changes prior to their next scheduled work. The LSW contacted all residents or their representatives and reivewed the changes to the faclility policy and reviewed their wishes for code status at that time. In addition, the DON made arrangements for CPR certification education to include competency demonstration by a in person CPR instructor for all licensed staff, but the noncompliance remained at the lower pattern scope and severity level of E, no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on record review, policy review and interview, the facility failed to provide adequate supervision during toileting for 1 of 1 (#1) residents in the sample who attempted a self-transfer without supervision and fractured a hip which resulted in actual harm for the resident. Findings include: Resident #1 who required the assistance of one staff, a walker and gait belt for ambulation and transfers was left unsupervised on the toilet, attempted a self-transfer and while being assisted back on the toilet the resident fell back hitting the bar on the edge of the toilet with her upper leg and sustained a fracture. Review of Resident #1's medical record indicated that the resident was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set ((MDS) dated [DATE], revealed the resident was cognitively modified independent with difficulty making decisions in new situations only and had limited short term memory. The MDS indicated Resident #1 required extensive physical assistance from one staff for transfers and toileting and was totally dependent on one staff for personal hygiene. Resident #1 had functional limitations of range of motion to one arm and hand. Review of the Resident Assessment Protocol Summary (RAPS) dated 5/26/10, for falls, stated, "...at high risk for falls as related to past CVA (cerebral vascular accident), unsteady gait, forgetfulness, and unable to transfer and walk per self." Review of the facility's Safety/Restraint Assessment form dated 5/14/10, with an update written 5/25/10, stated, "Sensor alarm applied to bed, found walking halls at noc (night) by self. Tab alarm added to bed, w/c (wheelchair) et (and) recliner d/t (due to) self transfers." Review of the facility's investigation report dated 7/1/10, stated, "...Assisted onto toilet with use of gait belt. Belt removed. Pad res (resident) wears was soiled. There were no garbage bags in wastebasket so NAR (nursing assistant registered) left res on toilet while she searched for bags. Returned a few minutes later to find res standing a couple steps away from toilet. NAR took res hands and assisted her back to toilet until she began to 'loose her feet'. NAR grabbed res by waist and held her to move her back onto toilet seat. Res left hip hit side railing and sat down 'hard' on toilet seat. Finished cleaning her up and res began to complain of pain..." Review of the facility's Progress Notes revealed the incident with Resident #1 occurred on 6/30/10, on the evening shift without an exact time of the incident documented. A progress note timed 9:31 p.m. stated, "...complaining of pain in left leg and requesting pain medication. Tylenol 650 mg (milligrams) administered." A progress note dated 6/30/10, at 9:48 p.m. stated, "Resident reported to nurse that she has pain in the left leg only on the back of her thigh...An ice pack was applied and Tylenol administered...now stating that she feels that her leg must be broken." A progress note dated 6/30/10, at 10:45 p.m. stated,"...continues to complain of pain to left leg et almost crying...resident unable to extend left leg to full extension. Some shortening noted...usually doesn't complain of pain...called ER et will send over to have x-ray..." Resident #1 was transported to the emergency room and diagnosed with [REDACTED]. Review of Resident #1's plan of care with a start date of 5/25/10, stated, "Self Care deficit in ADL's (activities of daily living)...Toileting: assist of one...Risk for falls r-t (related to) forgetfulness, unsteady gait and history of falls...5-22-10: Tab alarm to bed, w-c (wheelchair) and recliner. Self transfer attempts. Fall risk..." Resident #1's care plan was not developed to supervise the resident during toileting. When interviewed on 9/20/10, at 3:36 p.m. Nursing Assistant/NA-A revealed on the evening of 6/30/10, Resident #1 requested assistance to toilet. Resident #1 was ambulated to the toilet with one staff and the use of a gait belt. While on the toilet, the gait belt had been removed because NA-A was assisting Resident #1 to wash up prior to going to bed. NA-A indicated there were no plastic garbage bags in the restroom so NA-A left Resident #1's room to obtain the supplies. When NA-A returned to the bathroom a few minutes later, Resident #1 was standing and attempting to ambulate toward NA-A. As NA-A attempted to assist Resident #1 back unto the toilet the resident lost her balance and "sat hard" hitting the back of her leg on the metal grab bar that surrounded the toilet. NA-A revealed Resident #1 began complaining of knee pain and ambulated with a "limp" back to bed with one staff assist and the use of a gait belt. NA-A revealed she was not aware that residents with wheelchair alarms should not be left unsupervised while on the toilet. When interviewed on 9/20/10, at 12:45 p.m. the RN/Long Term Care Coordinator confirmed the facility did not have a policy and procedure to supervise residents during toileting when the resident required alarms in the wheelchair. When interviewed on 9/28/10, at 11:50 a.m. the Director of Nursing revealed the required supervision while on the toilet would depend on the resident but should be care planned if Resident #1 required supervision during toileting.