Every finding on record at The Gardens at Winsted LLC

Based on interview and document review, the facility failed to ensure residents' call lights were responded to timely to meet resident needs for 5 of 6 residents (R4, R6, R13, R20, and R38) reviewed for call light response times. This failure resulted in residents experiencing prolonged wait times for assistance and placed residents at risk for unmet care needs, including toileting, hygiene, and other requests for assistance.Findings include: R4's quarterly Minimum Data Set (MDS), dated [DATE], indicated R4 was cognitively intact, and diagnoses included chronic respiratory failure, heart failure, and anxiety disorder. R4 had lower extremity impairment on both sides, used a wheelchair, was dependent on staff for dressing, transfers, and toileting, and was frequently incontinent. During an interview on 7/20/25 at 2:23 p.m., R4 stated she was concerned about long call light times. During an interview on 7/22/26 at 3:56 p.m., nursing assistant (NA)-C stated R4 used her call light frequently and required the assistance of 2 staff with transfers with a mechanical lift. Review of R4's call light logs from 6/21/26- 7/22/26, identified multiple call light response times greater than 30 minutes: 6/24/26 at 12:51 p.m. - response time 44 minutes 6/25/26 at 5:47p.m. - response time 68 minutes 6/25/26 at 8:11 p.m. - response time 61 minutes 6/27/26 at 6:21 p.m. - response time 33 minutes 6/28/26 at 10:37 a.m. - response time 44 minutes 6/28/26 at 6:57 p.m. - response time 57 minutes 6/28/26 at 8:43 p.m. - response time 39 minutes 6/29/26 at 6:34 a.m. - response time 55 minutes 6/29/26 at 12:49 p.m. - response time 45 minutes 6/29/26 at 3:24 p.m. - response time 33 minutes 6/29/26 at 5:57 p.m. - response time 70 minutes 6/30/26 at 6:29 p.m. - response time 67 minutes 7/1/26 at 5:37 p.m. - response time 49 minutes 7/1/26 at 6:38 p.m. - response time 38 minutes 7/1/26 at 8:30 p.m. - response time 45 minutes 7/2/26 at 6:14 p.m. - response time 37 minutes 7/2/26 at 9:10 p.m. - response time 67 minutes 7/3/26 at 11:28 a.m. - response time 77 minutes 7/3/26 at 2:46 p.m. - response time 39 minutes 7/3/26 at 5:38 p.m. - response time 43 minutes 7/4/26 at 12:26 p.m. - response time 66 minutes 7/4/26 at 6:01 p.m. - response time 47 minutes 7/5/26 at 12:35 p.m. - response time 44 minutes 7/5/26 at 6:08 p.m. - response time 56 minutes 7/5/26 at 8:44 p.m. - response time 53 minutes 7/6/26 at 8:08 p.m. - response time 39 minutes 7/6/26 at 6:25 p.m. - response time 51 minutes 7/6/26 at 7:26 p.m. - response time 40 minutes 7/7/26 at 6:09 p.m. - response time 38 minutes 7/7/26 at 7:45 p.m. - response time 74 minutes 7/8/26 at 7:17 a.m. - response time 46 minutes 7/8/26 at 10:17 a.m. - response time 31 minutes 7/8/26 at 6:52 p.m. - response time 53 minutes 7/8/26 at 9:36 p.m. – response time 43 minutes 7/11/26 at 4:29 p.m. - response time 30 minutes 7/11/26 at 5:54 p.m. - response time 54 minutes 7/13/26 at 5:10 p.m. - response time 38 minutes 7/14/26 at 12:15 p.m. - response time 30 minutes 7/14/26 at 7:08 p.m. - response time 60 minutes 7/15/26 at 4:50 p.m. - response time 46 minutes 7/15/26 at 6:06 p.m. - response time 63 minutes 7/16/26 at 4:49 p.m. - response time 32 minutes 7/16/26 at 8:08 p.m. - response time 34 minutes 7/17/26 at 6:22 a.m. - response time 36 minutes 7/17/26 at 12:09 p.m. - response time 50 minutes 7/18/26 at 3:37 p.m. - response time 30 minutes 7/18/26 at 4:07 p.m. - response time 39 minutes 7/19/26 at 3:06 p.m. - response time 42 minutes 7/19/26 at 5:58 p.m. - response time 68 minutes 7/20/26 at 6:07 p.m. - response time 67 minutes 7/21/26 at 4:59 p.m. - response time 92 minutes 7/22/26 at 6:39 p.m. - response time 36 minutes R6's quarterly Minimum Data Set (MDS), dated [DATE], indicated R6 was cognitively intact, required staff assistance with toileting, had an indwelling catheter and was incontinent of bowel. R6's diagnoses included Crohn's disease (long-term type if inflammatory bowel disease), urinary tract infection, muscle weakness, chronic pain, neuromuscular dysfunction of bladder (lack of bladder control caused by brain, spinal cord or nerve damage), and neurogenic bowel (loss of normal bowel control and function). During an interview on 7/21/26 at 11:09 a.m., R6 stated she had complained several times that the call light was on for up to an hour waiting for staff to assist with incontinent cares. R6 stated she ends up sitting in a bowel movement for extended periods of time resulting in bladder infections. Review of R6's call light logs from 6/21/26- 7/22/26, identified multiple call light response times greater than 30 minutes: 6/22/26 at 6:09 p.m. - response time 115 minutes 6/22/26 at 9:04 p.m. – response time 60 minutes 6/25/26 at 6:23 p.m. – response time 39 minutes 6/25/26 at 7:49 p.m. – response time 71 minutes 6/26/26 at 11:11 a.m. – response time 53 minutes 6/26/26 at 8:46 p.m. – response time 85 minutes 6/27/26 at 9:14 p.m. – response time 31 minutes 6/29/26 at 10:24 a.m. – response time 32 minutes 6/29/26 at 7:39 p.m. – response time 80 minutes 7/1/26 at 4:24 p.m. - response time 38 minutes 7/1/26 5:41 p.m. - response time 44 minutes 7/1/26 at 7:23 p.m. - response time 32 minutes 7/2/26 at 12:33 p.m. - response time 47 minutes 7/2/26 at 6:40 p.m. - response time 62 minutes 7/2/26 at 9:16 p.m. - response time 53 minutes 7/3/26 at 6:44 p.m. – response time 69 minutes 7/6/26 at 8:33 a.m. – response time 42 minutes 7/7/26 at 2:45 p.m. – response time 51 minutes 7/7/26 at 8:07 p.m. - response time 36 minutes 7/8/26 at 6:29 p.m. - response time 47 minutes 7/10/26 at 1:25 p.m. - response time 37 minutes 7/10/26 at 5:37 p.m. - response time 50 minutes 7/11/26 at 6:58 p.m. - response time 37 minutes 7/13/26 at 4:49 p.m. - response time 45 minutes 7/13/26 at 9:32 p.m. - response time 32 minutes 7/14/26 at 5:37 p.m. - response time 61 minutes 7/14/26 at 7:11 p.m. - response time 36 minutes 7/14/26 at 8:47 p.m. - response time 37 minutes 7/15/26 at 3:57 p.m. - response time 136 minutes 7/16/26 at 7:39 p.m. - response time 44 minutes 7/18/26 at 9:15 a.m. – response time 48 minutes 7/19/26 at 8:43 p.m. – response time 47 minutes 7/20/26 at 5:26 p.m. - response time 67 minutes R13's quarterly MDS, dated [DATE], indicated R13 was cognitively intact, diagnoses included hip fracture, traumatic brain injury (TBI), and depression. R13 had lower extremity impairment on both sides, used a wheelchair, required assistance with transfers, and was frequently incontinent. On 7/22/26 at 9:38 a.m., R13 stated she was concerned about long call light times. R13 stated, I'm [AGE] years old. You don't want to be incontinent. Review of R13's call light logs from 6/21/26- 7/22/26, identified multiple call light response times greater than 30 minutes: 6/21/26 at 11:01 a.m. - response time 34 minutes 6/22/26 at 9:00 p.m. - response time 68 minutes 6/28/26 10:53 a.m. - response time 32 minutes 7/1/26 at 8:14 p.m. - response time 31 minutes 7/2/26 at 7:13 p.m. - response time 56 minutes 7/3/26 at 9:36 p.m. - response time 38 minutes 7/7/26 at 10:29 a.m. - response time 39 minutes 7/13/26 at 6:08 p.m. - response time 62 minutes 7/15/26 at 6:40 p.m. - response time 40 minutes 7/20/26 at 10:39 a.m. - response time 48 minutes 7/20/26 at 3:37 p.m. - response time 87 minutes During an interview on 7/23/25 at 3:54 p.m., nursing assistant (NA)-C stated call lights showed on the central monitor at the nurses' station and on the scroll boards. NA-C stated the busiest time for call lights was after supper, between 6:00 p.m. to 8:00 p.m. During an interview on 7/24/26 at 10:36 a.m., NA-F stated staff answered call lights in the order they were pushed, provided cares, and then went to the next resident until all call lights were answered. R20's admission MDS, dated [DATE], indicated R20 was cognitively intact and required assistance from staff with activities of daily living (ADLs). R20's diagnoses included emphysema (lung disease), major depression, panic disorder, post-traumatic stress disorder, and anxiety. On 7/20/26 at 10:40 a.m., an odor of urine was noted in R20's room, and a bedpan was observed on the floor under R20's bed. R20 stated there were several times the call light was on and R20 had to wait for staff to come for over half an hour. Review of R20's call light logs from 6/21/26- 7/22/26, identified multiple call light response times greater than 30 minutes: 7/2/26 at 4:32 p.m. - response time 41 minutes 7/3/26 at 4:33 p.m. - response time 46 minutes 7/4/26 at 6:21 p.m. - response time 56 minutes 7/5/26 at 6:39 a.m. – response time 63 minutes 7/16/26 at 4:29 p.m. – response time 32 minutes R38's care plan, dated 7/14/26, indicated R38 had an alteration in bladder and bowel elimination, with identified interventions of assist of one with toileting needs. R38's diagnoses included weakness, diabetes, edema and peripheral autonomic neuropathy (damage to peripheral nerves that control involuntary body functions like heart rate, digestion and sweating, common symptom included urinary incontinence. R38's bladder evaluation, dated 7/13/26, indicated R38 had urge incontinence which includes symptoms of strong uncontrolled urgency, frequency of urination, moderate to large amount of urine leakage and enuresis (bedwetting). During an interview on 7/20/26 at 11:41 a.m., R38 stated when the call light was turned on, he waited half an hour or more and has ended up sitting in urine-soaked sheets while waiting for the staff to answer the call light. Review of R38's call light logs from 7/13/26- 7/22/26, identified multiple call light response times greater than 30 minutes: 7/13/26 at 5:06 p.m. – response time 41 minutes 7/16/26 at 1:06 a.m. – response time 34 minutes 7/16/26 at 3:40 a.m. - response time 56 minutes 7/16/26 at 2:30 p.m. – response time 48 minutes 7/16/26 at 5:35 p.m. - response time 89 minutes 7/16/26 at 9:31 p.m. - response time 36 minutes 7/17/26 at 5:04 a.m. – response time 40 minutes 7/18/26 at 9:25 a.m. - response time 39 minutes During an interview on 7/24/26 at 10:47 a.m., anonymous staff A stated the call boards in the hallways were broken, and staff could only tell when call lights were on was from the nurses' station. Anonymous A stated there were pagers staff wore that alerted them to call lights, but the director of nursing (DON) got rid of those. Anonymous B stated the call light board in the transitional care unit was not working, the call board by the nurses' desk worked periodically, and call board at the end of the hall was broken, faced the floor and had been that way for a while. During an interview on 7/24/26 at 1:25 p.m., registered nurse (RN)-C stated call lights were expected to be answered within 8-10 minutes. During an interview on 7/24/26 at 1:29 p.m., DON stated when staff were in rooms, the staff would not know what call lights were on, so staff were expected to check boards or the screen when they came out of a resident's room. DON stated the staff were expected to look at the call light boards in the hallways or the screen at the nurses' desk. DON stated there had been occasional issues with the call lights not running due to wi-fi issues. DON stated she was not aware one of the boards was facing the floor. During an interview on 7/24/26 at 2:24 p.m., administrator stated they had completed call light audits on the floor, they had waited at the nurses' station for one to go on and watched the screen to see how long it took for the staff to turn them off. Administrator acknowledged they did not run call light logs to review for long call light times unless a resident had complained. The facility's Call Light policy, updated 5/16/23, indicated call lights must relay the call to a staff member or centralized location where staff were working such as the nurses' station, however, the policy did not address the timing for call lights to be answered.

Based on observation, interview and document review, the facility failed to maintain the walk-in freezer in a clean and safe condition, as evidenced by a large accumulation of ice on the freezer floor and on stored food boxes, and spilled food items. The facility failed to maintain the dining room resident refrigerator/freezer as evidenced by spilled and undated food items. Additionally, the facility failed to ensure staff completed hand hygiene and wore the appropriate hair coverings in the kitchen. This had the potential to affect all 32 residents residing in the facility.Findings include: During an observation on 07/20/2026 at 9:51 a.m., of the walk-in freezer, a large accumulation of ice was observed on the floor at the end of the shelving on the right side of the freezer. The mound of ice measured approximately 18 inches high with a base measuring approximately 3 feet by 2 feet. A separate chunk of ice measuring approximately 4 inches thick by 6 inches long by 5 inches wide was observed resting on top of a box. Another box stored in the corner had a coating of ice on the top and side. The food items inside the boxes were not observed to be frozen together or covered with ice. During an interview on 07/20/2026 at 9:51 a.m., head cook (HC) stated he had not been at the facility for five days and the ice accumulation was not present the last time he had worked. On 07/20/2026 at 12:50 p.m., the walk-in freezer was observed with regional culinary director (RCD). RCD stated the ice mound should have been taken care of long before this for safety. RCD stated, Someone could come in and slip, and the food could get affected with the ice on the boxes. He further stated it likely had taken approximately three to four months for the ice accumulation to reach its observed size. During an observation on 7/22/26 at 10:30a.m., dietary aide (DA)-A was observed positioned between the stove and metal table mopping the floor. DA-A had a full beard with no cover in place and his hair pulled back in a tail at the back of his neck with no hair cover. The dietary manager (DM) acknowledged DA-A should have a facial hair cover when in the kitchen and directed DA-A to go and apply one. During an interview on 7/22/26 at 10:35 a.m., DA-A reported he usually applied a facial hair cover when entering the kitchen area, but he had forgotten. During a meal service observation on 7/22/26 at 11:19 a.m., nursing assistant (NA)-D entered the kitchen area with her hair in a long ponytail and no hair net. Additionally, NA-D failed to perform hand hygiene upon entering the kitchen area. NA-D went to the walk-in cooler, entered, and returned carrying a glass of milk. During an interview on 7/22/26 at 11:23 a.m., NA-D reported she was retrieving a glass of milk upon a resident's request. NA-D confirmed she had not applied a hairnet, nor performed hand hygiene prior to entering the kitchen area. NA-D reported she should have applied a hairnet, and washed her hands, or requested dietary staff to retrieve the milk, instead of walking into the kitchen area. The DM observed the incident and stated staff walking into the kitchen was not acceptable practice and had been an ongoing issue with unauthorized staff walking into the kitchen. During an observation on 7/22/26 at 12:15 p.m., with the DM of the resident refrigerator/freezer located in the dining room the freezer compartment contained an approximate 1/2-inch layer of ice on the floor of the freezer. The following opened and undated items were in the freezer: 1.5-quart container of Casey's Carmel Cone Sunday ice cream, and a loaf of opened, undated Artesano Hawaiian bread. The door seal contained a granular black substance and food particles, and food particles were noted on the bottom and shelves to the freezer. The refrigerator section contained the following opened and undated items: an opened carton of Top the Tator sour cream dip, four plastic containers of pickles, a paper Culvers bag with a sandwich and fries. The seal of the refrigerator door had a black granular substance in the seal and hinge area of the door. The door frame, shelves, and bottom of the refrigerator contained spilled food particles. During an interview on 7/22/26 at 11:29 a.m., DM stated the cleaning schedule indicated the refrigerator had last been cleaned on 7/21/26, but it had not been cleaned according to DM's expectations. DM stated food placed in the resident refrigerator was expected to be written on the log posted on the front of the refrigerator, and was to include the date, placed in the refrigerator, name, date the item was opened. The facility's Refrigerators and Freezers policy, revised 12/2014, indicated supervisors would inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs, and manufacturer maintenance guidelines would be scheduled and followed. The facility's Food Brought by Family/Visitors policy, revised October 2017, indicated food brought by family or visitors and left for the resident to consume later was to be labeled and stored in a manner distinguishable from facility-prepared food. Non-perishable foods must be stored in re-sealable containers with tight-fitting lids. Perishable foods must be stored in re-sealable containers with tight fitting lids in a refrigerator. Containers must be labeled with the resident's name, the item, and the use by date. Nursing staff will discard perishable foods on or before the use by date. The nursing and/food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger.

