Every finding on record at Warroad Care Center

Based on observation, interview and document review, the facility failed to ensure staff completed COVID-19 self-testing per manufacturer guidelines and Centers for Disease Control (CDC) guidelines for 13 of 19 staff (DA-B, DA-C, HSKG-A, HSKG-B, LA-A, NA-J, NA-O, NA-P, LPN-B, LPN-C, RN-C, administrator) observed to complete COVID-19 testing. This had the potential to affect all residents residing in the nursing home. Findings include:The facility Line List dated [DATE], identified 15 residents had tested positive for COVID-19 since [DATE] and the facility was in current outbreak status.During an interview on [DATE] at 1:51 p.m., licensed practical nurse (LPN)-B stated she was informed a resident tested positive for COVID-19 when she arrived at the facility on [DATE] at approximately 7:30 a.m. Day shift staff were already at the facility, LPN-B placed the testing supplies at the timeclock and asked staff to test as they came on to their shift. LPN-B stated she was told staff had tests available on each wing in the nurses' stations and a lot of staff went to the nurses' stations to test themselves. LPN-B did not educate staff on how to do the testing correctly and stated I didn't feel like I needed to teach them how to do that because staff had been testing since the beginning of the pandemic. New staff had also been testing since [DATE] and LPN-B didn't teach them how to test correctly either because there were directions in the box. The CorDx COVID-19 Ag Test Quick Reference Instructions revised [DATE], identified the following instructions for use: Wash hands before testing. Check expiration date on the package. Do not use expired test kit! Remove the test cassette from the pouch and place it on a clean, flat surface. Insert the tube in the pre-made hole on the back of the kit box. Remove the foil from the top of the tube. Remove the swab from the pouch. Carefully insert the swab tip into one nostril about 1/2 to 3/4 inch. Firmly and slowly rotate the swab 5 times; brushing against the inside walls of the nostril to ensure both mucus and cells are collected. Do not push the swab further if you meet resistance. Using the same swab, repeat the process for the other nostril to ensure an adequate sample was collected from both nostrils. Insert the swab in tube to the bottom. Rotate the swab at least 10 times while pressing the swab head against the bottom and side of the tube. Remove the swab while squeezing the sides of the tub to express as much liquid as possible from the swab. Attach the drop tip firmly onto the tube. Gently squeeze the tube and dispense 3 drops of solution into the sample well. A false negative or invalid result may occur if less than 3 drops of fluid are added to the sample well. Wait 10 minutes. Read the result at 10 minutes. Do not read the result after 30 minutes. The result is valid when read at 10-30 minutes. If a positive result is obtained within 10 minutes, it should also be considered valid. Serial testing should be performed in all individuals with negative results; Individuals with symptoms of COVID-19 and initial negative results should be tested again after 48 hours. Individuals without symptoms of COVI0-19, and with initial negative results, should be tested again after 48 hours and. if the 2nd test is also negative, a 3rd time after an additional 48 hours. You may need to purchase additional tests to perform this serial (repeat) testing. If you test negative but continue to have symptoms of COVID-19, and both your first and second tests are negative, you may not have COVID-19, however you should follow-up with your healthcare provider. If your test is positive, then proteins from the virus that causes COVID-19 have been found in your sample, and you likely have COVID-19.Staff testing was observed on [DATE] and identified the following:At 5:50 a.m., dietary aide (DA)-A entered the building at the timeclock entrance and put on a surgical mask. DA-A then opened a large box containing multiple CorDx COVID Ag tests. DA-A carried a test box into the breakroom where two staff were already sitting unmasked.At 5:52 a.m., housekeeping (HSKG)-A entered the building and stood at the timeclock. I'm new here. Well, new enough. HSKG-A put on a surgical mask and brought a test with her. The other staff left the breakroom.At 5:53 a.m., DA-A completed the test and laid the soiled testing products on the table. DA-A used both swabs in the test box. At 5:54 a.m., DA-A explained to HSKG-A how to do the COVID-19 test by whispering together by the sink. DA-A threw away her tests and wrote negative next to her name on the form. DA-A did not clean the table after throwing away her soiled testing supplies. However, DA-A collected the test result after 2 minutes. At 5:55 a.m., HSKG-A opened the package, then used a swab to swab her nostril for less than 10 seconds. HSKG-A swished the swab in the tube and poured the entire contents of the tube onto the sample well. HSKG-A used the second swab and repeated the process. At 5:58 a.m., DA-B entered the breakroom with a test. HSKG-A threw away her test and wrote negative next to her name on the form. HSKG-A then stated, why is the table so dirty when we're all adults? However, HSKG-A did not clean the table and collected the test result after three minutes. HSKG-A stated she had tested before. Why did I do it wrong? Stated the first time she tested; she came to work and there were four people standing at the timeclock and everyone just did it together. At 6:00 a.m., DA-B completed the test by using both swabs in the test box.At 6:01 a.m., DA-C entered the breakroom with a test. DA-C used one swab to collect the test sample At 6:02 a.m., DA-B stated negative and left the breakroom after throwing away her test. DA-B did not clean the table after throwing away her soiled testing supplies. However, DA-B collected the test result after 2 minutes. At 6:04 a.m., DA-C threw away her test supplies then cleaned the table with a sanitizing disposable wipe. DA-C stated her test was negative. However, DA-C collected the test result after 3 minutes. At 6:09 a.m., NA-S entered the breakroom and stated she collected her test at home. That way I get into work faster. At 6:15 a.m., DA-D stated her test was negative, threw away her soiled supplies and wrote the result next to her name on the form. DA-D cleaned the table with a sanitizing disposable wipe. NA-S returned to the timeclock and pulled her test from her pocket. NA-S stated she always brought her test with her to show she was not lying that she was negative. I just feel if I have COVID-19, I shouldn't bring it into the building.At 6:21 a.m., NA-P entered the building. NA-P put on a surgical mask and brought a test into the breakroom. NA-P opened the test package and stated there were two tests in each box. I was so confused. NA-P was unsure if there was a swab for each nostril. NA-P rotated the swab in her nares x 5, then repeated on the other side. NA-P then swished the swab in the tube. NA-P dispensed 10 drops of solution into the sample well. NA-P set her phone time for 10 minutes then set the test down on the table. At 6:26 a.m. HSKG-B entered the breakroom and sat down next to NA-P. HSKG-B rotated the swab 5 times in each nares then swished the swab in the test tube.At 6:28 a.m., LPN-C collected her test sample while standing at the timeclock and then carried the test in her hand and stood in the breakroom doorway. At 6:28 a.m., NA-P stated she would just take the test with her and placed the test in her pocket. NA-P went to B wing before having a test result. HSKG-B left the breakroom and went down the hall. At 6:29 a.m., RN-C entered building and picked up a test. LPN-C stated she was negative, threw her test away and then wrote her result on the form next to her name. RN-C rotated the swab in each nares 5 times and then swished the swab in the tube for approximately 30 seconds, then dropped 10 drops of solution into the sample well. RN-C threw away his testing supplies and placed the test on the breakroom windowsill. At 6:32 a.m., NA-J rotated the swab in each nares 5 times, then swished the swab in the tube for approximately 20-30 seconds, then dropped 10 drops of test solution into the sample well.At 6:33 a.m., RN-C stated his test was negative and threw away his test after 4 minutes.At 6:34 a.m., NA-O and NA-T stood at the timeclock together and completed their tests. HSKG-B returned to the timeclock and wrote her negative result on the form.At 6:38 a.m., NA-A and NA-O carried their tests into the breakroom and sat down at a table. At 6:39 a.m., NA-O told NA-T she didn't check the time when she started the test and NA-O stated well, I was right behind you.At 6:41 a.m., NA-Q entered the building and stated he tested at home. Showed a photo of a test with 1217/25 written in marker on his phone. Wrote negative on the form before going to the unit for his shift.At 6:43 a.m., NA-O state she was negative, and NA-T stated she thought it had only been 8 minutes. NA-O threw away her test and wrote negative on the form.At 6:46 a.m., NA-T threw away her test and wrote negative on the form before going to the unit for her shift.At 7:06 a.m., licensed social worker (LSW) takes a test into the breakroom and sat down at a table. LSW opened the test package and inserted a swab into her nares approximately 3/4 inch, rotated the swab 10 times, then swished the swab in the tube for approximately 30 seconds. LSW then placed 5 drops of test solution into the sample well and set a timer for 10 minutes. LSW stated staff tested in the breakroom. If there were a lot of people testing. LSW would probably take her test to her office and test there. LSW stated she had been educated on testing by LPN-B but had read the instructions the first time she did it.At 7:11 a.m., laundry aide (LA)-A stood at the timeclock to test. LA-A rotated the swab in each nares 4 times, swished the swab in the tube 5 times, then placed 10 drops of test solution in the sample well. At 7:15 a.m., LA-A wrote negative results on the form after 4 minutes and stated, I'll hang on to it for a while. LA-A picked up her test and began walking down the hall. LA-A then stated she guessed she could wait in the breakroom. LA-A sat down with LSW and laid the test on the table. At 7:18 a.m., LSW's timer sounded. LA-A asked how long to wait, 10 minutes? LSW replied yes, 10 minutes. LSW threw away her test supplies and wrote her negative result on the log. At 7:20 a.m., LA-A threw away her test after 9 minutes and went to the floor for her shift. LA-A did not clean the table. At 7:30 a.m., LPN-B entered the building and punched in at the timeclock.At 7:31 a.m., LPN-B pulled out a test. At that time, the administrator entered the building, grabbed a test and went to her office. The administrator stated I'll be back. I just need to put this in my office.At 7:33 a.m., LPN-B rotated the swab in each nostril 5 times, swished the swab in the tube and dropped the solution into the sample well. LPN-B then used hand sanitizer. At 7:34 a.m., the receptionist stopped at the timeclock and punched. LPN-B was standing at the timeclock as well without wearing a surgical mask. The receptionist rotated the swab in each nares, then put on the surgical mask after LPN-B put on a surgical mask. The receptionist then placed the swab into the tube and swished the swab, then dropped the solution into the sample well.At 7:37 a.m., the administrator returned with her test in her hand with a surgical mask on.At 7:39 a.m., LPN-B picked up her test and threw it in the trash, then wrote negative on the form. However, LPN-B collected the test result after 6 minutes. At 7:40 a.m., the receptionist wrote negative on the form and threw her test away. The administrator looked at her test, threw it in the trash and wrote negative on the form. The administrator stated she usually did test in her office because it was just right there. The administrator stated there usually wasn't a bunch of staff all at the same time but guessed they try to space apart. Is doing it in my office not ok? Even if it's right there? I have a mask on. During an interview on [DATE] at 7:55 a.m., LPN-B stated staff were not testing correctly. Staff should not go into their office to test. I thought after 5-6 years they would know how to do it. Staff were expected to wait the full 10 minutes. There were two tests in each box and staff should be social distancing when they test. It's just a lot. LPN-B stated they could not ensure staff were not working while positive for COVID-19 because they were not testing correctly. We just can't. During an interview on [DATE] at 8:18 a.m., the DON stated the facility needed to do facility wide staff education related to testing. They have all been exposed with the risk of covid. Potentially, there was a risk of staff coming to work sick.During an interview on [DATE] at 8:42 a.m., the administrator stated she expected staff to test accurately and to follow CDC guidelines. It's interesting people didn't know through all this time how to test. The administrator stated she expected staff to be competent in testing and be able to test accordingly before they entered the building. The facility Infectious Disease Outbreak Policy revised [DATE], identified outbreak surveillance and control is a high priority for the Infection Prevention and Control Program. When one resident test positive for and any others exhibit similar symptoms of any type of infectious illness, an outbreak within the facility will be considered. Resident and staff illnesses will be monitored by the WSLC Infection Preventionist, since healthy personnel may acquire and transmit virulent pathogens. When a resident or resident has been identified to have a new cough or new shortness of breath and/or a fever (temperature >100 degrees), [NAME], tests will be performed in coordination and under the direction of [NAME], a medical provider and local Emergency Department. CDC and [NAME] guidance will be followed for all staff and resident testing based on community and facility positivity rates/cases.The CDC guidelines Infection Control Guidance: SARS-CoV-2 for HealthCare Providers dated [DATE], identified Source control is recommended more broadly as described in CDC's Core IPC Practices in the following circumstances: By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days); or Facility-wide or, based on a facility risk assessment, targeted toward higher risk areas (e.g., emergency departments, urgent care) or patient populations (e.g., when caring for patients with moderate to severe immunocompromise) during periods of higher levels of community SARS-CoV-2 or other respiratory virus transmission (See Appendix) Optimize the Use of Engineering Controls and Indoor Air Quality: Optimize the use of engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals (e.g., physical barriers at reception / triage locations and dedicated pathways to guide symptomatic patients through waiting rooms and triage areas). Take measures to limit crowding in communal spaces, such as scheduling appointments to limit the number of patients in waiting rooms or treatment areas.The CDC guidelines Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing: for Health Care Providers dated [DATE], identified: For healthcare providers who are handling specimens but are not directly involved in collection (e.g. handling self-collected specimens) and not working within 6 feet of the patient, follow Isolation Precautions. Healthcare providers should wear a form of source control (face mask) at all times while in the healthcare facility. Healthcare providers can minimize PPE use if patients collect their own specimens while maintaining at least 6 feet of separation. For example, the provider should wear a face mask, gloves, and a gown.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) guidelines including transmission-based precautions and documenting testing procedures 7 of 14 (R11, R16, R43, R34, R41, R20, R14) reviewed for COVID-19 procedures; and failed to ensure 26 of 50 staff (RN-A, RN-B, LPN-A, NA-A, NA-C, NA-D, NA-E, NA-F, NA-G, AA-A, LPN-A, NA-B, NA-G, NA-H, RN-D, NA-J, administrator, DON, RN-C, LPN-B, TMA-A, NA-I, NA-K, NA-L, NA-M, NA-N) were tested according to CDC broad based testing guidelines; and the facility failed to monitor and track staff illness for 2 of 2 (AA-A, AA-B) staff who called in during a COVID-19 outbreak; and the facility failed to ensure resident signs/symptoms of illness were tracked during monthly surveillance for 2 of 14 (R19, R35) residents reviewed for illness. In addition, the facility failed to ensure residents were provided an FDA skin-safe approved hand sanitizer during meals. These practices had the potential to affect all residents residing in the nursing home. RESIDENT COVID-19 PROTOCOLS:R11R11's quarterly MDS dated [DATE], identified R11 was [AGE] years old, had a moderate cognitive impairment and diagnoses that included Alzheimer's disease, obesity, heart failure, and venous insufficiency.R11's nursing progress notes identified the following:12/7/25 at 9:30 p.m., R11 had a non-productive cough this evening, showed no other signs of illness until 9:35 p.m., when a nursing assistant summoned this author reporting R11 had a temperature of 101 degrees F. Upon assessment R11was febrile with a temperature of 100.8 degrees F. R11's scheduled dose of Tylenol (an antifever medication) 1000 milligram (mg) was given prior at 8:09 p.m. A rapid COVID-19 test was done and came back positive. Blood pressure 130/77, pulse 67, respirations 24, temperature 101.0 degrees F and oxygen saturations 93 percent on 2 liters (L) of oxygen.12/7/25 at 10:54 p.m., R11's wife was notified of R11's condition.12/8/25 at 12:30 a.m., writer was updated by the evening nurse regarding the R11's status and condition, prompting an immediate assessment. Upon evaluation, R11 presented as weak and pale, with noticeably decreased responsiveness and appearing disoriented. Respiratory effort was significantly compromised; breathing was labored, uneven, and shallow. R11 was observed repeatedly lifting his left arm and puffing his chest with each breath, indicating increased work of breathing and use of accessory muscles. Lung sounds were diminished throughout all fields upon auscultation. Despite being on 2L per nasal cannula, R11 was unable to maintain oxygen saturation levels above 90%, indicating inadequate oxygenation. Writer notified R11's wife of the change in condition and recommended sending the R11 to the emergency department for further evaluation and treatment. The family agreed with the plan. Writer then contacted EMS. EMS arrived at the facility at 12:00 a.m. and departed with R11 on a gurney at 12:15 a.m. The transfer from bed to gurney required extensive assistance and was completed with the support of 2 EMS personnel and 2 facility staff members. Vitals: blood pressure 144/77, pulse 66, temperature 101.1F, respirations 20, and oxygen saturations 82 percent on 2L per nasal canula.12/8/25 at 3:09 a.m., a hospital nurse updated writer of R11's status. R11 will be admitted family were informed as per life care nurse. Diagnosis COVID-19, pneumonia and pleural effusion (the accumulation of fluid in the pleural space around the lungs, which can lead to breathing difficulties). Nurse coordinator updatedDuring an interview on 12/16/25 at 6:13 p.m., nursing assistant (NA)-Q stated R11 was coughing earlier in the evening at supper in the dining room. You could tell R11 was distressed. Then, R11 was supposed to have a bath that night. R11 wasn't doing well. R11 was confused and coughing more. When R11 was in bed, NA-Q notified the nurse of R11's condition.The medical record failed to identify R11 was placed on transmission-based precautions when symptoms were identified. R41R41's quarterly MDS dated [DATE], identified R41 was [AGE] years old, had a mild cognitive impairment and diagnoses that included Alzheimer's disease, and Downs syndrome.R41's nursing progress notes identified the following:12/8/25 at 1:47 p.m., consent obtained for Covid-19 testing, results were negative. Will continue to monitor.12/10/25 at 8:15 p.m., consent obtained for Covid testing earlier day shift, results were negative. This evening R41 had a hoarse voice, did an antigen test and there was a barely visible positive line. R41 put on isolation. Plan of care on going.12/10/25 at 8:39 p.m., R41 tested positive for COVID-19 on 12/10/25 evening shift. Isolation precautions were in place per CDC regulations regarding a positive COVID-19 test. R41 was in a single room with no roommate and private bathroom; all services including meals and medications were brought to R41's room and R41 was encouraged to remain in her room (not very happy about it). R41 had staff that wore personal protective equipment (PPE) for airborne precautions. Staff monitored every shift for symptoms/complications related to COVID-19 virus. R41 active and alert but had a hoarse voice and a sore throat. Temperature 97.2 degrees F, respirations 15, pulse 59, and oxygen saturations at 92 percent on room air. Fluid and rest encouraged. Family notified of R41's status.12/11/25 at 10:23 p.m., R41 remained in room due to COVID-19. R41 remained alert with no changes in cognitive status. Appetite was good this evening. Continued to have cough and hoarse voice. R41 had no concerns this evening.12/15/25 at 7:52 p.m., R41 was observed to be experiencing increased coughing, a noticeably hoarse voice, and a runny nose throughout the shift. R41 reported feeling mildly congested. Denied shortness of breath, chest pain, or any new or significant discomfort. No noticeable fever at this time, and the R41 was alert and oriented to x3.12/15/25 at 8:22 p.m., consent obtained for COVID-19 testing, result was positive.12/19/25 at 9:47 p.m., R41 upset, not understanding why she had to be in isolation. Stated I didn't do anything wrong; I am fine. This is day 8 of isolation. R41 was not coughing at this time and was afebrile. Consented to Covid test and results were negative. R41 begged to come out of room. R41t agreed to wear a mask when out of room and agreed to eat at a table in the living room. Staff would remind R41 to wear her mask. Will retest on 12/19/25 to follow up.During an observation on 12/15/25 at 1:28 p.m., R41 stated she was just off precautions due to COVID-19 today. R41 was in the dining room eating lunch. R41 was seated at a small table with another resident seated across from her. R41's eyes are red rimmed. R41 denied itching or burning. R41 had an occasional loose sounding cough. R41's face was flushed and did not appear to be feeling well. On 12/15/25 at 4:18 p.m., nursing assistant (NA)-Q stated when he came in that morning R41 was off precautions. R41 was excited to be coming off precautions yesterday and was feeling ok yesterday but R41 did not look well. R41 wasn't acting right, R41's face was all red and kind of drawn. NA-Q was not sure why R41 came off precautions and would have to ask the nurse. R41 was coughing a lot when she first got sick but not so much anymore. NA-Q checked R41's temperature which was 98.3 degrees F. On 12/15/25 at 4:47 p.m., RN-D stated R41 was allowed to come out of isolation because R41 no longer had symptoms of COVID-19, and it had been 5 days since she tested positive for COVID-19. Business office assistant greeted R41 and stated, every time I see you today, you seem stuffier and stuffier. R41 stated she was ok. R41 was very congested, voice was hoarse and reddened face. RN-D stated R41's temperature that day was 98.2 degrees F.At 5:05 p.m., R41 was in the lobby area sitting with eyes closed. R41 was coughing heavily and sniffling At 5:09 p.m., R41 was wandering about the dining room without a mask, making coffee and sat down at her table with another resident seated directly across from her. At 5:23 p.m., R41 was coughing in the dining room. R41 made no attempt to cover her cough. R41 was up and down, filling her cup with water at water dispenser and coffee dispenser. At 6:10 p.m., RN-D stated no one directed him to offer R41 a mask to wear since out of isolation that day or to keep R41 away from other residents. RN-D stated R41 would wear a mask if offered one. During an interview on 12/15/25 at 5:47 p.m., LPN-B stated R41 tested positive for COVID-19 on 12/10/25 and was in isolation for 5 days but staff couldn't keep R41 in isolation any longer. LPN-B suggested R41 wear a mask, but R41 refused, and LPN-B couldn't make R41 wear a mask. LPN-B stated she was unaware R41 would sit in the dining room and LPN-B stated she had not directed staff to keep R41 away from other residents. LPN-B was unaware if other staff had encouraged R41 to wear a mask either. LPN-B thought R41 would eat in the living room area. The facility liked to keep all positive COVID-19 residents in transmission-based precautions for 7-10 days, but it was hard enough keeping R41 in for 5 days. R41 had been walking down to LPN-B's office that morning and when LPN-B told R41 she needed to go back to the unit, R41 stated it had been 5 days, and she couldn't stay in her room anymore. Staff should have been offering a mask every time R41 was out of her room. R41 was a tough one. R41 fought staff on everything, and staff did not want to hurt R41's feelings. Today was not a good day.R16's medical record lacked evidence on how the facility staff were managing R16's symptoms to try and mitigate transmission to others on the unit. R16R16's quarterly MDS dated [DATE], identified R16 was [AGE] years old, had a moderate cognitive impairment and diagnoses that included Alzheimer's disease.R16's nursing progress notes identified the following:12/9/25 at 8:20 p.m., R16 tested positive for COVID-19. Isolation precautions were in place per CDC regulations regarding a positive COVID-19 test. R16 was in a single room with no roommate and private bathroom; all services including meals and medications were brought to R16's room and R16 was encouraged to remain in her room. R16 had staff that wore PPE equipment for airborne precautions. Staff monitored every shift for symptoms/complications related to COVID -19 virus. R16 tired, weak, had a poor appetite, hoarse voice and clammy. Temperature 97.3, respirations 20, and oxygen saturations at 91 percent on room air. Fluid encouraged when awake. Family notified of R16's status.12/10/25 at 6:23 a.m., R16 afebrile, denied pain or discomfort. No complaints shortness of breath or chest pain. R16 did vomit once. Will continue to monitor.12/10/25 at 3:15 p.m., R16 afebrile this shift, ate 100% for breakfast about 25% for lunch. Tired, periodic twitching, congested, as needed tussin (a medication that helps loosen phlegm and think bronchial secretions) given. Plan of care on going.12/10/25 at 10:02 p.m., R16's temperature was 101.1 degrees F later this shift, pulse 102, 02 91percent on room air, and respirations 20. As needed tussin given. R16 looked pale and clammy, awake most of the shift watching television and tinkering with her blanket. Fluid and rest encouraged. Plan of care on going.12/11/25 at 5:16 a.m., writer sending R16 to the emergency room (ER) for further management and evaluation. R16 was noted having shortness of breath. Oxygen saturations 81 percent at room air. R16 started oxygen at 2L per nasal canula, and oxygen saturations increased to 85 percent. Pulse 138, wheezing noted. Family updated on R16's condition.12/11/25 10:16 a.m., received nurse to nurse report identifying R16 would return to the facility on comfort cares.12/11/25 11:10 a.m., R16 returned to facility around 10:50 a.m. via ambulance. Upon arrival R16 was awake, smiling, and with eyes open. R16 transferred to her bed with assist of 4, hygiene cares completed and tolerated well. Oxygen saturations 95% on 4L per nasal cannula, pulse 112, temp 97.8. R16 tolerated care well, no signs of acute distress noted at this time. New orders for Morphine 10mg every 2 hours as needed for pain. Xanax (an antianxiety medication) 13mg every 2 hours as needed for anxiety and 1 drop of atropine every hour as needed for secretions. Family at bedside.12/11/25 at 9:06 p.m., R16 had involuntary limb movement. Grimacing at times. Morphine given for comfort/pain per order.12/11/25 at 10:16 p.m., R16 was awake on and off this shift. Involuntary movements noted to extremities. Facial expression appeared to be fearful/anxious at times. Ativan and morphine given per orders. Family has been present this shift. Vitals stable. Afebrile. Continued oxygen therapy keeping sats above 90%.12/12/25 at 4:44 p.m., R16 continued to have involuntary muscle movements. Family reported R16 reporting she was having pain today. Family requested to continue with scheduled morphine every 2 hours along with Ativan every 4 hours as felt this was helpful to resident relax with less muscle spasticity.12/14/25 at 6:59 a.m., R16 received as needed morphine 0.5 ml every hour this shift. As needed Ativan 0.25ml every 4 hours. Respirations remain regular but shallow. Per discussion with daughters, oxygen was removed 2:00 a.m. as R16 oxygen saturations were 78-80 percent at 11:00 p.m. Pulse remains elevated at130-140. Temperature noted to be elevated at103.2 degrees F at 3:00 a.m. Day shift nurse to give Tylenol suppository. R16 was resting comfortably all shift. Turned and repositioned every 2 hours. Family at bedside.12/14/25 at 09:34 AM, R16 was found unresponsive in bed with no signs of life. No respiratory effort was noted, and heart and lung sounds were absent upon auscultation.R16's medical record failed to identify if she had been tested for COVID-19 during outbreak testing on 12/8/25.R43R43's quarterly MDS dated [DATE], identified R43 was [AGE] years old, had a severe cognitive impairment and had diagnoses that included dementia.R43's nursing progress notes identified the following:12/10/25 at 8:18 a.m., R43 tested positive for COVID on 12/10/25. Isolation precautions were in place per CDC regulations regarding a positive COVID test. Staff attempted to isolate R43 as best as possible. R43 was in a single room with no roommate and private bathroom; all services including meals and medications were brought to R43's room and R43 was encouraged to remain in her room. R43 had staff that wore PPE equipment for airborne precautions. Staff monitored every shift for symptoms/complications related to COVID virus. R43 active and alert but had a hoarse voice. Temperature 97.6 degrees F, respirations 16, and oxygen saturations 93 percent on room air. Fluid encouraged when awake. Plan of care on going.12/10/25 at 4:10 p.m., Writer notified R43's family notified of R43 status.R43's medical record failed to identify if R43 was tested for COVID-19 during outbreak testing on 12/8/25.R34R34's annual MDS dated [DATE], identified R34 was [AGE] years old, had a moderate cognitive impairment and diagnoses that included dementia, hemiplegia, DMII, and hypothyroidism.R34's nursing progress notes identified the following:12/10/25 at 3:23 p.m., R34 tested positive for COVID on 12/10/25. Isolation precautions were in place per CDC regulations regarding a positive COVID-19 test. Staff tried our best to quarantine R34. R34 was in a single room with no roommate and private bathroom; all services including meals and medications were brought to R34's room and R34 was encouraged to remain in her room. R34 had staff that wore PPE equipment for airborne precautions. Staff monitored every shift for symptoms/complications related to COVID-19 virus. R34 active and alert but have a hoarse voice, and yelling for help, help. Temperature 97.8 degrees F, respirations 18, and oxygen saturations 97 percent on room air. Fluid encouraged as R34 would allow. Plan of care on going.12/10/25 at 4:02 p.m., family notified of R34's status.12/11/25 at 10:12 p.m., R34 remained in isolation due to COVID-19 diagnosis. Vitals stable. R34 active and alert. Poor appetite this evening. Hoarse voice with occasional cough. R34 did not appear in any type of distress.R34's medical record failed to identify if R34 was tested for COVID-19 during outbreak testing on 12/8/25.R14R14's quarterly MDS dated [DATE], identified R14 was [AGE] years old, had a severe cognitive impairment and diagnoses that included Alzheimer's disease, sleep apnea, chronic kidney disease, and hypertension.R14's nursing progress notes identified the following:12/12/25 at 4:15 p.m., Consent obtained for COVID-19 testing. R14 tested positive.12/15/25 at 1:19 p.m., R14 tested positive of COVID-19 on 12/12/25. Today, R14 was afebrile with no signs or symptoms of COVID-19. R14 was noncompliant to current isolation precautions as he continued to get out of his room multiple times.During an observation on 12/15/25 at 1:46 p.m., R20 was seated in the common area next to R14. Neither resident was wearing a face mask and were talking back and forth constantly. Staff did not attempt to intervene or encourage either resident to wear a mask.At 2:03 p.m., staff walked up to R20, stated R20 needed to stay away from R14, then asked R14 if he wanted to look at the snow before walking away with R14. At 4:30 p.m., R20 was standing in the dining room area, talking with R14. Neither resident was wearing a mask. During an interview on 12/16/25 at 10:02 a.m., RN-C there were six residents positive for COVID-19. Most of the residents stayed in their rooms, they listened to staff and knew they needed to stay in their rooms. R20 and R14 were observed seated in the dining room. Neither resident was wearing a mask.During an observation on 12/17/25 at 7:50 a.m., R14 was seated in the dining room without a mask and waiting for his morning meal.On 12/17/25, at 7:51 a.m., R20 walked out of his room and into the dining room to sit across the table from R14. Both began eating their meal. During an observation on 12/16/25 from 6:30 pm through 8:00 pm observed R20 and R14 walking up/down the hallway or seated in the recliners in the common areas. R14 had a loose, non-productive cough. R20 also had a loose, non-productive cough but was less than R14. Staff did not attempt to encourage either resident to wear a mask.R20 R20's quarterly MDS dated [DATE], identified R20 was [AGE] years old, had a severe cognitive impairment and diagnoses that included dementia, obstructive sleep apnea and atrial fibrillation (irregular heartbeat).R20's nursing progress notes identified the following:12/10/25 at 1:20 p.m., R20's COVID-19 test was negative.12/12/25 at 6:49 p.m., R20's COVID-19 covid test was negative.12/16/25 at 12:07 p.m., received a text message from R20's family on 12/14/25 at 3:34 pm stating the following: SOOO . I don't want my dad tested for Covid. I don't trust those swabs. They have Covid-19 in them. Please pass this on right away. Might sound crazy but I've done my research. Those PCR tests have been proven to be fraudulent, and they haven't changed the test swabs. So, no he doesn't need to enter their Numbers. This information was passed on to the infections control nurse and interim director of nursing (DON). R20's electronic health record (EHR) failed to identify a plan for R20's lack of COVID-19 testing, including isolation and transmission-based precautions. During an interview on 12/18/25 at 10:50 a.m., the licensed social worker (LSW) stated she received a text message from R20's family on 12/14/25 refusing R20's COVID-19 testing. LSW entered a note in R20's chart and passed the information to the infection prevention nurse and the DON. LSW made sure to let them know it was a family request. During an interview on 12/18/25 at 10:52 a.m., the DON stated she notified staff as soon as she found out about R20's family refusal for COVID-19 testing. The DON directed staff to not test R20 any further. The DON stated she did not provide any COVID-19 education to R20's family and should have. Staff should have been encouraging R20 to remain in his room but R20 wouldn't do that anyway. Staff should also encourage R20 to wear a mask, but the DON didn't believe R20 would wear a mask. Also, R20 should have been encouraged to stay away from other residents because R20 was at risk due to the high prevalence of COVID-19 positive residents on the unit, wandering the unit and risk for exposure to COVID-19. Additionally, the DON stated interventions should have been care planned and staff educated on the interventionsDuring an interview on 12/15/25 at 5:47 p.m., licensed practical nurse (LPN)-B stated resident testing was documented with a note in the resident's progress notes. On 12/8/25, R11 tested positive for COVID-19. I think his family brought it in. There were no positive staff prior to R11's positive test and R11 was transferred to the hospital right away. The next day on 12/8/25, LPN-B tested everyone for COVID-19. Then on 12/9/25, R16 tested positive for COVID-19 as well. Broad-based outbreak testing continued 12/10/25 and 12/12/25. If anyone had symptoms, they were tested and then LPN-B was going to test twice this week. The facility continued to have positive resident test results on 12/14/25 and 12/15/25. I expect everyone on Pine to test positive. LPN-B stated she wasn't at the facility when R11 was tested but read the progress notes. R11 was wheezy, weaker and lethargic, and his oxygen saturations may have dropped. All the other positive residents were expected to complete seven days before discontinuing transmission-based precautions.During an interview on 12/17/25 at 8:18 a.m., the DON stated if a resident was symptomatic of COVID-19, they should be tested and then follow up whether the test is negative or positive. If positive, try to put them into isolation and start precautions. If negative, try to keep them as healthy as possible. If a symptomatic resident wanted to come out of their room, they had the right to do so. The DON then stated the facility really need to do facility wide staff education on testing. All residents and staff have been exposed to the risk of COVID-19.During an interview on 12/17/25 at 8:42 a.m., the administrator stated staff were expected to test and isolation all residents to the extent staff can and follow CDC guidelines. STAFF TESTINGThe facility COVID testing form undated, identified the staff name, date and result. However, the form failed to identify who was required to test or when they were required to test, there was no evidence the facility was doing contract-based testing and was using a broad-based approach. Review of the form dated 12/8/25 through 12/16/25, identified the following:8 staff (RN-A, RN-B, LPN-A, NA-A, NA-C, NA-D, NA-E, NA-F, NA-G, AA-A) worked in the facility during the COVID-19 outbreak and had not tested for COVID-19.4 staff (LPN-A, NA-B, NA-G, NA-H) floated between resident units and have not tested for COVID-19.2 staff (RN-D, NA-J) floated between resident units and did not test according to CDC guidelines.10 staff (administrator, DON, RN-C, LPN-B, TMA-A, NA-I, NA-K, NA-L, NA-M, NA-N) tested intermittently but did not test according to CDC guidelines.During an interview on 12/15/25 at 6:06 p.m., LPN-B stated she had not policed staff COVID-19 testing because she had not had a chance. LPN-B had not reviewed staff testing to ensure all staff working had tested. Upon a quick review of the testing forms, LPN-B stated looking at the numbers staff tested. Maybe not the travel staff but they were told to test. LPN-B did not provide education to the travel staff regarding COVID-19 to ensure the test sample was collected accurately. During an interview on 12/16/25 at 1:51 p.m., LPN-B stated she was informed of R11's positive COVID-19 test result when she arrived at the facility on 12/8/25 at approximately 7:30 a.m. Day shift staff were already at the facility, LPN-B placed the testing supplies at the timeclock and asked staff to test as they came on to their shift. LPN-B did not test the staff that were already working that day. LPN-B stated she was told staff had tests available on each wing in the nurses' stations and a lot of staff went to the nurses' stations to test themselves. LPN-B did not know why staff did that. All the staff had been testing since the COVID-19 outbreak began on 12/8/25. However, LPN-B had not monitored the staff testing logs to ensure all staff that had worked in the facility during the outbreak period had tested. During an interview on 12/16/25 at 2:17 p.m., NA-P stated she had tested and wrote it down on the list. The test came with 2 swabs and NA-P was all confused because she didn't know what she was supposed to do. NA-P brought the test to the B wing nurses' station and one of the other staff showed NA-P how to do it. Then, when NA-P went back to the timeclock, NA-P wrote it down. NA-P stated she had never used that test before. During an interview on 12/16/25 at 2:22 p.m., LPN-C stated she found out staff needed to test for COVID-19 because there was a sign on the timeclock about the outbreak. Then, LPN-B came around on 12/15/25 and tested all the residents. LPN-C stated you can't stand at the timeclock for 10 minutes so staff would bring the test to the B wing nurses' station. LPN-C stated she probably forgot to write the result down on the form. Yea, if a staff member was positive and they brought the test to the wings to test, they would have gone through the whole facility before knowing the result. Some days, the list wasn't even there to write down the result. LPN-B then stated she couldn't even say if she tested on [DATE] but believed she tested on [DATE]. They change the test all the time. During a telephone interview on 12/16/25 at 2:03 p.m., the DON stated she had tested negative on 12/15/25 and again 12/16/25 but hadn't had a chance to document it on the COVID testing form. The DON talked to LPN-B all the time and told LPN-B she tested and was negative. The DON stated the tests should have been documented because it was necessary to have accurate tracking to ensure all staff were testing and not bringing COVID-19 into the building for the safety of the residents and staff. During an interview on 12/17/25 at 8:42 a.m., the administrator stated she expected staff to test accurately and to follow CDC guidelines.The facility Infectious Disease Outbreak Policy revised 10/23/20, identified outbreak surveillance and control is a high priority for the Infection Prevention and Control Program. When one resident test positive for and any others exhibit similar symptoms of any type of infectious illness, an outbreak within the facility will be considered. Resident and staff illnesses will be monitored by the WSLC Infection Preventionist, since healthy personnel may acquire and transmit virulent pathogens. When a resident or resident has been identified to have a new cough or new shortness of breath and/or a fever (temperature >100 degrees), the health department tests will be performed in coordination and under the direction of the health department, a medical provider and local Emergency Department. CDC and health department guidance will be followed for all staff and resident testing based on community and facility positivity rates/cases.STAFF ILLNESSThe December 2025 Activities Schedule identified activity aide (AA)-A and AA-B were ill on 12/15/25. The schedule provided no further information. AA-A had last worked at the facility on 12/13/25 and AA-B had not worked at the facility since 12/9/25.The COVID Testing form dated 12/8/25 through 12/16/25, identified AA-B tested on [DATE] and 12/11/25. The form failed to identify a test result for AA-A.During an interview on 12/17/25 at 7:55 a.m., LPN-B stated she was unaware AA-A or AA-B had reported illness and was unaware of either of their symptoms.The facility Infectious Disease Outbreak Policy revised 10/23/20, identified outbreak surveillance and control is a high priority for the Infection Prevention and Control Program. When one resident test positive for and any others exhibit similar symptoms of any type of infectious illness, an outbreak within the facility will be considered. Resident and staff illnesses will be monitored by the WSLC Infection Preventionist, since healthy personnel may acquire and transmit virulent pathogens. When a resident or resident has been identified to have a new cough or new shortness of breath and/or a fever (temperature >100 degrees), [NAME], tests will be performed in coordination and under the direction of [NAME], a medical provider and local Emergency Department. CDC and [NAME] guidance will be followed for all staff and resident testing based on community and facility positivity rates/cases.The Centers for Disease Control and Prevention (CDC) dated 3/10/25, identified people with COVID-19 have a wide range of symptoms ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Symptoms may start as mild, and some people will progress to more severe symptoms. The following are signs and symptoms of COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, sore throat, congestion or runny nose, new loss of taste or smell, fatigue, muscle or body aches, headache, nausea or vomiting and diarrhea.The CDC's Guidance for SARS -COV-2 Rapid Testing in Point-of-Care Settings dated 9/5/25, identified Point-of-care testing uses rapid diagnostic tests performed or interpreted by someone other than the individual being tested can be performed in a variety of settings. Rapid tests used in point-of-care settings can be Nucleic Acid Amplification Tests (NAAT) (a type of viral diagnostic test for SARS-CoV-2, the virus that causes COVID-19. NAATs detect genetic material (nucleic acids). NAATs for SARS-CoV-2 specifically identify the RNA (ribonucleic acid) sequences that comprise the genetic material of the virus) or antigen tests (rapid tests that usually produce results in 15-30 minutes. Positive results are accurate and reliable. However, in general, antigen tests are less likely to detect the virus than NAAT tests, especially when symptoms are not present. Therefore, a single negative antigen test cannot rule out infection.) These tests can be used to diagnose SARS-CoV-2 infections in various point-of-care settings, including but not limited to long-term care facilities and nursing homes.The CDC's Infection Control Guidelines: SARS-COV-2 dated 6/24/24, identified anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Duration of Empiric Transmission-Based Precautions for Symptomatic Patients being Evaluated for SARS-CoV-2 infectionThe decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test.If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and confirming with a second negative NAAT.If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test.If a patient suspected of having SARS-CoV-2 infection is never tested, the decision to discontinue Transmission-Based Precautions can be made based on time from symptom onset as described in the Isolation section below. Ultimately, clinical judgment and suspicion of SARS-CoV-2 infection determine whether to continue or discontinue empiric Transmission-Based Precautions. Examples of when empiric Transmission-Based Precautions following close contact may be considered include:Patient is unable to be tested or wear source control as recommended for the 10 days following their exposurePatient is moderately to severely immunocompromisedPatient is residing on a unit with others who are moderately to severely immunocompromisedPatient is residing on a unit experiencing ongoing SARS-CoV-2 transmission that is not controlled with initial interventionsPatients placed in empiric Transmission-Based Precautions based on clos

Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 4 of 5 residents (R11, R13, R32, R35) reviewed for immunizations. Findings include:The Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Recommendations dated 10/26/24, identified a pneumococcal vaccination was recommended for adults 50 years or older. Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received bothPCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old.R11's undated admission Record, identified an admission date of 10/15/24, R11 was [AGE] years old and had diagnoses that included Alzheimer's disease, heart failure, type 2 diabetes, obesity and hypertension.R11's Immunization Audit Report dated 12/18/15, failed to identify if R11 had received a pneumococcal vaccine.R11's Immunization Summary dated 8/11/21, identified the following: On 11/29/06, R11 received a PPSV23. On 2/13/14, R11 received a PPSV23.On 2/18/15, R11 received a PCV13.On 3/19/19, R11 received a PCV13.R11's electronic health record (EHR) did not include evidence R11 or R11's representative received education regarding pneumococcal vaccine booster and there was no indication R11 was offered the pneumococcal vaccine per CDC guidance.R13's undated admission Record, identified an admission date of 6/10/25, R13 was [AGE] years old and had diagnoses that included vascular dementia, sleep apnea, type 2 diabetes, and hypertension.R13's Immunization Audit Report dated12/18/25 identified the following:On 10/1/12, R13 received a PCV13On 3/19/18, R13 received a pneumococcal vaccine, however, the report failed to identify which vaccine was received.R13's electronic health record (EHR) did not include evidence R13 or R13's representative received education regarding pneumococcal vaccine booster and there was no indication R13 was offered the pneumococcal vaccine per CDC guidance.R32's undated admission Record, identified an admission date of 9/30/21, R32 was [AGE] years old and had diagnoses that included dementia, chronic kidney disease and congestive heart failure.R32's Immunization Audit Report dated 12/18/25, identified the following:On 7/25/17, R32 received a dose of pneumococcal vaccine. However, the report failed to identify which vaccine was received.On 10/5/21, R32 received a dose of pneumococcal vaccine. However, the report failed to identify which vaccine was received.R32's electronic health record (EHR) did not include evidence R32 or R32's representative received education regarding pneumococcal vaccine booster and there was no indication R32 was offered the pneumococcal vaccine per CDC guidance.R36's undated admission Record, identified an admission date of 2/12/24, R36 was [AGE] years old and had diagnoses that included dementia, hypertension, and left sided hemiplegia (paralysis) and hemiparesis (weakness).R35's admission Record dated 12/18/25, identified an admission date of 2/12/24, R35 was [AGE] years old and had diagnoses that included dementia, hypertension, and left sided hemiplegia (paralysis) and hemiparesis (weakness).R35's Immunization Audit Report dated 12/18/25, identified the following:On 10/13/15, R35 received a pneumococcal conjugate vaccine (PCV13). On 4/25/24, R35 received a pneumococcal polysaccharide vaccine (PPSV23).R35's electronic health record (EHR) did not include evidence R35 or R35's representative received education regarding pneumococcal vaccine booster and there was no indication R35 was offered the pneumococcal vaccine per CDC guidance.During an interview on 12/18/25 at 9:04 a.m., licensed practical nurse (LPN)-A stated when resident immunizations were offered, she filled out either a paper consent or declination. Those were kept in a binder in her office until the following spring, then the form would be scanned into the medical record. LPN-A would then enter the immunization into the immunization section of the resident's chart. LPN-A stated when she worked in the clinic, if a patient had received a PCV13 and a PCV23, they were complete and a PCV20 or 21 was not required. Because of this, R11, R13, R32 and R36 were not offered a PCV20 or 21.The facility policy Pneumococcal Vaccination dated 10/7/25, identified it was the facility's policy to offer residents immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders. 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education documented in the clinical record. a. The individual receiving the immunization, or the resident representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine. b. If necessary, the vaccine information statement will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding.

Based on observation, interview, and document review, the facility failed to obtain COVID-19 vaccination information for 1 of 2 facility employees (NA-N) reviewed for immunizations. Findings include:A copy of nursing assistant (NA)-P COVID-19 Informed Consent form was requested but not received.During an interview on 12/17/25 at 6:25 a.m., NA-P stated she was unvaccinated against COVID-19. I don't trust the government.During an interview on 12/18/25 at 9:04 p.m., licensed practical nurse (LPN)-B stated employees were offered COVID-19 every fall during the facility's vaccine clinic. A pink binder was kept with a list of employees. Once the employee was done, the name was highlighted. New employees were added upon hire. However, LPN-B was not listed. When an employee declined the COVID-19 vaccine, a declination form was completed. The forms were kept in the pink binder in alphabetic order, and no form was found for NA-P. NA-P was a new employee and LPN-B stated, I must have missed her. The facility policy COVID-19 Vaccination dated 9/26/25, identified it was a policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. The facility will maintain documentation related to staff COVID-19 vaccination and include at a minimum: a. Education to the staff regarding the risks, benefits, and potential side effects of the COVID-19 vaccine. b. The offering of the COVID-19 vaccine or information on obtaining the COVID-19 vaccine. c. The COVID-19 vaccine status of staff and related information as indicated by NHSN.

Based on interview and document review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN CMS10055) was provided to 2 of 3 residents (R1and R5) reviewed for beneficiary notification. Findings include:R1's face sheet dated 12/18/25, identified R1 was admitted to the facility on [DATE], and remained in the facility. R1's diagnoses included liver and bone cancer, pneumonia, weakness, and pleural effusion (a buildup of fluid between the layers of tissues that line the lungs and chest cavity). R1's Notice of Medicare Non-Coverage (NOMNC) dated 11/24/25, identified R1 was being discontinued from services due to lack of meeting services hours five times a week. R1's first day of services was 11/14/25, and the last covered day was 11/26/25. R1's medical record lacked a completed SNFABN to outline services and continued cost of services.R5's face sheet dated 12/18/25, identified R5 was admitted to the facility on [DATE], and remained in the facility. R5's diagnoses included femur fracture and artificial hip. R5's first day of services was 4/7/25, and the last covered day was 6/26/25. R5's NOMNC dated 6/24/25, identified R5's services were ending due to the condition improved. There was also a communication note dated 6/24/25, that identified R5's payor source would change from Medicare Part A to private insurance. The communication form lacked any indication if resident wanted to continue services or what the cost or services covered would entail. R5's medical record lacked a completed SNFABN to outline services and continued cost of services.During an interview on 12/18/25 at 11:31 a.m., the licensed social worker (LSW) stated she was responsible for giving resident the NOMNC when their services had ended. The LSW stated they were never trained to give the SNFABN for when ending services. They were not aware it was needed and had not been done. The facility's Advance Beneficiary Notice (ABN) policy dated 12/20/24, identified the facility will provide an ABN to Medicare beneficiaries in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines. The notice must clearly describe the services, reason for expected denial, and estimated cost.

Based on observation, interview and document review the facility failed to develop care planned interventions for 1 of 3 residents (R1) reviewed who displayed behaviors toward other residents.Findings include:R1's Transfer/Discharge Report indicated she admitted to the facility 3/27/25. R1's diagnosis included adjustment disorder, delusional disorders, and dementia.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was independent with wheelchair mobility on the unit. The MDS indicated R1 displayed physical, verbal and other behaviors.R1's care plan dated 10/31/25, indicated she was taking psychotropic medications for treatment of behavioral symptoms related to dementia, severe agitation and delusional disorder. The care plan lacked a behavior care plan.R1's Progress Notes identified the following:10/27/25, R1 was wandering around the household going into other resident's room.11/5/25. R1 was wandering around the household, collecting anything she liked along the way. 11/5/25, R2 was found in another resident's room washing her clothes that were covered in feces. 11/6/25. R1 had an altercation with another resident during supper time. R1 got upset and slapped R3 on the arm. R3's quarterly MDS dated [DATE] indicated a diagnosis of Early onset Alzheimer's and Severe Dementia with anxiety. During observation on 12/4/25, R1 was propelling on the unit in her wheelchair stating, I have no place to go. At 7:54 a.m., R1 approached survey and when asked, stated I am fine, I have my baby (referring to a stuffed dog). R1 also had a banana, spoon, clothing protector and a newspaper on her lap. At 9:13 a.m., another resident's motion sensor activated as R1 entered the resident's room.During interview on 12/4/25 at 12:46 p.m., licensed practical nurse (LPN)-B stated R1 could be a little spicy. LPN-B said when she was in a mood she tried to keep R1 and R3 away from each other. LPN-B said R1 and R3 had an incident at the dinner table one time and said they had no problem swearing at each other. Facility policy Comprehensive Care Plans dated 12/22/24, indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview and document review the facility failed to implement care planned interventions to reduce the risk of abuse for 1 of 3 residents (R2) who had a history of inappropriately touching female residents. Findings include:R2's Transfer/Discharge Report indicated he admitted to the facility on [DATE]. R2's diagnosis included adjustment disorder with depressed mood, vascular dementia, and muscle weakness.R2's quarterly Minimum Data Set, dated [DATE], indicated he was independent with bed mobility, and required supervision to ambulate.R2's care plan dated 11/5/25, identified vulnerability related to functional limitations and poor impulse control and identified behaviors that included touching fellow female residents inappropriately. The care plan identified the use of a motion sensor and floor alarms. The care plan indicated R2 was to be provided one to one staff supervision in common areas to ensure his behaviors were appropriate and fellow residents were free from distress.R2's Progress Note dated 11/25/25, indicated he had an episode of touching a female resident's breast. The medication administration record was updated to include: one to one staff supervision with male staff when in public areas.During interview on 12/3/25 at 1:41 p.m., nursing assistant (NA)-B stated on 11/25/25, she heard the door alarm and saw R1 going down the hall in her wheelchair. NA-B stated the activity aide was with R1 and two other residents. NA-B saw R2's hand in the vicinity of R1's breast and moved his hand away. NA-B was not sure if R2 had his hand on R1's breast but said he had been reaching that way. NA-B stated some of the nurses had told her not to turn her back on R2 because he was grabby. NA-B stated R2 was not dependent on staff and could ambulate independently.During observation on 12/3/25 at 4:18 p.m., R2 was in his room, lying down with his feet on the floor. R2's floor sensor alarm was approximately a foot away from his bed. Upon entrance and exit from room, R2's motion sensor did not activate. During observation and interview on 12/3/25 at 4:22 p.m., NA-A stated R2 required standby assist and staff needed to watch him because he was inappropriate with other residents. NA-A stated R2 got up very quickly and had a monitoring system in his room to alert staff if he got up. R2's room was observed with NA-A who confirmed the motion sensor did not activate upon entrance or exit from the room. NA-A stated the motion sensor had not been turned on. Further NA-A acknowledged the floor mat was not next to the bed and stated R1 may have kicked it out of the way. NA-A said the floor mat should have been next to the bed.During interview on 12/3/25 at 4:27 p.m., licensed practical nurse (LPN)-A stated R2 had to be watched as he liked to touch people inappropriately. Staff supervised him to ensure he was away from female residents. LPN-A stated R2 had alarms to alert staff he left his room.During interview on 12/4/25 at 9:09 a.m., NA-C stated the purpose of R2's alarms was to know where he was, if R2 got up or if someone else was in his room so staff could intercept. NA-C stated R2 wandered on the unit. During observation on 12/4/25 at 9:13 a.m., R2's motion sensor activated. R1 had wheeled into his room. R2 was in the dining room at the time of the observation. Facility Policy Resident Abuse Prohibition Policy dated 11/24/24, defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy indicated; It is the policy of WSLC that each resident will be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse can include but is not limited to physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse, or involuntary seclusion from any source. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection.

Based on interview and document review the facility failed to promote resident dignity following a fall for 1 of 3 residents (R1) reviewed when R1 sustained a fall, and staff left him to sleep on the floor. Findings include: R1's Admission Record indicated he admitted to the facility on [DATE]. R1's diagnosis included dementia with agitation, restlessness, mood disorder and neurocognitive disorder. R1's discharge Minimum Data Set (MDS) dated [DATE], indicated he displayed physical, verbal, and other behaviors. The MDS indicated R1 was impendent with transfers and ambulation and had not fallen since the prior assessment. R1's Baseline Care Plan dated 3/13/25, indicated he could not easily communicate with staff and communicated with gestures and incoherent vocalizations. The care plan indicated R1 required supervision for dressing and hygiene and was independent with transfers and ambulation without the use of mobility devices. The care plan identified cognitive impairment. The care plan further indicated R1 did not have a history of falls. Facility document titled Post Fall Questions dated 3/19/25, indicated R1 fell at 8:45 a.m. Staff found R1 on his right side on the floor next to his bed. During interview on 3/26/25 at 2:47 p.m., nursing assistant (NA)-A stated R1 had been confused and could not communicate with staff. NA-A said R1 had gone to the hospital and after he returned, he was very tired and seemed out of it. When NA-A worked with R1 the morning after he returned from the hospital, he got out of bed but could not stand and he fell to the floor. During interview on 3/27/25 at 10:00 a.m. anonymous staff (AS) stated following R1's hospitalization on [DATE], there were concerns about R1 being sedated and how staff were to transfer him when he woke up. As said staff mentioned the concern at the end of a staff meeting and were told, we don't know by the management. On 3/19/25, at the beginning of the shift R1 was on the floor, disoriented, non-verbal and uncoordinated and AS was told to just leave him on the floor. AS put a pillow under his head and hip and covered him with a blanket. During interview on 3/27/25 at 10:35 a.m., licensed practical nurse (LPN)-A stated R1 had returned from the hospital sedated from medication. On 3/19/25 in the morning, R1 had been up and when staff entered the room he was on the floor. LPN-A went to the interdisciplinary team (IDT) and was told to leave R1 on the floor, so they made him comfortable and left him. LPN-A said R1 got up around 2:00 - 3:00 p.m. During interview on 3/27/25 at 12:10 p.m. registered nurse (RN)-A said when R1 returned from the hospital he had been sleepy and lethargic. The next morning R1 had been sleeping and tried to stand at some point and fell . RN-A had been in the IDT meeting and said when staff reported the fall, they told her to make him comfortable with a pillow and something under him. RN-A stated the social services designee (SSD) had taken the lead on the decision to leave R1 on the floor and said she would have liked to see him put in the bed. On 3/27/25 at 1:58 p.m., the director of nursing (DON and SSD were interviewed. The DON said R1 had been hospitalized on [DATE], and when he returned, he was like a zombie. The next morning staff went to his room and found him sleeping on the floor. The DON said the IDT was in their morning meeting when LPN-A came and reported the fall and said they had decided to leave him there. The SSD said when she went to R's room, he was on the floor with a pillow under him and she agreed he soul be left on the floor. The DON stated it was not appropriate to leave R1 on the floor. Facility policy Dignity: Quality of Life dated 1/23/24, indicated residents shall always be treated with respect and dignity. Treated with dignity means the resident will be assisted in maintaining and enhancing their self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity.