Based on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) who was also the director of nursing (DON) had appropriate oversight of the infection control (IC) program that included employee surveillance of all employees. This had the potential to affect all 32 residents. Findings include: Review of facility infection control surveillance documents identified the infection preventionist (IP) managed resident illness surveillance, which was included in the infection control surveillance documentation. However, no employee surveillance was included in the infection control surveillance documentation. During an interview on 7/22/26 at 10:23 a.m., the director of nursing/infection preventionist (DON/IP) stated she had nothing to do with tracking or managing employee illness. DON/IP stated employee illness was tracked and managed by the human resources (HR)/scheduling coordinator. The DON/IP stated when an employee called in sick, the scheduling coordinator received the call and tracked their illness by asking the appropriate questions per policy and procedure. The DON/IP reported employee illnesses (call-ins) were discussed during the morning meeting which allowed nursing to add in any suspected correlation between employee illness and resident illness. The DON/IP identified she did not maintain documentation of the morning meetings. During an interview on 7/22/26 at 2:32 p.m., the staffing coordinator (SC) stated when a staff person called-in ill, they were to call both the facility and the staffing phone to notify the department head which staff were calling in and administration. SC reported she primarily delt with nursing staff and when she received a call-in, she attempted to find a replacement. SC identified the forms filled out for staff call-ins were kept in the scheduling binder in her office. SC stated she was not responsible for activity, or culinary staff and managers of those departments managed their own staff call-ins. Review of the forms filled out for staff call-ins indicated the following: -Nursing assistant (NA)-E had called-in on 4/22/26 with reported symptoms of diarrhea beginning 4/20/26 through 4/22/26. NA-E returned to work on 4/25/26, but there was no indication of resolution of symptoms, if the facility had followed infection control standards for criteria in-order to ensure NA-E was safe to return to work, or if NA-E had been prohibited from work for an appropriate amount of time. NA-E's time punches were requested but not provided. -NA-C left her shift on 4/5/26 with complaints of nausea and returned to work on 4/19/26. There was no indication of resolution of symptoms, if the facility had followed infection control standards for criteria in-order to ensure staff were safe to return to work, or if NA-C had been prohibited from work for an appropriate amount of time. NA-C's time punches were requested but not provided. -Cook-A called-in with vomiting on 5/3/26, reported symptoms resolved on 5/4/26 and returned to her shift in dietary on 5/5/26. There was no indication if the facility had followed infection control standards for criteria in-order to ensure cook-A was safe to return to work, or if cook-A had been prohibited from work for an appropriate amount of time. Cook-A's time punches identified she was off 5/3/26-5/4/26 and returned on 5/5/26. -Dietary Aid (DA)-A called-in on 6/30/26 with complaints of nausea, no additional data was provided and review of DA-A's timecard identified he returned to his shift in the dietary department the next day, on 7/1/26. There was no indication of resolution of symptoms, if the facility had followed infection control standards for criteria in-order to ensure DA-A was safe to return to work, or if DA-A had been prohibited from work for an appropriate amount of time. During an interview on 7/22/26 at 4:15 p.m., with the dietary manager (DM) reviewed timecards for the two dietary staff that had call-in with GI symptoms and identified he had followed the MN policy posted in the kitchen which listed an employee must wait 24 hours from their last symptom before returning to work. DM stated cook-A had started her shift on 5/5/26 at 5:00 a.m. which was not within the required time from her last symptom. DM also reported he had been out on leave from 6/15/26 through 7/21/26 and did not know who was overseeing the monitoring of illness for dietary department when he was out on leave, but he assumed someone had. The Infection Preventionist job description identified the IP was responsible to evaluate practice in culinary, laundry, housekeeping, maintenance, and nursing departments to ensure consistency with recommended infection control standards. The IP conducts ongoing infection surveillance, compiles and analyzes data, and prepares reports for presentation to the Infection Prevention and Control Oversight Committee. The facility's Infection Prevention and Control Program policy, dated 4/26/26, indicated it was comprehensive and addressed detection, prevention, and control of infections among residents and personnel. The infection prevention and control program is coordinated and overseen by the IP. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Surveillance tools are used for recognizing the occurrence of infection, recording their number and frequency, detecting outbreaks, monitoring employee infections, and detecting unusual pathogens with infection control implications. The major elements of the program included coordination/oversight, surveillance, outbreak management, prevention of infection, and employee health.

Based on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed for all medications kept at bedside for 3 of 3 residents (R1, R13, R30) observed with medications at their bedside. Findings include: R1's significant change Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact and required assistance with activities of daily living. R1's diagnoses included respiratory failure, chronic pain, anxiety, and asthma. R1's Order Summary Report, printed 7/27/26, indicated R1 had an order for Ventolin HFA Inhalation Aerosol Solution (short acting inhaler, relaxes tight muscles in the airway) 108 micrograms/actuation (Mcg/Act) 2 puffs inhale every four hours as needed for shortness of breath. The summary report also indicated R1 had an order dated 1/28/26 for okay to self-administer inhalers at bedside after set-up pending nursing assessment of self-administration. R1's Self Administration of Medication (SAM) Evaluation, dated 6/23/26, indicated per staff resident no longer self-administered any medications or creams. She used to but no longer does self-administer nor does she request to do so. During an observation on 7/22/26 at 3:02 p.m., R1's Ventolin inhaler was observed on the overbed table next to R1's bed, within reach of R1. During an observation on 7/23/26 at 8:29 a.m., R1's inhaler was observed on top of overbed table next to R1's bed. During an interview on 7/23/2026 1:47 p.m., registered nurse (RN)-A stated R1 had an inhaler but it was no longer kept at her bedside. RN-A stated the nurse manager or the director of nursing (DON) completed the self-administration of medications assessments. During an interview on 7/24/26 at 1:04 p.m., RN-C stated R1 needed to demonstrate how to use the inhaler correctly and verbalize when to use the inhaler. RN-C reviewed R1's assessment and verified RN-C's name was on the assessment as having completed the assessment for R1. R13's quarterly MDS, dated [DATE], indicated R13 was cognitively intact, and diagnoses included traumatic brain injury (TBI), diabetes, and asthma. On 7/20/26 at 9:38 a.m., a medication cup with 9 tablets/capsules was observed on R13's bedside table. R13 stated she had just woken up and found the medication left at her bedside. During an observation on 7/21/26 at 9:34 a.m., a medication cup with 8.5 tablets/capsules was observed on R13's bedside table. R13 was not in the room at the time. On 7/22/26 at 9:25 a.m., a medication cup with tablets/capsules was observed on R13's bedside table. R13 stated medications had been left at bedside for at least 6 months. R13's Order Summary Report, dated 7/8/26, indicated R13 had an order dated 5/11/26 for may self-administer medication after nursing setup. R13's SAM Evaluation, dated 5/13/26, indicated R13 was safe to self-administer medication after nursing set up, and inhalers and lozenges kept at bedside. R13's SAM Evaluation, dated 5/25/26, indicated R13 was able to keep inhaler and lozenges at bedside and self-administer inhalers as ordered, and was able to self-apply lotions and ointments after nursing set up. The evaluation further indicated, All other medications will be set up and administered by nursing as there have been multiple events of resident forgetting to take medications after they area [sic] set up and left with resident, resulting in missed doses. However, R13's electronic health record (EHR) lacked evidence the 5/25/26 SAM evaluation results had been communicated to the provider. Additionally, the EHR lacked evidence R13's orders and care plan had been updated to reflect the updated evaluation findings. R13's Medication Administration Record (MAR), dated July 2026, indicated ok to leave tizanidine and Lyrica at bedside, with a start date of 7/14/26. However, no other medications were ordered as okay to leave at bedside. During an interview on 7/22/26 at 9:44 a.m., RN-B stated he had set up R13's medications that day. RN-B stated he left the medications at the bedside for R13 as allowed per provider orders. R30's quarterly MDS, dated [DATE], indicated R30 was cognitively intact and diagnoses included hepatic encephalopathy (a worsening of brain function when a damaged liver can no longer remove toxic substances from the blood), heart failure, and diabetes. R30's SAM Evaluation, dated 4/21/26, indicated R30 was not reliably safe to self-administer medications. Additionally, the evaluation did not indicate that R30 was able to keep any medications at bedside. On 7/21/26 at 10:38 a.m., fluticasone propionate nasal spray was observed at R30's bedside. R30 stated she normally self-administered the nasal spray. R30's MAR, dated July 2026, indicated R30 had an order for Fluticasone Propionate nasal suspension 50 mcg/act 2 spray in each nostril two times a day for allergic rhinitis. No orders for self-administration or medications at bedside were indicated on the MAR. During an interview on 7/24/26 at 11:12 a.m., director of nursing (DON) verified R13's SAM evaluation indicated she was not safe to self-administer medications. The facility's Self-Administration of Medications policy, dated 2/2024, indicated the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.

Based on interview and document review, the facility failed to provide reasonable accommodation of needs and preferences for 1 of 1 resident (R28) reviewed for environmental scents.Findings include: R28's quarterly Minimum Data Set (MDS), dated [DATE], indicated R28 was cognitively intact, and diagnoses included diabetes, heart failure, asthma, and allergies. R28's care plan, last revised 5/21/26, indicated R28 had multiple allergies and intolerances, many allergies to different scents, and required assist of one with bathing. During an interview on 7/20/26 at 2:30 p.m., R28 stated she does not participate in activities due to allergies and used an N-95 mask to provide scent blockage. R28 stated because of the chemicals and fragrances used in the shower room, she did not get her scheduled shower. R28 stated she has gone up to three weeks a couple of times without showers. R28 stated that one time staff had her use the shower room before any other residents and she showered without any issues. During an interview on 7/23/26 at 2:12 p.m., nursing assistant (NA)-D stated R28 was very sensitive to smells and wore a mask a lot. During an interview on 7/23/26 at 3:49 p.m., NA-E stated R28 required supervision with showers, and R28 was very sensitive to scents or odors. During an interview on 7/24/26 at 10:31 a.m., environmental service (ES) stated the facility took residents' sensitivity to chemical smells seriously. ES stated R28 had a sign on her door that it is a scent-free room due to R28's allergies, and staff followed the posted restrictions. ES stated the employee handbook instructed staff to not wear strong perfume or extra aroma items because it showed respect for the residents. During an interview on 7/24/26 at 2:46 p.m., registered nurse manager (RN)-C stated the facility made arrangements one time for R28 to be offered the first shower of the day. RN-C stated R28 has not requested the first shower of the day since. The facility's Employee Handbook 2026 indicated scents must be limited and barely perceptible, in recognition of resident sensitivities and allergies.

Based on interview and document review, the facility failed to ensure a resident remained free from physical restraints not required to treat a medical symptom when the facility incorporated the use of law enforcement handcuffs into resident's care plan for 1 of 1 resident (R45) reviewed for restraints. Findings include: R45's admission record, printed 7/24/26, indicated R45 admitted to the facility on [DATE], and diagnoses included abdominal aortic aneurysm without rupture and diabetes. R45's care plan, initiated 7/21/26, indicated a physical restraint was deemed necessary by county policy due to R45's criminal history. The care plan indicated corrections staff would remain in R45's room or observe R45 at all times. The care plan further indicated R45 would be handcuffed if security left the room, and security staff would place and remove handcuffs for the resident. However, the care plan also indicated staff would place and remove handcuffs PRN (as needed). R45's Informed Consent for Use of Physical Restraints, signed 7/21/26, listed the type of restraint as handcuffs when not in vision of security guard due to the need for 24-hour supervision related to admitting to hospital and SNF from jail. R45's Order Summary Report, dated 7/24/26, indicated an order OK to apply handcuffs to resident as needed for safety every shift, with a start date of 7/21/26. However, the order did not identify a medical symptom that warranted the use of the restraint. During an interview on 7/24/26 at 10:47 a.m., anonymous staff A stated there was an inmate in the facility. Staff had been instructed to provide a shower for R45 with two staff present, the guard was to remain in the room and R45 was to be handcuffed to the shower chair. However, the correctional officer left the shower area, leaving the two nursing assistants alone with the resident while he was not handcuffed. During an interview on 7/24/26 at 12:49 p.m., the correctional officer stated he had been informed by the facility that handcuffing the resident was not necessary if the officer briefly stepped away from the room. During an interview on 7/24/26 at 1:49 p.m., director of nursing (DON) stated the resident was to be handcuffed to the bed whenever the guard left the room, staff were to complete skin assessments related to the handcuffs, and the guard would leave the key with nursing staff in case of an emergency. DON stated only the guards applied or removed the handcuffs, and facility staff were not to be in control of the restraint. During an interview on 7/24/26 at 2:34 p.m., administrator stated that R45 was handcuffed whenever the guard stepped away from the room. The guard was required to inform the staff they were stepping away and handed the keys to the nurse. Administrator stated the facility staff were allowed to remove the handcuffs in case of emergency. Facility policy regarding physical restraints was requested, however, none was provided.

Based on interview and document review, the facility failed to ensure residents were free from unnecessary psychotropic medications, including failure to ensure as needed (PRN) psychotropic medications had appropriate stop dates for 1 of 5 residents (R20) reviewed for unnecessary medications.Findings include: R20's admission Minimum Data Set (MDS), dated [DATE], indicated R20 was cognitively intact and required assistance from staff with activities of daily living (ADLs). R20's diagnoses included emphysema (lung disease), major depression, panic disorder, post-traumatic stress disorder, and anxiety. R20's physician orders, dated 7/8/26, identified R20 had orders for olanzapine (an antipsychotic) 5 milligrams (mg) by mouth every twelve hours PRN for anxiety initiated 7/2/26, trazodone (an antidepressant) 25mg every twenty-four hours PRN for insomnia initiated 7/2/26, and hydroxyzine (a sedating antihistamine/psychotropic) 50 mg every six hours PRN for anxiety initiated 7/2/26. However, R20's olanzapine, trazodone and hydroxyzine orders did not include a stop date, specific duration, or documented prescriber rationale for extending the PRN psychotropic medication beyond 14 days, as required. During an interview on 7/24/26 at 1:04 p.m., registered nurse (RN)-C stated PRN psychotropic medications required an end dated of at least 14 days, the provider could write the order for longer but had to provide a rational. RN-C reviewed R20's physician orders and verified end dates were not indicated on the orders. During an interview on 7/24/26 at 1:06 p.m., director of nursing (DON) stated when PRN psychotropic medication orders were received, the expectation was for the nurses to contact the provider and obtain an end date as required. DON reviewed R20's medications and confirmed there were no end dates for R20's psychotropic medications. The facility's Psychotropic Medication Use policy, revised 5/2025, indicated PRN orders for psychotropic medications would be limited to 14 days unless the physician identified the rational to extend the medication beyond 14 days.

Based on observation, interview, and document review the facility failed to ensure 1 of 1 resident's (R43) discontinued controlled narcotic medication was not stored with in-use medications in 1 of 3 medication carts.Findings include: During an observation on 7/21/26 at 10:56 a.m., of the South Hall medication cart narcotic cabinet with registered nurse (RN)-A identified three medications identified for R43 who passed away on 7/17/26. R43's-controlled medications remained in the narcotic cabinet with current in use medications. The medications included: Lorazepam (Ativan a controlled medication used for anxiety), 1 blister package card containing 30 0.5 milligram (mg) tablets.Lorazepam liquid in a 25-milliliter bottle with orders 0.25ml by mouth (PO) every (Q) 4 hours (H) scheduled and 0.25ml Q2H as needed (PRN). 24.75 ml remained in the bottle. Hydromorphone (Dilaudid a prescription opioid medication) liquid with orders to administer 1 ml Q4H scheduled, and Q1H PRN. 109ml remained in the bottle. During an interview on 7/21/26 at 11:00 a.m., RN-A identified controlled medications remained stored in the locked narcotic drawer on medication carts until 2 licensed nurses had time to destroy and log them. RN-A reported she was unaware that discontinued controlled medication were not to be stored with in-use medications. During an interview on 7/21/26 at 11:16 a.m., director of nursing (DON) confirmed R34 had passed away in the facility on 7/17/26 and her medications should have been counted, documented in the narcotic log, and removed from the narcotic cabinet on the medication cart, and stored in a secure, double locked, area until 2 licensed nurses were able to destroy them. A policy on management of controlled discontinued medications was requested but not provided.

Based on interview and record review, the facility failed to ensure there are a sufficient number of nursing personnel to provide care and respond to each resident's basic needs as required by the resident's diagnoses or plan of care resulting in delayed responses to call lights and an inability to provide timely care. The failure affected multiple residents (R1, R5, R6, R8, R9) and placed all residents at risk for unmet care needs, avoidable discomfort, and potential decline.Findings include:R1's admission comprehensive Minimum Data Set (MDS) dated [DATE], indicated R1 had no cognitive impairment, was receiving diuretic medication, and required partial/moderate assistance with toileting and transfers.During an interview on 4/29/26 at 3:47 p.m., R1 stated when she pressed her call light button, she sometimes had to wait at least an hour before anyone responded. R1 reported these delays made her feel as though staff had forgotten about her. R1 further stated on one occasion she was experiencing shortness of breath (SOB) and waited approximately one hour before a nurse arrived. She reported the nurse provided a rescue inhaler rather than oxygen, which she believed would have helped increase her oxygen saturation level. R1 added call light response times were even longer at night, and as a result, she tried not to use the call light unless absolutely necessary because she knew it would take a long time for staff to respond.Review of R1's facility call light log identified the following 4/3/26: Call at 7:05 a.m., answered at 8:21 a.m. (1 hour 16 minutes) 4/1/26: Call at 10:12 p.m., answered at 11:05 p.m. (52 minutes) R5's admission comprehensive Minimum Data Set (MDS) dated [DATE], indicated R5 had no cognitive impairment, was receiving a diuretic medication, and required supervision or touching assistance with toileting and transfers and substantial/maximal assistance for sitting to stand.During an interview on 4/28/26 at 12:32 p.m., R5 stated he frequently waited extended periods after activating his call light, reporting wait times of 45 minutes or more before staff responded. R5 explained the facility was short staffed and often relied on agency personnel who did not know our needs. R5 reported nursing assistants (Nas) had told him they were short staffed and were doing the best they could, but he stated the response times still took too long. R5 described feeling frustrated because staff often appeared rushed and unable to respond promptly to his needsReview of R5's facility call light log identified the following 4/28/26: Call at 10:33 a.m., answered at 11:03 a.m. (30 minutes) 4/24/26: Call at 10:40 a.m., answered at 11:15 a.m. (34 minutes) 4/22/26: Call at 6:16 a.m., answered at 7:10 a.m. (54 minutes) 4/17/26: Call at 12:28 p.m., answered at 1:20 p.m. (52 minutes) R6's quarterly comprehensive Minimum Data Set (MDS) dated [DATE], indicated R6's active diagnoses included congestive heart failure (CHF), hypertension, and diabetes Mellitus. Additionally, R6 had no cognitive impairment, was receiving a diuretic medication, was dependent on toileting hygiene, and transfers.During an interview on 4/28/26 at 1:12 p.m., R6 stated she avoided using the call light unless absolutely necessary because staff responses were consistently delayed. R6 explained many of the NAs were still in school and the facility was short staffed, though NAs were doing what they could. R6 reported her call light wait times typically ranged from 30 minutes up to one hour.Review of R6's facility call light log identified the following 4/1/26: Call at 1:31 p.m., answered at 2:21 p.m. (50 minutes) 4/10/26: Call at 8:44 p.m., answered at 9:45 p.m. (60 minutes) 4/13/26: Call at 7:37 a.m., answered at 8:23 a.m. (46 minutes) 4/17/26: Call at 7:07 p.m., answered at 8:08 p.m. (59 minutes) 4/22/26: Call at 7:11 a.m., answered at 8:23 a.m. (1 hour 11 minutes) R8's admission comprehensive Minimum Data Set (MDS) dated [DATE], indicated R8's active diagnoses included CHF, hypertension, and renal failure. Additionally, R8 had no cognitive impairment and required substantial/maximal assistance for toileting and transfers.Review of R8's facility call light log identified the following 4/27/26: Call at 7:21 p.m., answered at 8:11 p.m. (50 minutes) 4/25/26: Call at 8:32 p.m., answered at 9:17 p.m. (45 minutes) 4/20/26: Call at 7:23 a.m., answered at 8:29 a.m. (66 minutes) 4/4/26: Call at 7:06 p.m., answered at 8:49 p.m. (1 hour 42 minutes) R9's quarterly comprehensive Minimum Data Set (MDS) dated [DATE], indicated R9's active diagnoses included diabetes mellitus, hip fracture, and traumatic brain injury. Additionally, R9 had moderate cognitive impairment, and required partial/moderate assistance for toileting and transfers.During an interview on 4/29/26 at 11:58 a.m., R9 stated the call light system was a big issue in the facility. R9 explained when staff were busy with other residents, her call light could remain on for a while, and she often had to wait at least an hour before anyone responded. R9 reported these delays caused her to feel uncomfortable and sad, describing situations where she had to sit in her own waste for extended periods while waiting for assistance.Review of R9's facility call light log identified the following 4/27/26: Call at 7:02 p.m., answered at 8:01 p.m. (59 minutes) 4/15/26: Call at 7:09 a.m., answered at 7:58 a.m. (49 minutes) 4/9/26: Call at 6:09 p.m., answered at 6:54 p.m. (44 minutes) 4/4/26: Call at 7:02 p.m., answered at 8:01 p.m. (59 minutes) 4/2/26: Call at 9:02 a.m., answered at 9:52 a.m. (50 minutes) During an interview on 4/28/26 at 1:28 p.m., nursing assistant (NA) A stated the facility was short staffed, especially during the evening and night shifts. NA A explained they could not respond to call lights right away because sometimes there were only two NAs for the whole facility. NA A reported that if they were assisting one resident, other call lights had to wait. Staff were trying to answer call lights as quickly as possible, but there just were not enough of them on the floor to respond promptly.During an interview on 4/30/26 at 12:11 p.m., NA B stated she had been assigned to answer call lights and assist other staff as a float earlier that morning. NA B stated a reasonable call light response time should be 5 to 10 minutes. When multiple residents required assistance at the same time, call lights could remain unanswered for extended periods. NA-B frequently felt rushed and unable to respond promptly to all residents' needs. NA B stated staffing shortages had been an ongoing issue and that supervisors were aware of the problem. During an interview on 5/1/26 at 1:14 p.m., registered nurse (RN) C stated she never got time to get nursing tasks done due to the workload and staffing levels. RN C explained staff should answer call lights immediately or within a reasonable timeframe. She reported call light response times were often delayed because of insufficient staffing, particularly during the day and evening shifts.During an interview on 5/1/26 at 3:15 p.m., the Director of Nursing (DON) stated she expected staff to answer call lights immediately or within a reasonable timeframe. The DON explained the facility's goals were to reduce the number of call lights, decrease call light wait times, and increase resident satisfaction.A recent call light audit was requested from the facility but was not provided. Instead, the facility sent an email stating: There was an ad hoc QAPI between the administrator and Clinical Leadership on 04/27/2026. An auditing process was determined at that time, and they were to be initiated on May 4th.The facility's Ad Hoc QAPI & Internal Four Point Plan of Correction, dated 4/27/26, identified opportunities for improvement related to reducing the number of call lights, decreasing call light wait times, and increasing resident satisfaction. The document cited several potential contributing factors, including lack of teamwork, lack of knowing the residents' transfer status, lack of availability to specific requiring extensive amount of time for assistance or the necessity for cares in pairs and not cancelling call light once in the resident's room.Policy regarding call light timely respond was requested and was not received.

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for 1 of 3 residents (R7) reviewed for non-pressure related skin injuries.Findings include:R7's order summary report dated 2/12/26, identified R7's diagnoses included respiratory failure with hypoxia, a stage 3 pressure ulcer stage to spine, and colostomy/ileostomy. The order summary included an order for weekly skin inspection by licensed nurse every Monday on day shift.R7's admission comprehensive Minimum Data Set (MDS) dated [DATE], indicated R1 had no cognitive impairment, was receiving surgical wound care, and required substantial/maximal assistance with toileting and transfers.Review of R7's March and April 2026 Treatment Administration Record (TAR) showed check boxes indicating weekly skin check tasks were completed on 3/16/26, 3/23/26, and 4/13/26. However, there was no corresponding skin assessment documentation to support whether the assessments were completed.During an interview on 5/1/26 at 1:14 p.m., RN-C stated she cared for R7 on the evening shift of 3/23/26. RN-C confirmed she checked off the skin assessment task in the TAR but did not complete the skin assessment. RN-C explained she verbally passed the task to the night shift because she was behind on medication administration. RN-C stated she should have completed the skin assessment and documented the assessment, but did not have time to get task done before the end of the shift.During an interview on 5/1/26 at 1:32 p.m., a licensed practical nurse (LPN)-A stated he cared for R7 on 3/16/26 but did not recall completing a skin assessment. LPN-A explained if the TAR indicated the task was completed, there should also be a corresponding skin assessment form in the record.During an interview on 5/1/26 at 3:15 p.m., the DON stated when a licensed nurse checked a box indicating a weekly skin check was completed, the nurse was also required to complete supporting documentation identifying the presence or absence of impaired skin integrity. The DON explained she was unable to locate documentation for R1's skin assessment dated [DATE], 4/11/26 and 4/25/26 or for R7's assessment dated [DATE], 3/23/26, and 4/13/26.The facility Skin Assessment and Wound Policy dated 2/2025 indicated a weekly skin inspection will be completed by licensed staff.Policy regarding resident medical records was requested and was not received.

Based on interview and document review the facility failed to ensure the facility assessment included the required components of involvement from direct care staff, considering staffing needs of each unit in the facility, and a plan to recruit and retain staff. This had the opportunity to affect all 33 residents. Findings include: Review of the facility assessment, dated 7/22/24, failed to include input and active involvement from direct care staff, including but not limited to registered nurses (RN), licensed practical nurses (LPN), and nursing assistants (NA). The document indicated the following people were involved in completing the assessment: administrator, director of nursing (DON), Governing Body representative, the medical director, the pharmacist, and residents/resident representatives/family members through letters, family council and resident council. The facility assessment failed to consider staffing needs for each unit in the facility and failed to consider staffing needs for each shift. The document indicated acuity needs of residents was reviewed and evaluated regularly and determined by resident assessments, care plans, and census. The staffing plan section of the document indicated staffing needs were determined by reviewing the resident population, case mix index (CMI) and census daily. Admissions and discharges assist in determining staffing needs for each day. The facility assessment lacked a plan and maximized recruitment and retention of direct care staff. It also lacked a contingency planning for events that did not require activation of facility's emergency plan, but had the potential to affect resident care, such as availability of direct care nurse staffing or other resources for resident care. The facility daily schedules from 7/15/25 through 8/14/25 indicated the facility staffed nurses and trained medication aides (TMA) for the north and south units. The facility staffed NAs for rooms 200-224, rooms 207-225 and 226-228, 229-244, and a float aide. (Actual room layout is not in numerical sequence.) Facility call light records reviewed for 4 residents from 7/15/25 through 8/14/25 identified excessive call light wait times, with the longest response time of 120 minutes. The review identified the following: 115 call light wait times that exceeded 20 minutes 28 call light wait times that exceeded 30 minutes 50 call light wait times that exceeded 40 minutes 3 call light wait times that exceeded 50 minutes 4 call light wait times that exceeded 60 minutes 2 call light wait times that exceeded 70 minutes 2 call light wait times that exceeded 80 minutes 1 call light wait times that exceeded 90 minutes 1 call light wait time was exceeded 120 minutes On 8/14/25, at 8:10 a.m., family member (FM)-A stated family felt uncomfortable leaving R1 at the facility without their presence due to the facility's slow response time to the call light. FM-A stated they often waited for 40 minutes for the staff to answer the call lights. On 8/14/25, at 1:11 p.m., FM-B stated it was common to wait 45 minutes for R1's call light to be answered. On 8/14/25, at 2:06 p.m., R3 stated she has had to wait for over two hours at times for her call light to be answered, resulting in her sitting in feces, due to the facility cutting staff. On 8/14/25, at 2:30 p.m., R4 stated call wait times were addressed with the facility management through resident council meetings and their response was they had the right number of staff they were required to have. He stated, There just aren't enough people. He also stated he always experienced long call light wait times. R4 stated he pressed his call light at 1:40 p.m., on 8/14/25, to use the commode. He stated he had become incontinent while waiting for staff assistance, which took 20 minutes. On 8/14/25, at 2:40 p.m. R5 stated he put his call light on around 1:30 p.m., on 8/14/25. He stated he had not been incontinent when he first pressed his light, but due to waiting for over 30 minutes, he urinated in his brief. R5 stated it happened often, as the facility was short-staffed, and the wait was worse overnight. On 8/14/25, at 2:55 p.m., R6 stated call wait times were very long. She stated at the last resident council meeting another resident stated he had waited over 2 1/2 hours for his call light to be answered. On 8/14/25, at 4:43 p.m., NA-A stated the facility was cutting staff, due to empty beds in the facility. She stated, One person has to go home at 9:00 p.m. She stated the staff has attempted to address their staffing concerns with management, but felt management did not care. On 8/14/25, at 4:48 p.m., NA-B stated, I feel like a lot of call lights are on for a long time, it's been busy, and residents are waiting. She also stated one NA has to leave the shift early, at 9:00 p.m. NA-AD stated some of the residents had complained about the response time to the call lights. NA-AD stated several residents required the assistance of two staff for transfers. On 8/14/25, at 4:53 p.m., RN-A stated she did not feel the facility had enough staff. She said the residents had to wait for their call lights to be answered, causing them to be incontinent by the time the staff responded. RN-A stated residents had complained about the length of time they had to wait. She stated it was hard when one of the NA's was required to leave at 9:00 p.m., due to low census. RN-A stated she shared these concerns with management. On 8/15/25, at 8:30 a.m., the staffing coordinator (SC) stated the staffing level was determined by census and nursing hours per patient day (PPD). She stated the facility was trying to cut hours to meet labor and census. She stated she felt it was unsafe to cut any additional hours as they were already getting quite low on floor staff. She stated the staff reported they felt they needed more help to her. The SC stated she was cutting hours by having the evening shift come in late and having someone leave the evening shift early. On 8/15/25, at 9:52 a.m., the therapeutic recreation director stated she attended every resident council meeting. She stated call light response times were addressed in almost every meeting and she shared the concerns addressed in the meeting with the appropriate department leaders. On 8/15/25, at 10:10 a.m., the DON stated she felt the facility had enough staffing and had not been told of any concerns by the residents. She stated the call light response times were evaluated if there was a complaint concerning them. The DON stated the call lights should be answered as soon as possible, but within 15 minutes. The DON stated a 45-minute call light response time was not acceptable. On 8/15/25, at 11:50 a.m., the administrator stated the facility assessment was to be completed annually. She stated some residents take two people to be transferred requiring longer time with staff, resulting in residents complaining about the wait times. She stated she reviewed the call light logs if there were complaints. She stated she had not observed any extended call light response times over the last 30 days. The administrator stated the call lights should be answered within 15 minutes. She stated she evaluated the call light response times by running average response times. The facility lacked a policy for the facility assessment.