Based on observation, interview and document review, the facility failed to ensure staff were following care planned interventions of two staff assist when transferring residents with a ceiling lift; and failed to complete therapy/or nursing assessments to determine the appropriate sling sizes per manufacturers guidelines for 3 of 4 residents (R12, R7, R2) reviewed who were transferred via ceiling lifts. These deficient practices resulted in immediate jeopardy (IJ) for R12, R7 and R2 who were at risk of serious injury as a result of the deficient practice. The IJ began on 10/29/24, when R7 was observed to be transferred in the ceiling lift from her bed to the toilet by assist of one staff when R7 was care planned to be transferred with two staff. The administrator and director of nursing (DON) were notified of the IJ on 10/30/24 at 12:57p.m. The IJ was removed on 11/5/24, at 9:09 p.m.; but noncompliance remained at the lower scope and severity, level 2, (D) which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The Maxi Sky 440 Instruction for Use revised 3/2020, identified the lift was designed to assist caregiver in hospitals, long-term care, nursing homes and home care environments, including private homes and patients with reduced mobility. Patient transfers must be done under the supervision of appropriately trained caregivers in accordance the instructions. Constant attention to the patient was required from caregiver during the whole transfer. In the unlikely event of a failure of the device, the caregiver must be ready to react. The Maxi Sky 440 Portable Lift and Charger Station Product Description undated, identified ceiling lifts enabled a single caregiver to transfer patients or residents smoothly without any manual lifting. All slings are color coded for size by having a different colored edge binding or attachment strap coloring: - Grey or Teal -Extra Extra Small -XXS [weight range 0-55 pounds (lbs)] - [NAME] or [NAME] -Extra Small -XS [weight range 55-77 pounds (lbs)] - Red -Small -S [weight range 77-132 pounds (lbs)] - Yellow -Medium -M [weight range 121-165 pounds (lbs)] - [NAME] -Large -L [weight range 154-264 pounds (lbs)] - Blue -Extra Large -XL [weight range 308-440pounds (lbs)] - Terracotta -Extra Extra Large -XXL [weight range 440-500 pounds (lbs)] The option of a headrest for many slings was available if it is considered necessary for a particular patient. A range of special purpose slings were available as accessories. R12: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12 had severe cognitive impairment and R12 was dependent on staff (helper performed all the effort and resident does none of the effort to complete the activity) for toileting and bed to chair transfers. R12's care plan dated 8/9/24, identified R12 was cognitively impaired and required assist of two staff for ceiling lift transfers. R12's care plan did not identify the ceiling lift sling size to be used with the transfer. R12's Rehabilitation Services Physical Therapy Out-Patient Treatment Note dated 5/10/23, identified a mechanical lift was used with assistance x 2 to transfer. The note failed to identify what ceiling lift sling size staff should use for R12. R12's medical record identified R12 weighed 167.1 lb. During an interview on 10/28/24 at 2:38 p.m., R12 stated, last week a nursing assistant left R12 in the bathroom in the ceiling lift alone. R12 was unable to say a name or date but R12 was crying and stated R12 waited at least 20 minutes. R12 was in the bathroom already in the lift, up in the air, and R12's feet were dangling and going numb. R12 stated staff usually left R12 in the ceiling lift, hanging over the toilet, but usually not for that long. R12 stated she urinated almost immediately when she got to the toilet and could have gone back to bed. R12 did report the incident to facility staff and was told by facility staff it always felt longer when you're in the lift, but it wasn't that long. R12 was crying and stated she felt neglected. I don't like to complain and get people in trouble, but I can't put up with this either. I just can't. R12 was grasping her bed linens in her hands and stated she was told there were many other people to help take care of. During an observation on 10/29/24 at 5:50 p.m., NA-E and registered nurse (RN)-B transferred R12 with the ceiling lift into the bathroom using a green (large sling). R12 was holding the sling straps with her shoulders extended 90 degrees with the sling bunched up in her underarms. R12's fingers were grasping the straps tightly and her knees were pointed up towards the ceiling and her bottom hanging from the bottom of the sling. During an observation on 10/30/24 at 5:20 p.m., R12 had a green (large) sling laying in her bathroom. R7: R7's significant change MDS dated [DATE], identified R7 had severe cognitive impairment and was dependent for toileting, personal hygiene, and bed to chair transfers. R7's care plan dated 8/9/24, identified R7 was cognitively impaired and required assist of two for ceiling lift transfers and R7 used a size medium ceiling lift sling. R7's Kardex dated 10/29/24, directed staff to provide assist of one with transfers using the ceiling lift. However, the Kardex additionally directed staff to use ceiling lift with total assist of two with a medium Arjo sling. R7's medical record failed to identify a physical therapy or nursing evaluation was completed to determine safe transferring of R7 or what ceiling lift size should be used. R7's medical record identified R7 weighed 130.1 lb. During an observation on 10/29/24 at 12:23 p.m., nursing assistant (NA)-C assisted R7 to the bathroom using a ceiling lift, without another staff person present as care planned. R7 was in the ceiling lift and holding the sling straps with both hands. R7's shoulders were extended 90 degrees and R7's bottom was hanging from the bottom of the sling. R7 had facial grimacing and moaned ooohh. NA-C asked R7 if she was having pain and R7 stated yes, along her ribcage. NA-C stated this was residual pain due to R7 having just recovered from COVID-19. NA-C stated she would report R7's pain to the nurse. During an interview on 10/29/24 at 12:45 p.m., NA-C stated R7 had been an assist of one with the ceiling lift since NA-C started working at the facility two years ago. NA-C stated R7's care plan contradicted itself and NA-C wasn't even sure what R7's care planned need for transfer was. NA-C never asked anyone what R7 needed because she felt safe transferring R7 in the ceiling lift by herself. NA-C stated she used the sling in her room. Laundry replaced the sling if it was soiled, and NA-C didn't have to get a new one. NA-C stated she didn't even know how to tell what size the sling was. During an interview on 10/29/24 at 6:46 p.m., NA-E stated R12 was never to be left alone while in the ceiling lift. Staff routinely transferred R12 using the ceiling lift with assist of one, but NA-E wasn't comfortable with this because you saw. She [R12] has chicken wings sticking out. NA-E didn't trust R12 not to fall. R7 was the same way. NA-E wouldn't transfer R7 alone either. NA-E stated she always just asked the nurse to help her because if R7 or R12 raised their arms due to the pressure of the sling they would slip right out and fall. NA-E stated staff transferred residents with assist of one because they can't find anyone to help. During an interview on 10/29/24 at 6:55 p.m., RN-B stated R7 and R12 were care planned for assist of two with ceiling lift transfers but with the way staffing was going, staff usually transferred using assist of one. Nursing helped as much as they could but there just wasn't enough staff. If the nurse couldn't help with transfers, the nursing assistants had been doing assist of one. R12 had lost a lot of muscle tone and just kind of hung in the sling like that. Hanging in the sling like that could potentially lead to a shoulder dislocation or a rotator cuff injury. If that happened, R12 could slip out of the sling and fall, however, RN-B had never heard of that happening. RN-B never reported any safety concerns for R7 or R12 during ceiling lift transfers to the unit coordinator nor had requested a physical/occupational therapy evaluation to determine if they were safe to transfer. I'm just a floor nurse so I'm not the one to ask about that. R2: R2's annual MDS dated [DATE], identified R2 had severe cognitive impairment and a diagnosis of dementia. R2 had functional limitation with range of motion in both lower extremities and was dependent on staff for bed mobility, toileting, and transfers. R2 had one fall with injury (including skin tears, abrasions, lacerations, superficial bruises, hematoma's, and sprains) during assessment dates. R2's care plan dated 6/28/22, identified R2 required assist of two staff to move between surfaces using the ceiling lift. The ceiling lift sling size was not identified on the plan. R2's therapy orders dated 8/1/24, recommended staff use the ceiling lift or total mechanical lift to transfer the resident. The orders failed to identify how many staff were required for transfers and what size sling to use. R2's medical record lacked any other assessment to identify how many staff were needed to transfer and what size lift sling to use. R2's medical record identified R2 weighed 166 lbs. On 10/30/24 at 8:22 a.m., nursing assistant (NA)-D was standing in R2's room. R2 was fully dressed in their wheelchair. The ceiling lift sheet, size unidentified, was underneath with the straps crossed between the resident's legs. NA-E proceeded to use the ceiling lift to transfer R2 from the bed to the toilet, without a second staff member present as care planned. NA-E stated when R2 was calm like today she would transfer the resident by herself using the ceiling lift. When R2 was resistive NA-D would ask for other staff assistance. The care plan provided direction that two staff were required for ceiling lift transfers. NA-E stated she did not have any problems and the transfer went as it usually did when R2 was calm. NA-E stated she had not looked at the care plan and was uncertain how many staff were required to safely transfer R2 with the ceiling lift. On 10/30/24 at 8:22 a.m., NA-D stated she had no time to check the care plan so was unaware what the care plan directed. On 10/30/24 at 9:17 a.m., the director of nursing (DON) stated all staff were aware all mechanical lifts, including the ceiling lifts, required two staff to safely transfer a resident. During an observation on 10/30/24 at 5:20 p.m. R7 had a yellow (medium) sling folded in a chair in her room. During an interview on 10/30/24 at 9:20 a.m., licensed practical nurse (LPN)-A stated she was very concerned regarding resident and staff safety. The facility did not have enough staff to provide assist of 2 with ceiling lift transfers. Residents were being left alone in the lifts in the bathrooms, staff were transferring resident by assist of 1 with the ceiling lifts, and not answering call lights timely. LPN-A stated she knew of an incident on 10/25/24, between R12 and NA-D where R12 was left alone in the bathroom hanging from the ceiling lift. LPN-A did not report this to anyone but stated R12 was not safe to be left unattended in the ceiling lift in the bathroom. R12 did not have the ability to sit up and could have fallen. LPN-A further stated there were five residents who required assist of two for ceiling lift transfers and staff routinely transferred using assist of one. Staff were supposed to ask for assistance, but who were they going to ask? By the time a staff person was found to help, the resident only waited even longer. Plus, with call lights, bed alarms and chair alarms going off, what were staff supposed to do? That's what happened when R12 was left in the bathroom, NA-D was answering call lights. During an interview on 10/30/24 at 9:44 a.m., NA-C stated the facility was always short staffed. The A-wing was just too heavy of care for one nursing assistant. There was supposed to be a float nursing assistant that would go between the different units but that rarely happened and especially when the nurse had to bounce between units as well. Again, NA-C stated she got confused by the rules for ceiling lift transfers. One day, staff are told it's ok to use assist of one then they're told only use assist of two. NA-C just did her thing and, besides, NA-C couldn't magically pick up a staff member to help. When directed to use assist of two for ceiling lift transfers, NA-C stated she told administration that the workload was too heavy to do that. NA-C stated she felt it was safe to transfer using assist of one and/or to leave a resident in the bathroom while in the ceiling lift. NA-C routinely transferred R12 and R7 in the ceiling lift by herself without assistance of another staff person. NA-C stated she had heard about an incident on 10/25/24, where R12 was left alone in the bathroom because staff were answering call lights because there wasn't enough staff. NA-C stated she felt R12 was safe to be in the bathroom alone and had left R12 alone as well to answer call lights. There were residents who were at risk for falling and staff had to check on them. Who else would do it? During an interview on 10/30/24 at 9:58 a.m., the DON stated staff were expected to follow care planned interventions for ceiling lift transfers for the resident and staff safety. That's so unsafe. During an interview on 10/30/24 at 10:34 a.m., NA-D stated she had worked at the facility a little over a month as an agency nursing assistant. NA-D was trained by another traveler and wasn't told where they could find care plans or cheat sheets. NA-D had to go to the interim DON and ask where to find it. NA-D was not going to transfer someone until NA-D knew how it was supposed to be done. NA-D stated she was told to look at the kardex, but with twelve residents to care for it was hard to be read through each one. NA-D stated she asked for a little sheet for like teeth, diet, transfers and was told there was a sheet but it was not up to date. There were residents that the sheet said were sit-to-stands but because things happened and they became weaker, they can't do it. The sheet needed to be updated. NA-D would have liked better training. Agency nursing assistants knew what their job consisted of but haven't cared for these residents before. NA-D told the interim DON that the facility needed staff who were employees of the facility to train agency nursing assistants. When NA-D asked the nurse or the float nursing assistant to help with assist of two transfers. NA-D was told the ceiling lifts required assist of two, then it changed to assist of one, and now it was assist of two again. NA-D needed a definite answer for this because NA-D didn't want to lose her certificate for something that was out of her control. Regarding the 10/25/24, incident with R12, NA-D wouldn't call it an incident. R12 wanted to sit on the toilet because she was smearing bowel movement (BM). NA-A transferred R12 to the toilet via the ceiling lift but had never worked with R12 before. NA-D didn't know R12 got anxiety in the bathroom if left alone. NA-D left R12 in the ceiling lift sling and left her in the bathroom alone and answered other call lights. NA-D went back into R12 and R12 was like what took you so long. NA-D stated she told R12 NA-D tried to get to R12 as fast as NA-D could. The float nursing assistant couldn't use the lift because she was [AGE] years old. It was probably 10 minutes. NA-D did someone's cares and went back and did my thing. The next day NA-D reported the bathroom thing.The staff were shorthanded. NA-D did the best she could. R12 should have been assist of two and staff should have stayed with R12 while she was in the bathroom. NA-D did not know why they didn't stay because it was dangerous to leave R12. R12's feet were literally up in the air, not resting on the floor, because R12 was unstable. R12 was unstable and flailing and moving all the time so R12 needed assist of two with ceiling lift transfers. Staff have said if R12 was calm he could be assist of one. On 10/30/24, R12 was calm so NA-D transferred him in the ceiling lift by herself. No, I shouldn't have. NA-D stated she had no idea where it said there were times R12 could be assist of one because NA-D had never been able to read all the care plans. During an interview on 10/30/24 at 1:25 p.m., NA-B stated R12 reported the 10/25/24, bathroom incident to her and NA-B reported it to the nurse. After that, NA-B didn't know what happened. During a telephone interview on 10/30/24 at 2:36 p.m., the medical director stated staff were expected to follow a resident's care plan to ensure safety. During an interview on 10/30/24 at 2:39 p.m., the social worker designee (SWD) stated she was informed of R12's bathroom incident and staff were expected to not leave residents unattended in the bathroom while in the ceiling lift and were expected to follow the resident's care plan during ceiling lift transfers to ensure safety. On 10/30/24 at 5:09 p.m., RN-A stated the nursing assistants were trained to size slings for residents. The slings were color coded for size. However, RN-A stated she did not know if the size was documented in the resident's care plan or not. She would have to ask. During an interview on 10/30/24 at 5:24 p.m., NA-E stated she just knew what size a resident needed. For example, a reddish pink color was an extra small, a yellow was a small and a green was a medium. For R12, she used a green and it was kind of big and NA-E had considered getting a different size for her to try. Staff just went in the cage and got one. NA-E stated she didn't know if there was a size listed for the residents anywhere, even the care plan or Kardex. NA-E stated that was a good question, but NA-E just went by her gut. For example, another resident in the facility had a pink sling in his room. NA-E knew that was way too small, so NA-E just grabbed a bigger sized sling to be safe. I go by my gut, During an interview on 10/30/24 at 5:26 p.m., NA-F stated staff were usually assigned to a certain wing all the time and staff just knew what sling a resident used. Like R12, used a green sling and, if it was dirty, staff just went to the cage and got a new one. If staff were floated to a different wing and they didn't know what sling to use, they would just ask the nurse or another aide which sling to use. NA-F didn't know if sling size was written down anywhere. NA-F knew the nurses did check the slings and would put different ones in the rooms sometimes, but NA-F stated she didn't know if they put that anywhere either. You just know. During an interview on 10/30/24 at 6:14 p.m., the DON stated R12 and R2 did not have a ceiling lift sling size care planned. R7's care plan directed staff to use a size medium sling, however, R7 had lost weight since admission and her size may be incorrect. It was important to have a resident's sling size care planned so all staff were able to easily determine the correct size to ensure safe transferring of the resident. Unsafe ceiling lift transfers could result in resident injury or a fall. Any nurse could request a physical therapy (PT) evaluation for sizing, and it was important for sling size to be care planned for safety for everyone to see. Further, no unlicensed staff member should attempt to size a ceiling lift sling for a resident. During an interview on 10/30/24 at 6:21 p.m., the administrator stated staff were expected to report concerns with sling size and to request a PT evaluation to ensure resident safety. The facilities Safe Resident Handling Program dated 5/14/24, identified it was the policy of the facility that when residents required assistance to move, the assistance would be provided in a manner that was safe for both the resident and employee. A facility policy regarding ceiling lift slings and transfers was requested but the facility did not have one to provide. The IJ was removed on 11/6/24 at 9:09 p.m., when it could be verified through observation, interview and document review the facility implemented the following immediate interventions of: assessing R12, R7 and R2 for correct amount of staff to ensure safe transfers, assessed for the appropriate sling size per manufacturers recommendation's, educated nursing staff and created a policy for ceiling lift assessments and ensured there were enough staff to transfer residents according to their care plans. 42075

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R39) with a known history of sexual behaviors towards others was comprehensively assessed and interventions implemented to mitigate risk to prevent ongoing sexual abuse for 2 of 2 residents (R31, R6) who were cognitively impaired, dependent on staff for their care, and were sexually abused by R39. The immediate jeopardy (IJ) began on 9/6/24, when R39 came up behind R31 and fondled her breasts. The facility failed to comprehensively assess and develop interventions to help manage and reduce the risk of injury or assault to others. This contributed to R39 continued episodes of sexual abuse toward R31 on 9/25/24, and again on 10/14/25, and toward R6 on 10/15/24. The administrator and director of nursing (DON) were notified of the IJ on 10/30/24, at 11:43 p.m. The IJ was removed on 11/5/20, at 9:09 p.m. when the facility successfully implemented a removal plan; but noncompliance remained at the lower scope and severity level 2, D-isolated, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R31: R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 had severe cognitive impairment and exhibited physical behaviors of grabbing, hitting, scratching, or abusing others sexually one to three days per week, and verbal behaviors toward others one to three days per week. R31 required substantial assistance to dress and was independent with transfer and ambulation. Diagnoses included Alzheimer's disease, anxiety, mood disorder, dementia, restlessness, and agitation. R31's care plan dated 10/29/24, identified R31 was vulnerable due to disorientation, functional limitations, confusion, and repetitive verbalizations. R31 could be easily exploited or had a history of giving away money or belongings. R31 exhibited behaviors of pacing, rummaging, wandering, yelling, resistive to care, physically abusive toward staff, false beliefs, anger with self and others and easily annoyed. Staff were to use dementia approach, introduce self, uses short sentences, avoid questions, avoid saying no to resident, 1:1 visit, redirection, offer reassurances, determine, and meet basic needs, allow space when resistive. R31 had impaired cognitive function or thought processes related to dementia. Staff were directed to face resident when speaking, reduce distractions. R31 understood consistent, simple, directive sentences. Provide support when needed. R31 needed support and assistance with safe decision making. The care plan did not identify any interventions to protect R31 from resident-to-resident sexual abuse. R31's medical record lacked any assessment on capacity to consent to sexual activity. R6: R6's quarterly MDS dated [DATE], identified R6 had moderate cognitive impairment and exhibited delusions, physical behaviors of grabbing, hitting, scratching, or abusing others sexually one to three days per week, verbal behaviors toward others four to six days per week and other behaviors not directed toward others four to six days per week. R6 required substantial assistance to dress and partial assistance with transfers. R6 was independent with ambulation once standing. Diagnoses included depression, anxiety, dementia, and sever mood disturbance. R6's care plan dated 8/1/24, identified R6 had a history of trauma related to experienced physical and verbal abuse from a care giver. Staff were directed to: express patience and not to rush resident with care, reassure R6 she was safe and cared for by staff and her family. The care plan identified R6 was vulnerable due to disorientation, history of delusions, functional limitations, confusion, and repetitive behavior. R6 could be easily exploited or had a history of giving away money or belongings. R6 exhibited behaviors of paranoia, false beliefs, pacing, disrobing in public areas, delusions, negative, anxious, or depressed statements, exit seeking, and crying. Interventions included: R6 preferred female caregivers and to avoid male caregivers, introduce self, explain each step of care, speak in short sentences, anticipate, and meet basic needs, offer reassurances, redirect, listen when resident has concerns and diversional activity. The care plan did not identify any interventions to protect R31 from resident-to-resident sexual abuse. R6's medical record lacked any assessment on capacity to consent to sexual activity. R39: R39's quarterly MDS dated [DATE], identified R39 had severe cognitive impairment with physical behaviors of grabbing, hitting, scratching, or abusing others sexually one to three days per week. R39 was able to transfer and ambulate independently. R39 diagnoses included dementia, psychotic disturbance, mood disturbance and anxiety. R39's care plan dated 9/24/24, identified R39 had targeted behaviors of wandering and touching female staff inappropriately. Interventions directed staff to provide verbal and tactile cues if he exhibited inappropriate touching and remind him to keep his hands to himself. Staff were directed to avoid having their back to R39, engage R39 in household activities, and to be out with other residents and staff. The care plan failed to identify R39's sexually inappropriate behaviors toward other residents and lacked interventions to ensure other residents' safety. R39's progress notes identified the following: - 8/23/24, R39 was observed to take R31 by her hands and lead R31 to his room and close the door. When staff entered the room, R39 was lying on his side in bed and R31 was just seated on R39's bed. Staff directed R31 out of room and reminded R39 they were not allowed alone in room with door shut. - 9/6/24, licensed practical nurse (LPN)-A documented R39 had approached a female resident [identified as R31 from interview] from behind and gave the resident what appeared to be a bear hug [identified in interview to be reaching from behind and grabbing breast] which staff observed from behind. The social service designee (SWD) was notified. - 9/18/24, R39 made attempts to enter an unidentified female resident's room when she was sleeping in bed with lights off. Staff redirected R39 out of the room several times. - 9/25/24, R39 was observed fondling R31's breast. Staff intervened and separated the two residents. - 10/11/24, R39 was walking back to his room when R39 approached a female resident [identified as R31 through interview] to grab her breast area. R39 was redirected away and reminded it was inappropriate to touch anyone without permission. The DON was notified. - 10/15/24, R6 was found in R39's room with the door closed. R6 was seated in her wheelchair beside R39's bed and R39 was fondling R6's breast. R6 was removed from area and R39 was reminded the behavior was not appropriate. R6 stated the incident made her uncomfortable and R39 had been squeezing her breast pretty hard. The DON and SWD were notified. R39's medical record lacked evidence R39's inappropriate sexual behaviors toward other residents had been comprehensively assessed and interventions implemented to mitigate potential abuse toward other residents, despite R39 being independently mobile and displaying ongoing inappropriate sexual behaviors. R31's medical record lacked any assessment to ensure her psychosocial needs were met and interventions implemented. R6's medical record lacked any assessment to ensure her psychosocial needs were met and interventions implemented. On 10/31/24 at 9:40 a.m., R39 was observed in the television area seated between two female residents, one on either side. SWD approached R39 to speak with him. R39 reached his hand underneath SWD's sweater and attempted to grab her breast. SWD pushed R39's hand down and left the area, leaving R39 to remain seated between the two female residents. Nursing assistant (NA)-A, who was present, stated R39 was 1:1 supervision now due to his behaviors. On 10/29/24 at 11:00 a.m., NA-A stated R39 could get grabby and try to grab staff breasts, you just needed to watch for it and remind him the behavior was not appropriate. NA-A was not aware R39 had inappropriate sexual behaviors toward other residents. The facility usually staffed the locked unit with one nursing assistant and a nurse would come on the unit on and off to pass medications. Once in a while they would have a float nursing assistant that would come on the unit occasionally to see if help was needed, but that did not happen very often. On 10/29/24 at 12:30 p.m., NA-B stated R39 liked to touch women's breasts. NA-B knew of R39 touching R31. NA-B and R31 were standing in the hall visiting when R39 came up behind R31 with a sort of bear hug and R39 clasped both his hands over R31's breasts in a kind of thrusting up motion. R39 let go and giggled. NA-B remembered R31's hard a startled look on R31's face. NA-B reported the incident to the charge nurse and the DON at the time. NA-B did not remember any changed interventions or approaches being implemented after that. When interviewed on 10/29/24, at 1:00 p.m. licensed practical nurse (LPN)-A stated R31 was observed walking back to R31's room and R39 was walking back to his. When R39 saw R31, R39 veered off toward R31 walking straight towards R31 and attempted to touch R31's breasts. LPN-A intervened and directed R39 to R39's room. LPN-A immediately reported the incident to SWD and the DON. LPN-A was told to make sure the incident was documented in R39's medical record and the DON and SWD would look into the incident. LPN-A asked SWD and the DON how much charting would need to occur before anything was done regarding R39's behaviors but was not given an answer. On on 9/6/24, LPN-A observed R39 approach R31 from behind, placing his arms on either side of R31 in a bear hug and grabbed R31's breasts. On 9/11/24, LPN-A stated housekeeper (HSK)-A watched R39 sit near R31 on the couch in the television room when R39 stood and took R31's hands and led her to his room and was just shutting the door. HSK-A went to the adjacent unit (unit A) to notify LPN-A. LPN-A entered the room and separated the two residents. Further, on 8/23/24, LPN-A stated R31 was in R39's room with R39 lying in bed. HSK-A observed the behavior and went to unit A to notify LPN-A. When LPN-A entered, R31 had just sat on R39's bed and LPN-A separated the two residents. LPN-A documented all the incidents into R39's medical record and reported each incident to either the DON or SWD after each occurrence. During interview on 10/29/24, at 2:00 p.m. RN-A stated she worked on the locked unit on 10/14/24, and observed R39 reach out to grab R31's breast in the common area. RN-A hollered to R39 No, don't do that and he immediately stopped. R31 stated, I told him that to. RN-A immediately reported the incident to SWD, however did not document the incident in R39's medical record. RN-A was not aware R39's inappropriate sexual behavior toward other residents was not addressed on R39's care plan, but RN-A was sure staff were aware of the behaviors. When interviewed on 10/29/24, at 1:30 p.m. SWD stated she was notified of some incidents with R39's behavior toward residents. SWD received calls regarding incidents of R39 inappropriately touching other residents on 10/14/24 and 10/15/24. SWD discussed the incidents regarding R31's behavior with the DON and it was determined there were no non-consensual type of feelings. The residents had not seemed upset, so SWD and the DON determined it would be ok to just document the incidents when they occurred. When the DON called SWD on 10/15/24, regarding R39 inappropriately fondling R6's breasts, SWD and the DON discussed the incident and determined there was no willful intent and the residents did not seem upset, so the behavior was fine. SWD stated she did not follow up on any of the reported incidents or change anything. Assessments were not completed with any of the residents involved. The reported incidents that occurred with R39 had not been investigated because it was determined both participants were willing and did not seem upset. R39's care plan did not get updated to reflect the inappropriate sexual resident to resident behavior because the facility had hired a new MDS coordinator. The MDS coordinator was going through all the resident care plans and trying to get them all updated and they were all just trying to catch up and survive. SWD did feel a reasonable person would be upset when approached from behind and breasts grabbed and SWD had just assumed someone else was looking into R39's behavior incidents. When interviewed on 10/29/24, at 2:00 p.m. the DON stated she was only aware of the two most recent incidents involving R39's inappropriate sexual behaviors toward other residents. DON discussed the incidents with SWD, and they determined because both residents had severe cognitive impairment and there did not seem to be any willful intent to be a sexual predator, the incidents would not need to be reported. The facility did not investigate any of the resident-to-resident incidents beyond reviewing the initial reports reported to them by staff. The DON had not been aware of all the incidents or near miss incidents of abuse. Had the staff notified the DON she would have realized there was a pattern and would have done things to prevent the incidents, such as placing an alarm on R39's room door as well as implementing care planned interventions and approaches to prevent resident to resident occurrences. R39's inappropriate sexual behaviors toward other residents should have been care planned with interventions for staff to follow. Assessment and care planned interventions had not been completed as the DON had not been aware there had been so many incidents. Even one incident would not be ok, but R39 was showing a pattern of behavior. If the DON had known a pattern had been identified, the facility could have done so much more to prevent reoccurrences. When interviewed on 10/29/24, at 5:30 p.m. family member (FM)-A stated he had not been notified of any resident-to-resident incidents regarding R31. FM-A felt it would have been very upsetting for R31 to be fondled in that manner. R31 would have never been ok with that type of attention. FM-A was surprised the facility had not notified him of the incidents as it was something R31's family would have wanted to have been made aware of. During interview on 10/29/24, at 5:30 p.m. the administrator stated he was not made aware of R39's inappropriate sexual behaviors toward other residents until the DON spoke with him around 3:00 p.m. or 4:00 p.m. on 10/29/24. Had the administrator been made aware of R39's behaviors he would have reported the incidents, notified the POA's of the residents, notified the physician and the ombudsman and investigated. During telephone interview on 10/30/24, at 10:00 a.m. R39's medical doctor (MD)-B stated he was not aware of any resident-to-resident inappropriate sexual incidents. MD-B would have certainly expected the facility to have mentioned R39's inappropriate resident to resident incidents when completing rounds at the facility on 9/20/24, as the incidents had been occurring even then. MD-B would have liked to have known. R39 was a challenge as R39 had no sense of boundaries. MD-B stated it was not known if R39 had a history of such behaviors prior to his placement in the nursing home. The sexual behaviors toward staff had started after his placement. MD-B would have liked to know when R39 started to direct the inappropriate behavior toward other residents. MD-B may have had the memory clinic get involved to address R39's behavior. Staff reported to MD-B in September R39's behavior had improved for staff related incidents, it could have been because R39 was directing sexual behaviors toward residents, targeting other residents instead of staff. The facility provided handwritten note undated, identified laundry aide (LA)-A entered R39's unit to pick up laundry and LA-A found R39 coming up behind R31 and her sides and R31 jumped and said you. LA-A called R39's name at the same time (LA-A was just seconds behind) and LA-A told R39 that was inappropriate, and we all needed to keep our hands to ourselves. R39 left R31 alone immediately. LA-A reported to the nursing assistant on the unit, and she reported to the nurse. At the time of the incident, the nursing assistant was getting someone food in the dining room. The note failed to identify when the incident occurred, how R39 touched R31, or staff involved. The facility High Risk Monitoring Household: Pine dated 11/4/24, identified a grid of 30-minute time slots for five residents including R31 and R39. At 1:00 p.m., the form identified R39 grabbed R31 along with NA-B's initials. During an interview on 11/4/24 at 3:16 p.m. NA-G stated, before 11/4/24, staff were trying to keep R39, 6 feet away from female residents and were doing 15-minute checks. R39 was still on 15-minute checks but it was more that R39 needed to be an arm's reach away from female residents. R39 had been vacuuming all afternoon and staff were giving him fidgets to keep R39's hands busy. There was also a motion sensor on R39's door to alert staff of anyone going in or out of R39's room. NA-G provided the High-Risk Monitoring Household: Pine form and stated staff were to check on the residents every 30 minutes and mark the appropriate slot in the grid with a check mark. When asked what grabbed meant, NA-G stated she did not know because she wasn't working at that time but was told R39 gave a bear hug to R31. The nurse knows. During an interview on 11/4/24 at 3:40 p.m., the DON stated the 15-minute check were only for the first 36 hours because it wasn't feasible to do it with staffing. There was an incident on 11/4/24, and R39 gave a bear hug to R31. It was a good question how that happened because R39 was supposed to not have contact with female residents. The DON stated a call had been placed to find R39 placement at another facility because R39 was the only male resident on the unit. During an interview on 11/4/24 at 3:54 p.m., with the DON and administrator, the DON stated she was told by NA-B that LA-A just saw R39 come up behind R31. The DON did not assess R31 nor R39 and was told staff had taken R39 to his room. The DON was told R31 had said Oh and was surprised but not hurt. R39 went up behind R31 and (made gesture of grabbing breasts from behind). R39 grabbed R31's breasts. The DON stated she had spoken with the nurse on the unit regarding the 15-minute checks were not feasible and the 15-minute checks were removed after 48 hours on 11/2/24. After the 11/4/24, incident the DON directed staff to provide 1:1 observation and directed the SWD to call for placement in another facility, however, placement was not available. During an interview on 11/5/24 at 8:20 a.m., NA-B stated she was working on 11/4/24, when R39 grabbed R31. NA-B was in a resident room and when she came out of the room, LA-A told NA-B what happened. NA-B stated she did not know if R39 grabbed R31's breasts because she did not see it. When NA-B went into the resident room, R39 was in his room and R31 was really confused and wandering. NA-B immediately went to licensed practical nurse (LPN)-A and told her, but LPN-A was busy, and NA-B reported it to the DON. The DON told NA-B she would take care of it. Staff were doing 30-minute checks and watching the residents. NA-B stated she had to go into the resident room but the door between the dining rooms was open and LPN-A could see into the unit. Since the incident, staff were doing 1:1 observation of R39 and the High-Risk Monitoring form was changed. Staff were supposed to write down what the resident was doing like sleeping, wandering. Things like that. There was also a monitor in R39's room to tell staff when someone went in or out. R39 liked to play bingo and had a fishing game he would play with. R39 liked to vacuum and really enjoyed it. Staff were trying their best to prevent R39 from approaching R31, but R39 was just so fast. During an interview on 11/5/24 at 9:15 a.m., LPN-A stated, since midnight the night before, staff were doing 1:1 observation with R39. Before that, the DON was doing the 1:1 observation. Whoever was assigned to R39 had to always have eyes on R39. It was the only thing that would work. During an interview on 11/5/24 at 10:19 a.m., LA-A stated on 11/4/24, LA-A came onto the unit to get soiled laundry, had gone past R39's room and turned around because LA-A heard R39 moving. It was that quick. R39 went up to R31 from behind and grabbed R31 at the waist with both hands then said rawr like R39 was surprising R31. R31 was startled. LA-A told NA-B right away and then NA-B told LPN-A. LPN-A called and spoke with LA-A about it. The DON nor SWD-A spoke with LA-A about the incident. LA-A stated she did write down the description of the incident but never knew how much to put in those things. LA-A could not be sure if R39 touched R31's breast, it was more like he was trying to surprise R31. LA-A stated NA-B was in a room and R39 was unattended. The facilities Resident Abuse Prohibition Policy dated 6/7/23, identified sexual assault as sexual contact that resulted from threats, force, or the inability of the person to give consent. Sexual abuse was non-consensual sexual contact of any type with a resident, The facility's population may need to include monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as a history of cognitive deficits, sensory deficits, aggressive behaviors, entering other residents rooms, wandering, self-injurious behaviors, verbal outbursts, communication disorders, nonverbal and those residents that required heavy care or totally dependent on staff. In event of suspected maltreatment, the needs of the resident would be immediately assessed and the safety of the resident would be ensured. Immediate steps would be taken to ensure that no resident remained in danger of maltreatment. The resident would be assessed for physical appearance, skin injuries, trauma, or changes in resident affect, mood and behavior, The residents responsible party and physician would be notified as soon as possible. All staff would monitor residents for possible signs of abuse and know how to identify signs and symptoms of abuse. When an incident or suspected incident of abuse was reported, the administrator or designee would investigate the incident which would consist of review of the report, an interview with the person reporting the incident and staff. A review of the resident's medical record and root cause analysis of all circumstances surrounding the incident. The resident or representative would be informed of the progress of the investigation. The investigation would be recorded and attached to the report. The resident and/or representative would be informed of the results of the investigation and corrective action taken. All residents would be protected from the alleged offender. The IJ that began on 9/25/24, was removed on 11/5/24, at 9:09 p.m. when the facility implemented the following immediate interventions; immediately seperated R6 and R31 from R39, referred R39 for psychological assessment, completed a comprehensive behavior assessment for R39, implemented increased supervision of R39, placed alarm outside R39's door, assessed R6 and R39 for psychological support, updated care plans to include safety measures, filed VA reports; and updated their abuse policy to include assessments and individualized interventions; educated staff on sexual abuse; and educated nurses on reporting, assessment and intervention. 40943

Based on interview and document review, the facility failed to provide facility specific abuse prevention training to 5 of 10 employees (DON, RN-E, LPN-C, NA-I, NA-B) reviewed for training. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including abuse. - Registered nurse (RN)-E last complete abuse training 6/27/23. - Licensed practical nurse (LPN)-C last completed abuse training 4/20/23. - Nursing assistant (NA)-I last completed abuse training 2/21/22. - NA-B completed no education in 2024. During an interview on 11/6/24 at 1:09 p.m., RN-C stated she was responsible for staffing training and was aware staff were not compliant with staff education requirements including abuse, neglect, and exploitation training. During an interview on 11/06/24 at 2:17 p.m., the DON stated she was just informed of the need for staff education. The DON believed she only needed to provide her continuing education transcripts when she started her role and did not have log in information until now to complete the assigned education. The DON stated she was informed of the lack of education/training and staff were expected to complete as directed in the facility policy. During an interview on 11/6/24 at 2:18 p.m., the administrator stated staff were expected to complete education as directed by the facility policy. The Facility Assessment 2023 dated 12/18/23, identified staff attend General Orientation upon hire and annually. General Orientation included abuse prevention. A facility policy related to staff training/education was requested but not provided.