Based on observation, interview and document review the facility failed to maintain residents' dignity for 2 of 3 residents (R4, R5) reviewed for dignity when it took 20 minutes for staff to answer call lights causing R4 and R5 to become incontinent. Findings included: R4's Brief Interview for Mental Status (BIMS), dated 4/11/25, indicated he was cognitively intact. R4's care plan, dated 4/29/25, indicated R4 was frequently incontinent of bladder and occasionally incontinent of bowel. It also indicated R4 was on diuretic and BPH medications. The care plan directed he required assistance of two staff with full ceiling lift, provide assistance with peri cares, provide incontinent products, and assist to change as needed. The care plan directed a toileting schedule of every two hours on the odd hour, during waking hours. R4's annual Minimum Data Set (MDS) dated [DATE] indicated he had diagnoses of heart failure, benign prostatic hyperplasia (BPH, an enlarged prostate gland), hemiparesis (weakness on one side), and morbid obesity. The MDS indicated he was dependent on staff for assistance with toileting and personal hygiene, as well as transfers from bed to chair and from the chair to the bed. The MDS indicated a toileting program had not been trialed for R4. The MDS did not assess R4's cognitive status. R4's bladder and bowel assessments, dated 7/9/25, indicated he was continent of bladder and bowel. It indicated R4 stated he only had incontinent episodes if staff cannot answer his call light. R4's care area assessment (CAA), dated 7/18/25, indicated R4 triggered for need for assistance with toileting and urinary incontinence. The CAA indicated R4 was frequently incontinent of bowel and bladder. The CAA indicated staff will continue to follow current care plan to aide in prevention of complications of incontinence including assistance with managing incontinent products, assisting with toileting needs as he requests/allows monitoring for signs and symptoms of infection and assisting with peri cares as appropriate. The device activity report indicated R4 had his call light on for 20 minutes, starting at 1:40 p.m., on 8/14/25. On 8/14/25, at 2:30 p.m., R4 stated he had an incontinent episode after waiting for staff to respond to his call light. He stated his call light had been on for 20 minutes. R4 stated call wait time were always long, adding at times it took over an hour for the staff to respond to his call light. R4 stated this resulted in him having more incontinence episodes, leaving him to feel uncomfortable and as if the staff does not care about him. R4 stated he had been on diuretics for five years which creates more urgency and frequency during the morning hours. He stated long call wait times had been addressed through grievances and at the resident council meetings. He stated he was not on a toileting schedule but had been in the past. R5's CAA, dated 9/12/24, indicated R5 was incontinent, wore incontinence products, would call for assistance to the toilet, and was taking a diuretic plus medications to help with urination. R5's bladder assessment, dated 12/27/24, indicated he was frequently incontinent of bladder, was able to make his needs known, required assistance of one staff for transfers. R5's bowel assessment, dated 12/27/24, indicated he was continent of bowel and transferred with the assistance of one staff. R5's quarterly MDS, dated [DATE], indicated had heart disease, renal insufficiency, and BPH. The MDS indicated he was cognitively intact and required partial to moderate assistance with personal and toileting hygiene. The MDS indicated R5 used his wheelchair independently and was independent with transfers from the chair to the bed and from the chair to the toilet. The MDS indicated R5 was always incontinent of urine and always continent of bowel. It also indicated no trial of a toileting program had been implemented or trialed for R5. R5's care plan, dated 8/5/25, indicated he had alteration in elimination related to impaired mobility. The care plan directed assistance of one staff to/from toileting, assist with peri cares, provide incontinent products, and assist to change as needed. The device activity report indicated R5 had his call light on for 20 minutes, starting at 1:40 p.m., on 8/14/25. On 8/14/25, at 2:40 p.m., R5 stated he had been waiting for a half an hour when the NA responded to his call light at 2:00 p.m. He stated when he pressed the call light, he had not been incontinent yet, but due to the wait he urinated in his brief. R5 stated this made him feel anxious and mad. He also stated, I don't like sitting in wet pants. R5 stated, This happens often, and that it occurs more often late in the evening and in the middle of the night. On 8/15/25, at 10:10 a.m., the director of nursing (DON) stated she expected call lights to be answered as soon as possible, but within 15 minutes. She stated toileting schedules should be implemented for R4 and R5 to promote continence. On 8/15/25, at 11:50 a.m., the administrator stated the NA's should be answering call lights within 15 minutes. A facility document, Activities of Daily Living (ADLs) Maintain Abilities Policy, dated 3/31/23, directed It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs.1. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable.2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living.3. The facility will provide care and services for the following activities of daily living: hygiene, mobility, elimination, dining, and communication.4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview and document review, the facility failed to develop and implement interventions to maintain continence for 2 of 3 residents (R4, R5) reviewed for care plans. Findings include: R4's Brief Interview for Mental Status (BIMS), dated 4/11/25, indicated he was cognitively intact. R4's care plan, dated 4/29/25, indicated R4 was frequently incontinent of bladder and occasionally incontinent of bowel. R4 was on diuretic and benign prostate hyperplasia (BPH) medications. The care plan directed he required assistance of two staff with full ceiling lift, provide assistance with peri cares, provide incontinent products, and assist to change as needed. The care plan directed a toileting schedule of every two hours on the odd hour, during waking hours. R4's annual Minimum Data Set (MDS) dated [DATE] indicated he had diagnoses of heart failure, benign prostatic hyperplasia (BPH, an enlarged prostate gland), hemiparesis (weakness on one side), and morbid obesity. The MDS indicated he was dependent on staff for assistance with toileting and personal hygiene, as well as transfers from bed to chair and from the chair to the bed. The MDS indicated a toileting program had not been trialed for R4. The MDS did not assess R4's cognitive status. R4's bladder and bowel assessments, dated 7/9/25, indicated he was continent of bladder and bowel. It indicated he stated he only had incontinent episodes if staff cannot answer his call light. R4's care area assessment (CAA), dated 7/18/25, indicated R4 triggered for need for assistance with toileting and urinary incontinence. The CAA indicated R4 was frequently incontinent of bowel and bladder. The CAA indicated staff will continue to follow current care plan to aide in prevention of complications of incontinence including assistance with managing incontinent products, assisting with toileting needs as he requests/allows monitoring for signs and symptoms of infection and assisting with peri cares as appropriate. On 8/14/25, at 2:30 p.m., R4 stated he had an incontinent episode after waiting for staff to respond to his call light. He stated his call light had been on for 20 minutes. R4 stated call wait time were always long, adding at times it took over an hour for the staff to respond to his call light. R4 stated this resulted in him having more incontinence episodes, leaving him to feel uncomfortable and as if the staff does not care about him. R4 stated he had been on diuretics for five years which creates more urgency and frequency during the morning hours. He stated long call wait times had been addressed through grievances and at the resident council meetings. He stated he was not on a toileting schedule but had been in the past. R5's CAA, dated 9/12/24, indicated R5 was incontinent, wore incontinence products, would call for assistance to the toilet, and was taking a diuretic plus medications to help with urination. R5's bladder assessment, dated 12/27/24, indicated he was frequently incontinent of bladder, was able to make his needs known, required assistance of one staff for transfers. R5's bowel assessment, dated 12/27/24, indicated he was continent of bowel and transferred with the assistance of one staff. R5's quarterly MDS, dated [DATE], indicated had heart disease, renal insufficiency, and BPH. The MDS indicated he was cognitively intact and required partial to moderate assistance with personal and toileting hygiene. The MDS indicated R5 used his wheelchair independently and was independent with transfers from the chair to the bed and from the chair to the toilet. The MDS indicated R5 was always incontinent of urine and always continent of bowel. It also indicated no trial of a toileting program had been implemented or trialed for R5. R5's care plan, dated 8/5/25, indicated he had alteration in elimination related to impaired mobility. The care plan directed assistance of one staff to/from toileting, assist with peri cares, provide incontinent products, and assist to change as needed. On 8/14/25, at 2:40 p.m., R5 stated he had been waiting for a half an hour when the NA responded to his call light at 2:00 p.m. He stated when he pressed the call light, he had not been incontinent yet, but due to the wait he urinated in his brief. R5 stated this made him feel anxious and mad. He also stated, I don't like sitting in wet pants. R5 stated, This happens often, and that it occurs more often late in the evening and in the middle of the night. R5 stated he was not on a toileting schedule. On 8/14/25, at 4:43 p.m., NA-A stated residents who cannot use their call lights are on toileting schedules every two hours She stated all other residents use their call light when they need to use the restroom and call lights are answered in the order they are pressed. She stated R4 and R5 were assisted to the bathroom as they requested it and were not on a schedule. On 8/15/25, at 9:48 a.m., NA-C stated R4 and R5 were supposed to be on a toileting schedule on the odd hours, but it was not followed. She stated it was implemented by the previous director of nursing (DON). On 8/15/25, at 10:10 a.m., the DON stated toileting schedules were intended to prevent incontinence episodes, by assisting the resident to the restroom on a regular basis and promote continence. She stated R4 was on a toileting schedule every two hours while awake. She stated the bladder assessment, dated 7/9/25 was not accurate, as it indicated R4 was continent. She also stated it was incomplete as it did not include pertinent diagnosis and medications related to urinary urgency and frequency. The DON stated R5 was not on a toileting schedule. The DON stated based on R5's bladder assessment, dated 12/27/24, she would expect the facility to have implemented a toileting schedule to offer him assistance to the restroom every 2 -3 hours, with a follow up to determine effectiveness. A facility document, Care Planning, dated 11/2024, directed in accordance with state and federal regulations, each resident will have a person-centered care plan developed by the interdisciplinary team for the purpose of meeting the resident's individual medical, physical, psychosocial, and functional needs. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive person-centered care plan will be consistent with the resident's rights to identify problem areas and their causes and develop interventions that are targeted and meaningful to the resident. The resident has the right and is encouraged to participate in the development of their care plan. The care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purposes of providing care or services to the resident. The plan of care will be utilized to provide care to the resident. The care plan is to be modified and updated as the condition and care needs of the resident changes.

Based on observation, interview, and document review the facility failed to ensure residents incontinent of bladder and bowel received services to maintain continence when 2 of 3 residents (R4, R5) reviewed for continence care did not receive timely care, resulting in bladder incontinence. Findings include: R4's care plan, dated 4/29/25, indicated R4 was frequently incontinent of bladder and occasionally incontinent of bowel. It also indicated R4 was on diuretic and BPH medications. The care plan directed he required assistance of two staff with full ceiling lift, provide assistance with peri cares, provide incontinent products, and assist to change as needed. The care plan directed a toileting schedule of every two hours on the odd hour, during waking hours. R4's Brief Interview for Mental Status (BIMS), dated 4/11/25, indicated he was cognitively intact. R4's annual Minimum Data Set (MDS) dated [DATE] indicated he had diagnoses of heart failure, benign prostatic hyperplasia (BPH, an enlarged prostate gland), hemiparesis (weakness on one side), and morbid obesity. The MDS indicated he was dependent on staff for assistance with toileting and personal hygiene, as well as transfers from bed to chair and from the chair to the bed. The MDS indicated a toileting program had not been trialed for R4. The MDS did not assess R4's cognitive status. R4's bladder and bowel assessments, dated 7/9/25, indicated he was continent of bladder and bowel. It indicated he stated he only had incontinent episodes if staff cannot answer his call light. The assessment lacked pertinent diagnoses that may affect urinary function, identification of medications related to urinary urgency and frequency, voiding patterns. The assessments lacked interventions to manage R4's incontinence.R4's care area assessment (CAA), dated 7/18/25, indicated R4 triggered for need for assistance with toileting and urinary incontinence. The CAA indicated R4 was frequently incontinent of bowel and bladder. The CAA indicated staff will continue to follow current care plan to aide in prevention of complications of incontinence including assistance with managing incontinent products, assisting with toileting needs as he requests/allows monitoring for signs and symptoms of infection and assisting with peri cares as appropriate. On 8/14/25, at 2:30 p.m., R4 stated he had an incontinent episode after waiting for staff to respond to his call light. He stated his call light had been on for 20 minutes. R4 stated call wait time were always long, adding at times it took over an hour for the staff to respond to his call light. R4 stated this resulted in him having more incontinence episodes, leaving him to feel uncomfortable and as if the staff does not care about him. R4 stated he had been on diuretics for five years which creates more urgency and frequency during the morning hours. He stated long call wait times had been addressed through grievances and at the resident council meetings. He stated he was not on a toileting schedule but had been in the past. R5's CAA, dated 9/12/24, indicated R5 was incontinent, wore incontinence products, would call for assistance to the toilet, and was taking a diuretic plus medications to help with urination. R5's bladder assessment, dated 12/27/24, indicated he was frequently incontinent of bladder, was able to make his needs known, required assistance of one staff for transfers. The assessment indicated it was not appropriate for a bladder retraining program. R5's bowel assessment, dated 12/27/24, indicated he was continent of bowel and transferred with the assistance of one staff. R5's quarterly MDS, dated [DATE], indicated had heart disease, renal insufficiency, and BPH. The MDS indicated he was cognitively intact and required partial to moderate assistance with personal and toileting hygiene. The MDS indicated R5 used his wheelchair independently and was independent with transfers from the chair to the bed and from the chair to the toilet. The MDS indicated R5 was always incontinent of urine and always continent of bowel. It also indicated no trial of a toileting program had been implemented or trialed for R5. R5's care plan, dated 8/5/25, indicated he had alteration in elimination related to impaired mobility. The care plan directed assistance of one staff to/from toileting, assist with peri cares, provide incontinent products, and assist to change as needed. On 8/14/25, at 2:40 p.m., R5 stated he had been waiting for a half an hour when the NA responded to his call light at 2:00 p.m. He stated when he pressed the call light, he had not been incontinent yet, but due to the wait he urinated in his brief. R5 stated this made him feel anxious and mad. He also stated, I don't like sitting in wet pants. R5 stated, This happens often, and that it occurs more often late in the evening and in the middle of the night. R5 stated he was not on a toileting schedule. On 8/14/25, at 4:43 p.m., NA-A stated residents who cannot use their call lights are on toileting schedules every two hours She stated all other residents use their call light when they need to use the restroom and call lights are answered in the order they are pressed. She stated R4 and R5 were assisted to the bathroom as they requested it and were not on a schedule. On 8/15/25, at 9:48 a.m., NA-C stated R4 and R5 were supposed to be on a toileting schedule on the odd hours, but it was not followed. She stated it was implemented by the previous director of nursing (DON).On 8/15/25, at 10:10 a.m., the DON stated toileting schedules were intended to prevent incontinence episodes, by assisting the resident to the restroom on a regular basis and promote continence. She stated R4 was on a toileting schedule every two hours while awake. She stated the bladder assessment, dated 7/9/25 was not accurate, as it indicated R4 was continent. She also stated it was incomplete as it did not include pertinent diagnosis and medications related to urinary urgency and frequency. The DON stated R5 was not on a toileting schedule. The DON stated based on R5's bladder assessment, dated 12/27/24, she would expect the facility to have implemented a toileting schedule to offer him assistance to the restroom every 2 -3 hours, with a follow up to determine effectiveness. A facility document, Care Planning, dated 11/2024, directed in accordance with state and federal regulations, each resident will have a person-centered care plan developed by the interdisciplinary team for the purpose of meeting the resident's individual medical, physical, psychosocial, and functional needs. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive person-centered care plan will be consistent with the resident's rights to identify problem areas and their causes and develop interventions that are targeted and meaningful to the resident. The resident has the right and is encouraged to participate in the development of their care plan. The care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purposes of providing care or services to the resident. The plan of care will be utilized to provide care to the resident. The care plan is to be modified and updated as the condition and care needs of the resident changes. A facility document, Activities of Daily Living (ADLs) Maintain Abilities Policy, dated 3/31/23, directed It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs.1. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable.2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living.3. The facility will provide care and services for the following activities of daily living: hygiene, mobility, elimination, dining, and communication.4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and document review, the facility failed to report an allegation of sexual abuse to the State Agency (SA) within two hours, as required, for 1 of 3 residents (R1) reviewed. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included paraplegia, neurogenic bowel (neurological condition disrupt the normal communication between the brain and colon, leading to difficulties in controlling bowel movements), and major depressive disorder. R1 was cognitively intact and did not exhibit any behaviors. Review of facility report number 360763 to the SA dated 6/6/25 at 1:07 p.m., indicated R1 reported she used the call light to request assistance with a brief change. She was turned onto their left side and participated in the repositioning by gripping the grab bar on that side of the bed. R1 indicated the nursing assistant (NA), while cleaning the resident, informed her that they needed to see how much stool was coming out. R1 reported the NA put their right hand on her right hip and with the left hand put their finger into her anus. R1 reported they have never had anal sex but the way the NA put his finger in and out of R1's anus was anal sex to them. R1 described the sensation of the finger entering her as painful and upsetting. Further, report identified registered nurse (RN)-A was made aware of the allegation on 6/6/25, at 11:05 a.m. On 6/18/25 at 10:42 a.m., NA-A indicated R1 required assistance by staff for incontinent cares and R1 had no cognitive impairments or behaviors. NA-A stated on 6/6/25, at approximately 6:00 a.m., R1 requested assistance with changing her brief. During the encounter, NA-A stated R1 the allegation of sexual abuse that occurred on the overnight. NA-A stated R1 was stated her rectum was painful and R1 was in tears. Further, NA-A stated following assisting R1, she exited her room and continued to assist other residents with morning cares until she seen RN-A at the nursing station. NA-A stated she reported R1's allegation to RN-A at approximately 8:30 a.m., because she did not see another other nurse around before that. In addition, NA-A stated staff were expected to report abuse immediately to the charge nurse. On 6/18/25 at 11:02 a.m., NA-B stated R1 was cognitively intact and did not exhibit any behaviors. NA-B stated she was made aware of R1's abuse allegation on 6/6/25, at approximately 9:00 a.m., when R1 had reported the overnight NA had fingered her anus. NA-B stated she exited R1's room and reported the allegation to NA-A, who then reported the allegation to RN-A. In addition, NA-B stated staff were expected to report abuse to the charge nurse right away but within two hours. On 6/18/25 at 12:55 p.m., RN-A stated on 6/6/25, at approximately 11:05 a.m., NA-A approached him and stated R1 wanted to speak with him, but NA-A did not report any abuse concerns at that time. RN-A administered insulin to another resident, and then went to speak with R1. RN-A stated upon entering R1's room he observed R1 was very upset, and she was crying. RN-A stated R1 had reported the overnight NA was assisting with a brief change and R1 felt the NA's finger go into her anus. RN-A stated he immediately went to report the abuse concern to the administrator and a report was submitted to the SA. On 6/18/25 at 3:05 a.m., interim director of nursing (DON) stated staff are expected to report abuse allegations immediately to the administrator and/or DON and within two hours to the SA. Review of facility policy titled Abuse Prohibition/Vulnerable Adult Policy revised 4/25, directed staff suspected abuse shall be reported to the SA online reporting process no later than 2 hours after forming the suspicion of abuse.