Based on interview and document review, the facility failed to ensure staff completed mandatory training for resident rights for 3 of 10 staff (DON, RN-E, NA-A) reviewed for training requirements. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) had not completed staff education including resident rights. - Registered nurse (RN)-E had not completed staff education including resident rights since 9/20/23. - Nursing assistant (NA)-I had not completed staff education including resident rights. During an interview on 11/6/24 at 1:09 p.m., RN-C stated she was responsible for staffing training and was aware staff were not compliant with staff education requirements including resident rights training. During an interview on 11/06/24 at 2:17 p.m., the DON stated she was just informed of the need for staff education. The DON believed she only needed to provide her continuing education transcripts when she started her role and did not have log in information until now to complete the assigned education. The DON stated she was informed of the lack of education/training and staff were expected to complete as directed in the facility policy. During an interview on 11/6/24 at 2:18 p.m., the administrator stated staff were expected to complete education as directed by the facility policy. Facility Assessment 2023 dated 12/18/23, identified staff attend General Orientation upon hire and annually. General Orientation included Resident Rights. A facility policy related to resident rights was requested but not provided.

Based on interview and document review, the facility failed to ensure staff completed mandatory communication training for 4 of 10 staff (DON, RN-E, NA-B, NA-I) reviewed for training requirements. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) had not completed staff education including effective communication. - Registered nurse (RN)-E had not completed staff education including effective communication. - Nursing assistant (NA)-B had not completed staff education including effective communication. - NA-I had not completed staff education including effective communication. During an interview on 11/6/24 at 1:09 p.m., RN-C stated she was responsible for staffing training and was aware staff were not compliant with staff education requirements including effective communication training. During an interview on 11/06/24 at 2:17 p.m., the DON stated she was just informed of the need for staff education. The DON believed she only needed to provide her continuing education transcripts when she started her role and did not have log in information until now to complete the assigned education. The DON stated she was informed of the lack of education/training and staff were expected to complete as directed in the facility policy. During an interview on 11/6/24 at 2:18 p.m., the administrator stated staff were expected to complete education as directed by the facility policy. The Facility Assessment 2023 dated 12/18/23, identified the community surrounding the facility was home to a Laotian community and the facility had served Laotian residents in the past five to ten years. During admission, residents were given the opportunity to make special requests in terms of food, spiritual needs, and cultural considerations. Cultural considerations were included on our care conference agenda and addressed upon admission and quarterly. However, the assessment failed to identify how staff would effectively communicate with a resident that was a non-English native speaker.

Based on interview and document review, the facility failed to assure employee infection control training and education was completed for 4 of 10 (LPN-A, LPN-B, RN-A, DON) staff reviewed for training and education.This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including: dementia care, abuse, resident rights, quality assurance, infection prevention, compliance and ethics, behavior health, and activities of daily living (ADLs). - Registered nurse (RN)-E completed education for resident rights 9/20/23, behavior health 8/3/23, and abuse 6/27/23, but had no further completed education. - Nursing assistant (NA)-I did not complete education regarding effective communication - NA-B completed no education in 2024. During an interview on 11/6/24 at 12:42 p.m., human resources (HR)-A stated she used to assign the annual staff education but registered nurse (RN)-C now assigned assigned the annual training for staff and presented some of the general orientation education. The annual training was according to staff hire date: - RN-E: HR-A stated RN-E hire date was 8/29/13 and was past due for annual training. RN-C assigned annual trainings at the beginning of the staff's anniversary month and a reminder sheet with their log in was put in their box. However, HR-A stated it did not appear that RN-E had annual trainings assigned to RN-E. - DON: HR-A stated the DON did not complete any of the new hire trainings. - NA-I: HR-A stated NA-I's hire dated was 6/27/23. NA-I had no specific dementia training at the time she transferred position from dietary to nursing. NA-I's last dementia training was in 2022. NA-I would have needed extra courses assigned to her that dietary were not assigned. However, HR-A could not determine if any education was assigned to NA-I. - NA-B: HR-A stated NA-B's hire date was 6/28/16 and annual training was assigned to NA-B on 11/9/23. However, NA-B had not completed any training since that time. During an interview on 11/6/24 at 1:09 p.m., RN-C stated she did the general orientation and assigned staff education; which they were behind on. RN-C had missed assigning education for RN-E. RN-C stated she (RN-C) was responsible to follow-up and ensure the education had been done. RN-C had begun her role July 2024 and had not figured out a process to ensure staff had completed education. RN-C the person formerly responsible for it had a spreadsheet but RN-C had not figured out a process yet. It was important for staff to complete education as expected so staff knew how to take care of our vulnerable residents. During an interview on 11/06/24 at 2:17 p.m., the DON stated she was just informed of the need for staff education. The DON believed she only needed to provide her continuing education transcripts when she started her role and did not have log in information until now to complete the assigned education. The DON stated she was informed of the lack of education/training and staff were expected to complete as directed in the facility policy. During an interview on 11/6/24 at 2:18 p.m., the administrator stated staff were expected to complete education as directed by the facility policy. The Facility Assessment 2023 dated 12/18/23, identified staff attend General Orientation upon hire and annually. General Orientation included: - Emergency Preparedness - Abuse Prevention - Vulnerable Adult Reporting - Resident Rights - AWAIR&OSHA - Infection Control, TB, Blood borne pathogens, Emerging Infectious Diseases - Medicare Fraud, Waste & Abuse - Safety Program & Plan - Elder Justice Act - Safe Resident Handling - HIPAA - Trauma Informed Care - QAPI, Survey Preparedness - Compliance & Ethics - Communication - Staff Burnout - Assisted Living [NAME] of Rights - Mechanical Lift Training/Competencies Direct caregivers were provided 8 hours of dementia education upon hire. Non-direct caregivers were provided 4 hours of dementia education upon hire. All staff are provided at least 2 hours of dementia education annually. However, the assessment failed to identify nursing assistants required 12 hours of continuing education annually. A facility policy related to staff training/education was requested but not provided

Based on observation, interview and document review, the facility failed to develop and implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting infections and communicable disease along with a monthly analysis; failed to conduct COVID-19 testing of staff and residents per Centers for Disease Control (CDC) guideline; failed to implement contact precautions and/or enhanced barrier precautions (EBP) for 2 of 2 residents (R7, R30) reviewed with a multi drug resistant organism (MDRO) and chronic wounds; and failed to implement standard precautions while catheterizing 1 of 1 resident (R99) observed to be catheterized. In addition, the facility failed to review and update their infection control policies on an annual bases. These deificient practices had the potential to affect all 46 residents residing in the facility. Findings include: Surveillance: The Monthly Infection Control Log (Line List) September 2024, for Unit A, identified resident name, date of onset, body site, and type of infection, antibiotic start date and type, date resolved and type of isolation. The log identified one resident (R7) with skin infection which was treated with antibiotic. The isolation type initiated and date the infection was resolved was not documented. The log further identified two residents (R7, R5) both who had tested postive for COVID-19 and placed on contact precautions. There were no listed infections or resident infection symptoms which were not treated with antibiotics (i.e. common cold symptoms, viral infections). The facility did not provide an analysis of the infections to include patterns or what interventions were implemented to reduce incidences of further infection. The Monthly Infection Control Log (Line List) September 2024, for Unit B, identified resident name, date of onset, body site, and type of infection, antibiotic start date and type, date resolved and type of isolation. The log failed to identify any resident not treated with an antimicrobial. The log identified three residents (R30, R32, R40,) with skin infections requiring antibiotics, Organisms or culture results were not identified for the wounds. The residents were placed on barrier precautions and date resolved was listed as ongoing. The log further identified one resident (R10) with respiratory infection requiring antibiotic treatment. The resident was placed on precautions and resolved date was recorded. There were no listed infections or resident infection symptoms which were not treated with antibiotics (i.e. common cold symptoms, viral infections). The facility did not provide an analysis of the infections to include patterns or what interventions were implemented to reduce incidences of further infection. The Monthly Infection Control Log (Line List) October 2024, for Unit A, identified resident name, date of onset, body site, and type of infection, antibiotic start date and type, date resolved and type of isolation. The log failed to identify any resident not treated with an antimicrobial. The log identified three residents (R19, R7, R99) with urinary tract infections, one with colonized Methicillin-resistant Staphylococcus Aureus (MRSA), all three requiring antibiotics. Barrier isolation was identified and the infections were listed as ongoing. There were no listed infections or resident infection symptoms which were not treated with antibiotics (i.e. common cold symptoms, viral infections). The facility did not provide an analysis of the infections to include patterns or what interventions were implemented to reduce incidences of further infection. The log failed to identify R7 and R19 signs and symptoms of potential infection (identified below). The Monthly Infection Control Log (Line List) October 2024, for Unit B, identified resident name, date of onset, body site, and type of infection, antibiotic start date and type, date resolved and type of isolation. The log failed to identify any resident not treated with an antimicrobial. The log identified two residents (R32, R43,) with urinary tract infections, with the same organism, requiring antibiotics. Isolation and date resolved was not docuemented. The log further identified one resident (R30) with a wound infection and organism identified as MRSA requiring antibiotic treatment. The log identified a date of resolved infection and that isolation was required, however, did not list type of isolation implemented. There were no listed infections or resident infection symptoms which were not treated with antibiotics (i.e. common cold symptoms, viral infections). The facility did not provide an analysis of the infections to include patterns or what interventions were implemented to reduce incidences of further infection. R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 was [AGE] years of age. Diagnoses included multiple sclerosis, peripheral vascular disease, pulmonary edema and diabetes. R7's nursing progress note dated 10/27/24, identified R7 had nausea and vomiting after supper. R7's medical record failed to identify if any further follow up was completed or if R7 had been placed in isolation. R19's quarterly MDS dated [DATE], identified R19 was [AGE] years of age. Diagnoses included diabetes, hypertension, atrial fibrillation and dementia. R19's nursing progress note dated 10/21/24, identified R19 complianed of not feeling good. R19 was flushed and having difficulty staying awake. Afebrile and tested negative for COVID antigen test. R19's medical record failed to identify in any further follow up was completed or if R19 had a confirmatory COVID-19 test or if R19 had been placed in isolation. There was no documented, provided evidence which demonstrated the facility had a system for tracking non-antibiotic treated infections (i.e. viral infections); nor any evidence demonstrating a comprehensive analysis of the identified infections was completed despite have two UTI with the same causative organism. Further, there was no provided evidence the facility had reviewed or investigated the developed infections for potential causes and addressed any subsequent action needed to reduce the risk of recurrence to the same and/or other resident(s). When interviewed on 10/31/24, at 3:00 p.m. registered nurse (RN)-A stated she had not been tracking or trending resident or staff illness/symptoms. The nurse responsible for infection control quit in September and RN-A had not taken the program over until about two weeks ago. RN-A was trying to get resident antibiotic use logged and tracked and had not started on tracking resident or employee symptoms of illness or infection. RN-A told the director of nursing (DON) the facility should be tracking when a resident had diarrhea or a fever, but RN-A had not been able to get tracking of infections implemented. The facility was using an infection control program called Peerlytics, but RN-A was unable to access that program. The facility was working on getting RN-A access to the computerized infection control program. - RN-A was not tracking employee illness and only recorded when staff called in with positive COVID-19. The facility did not require confirmation of test results when employees reported symptom of illness. RN-A stated it would be important to track other illness in both staff and residents to determine the source of illness and track if it could spread. RN-A just did not have the time and had only recently taken the infection preventionist role. The facility did not isolate residents for symptoms of illness. Residents were only isolated if they tested positive for COVID-19. RN-A felt the residents all had a private room and so were kind of isolated anyway. If a resident exhibited symptoms such as a cough, fever, or diarrhea the facility did not isolate them and did not require staff to wear personal protective equipment (PPE) when providing care to symptomatic residents. RN-A supposed some of the symptom's residents exhibited should require some PPE, but the facility did not direct staff to wear PPE when residents exhibited symptoms of illness. Staff should wear PPE when caring for residents with potentially contagious symptoms. Staffing took up so much of RN-A's time, there was only so much a person could do. RN-A was just trying to get what she could done. At this time, the surveillance and analysis of the facility's infection prevention and control program was requested. During interview on 10/31/24, at 2:40 p.m. the DON stated tracking and trending of resident and employee illness should be done and it was not currently being completed. The tracking and trending of illness was important so the facility could quickly recognize when they had a problem. The facility should be isolating and implementing PPE with any resident that was noted with infectious type of symptoms such as cough, fever, or diarrhea. The facility's policy Infection Control Surveillance with revision date 4/4/24, identified infection prevention began with ongoing surveillance to identify infections that were causing or have the potential to cause an outbreak. The facility would establish routine, ongoing and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections, infection risks, communicable disease outbreaks, and to maintain or improve resident health status. The facility nurses would identify residents with symptoms or identified infections and complete a wait and watch in Peerlytics and in the residents' medical record, documenting the signs and symptoms the resident was exhibiting. The infection preventionist would be alerted to identify any necessary interventions and add to Peerlytics for follow up and data collection. The infection preventionist would utilize the information to monitor infection sit, type, pathogen if known, signs and symptoms and resident location to identify trends or clusters for action. COVID-19 Testing: Centers for Disease Control (CDC) website Infection Control Guidance: SARS-CoV-2 (COVID-19) dated 6/24/24, identified a single new case of COVID-19 infection in any health care provider (HCP) or resident should be evaluated to determine if others in the facility could have been exposed. Perform testing for all residents and HCP identified as close contacts or on the affected unit. Testing was recommended at day 1, day 3 and day 5, where day of exposure is day 0. If additional cases were identified, testing should continue on affected units or facility-wide every 3 to 7 days until there were no new cases for 14 days. A facility Employee COVID Line List Spread Sheet for months of September and October 2024 identified employee name, age, sex, onset date, positive testing collection date, day one isolation, day 7 test result, day 10 test result and date return to work. The spread sheet identified eight employees with onset positive dates which included: maintenance (maint)-A on 9/22/24, housekeeper (HSK)-A on 9/25/24, cook (CK)-A on 9/26/24, the director of nursing (DON) on 9/26/24, nursing assistant (NA)-F on 9/26/24, registered nurse (RN)-D on 9/27/24, NA-B 10/14/24 and care coordinator (CC)-G on 10/27/24. A facility Resident COVID Line List Spread Sheet for the month of September 2024 identified resident name, age, sex, onset date, positive testing collection date, day one isolation, day 7 test result, day 10 test result and date out of isolation. The spread sheet identified two resident names with positive test results; R5 on 9/24/24 and R7 on 9/25/24. A facility October calendar listed resident testing dates for all units on 10/2/24, 10/4/24, 10/7/24, 10/9/24, 10/11/24. Residents who resided on unit A were tested on [DATE] due to an exposure with NA-B on 10/14/24, however, the facility failed to continue COVID-19 testing day 3 and day 5 to determine if there were any additional positive cases as required. Unit A residents were tested again on 10/28/24 due to an exposure with CC-G on 10/27/24, however, the facility failed to continue COVID-19 testing day 3 and day 5 to determine if there were any additional positive cases as required. On the bottom of the calendar it was indicated any other resident testing would be done randomly with any resident that exhibited symptoms and not every three to seven days until no further new cases were identified as required. The facility documented when testing occured on resident units, the facility failed to track which residents were tested and results of individual tests. The facility documented positive employees COVID-19 test results when the tests results were reported by the employee. The facility failed to produce evidence of any employee testing. The facility failed to track and document which employees tested , when and how the employees tested as well as employee COVID-19 test results. Furthermore, the facility failed to track and document if employees tested and/or results of COVID-19 testing prior to working their scheduled shifts . The testing of residents was not completed on day 1, day 3 and day 5, after a known exposure from a positive staff members 10/14/24 and 10/28/24, as required. Nor did testing occur every three to seven days until no further additional staff or residents tested positive for COVID-19. During interview on 10/29/24, at 9:30 a.m. RN-A stated she did not have documentation of residents testing or testing results other than individual entries in each resident's chart that were tested . RN-A was unable to identify exactly which residents had tested without going into each individual resident medical record and was unable to identify if any residents had refused or were absent when COVID-19 testing was conducted. RN-A stated she thought the facility was in outbreak when three employees all tested positive on 9/26/24, despite having been notified an employee (maintenace (maint)-A) had tested positive on 9/22/24, after working the day prior. RN-A instructed all employees to test when the facility was in outbreak, however did not track or record which employees tested or their results. The facility continued testing all residents and employees were reminded to test for COVID-19 until 10/12/24. RN-A felt, because the facility had not had any further positive COVID-19 test results since 9/27/24, the facility completed outbreak testing and were out of outbreak status on 10/12/24. On 10/14/24, NA-B reported fatigue, sore throat and a positive COVID-19 test. NA-B had worked the weekend (10/12/24 & 10/13/24) prior to positive test result on 10/14/24. RN-A did not conduct or record any formal contact tracing, other than review of where NA-B had been scheduled. RN-A felt only residents on unit A had been exposed to NA-B, because that was the unit NA-B was scheduled, so RN-A tested all residents on unit A on 10/15/24. RN-A had instructed staff to test if they knew they had exposure to NA-B, however, did not track or document which staff had contact with NA-B and/or tested . RN-A felt staff would know if they had an exposure and test accordingly. RN-A did not do formal contact tracing of who NA-B had contact with when she worked on 10/13/24 and 10/14/24, prior to having symptoms of fatigue and sore throat on 10/14/24, and positive test result. All residents on unit A tested negative for COVID-19 on 10/15/24, and no further testing was conducted. RN-A did not know why testing exposed residents was not completed on day 3 and day 5 of exposure as required. RN-A did not conduct contact tracing on employees who may have been exposed to NA-B and did not know which employees had tested when NA-B had reported positive on 10/14/24. RN-A stated CC-G reported nausea, vomiting, headache and positive COVID-19 test result on 10/27/24. RN-A did not conduct or record any formal contact tracing, other than review of where CC-G had been scheduled. RN-A felt only residents on unit A had been exposed to CC-G, so RN-A tested all residents on that unit on 10/28/24. All residents on unit A tested negative for COVID-19 on 10/28/24, and no further testing was conducted. RN-A did not know why testing exposed residents was not completed on day 3 and day 5 of exposure as required. RN-A did not conduct contact tracing on employees who may have been exposed to CC-G and did not know which employees had tested when CC-G had reported positive on 10/28/24. RN-A felt staff would know if they had an exposure and test accordingly. RN-A could not say if all staff were tested prior to starting their shift, even during the outbreak. RN-A had given all staff instructions via communication email, to test prior to their shift and so all staff were aware they needed to test. Tracking or documentation of staff testing had not been completed to ensure testing had been completed, other than documentation of the positive tests that were reported to RN-A. Employees were not required to provide proof of testing When interviewed on 10/31/24, at 2:30 p.m. the DON stated staff testing should have been tracked to keep the transmission of COVID-19 to a minimum and to keep residents safe. All testing for COVID-19 should have been documented. The facility's Long Term Care and Assisted Living Response Plan for COVID-19 Testing, approved 9/1/20, identified an outbreak and testing trigger as one or more residents confirmed to have COVID-19, a direct care staff member who tested positive for COVID-19 and worked in the facility while ill or 48 hours prior to development of symptoms or a symptomatic resident who has tested negative. MDH and CDC would be consulted for current recommendations for the particular disease epistemology at the time that testing was considered. The infection preventionist would ensure that records were maintained regarding the testing process, resident and staff consent for testing and test results. 40943 Contact/Enhanced Barrier Precautions: R7's significant change MDS dated [DATE], identified R7 had severe cognitive imairment R7 had two stage 3 pressure ulcers and had a suprapubic indwelling urinary catheter (a tube that drains from your bladder through a small incision in your abdomen). The MDS failed to identify R7 had an MDRO. Diagnoses included multiple sclerosis (MS), type 2 diabetes, history of UTI, and peripheral vascular disease. R7's care plan revised 8/9/24, identified R7 had an activities of daily living self-care performance deficit due to weakness related to MS. The care plan directed staff to provide assist of 1-2 for repositioning, dressing, grooming, and toileting/catheter care. However, the care plan failed to address R7's need for contact precautions or enhanced barrier precautions (EBP). R7's Physical Therapy Skilled Nursing Facility Treatment Note dated 9/12/24, identified R7 had an open wound on her right ischial tuberosity and had an increased risk of infection. Precautions/Restrictions: methicillin-resistant staphylococcus aureus (MRSA). During an observation on 10/29/24 at 10:17 a.m., nursing assistant (NA)-B was providing morning cares for R7. There was a 3-drawer plastic bin outside of R7's door containing gowns, gloves, facemasks and face shields. No signage was on R7's door directing staff what personal protective equipment (PPE) was required or when it was required. R7's catheter bag was uncovered and lying on the floor. NA-B did not apply a gown or gloves and stated the only time she needed to do so was if she was emptying R7's urinary catheter bag because pee could get on me. Wearing gowns and gloves for catheters was something new, but NA-B could not remember what it was called. No one had ever explained why sometimes staff needed to wear personal protective equipment (PPE) and it was something staff never did before. It's just something to be 'extra'. It doesn't make sense but there's so many by-the-book rules in nursing homes. The bag touching the floor was overkill. To tell you the truth, in a nursing home, care was never going to be perfect and just too much was expected. NA-B could not explain what an MDRO was and/or if R7 was known to have a history of MRSA. During an observation on 10/29/24 at 12:23 p.m., NA-C assisted R7 to the toilet using the ceiling lift. NA-C did not don a gown and gloves. - At 12:28 p.m., NA-C put on gloves and pulled down R7's pants, then lowered R7 onto the toilet. NA-C then hung R7's catheter bag from the toilet handrail. - At 12:29 p.m., R7's catheter bag fell on to the floor. NA-C picked up the bag and again hung it from the toilet handrail. I don't know if it will hang there or not. NA-C did not clean R7's catheter bag. NA-C did not remove her soiled gloves and was touching scrubs and high touch areas in the bathroom. - At 12:33 p.m., NA-C straightened R7's pillows and bed linens. NA-C continued to wear the same soiled gloves. - At 12:35 p.m., NA-C raised R7 off the toilet and pulled up R7's pants. NA-C stated R7 didn't have a bowel movement so did not need wiping. NA-C continued to wear the same gloves. NA-C transferred R7 to bed using the ceiling lift and continued touching high touch areas with the same soiled gloves. During an interview on 10/29/24 at 12:23 p.m., NA-C stated you only need to wear a gown when you empty R7's catheter. That's it. NA-C stated she wore gloves, but the 3-drawer bin outside R7's room was left over from when R7 had COVID-19 in previous weeks. Someone just forgot to take it away. NA-C stated she was unaware if R7 had a history of a MRSA or any type of infection. NA-C stated she had never been told why sometimes staff wore PPE and other times they didn't need to. During an interview on 10/29/24 at 10:39 a.m., licensed practical nurse (LPN)-A could not recall what EBP was called or when it was required but only staff needed to wear a gown when doing anything with the catheter. I don't know why but that's what we were told. It started about a year ago, when staff needed to wear a gown when doing anything with a wound and/or a catheter. Staff were given a bunch of papers to review. LPN-A stated she asked for a simple explanation and not a stack of papers because it was just too much to understand, but LPN-A was told it's just the rules. That was just it. Staff should be wearing a gown and gloves every time they're in R7's room because we're supposed to. That's just what staff were told. During an observation on 10/30/24 at 7:42 a.m., NA-B did not gown or glove and entered R7's room to answer R7's yell for help. NA-B stated she did not gown or glove because she was told she only needed to do that if she was doing catheter care, but now that's changed. I don't know what I'm supposed to do now. NA-B pointed to R7's 3 drawer plastic bin that contained PPE and stated, I really don't know what that's about. NA-B stated she had not received any education regarding infection prevention precautions. You're my education. During an interview on 10/30/24 at 9:14 a.m., LPN-A stated anytime staff go into R7's room and provide care, staff were supposed to wear a gown. We need to work on that. LPN-A stated R7 had MRSA in her (R7) wounds. LPN-A could not explain the different types of precautions: standard, contact, droplet, and/or EBP. LPN-A became tearful and stated staff did not receive education. It started at the top and never trickled down to staff on the floor. We're not safe. During an interview on 10/31/24 at 1:10 p.m., registered nurse (RN)-A stated she took over the role of facility infection preventionist two weeks prior for the duration of her contract. I inherited this. Staff needed education regarding precautions. Any resident with a catheter or a wound (because there could also be an unknown organism) needed Enhanced Barrier Precautions (EBP). However, RN-A did not have a listing of residents with a known MDRO, a wound or a catheter. RN-A went room to room to look for a catheter. I just know. For MDRO, staff wouldn't know that unless they went digging in the charts. RN-A had just found out the other day R7 was colonized with MRSA and should be on Contact Precautions. Well, I guess staff did need to dig in charts. You know you are asking me for information. I find it hard to I know I'm accountable for speaking for the previous IP nurse. Staff were expected to follow Centers for Disease Control and Prevention (CDC) guidance to prevent the spread of infection. During an interview on 10/31/24 at 2:18 p.m., the director of nursing (DON) stated staff were expected to follow CDC precautions guidance for donning/doffing PPE per facility policy and to demonstrate understanding of infection control to prevent the spread of microorganisms in the facility to prevent possible infections. 40948 R30's admission MDS dated [DATE], identified R30 was cognitively intact and had a stage 3 pressure ulcer with a multi-drug resistant organism (MDRO). R30's care plan dated 10/1/24, identified Methicillin-resistant Staphylococcus aureus (MRSA) (an infection which is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections. A type of MDRO) Intervention included contact isolation(precautions): wear gown, gloves and mask when providing any cares. Mask or face shield to be worn during procedures. The care plan did not address EBP for having a chronic wound. R30's provider's order dated 9/26/24, identified dressing change to right residual limb (the limb with stage 3 pressure ulcer and MRSA): cleanse with wound cleaner, Aquacel ribbon (a wound dressing that absorbs wound fluid and creates a moist environment to help wounds heal) lightly packed into wound bed and cover with a large Tegaderm foam (a highly absorbent, breathable wound dressing). During observation on 10/29/24 at 10:19 a.m., there was a sign on R30's door identifying resident was on contact precautions. An isolation cart was located outside her door and held gowns, gloves, face masks, and eye protection. During an interview on 10/29/24 at 12:40 p.m., nursing assistant (NA)-A stated R30 was on contact precautions and whenever NA-A would go into the room to assist the resident with cares, bed mobility, transfers, toileting or changing linens NA-A would wear a gown and gloves to help. During observations on 10/30/24 at 8:43 a.m., physical therapy assistant (PTA)-A approached R30's room and took gloves from the isolation cart outside of the door. PTA-A then entered the room without putting on gloves. PTA-A gathered the supplied for the dressing change and prepared them for the dressing change. With the ungloved hands, PTA-A removed the ace bandage, lymph wrap (a wrap for legs to offer management of swelling and surgical areas) and stump sock (a compression stocking placed on a recently amputated limb). PTA-A then sanitized her hands and put gloves on and removed the final dressing over the wound. The bandage had some red drainage on it and the surgical site wound had a pencil eraser size hole with a small amount of purulent (pus) drainage. Wearing the same gloves, she cleaned the wound with saline spray and a 4 x 4 gauze dressing. PTA-A then removed the gloves and sanitized her hands. PTA-A took a cell phone from her pocket and took a picture of the wound for R30's chart and then placed the cell phone directly on R30's bed. PTA-A then sanitized her hand and placed clean gloves on. PTA-A then placed iodoform gauze (an antiseptic), then covered with an Aquacel dressing (a dressing to help contain drainage) and then placed foam dressing over the wound. PTA-A then removed the dirty gloves and sanitized her hands and gathered the remaining supplies and put them away in R30's room and placed the cell phone in her bag and then sanitized her hands. - At 9:00 a.m., PTA-A was finished with the dressing change and proceeded to work on exercises with R30 without wearing gloves. Exercises included marching in place while sitting on the edge of the bed by lifting her knees. Then asked resident to kick out with amputated limb and was placing ungloved hand on the dressing she just changed. PTA-A then rubbed her hands together and placed them on the outside of each knee and had R30 push against her hands. PTA-A then moved to the inside of the knees and did the same. A gait belt was then placed on R30 and with a walker PTA-A assisted R30 to stand while she held the gait belt and walker with her ungloved hands. R30 then proceeded to exercise her amputated limb. PTA-A was standing by R30 with on ungloved hand on the gait belt and one on the walker and did that exercise twice. R30 was then seated on the edge of her bed and repeated the initial exercises done with ungloved hands, which included placing the ungloved hands on the dressing which was just changed. When finished with the exercises PTA-A with her ungloved hands rolled up the Ace bandage which was originally wrapped around the amputated limb at the beginning of the observation. PTA-A then sanitized her hands and left the room. PTA-A did not wear a gown at any time during the encounter. During an interview on 10/30/24 at 7:56 a.m., PTA-A stated she seen the sign on door indicating contact precautions and knew it was for an infection in the wound. Since it had been mostly contained, she had been only wearing gloves during the dressing changes and was unsure of why a gown would be needed. PTA-A stated nobody reviewed contact precautions, and the only times a gown was worn is if wounds were worse than R30's, if the resident had a catheter or covid. R30 was on contact precautions, and she should probably have been wearing a gown and gloves. During and interview on 10/31/24 at 12:50 a.m., RN-A stated residents who were colonized with MDRO in urine and had a catheter or had an MDRO in a wound would be expected to be on contact precautions. Meaning any staff doing close contact cares, bed mobility, or dressing changes with a resident on contact precautions would be wearing a gown and gloves. The importance of contact precautions is to protect the resident on any infections that staff my unknowing bring into the room, and to protect the staff and other resident after contact with infected resident. R30 was on contact precautions for a MDRO in a wound on her leg and would expect all staff to follow contact precautions. During an interview on 10/31 24 at 1:07 p.m., the DON stated it was the expectation that all staff would follow infection control policies, and this included contact precautions. This was to protect the resident on contact precautions and all the other residents in the building. The facility's Transmission Based Precautions policy dated 4/4/24 identified contact precautions were intended to prevent transmission of infections and require the use of gown and gloves upon entering the room. The facility's Multidrug Resistant Organisms (MDROs) policy dated copyright 2009 identified contact precautions shall be considered for residents infected or colonized with a MDRO. 42075 Standard Precautions: R99's admission MDS dated [DATE], identified R99 had moderate cognition and required intermittent catheterization. Diagnoses included neurogenic bladder, Alzheimer's disease, and dementia. R99's physician notes dated 10/17/24, identified R99 performed catheterization by himself as needed to empty his bladder. R99's care plan dated 10/22/24, failed to identify R99's catheterization plan and goals including what personal protective equipment was needed. R99's medication administration report (MAR) dated 10/1/24 through 10/31/24, identified staff were required to perform catheterization for R99 every shift or as requested by the resident due to the resident's neuromuscular dysfunction of the bladder. On 10/29/24 at 10:17 a.m., R99 was seated in a wheelchair in his room. R99 stated he used a catheter to empty his bladder due to being unable to urinate on his own. Staff used gloves but did not wear gowns when catheterizing him. On 10/30/24 at 1:30 p.m., registered nurse (RN)-A stated when providing direct cares for R99, including being straight cathed, staff were required to wear a gown and gloves. On 10/30/24 at 1:55 p.m., licensed practical nurse (LPN)-A stated R99 required staff to use a straight catheter to empty

Based on interview, and document review, the facility failed to develop, monitor, and evaluate their identified performance measures. This had the potential to affect all 46 residents residing in the facility. Findings include: The February QAPI Education Report dated 3/8/24, identified staff education compliance was at 72.8%, however, the report failed to identify actions taken to increase compliance. The Quality and Safety Meeting (Quarter 1 Data) dated 4/15/24, identified the QAPI team reviewed the following topics: - Emerging infectious disease - Staff influenza vaccination program - Emergency preparedness - Environmental services - Minnesota Pollution Control Agency (MPCA) - Skilled nursing safety report (Casper, MDS, QIIP) - Safe resident handling - Consultant pharmacist report - PIP discussion. The data failed to identify the facility developed and implemented action plans with measurable goals and/or identify actions taken. The Quality and Safety Meeting (April Data) dated 5/20/24, identified the QAPI team reviewed the following topics: - Emerging infectious disease - Staff influenza vaccination program - Emergency preparedness - Environmental services - Housing Report - Social Services Report - Employee incidents The data failed to identify the facility developed and implemented action plans with measurable goals and/or identify actions taken. The Quality and Safety Meeting (May Data) dated 6/17/24, identified the QAPI team reviewed the following topics: - Emerging infectious disease - Staff influenza vaccination program - Emergency preparedness - Environmental services - Housing Report - Social Services Report - Skilled Nursing Safety Report - Safe resident handling: Annual Safe Resident Handling Assessment completed on 5/15/24, poor attendance. NAR meetings will start being held on the 2nd Wed of each month at 1:30 p.m. and 3:00 p.m. and the following Thurs at 7:00 a.m. to accommodate night shift. These meetings are part of the Safe Resident Handling policy. Follow-up from previous meeting: lock-out-tag-out policy was going to be reviewed (r/t [NAME] Steady lift had loose hardware). Update: Lock-out/Tag-out policy is primary designed for electrical equipment. Will be reviewing policies including equipment maintenance policies to ensure that protocols were in place for equipment such as the [NAME]-Steady lifts. - Consultant pharmacy resport - PIP discussion The data failed to identify the facility developed and implemented action plans with measurable goals and/or identify actions taken. The QAPI Meeting Minutes dated 8/12/24, identified the following: - Falls- 26 falls documented in the month of July. PIP written and reviewed on 4/15/24 for fall reduction. PIP was ongoing and continued to be implemented. The fall committee initiated weekly meetings along with the introduction of the Falling star program and policy the week of 8/1/24. 13 less falls identified than the previous 60 days. - Resident Council- held 7/3/24 - All concerns have been communicated and completed. - Grievances - No formal family or resident in the month of July - Resident Quality of Life/Nursing Home report card-addressed with team and will continue in the month of August The data failed to identify the facility developed and implemented action plans with measurable goals and/or identify actions taken. The Facility Assessment 2023 dated 12/18/23, revealed the facility had identified the need to develop and implement policies and procedures for the provision of care and the following areas of concern were identified: - Staff turnover rate: YTD as of December 11, 2023 was 22.95%. Turnover had declined from one year ago when it was 24.44%. Staff will continue to work on creating a great culture and sufficient staffing levels in all areas to be able to hire and keep good people on our team. We are impacted by the current labor shortages as well as students both leaving for and returning to school. Our goal was to reduce our number to approach 20%. However, the assessment failed to identify interventions to improve the staff turnover rate nor how to ensure safe resident care was provided. - An Infection Prevention Risk Asscssmenl is completed annually, which guides infection prevention improvements. APIC's Infection Preventionists Guide to Long [NAME] Care and the Centers for Disease Control are the primary resources that guide our Infection Prevention Program. The facility was registered with NHSN. Covid-19 reporting was being done. However, the facility assessment failed to identify changes in guidance related to Enhanced Barrier Precautions (EBP) and/or staff education needs related to infection prevention. During an interview on 11/06/24 at 1:53 p.m., the administrator stated he was a contracted interim administrator and began his role at the facility on 10/9/24. The facility had undergone several administration changes since the previous survey and the administrator had been told the facility held a QAPI meeting in July or August but he could not find any data that reflected that. The administrator did find an agenda but nothing substantial that reflected how the facility was working towards improvement. The administrator stated he was unsure what happened to the facility files because even common items were missing. The QAPI plan should be reviewed at the end of every QAPI meeting and PIP discussed as well. Does it need to be changed? Is there improvement and, if not, why? The administrator expected staff to report concerns to discuss during QAPI, the minutes to reflect work done and to work towards improvement. The facility Quality Assurance Performance Improvement Plan dated 2/24/17, identified the written QAPI plan provided guidance for the overall quality improvement program. Quality assurance and performance improvement principles w drive the decision making within our organization. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions. Focus areas will include all systems that affect resident and family satisfaction, quality of care and service provided, and all areas that affect the quality of life for persons living and working in our organization. The executive director will assure that the QAPI plan is reviewed minimally on an annual basis by the QAA committee. Revisions will be made to the plan ongoing, as the need arises, to reflect current practices within our organization. These revisions will be made by the QAA committee. Revisions to the QAPI plan will be communicated as they occur to board members, residents, families, and staff through meetings and newsletters as deemed appropriate by the QAA committee. A project charter will be developed for each PIP at the beginning of the project that clearly establishes the goals, scope, timing, milestones, team roles, and responsibilities. The PIP charter will be developed by the QAA committee and then will be given to the team that will carry out the PIP. For ongoing monitoring of the PIP, we will use the CMS PIP Inventory to include milestones, PDSAs, outcomes, and other lessons learned from the PIP. Information about PIPs will be shared via our quality improvement dashboard, quarterly newsletter provided to all residents, families, and staff, and discussed during the QAPI agenda items on all staff, resident, and family monthly meetings.

Based on interview, and document review, the facility failed to develop and implement appropriate plans of action to correct quality deficiencies identified during the survey that the facility was aware of or should have been aware. This had the potential to adversely affect all 46 residents residing in the facility. Findings include: See also F600: The facility failed to ensure 1 of 1 resident (R39) with known sexual behaviors towards others was comprehensively assessed and interventions implemented to mitigate risk to others and prevent ongoing sexual abuse for 2 of 2 residents (R31, R6) who were cognitively impaired and dependent on staff for their care and were sexually abused by R39. See also F689: The facility failed to ensure staff were following care planned interventions when transferring residents with a ceiling lift; and complete therapy/or nursing assessments to determine the appropriate sling sizes per manufacturers guidelines for 3 of 4 residents (R12, R7, R2) to ensure resident and staff safety. These deficient practices resulted in immediate jeopardy for R12, R7 and R2 but had the potential to affect all 12 residents who used ceiling lifts. See also F880: The facility failed to develop and implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting infections and communicable disease along with a monthly analysis; failed to conduct COVID-19 testing of staff and residents per Centers for Disease Control (CDC) guideline; failed to implement contact precautions and/or enhanced barrier precautions (EBP) for 2 of 2 residents (R7, R30) reviewed with a multi drug resistant organism (MDRO) and chronic wounds; and failed to implement standard precautions while catheterizing 1 of 1 resident (R99) observed to be catheterized. In addition, the facility failed to review and update their infection control policies on an annual bases. These deificient practices had the potential to affect all 46 residents residing in the facility. See also F725: The facility failed to provide sufficient staff to transfer residents in lifts according to their care plan for 3 of 4 residents (R12, R7, R2); failed to provide appropriate supervision to mitigate resident-to-resident abuse for 2 of 2 (R31, R6) residents abused by 1 of 1 residents (R39) reviewed for abuse: failed to provide sufficient staff to complete range of motion for 4 of 4 residents (R7, R19, R22, R43) reviewed for restorative therapy. In addition, 4 of 46 residents (R7, R30, R25, R34,) 10 of 10 staff members (RN-A RN-B, NA-D, LPN-A, NA-C, NA-A, SWD, RT-A, NA-H, DON); 1 of 3 family members (FM-A) voiced concerns of lack of sufficient staffing in the facility. The lack of sufficient staffing had the potential to affect all 46 residents in the facility. The Facility Assessment 2023 dated 12/18/23, identified the facility had identified the need to develop and implement policies and procedures for the provision of care and the following areas of concern were identified: - Staff turnover rate: YTD as of December 11, 2023 was 22.95%. Turnover had declined from one year ago when it was 24.44%. Staff will continue to work on creating a great culture and sufficient staffing levels in all areas to be able to hire and keep good people on our team. We are impacted by the current labor shortages as well as students both leaving for and returning to school. Our goal was to reduce our number to approach 20%. However, the assessment failed to identify interventions to improve the staff turnover rate nor how to ensure safe resident care was provided. - An Infection Prevention Risk Asscssmenl is completed annually, which guides infection prevention improvements. APIC's Infection Preventionists Guide to Long [NAME] Care and the Centers for Disease Control are the primary resources that guide our Infection Prevention Program. The facility was registered with NHSN. Covid-19 reporting was being done. However, the facility assessment failed to identify changes in guidance related to Enhanced Barrier Precautions (EBP) and/or staff education needs related to infection prevention. The February QAPI Education Report dated 3/8/24, identified staff education compliance was at 72.8%, however, the facility could not provide evidence actions were taken to increase compliance. The Quality and Safety Meeting (Quarter 1 Data) dated 4/15/24, identified a table of QAPI team reviewed topics: emerging infectious disease, staff influenza vaccination program, emergency preparedness, environmental services, Minnesota Pollution Control Agency (MPCA), skilled nursing safety report (Casper, MDS, QIIP), safe resident handling, consultant pharmacist report, and performance improvment project (PIP) discussion. The data failed to identify goals and measurable actions taken regarding abuse, staffing concerns, accidents and/or infection prevention. The Quality and Safety Meeting (April Data) dated 5/20/24, identified a table of QAPI team reviewed topics: emerging infectious disease, staff influenza vaccination program, emergency preparedness, environmental services, Minnesota Pollution Control Agency (MPCA), skilled nursing safety report (Casper, MDS, QIIP), safe resident handling, consultant pharmacist report, and performance improvment project (PIP) discussion. The data failed to identify goals and measurable actions taken regarding abuse, staffing concerns, accidents and/or infection prevention. The Quality and Safety Meeting (May Data) dated 4/15/24, identified a table of QAPI team reviewed topics: emerging infectious disease, staff influenza vaccination program, emergency preparedness, environmental services, Minnesota Pollution Control Agency (MPCA), skilled nursing safety report (Casper, MDS, QIIP), safe resident handling, consultant pharmacist report, and performance improvment project (PIP) discussion. The data failed to identify goals and measurable actions taken regarding abuse, staffing concerns, accidents and/or infection prevention. The Annual Safe Resident Handling Assessment completed on 5/15/24, idendentified poor attendance. NAR meetings would start being held on the 2nd Wed of each month at 1:30 p.m. and 3:00 p.m. and the following Thurs at 7:00 a.m. to accommodate night shift. The meetings were part of the Safe Resident Handling policy. Follow-up from previous meeting: lock-out-tag-out policy was going to be reviewed (r/t [NAME] Steady lift had loose hardware). Update: Lock-out/Tag-out policy is primary designed for electrical equipment. Will be reviewing policies including equipment maintenance policies to ensure that protocols were in place for equipment such as the [NAME]-Steady lifts. The data failed to identify goals and measurable actions taken for staffing concerns, accidents and/or infection prevention and no further data was provided regarding the NAR meeting attendance. The QAPI Meeting Minutes dated 8/12/24, identified the following: - Falls- 26 falls documented in the month of July. PIP written and reviewed on 4/15/24 for fall reduction. PIP was ongoing and continued to be implemented. The fall committee initiated weekly meetings along with the introduction of the Falling star program and policy the week of 8/1/24. 13 less falls identified than the previous 60 days. - Resident Council- held 7/3/24 - All concerns have been communicated and completed. - Grievances - No formal family or resident in the month of July - Resident Quality of Life/Nursing Home report card-addressed with team and will continue in the month of August. The data failed to identify goals and measurable actions taken regarding abuse, staffing concerns, accidents and/or infection prevention. During an interview on 11/06/24 at 1:53 p.m., the administrator stated he was a contracted interim administrator and began his role at the facility on 10/9/24. The facility had undergone several administration changes since the previous survey and the administrator had been told the facility held a QAPI meeting in July or August but he could not find any data that reflected that. The administrator did find an agenda but nothing substantial that reflected how the facility was working towards improvement. The administrator stated he was unsure what happened to the facility files because even common items were missing. The QAPI plan should be reviewed at the end of every QAPI meeting and PIP discussed as well. Does it need to be changed? Is there improvement and, if not, why? The administrator expected staff to report concerns to discuss during QAPI, the minutes to reflect work done and to work towards improvement. The facility Quality Assurance Performance Improvement Plan dated 2/24/17, identified the written QAPI plan provided guidance for the overall quality improvement program. Quality assurance and performance improvement principles w drive the decision making within our organization. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions. Focus areas will include all systems that affect resident and family satisfaction, quality of care and service provided, and all areas that affect the quality of life for persons living and working in our organization. The executive director will assure that the QAPI plan is reviewed minimally on an annual basis by the QAA committee. Revisions will be made to the plan ongoing, as the need arises, to reflect current practices within our organization. These revisions will be made by the QAA committee. Revisions to the QAPI plan will be communicated as they occur to board members, residents, families, and staff through meetings and newsletters as deemed appropriate by the QAA committee. A project charter will be developed for each PIP at the beginning of the project that clearly establishes the goals, scope, timing, milestones, team roles, and responsibilities. The PIP charter will be developed by the QAA committee and then will be given to the team that will carry out the PIP. For ongoing monitoring of the PIP, we will use the CMS PIP Inventory to include milestones, PDSAs, outcomes, and other lessons learned from the PIP. Information about PIPs will be shared via our quality improvement dashboard, quarterly newsletter provided to all residents, families, and staff, and discussed during the QAPI agenda items on all staff, resident, and family monthly meetings.

Based on interview and document review, the facility failed to develop a policy and procedure defining the responsibilities of the medical director and ensure the medical director assisted in the implementation and guidance of resident care policies, and coordination of resident medical care in the facility. This had the potential to impact all 46 residents who resided in the nursing home at the time of the survey. Findings Include: During an extended survey, on 11/6/24, a medical director (MD) policy and the MD's job description and/or contract was requested; however, these items were not provided. During a telephone interview on 10/30/24 at 2:36 p.m., MD stated he was at the facility twice per month. Once to do residents rounds and the other was for paperwork; signing orders etc. The MD attended quality meetings as well. The MD was informed of staffing concerns; however, he was not in control of staff. The MD provided medical care to the residents, and he did review resident incident reports such as falls as well. During an interview on 11/6/24 at 2:18 p.m., the administrator stated he was a contracted interim administrator and began his role at the facility on 10/9/24. The facility had undergone several administration changes since the previous survey, and he was unable to find the MD job description and/or policy related to the MD's responsibilities at the facility. The administrator stated he expected the facility to have all the required policies and/or job descriptions. No further information was provided.

Based on interview and document review, the facility failed to update the facility assessment when changes occured to ensure an effective plan was in place to maintain the highest practicable care for residents. This had the potential to affect all 46 residents residing at the facility. Findings include: During the course of the survey conducted on 10/28/24 through 11/6/24, an immediate jeopardy level deficiency was identified related to a resident (R39) who had known inappropriate sexual behaviors and the facility's failure to conduct comprehensive assessments and implement interventions to mitigate risk to others and to prevent ongoing sexual abuse for 2 of 2 residents (R31 and R6) who were cognitively impaired and dependent on staff for their care and were sexually abused by R39 (See F600). During the course of the survey conducted on 10/28/24 through 11/6/24, an immediate jeopardy level deficiency was identified related to the facility failed to ensure staff were following care planned interventions when transferring residents with a ceiling lift; and complete therapy/or nursing assessments to determine the appropriate sling sizes per manufacturers guidelines for 3 of 4 residents (R12, R7, R2) to ensure resident and staff safety. These deficient practices resulted in immediate jeopardy for R12, R7 and R2. The Facility Assessment 2023 dated 12/18/23, included the facility identified the need to develop and implement policies and procedures for the provision of care and the following areas of concern were identified: - Staff turnover rate: YTD as of December 11, 2023 was 22.95%. Turnover had declined from one year ago when it was 24.44%. Staff will continue to work on creating a great culture and sufficient staffing levels in all areas to be able to hire and keep good people on our team. We are impacted by the current labor shortages as well as students both leaving for and returning to school. Our goal was to reduce our number to approach 20%. However, the assessment failed to identify interventions to improve the staff turnover rate nor how to ensure safe resident care was provided. - An Infection Prevention Risk Assessmenl was completed annually, which guides infection prevention improvements. APIC's Infection Preventionists Guide to Long [NAME] Care and the Centers for Disease Control are the primary resources that guide our Infection Prevention Program. The facility was registered with NHSN. Covid-19 reporting was being done. However, the facility assessment failed to identify changes in guidance related to Enhanced Barrier Precautions (EBP) and/or staff education needs related to infection prevention. - Additionally, the facility assessment failed to identify the changes in leadership and/or how to mitigate the risks in resident care due to lack of leadership. During an interview on 11/6/24 at 2:18 p.m., the administrator stated he was a contracted interim administrator and began his role at the facility on 10/9/24. The facility had undergone several administration changes since the previous survey. The administrator reviewed the facility assessment and stated he expected the assessment to be reviewed at the end of every Quality and Performance Improvement (QAPI) meeting and revised at that time to reflect identified needs. However, the administrator could not find any revised facility assessment documents since 12/1/23, and did not have an answer as to why. A policy related to the facility assessment review and revision was requested and none was provided.