Based on interview and document review, the facility failed to ensure contracted agency staff were trained on the facility's abuse policy and annual abuse training which had the potential to affect all 37 residents currently residing in the facility at the time of the survey. Findings include: Review of facility report number 360763 to the SA dated 6/6/25 at 1:07 p.m., indicated R1 reported she used the call light to request assistance with a brief change. She was turned onto their left side and participated in the repositioning by gripping the grab bar on that side of the bed. R1 indicated the nursing assistant (NA)-C, while cleaning the resident, informed her that they needed to see how much stool was coming out. R1 reported the NA-C put his right hand on her right hip and with the left hand put his finger into her anus. R1 reported they have never had anal sex but the way the NA-C put his finger in and out of R1's anus was anal sex to them. R1 described the sensation of the finger entering her as painful and upsetting. Further, report identified registered nurse (RN)-A was made aware of the allegation on 6/6/25, at 11:05 a.m. Review of New Employee Orientation dated 12/24, document provided by NA-C's contracted agency staffing company revealed training on resident abuse, physical abuse, emotional abuse, financial abuse, neglect, and reporting abuse and neglect. The document failed to provide evidence of education related to sexual abuse and the reporting requirements. On 6/17/25 at 2:17 p.m., requested NA-C's abuse training. At 5:06 p.m., email was received from administrator stating the facility did not have abuse training for NA-C. On 6/18/25 at 9:43 a.m., NA-C stated he was contracted through an agency and had been working at the facility for two years but has only picked up about 10 shifts so far in 2025. NA-C stated through his agency he had completed some training regarding abuse and reporting, however, had not completed any training with the facility in regard to their abuse policy and procedure. On 6/18/25 at 10:34 a.m., director of recruitment from contracted staffing agency confirmed their employees received abuse training as part of their orientation and confirmed NA-C had not completed abuse training since October 2023. On 6/20/25 at 4:22 p.m., email received from administrator with NA-C education records from contracted agency company verified abuse training was completed on 8/21/24. However, training completed lacked evidence of sexual abuse training and reporting requirements. Review of facility policy titled Abuse Prohibition/Vulnerable Adult Policy revised 4/20/25, indicated the facility would provide orientation to all new employees which Resident Rights and Vulnerable Adult Law policies and procedures would be reviewed, and staff receive an employee policy book which outlines these policies/procedures, all new employees receive training on how to report alleged abuse/neglect upon hire, and all employees received annual in-service training on Vulnerable Adult Policies and Procedures. The policy lacked evidence of how contracted staff would be included and who would ensure contracted staff received education and training.

Based on observation, interview and document review, the facility failed to perform hand hygiene and change gloves appropriately for 1 of 1 residents (R2) observed for personal cares. In addition, the facility failed to develop a trending and tracking program system for monitoring residents who showed signs of illness, but were not on an antibiotic, these practices had the potential to affect all 37 residents currently residing in the facility. Findings Include: R2's 3/21/25, significant change Minimum Data Set (MDS) identified her cognition was severely impaired, and she was dependent on staff for activities of daily living (ADL)s. R2 had diagnoses of anemia (low levels of red blood cells (which carry oxygen to the tissues) which causes weakness and fatigue), hypertension (high blood pressure), arthritis (inflammation of the joints), neuropathy (nerve pain which can lead to pain, weakness, or numbness), and urinary retention. R2's care plan initiated 2/24/25, identified R2 had enhanced barrier precautions (EBP) in place due to use of an indwelling catheter. Enhanced barrier precautions was a risk-based approach to personal protective equipment (PPE) use designed to reduce the spread of multi-drug-resistant organisms (MDROs-super bugs which were difficult to treat with antibiotics) which involved the use of gown and gloves during high-contact resident care activities for residents at high risk of colonization with an MDRO. The care plan directed staff to follow the EBP and to don/doff (apply and remove) PPE per EBP when providing high contact cares. The care plan directed staff to perform peri-cares every morning, evening, and as needed. The staff were directed to perform Foley catheter care per policy. R2's care plan also identified R2 had self-care deficit due to weakness and directed staff to provide assistance of one with dressing and personal hygiene. On 4/30/25 at 7:32 a.m., R2 was observed resting on her bed, with head of the bed elevated 30 degree angle. Resident was observed to be in bed clothes, under covers, and was awake at this time. On 4/30/25 at 7:40 a.m., certified nursing assistant (CNA)-A greeted R2 from the door way, performed hand hygiene with alcohol based rub, and placed gown and gloves prior to entering the room. After gathering R2's clothing, towels and washcloths, CNA-A proceeded with personal cares. CNA-A removed the blanket from R2 and proceeded to place R2's pants on. CNA-A ran the catheter bag and tubing through the pants leg, and placed the catheter bag on the bed. CNA-A removed R2's gown and proceeded to wash R2's underarms, and then proceeded to wash under R2's breasts. After R2 was washed, CNA-A proceeded to apply powder under R2's breasts, and deodorant on under R2's arms. R2 was then dressed in a t-shirt. CNA-A proceeded to remove brief and completed pericare, with the use of a fresh washcloth. CNA-A completed catheter care by wiping down catheter tubing from meatus (opening of the urinary system) down the catheter tube. Following completion of pericares and catheter cares, R2 was assisted to reposition to replace the incontinence brief. Once brief was placed, CNA-A reached into her pocket to use her walkie talkie to summon assistance. Of note, during the observation of personal cares, initial gloves have not been removed, nor was hand hygiene performed. CNA-A's walkie talkie was returned to uniform pocket, behind gown, and CNA-A continued with cares. CNA-A was unsure if anyone heard request for assistance, stepped over to door, and opened door, looked down hallways, closed door and returned to cares. At this time, original gloves remain and hand hygiene had not been performed. While waiting for assist of staff, CNA-A proceed to wash R2's face with a fresh washcloth, taking care to wash from the inner corner of the eye outward. While providing care, CNA-A noted R2's mouth was very dry. While waiting for assistance, CNA-A proceeded to straighten up the room. CNA-A noted skin protector on bedside table, commented it was hers, and placed back in her pocket, moving gown aside. At this time, original gloves remain in place and no hand hygiene has been performed. At 7:59 a.m., CNA-D arrived to assist. Once hand hygiene was performed, gown and gloves applied, R2 was turned to complete pulling up of pants, and place sling for transfer. R2 was assisted by two staff to transfer into her chair with the use of a mechanical lift and sling. Once transfer was completed, CNA-D removed gown and gloves, performed hand hygiene and left the room. Resident was adjusted in chair so she was well supported. CNA-A proceeded to make R2's bed, and then provided a blanket to R2's lap. CNA-A continued to have initial gloves in place, with no hand hygiene performed. CNA-A proceeded to comb R2's hair. CNA-A then performed oral hygiene with toothbrush and toothpaste. R2 was provided a small amount of water to rinse mouth and stated teeth felt better once brushed. CNA-A proceed to remove original gown and gloves. CNA-A then placed portable liquid oxygen on the chair, and placed the nasal cannula into nostrils. CNA-A performed hand hygiene upon exit of room, using an alcohol based rub. During interview on 4/30/25 at 8:14 a.m., with CNA-A stated that she used gloves with personal cares. CNA-A was aware of the use of gown and gloves for EBP with R2. Gloves were placed upon entrance to each room for provision of cares. CNA-A stated when providing cares, she did change gloves throughout cares if they became visibly soiled, and stated if there was poop on them. Then I change them. CNA-A confirmed she did not change gloves throughout the provision of cares with R2. During interview of 4/30/25 at 3:46 p.m., the director of nursing (DON) stated staff were to perform hand hygiene prior to entering all rooms. DON expected staff to assist residents with personal hygiene by going from the cleanest to the dirtiest areas. DON stated if for some reason the staff needed to perform more personal cares before completing more clean cares, staff were to remove gloves, perform hand hygiene, and place new gloves. DON stated it was her expectation to perform hand hygiene as outlined, even if gloves were not visibly soiled. On 5/1/25 at 9:14 a.m., registered nurse (RN)-A stated hand hygiene was to be completed before and after providing care to any resident. RN-A stated hand hygiene was to be performed with any cares and identified hand hygiene should be completed before entering any room. RN-A stated the order of the bed bath performed was for the staff to start with the face first, and make your way down to the arms, stomach, legs, and finishing with peri area. RN-A stated gloves should be changed following pericare, and hand hygiene performed before going to any other areas of care. Policies were requested for performance of bedbaths, and completion of hand hygiene with cares, but not received. 40938 Infection Control: The facilities infection control logs were reviewed from January 2025 through March 2025. April 2025 infection control log was requested; however, this was not provided. The facility provided documents with the month and year written along the top of the first page. The headings on the document included; unit, name, room number, admitted , infection present on admission (yes or no), existing infection from previous month (yes or no), infection type, body system of infection, diagnosis, surveillance definition (yes or no), symptoms, onset date, device type(s), date(s) of insertion, date(s) of removal, device days, infection risk factors, diagnostic test performed (yes or no), test date, type of test, specimen source, results (organism colony count for urine), antibiotic resistant organism (yes or no), antibiotic name, class, other medications not listed, dose, route, frequency, provider, antimicrobial prescription origin, antibiotic start date, antibiotic end date, total days of therapy, meets criteria (yes or no), antibiotic reassessment performed, other antimicrobial prescribed name, other antimicrobial's prescribed class, transition based precautions required (yes or no) if yes specify, and date symptoms resolved. January 2025 infection log identified six-line entries for resident infections carried over from December 2024. There were 22 entries of infections during the month of January. Seven-line entries addressed respiratory tract infections which were treated with antibiotic therapy, with two lines contributed to one resident. Eight-line entries addressed urinary tract infections (UTI) which were treated with antibiotic therapy, with two residents having had two-line entries each. Four-line entries addressed skin infections which were treated with antibiotic therapy with two entries contributed to one resident. One-line entry addressed gastrointestinal (GI) which was treated with antibiotic therapy. One-line entry addressed eye infection treated with antibiotic therapy, and one-line entry addressed shingles treated with antibiotic therapy. There were no viral, fungal, yeast or viral illnesses identified, only illnesses that were treated with antibiotics. February 2025 infection log identified 30-line entries for the month. Ten-line entries addressed UTI treated with antibiotic therapy, with two residents that contributed to two lines each. Twelve-line entries addressed respiratory illness treated with antibiotic therapy, of which two residents contributed to three entries each and two residents contributed to two entries each. Four-line entries were contributed to one resident treated with antibiotic therapy for graft versus host disease. four-line entries addressed cellulitis (bacterial infection of the skin and underlying tissues) treated with antibiotic therapy. There were no viral, fungal, yeast or viral illnesses identified, only illnesses that were treated with antibiotics. March 2025 infection log identified four-line entries carried over from February 2025. thirteen lines were entered for March infections. One-line entry identified the infection type of prophylaxis antibiotic (preventative). Three-line entries addressed skin treated with antibiotic therapy, with two entries contributed to one resident. Two-line entries addressed GI treated with antibiotic therapy. Two-line entries addressed respiratory treated with antibiotic therapy, both contributed to one resident. Four-line entries addressed UTI treated with antibiotic therapy. One entry addressed hepatic encephalopathy (brain dysfunction caused by liver dysfunction) treated with antibiotic therapy. There were no viral, fungal, yeast illnesses identified, only illnesses that were treated with antibiotics. However, the facility did complete a Minnesota Department of Health (MDH) line listing for norovirus (very contagious virus that causes vomiting and diarrhea) outbreak that affected 29 residents. When interviewed on 4/30/25 at 3:40 p.m., director of nursing/infection preventionist (DON) stated resident infections and symptom tracking were completed on clinical DON update for morning meeting on weekdays with Mondays looking at the past weekend. There was no spreadsheet or log of symptom tracking for potential infections that did not require antibiotic therapy. Infection log was completed as infections were identified with a full review at the end of the month. On 5/01/25 at 8:13 a.m., DON provided clinical DON update before morning meeting for April 2025. Pages identified date with table for infections with headings of Resident, infection type, antibiotic, dates of treatment, MeGeers (a set of definitions used to identify and track healthcare-associated infections in long-term care facilities) and 72-hour antibiotic time out, added to infection tracking, and follow up. Review identified three residents with UTI treated with antibiotic therapy, one resident with cellulitis treated with antibiotic therapy. One resident with a nail infection treated with antibiotic therapy, and one resident with osteomyelitis (bone infection) treated with antibiotic therapy. No infections listed indicated they were added to infection tracking log. There was no April 2025 infection tracking log provided. There were no viral, fungal, yeast or viral illnesses identified, only illnesses that were treated with antibiotics. Facility Infection Prevention and Control Program policy dated 11/6/24, indicated surveillance tools were used to recognize the occurrence of infections, detected unusual pathogens with infection control implications. Data gathered during surveillance was used to oversee infections and spot trends. However, the policy did not address tracking symptoms and/or illnesses that did not require antibiotic therapy.

Based on interview and document review, the facility failed to ensure resident mail was delivered to residents on Saturdays for 2 of 2 residents (R3 and R28) who voiced concerns with mail delivery during Resident Council. This had the potential to affect all 37 residents residing in the facility. Findings include: On 4/30/25 at 3:00 p.m., a Resident Council meeting was held with six residents from varied areas of the facility. During the meeting, R3 voiced a concern mail was not delivered to residents on Saturdays. This was verified by R28. R3 indicated mail was delivered to the facility on Saturdays and was placed in the black box outside of the front entrance. Historically, this was then gathered on Monday morning and delivered by the receptionist. This process has changed somewhat since the position of receptionist was not currently filled. On 5/1/25, at 9:53 a.m. the business office manager (BOM) affirmed the mail is delivered by the post office to the outside collection box. BOM stated the business office gets it Monday, as the key is locked up for the post office box outside. BOM stated the mail delivery is then coordinated on Mondays. During interview on 5/1/25, at 10:34 a.m. , interim administrator (IA) acknowledged awareness of mail delivery on Saturdays. Corporate nurse (CN)-A stated she was unaware of this requirement. On 5/1/25, at approximately 11:19 a.m. CN-A informed survey team member upon review of facility process, they were mistaken. CN-A stated the mail was not delivered to the facility on Saturdays. On 5/1/25, at 11:29 a.m., a call was placed to the United States Post Office in follow up. At this time, surveyor was informed by Post Master mail delivery occurred Monday through Saturday to the facility and the mail was placed in the locked box outside of the facility. On 5/1/25, at 11:39 a.m., IA stated upon investigation with the mail delivery, they spoke with corporate maintenance director and had been informed mail delivery on Saturdays was at the discretion of the community as to whether or not mail is delivered to facilities on Saturdays. Surveyor informed IA they had spoken with Post Master who had affirmed mail was delivered to this facility on Saturdays. IA stated she would seek further clarification on this. Surveyor provided contact information for local Unities States Post Office. No additional information was provided by the facility regarding mail deliver. A facility policy was requested for mail delivery on Saturdays, however, was informed no policy was available.