Based on observation, interview and document review, the facility failed to provide sufficient staff to transfer residents in lifts according to their care plan for 3 of 4 residents (R12, R7, R2); failed to provide appropriate supervision to mitigate resident-to-resident abuse for 2 of 2 (R31, R6) residents abused by 1 of 1 residents (R39) reviewed for abuse: failed to provide sufficient staff to complete range of motion for 4 of 4 residents (R7, R19, R22, R43) reviewed for restorative therapy. In addition, 4 of 46 residents (R7, R30, R25, R34,) 10 of 10 staff members (RN-A RN-B, NA-D, LPN-A, NA-C, NA-A, SWD, RT-A, NA-H, DON); 1 of 3 family members (FM-A) voiced concerns of lack of sufficient staffing in the facility. The lack of sufficient staffing had the potential to affect all 46 residents in the facility. Findings include: Transfer with Lifts: See also F689: Based on observation, interview and document review, the facility failed to ensure staff were following care planned interventions when transferring residents with a ceiling lift; and complete therapy/or nursing assessments to determine the appropriate sling sizes per manufacturers guidelines for 3 of 4 residents (R12, R7, R2) reviewed who were transferred via ceiling lifts. R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 had severe cognitive impairment and R12 was dependent on staff (helper performed all the effort and resident does none of the effort to complete the activity) for toileting and bed to chair transfers. R12's care plan dated 8/9/24, identified R12 was cognitively impaired and required assist of two staff for ceiling lift transfers. R12's care plan did not identify the ceiling lift sling size to be used with the transfer. During an observation on 10/29/24 at 5:50 p.m., NA-E and registered nurse (RN)-B transferred R12 with the ceiling lift into the bathroom using a green (large sling). R12 was holding the sling straps with her shoulders extended 90 degrees with the sling bunched up in her underarms. R12's fingers were grasping the straps tightly and her knees were pointed up towards the ceiling and her bottom hanging from the bottom of the sling. R7's significant change MDS dated [DATE], identified R7 had severe cognitive impairment and was dependent for toileting, personal hygiene, and bed to chair transfers. R7's care plan dated 8/9/24, identified R7 was cognitively impaired and required assist of two for ceiling lift transfers and R7 used a size medium ceiling lift sling. R7's Kardex dated 10/29/24, directed staff to provide assist of one with transfers using the ceiling lift. However, the Kardex additionally directed staff to use ceiling lift with total assist of two with a medium Arjo sling. During an observation on 10/29/24 at 12:23 p.m., nursing assistant (NA)-C assisted R7 to the bathroom using a ceiling lift, without another staff person present as care planned. R7 was in the ceiling lift and holding the sling straps with both hands. R7's shoulders were extended 90 degrees and R7's bottom was hanging from the bottom of the sling. R7 had facial grimacing and moaned ooohh. NA-C asked R7 if she was having pain and R7 stated yes, along her ribcage. NA-C stated this was residual pain due to R7 having just recovered from COVID-19. NA-C stated she would report R7's pain to the nurse. R2's annual MDS dated [DATE], identified R2 had severe cognitive impairment and a diagnosis of dementia. R2 had functional limitation with range of motion in both lower extremities and was dependent on staff for bed mobility, toileting, and transfers. R2 had one fall with injury (including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains) during assessment dates. R2's care plan dated 6/28/22, identified R2 required assist of two staff to move between surfaces using the ceiling lift. The ceiling lift sling size was not identified on the plan. During an interview on 10/29/24 at 6:55 p.m., registered nurse (RN)-B stated R7 and R12 were care planned for assist of two with ceiling lift transfers but with the way staffing was going, staff usually transferred using assist of one. Nursing helped as much as they could but there just wasn't enough staff. On 10/30/24 at 8:22 a.m., nursing assistant (NA)-D was standing in R2's room. R2 was fully dressed in their wheelchair. The ceiling lift sheet, size unidentified, was underneath with the straps crossed between the resident's legs. NA-E proceeded to use the ceiling lift to transfer R2 from the bed to the toilet, without a second staff member present as care planned. NA-E stated when R2 was calm like today she would transfer the resident by herself using the ceiling lift. When R2 was resistive NA-D would ask for other staff assistance. The care plan provided direction that two staff were required for ceiling lift transfers. On 10/30/24 at 8:22 a.m., NA-D stated she had no time to check the care plan so was unaware what the care plan directed. During an interview on 10/30/24 at 9:20 a.m., licensed practical nurse (LPN)-A stated she was very concerned regarding resident and staff safety. The facility did not have enough staff to provide assist of 2 with ceiling lift transfers. Residents were being left alone in the lifts in the bathrooms, staff were transferring resident by assist of one with the ceiling lifts, and not answering call lights timely. During an interview on 10/30/24 at 9:44 a.m., NA-C stated the facility was always short staffed. The A-wing was just too heavy of care for one nursing assistant. There was supposed to be a float nursing assistant that would go between the different units but that rarely happened and especially when the nurse had to bounce between units as well. Abuse: See also F600: Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R39) with a known history of sexual behaviors towards others was comprehensively assessed and interventions implemented to mitigate risk to prevent ongoing sexual abuse for 2 of 2 residents (R31, R6) who were cognitively impaired, dependent on staff for their care, and were sexually abused by R39. R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 had severe cognitive impairment and exhibited physical behaviors of grabbing, hitting, scratching, or abusing others sexually one to three days per week, and verbal behaviors toward others one to three days per week. R31 required substantial assistance to dress and was independent with transfer and ambulation. Diagnoses included Alzheimer's disease, anxiety, mood disorder, dementia, restlessness, and agitation. R6's quarterly MDS dated [DATE], identified R6 had moderate cognitive impairment and exhibited delusions, physical behaviors of grabbing, hitting, scratching, or abusing others sexually one to three days per week, verbal behaviors toward others four to six days per week and other behaviors not directed toward others four to six days per week. R6 required substantial assistance to dress and partial assistance with transfers. R6 was independent with ambulation once standing. Diagnoses included depression, anxiety, dementia, and sever mood disturbance. R39's quarterly MDS dated [DATE], identified R39 had severe cognitive impairment with physical behaviors of grabbing, hitting, scratching, or abusing others sexually one to three days per week. R39 was able to transfer and ambulate independently. R39 diagnoses included dementia, psychotic disturbance, mood disturbance and anxiety. R39's progress notes identified the following: - 8/23/24, R39 was observed to take R31 by her hands and lead R31 to his room and close the door. When staff entered the room, R39 was lying on his side in bed and R31 was just seated on R39's bed. Staff directed R31 out of room and reminded R39 they were not allowed alone in room with door shut. - 9/6/24, licensed practical nurse (LPN)-A documented R39 had approached a female resident [identified as R31 from interview] from behind and gave the resident what appeared to be a bear hug [identified in interview to be reaching from behind and grabbing breast] which staff observed from behind. The social service designee (SWD) was notified. - 9/18/24, R39 made attempts to enter an unidentified female resident's room when she was sleeping in bed with lights off. Staff redirected R39 out of the room several times. - 9/25/24, R39 was observed fondling R31's breast. Staff intervened and separated the two residents. - 10/11/24, R39 was walking back to his room when R39 approached a female resident [identified as R31 through interview] to grab her breast area. R39 was redirected away and reminded it was inappropriate to touch anyone without permission. The DON was notified. - 10/15/24, R6 was found in R39's room with the door closed. R6 was seated in her wheelchair beside R39's bed and R39 was fondling R6's breast. R6 was removed from area and R39 was reminded the behavior was not appropriate. R6 stated the incident made her uncomfortable and R39 had been squeezing her breast pretty hard. The DON and SWD were notified. R39's medical record lacked evidence R39's inappropriate sexual behaviors toward other residents had been comprehensively assessed and interventions implemented to mitigate potential abuse toward other residents, despite R39 being independently mobile and displaying ongoing inappropriate sexual behaviors. R31's medical record lacked any assessment to ensure her psychosocial needs were met and interventions implemented. R6's medical record lacked any assessment to ensure her psychosocial needs were met and interventions implemented. On 10/29/24 at 11:00 a.m., NA-A stated R39 could get grabby and try to grab staff breasts, you just needed to watch for it and remind him the behavior was not appropriate. NA-A was not aware R39 had inappropriate sexual behaviors toward other residents. The facility usually staffed the locked unit with one nursing assistant and a nurse would come on the unit on and off to pass medications. Once in a while they would have a float nursing assistant that would come on the unit occasionally to see if help was needed, but that did not happen very often. When interviewed on 10/29/24, at 1:30 p.m. SWD stated she was notified of some incidents with R39's behavior toward residents. SWD received calls regarding incidents of R39 inappropriately touching other residents on 10/14/24 and 10/15/24. SWD discussed the incidents regarding R31's behavior with the DON and it was determined there were no non-consensual type of feelings. The residents had not seemed upset, so SWD and the DON determined it would be ok to just document the incidents when they occurred. The MDS coordinator was going through all the resident care plans and trying to get them all updated and they were all just trying to catch up and survive. Range of Motion: See also F688: Based on observation, interview and document review, the facility failed to provide range of motion (ROM) services for 4 of 4 residents (R7, R19, R22 ,R43) reviewed for range of motion. R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 had severe cognitive impairment. Diagnoses included multiple sclerosis (MS) (a potentially disabling disease of the brain and spinal cord that affects nerve fibers and causes communication problems), type 2 diabetes and peripheral vascular disease (PVD) (reduced blood flow to the arms and legs). R7 had a restorative nursing program (RNP) but R7 did not participate during the look back period. R7's care plan revised 8/9/24, directed staff to provide: RT- UBC x15 mins (tension 90). Pulleys at level 2 (reps of 5 as tolerated). Red squeeze ball (30 second reps). [NAME] level 3 Thera putty. 3# free weight bicep curls. AROM with green Thera Bands. Lower AROM (AAROM - marching, knee extensions, hip adductions and abductions, ankle pumps). 5 times a week or as tolerated. R7's Range of Motion task documentation dated 10/7/24 through 11/1/24, identified R7 received RNP services 3 times, was unavailable 2 times, R7 refused 2 times and was not applicable for 5 times. During the time-period, R7 should have been offered RNP services a total of 17 times. R19's quarterly MDS dated [DATE], identified R19 had moderately impaired cognition and diagnoses included Alzheimer's disease, anxiety and heart failure. R19 had a restorative nursing program (RNP) but R19 did not participate during the look back period. R19's care plan revised 8/1/24, directed staff to provide seated general lower and upper extremity exercises to be completed 3 times a week. R19's Range of Motion task documentation dated 10/7/24 through 11/1/24, identified R19 received RNP services 3 times, was unavailable 1 time and not applicable 7 times. During the time period, R19 should have been offered RNP services a total of 11 times. R22's significant change MDS dated [DATE], identified severe cognitive impairment. R22 had no impairment in range of motion and required substantial to maximal (helper does more than half the effort) with bed mobility, transferring and toileting. R22's diagnoses included arthritis, Alzheimer's disease, and lumbago with sciatica (pain radiating from back to legs and feet which can be eased with range of motion/stretching). R22 did not have a restorative nursing program. R22's provider's order dated 10/2/24, identified R22 was to receive functional maintenance program (FMP) by restorative therapy (RT). The order directed staff to complete active ROM (AROM) (resident helping with range of motion) to both arms and legs in all ranges and planes (normal range of motion) for all joints and to walk as tolerated with transfers five times a week. R22's restorative therapy documentation from 10/4/24 through 11/3/24, identified 21 opportunities for R22 to receive AROM. There was one documented occurrence of AROM being done, one documented resident not available, and 19 marked not applicable. R43's quarterly MDS dated [DATE], identified R43 had moderate cognitive impairment. R43 required supervision to touch assistance with transfers, toileting, and walking. R43 had a diagnosis of Parkinson's disease. R43 had one fall without injury since last assessment. R43 was not part of a restorative nursing program. R43's provider order dated 7/25/24, identified RT program-seated or standing general lower extremity exercises as tolerated. Nustep level 2-5 up to 15 minutes 3 times a week. R43's care plan dated 7/30/24, identified R43 was to receive RT seated or standing general lower extremity exercises as tolerated. Nustep (a low impact exercise machine) level 2-5 up to 15 minutes 3 times a week. R43's restorative therapy documentation from 10/4/24 through 11/3/24, identified 13 opportunities for R43 to receive RT. There were three documented occurrences of RT being done, one refusal, and 9 times were marked not applicable. During an interview on 11/4/24 at 11:51 a.m., restorative therapy (RT)-A stated RNP services were supposed to be offered Monday through Saturday every week and RT-A scheduled each resident according to their RNP on the calendar. RT-A stated the RT department had staffing problems and RT-A was the most consistent staff member. Currently, there was another staff member trained and passed competency, but that person had not been at the facility often. RT-A worked at the facility Mondays, Wednesdays, and Fridays. The other days were not consistently staffed and no RNP was offered on those days unless a resident was independent enough to do the exercises on their own without staff assistance. I just can't complete it. RT-A stated she did inform administration that she was not able to complete tasks but there were no other staff available. During an interview on 11/5/24 at 3:30 p.m., the director of nursing (DON) stated she was aware the facility's restorative aide was at the facility only three days a week even though there were residents requiring RNP 5 days a week. However, a plan to address the issue had not been implemented. Staff were expected to provide RNP to maintain a resident's abilities and/or to prevent contractures. General Resident/Staff and Family Staffing Concerns: During an interview on 10/28/24 at 12:43 p.m., R7 stated a lot of the time you wait at least a half hour for someone to come when you turn on your call light. R7 had times when she was incontinent of bowel because she didn't make it to the bathroom on time. That makes me [R7] feel embarrassed. Dumb. R7 was weepy and wiped away tears. During an observation on 10/30/24 at 7:27 a.m., R7 was lying in bed with her lights off. R7's door was partially open and R7 was screaming help over 10 times. - At 7:28 a.m., R7 screamed help 8 times. R7 can be clearly heard at each each of the unit. - At 7:29 a.m., R7 was again screaming help. R27 came out of her room and asked if R7 was alright. No staff were in the area. - At 7:31 a.m., R7 continued to scream help repeatedly, however, there were no staff to assist R7. - At 7:32 a.m., R27 came out of her room and stood in her doorway rubbing at her eyes and stated she was worried for R7. Is she ok? - At 7:33 a.m., R7 screamed help 5 times in a row. R27 walked to R7's doorway and peeked in stating What's going on? R27 was barefoot on the right foot and a gripper sock on the left. No staff were in the area and R27 turned back to her room. - At 7:39 a.m., R7 screamed help and nursing assistant (NA)-B entered R7's room and asked R7 if she had a bad dream. Provided a blanket for R7 and told R7 she could go back to sleep. - At 7:42 a.m., NA-B stated she was the float nursing aide that day. NA-C was the nursing aide assigned to R7's wing and had a phone that NA-C carried that alerted her to the call lights. The float nursing aide used to have a phone but didn't anymore. NA-B did not know why. NA-B stated when she's in a room she was able to hear the call light box that announced call lights at the nurses' station. That's how she knew she needed to check on R7 because R27's bed alarm went off, or that's how NA-B heard R7 screams for help. When in a room, staff could turn on the call light if they needed help. There was no walkie system or any other way to request help unless staff left the room. On 10/28/24 at 3:27 p.m., NA-H stated there was usually one staff on either side and a float that went back/forth between the two units. If there wasn't a float staff, then she would have to run over to the other side or find the medication nurse will help with two person transfers. STAFF INTERVIEWS: On 10/28/24 at 3:27 p.m., NA-H stated there was usually one staff on either side and a float that went back/forth between the two units. If there wasn't a float staff, then she would have to run over to the other side or find the medication nurse will help with two person transfers. During an interview on 10/28/24 at 4:07 p.m., family member (FM)-A stated R7 had wounds and a physical therapist changed the dressings at 1:00 p.m. Because of that, there was a lot of days R7 didn't get out of bed until after that because there wasn't enough staff. During interview on 10/30/24 at 8:22 a.m. NA-D stated she was uncertain if R2 needed assist of one or two for ceiling transfers. NA-D stated she had not reviewed the care plan prior to transferring R2 because she did not have time. On 10/30/24 at 9:58 a.m., a resident council meeting was held and R34, R25 and R20 expressed concerns regarding staffing. - R34 stated she had to wait a long time for her food at meals. R34 was unable or unwilling to share specific date/times of incidents, although stated it happened frequently. R34's significant change MDS dated [DATE], identified R34 had intact cognition and was dependent on staff for toileting; partial/moderate assistance with bathing; and substantial/maximal assistance for dressing. - R25 stated more times than not there were not enough staff. R25 was unable or unwilling to share specific date/times of incidents, although stated it happened frequently. R25's quarterly MDS dated [DATE], identified R25 had intact cognition and needed substantial/ maximal assistance with for toileting, bathing, and dressing. - R20 stated the wait time of call lights at times was too long. R20 was unable or unwilling to share specific date/times of incidents, although stated it happened frequently. R20's annual MDS dated [DATE], identified R20 had intact cognition and was dependent on staff for toileting, bathing; and substantial to dependent on staff for dressing. During interview on 10/31/24 at 10:14 a.m. RN-A stated she was trying to do the DON position and work the floor. Staffing took up so much time and there was only so much a person could do and they were trying to get done what they could. The Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of 2024, identified excessively low weekend staffing. The daily staffing/working schedules from 8/1/24 thru 10/28/24 were reviewed. The facility was unable to provide a working schedule for 8/3/24, 8/4/24, 8/10/24, and 8/11/24. The Facility assessment dated 2023, identified a need for a ratio of nurse (RN/LPN) to resident was 1:16 to 1:24 for day shift and evening shift and 1:24-1:48 for overnight shift. The assessment also identified a ratio of NA's to residents including: 1:12 -1:13 during each shift (day, evening, overnight) and each shift would consist of a minimum of 4 NA's. The facility daily staffing/working schedules dated 8/17/24 and 8/25/24 identified only 2 NA's were scheduled for the overnight shift; and the nurse staff posting observed on 10/29/24 at 4:53 p.m. identified there was one nurse for A-wing (Pine Island, and The Angle), one for B-wing (Birch-Lake of the Woods) during day and evening. B-wing also had a TMA for day. Each wing had three nursing assistants a.m. and two nursing assistants for B-wing and 2.5 nursing assistants for A-Wing in evening. There was 1 nurse and three nursing assistants combined for the A and B wings. During an interview on 10/30/24 at 9:58 a.m., the DON stated when the DON first started at the facility, she approached the former administrator because they were using 70% agency staff and had lost many experienced staff. To determine resident to staff ratios, they looked at resident acuity and the number of residents requiring lifts. The previous administrator insisted all lifts required assist of 2 staff to complete. However, it took one aide away from a wing entirely to help the other side if the nurse was busy. It's a mess. The DON stated she went to the administrator and requested to add two nursing assistants to A-wing as That's what I needed. The DON needed two staff on another unit as well. That was the goal. I'll be honest with you, it's difficult. Sometimes, there was a float, but it hadn't come to fruition yet and hasn't been consistent. The DON also went to the board and explained staff couldn't be retained and/or incentivized, especially when the facility was losing agency staff as well, when the facility's wages were $5 lower than all the other facilities around. The facility finally approved a pay increase, but it was on pause due to the start of survey. The DON stated she was excited because the former administrator just would not let that happen. The DON stated she also needed a care coordinator for a unit. Ultimately, the DON's plan was to incentivize to get staff to come and get agency staff out of the facility. Some agency staff were great and most worked evenings. A policy on staffing was requested but none were received. 40943 42075

Based on observation, interview and document review the facility failed to provide the physician ordered mechanically altered diet for 1 of 3 residents (R1) reviewed who was at risk for choking and served the wrong textured diet. This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 5/28/24, when R1 was served a regular diet instead of the physician ordered pureed diet which resulted in R1 choking and requiring the Heimlich Maneuver to dislodge a corn dog. The administrator was notified of the IJ on 6/12/24, at 3:21 p.m. The IJ was removed on 6/13/24, at 1:15 p.m., but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1's Transfer/Discharge Report (no date) identified diagnosis that included Dysphagia (difficulty swallowing), quadriplegia and dementia. R1's Care Area Assessment (CAA) dated 10/9/23, identified swallowing problems and cognitive loss. The CAA indicated a swallowing evaluation was completed and a pureed, pudding thick diet was recommended. The CAA indicated R1 usually required total assistance from staff for eating and drinking and continued to cough at times when swallowing. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he had upper extremity impairments on both sides. The MDS indicated R1 received a mechanically altered diet and was dependent on staff to eat. R1's care plan updated 5/30/24, identified a self care deficit and directed staff to provide total assistance to eat. The care plan further identified a nutritional problem due to dysphagia and directed staff to provide/serve diet as ordered: pureed texture, nectar thick liquids. Ensure upright position and remain upright for 30 minutes after meals. A facility Risk Review dated 4/24/24, indicated the recommended diet for R1 was pureed texture with nectar thick liquids. The report indicated R1 was an aspiration/choking risk. The report identified risks that included: choking, shortness of breath, poor communication abilities, aspiration pneumonia that could lead to hospitalization and potentially death. R1's Order Summary Report printed 6/17/24, identified an order dated 11/7/23, pureed texture diet with nectar thick liquids related to Dysphagia. A facility document titled Lake Dining, updated 5/29/24, indicated R1's diet was pureed with nectar thick liquids. R1's Progress Note dated 5/28/23, indicated at 6:00 p.m., author walked into dining room. Upon entering, nursing assistant (NA) was performing Heimlich maneuver on R1. Food noted to be dislodged. Noted that resident was nectar thick with pureed food. Resident denied any pain or discomfort. No bruising noted. Physician notified of incident with orders to monitor for pain in ribs and/or while breathing. Physician did not feel an x-ray was appropriate at this time. Education was provided to NA about following care plan. A facility investigation dated 6/5/24, indicated on 5/28/24, R1 received a regular textured diet instead of the physician ordered pureed diet. During interview on 6/12/24 at 8:51 a.m., the activity director (AD) said she assisted with feeding residents. The AD said she went to the serving window and told the staff who she wanted food for and they gave it to her. When asked if she knew where to look for a residents diet type, the AD said, I just know so I tell my staff. The AD said the diets were also posted in the kitchenette. During observation on 6/12/24 at 11:51 a.m., activity aide (AA)-A was passing out food to residents in the dining room. AA-A was observed going to a window in the dining room where kitchen staff served the meal. AA-A would request food for a resident, dietary aide (DA)-A plated the food and AA-A brought food to the residents. During interview on 6/12/24 at 12:05 p.m., DA-A was asked how she knew what texture to serve the residents. DA-A said the diets were posted on the wall in the kitchenette and she had received training so she knew what to serve. The diets were observed hanging on the wall in the kitchenette and identified a pureed diet for R1. DA-A was asked to identify which food was pureed and pointed to a container with ground meat and gravy (mechanical soft, not pureed). When asked about reference materials related to textures, DA-A said there were none. During observation on 6/12/24 at 12:07 p.m., R1 was seated at a table in the dining room with NA-A. Across the table licensed practical nurse (LPN)-A was seated, assisting another resident to eat. R1's meal consisted of mashed potatoes with gravy and ground hamburger with gravy (mechanical soft). When asked about the texture of R1's hamburger, NA-A described the hamburger as minced and moist. NA-A said pureed food should have been put in a blender. Surveyor intervened before R1 was served incorrect diet. During interview on 6/12/24 at 12:17 p.m., cook (C)-A described a pureed diet and said they placed the food into the blender and blended until it looked like pudding. C-A said the finely ground meat was mechanical soft. C-A accompanied surveyor to R1's unit and verified pureed hamburger had been available and verified what R1 had received was not the correct diet. During a subsequent interview on 6/12/24 at 12:23 p.m., DA-A was asked why she had served R1 a mechanical soft diet. DA-A stated the girl in the colorful shirt (NA-B) asked for his ground food. During interview on 6/12/24 at 12:54 p.m., AA-A stated she assisted with meal service and served coffee and snacks. AA-A said if she was not sure what to serve, she would ask a nurse. AA-A stated she would not know the difference between the different textured diets and said she expected the dietary staff to serve the right diet. During interview on 6/12/24 at 12:58 p.m., NA-B stated R1 was prescribed a pureed diet and said she had delivered R1's food to the table and said he had mashed potatoes but the meat was not pureed. NA-B acknowledged she should not have served the food if she was aware it was not correct. NA-B stated she served the ground meat to R1 because she did not think they had the right food available. During interview on 6/12/24 at 12:28 p.m., registered nurse (RN)-A stated R1 had a recent choking event on 5/28/24. RN-A said she had walked into the dining room and witnessed a NA performing the Heimlich Maneuver on R1. RN-A said the NA had dislodged a mini corn dog. RN-A stated the nursing assistant care guides listed the residents diets and said R1 was ordered a pureed diet with nectar thick liquids. RN-A stated staff were supposed to view the care guides at the beginning of their shift. On 6/12/24 at 1:17 p.m., the director of nursing (DON) and the dietary manager (DM) were interviewed. The DON stated when R1 had choked on 5/28/24, it appeared the NA had gone to the serving window and got a regular diet. The DON stated the NA served R1 the regular diet which resulted in R1 choking on the corn dog and required the Heimlich maneuver to dislodge the food. The DON stated the NA had been re-educated immediately following the incident and said all residents orders had been reviewed and posted in the kitchenettes for the dietary staff. No other staff involved in meals received re-education. The DM stated the servers should look at the chart in the pantry for the residents specific diet order and use that when serving. The DM acknowledged the servers did not have a visual guide that showed what each texture should look like but said they completed annual training that contained visual aides. Facility policy Texture and Consistency- Modified Diets dated 4/18/21, indicated the food and nutrition services department will be responsible for preparing and serving the diet texture and fluid consistency as ordered. Care will be take to serve the foods and fluids as ordered on the consistency altered diet or fluids. The IJ was removed on 6/13/24, when it was verified through observation, interview and document review the facility completed the following: - Reviewed and revised policies and procedures related to serving resident meals and ensuring residents receive correct textured meals. - Educated to procedures and revisions as appropriate. - Educated dietary and all staff who serve resident food to recognize each specific diet type/textured meal. - Educated dietary staff related to the importance of serving the correct diets to residents. - Educated all staff who serve resident food items on the importance of checking the diet slip, ensure the resident is getting the correct textured food, and then delivering the correct diet order to the resident. - Developed and implemented a plan to complete all training before each staff worked their next shift.

Based on observation, interview and document review the facility failed to assess safety for 2 of 4 residents (R1, R4) following falls from recliner chairs. This resulted in actual harm for R1 who fell from a recliner chair and sustained lacerations and a brain bleed. Findings include: During observation on 11/21/23, at 3:05 p.m. R1 was lying on his back in bed. In the corner of the room was a manual recliner chair. R1's significant change Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and identified no behaviors. The MDS indicated R1 had upper extremity impairment on one side and was dependent on staff for transfers and toilet use. R1's care plan dated 11/7/23, identified a self care deficit and a risk for falls. The care plan directed staff to use a ceiling lift for all transfers and encourage R1 to use a call light for assistance. The care plan further indicated R1 needed prompt response for all requests for assistance, non slip Dycem in his wheel chair and indicated he was on a 30 minute rounding schedule for safety. R1's Morse Fall Scale dated 10/19/23, indicated he was at high risk for falls, had fallen before and overestimated his limits. Facility Progress Note dated 6/16/23, indicated staff responded to R1's chair alarm and found him sitting on the floor in front of his recliner. R1 stated he slipped out of the chair. R1 had an abrasion to his right elbow. A facility document titled Post Fall Investigation Report dated 6/16/23, indicated R1 slipped out of his chair and identified an initial intervention of Dycem in chair. The root cause review section was not completed. Additionally, Post Fall investigation lacked enough evidence to determine if Dycem in chair was appropriate intervention (was chair fully inclined or reclined at time of fall). Facility Progress Note dated 7/19/23, indicated staff found R1 lying on the floor in front of his recliner. R1 stated he had been trying to get up and had raised the chair up high. R1 had an abrasion to his forehead and nose and two skin tears to his left elbow. A facility document titled Post Fall Questions dated 7/19/23, indicated R1 had raised his electric chair up to get out of it. Root Cause Review portion of the form was blank and document lacked identified intervention to prevent future falls. Facility Progress Note dated 11/9/23, indicated staff responded to R1's call light and found him on the floor in front of his recliner. R1 had a laceration above his left eyebrow and was sent to the emergency department (ED). Other injuries included a skin tear to his left elbow, skin tear to left knee and skin tear to his finger. R1's ED to Hospital Admission Discharge Summary dated 11/10/23, indicated R1 suffered a small subarachnoid hemorrhage (bleeding in the space that surrounds the brain). During interview on 11/21/23, at 3:06 p.m. nursing assistant (NA)- A stated she was aware R1 had a fall history and stated she had heard it's more when he is in the recliner. NA-A stated R1's recliner had been switched from a remote controlled to a manual recliner. NA-A said R1 like to push the buttons on the remote control and said when R1 needed to use the bathroom he would get very agitated and try to raise the recliner. During interview on 11/21/23, at 3:59 p.m. registered nurse (RN)-A stated R1 had a history of falls and said fall interventions included alarms and frequent rounding. RN-A said R1 had been known to throw himself on the floor when his significant other was gone for a few days. RN-A said during times when R1's significant other was gone staff watched him more and tried to keep him on common areas. RN-A said staff put R1 in the recliner and kept his remote out of reach because they had seen him raise his chair all the way up and then back down. RN-A said R1's power recliner had been removed from his room and replaced with a manual chair. Review of R1's care plan lacked evidence of history to throw himself on the floor or interventions related to more frequent rounding when significant other was out of town. During interview on 11/21/23, at 4:05 p.m. NA-B stated R1 had always been extremity active and had admitted to the care center because of falls at home. NA-B said staff tried to keep R1 in the recliner with his feet up because he would lean forward and fall out of his chair. During interview on 11/22/23, at 8:37 a.m. RN-B stated R1 had a fall history. RN-B said when R1's significant other was not at the facility staff kept more eyes on him. RN-B stated when R1 had the most recent fall from the recliner his chair alarm was sounding and his call light had been on. RN-B said R1 previously had not used the buttons on his recliner. RN-B said the power chair had been removed after the last fall. During interview on 11/22/23, at 9:46 a.m. NA-C stated she was aware R1 had fallen from his recliner chair but said no else had lately that she was aware of. During interview on 11/22/23, at 9:53 a.m. licensed practical nurse (LPN)-A stated R1 had fallen from the recliner because his significant other was out of town. LPN-A said staff put R1 in a recliner and tucked the remote away or put him in a recliner without a remote. LPN-A said she was not aware of any criteria related to recliner chair safety. R4's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she required substantial assistance from staff for transfers and toileting. R4's care plan dated 6/29/23, identified a self care deficit and a risk for falls related to cognitive impairment and balance problems. The care plan directed staff to ensure call light in reach, anticipate needs, and use of alarms. R4's facility Progress Note dated 10/23/23, indicated R4's alarm sounded and she was found on her hands and knees on the floor at the foot of the recliner which was still reclined. R4 was unable to verbalize what she was trying to do. Post Fall Questions dated 10/23/23, indicated R4 was in the living room by recliner and was found on the floor with the chair still reclined. During observation on 11/22/23, at 9:46 a.m. R4 was seated in a power recliner chair in a common area of the unit. NA-C stated R4 used an alarm because she was a fall risk and was sneaky. NA-C said she had not seen R4 use the controls on the chair but she usually placed the control in the pocket of the chair out of R4's reach. When asked how she knew who was safe to be placed in a recliner chair and left unattended, NA-C stated, I guess I just know. At 10:57 a.m. NA-C stated R4 could not operate the chair to get out of it safely. During interview on 11/22/23, at 11:57 a.m. the interim director of nursing (DON) stated the facility did not have a formal assessment tool for safety related to the use of recliners. The DON said after a fall from a recliner she would expect staff to make sure residents were safe to use the chairs. The DON stated she had not been aware R1's fall from the recliner was not his first one and had not been aware R4 had fallen from a recliner chair. The DON said at the time of the first falls the residents should have been assessed and the chairs should have been removed. During interview on 11/22/23, at 12:59 p.m. RN-B stated no assessments or interventions had been implemented following R1 or R4's falls from the recliner. A device assessment policy was requested but not received.

Based on observation, interview, and document review the facility failed to maintain resident safety when a resident with a history of exiting the facility unsupervised, eloped through the Assisted Living (AL) wing of the facility at approximately 4:15 a.m. on 8/22/23. This resulted in an immediate Jeopardy (IJ) situation for R1. In addition, the facility failed to implement a system to ensure proper functioning of their Wander Alert system resulting in 1 of 3 residents (R3) reviewed for elopement, exiting the unit unnoticed by staff during the survey. The IJ began on 8/22/23, when R1 exited the facility via the attached AL wing of the facility after staff left her unattended in the lobby for the second time during the overnight shift at 4:15 a.m. R1 was not located again until 4:45 a.m. when she was attempting to re-enter the building. The director of nursing (DON), administrator and licensed social worker (LSW)-A were notified of the IJ on 9/7/23, at 1:00 p.m. The IJ was removed on 9/8/23, at 11:00 a.m., but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1's Admission Record indicated she admitted to the facility on [DATE]. The Admission Record identified diagnosis that included Alzheimer's Disease, dementia and impulse disorder. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and indicated she experienced hallucinations. R1's MDS indicated she ambulated independently on and off the unit and indicated she did not display wandering behaviors. R1's Wandering Risk Scale dated 7/14/23, identified cognitive loss/dementia and indicated she had no history of wandering and no episodes of wandering in the past three months. The Wandering Risk Scale indicated R1 did not wander aimlessly but indicated R1 enjoyed walking down to AL to visit friends who resided in that area of the building. She had Alzheimer's type dementia and verbalized statements regarding her dislike of skilled nursing facility placement and her desire to leave and had made verbal threats to do so. She had exited the building without supervision during the past quarter. R1 was on safety rounds every hour so that staff knew of her whereabouts. A WanderGuard was applied to R1's wrist on 7/3/23, but she subsequently cut it off and refused to wear it. Care Coordinator and Social Worker had been working frequently with resident, family, physician, and behavioral health provider regarding resident's mood/behavioral symptoms that were contributing to her desire to leave facility. R1's care plan dated 7/17/23, indicated she had been identified to be vulnerable due to the following factors: Disoriented to person, place, and/or time and functional limitations. The care plan identified target behaviors that included threats/attempts to elope from the facility. The care plan identified the following interventions: Wander Alert, however, R1 had removed per self in the past. Staff were directed to monitor for placement every shift and document if she refuses to wear it or have it placed on her walker. In addition, a Sensor mat was placed outside of R1's door to notify staff if she was leaving her room, due to refusals of the Wander Alert Monitor. Staff were directed to monitor placement of the mat every shift. The care plan further identified a risk for elopement and directed staff to distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television or a book and indicated R1 preferred visiting with other residents, staff or family. R1's facility Progress Notes identified the following: 6/6/23, Nurse was informed by other nursing/activity staff that R1 was seen walking on the road next to the employee parking lot at 4:24 p.m. This was noted to be on other side of the building from her room. Staff approached her and offered a ride back to facility. R1 stated she was going to find her friend. Staff offered conversation regarding details of her exact destination. During this time, AL staff approached her with the facility van and were able to get her to agree to return to the nursing home (NH). Staff implemented 30 minute rounding to ensure safety. 7/2/23, at 12:26 p.m. R1 was found outside in the front of the building by activities staff. R1 was outside without her walker and stated she was looking for her kids. Staff was able to re-direct R1 back into the building with 30 minutes checks continued. R1 stated it was hot outside and was unsteady on her feet. After returning inside R1 needed to sit down. 7/3/23, 3:02 p.m. placed WanderGuard on resident's left wrist this morning. Resident was agreeable to it at the time. Since then, resident has set off the alarm on Birch twice and has threatened to cut it off. Will continue to monitor. 8/22/23, R1 had been awake all shift. R1 ambulated to the AL lobby at approximately 3:00 a.m. Staff found R1 and escorted her back to the NH area of the facility. R1 stated she will get out of here one way or another and stated wait until you go to the bathroom or go home implying that she would attempt to leave the facility again at that point. When asked, R1 stated she was going to see her friend who lived in the AL. 8/22/23, R1 was found in the AL lobby area for the second time this shift at approximately 3:45 a.m. R1 left her room when staff was out of view assisting other residents. R1 refused to return from the AL lobby and stated I can sit here if I want to. Due to R1's increased level of agitation writer let R1 sit in the lobby as the front doors were locked and AL staff was made aware of the situation. Upon returning to check on R1 at approximately 3:55 a.m. she was no longer in the lobby. Writer began to check restrooms and other common areas of the AL. R1 ambulated in from outside through the AL door. When questioned how she got out, R1 replied, I'm not telling you. R1 ultimately agreed to return to her room but was complaining about having to stay in this place and stated I could just as well be in prison. Continue 30 minute rounding. 8/22/23 at 5:22 a.m., Staff asked R1 if they could put a Wander Alert on her or her walker. R1 stated No, you are not going to keep me in here. A sensor mat was placed outside of her door to alert staff when R1 stepped out of her room. 8/24/23 at 10:37 p.m., R1 was speaking to another resident on the unit and expressing her dislike of the facility. R1 stated to a staff member, If you're lucky, I won't be here for long. 8/25/23 at 2:18 p.m., R1 was talking about her frustrations with staff and the facility. R1 spoke about needing to figure out what to do to get out of the facility. 8/27/23 at 2:38 p.m., R1's floor mat alarm went off. R1 was found standing by the double doors of the wing tearful. Author attempted to communicate with R1 who made statements such as I've been here too long. They won't let me out of this damn place. I want you to get me out of here. 8/30/23 at 10:31 a.m., R1 had a sensor mat in front of her door which she has figured out to move in front of B100 (room next door) or to go around it at different times. On 9/7/23, at 10:03 a.m. a tour of the AL wing of the facility was conducted with licensed social worker (LSW)-A. The main entrance of the wing had a set of entry doors with a vestibule leading to a second set of doors. On the wall on the inside of the facility, outside the doors was a green button that could be pushed to exit the doors. LSW-A stated she was unsure if the button would disengage the lock after hours when the doors were locked. LSW-A stated she thought R1 had exited through the AL wing of the facility. To the left of the front door was a short hall that led to a longer hall which led to a garage on the end and to the right an interior door which led to an exit door to the outside The door could not be opened from the outside therefore, R1 would not have been able to get back into the building unassisted. Outside the garage and the exit door of the independent living wing was a large partially fenced construction site. Surrounding the facility was a highway to the south and west and a housing development to the east. At 10:18 a.m. the video surveillance camera was reviewed with LSW-A. LSW-A stated the time was off on the camera by approximately two hours. On 8/22/23, at approximately 3:09 a.m. (actual time), R1 was seen in the lobby of the AL. R1 moved out of view of the camera and was seen again at approximately 3:10 a.m. pushing on the entry doors numerous times. R1 then left her walker and returned to the doors and continued to push on them. At approximately 3:12 a.m. registered nurse (RN)-A was seen speaking with R1 and walked with R1 out of view of the camera. At approximately 4:00 a.m. RN-A was seen back in the lobby with R1. At approximately 4:15 a.m. RN-A was seen walking away from the door toward the AL wing. R1 was not visible on the camera. At approximately 4:38 a.m. RN-A returned to the lobby in view of the camera and R1 was not there. At 4:45 a.m. RN-A is seen talking on the phone in the lobby and R1 appeared at the front door from outside the building. During interview on 9/6/23, at 4:32 p.m. NA-B stated she was aware of R1's attempts to leave the facility and said there had been a handful of attempts. NA-B stated R1 had a sensor mat outside her door and had a Wander Alert bracelet but said she heard R1 had cut the bracelet off. NA-B said R1 was on a rounding schedule, either hour or half hour. NA-B stated if R1 attempted to leave staff were supposed to follow her but said she was not sure what to do if R1 refused to return and said she had not had to deal with that before. On 9/6/23, at 4:44 p.m. NA-A stated R1 just does whatever she wants, sometimes she jumps the mat so we can't hear it. NA-A said a little while earlier she saw R1 walk out the door and go in through the other door and said R1 went to see someone on the other side of the unit and she had to go see where R1 had gone. When asked what she was supposed to do if R1 left, NA-A stated she had never been there when it had happened so she was not sure. NA-A further stated she had been told to try to get her back and said R1 was not on any extra checks that she was aware of. At that time (NA)-A demonstrated how R1's alarming floor mat worked. When NA-A stepped on the mat the alarm did not sound. At 4:50 p.m. NA-A returned to the mat with NA-B holding a small plastic box at which time the alarming floor mat sounded when stepped on. On 9/6/23, at 5:13 p.m. NA-D stated he had been working on the night of 8/22/23, but said he had not been aware R1 had been outside the facility. NA-D said he typically worked on the secured unit but did occasionally move around. NA-D said no one had told him R1 had eloped from the facility and said he was not familiar with what happened on the other wing of the NH. During interview on 9/7/23, at 8:29 a.m. licensed practical nurse (LPN)-A stated R1 had a mind of her own and was extremely difficult to redirect. LPN-A stated R1 thought she could go wherever she wanted but in reality she couldn't and staff could not convey that to her. LPN-A stated she was aware of R1's previous elopement attempts and said R1 needed a one to one but there was not enough staff to provide it. LPN-A stated she was not aware R1 was outside on the night of 8/22/23, until she heard the surveyor was onsite and she was told why. LPN-A stated if R1 left while she was working she would call 911 and said R1 was not safe if she got outside. On 9/7/23, at 8:41 a.m. NA-C stated she had been told R1 had eloped from the facility in the past. NA-C said when she arrived to work she would check to see of R1 was in her room and check on her at half hour to one hour intervals. NA-C stated R1 was allowed to go to the AL side of the facility unsupervised and if she went staff were to keep track of time and see when R1 came back. NA-C stated she thought it had been a while since R1 had attempted to leave the facility and had not been aware of the recent elopement. On 9/7 at 8:48 a.m., the care coordinator LPN-B stated interventions to prevent R1 from eloping from the facility included working with a memory care clinic and recently the alarming floor mat but said R1 would walk over the mat so it would not alarm. LPN-B stated they were working to get R1 to a memory clinic for an in-patient stay but in the meantime staff proved hourly checks and activity staff spent extra time with her. On 9/7 at 9:16 a.m., the DON stated the last she heard R1 was going to an in-patient stay at a memory unit but they did not know when it would occur. The DON stated she believed R1 was on hourly checks. The DON stated she was in the building on 8/22/23, when R1 eloped from the facility. The DON said R1 had been increasingly agitated and the two staff on the unit would peek in on her. She said around 3:20 a.m. RN-A told her R1 was being aggressive and said he could watch her on the cameras. She said RN-A walked to the AL and R1 was sitting by the door and did not want to go back so she directed staff to check on her every 15 - 20 minutes. The DON said she then got a phone call that R1 was not there and RN-A did not know where she was. She said she asked RN-A to talk to the AL staff and she checked the NH. The DON said she went to check the AL doors and they were locked and said RN-A called her shortly after and said R1 returned from outside the front doors of the AL and RN-A had to let her in. The DON said she was not sure how R1 got out of the building but assumed she went out the exit by the stairs because those doors were not locked. The DON said she believed R1 had gone to the AL twice that night shift and had been brought back once and then went back. She said when RN-A went to get her the second time R1 was more verbally aggressive which was why RN-A left her there assuming she could not get out. The DON said they immediately placed an alarming floor mat in front of R1's door and were doing 15 minute checks on her. The DON said R1 was still allowed to go to the AL and they could watch the clips on the camera to see where she ended up and if it had been a little long they did half hour checks. The DON stated they could not provide R1 with one to one staffing. The IJ was removed on 9/8/23, at 1:00 p.m. when it was verified through interview and document review the facility reassessed R1's elopement risk, implemented a motion sensor above R1's door and out of R1's reach, implemented 15 minute safety checks and obtained two phones for staff to utilize for communication should R1 leave her room. Further, staff will supervise R1 when she makes the choice to go to the AL to visit friends. All staff were educated on the procedures. R3's quarterly MDS dated [DATE], identified moderate cognitive impairment and indicated he displayed wandering behaviors. The MDS indicated R3 was independent with locomotion on the unit and required supervision when off the unit. R3's care plan dated 11/4/22, indicated he was a wandering risk related to history or attempts to go outside unattended and impaired safety awareness. The care plan directed staff to distract R3 from wandering by offering pleasant diversions, structured activities, food, conversation, television or a book. The care plan further identified the use of a Wander Alert and directed staff to check placement daily. During observation on 9/7/23, at 3:06 p.m. R3 propelled himself to the closed door of the unit, pushed the green button on the right side of the door. The door opened and R3 propelled himself off the unit without staff supervision. Surveyor alerted NA-E that R3 had left the unit. At 3:08 p.m. NA-E and LPN-B were observed placing a new Wander Alert bracelet on R3's wheel chair. During interview on 9/7/23, at 3:09 p.m. LPN-B stated R3 had a Wander Alert on his chair when he exited the unit but it had not functioned correctly. On 9/8/23, at 10:32 a.m. LPN-B stated staff checked function of the Wander Alert by taking the residents by the doors during the day or at night if wheel chairs were being washed. LPN-B stated the facility did not have a device for checking the Wander Alerts for functioning nor was there a clear process for staff to follow to ensure proper functioning on a routine basis. Review of R3's record indicated staff checking Wander Alert placement but lacked evidence of checking Wander Alert function. Facility policy Elopement Prevention dated 7/18/14, indicated transmitters would be replaced according to life expectancy and as needed. Transmitters will be tested weekly and as needed with a hand held device to ensure they are working properly. Facility policy Missing Resident Policy dated 10/19/17, indicated upon return of a missing resident to the facility the charge nurse or designee will assess and plan if elopement occurred and put into place safety measures to prevent further elopements.