Based on observations, interviews and document review, the facility failed to ensure resident living areas are free from odors for 2 of 2 residents (R8 and R14) in the sample whose room odors permeated the surrounding halls. This had the potential to affect residents in surrounding rooms, visitors and facility staff. In addition the facility failed to fully investigate missing personal items for 1 of 1 residents (R9) with reports of missing clothing that was reported missing for approximately two months. Findings include: R8 In review of R8's Diagnosis Report (print date 4/30/25) documented the diagnoses of morbid obesity with alveolar hypoventitlation {a condition where the lungs don't move enough air in and out, leading to a buildup of carbon dioxide (hypercapnia) and a decrease in oxygen levels in the blood}, and type 2 diabetes. R8's 5-day Minimum Data Set (MDS) - post hospitalization , dated 2/12/25, indicated R8 was independent with self cares, requiring partial/moderate assistance with toileting and substantial/maximal assistance with showering/bath. In review of R8's Brief Interview for Mental Status (BIMS), resident was assessed to be cognitively intact. During screening interview on 4/28/25 at 2:12 p.m., there was a distinct urine and other odors to R8's room, however, R8 stated it was due to being toileted after an incontinent bowel movement. On 4/29/25 at approximately 9:30 a.m., noted a strong almost necrotic odor (a foul-smelling odor that often arises from the breakdown of dead tissue and bacterial activity within the wound) emanating from R8's room. R8 was noted to be sitting in his wheel chair, reading papers on his tray table. R8 was asked about the odor, to which he stated he had not yet done his morning cares. During an interview on 4/29/2025 at 10:17 a.m., nursing assistant (NA)-A stated R8 has a really strong odor to himself, and refuses staff to assist him with his activities of daily living (ADLs). R8 only feels a need for a weekly bath and did his own peri-area and washing up. We offer to assist and will occasionally allow staff to wash his back. A review of R8's care planned area of Self care (dated 7/17/24), under the Intervention/Tasks section the following was documented: Assist resident with personal hygiene including pericares in the morning, evening and as needed. Resident will at times refuse for staff to assist with completing cares as he prefers to be independent with this task. Throughout the day of 4/29/25, the odor continued to be noted as one passed R8's room. During environmental tour on 4/29/25 at 3:30 p.m., the following facility staff accompanied surveyor to R8's room: regional maintenance director (CMD), regional administrator (RA), the facility's maintenance director (FM), director of nursing (DON) and interim administrator (IA). CMD stated he was unaware of the odor until this morning when he arrived and walked by R8's room. CMD stated he would check with the facility house keeping department to see if an odor block container had been placed. DON stated R8 didn't have any open areas that would have potentially caused the smell. DON attributed the smell to resident being obese with multiple abdominal folds, R8 has an issue with yeast build up in those areas. DON stated R8 provides all his personal cares while he was not wishing staff to assist due to embarrassment. R8 occasionally allows staff to wash his back and assist during showers, however refused staff to assist with pericare and washing and drying of abdominal folds. During further interview on 4/29/25 at 4:40 p.m., CMD and facility housekeeping director (FHD), noted R8 was not currently in his room, showed the facility had placed an odor block container behind his wardrobe and was 1/2 empty. FHD stated the house keepers have done a deep cleaning of R8's room and every time resident has a shower and/or his sheets are changed, housekeeping wipes down R8's mattress with a sanitizer / deodorizer. FHD stated the odor goes away for a short period of time then returns. R14 In review of R14's Diagnosis Report (print date 4/30/25) documented the diagnoses of Neuromuscular dysfunction of bladder, lumbar spina bifida with hydrocephalus (a birth defect where the spine and spinal cord don't close completely, is often associated with hydrocephalus, a condition where excess fluid accumulates in the brain) and morbid obesity. R14's significant change MDS, dated [DATE], indicated R14 was cognitively intact and required supervision and touch assistance with verbal cueing for all ADLs. During initial tour of surveyor's assigned area, on 4/28/24 at 1: 00 p.m., which included R14's room, a strong odor of urine was noted, emanating from resident's room. It was also noted the door to R14's room was closed. The odor could be noted into the adjacent dayroom and within approximately 6 feet of the joining hall of rooms. On 4/28/25 at 1:13 p.m., after knocking on R14's door and being invited in, the odor of urine became even more apparent. Inside the room, R14 was laying on her bed using her iPad as introductions were made. Against the window was was a bariatic commode, the curtains were pulled and lights were out. While being interviewed, R14 was asked about the odor in the room. R14 stated the odor in the room is from her, and stated she doesn't notice it, I have the scent sticks that cover and absorb. When asked how often housekeeping comes in to clean, R14 stated at least weekly. R14 stated she is working on writing fantasy series of books and needed to concentrate. R14 stated she toilets herself, only asking staff to assist when she is tired. During interview on 04/28/2025 at 1:34 p.m., nursing assistant (NA) - A stated she is responsible for the resident on the south end of the wing. NA-A stated R14 rarely leaves the room, occasionally when they can talk her into having a shower. R14 washes self after set up by staff, but usually refuses assistance. NA stated R14's room has had an odor for a very long time, and she doesn't always allow staff to come in, especially housekeeping. During interview on 04/28/2025 at 3:50 p.m., NA-B stated R14 requires assistance with most of her cares, however normally only allowed set up of supplies. NA-B stated staff do encourage her to allow them to assist, but she feels she does an adequate job herself. R14 did request staff, in the evenings to assist her to the commode, when she was tired. R14 did not like staff touch her stuff. In a further interview on 04/28/2025 at 6:12 p.m., NA-C stated she occasionally helped near R14's room. NA-C stated the room and the hall area of R14's room had a strong odor of urine for awhile. NA stated R14 kept the room door closed and did not allow many staff in, R14 felt she was independent. During environmental tour on 4/29/25 at 3:45 p.m., the following facility staff accompanied surveyor to R14's room: CMD, RA, the FM, DON and IA. The door to R14's room was closed and while standing in the adjacent dayroom and joining hall, the facility team assembled stated they to were able to notice the strong urine odor. CDM state he was unaware of the issues and the facility could utilize an odor blocker container in the room if it had not already been placed. The DON and FM stated R14 doesn't leave the room and rarely allows housekeeping to clean the room. DON stated R14 will allow for a weekly cleaning (usually Friday) as she did not want to be disturbed. R14 only lets the staff change her sheets when she thought they were dirty enough. In a further interview on 4/29/25 at 4:40 p.m., CMD and the FHD stated the facility had placed a odor block container (located between R14's bed and bedside cabinet), but the room needed a through deep cleaning which R14 has not allowed. A review of R14's care plan area of Self care (last revised 10/02/24), documented that R14 was to have the assistance of one with personal hygiene. In further review of this care plan for Elimination, with a revision date of 9/10/24, indicated the following: Provide assistance with peri-cares AM, HS, following each incontinent episode, and [as needed]. The policy entitled: Daily Cleaning Procedures (YONA Solutions - undated), the following areas and processes were outlined: 1. wash hands, put on gloves and place wet floor sign at the door entrance, 2. knock on door and enter room, 3. empty trash, 4. high dust, 5. disinfect, 6. spot clean walls and inspect privacy curtains, 7. clean room, 8. dust mop, 9. damp mop and 10. place soiled rags in plastic bag on cart, remove and discard gloves, and wash hands prior to leaving room. Each of the sections provided staff definitions / descriptors of what was involved in each of the tasks. The policy entitled: Deep Clean Procedures (YONA Solutions - undated), mirrored the Daily Cleaning Procedure policy, however directed staff to include the cleaning of dressers, chairs, closet, windows, heating unit, night stand, bed, bedside tables, lights over the bed, call light and remove build-up on floor between room and hallway. 35992 R9 R9's quarterly MDS of 4/11/25, indicated R9 was alert and oriented and readily able to communicate her needs. The MDS lacked any indication of behavioral concerns. R9 was able to complete activities of daily living (ADL's) independently, except for meeting her toileting and bathing needs. R9's medical diagnoses included anemia (low levels of healthy cells to carry oxygen), chronic obstructive pulmonary disease with acute exacerbation (a persistent respiratory disease that may cause long-term, progressive lung damage), chronic pain syndrome, and history of cerebral infarction (stroke) without residual deficits (lasting effects related to the stroke). During interview on 4/28/25 at 12:58 p.m., R9 stated she had an item of clothing, a pink Under [NAME] long sleeve shirt, which she had sent to the laundry which had not been returned. R9 stated she had informed the housekeeping assistant (HA)-A of this. R9 stated this had been missing for approximately two months and had not been found yet. On 4/29/25 at 4:35 p.m., facility housekeeping director (FHD) stated she was unaware of any missing items, but would follow up with HA-A, as HA-A often spoke with R9. FHD stated HA-A had left for the day and would follow up on 4/30/25. On 4/30/25, surveyor spoke with both HA-A and FHD, who both stated the item had not yet been found. It was identified this was missing for approximately two months without being found. HA-A stated R9 had totes of personal belongings and thought she had seen a pink item through the clear side of the tote. HA-A stated FHD was going to go through them with R9 in attempt to locate the item. On 5/1/25 at 11:00 a.m., FHD stated she had looked in tote with both R9 and the corporate licensed social worker (CLSW), and was unable to find the item in R9's totes. FHD stated missing items were identified during morning meetings, and then FHD and HA-A proceeded to look for it. FHD stated there was no time frame for follow through and there was no tracking system in place that she was aware of, however, stated her previous boss had tracked this on paper. FHD stated R9's missing clothing was reviewed again this morning in report. FHD stated she planned to make a policy, and planned to track items on piece of paper. FHD stated she was unaware of any items previously being replaced, as items were typically found. On 5/1/25 at 11:30 a.m., FHD stated there was a policy in place, however, she was unaware of this. The Missing Item report form was filed in a pocket folder near the elevator. The document was dated 10/20. FHD was unaware of this, and had not used a tracking log to monitor missing items. A review of the facility grievance log, from 8/28/24 to 5/1/25, indicated 15 items identified as being missing, and of those items, 11 items were found. Of the four missing items, three of the remaining items missing were replaced by the facility, with the replacement of one of the items refused. The facility policy, Lost, Missing and Damaged Items policy, last reviewed 2/23 identified if an item was said to be missing, a Grievance Form was to be completed. The policy identified the employee who received the original missing valuables communication was responsible for initiating the Grievance form. The form was then to be signed by the person who completed the missing item report. This report was then to be returned to the Administrator's or Social Services office. The grievance process was then to be followed to determine the appropriate next steps. The Complaint and Grievance Policy, last revised 9/23, identified once a grievance was received, the Administrator, or designated grievance official completed an investigation to determine the validity of the grievance. Once the grievance was received, and the investigation was completed, the resident was provided with a verbal or written summary of the findings. The summary findings included date of grievance, summary of the grievance, steps taken to investigate, summary of the pertinent finding/conclusions, a statement which identified if the grievance was confirmed, and the dated the written decision was issued.