Based on observation, interview and document review, the facility failed to ensure fall interventions were implemented as care planned to prevent falls for 1 of 4 residents (R44) reviewed for falls. This resulted in actual harm to R44 who's fall resulted in a femur fracture. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had severe cognitive impairment, required limited assistance with transfers and supervision with walking. R30 had a history of falls without injury and used a bed alarm daily. R30's Falls Care Area Assessment (CAA) dated 3/1/22, identified the CAA was triggered due to unsteadiness with transitions, history of falls and wandering. R30 walked with a fast paced, steady gait most of the time. R30 had pain related to arthritis and gait could be weak/unsteady at time due to pain and age. R30 had poor safety awareness due to cognition impairment. R30's care plan would include interventions to prevent injury from falls. R30's care plan revised 3/16/22, identified R30 was at high risk for falls related to confusion, psychoactive drug use, vision/hearing problems and wandering. The care plan instructed staff to do the following: - 30-minute rounds - Anticipate and meet R30's needs - Be sure R30's call light was in reach and encourage R30 to use it for assistance as needed. R30 needed prompt response to all requests for assistance - Ensure R30 was wearing appropriate footwear: brown leather shoes when ambulating - Follow facility fall protocol - Keep garbage can in the shower with the curtain closed to deter R30 from attempting to void in the garbage can - Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate R30/family/caregivers/IDT as to causes - R30 needed a safe environment with even floors, free from spills and/or clutter; adequate, glare-free light; a work and reachable call light, the bed in lowest position; handrails on walls, personal items within reach - Bed alarm: was bed alarm in place and functioning properly during your shift? R30's Morse Fall Scale dated 8/31/22, identified R30 was at high risk for falls. R30's progress note dated 10/18/22, identified R30 was found on floor at 6:45 a.m. Upon entering room, it was immediately obvious R30 was in a lot of pain as she was hollering out and rubbing her right hip. A pillow was placed under her head and R30 was comforted until the ambulance arrive. Staff did not attempt to move R30 at any time and allowed the ambulance staff to take over once they arrived. R30's Night Shift: Pine Toileting and Repositioning form dated 10/18/22, identified R30 required checks every 30 minutes. The form had a column to track half-hour checks from 10:30 p.m. to 6:30 a.m. The form identified an ok section next to every half-hour mark indicating R30's location and condition were observed. Staff checked off ok hourly, which identified R30 was not checked on every half hour as care planned. R30's Hospital Progress note dated 10/18/22, identified R30 had fallen and sustained a right femoral intertrochanteric hip fracture (between the trochanters, which are bony protrusions on the femur [thighbone]. They're the points where the muscles of the thigh and hip attach. There are two trochanters in the body: the greater trochanter and the lesser trochanter. An intertrochanteric fracture occurs between the greater and lesser trochanters) that required surgical repair. R30's Post Fall Questions dated 10/18/22, identified 30+ minutes had passed since R30 was last checked. During an observation on 10/25/22, at 3:40 p.m. R30 was lying in bed in the lowest position. R30's eyes were closed, and she appeared to be sleeping. Her wheelchair was positioned close to her bed to ease transfers and her bed alarm was on. During an observation on 10/25/22, at 5:17 p.m. R30's bed alarm sounded, and registered nurse (RN)-C entered R30's room within 10 seconds. RN-C and nursing assistant (NA)-B assisted R30 to ambulate to a chair in the common area. During an interview on 10/27/22, at 8:13 a.m. licensed practical nurse (LPN)-B stated she wasn't working when R30 fell but was told R30 was found on the floor in an empty room adjacent to hers. No other residents were in the room and R30 laid down in the bed. During a phone interview on 10/27/22, at 8:56 a.m. nursing assistant (NA)-C stated he was working when R30 fell . NA-C was doing rounds and working his way back to R30 when she fell . R30 was in the empty room adjacent to hers, and crawled onto the foot of the bed and fallen asleep. It was normal for R30 to crawl into anyone's bed and if she was safe, they tended to allow her to sleep. NA-C was not sure when R30 was last checked that morning. NA-C he didn't receive any education on the importance of R30's 30 minute checks. Staff tried to keep an eye on the residents but with alarms going off, that could be tricky. At 10/27/22, at 9:03 a.m. an attempt to call LPN-C, the nurse on duty at the time of R30's fall, was made; however, LPN-C did not return the call. During an interview on 10/27/22, at 9:15 a.m. NA-B stated she was working the morning R30 fell and found R30 on the floor. She was told R30 crawled up on the foot of the bed and fell asleep curled up into a ball. NA-A believed the bed was in the lowest position; however, there was no bed alarm. Prior to the fall, NA-A stated she and NA-C were doing morning rounds and checking on where all the residents were. Residents constantly wandered the unit and staff needed to ensure everyone's safety. NA-B was told R30 was last checked on at 5:30 a.m. During an interview on 10/27/22, at 9:50 a.m. registered nurse (RN)-C stated R30 was care planned for a dementia approach which was, if it was not physically hurting R30 or another resident, to allow R30 to be when she was sleeping because R30 could become agitated when disturbed. R30 was found on the floor in another resident's room on the morning of 10/18/22, at approximately 6:40 a.m. The bed was in its lowest position, but there was no bed alarm. Upon review, of R30's 30-minute check form, RN-C stated she was aware the last time R30 was checked prior to her fall was 5:30 a.m. The form identified R30 was checked only hourly. At that time, RN-C stated she didn't educate staff regarding the importance of R30's 30-minute checks because [NA-C] could see by the look on my face and had to give her staff credit for doing hourly checks, nor was she monitoring interventions for follow through. During an interview on 10/27/22, at 10:58 a.m. the director of nursing (DON) stated when a resident fell , the staff followed a facility fall protocol packet. The packet included a checklist of tasks that needed to be completed: the first-person report, investigation form, what happened, what interventions were implemented, call the family, and notify the doctor. Afterwards, there is a high-risk meeting that goes over all falls and the staff discuss potential causes and interventions. -The DON recounted R30's fall and identified R30 was found on the floor in another room, and it was early in the morning. R30 was having a lot of pain, the staff suspected a fractured hip, and the ambulance was called. Prior to R30's fall, 30-minute checks were implemented and R30 was last checked approximately 30 minutes prior to her fall. R30 was care planned for a bed alarm; however, she wasn't in her bed, so she didn't have a bed alarm that morning. The staff heard her screaming and that was what alerted staff about the fall. The DON was not aware R30's 30-minute checks were not conducted as care planned. This was important so staff education and monitoring could be completed. During an interview on 10/27/22, at 11:33 a.m. the administrator stated staff were expected to follow resident care planned fall interventions. A facility fall prevention policy was requested but not received. The facility policy Quality of Care revised 3/11/22, identified quality of care was a fundamental principle that applied to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The policy provided staff direction that included the following: - The facility will ensure that the resident environment remains free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents. - The facility will provide training to staff related to the above-mentioned programs as well as training required by State and Federal regulations related to the above-mentioned areas. Staff training may be facilitated through any combination of in-person instruction, webinars and/or supervise practical training hours wand will be competency based.

Based on observation, interview, and document review, the facility failed to ensure unpasteurized shell eggs were fully cooked and prepared in a manner to prevent foodborne illness. This resulted in an immediate jeopardy (IJ) situation for 1 of 1 residents (R20) who was observed to consume undercooked unpasteurized eggs; 9 of 9 residents (R3, R5, R6, R16, R24, R33, R44, R45, R46) who were identified to frequently request and consume undercooked unpasteurized eggs on a routine basis. The IJ that began on 8/11/21, when the facility prepared and served unpasteurized egg(s) on a made to order basis with runny yolk(s), which were not fully cooked resulting in an increased potential for foodborne illness. On 8/11/21, at 4:47 p.m. the administrator, director of nursing and dietary manager (DM)-E were notified of the IJ. The IJ was removed on 8/12/21, at 3:06 p.m.; however, non-compliance remained at the lower scope and severity of no actual harm, with potential for more than minimal harm, pattern that was not immediate jeopardy. (Level E) Findings include: A United States (US) Food and Drug Administration (FDA) Egg Safety: What You Need To Know feature dated March 17, 2021, identified fresh eggs may contain bacteria called, Salmonella, a bacterial infection which can cause diarrhea, fever, and abdominal cramps and can lead to hospitalization or death, which was identified as a common cause of food poisoning in the United States. The feature explained certain group(s) of people were at higher risk of having severe illness, as a result of contracting Salmonella and listed these people to be, . children, older adults, pregnant women, and people with weakened immune systems (such as transplant patients and individuals with [CONDITION(S)]/AIDS, cancer, and diabetes). There were several steps listed to help reduce and/or eliminate the risk of Salmonella including, Cook eggs until both the yolk and the white are firm. Scrambled eggs should not be runny. All cartons of shell eggs that have not been treated to destroy Salmonella were required to carry a safe handling statement that indicated to prevent illness from bacteria: keep eggs refrigerated, cook eggs until yolks are firm, and cook foods containing eggs thoroughly. A Centers for Disease Control and Prevention (CDC) Feature Salmonella and Eggs dated 2/16/21, identified the inside of shell eggs which appear normal may contain the bacteria Salmonella which, . can make you sick, especially if you eat raw or lightly cooked eggs. The article listed several steps which could reduce this risk including, Consider buying and using pasteurized eggs and egg products, which are widely available, and, Cook eggs until both the yolk and white are firm. Further, the article identified Salmonella infections, can be serious and is more dangerous for certain people, which included older adults and people with weakened immune systems dictating these affected people, . may get a more serious illness that can even be life-threatening. On 8/9/21, at 3:30 p.m. an initial tour of the main kitchen was completed with cook (CK)-C. The kitchen had a single walk-in refrigerator in use which was opened and inspected. There was a cardboard box labeled Glenview Farms, with a flat of eggs placed in them. There were several missing flats (eggs were already used) and several flats that contained plain, white eggs free of any visible markings as well as open holes where eggs had been removed, inside of the box . The Glenview Farms box lacked evidence the eggs were pasteurized (a process used to reduce the risk of food-borne illness in items that are not cooked or are only lightly cooked; typically done with shell eggs and marked with a visible stamp on the eggs). CK-C stated the fresh eggs contained in the cardboard box were used for fried eggs for resident's breakfast. The baker used liquid eggs in cartons that were also located in the walk-in refrigerator, for general cooking. CK-C stated she did not know if the eggs were pasteurized and was unable to find any markings on the eggs or box to identify the eggs as pasteurized. CK-C was the only dietary person in the facility that evening and did not do the ordering of the eggs or use the eggs in the box. Further, CK-C was unsure who she could ask regarding if the eggs were pasteurized. R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 had intact cognition and was [AGE] years old. The MDS included a diagnosis of secondary parkinsonism. - R20's progress notes were reviewed from December 2020, through June 2021 and identified R20 had intermittent loose stools since her admission in December 2020. During observation of the morning meal service on the Angle unit on 8/10/21, at 8:22 a.m. two unidentified female residents had fried eggs on their plates. The eggs were cooked to medium (yolk was semi firm with slight pooling along the edges) doneness. The whites of the eggs were firm and fully cooked. Dietary aide (DA)-F stated the eggs were fried in the kitchen and brought out to each unit. The eggs were soft (yolk is runny and not cooked through) fried in the kitchen, but firmed up when sitting in the food warmers. During observation of the morning meal service on angle unit on 8/11/21, at 8:52 a.m. residents were seated in the dining room eating breakfast of scrambled eggs and sausage patty. Licensed practical nurse (LPN)-B was preparing fried eggs at the kitchenette stove top for R20, who had special requested soft fried eggs for breakfast. LPN-A plated the fried eggs and toast, gathered silverware and exited the kitchenette to deliver the eggs to R20. LPN-A did not obtain a temperature on the eggs prior to delivering the breakfast to R20. -At 9:10 a.m. R20 was eating her breakfast in bed. R20 had two fried eggs on her plate with yolks that were running slightly onto her plate and not cooked all the way through. R20 dipped her toast into the yolk of the eggs and eat the toast/ eggs. R20 stated her breakfast meal was very good and the eggs were cooked the way she liked them. During a subsequent tour of the kitchen on 8/11/21, at 12:17 p.m. DM-E opened the single walk-in refrigerator and pointed out the cardboard box containing fresh, unmarked, white eggs. DM-E stated the eggs were used for over easy (yolk that was runny and not cooked all the way through) fried eggs; however, he was unsure if the eggs were pasteurized or not. DM-E could not identify any markings on the egg box or the eggs themselves to indicate the eggs were pasteurized. DM-E was not aware of pasteurized and unpasteurized eggs and was unsure if he would be able to order eggs that were pasteurized. Further, he would look into ordering pasteurized egg. During interview on 8/11/21, at 12:30 p.m. CM-E stated he developed the facility menus with the dietician and rotated the three week menus for the facilities spring/summer quarter. The facility provided a three week menu rotation dated 7/26/21 through 8/15/21. The menus identified each day of the week (Monday - Sunday) along with each of the three separate meals being provided on each day. - Week one, Tuesday and Thursday, Fried Egg, was listed as being offered and/or served for the first meal of the day. - Week two ,Wednesday, Fried Egg, was listed as being offered and/or served for the first meal of the day. - Week three, Monday and Sunday, Fried Egg was listed as being offered and/or served for the first meal of the day. On 8/11/21, at 1:02 p.m. nursing assistant (NA)-M stated all the food in the kitchenette's on the unit came from the main kitchen, including the eggs. The nurses on the units fried the special order eggs and the residents who ordered them usually wanted them over easy. The unit refrigerator was observed and there was one white unmarked egg on an egg flat, which had several open holes for additional eggs. During interview on 8/11/21, at 1:24 p.m. DM-E stated he discovered the fresh eggs the facility used were not pasteurized. The kitchen only served over easy or over medium eggs to the residents when they were on the menu. He was unsure which residents received special order fried eggs on the units and would have to check with an activity or nursing staff. There was a potential for foodborne illness from bacteria getting into the fresh eggs and then causing illness. Further, DM-E stated he ordered two boxes of pasteurized eggs and they would be delivered to the facility the next day. On 8/11/21, at 1:30 p.m. NA-B and NA-N identified R20, R44 and R33 would order special order over easy fried eggs, where the yolk was runny, for breakfast on the Angle unit. R33's annual MDS dated [DATE], identified R33 had moderate cognitive impairment and was [AGE] years old. The MDS included diagnoses of [CONDITION(S)] and heart disease. R44's quarterly MDS dated [DATE], identified R44 had intact cognition and was [AGE] years old. The MDS included a diagnosis of [CONDITION(S)] thyroiditis. During interview on 8/11/21, at 1:35 p.m. activity aide (AA)-C stated she fried special order eggs on the Birch and Lake units every Wednesday, for the last several months. AA-C would take special orders of how every resident wanted their eggs done and would fry them as the resident requested. AA-C identified R5, R12, R16, R24, and R45 on Birch unit ordered their eggs over easy on Wednesdays and R3, R6, and R46 on Lake unit ordered their eggs over easy. Further, R46 especially liked his eggs even more over easy than the other residents. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was [AGE] years old and had moderate cognitive impairments. The MDS included diagnoses of diabetes mellitus and had minimal cognitive impairment. R5's quarterly MDS dated [DATE], identified R5 had intact cognition and was [AGE] years old. The MDS included diagnoses of heart and kidney disease and diabetes mellitus. R6's annual MDS dated [DATE], identified R6 had moderate cognitive impairment and was [AGE] years old; however, did not have any diagnoses listed to place R6 was greater risk. R12's quarterly MDS dated [DATE], identified R12 had severe cognitive impairment and was [AGE] years old. The MDS included diagnoses of diabetes mellitus and [CONDITION(S)]. R16's significant change MDS dated [DATE], identified R16 had moderate cognitive impairment and was [AGE] years old. The MDS included diagnoses of [CONDITION(S)] and kidney disease. R24's quarterly MDS dated [DATE], identified R24 had moderate cognitive impairment and was [AGE] years old. The MDS included diagnoses of diabetes mellitus, heart disease and kidney disease. R45's quarterly MDS dated [DATE], identified R45 had severe cognitive impairment and was [AGE] years old. The MDS included diagnoses of heart disease and kidney disease. R46's admission MDS dated [DATE], identified R46 had moderate cognitive impairment and was [AGE] years old. The MDS included diagnoses of diabetes mellitus, and heart disease. During interview on 8/11/21, at 2:09 p.m. R46 stated he liked his eggs over easy. He indicated he preferred to have them just cooked slightly on one side, flipped and then served. R46's progress notes dated 8/1/21 and 8/8/21, identified R46 had experienced loose stools. The facility's corresponding menu indicated fried eggs were served on 8/1/21, and 8/8/21. On 8/11/21, at 3:56 p.m. DM-E stated the facility food preparation policy directed dietary staff to only use pasteurized fresh eggs. The facility provided US Foods (food supply vendor) invoices dated 8/1/20 to 8/4/21, identified the facility ordered and received unpasteurized egg shells on 2/8/21, and continued to 8/4/21. A total of 16 cases (each with 15 dozen) of unpasteurized eggs were delivered over 16 separate deliveries during these weeks. Invoice dated 8/11/21, identified the facility received a case (with 15 dozen) pasteurized egg shells. The facility's undated policy, General Food Preparation and Handling, identified no raw eggs would be served. Eggs must be cooked completely. Pasteurized eggs were the exception (these may be served soft cooked). Although, the FDA identified the risk for Salmonella infection is relatively small statistically, elderly patients and people with compromised immune systems or disease processes have a higher risk and are more likely to experience a severe illness from an acquired Salmonella bacterial infection. This unnecessary risk resulted in a need for immediate correction as it had a high potential for serious harm, injury, or death should any infection be acquired from eating the unpasteurized, fried eggs which were prepared undercooked and consumed. The IJ was removed on 8/12/21, at 3:06 p.m. when it was verified through observation, interview and record review the facility implemented a removal plan which included: The unpasteurized eggs were removed from the building and from the made-to-order service menu while awaiting pasteurized eggs to use when preparing cooked to order fried eggs; Revised the facility policy to include purchasing only pasteurized eggs to avoid improper use of non-pasteurized eggs; and Provided education to the dietary, nursing and activity staff regarding State and Federal requirements for safe egg handling and preparation.

Based on observation, interview and document review, the facility failed to appropriately cool vegetable beef soup in a manner that prevented and/or minimize the risk for food borne illness. This deficient practice resulted in an immediate jeopardy (IJ) due to the potential risk of serious illness for all 47 residents who resided in the facility and received meals from the kitchen. The immediate IJ was identified on 6/11/18, when it was determined the vegetable beef soup had not cooled to the appropriate temperature within the required timeframe in order to prevent the growth of infectious organisms which cause food borne illnesses. The administrator and the director of nursing (DON) were informed of the IJ on 6/11/18, at 8:26 p.m. The IJ was removed on 6/13/18, but non-compliance remained at the lower scope and severity of an F, widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During the initial kitchen tour on 6/11/18, at 3:14 p.m. with cook (C)-A, the following was observed sitting on the counter, uncovered: -A two gallon, square plastic container with approximately a ¼ inch congealed surface. The container was completely full. -A two gallon stock pot type kettle with approximately a ½ inch thick, crust like, congealed surface. The pot was ½ full. At the time of the observation, C-A stated she had finished making vegetable beef soup at 2:00 p.m and placed it in the above containers and on the counter to cool. C-A stated at that time the soup was put into the containers, it measured 207 degrees. C-A stated the soup was for the next day's lunch meal. C-A stated it would take about an hour and a half to cool down to the appropriate temperature. The soup had not been stirred since placed on the counter. At the request of the surveyor, C-A checked the temperature of both containers which revealed both measured 120 degrees. C-A stated the soup was getting closer to being able to be put in the refrigerator and would be putting the soup in the cooler once it had cooled down some more. -At 5:15 p.m. the dietary manager (DM) confirmed the findings and stated for now, they had put the soup in the coolers. The DM stated the cooling time for food should be less than two hours. The DM also stated within two hours, the temperature of the cooling food should have been below the danger zone (period when bacteria grow most rapidly) of 41 degrees. The DM also stated in order to properly cool food, it should have been put into smaller divided containers and directly into the cooler. The DM stated he had worked at the facility for about two months and was previously ServSafe certified, however, he had not kept up the certification. In addition, the DM stated there was only one kitchen staff member that was currently ServSafe certified. -At 6:03 p.m. both containers of soup were observed on the bottom shelf of the cooler. The DM stated he was unsure what time the soup was actually placed in the cooler and referred to a log. The DM stated according to the documentation on the log, the soup measured 100 degrees at 4:30 p.m. just prior to it being put in the cooler, however, he did not know if that was for both containers, or just one. The DM verified there was no further documentation of the soup's temperatures having been taken/monitored as it was cooling. At this time, the DM obtained the temperature of both containers. The plastic container's soup was 130 degrees and the metal pot was 90 degrees. The DM stated he was uncertain of the cooling protocols for all foods and was in the process of purchasing cooling/ice sticks to aid in the rapid cooling of foods but confirmed he had not ordered any, yet. -At 6:38 p.m. the DM confirmed the soup should have been cooled sooner and faster. The DM again confirmed the soup had less than two hours for cooling time to prevent bacterial growth, therefore should have been placed in a cooler in smaller divided containers in order to cool properly in order to prevent food borne illness. The DM stated the soup was going to be discarded. On 6/14/18, at 11:47 a.m. the registered dietician (RD) who was on leave had arrived at the facility to assist with the removal of the IJ, confirmed the soup was not cooled properly and was discarded. The RD stated education would be provided to the staff. On 6/14/18, at 12:21 p.m. the on call dietary consultant stated the administrator had informed her of the IJ and agreed the soup was improperly cooled which could have caused food borne illness if consumed. The facility's undated, General HACCP Guidelines for Food Safety policy and procedure bullet #5, titled, Essentials of Cooling, directed the staff to cool food from 135 degrees to 70 degrees in two hours and from 70 degrees to 41 degrees in four hours, not to exceed six hours. If food was not cooled to 41 degrees within six hours, reheat to 65 degrees for at least 15 seconds (within two hours) and discard if not served immediately. This included mechanically altered foods. Take temperatures frequently to determine if altered methods of cooling are needed. The policy also directed staff to: -divide food into several smaller batches, and in containers that permitted the food to cool rapidly. Place in smaller pre-chilled stainless steel pans. -Place pans in an ice bath and stir foods as they cool, then refrigerate (ice bath should contain more ice than water). Avoid cooling foods in storage refrigerators or freezers. (This can bring the total temperature of the unit to an unsafe level). -Place cooling items on the top shelf of the refrigerator or freezer uncovered or loosely covered in two inch shallow pans and stir every 15 to 60 minutes. -Allow air to circulate around the food. On 6/13/18, at 11:08 a.m. the administrator was notified that the IJ had been removed after the following facility interventions were implemented: -discarded the soup at 9:00 p.m. on 6/11/18, and initiated an alternate menu in place of the soup. -inspected the kitchen for any similar concerns in the coolers and other food storage areas. -notified the RD who was on leave and agreed to come to the facility to assist with the removal plan and education. -reviewed the upcoming menu for any potential concerns related to cooling/food handling. -contacted the consultant dietician to seek assistance with training materials and suggestions. -reviewed and/or revised policies and procedures related to the proper cooling of foods. -online education (ServSafe Food Handler) related to food safety was purchased and the training for all dining service team members would begin on 6/13/18, and would be completed by 6/20/18. -revised/updated current policies and procedures. -educated all kitchen staff on the revised/updated policies and procedures specifically related to the safe and proper cooling of foods.