Based on observation, interview and documentation, the facility failed to identify personal activity preferences, develop resident specific care plan, and coordinate activities of interest for 5 of 5 residents (R3, R22, R28. R31,and R36 ) reviewed for activities. Findings include: R3 R3's annual Minimum Data Set (MDS) assessment, dated 1/2/25, indicated R3 was cognitively intact and was readily able to communicate her thoughts, needs and wishes. R3's quarterly assessment of 4/4/25, indicated R3 had lower extremity deficit in mobility and was able to get around with the use of a wheelchair. R3's medical diagnoses included metabolic encephalopathy (brain dysfunction caused by systemic metabolic disturbances), anemia (a disease caused by low red blood cells that can cause shortness of breath and fatigue), hypertension (high blood pressure), diabetes mellitus (a group of disease that affect how the body uses blood sugar), arthritis (swelling or tenderness of one or more joints), multiple sclerosis (a chronic disease which affects your nervous system and causes inflammation, damage, and scarring in your brain and spinal cord), and idiopathic peripheral autonomic neuropathy (a disease which occurs when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged). R3's care plan indicated R3 was alert and oriented and was independent with her own activity choices. It also identified R3 was able to make her leisure needs known. It went on to state she was open to invites to facility group activities. The goal statement indicated Resident will continue to make independent choices related to her daily activities. She will express satisfaction with her current activity level through positive statements and continued daily activities of choice. R3's care plan interventions included: Invite and encourage R3 to participate in facility activities that she may enjoy. The care plan indicated staff were to target cards/games, crafts, music and social events. Staff were to offer to assist as needed. Additional interventions included staff were to provide with a monthly activity calendar for her room and offer to assist her as needed. Staff were directed to respect resident's right to refuse activities. Staff were also directed to provide facility updates, notify of upcoming special events, and to offer supplies for in-room activities. R3's Activity Participation Review of 1/8/24 and 4/10/25 were reviewed. The documents indicated R3's care plan was reviewed and goals were met. Under the review of the Activity Plan Review, the documents indicated the activity related focuses remained appropriate per care care. The documentation lacked indication for changes in activity focus, goals, or interventions. R3's Daily Activity Attendance reviewed from 1/1/25 through 4/30/25. Although R3's care plan stated enjoys crafts, the Daily Activity Attendance records lacked indication of participation in crafts in January, February, March and April. R3's care plan indicated she enjoyed cards/games. A review of the Activity Attendance lacked indication of participation in the months of January, February, March and April. Although these were areas of interest, interventions were not implemented/participated in, this was not addressed in the Activity Participation Review to determine if these areas continued to be R3's primary areas of interest. Additionally, although crafts were identified as an area of interest, there was no documentation present to indicate how these interests were supported or facilitated. R3's electronic medical record (EMR) lacked additional information regarding activities attendance, either in narrative notes or scanned documents. The EMR lacked documentation of activity attendance for 2025. During interview on 4/28/25, at 1:57 p.m. R3 stated the activities program consisted of Bingo. R3 stated she had wished they would do exercises, or do routine readings of the daily newspapers. R3 was aware of budgetary concerns, however, indicated these activities lacked additional cost, with the exception of staff time. On 4/29/25, at 3:08 p.m. a review was completed of the April Activity Calendar. It was noted there were no weekend activities identified, with the exception of the notation Independent Leisure. A review of the Activity Calendar identified the latest activity started at 3:45 p.m. on Tuesdays for Bible Study. There were no craft activities identified on the April Activity Calendar. During interview on 4/30/25, at 9:58 a.m. activities director (AD) stated the staff who managed the activities kept a running record for each resident. AD stated she was unsure as to when/if they were scanned into the EMR, however, stated she had hand written records in her drawer and had binders for each month since October of 2024. AD stated the documents and information had not been scanned in, or entered, since she had started her role in October. AD stated the residents were asked at Resident Council meetings if there were activities they were interested in. The activity department then assisted with coordination of the activities. They tried new activities. AD stated she also received ideas for activities from other therapeutic recreation directors. The activity calendar was reviewed with AD. AD stated the activity Rendever was a virtual reality experience with four headsets, four controllers, and an iPad. This was last used in February, however, was discontinued due to a lack of interest by the residents. Upon review of the activity calendars from March and April, the AD affirmed Rendever continued to be listed as a weekly activity. During the Resident Council meeting, and during individual interviews, residents identified budgetary concerns and the impact on activities (example provided was a decrease in Bingo frequency, absence of Bingocize, and a change of prizes). AD stated Bingo was no longer prized with quarters, but prizes given were candy, snacks, or items used on a daily basis. AD stated there were staff for weekend activities, however, the activities were not placed on the calendar. AD stated residents were informed of weekend activities on Fridays when the weekend calendar was passed out with menus. AD stated there are different activities that they were going to be doing, which included reading the newspaper at 4:00 p.m. AD affirmed there were no evening activities, unless CNA (certified nursing assistant) staff try to do something with them. She was unsure if CNA's did this. AD stated she was unaware of any concerns identified with Activities, however, added concerns were very rarely identified. AD was aware of the request from one resident for outings. Upon review of the calendar, noted many of the events were religious themed in nature (Bible study, Catholic services, Lutheran services, hymn sing) with few activities potentially being of interest to younger residents. AD stated the activity staff generally went with what the residents like to do and offered different things, adding they were going to trial a book club. AD stated more one to one interactions were added to the activity program, as a lot of residents refused to go out to activities. AD stated one to one visits were done by activity staff, and the activity staff provided her notes regarding the visits. She had not documented one to one visits in the EMR. AD stated the care plans were updated when they were due (Initial, quarterly, significant change, and annual reviews). On 5/1/25, at 10:06 a.m. a review of the May activity calendar was completed and it was noted reading of the newspaper was added on a weekly basis in the morning, however, not in the evening as discussed. In addition, the Twins schedule was added to the calendar. A facility policy was requested for activities program development and implementation, but was identified as not available. 40938 R22 R22's admission MDS dated [DATE], indicated R22 was cognitively intact and required extensive assistance with activities of daily living (ADLs). R22's medical diagnoses included stricture of artery (abnormal narrowing or constriction of an artery), hypertension, neuropathy (disorder that impairs the function of nerves, often causing pain, numbness, tingling, or weakness in the body), major depression, diabetes, and vitreous degeneration (changes in the vitreous humor, the clear, jelly-like substance that fills the space between the lens and retina in the eye). R22's care plan indicated R22 was independent with her daily activity choices, enjoyed reading and watching TV, was interested in participating in facility group activities, preferring smaller groups. R22 was noted to have a supportive family. The goal statement indicated R22 would express satisfaction with activity level through positive statements and continued daily activities of choice. R22's care plan interventions included: Invite and encourage to participate in facility group activities. Targeting crafts, card games, music, gardening, and being outside. Staff were to offer assistance as needed. Additional interventions included staff were to provide with a monthly activity calendar for her room and offer to assist her as needed. Staff were directed to respect resident right to refuse activities. Staff were also directed to provide facility updates, notify of upcoming special events, and to offer supplies for in-room activities, such as a deck of cards and reading materials. R22's therapy recreation (TR) evaluation and social history assessment dated [DATE], indicated R22 enjoyed cards and games, arts and crafts, exercises and sports, music, reading, television (TV), going to church, being wheeled around outside, gardening and plants, and small group activities. R22's Daily Activity Attendance was not found within the electronic medical record. Upon request from the activity staff, handwritten attendance sheets were provided. Although R22's care plan stated enjoys arts and crafts, the Daily Activity Attendance records lacked indication of participation in arts and crafts in February, March and April. R22's care plan indicates she enjoys cards/games. A review of the Activity Attendance lacked indication of participation in the months of February, March and April. R22's care plan stated she enjoyed exercise, TV and reading; review of Daily Activity Attendance records lacked indication of participation in these activities. When interviewed on 4/28/25, at 12:43 p.m. R22 stated there was not enough activities, nothing to do on weekends, nothing to do after supper. R22 stated would really like more activities to do, found herself bored, and was tired of watching TV. On 4/29/25, at 3:08 p.m. a review was completed of the April Activity Calendar. It was noted there were no weekend activities identified, and the calendar identified activities on those days to be Independent Leisure. A review of the Activity Calendar identified the latest activity starts at 3:45 p.m. on Tuesdays for Bible Study. There were no craft activities identified on the April Activity Calendar. When interviewed on 4/30/25, at 9:58 a.m. activities director (AD) stated the staff who managed the activities kept a tracking record for each resident. AD stated she was unsure as to when/if they were scanned into the EMR, although did have the handwritten records in her drawer in binders for each month since October of 2024. AD stated the residents were asked at Resident Council meetings as to which activities they would like to have done. AD stated she received activity ideas from other therapeutic recreation directors. AD stated there were staff for weekend activities, however, the activities are not placed on the calendar. AD stated residents are informed of weekend activities on Fridays when they passed out the calendar for the weekend. AD affirmed there were no evening activities, and added, unless CNA staff try to do something with them. AD stated she was unsure if CNA's did this. When interviewed on 5/01/25, at 1:07 p.m. trained medication aid (TMA)-A stated R22 watched a lot of TV, would be nice if there were more activities for the residents including weekends and evenings, calendars are copy pasted from the month before, there was no variety offered. R28 R28's quarterly MDS dated [DATE], indicated R28 had moderate cognitive impairment and was independent with ADL's. R28's medical diagnoses included cirrhosis of liver with ascites (severe liver damage leading to scarring and fluid buildup in the abdomen), protein-calorie malnutrition, congestive heart failure (CHF), hepatic encephalopathy, acute cystitis (sudden inflammation of the urinary bladder), and anxiety. R28's care plan indicated R28 was independent with her activity choices. The care plan also identified R28 enjoyed watching TV, reading, coloring, playing on her phone, and was interested in facility group activities. The goal statement indicated R28 would remain independent with daily activity choices, express satisfaction with her current activity level through positive statements and continued daily activities of choice. R28's care plan interventions included invite and encourage to participate in facility group activities she may enjoy, with staff targeting music, crafts, sports/exercises, social events, and cards/games. Staff were to offer to assist to and from activities as needed. Staff to offer hand massage, aromatherapy and/or healing touch for physical and psychosocial comfort. Additional interventions included staff were to provide with a monthly activity calendar for her room and offer to assist her as needed. Staff were also directed to provide facility updates, notify of upcoming special events, and to offer supplies for in-room activities, such as magazines, deck of cards, coloring supplies, and crafts. R28's Activity Participation Review dated 4/14/25 was reviewed. The document indicated that resident's care plan was reviewed, and goals were met. The document indicated that the activity related focuses remained appropriative per care plan. The documentation lacked indication for any changes in activity focus, goals, or interventions. R28's TR Evaluation and Social history assessment dated [DATE], indicated R28 enjoyed cards, games, crafts, making jewelry, exercises and sports with watching sports and bicycling indicated, variety of music, reading local news and magazines, walking, shopping, gardening, small groups, anything to stay busy. R28's Daily Activity Attendance was not found within the electronic medical record. Upon request from the activity staff, handwritten attendance sheets were provided. Although R28's care plan stated enjoys arts and crafts, the Daily Activity Attendance records indicated one participation in arts and crafts in January, February, March and April. R22's care plan indicates she enjoys cards/games, exercise, TV, music, and reading. A review of the Activity Attendance lacked indication of participation in these activities in the months of January, February, March and April. When interviewed on 4/28/25, at 1:29 p.m. R28 stated there was nothing to do on weekends. R28 stated she would like to have something more to do than watching TV. On 4/29/25, at 3:08 p.m. a review was completed of the April Activity Calendar. It was noted there were no weekend activities identified, and the calendar identified activities on those days to be Independent Leisure. A review of the Activity Calendar identified the latest activity starts at 3:45 p.m. on Tuesdays for Bible Study. There were no craft activities identified on the April Activity Calendar. When interviewed on 4/30/25, at 9:58 a.m. activities director (AD) stated the staff who managed the activities kept a tracking record for each resident. AD stated she was unsure as to when/if they were scanned into the EMR, although did have the handwritten records in her drawer in binders for each month since October of 2024. AD stated the residents were asked at Resident Council meetings as to which activities they would like to have done. AD stated she received activity ideas from other therapeutic recreation directors. AD stated there were staff for weekend activities, however, the activities are not placed on the calendar. AD stated residents are informed of weekend activities on Fridays when they passed out the calendar for the weekend. AD affirmed there were no evening activities, and added, unless CNA staff try to do something with them. AD stated she was unsure if CNA's did this. On 4/30/25, at 1:56 p.m. R28 was observed sitting on the edge of her bed, with TV on. R28 stated there's nothing else to do around here. On 4/30/25, at 2:58 p.m. R28 was walking down the hallway, stated she had won a dollar at bingo then stated now there's nothing to do the rest of the day. When interviewed on 5/01/25, at 1:07 p.m. TMA-A stated R28 would get her nails done, occasionally worked on puzzles on the table down the hall. R31 R31's admission MDS dated [DATE], indicated R31 was cognitively intact and required extensive assistance with ADLs. R31's diagnoses included bipolar, atrial fibrillation, insomnia, diabetes, history of strokes, chronic kidney disease, cushings syndrome (hormone disorder caused by too much cortisol), and atherosclerotic heard disease. R31's care plan lacked any evidence of an activity plan of care having been created for R31. R31's TR Evaluation and Social History assessment dated [DATE], indicated R31 enjoyed painting, soft jazz, soul music, watching TV, reading, trips, shopping, wheeling around, and small groups. R31's Daily Activity Attendance was not found within the electronic medical record. Upon request from the activity staff, handwritten attendance sheets were provided. Although R31's TR Evaluation and Social History indicated R31 enjoyed, painting, soft jazz, soul music, watching TV, reading, trips, shopping, wheeling around, and small groups a review of R31's Daily Activity Attendance records lacked indication of participation in any of these activities in March or April. When observed on 4/29/25, at 11:14 a.m. and 3:51 p.m. R31 was lying in bed with lights off and no TV or music on. On 4/29/25, at 3:08 p.m. a review was completed of the April Activity Calendar. It was noted there were no weekend activities identified, and the calendar identified activities on those days to be Independent Leisure. A review of the Activity Calendar identified the latest activity starts at 3:45 p.m. on Tuesdays for Bible Study. There were no craft activities identified on the April Activity Calendar. When observed on 4/30/25, at 7:20 a.m., 2:07 p.m. and 2:58 p.m. R31 was lying in bed with lights off, no TV or music on in room. When interviewed on 4/30/25, at 9:58 a.m. activities director (AD) stated the staff who managed the activities kept a tracking record for each resident. AD stated she was unsure as to when/if they were scanned into the EMR, although did have the handwritten records in her drawer in binders for each month since October of 2024. AD stated the residents were asked at Resident Council meetings as to which activities they would like to have done. AD stated she received activity ideas from other therapeutic recreation directors. AD stated there were staff for weekend activities, however, the activities are not placed on the calendar. AD stated residents are informed of weekend activities on Fridays when they passed out the calendar for the weekend. AD affirmed there were no evening activities, and added, unless CNA staff try to do something with them. AD stated she was unsure if CNA's did this. When observed on 5/01/25, at 9:19 a.m. 10:20 a.m., 11:34 a.m. and 12:40 p.m. R31 was lying in bed with lights off, curtains open and no TV or music on in room. When interviewed on 5/01/25, at 1:31 p.m. TMA-A stated R31 loved bingo and was very religious. TMA-A stated R31's daughter would take her out to have nails done. When interviewed on 5/01/25, at 2:13 p.m. registered nurse (RN)-A stated she hadn't seen R31 do any activities, went out with daughter one to two times a week. R36 R36's admission MDS dated [DATE], indicated R36 had severe cognitive impairment and required extensive assistance with ADLs. R36's diagnoses included hyperkalemia, dementia, hypertension, hyperlipidemia, urine retention, and weakness. R36's care plan indicated R36 was independent with his activity choices. He enjoyed watching TV, tinkering around, reading, using his cell phone, being outside in his free time and was open to invites to facility group activities. R36 was noted to have a supportive family. The goal statement indicated R36 would remain independent with daily activity choices, express satisfaction with his current activity level through positive statements and continued daily activities of choice. R36's care plan interventions included invite and encourage to participate in facility group activities he may enjoy, with staff targeting church, sports events, gardening, music, and socials/special events. Staff were to offer to assist to and from activities as needed. Additional interventions included staff were to provide with a monthly activity calendar for his room and offer to assist him as needed. Staff were also directed to provide facility updates, notify of upcoming special events, and to offer supplies for in-room activities, such as reading materials and a deck of cards. R36's TR Evaluation and Social History assessment dated [DATE], indicated R36 enjoyed cards, games, exercises, sports with basketball being named as a favorite, music, reading, all kinds of music, TV, spiritual and religious activities, wheeling around outdoors, trips/shopping, gardening, conversing with others, independent activities, and group activities. R36's Daily Activity Attendance was not found within the electronic medical record. Upon request from the activity staff, handwritten attendance sheets were provided. Although R36's care plan indicated R36 enjoyed watching TV, tinkering around, reading, using his cell phone, being outside in his free time; and R36's TR Evaluation assessment indicated R36 enjoyed cards, games, exercises, sports with basketball being named as a favorite, music, reading, all kinds of music, TV, spiritual and religious activities, wheeling around outdoors, trips/shopping, gardening, conversing with others, independent activities, and group activities a review of R36's Daily Activity Attendance records lacked indication of participation in any of these activities in March or April. When observed on 4/28/2, at 1:47 p.m. R36 was lying in bed with lights off, no TV or radio on in room. At 2:29 p.m. bingo was in the chapel, R36 was lying in bed with lights off and no TV or music on. When observed on 4/29/25, at 11:16 a.m. R36 was sitting in his wheelchair in common area. At 12:50 p.m. R36 was observed wheeling his wheelchair from the dining room. At 3:50 p.m. R36 was lying in bed, light off with no TV or radio on. On 4/29/25, at 3:08 p.m. a review was completed of the April Activity Calendar. It was noted there were no weekend activities identified, and the calendar identified activities on those days to be Independent Leisure. A review of the Activity Calendar identified the latest activity starts at 3:45 p.m. on Tuesdays for Bible Study. There were no craft activities identified on the April Activity Calendar. When observed on 4/30/25, at 8:09 a.m. R36 was being assisted by staff to the dining room. At 12:11 p.m. R36 was sitting in the dining room for lunch. At 1:58 p.m. R36 was lying in bed, lights off and no TV or radio on. At 2:57 p.m. R36 was lying in bed, lights off with no TV or radio on. When interviewed on 4/30/25, at 9:58 a.m. activities director (AD) stated the staff who managed the activities kept a tracking record for each resident. AD stated she was unsure as to when/if they were scanned into the EMR, although did have the handwritten records in her drawer in binders for each month since October of 2024. AD stated the residents were asked at Resident Council meetings as to which activities they would like to have done. AD stated she received activity ideas from other therapeutic recreation directors. AD stated there were staff for weekend activities, however, the activities are not placed on the calendar. AD stated residents are informed of weekend activities on Fridays when they passed out the calendar for the weekend. AD affirmed there were no evening activities, and added, unless CNA staff try to do something with them. AD stated she was unsure if CNA's did this. When observed on 5/01/25, at 9:13 a.m., 10:18 a.m., and 11:36 a.m. R36 was lying on his bed with lights off and no TV or radio on in room. When interviews on 5/01/25, at 1:16 p.m. TMA-A stated R36 was a pleasantly confused man. TMA-A stated when there was a memory care unit there had been many more activities provided throughout the day to stimulate the residents. When interviewed on 5/01/25, at 1:55 p.m. RN-A stated was harder for R36 to participate in activities, R36 required someone to sit with him during the activities to help him participate. A facility policy was requested for activities program development and implementation, but was identified as not available.

Based on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who were at risk for elopement. This resulted in an immediate jeopardy (IJ) however, the facility implemented corrective action prior to the investigation so the deficiency remained at past non-compliance. The IJ began on 1/17/24 at 7:09 p.m. when the administrative hallway exit door alarm sounded and staff did not respond appropraitely. At 7:36 p.m. R1 on was located outside, approximately 15 feet from the building. AccuWeather temperature identified it was between 10 degrees Fahrenheit (F) and -3 degrees F on 1/17/24. The facility administrator and director of nursing (DON) were notified of the IJ on 1/25/24 at 3:02 p.m. The facility had implemented corrective action on 1/22/24, prior to the start of the survey and was issued at past non-compliance. Findings include: R1's Face Sheet printed 1/25/24, indicated diagnoses which included malignant neoplasm of the brain, and reduced mobility. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had moderate cognitive impairment. The MDS also indicated R1 used a walker or wheelchair for mobility, and had a history of falls. The MDS indicated R1 did not have wandering behaviors. R1's Elopement Risk Assessment on 1/2/24 indicated he was at risk for elopement and aimlessly roamed in his wheelchair without a destination. R1's care plan dated 10/5/23, indicated R1 was at risk for elopement. R1 had a safety alarm bracelet (to alarm on certain doors to alert staff if he was trying to go out the door) on his left wrist. Interventions included the safety alarm bracelet would be monitored for proper functioning. and the door alarms would be answered promptly. On 11/14/23 a progress note indicated R1 had been noted to be wandering into empty rooms, and had been found sleeping in open beds. On 12/2/23 at 1:49 a.m., a progress note indicated R1 was up and wandering multiple times overnight. Staff attempted toileting and snack. R1 did not want to go to bed and was in the therapy lounge area. Shortly after staff left R1 alone, another resident called for help[, and staff found R1 lying in the other resident's bed. R1 was redirected back to his room and into bed. On 12/22/23 at 3:52 a.m., a progress note indicated R1 was up and wandering the hallways overnight. R1 attempted to enter other resident's rooms. R1 could not say what he was doing or if he needed anything. R1 was assisted back to his room multiple times. Staff also attempted offering a snack or toileting, but those interventions did not deter the wandering. On 1/17/24, at 11:45 p.m. a progress note indicated R1 exited the facility through the exit door in the administrative wing. R1's safety alarm bracelet did sound. R1 held the door until it opened. R1 stated he walked down the stairs and pulled his wheelchair with him. R1 stated he fell on the stairs and got back up and into his wheelchair. R1 exited the building through the exit door and was found by staff at approximately 7:35 p.m. R1 was able to walk up the stairs with 1 staff assist. An assessment completed at that time, and indicated R1 had full range of motion (ROM) to all extremities, no complaints of pain, neuro checks were stable. A skin check completed, with swelling noted and an abrasion on his left eye. R1 also had two scraped abrasions to the left mid/upper back approx 9 centimeters (cm) x 2 cm each. R1's left elbow was red with no noted swelling. Family contacted at 11:00 p.m. and did wish for R1 to be evaluated in the emergency room (ER) for any possible injury. R1 was sent to the ER for evaluation at 11:30 p.m. On 1/21/24 an Investigative Report Summary indicated at approximately 7:00 p.m. the alarm on the administrative hallway exit door sounded. NA-A responded to the alarm, and without looking outside, reset the alarm. The same door alarm went off again at approximately 7:10 p.m. NA-B looked around, and without looking outside, reset the alarm. At approximately 7:20 p.m. the door alarm went off again. At this time, RN-B and NA-A went to search for R1, and found him outside at approximately 7:30 p.m. On 1/24/24 at 2:48 p.m., RN-B stated she was working the evening of 1/17/24. RN-B stated she heard the door alarm around 7:00 p.m. RN-B stated it was unclear which door was causing the system to alarm and the door kept alarming, buzzing. RN-B stated around 7:30 p.m. she heard one of the nursing assistants looking for R1, and all staff began to search for him at that time. RN-B stated R1 was found outside just after 7:30 p.m. RN-B stated R1 appeared to have fallen at some point because he had a bump on his head and scrapes to his back. On 1/24/24 at 3:17 p.m., RN-A stated she was working the evening of 1/17/24. RN-A stated she heard someone ask if anyone knew were R1 was over the walkie-talkie. When she stepped out into the hallway, she could hear the alarm. RN-A stated she was unable to determine which exit door was going off. RN-A stated over the walkie-talkie, staff were communicating areas of the facility that had been searched. RN-B stated she and NA-A went to the administrative hallway exit door. RN-A stated NA-A saw R1 outside, in his wheelchair, on the sidewalk. RN-A stated R1 had a bump over his eye. Due to R1 being mostly non-verbal, RN-A stated it was unclear if he had fallen. RN-A stated it was cold outside, and R1 was not wearing a coat. On 1/25/24 at 9:39 a.m., NA-B stated she was working the evening of 1/17/24. NA-B stated she heard the first door alarm around 7:00 p.m. She said NA-A cleared the alarm. NA-B stated about 10 minutes later, the door alarm was sounding again. NA-B stated she looked around, didn't see anyone, and she reset the alarm. NA-B stated around 7:30 p.m. NA-A called over the walkie-talkie to announce she couldn't locate R1. NA-B stated all staff began to search the building and then the outside premises. NA-B stated R1 was found outside by RN-A and NA-A, near the administrative offices exit. On 1/25/24 at 10:17 a.m., the DON stated when door alarms sounded, she expected the staff to open the doors to visualize outside. The DON drove to the facility and staff told her R1 had eloped. She noted it was 3 degrees Fahrenheit (F) when she got in her vehicle. The DON stated she immediately began re-education for the staff on resetting door alarms. On 1/25/24 at 10:53 a.m., NA-A stated she was working the evening of 1/17/24. NA-A stated she responded when the administrative hallway exit door alarm went off the first time. NA-A stated she looked around and didn't see anyone, so she reset the alarm to the door. NA-A stated when the alarm went off again, she and NA-B looked around, but did not see anyone and NA-B reset the door alarm. NA-A stated R1 was found outside around 7:30 p.m. Per AccuWeather the temperature was between 10 degrees Fahrenheit (F) and -3 degrees F on 1/17/24. On 1/25/24 at 11:17 a.m., the administrator stated when door alarms sound, staff should open the doors to observe for residents outside. The administrator stated only herself or her designee (who could be a licensed nurse, but not a nursing assistant) could reset the door alarms. The administrator stated re-education for the staff included resetting door alarms, a review of the elopement policy, and additional education of how the safety alarm bracelet system worked. The administrator stated the Quality Assurance Performance Improvement (QAPI) committee met to review the incident on 1/18/24. The administrator stated elopement drills were conducted on 1/18/24 and would continue to be conducted monthly. The administrator stated the State Fire Marshall was contacted and granted permission to extend the administrative office door alarm from 15 to 30 seconds. This was implemented on 1/24/24 by the director of maintenance. The facility Elopement Policy dated 6/23, directed staff to assure each resident is assessed on an ongoing basis and has appropriate safety precautions in place. The policy also directed only the administrator (or designee) may authorize disabling the door alarm system, and were responsible for the method of monitoring residents' safety and resetting the alarm. The past noncompliance immediate jeopardy began on 1/17/24. The immediate jeopardy was removed and the deficient practice corrected by 1/22/24, after the facility implemented a systemic plan that included the following actions: In a meeting held on 1/18/24 staff were retrained on the facility's elopement policy, with an emphasis on clearing alarms only to be conducted by leadership or nurses. Additional education was provided to all staff on the safety alarm bracelet system. Two elopement drills were conducted with staff on 1/18/24. Verification of staff signatures on education provided reviewed. On 1/24/24, the administrative office door emergency release extended from 15 seconds to 30 seconds. Verification of corrective action was confirmed by observation, interview, and document review on 1/24/24 and 1/25/24.

Based on interview and document review, the facility failed to implement their policy to initiate cardio-pulmonary resuscitation (CPR) for 1 of 16 residents (R1) who had requested to be a full code status, meaning the resident wanted life-saving interventions implemented. The deficiency was identified as past non compliance and issued at Immediate Jeopardy (IJ). The IJ began on [DATE] when the facility failed to provide CPR for R1 after R1 became unresponsive during care and her heart stopped. However, the facility had implemented corrective action to prevent recurrence by [DATE]. The facility had immediately reviewed each resident's chart to verify code status and ensure POLST documentation was consistent between the paper chart and electronic medical record. In addition, facility policies had been reviewed for adequacy. Staff education had also been implemented to ensure each shift of staff understood the facility's policies, and drills had been conducted for each shift to verify staff could follow through with implementation of Code Blue protocols. The findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated she was moderately, cognitively impaired. The MDS indicated R1 required extensive assistance of staff with physical support for bed mobility, transfers, and locomotion on the unit. R1's face sheet, printed [DATE], indicated R1's [DIAGNOSES REDACTED]. R1's physician order [REDACTED]. R1's care plan revised [DATE], included: Full Code per POLST form with a goal wishes will be honored. Care plan interventions included: In the event that resident is not breathing and has no pulse, attempt resuscitation and provide all life-sustaining treatment. A facility report to the State Agency dated [DATE], included: On [DATE] at 10:32 a.m. nursing staff radioed out for Nurse STAT (immediately) to south shower room. Resident (R1) was found to be sitting in the wheel chair, was observed to be unresponsive, with coffee ground emesis coming out of her mouth and nose. Two nursing assistants who where working with her stated they had transferred R1 from the toilet to the wheel chair and that is when R1 had an emesis and went unresponsive. The TMA (trained medication assistant) took vital signs and found to have no pulse at 10:33 a.m. Nurse manager spoke with R1's sister about R1's death. R1's sister was visiting with R1 in her room prior to this incident. While nurse manager was speaking with R1's sister, the DON (director of nursing) entered the shower room and verified R1 had no pulse and instructed staff to take R1 to her room, transfer to bed and to begin end of life cares. The DON left the shower location. Staff wheeled R1 to her room located two doors down from the shower room. During that time the nurse manager, DON and Administrator looked at the medical record and determined R1's code status was Full Code. The DON immediately went to R1's room where staff was attempting to transfer resident into bed and were unable as the type of sling R1 was using required the resident to be alert, and R1 was slipping from the sling and R1 returned to the wheel chair. The DON ran and got a full body sling, and staff, including nurse manager, assisted with placing the sling under resident, then transferred R1 into bed. With every movement, watery, dark brown/black liquid was pouring form resident's mouth and nose. At the same time the administrator told the HUC (health unit coordinator) to call 911, which occurred at 10:47 a.m. CPR was initiated at 10:47 a.m., and AED (automated external defibrillator) applied. Staff attempted ambu bag, but mask filled with dark fluid with each compression. Chief of police arrived at 10:50 a.m., and asked to 'place airway' which staff allowed, with staff continuing CPR. Suction was initiated. Medical center paramedics arrived at 10:59 am., and at 11:03 a.m. EMS (emergency medical service) called time of death. During interview on [DATE] at 5:20 p.m., licensed practical nurse (LPN)-A stated she was present when the code blue had been announced for R1 last September. LPN-A stated the incident happened a while ago, but she recalled there was a page over the walkies to come to the shower room, We went rushing down there and R1 was clearly not breathing. LPN-A further stated, We did not have (R1's) POLST in front of us, but when we got it, I think it was minutes later I don't recall exactly because of what all was going on, and then CPR was started. I was was one of the staff doing CPR. We should have had R1's code status when we first responded. LPN-A stated she was uncertain why they didn't have R1's code status right away and acknowledged she hadn't thought to ask about it right away. LPN-A added, I think we maybe assumed she (R1) was DNR (do not resuscitate). LPN-A explained that she had been a case manager in training when the incident had occurred. She said she had been in touch with the nurses and R1's family about R1's declining health, stating the team had discussed changing R1's code status. LPN-A stated, (R1) was her own person and was full code at the time of the incident. We should have initiated CPR right away. During interview on [DATE] at 5:54 p.m. registered nurse (RN)-A stated she was the nurse manager working the day R1 had become unresponsive in the shower room, and had later assisted to give R1 CPR. RN-A stated she could not recall the exact date or time, but it was in (MONTH) around 10:30 in the morning. RN-A stated at the time of the incident, she was attending an interdisciplinary meeting in the conference room with the former administrator and DON when she heard the call come over the walkie. RN-A stated she ran through the chapel, and stated the south shower room is just around the corner in the main hallway. RN-A stated when she got the to shower room, she remembered there were two nursing assistants (NAs) and one other nurse present. RN-A stated, It was obvious to me (R1) had passed away. RN-A stated at the time it hadn't crossed her mind to inquire about R1's code status, or to ask the other nurse. RN-A stated she told the nurse aides to take R1 back to her room to get her cleaned up, then returned to the conference room to let the DON know what happened. RN-A stated the former administrator had asked what R1's code status was, and when the DON looked it up they then realized R1 should have been treated as a full code. RN-A stated she guessed about four minutes had elapsed by that time from when she'd first gone in to assess R1 in the shower room. RN-A stated she had immediately returned to the shower room, but by then the nursing assistants were trying to transfer R1 from her wheel chair into bed. RN-A stated R1 had a toileting sling on, and the the DON had come in with a full body sling. RN-A stated, (R1) was not a little person and because of her status at that time, it was hard to get her transferred. We eventually got her up on her bed and by that time other staff had arrived. RN-A added, I couldn't say who all was there, but it was busy. RN-A stated she then initiated CPR for R1, and you'd have to look at the time I started from our documentation, I can't recall. RN-A stated she helped with CPR, as did another nurse, the DON, and later the chief of police and finally the EMTs (emergency medicine technicians). RN-A said,The EMTs called R1's death a short time later. In looking back, I feel I'm the one who screwed up. I knew the resident was declining and in fact at our meeting, we had been discussing possible hospice placement for (R1). I don't know what to say, maybe I just assumed she was not full code. Having seen the condition (R1) was in when I first saw her in the shower room, I don't believe CPR made any difference. RN-A stated she at first questioned if the aides did the right thing but stated they had just transferred R1 and right away they called and the nurses came. RN-A also reported the aides who were assisting (R1), and the nurse who initially responded to their request for help, are no longer employed by the faciltiy. Of course, that is not an excuse. RN-A stated she had told staff in the past, You never really know what a resident status is, a resident can come off hospice, and be a full code, or they can change their minds. RN-A also stated there were immediate actions taken in light of this incident to make sure staff followed the facility's policies. There was a lot of training and practice drills that are on-going. (R1) was full code, in hindsight CPR should have been started right away. We have learned from this. The facilty policy, Initiation of CPR/AED (Automated External Defibrillators) and BLS (basic life support) Associate Training Expectation, revised [DATE], indicated CPR/AED was to be initiated on a resident who is found unresponsive, except when: 1) a Provider medical order states a code status of DNR; 2) a resident declination of CPR Form is present; or 3) there are signs of obvious, long-standing death of the resident present. In all other cases, Emergency Response Service (EMS) will be activated and CPR/AED will be initiated by a BLS (Basic Life support) certified, BHS (Benedictine Health System) associate when present at the scene. The policy further indicated: when it is identified that a resident has signs/symptoms requiring CPR/AED (i.e. unresponsive) and meets criteria, EMS will be activated immediately as follows: 1) 911 is called; 2) Door access to EMS is ensured; 3) If the associate does not know the code status of the resident, CPR/AED will be initiated whenever a BLS certified, BHS associate is present at the scene; and 4) Resuscitation status is verified. During interview on [DATE] at 9:07 a.m. the director of nursing (DON) stated she, the nurse manager (RN-A) and the administrator at the time, had been in a meeting when the call to help R1 came in around 10:30 a.m. [DATE]. The DON stated, (RN-A) went to assist and she returned four or five minutes later, and that's when the administrator asked about (R1's) code status. When we pulled the record up the computer it indicated 'Full code'. One of us called the 'code blue and someone called 911, (RN-A) rushed back to the shower room. By that time, (R1) had been moved to her room where we had some difficulty with the transfer using the ceiling lift with the sling (R1) had on, it was designed for toileting and the resident had to be more alert. The DON stated, (R1) was transferred into bed, and with every movement, she was moving her arms for positioning her in the sling and side to side, (R1) was having emesis, but CPR was started. The DON stated she would need to review documentation, but stated, It was about fourteen minutes from when the nurse made the initial assessment until CPR was started, that's the bottom line. The DON stated the first nurse who responded to the call from the nursing assistants, Was a new nurse and she should have called the code. The unit manager (RN-A) also should have asked for the code status. The DON verified the code status was first questioned by the administrator and added, But I was there too. We knew what to do once the call was made, we knew the process. The DON verfied at the time of the incident R1 was full code, and stated, We just didn't follow our policy. During continued conversation at that time, the DON described the actions taken following R1's code including: Notification of the failure to immediately initiate the code to R1's family, R1's personal physician (who is also the facility's medical director), and reported the failure to immediately implement CPR to the State Agency. Staff education was initiated immediately [DATE] so that staff would have to review the facility policies before the start of the next shift, and code blue drills were initiated to verify staff were competent. Code blue drills were conducted for each shift until all licensed staff, who had not already participated in a drill, had received the training. According to the facility's DON (director of nursing), The drills simulated a code blue event, and we trained on who could call a drill, who was expected to participate, what equipment and supples were to be brought, making sure we brought the resident's chart. We practiced calling out and verifying residents' code status' and how we communicated to coordinate the effort. Drills were done at various times, locations, with varying circumstances including use of the lifts. We even did QA (quality assurance) with the drills. While working a code blue drill during change of shift, we realized on-coming staff did not participate like they should, and we learned during shift change staff did not have a radio on during report. As a result, we revised the procedure to ensure the on-coming staff had a radio on. We wanted to ensure that at any time we could have maximum participation. The DON stated all charts were audited on the 18th to ensure all residents' POLSTs were in the chart, and to ensure congruency between the POLST in the paper chart and the resident's electronic health record. The DON stated further they reviewed the faciltiy policy after the incident and made no changes. The DON stated before the start of the next shift that same day, I had the nurses review our policy, and they had to sign off on that before they could work. The DON stated in addition to the policy review, and starting with the p.m. (evening) shift on the 18th, we completed code blue drills, and completing a drill each shift until all licensed staff, who had not been part of a drill, (due to not being on the schedule), had opportunity to participate and lead a drill. The DON stated the drills simulated a code blue event, and we trained who could call a drill, who was expected to participated, what equipment and supples were to be brought, making sure we brought the resident's chart, called out, and verified the code status, and how we communicated to coordinate the effort. The DON stated drills were done at various times, locations, with varying circumstances including use of the lifts. The DON said we even did a QA (quality assurance) with the drills, and stated while working a code blue drill during change of shift, they realized on-coming staff did not participate like they should. The DON said we learned during shift change, staff did not have a radio on during report, so we revised the procedure to ensure the on-coming staff have a radio on so that at any time we can have maximum participation. The DON stated code blue drills are on-going. The DON stated widespread training on what was learned from R1's incident was present at mandatory all-staff meetings, I'd have to look at the exact dates, but we had them in October. Further, the DON stated that following the incident, the facility reviewed employee orientation check lists, and and reviewed them to ensure we cover specifics about code blue. Also, the DON stated they audited resident records from (MONTH) (YEAR) to (MONTH) 18, (YEAR), and reviewed all records to see if any resident coded while in the faciltiy and what the faciltiy response was. The DON stated in the review, any resident who was full code, and had an emergency while in the facility, the resident was provided CPR. And, the DON stated, they reviewed all incidents going forward after [DATE] to see if there were any instances where a resident was full code and did not receive CPR; the DON stated there were no additional incidents. The DON concluded the interview stating the facility plans to continue the code status drills to ensure future compliance. The DON stated she feels the incident was serious, but was isolated, and confidently stated the correction taken has addressed the incident to ensure will not repeat. During interview on [DATE] at 12:42 p.m., the medical director (M-D) stated R1 had major gastro-intestinal concerns, but oddly was asymptomatic. The M-D said R1 was in transition, declining, going through significant changes, and emphasized that nothing implemented would have saved R1. The M-D stated the commencement of CPR for R1 would, sadly, not have changed the outcome for R1. However, the M-D stated that does not change what happened, nor is it an excuse. The M-D stated R1 was a full code and, in retrospect, facility staff should have taken the appropriate action. The M-D also stated the staff were upset and very affected by the incident, and it certainly caused them to review all the routines, look and examine the protocols, and raised everyone's attention to the details. The M-D stated We don't like to learn this way, but it has forced us to review the protocols. The M-D stated she was pleased with the actions faciltiy leadership implemented, and continue to practice, to prevent this from happening in the future. The past non-compliance that began on (MONTH) 18, (YEAR), was verified during the [DATE] onsite visit to have been corrected by (MONTH) 19, (YEAR). Verification of corrective action was confirmed by interview with a variety of nursing staff and documentation. Chart audits conducted verified resident's code status' and verified no other residents had failed to have their code status implemented. Nursing staff were re-educated to the facility policy and training was reinforced by drills. In addition, licensed staff CPR training and nursing licenses were reviewed to ensure they were current, and licensed and unlicensed staff orientation checklists, including specific code blue objectives were reviewed. The facility's CPR equipment had also been reviewed for proper location and to verify it was functional.