Based on observation, interview and document review, the facility failed to ensure pain had been assessed in order to identify appropriate interventions and/or medical attention for 1 of 1 resident (R12) reviewed for dental pain. This resulted in a harm level for R12. Findings include: R12 was observed on 6/11/18, at 5:40 p.m. in the dining room being fed by an unidentified nursing assistant (NA). R12 was observed to be making facial grimaces, clenching fists, and pushing self away from table while being fed and given liquids. R12 was observed to have several missing teeth. R12's Admission Record dated 6/14/18, included [DIAGNOSES REDACTED]. R12's annual Minimum Data Set ((MDS) dated [DATE], indicated that R12 had severe cognitive impairment and was rarely/never able to make self understood or understand others. R12 required extensive assistance with eating and oral cares. The MDS indicated R12 had indicators of pain (facial expressions - grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) one to two days and received scheduled pain medication. Section L for dental was coded as none of the above were present related to broken teeth, missing teeth, likely cavities, inflamed/bleeding gums, mouth or facial pain. However, the MDS was coded inaccurately as R12 underwent oral surgery to extract 14 teeth on 7/25/17. R12's pain Care Area Assessment (CAA) dated 10/1/17, indicated R12 does have pained facial expression at times, such as grimacing, furrow brow, etc It is not clear that this is pain-related due to R12's difficult time with communication and is mostly not possible to have a conversation with. R12 did have a history of back pain and was having presumed oral pain prior to dental surgery. Care plan will include interventions to monitor for and keep pain controlled. R12's quarterly MDS dated [DATE], indicated no notations in the oral care section and pain 1-2 days as noted by facial expressions or protective body movements. However, the MDS was coded inaccurately as R12 underwent oral surgery to extract 14 teeth on 7/25/17. R12's care plan provided on 6/14/18, directed one to two staff members to provide personnel hygiene which included oral care. The hygiene care plan indicated R12 had her own teeth and did not identify R12 had missing teeth. The care plan did not specify how or when to provide oral care and did not include and/or identification of goals to maintain dental health. The care plan directed staff to administer medications, monitor/record pain characteristics, report to nurse any signs or symptoms of non-verbal pain, and notify physician if interventions are unsuccessful or if current complaints were a significant change from past experience of pain. R12's care plan did not include dental pain. Pain in Advanced Dementia (PAINAD) assessment completed 4/3/18, indicated R12 to score a one on a 0 to 10 scale (0=no pain to 10=severe pain). The pain assessment did not identity the location of the pain. physician's orders [REDACTED]. The last Dental Observation completed on 9/30/16, indicated R12 was resistive to oral cares, staff attempt to brush teeth twice daily, but R12 will often clench mouth shut. Staff have tried giving R12 a prepared toothbrush with toothpaste and verbally prompt to brush but R12 is uncooperative. Will continue attempting oral cares and schedule dental exams as necessary. No further dental observations/assessments were completed. Review of R12's record revealed ongoing and worsening of oral pain and oral health without dental treatment and services. -on 7/25/17, oral surgery for [REDACTED]. -on 11/28/17, (referral form) nursing observation that R12 had been yelling more and grinding her teeth. Possible tooth pain. Physician's recommendation was to talk with son to see if he wants a dental appointment. The other option is pain control but did not know if there is infection of teeth which if present could get worse. R12's record lacked evidence of an oral assessment or attempts of, the record further lacked evidence of monitoring for signs and symptoms of infection, and also lacked evidence R12's family member (FM)-A was contacted in reference to a dental appointment for further evaluation. -on 12/15/17, (health status note) when physician was here in November, R12 was showing signs of possible mouth pain again and talked about possibility of having remaining teeth extracted. FM-B notified and asked if it looks like there is an increase in pain or infection, should arrangements be made to extract remaining teeth? FM-B responded yes, if it would help keep her comfortable. R12's record continued to lack evidence of oral examinations and documentation of monitoring for oral pain and or signs and symptoms of infection. From 12/15/17 to 4/12/18, the record had no mention and did not address or evaluate dental/oral health. Review of nursing progress notes (PN) and interdisciplinary team (IDT) notes from 4/12/18, through present day reflected an increase in staff observations of R12 demonstrating oral discomfort. - 4/12/18, PN, R12 lost one of her molar teeth that looked like it had rotten out. - 5/16/18, IDT, indicated grinding more - monitor tooth pain. -5/25/18, PN, R12 did not like the cold juice when taking medications. -5/26/18, PN, R12 had been grinding teeth this shift, when drinking cold liquid would pull back and get upset. R12 was asked multiple times if teeth hurt and at one point R12 did say yes. R12 will not open mouth to allow you to look at teeth. -5/27/18, PN, R12 was noted to be grinding her teeth on and off this shift, cold liquids irritate her and she pulls away. -5/30/18, PN, R12 did pull her head back while taking a drink through a straw and then stopped drinking. -5/30/18, IDT, indicated teeth? my teeth twitter yes Call Dentist. -5/31/2018, PN, when attempting to look in mouth to see current condition of teeth R12 clamped lips together and would not open mouth. -6/1/18, PN, R12 was grinding her teeth at the lunch table. -6/5/18, PN, R12 was noted to have reddened area to lower left jaw and upper right jaw, possibly due to tooth decay. Will notify family and make appointments as needed. -6/8/18, PN, R12 was grinding her teeth this shift while at the supper table, while changing into pajamas, and getting ready for bed. -6/9/18, PN, R12 pulled her head back and would shake her upper torso when trying to give food. -6/11/18, PN, R12 was noted to be grinding teeth while taking morning medications in milk. -6/11/18, PN, R12 was grinding teeth this evening while getting her PM medications. -6/13/18, PN, included teeth? in pain Despite documented concerns with teeth/oral pain, an examination/assessment of R12's oral cavity or attempts of assessment even after identification of possible signs and symptoms of infection was not completed. There was no ongoing monitoring of signs and symptoms of a possible oral infection. The physician was not notified of the notations of increased oral pain since 5/26/18, and was not notified of the signs and symptoms of an oral infection that began on 6/5/18. In addition, the record lacked evidence the family was notified R12 had lost a tooth, R12 had demonstrated an increase in oral pain, and the signs and symptoms of infection. The record further lacked evidence a dentist was contacted and/or a referral made as directed on 12/15/17, by a family member. R12's physician progress notes [REDACTED]. On 6/13/18, at 11:35 a.m. R12 was being fed in the dining room by nursing assistant (NA)-C and registered nurse (RN)-E was observing. R12 was observed making facial grimaces when drinking supplement from a straw. NA-C stated that the facial grimaces indicated that R12 was in pain although could not determine if it was related to sucking through straw or the liquids being cold. -At 12:04 p.m. RN-E stated she had spoken to son after referral on 11/28/17, and son wanted to hold off with dental referrals for awhile longer. RN-E stated at this time they were just monitoring her pain and signs or symptoms of infection daily. RN-E stated monitoring was what R12's family wishes were. RN-E verbalized there was no documentation of conversations with family. -At 12:36 p.m. RN-E was interviewed regarding progress note 6/5/18, which indicated family would be notified and appointments made as needed. RN-E stated she tried to contact FM-A and FM-B, left messages with them, had not heard back, and did not document the attempt in the record. RN-E confirmed R12's discomfort noted while drinking from a straw at lunch today could have been from dental discomfort. -At 12:45 p.m. NA-C stated R12 was showing an increase in mouth pain for the last month to month and a half. NA-C indicated R12 used to use a straw all the time and now could not without grimacing. -At 12:51 p.m. contacted family member (FM)-A who is the primary contact by telephone. FM-A stated R12 had 13 teeth pulled last year. FM-A stated there had not been any recent contact from the nursing home regarding recent signs of oral discomfort and FM-A would expect to be contacted with that concern. -At 2:33 p.m. director of nursing (DON) indicated her expectation was an appointment should have been made for R12 since she was experiencing signs of discomfort. The RN should not be awaiting contact from family as we already have the approval from them dated 12/15/17, to have teeth extracted if resident was experiencing pain. On 6/14/18, at 7:22 a.m. NA-A stated R12 made weird noises all the time, and it is common with Alzheimer's. NA-A added R12 grinds teeth. NA-A stated R12 was in pain, grinded her teeth all the time when awake and asleep. NA-A stated the pain had been reported to the RN. NA-A indicated that R12 has had decreased appetitive for awhile, however, could not recall for how long. -At 7:49 a.m. NA-C stated R12 was choosing not to eat and guessed it was related to pain. NA-C also stated R12 winced with the cold liquids and when using a straw R12 pulled back and grimaced. NA-C further stated, R12 would also do that with food too at times and at times it appeared that R12's teeth bothered her. NA-C indicated that last week, the left lower side of mouth was swollen/red and was reported to nurse. NA-C also indicated, R12 grinded her teeth most days, and would not let staff use a toothbrush but they use a diluted mouthwash and a pink swab which R12 resisted everyday by pulling her body back. NA-C then stated R12 had a little bit of a mouth odor, and there were days R12 would not eat much and on other days she would eat everything, and could not tell if it was because of her teeth or dementia. NA-A indicated that she lets beverages come to room temperature before offering and R12 takes them better. -At 8:09 a.m. NA-A entered room with breakfast tray consisting of oatmeal and carnation instant breakfast. R12 kept lips clamped shut, turned head away and verbalized no. NA-A would touch R12's lips with spoon and straw to attempt to get R12 to open mouth. NA-A indicated that R12's face appeared pink in color, but added R12 gets really warm. R12 began to take bites and drink milk, no grimacing noted or difficulty swallowing. -At 8:36 a.m. NA-A stated R12 consumed entire breakfast. NA-A made an attempt to do oral care with a pink swab and diluted mouthwash. R12 opened mouth once and sucked on swab then opened mouth again at which time NA-A placed pink swab on left side of mouth in a back and forward motion. R12 yelled out and pushed swab out of mouth. NA-A attempted to cleanse mouth three times with R12 holding mouth clamped tightly closed. -At 9:49 a.m. contacted dentist by telephone. R12 was never seen in the dentist office but dentist visited R12 on 6/21/17, at nursing home, concluding there were many teeth in need of extraction. FM-A decided only the bad teeth needed to be removed and left the molars in place. Dentist stated there have been no further consults regarding R12 and dentist does not have a contract with the nursing home. -At 10:30 a.m. activities aides (AA)-C indicated R12 had been grinding teeth. AA-C stated she usually assists R12 with eating three times a week and had not noticed any problems with cold drinks, just noticed tightness of her mouth and some sweating. No swelling of checks noted. During the last 2 weeks AA-C stated puckering/tightening of mouth increased and indicated pain could be the reason. -At 11:00 a.m. licensed practical nurse (LPN)-B stated she had not noticed grimacing/pulling away when drinking although R12 was only observed when administering medications. LPN-B stated swelling in the jaw area could be an indication of a tooth issue, which could be an infection, might require hospitalization , intravenous medications,[MEDICAL CONDITION] (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) could occur and possible death. LPN-B stated chances are pretty good that could happen with R12. When LPN-B examined R12's oral cavity she noted filled teeth and some of them were black. LPN-B indicated R12 has grinded teeth for a long time. -At 12:14 p.m. RN-E stated R12 began having dental concerns sometime last summer noting poor teeth and not allowing oral cares to be completed. The plan was to have all teeth extracted although family member intervened and requested only infected teeth be removed. RN-E believes R12 has three remaining teeth. RN-E stated R12 had recently been experiencing pain but unsure if it is dental or back issues from past accident. RN-E indicated it was difficult to examine R12's oral cavity. RN-E stated telephone conversations with family have occurred, although not documented, indicating to just keep monitoring. RN-E stated redness noted on 6/5/18, was just slight and was not reported to physician. RN-E was not able to speak regarding risks [MEDICAL CONDITION]. RN-E stated the MDS coordinator completes the oral assessments. RN-E indicated charting is not completed regarding oral cares. When asked expectation if staff reported pain to RN-E she indicated she would do an assessment, which she stated she attempted although did not document attempt and did not notify physician. -At 12:59 p.m. RN-A stated an oral exam and dental assessment is completed with annual MDS. RN-A indicated when completing R12's annual MDS (MONTH) (YEAR), no problems were noted on the assessment although she could not recall if she looked into R12's oral cavity. RN-A stated R12 had pain at the time but was unclear if dental or something else. -At 2:20 p.m. director of nursing (DON) stated a dentist should have been contacted for R12. DON confirmed a signed contract with a dentist for emergency services did not exist. DON stated the family should have been contacted and there should have been documentation regarding any conversations with family. It would be expected that risk and benefits should have been discussed with family. Attempts to contact FM-B were unsuccessful. Dental Services procedure dated 3/9/17, indicated oral health review will be completed with the data collection annually. Residents will be promptly referred to a dentist. Pain policy dated 3/1/17: · directed physician and staff to identify individuals who have pain or who are at risk for having pain related to oral or dental pathology. · nursing staff will assess when there is onset of new pain or worsening of existing pain. · nursing staff to assess pain using a consistent approach and a standardized pain assessment instrument · nursing staff will observe resident (during rest and movement) for evidence of pain · the staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, including complication such as sleep/rest, social activities, appetitive. · the physician will help identify causes of pain; for example by examining the resident directly, reviewing history, and discussion with staff. · nursing staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for newly identified pain. Pain Assessment and Management procedure dated 3/1/17: · pain management includes: assessing the potential for pain, effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions, modifying approaches as necessary, conduct a comprehensive pain assessment quarterly, when there is onset of new pain or worsening of existing pain, assess the resident's pain and consequences of pain at least each shift for acute pain. · report the following information to physician: significant changes in the level of the resident's pain, adverse effects from pains medications, prolonged, unrelieved pain despite care plan interventions.

Based on observation, interview and document review, the facility failed to ensure each resident was evaluated for therapy or restorative services upon changes in their condition and was provided with ambulation services when recommended, to prevent an avoidable decline, for 2 of 4 residents (R20 and R55) reviewed for ambulation services. This practice resulted in actual harm for both R20 and R55, when they each experienced an avoidable decline in their ability to ambulate. Findings include: R20's ambulation abilities declined from limited to extensive assistance and she was not re-assessed to evaluate her potential benefit from a therapy or restorative service program. R20's [DIAGNOSES REDACTED]. R20's admission plan of care (POC) dated 1/17/10, identified she required limited assistance from staff for transfers and walking in hallways. The POC indicated a goal for R20 to continue to ambulate safely in the facility hallways, with assistance or supervision. The POC approaches included providing step-by-step instructions during ambulation as needed, keeping the area free from clutter and encouraging her to stand upright while walking. Staff were instructed to observe R20 for good endurance and steady gait. The ambulation/walking goal was noted as discontinued, however, the record lacked a date to identify when it was discontinued. The activities of daily living (ADL) Care Area Assessment (CAA) dated 10/26/12, indicated R20 required supervision with ambulation. R20's care conference notes from the director of nursing (DON) dated 4/30/13, indicated her condition was declining due to dementia. The notes identified R20 was able to ambulate at times with assistance, but impulsively attempted to sit on the floor. The summary indicated R20 was combative with cares and pushed herself back when staff attempted to assist her with standing. A standing lift was increasingly required for transfers due to this behavior and R20 needed her wheelchair more often due to her refusals to walk and her inability to follow simple instructions. The care conference history from social services dated 4/30/13, indicated R20 was no longer up and wandering throughout the facility. The history revealed staff had been using a wheelchair because R20 was too difficult to stand-up. The current POC (undated), identified R20 required extensive assistance from two staff for transfers, toileting and for the use of a standing lift. The POC included a problem start date of 5/17/13, noting R20 had a Velcro seat belt alarm in place to prevent falls due to her poor safety awareness, impulsivity and physical/cognitive impairments. The goal was for R20 to have no negative outcomes from the use of this restraint. Approaches included checking the restraint every hour and releasing it every two hours to allow for toileting and repositioning. The quarterly Minimum Data Set ((MDS) dated [DATE], identified R20 had severe cognitive impairment and required extensive assistance from two staff for transfers and mobility. The MDS also indicated R20 had a trunk restraint which was used daily. The MDS revealed R20 required extensive physical assistance from one staff for locomotion on the unit and off the unit. Throughout the survey conducted on 9/16/13, from 2:30 p.m. until 8:00 p.m., on 9/17/13, from 8:00 a.m. until 4:30 p.m., on 9/18/13, from 7:00 a.m. until 4:30 p.m. and on 9/19/13, from 7:00 a.m. until 2:30 p.m. respectively, R20 was observed to sit in a wheelchair with a seat belt fastened (trunk restraint) when up. On 9/18/13, R20 was observed to be up, in her wheelchair at 7:20 a.m., seated at the dining room table. She remained there until 9:00 a.m., when she was wheeled into a day room area, in front of the television. At 9:55 a.m., nursing assistant (NA)-M wheeled R20 into the tub room and at 10:00 a.m. R20 was transferred to the toilet utilizing a mechanical, stand-up lift. NA-M stated that R20 needed to be transferred with a mechanical lift at all times and could not transfer without the lift. NA-M added that R20 could hardly bear weight for a transfer. During interview on 9/19/13, at 9:35 a.m. the physical therapist (PT)-B reported that if a resident was refusing ambulation and there had been a decline, there should have been documentation as to why the resident was not receiving any services. PT added that the facility needed to reassess such a resident at some point and attempt to provide services. During observation and interview on 9/19/13, at 10:20 a.m. NA-J was observed to wheel R20 into her resident room, unfastened her seat belt and transferred her to the toilet with the stand-up lift. NA-J stated R20 had not walked independently for a long time and was not able to walk any more, not even to take a few steps to the bathroom. On 9/19/13, at 11:15 a.m. registered nurse (RN)-A stated R20 used to walk continuously and wander in the facility's secured unit. RN-A added that R20 was unpredictable and unsteady. She reported R20's decline in ambulation was gradual. RN-A reported R20 had moved off the secured unit on 6/11/13, and was not walking at that time. RN-A verified R20's record lacked a comprehensive assessment of her ability to transfer or walk. She also verified R20 should have been referred to therapy for development of interventions to prevent a further decline in her ambulation abilities. RN-A verified R20 was not currently receiving any form of rehabilitation services or restorative nursing. On 9/19/13, at 12:05 p.m. RN-B confirmed R20 was able to stand up and walk on her own in the past, but no longer walked or transferred without the use of a mechanical lift. RN-B verified R20's record lacked a comprehensive assessment to determine whether R20 might have benefited from a nursing rehabilitation program. She also verified the record lacked documentation about the risk verses benefit of R20 having refused to participate in a rehabilitation program. RN-B stated that it appeared as though R20 had declined and she was not provided with any rehabilitating services. On 9/19/13, at approximately 1:05 p.m. the DON verified R20 did not ambulate anymore and this was why she was moved to a different household. The DON did not know whether R20 had been re-assessed to determine her potential benefit from therapy or restorative services. R55's ambulation program was not followed, which resulted in a decline of her ability to ambulate. R55's [DIAGNOSES REDACTED]. The PT progress note dated 4/19/12, indicated R55 was able to walk 200 feet with a front wheeled walker (FWW) and required a restorative nursing plan for ambulation. The fall risk CAA dated 5/2/13, indicated R55 had dementia, was confined to a wheelchair and had a lap restraint in place while in her wheelchair to prevent falls. The Activities of Daily Living (ADL) CAA dated 5/2/13, indicated R55 required extensive assistance with transfers, wheelchair mobility and ambulation. The 7/11/13, physician's telephone order indicated R55 was to walk to all meals with contact-guard assistance and a FWW. R55's current POC dated 7/12/13, indicated staff were to assist her with ambulation to and from all meals, provide contact guard assistance and use her gait belt and FWW. The PT note dated 7/24/13, indicated R55 was discharged from PT services due to a plateau with progress and significant confusion. The PT note indicated R55 was to be ambulated by nursing staff for 120 feet with a FWW. The note instructed that moderate assistance was to be provided and a wheelchair was to follow closely behind her for ambulation to the dining room for meals, as able. The quarterly MDS dated [DATE], indicated R55 was moderately cognitively impaired. The MDS also noted that R55 required staff assistance for bed mobility, transferring and ambulation. The current physician's orders [REDACTED]. The order noted recommendations for staff to assist her with all transfers and ambulation with a FWW. Nursing was to assist R55 with ambulating to all meals with a FWW. On 9/19/13, at 9:40 a.m. NA-A verified that any blanks on the Restorative Nursing flow sheets indicated R55 did not receive ambulation services during that shift. On 9/19/13, at 1:30 p.m. RN-A verified R55's POC was accurate, but was not consistently implemented. On 9/18/13, at 7:10 a.m. R55 was observed in the dining room, seated in her wheelchair with a lap belt (restraint) attached to the chair, preventing R55 from standing. At that time, NA-A was observed to wheel R55 into the dining room. At 9:10 a.m., NA-A was observed to wheel R55 to her room and assisted her to the bathroom. NA-A assisted R55 to a standing position using a transfer belt. R55 was observed to stand and walk very slowly for approximately ten feet before sitting down on the toilet. R55 required verbal cuing from NA-A while ambulating. At 12:50 p.m., R55 was observed sitting in her wheelchair at the dining table, when NA-A wheeled her to her room. R55 ambulated with a transfer belt, slowly. NA-A had to verbally cue R55 to walk to the toilet. R55 was observed to ambulate approximately eight feet. NA-A stated R55's ability to walk varied from day-to-day and this day was a good day. On 9/19/13, at 12:35 p.m. NA-G stated she had cared for R55 on the evening of 9/18/13. NA-G stated R55 could hardly stand up and there was no way she could have ambulated her to the dining room. Review of the Restorative Nursing Program flow sheets from 7/11/13, through 9/17/13, instructed R55 was to be ambulated to and from meals with contact guard assistance and a FWW, three times a day. The flow sheets indicated the following: From 7/11/13, through 7/31/13: -At breakfast time, 14 out of 20 opportunities were blank and for six out of 20 opportunities R55 was ambulated 100 to 150 feet. -At lunch time, 14 out of 20 opportunities were blank and for six out of 20 opportunities R55 was ambulated 100 feet. -At supper time, 20 out of 20 opportunities were blank. From 8/1/13, through 8/31/13: -At breakfast time, 16 out of 31 opportunities were blank, five of the 31 opportunities indicated no ambulation had taken place and for five of the 31 opportunities R55 was ambulated eight to ten feet. -At lunch time, 23 out of 31 opportunities were blank and five out of 31 opportunities had zero feet documented. -At supper time, 23 out of 31 opportunities were blank and eight out of 31 opportunities had zero feet documented. From 9/1/13, through 9/17/13: -At breakfast time, for two out of 17 opportunities R55 was ambulated 15 feet, six out of 17 opportunities had zero feet documented and eight out of 17 opportunities were left blank. -At lunch time, for one out of 17 opportunities R55 ambulated 15 feet, eight out of 17 opportunities had zero feet documented and eight out of 17 opportunities were left blank. -At supper time, for one out of 17 opportunities R55 ambulated 60 feet, two out of 17 opportunities had zero feet documented and 14 out of 17 opportunities were left blank. On 9/19/13, at 9:40 a.m. NA-A stated R55 could only walk to and from the bathroom in her room, and that was on a good day. NA-A reported it had been about two months since R55's ambulation began to decline. NA-A revealed he had informed the charge nurse of the decline and stated it had been discussed at R55's care conference, so the staff were aware. NA-A verified that any blanks on the Restorative Nursing flow sheets indicated R55 did not receive ambulation services during that shift. On 9/19/13, at 11:40 a.m. licensed practical nurse (LPN)-A stated R55's POC for ambulation was accurate. On 9/19/13, at 1:30 p.m. RN-A verified R55's POC was accurate. She added, R55 had a decline in ambulation and would need to be re-evaluated by the RN rehabilitation coordinator. The facility's Restorative Nursing Policy dated 1/6/13, directed each resident was to be provided with the opportunity to regain skills and abilities lost due to illness and disability. Therefore, each resident was to be evaluated after a significant change in condition for the potential benefit of participating in a restorative nursing program. Nursing was to collaborate with rehabilitation therapists in developing a restorative nursing program that could be implemented to improve each resident's ability or prevent a decline in ability. The policy added that residents had the right to refuse restorative services and information about how the services could have improved the resident's well-being was to be provided.

Based on observation, interview, and record review, the facility failed to ensure appropriate interventions and supervision to minimize falls/accidents had been implemented for 1 of 3 residents (R59) reviewed with falls. This practice resulted in actual harm when R59 sustained a right hip fracture. In addition, the facility failed to provide a planned assistive device in an attempt to minimize falls for 1 of 3 residents (R26) in the sample identified at risk for falls. Findings include: R59 fell 3 times within a 10 day period during the first 19 days following her admission to the facility. The facility failed to complete a comprehensive assessment of causal factors and risk factors to determine and implement appropriate interventions and supervision to minimize the risk for further falls or injury related to falls on 5/18/11, and 5/24/11. R59 sustained actual harm from a third fall on 5/28/11, which resulted in a right hip fracture. R59 was admitted [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], indicated R59 had memory and cognition problems. The MDS identified R59 required supervision with walking outside the room, limited assistance with hygiene, transfers, mobility, and walking in the room, and extensive assistance with toileting. The MDS indicated R59's balance during transitions and standing was "not steady, but able to stabilize without human assistance." According to the MDS, R59 did not have a history of falls within the last 6 months prior to admission, and at that time, had no falls since admission to the facility. The Falls Care Area Assessment (CAA) dated 5/16/11, identified R59 was at risk for falls due to requiring limited assistance for transfers, had an unsteady gait, had memory problems and was impulsive. It identified R59 was at risk for injury from falls and had a chair alarm in place and was working with physical and occupational therapy (PT and OT). The CAA indicated staff would assist R59 to the toilet as needed and "remind resident frequently to call for help before transferring." However, the Communication CAA dated 5/16/11, identified R59's problems with making self understood, and ability to understand others was impaired. The Urinary Incontinence CAA dated 5/16/11, identified R59 needed extensive assistance from staff with "toileting process." It indicated R59 was at risk for incontinence and falls, was able to ask for help to use the toilet, and wore small pads for protection in case of dribbling. It also indicated R59 was on HCTZ (hydrochlorithiazide, a diuretic medication used to treat high blood pressure) for hypertension. The temporary plan of care (POC) in template (check box) format initiated 5/9/11, identified R59 had forgetfulness and intermittent confusion. The POC indicated R59 required assist of 1 with transfers, ambulation, and positioning/repositioning. The POC included an area to address the resident's fall risk which was not checked. The directions under that section read, "If yes, implement safety measures." The "safety measures" and "special need" areas were blank. Under the bowel and bladder section the box was checked continent and the remainder of the section was blank including how much assistance was needed, or if the resident was on a timed schedule for toileting. The computer version POC dated 5/19/11, contained the following areas: cognition, communication, psychosocial, nutrition, activities, and spirituality. R59 was identified as having moderately impaired cognition and difficulty expressing thoughts and needs. Staff was directed to provide cues and supervision as needed each day for safety. Neither care plan addressed if R59 had the ability to use a call light appropriately, nor did the POCs include R59's recent fall history, any fall interventions, need for assistance with toileting, current UTI and associated symptoms, the need to monitor a diuretic/blood pressure lowering medication (HCTZ) which was new for R59 as of 5/17/11, or to monitor for side effects from the new pain medication also started 5/17/11, which had the potential to cause sedation. On 6/8/11, at 1:05 p.m. R59 was observed sleeping on her back in a low bed, call light attached to resident, bed alarm in use, and mats on the floor on both sides of bed. During random observations between 1:25 p.m. and 3:45 p.m. R59 remained the same, and while observed made no attempts to get out of bed. On 6/9/11, at 7:00 a.m. R59 was observed dressed, seated in a wheelchair (w/c) in the living room. R59 had an lap buddy (device attached to the wheelchair to prevent from rising) equipped with an alarm function and chair alarm present on w/c. At 8:00 a.m. and 8:30 a.m. R59 remained the same. During those observations, R59 made no attempts to get out of the wheelchair. Record review included the following: Admission nursing notes dated 5/9/11, identified R59's disorientation, memory problems, and need for extensive assist from one staff with ADLs (activities of daily living). PT notes dated 5/10/11, indicated R59's memory and cognition are "limiting progress at this time." Nursing notes dated 5/10/11, indicated R59 "needs to be checked on frequently as she gets up by herself and does walk away from activities and in room by herself. Continues to need help of 1 person with ADLs." Nursing notes dated 5/11/11, indicated R59 was up several times during the night and needed assist of 1 with ADLs and a lot of cues due to confusion. OT notes dated 5/13/11, identified R59 required maximum assist for clothing management before sitting on the toilet and all transfers were CGA (contact guard assist). The OT indicated R59 was "still showing significant confusion such that she will continue to require assistance with ADL completion due to poor safety/risk identification placing her at increased risk for falls and injury." R59's Bowel and Bladder assessment dated [DATE], indicated R59 was continent, required assist of 1 staff to transfer on/off toilet, and would be asked every 2 hours to go to the bathroom. The cognitive awareness section on the assessment identified R59 was able to use the call light at all times and had the ability to ask to go to the toilet at all times. R59's Fall Risk Assessment form completed 5/14/11, identified a risk of falling. Nursing notes from 5/14/11, indicated R59 was, "up and down a lot and very unsettled." Nursing notes dated 5/15/11, indicated R59 was up to the toilet per self. Another nursing note from 5/15/11, indicated R59's daughter requested a urinalysis since R59 was voiding more often than usual. PT notes from 5/16/11, indicted R59 continued to require extensive assist for safety. Physician's progress notes dated 5/17/11, indicated R59's blood pressure had been elevated, she had complained of left shoulder pain, and was diagnosed with [REDACTED]. Therefore, the physician started R59 on hydrochlorithiazide, Neurontin (a medication used to treat nerve pain), and amoxicillin (an antibiotic). In regards to the Neurontin, the physician's note read, "I warned the nurses that this much might cause sedation, so if it is creating too much sedation, we will need to readjust the dosage and they need to let me know." However, no indication of monitoring the UTI symptoms, or monitoring of the new medications actions or side effects were documented in R59's record. OT notes dated 5/17/11, indicated R59 tolerated all activity poorly and identified R59 a significant risk for safety with ADL completion due to cognition. OT notes dated 5/18/11, indicated R59 would "need to remain in 24 hour supervised care due to low cognitive function to allow safety with all ADL completion." OT was discontinued. The record documented R59 had sustained 3 falls: 1. Nursing notes dated 5/18/11, indicated R59 was found sitting on floor in the doorway of her room that morning. No injuries were noted. The note indicated R59 did not know how she got there due to confusion. New interventions included a bed alarm as R59 already had a chair alarm. The note indicated R59 was started on Neurontin the prior day, also HCTZ for high blood pressure, and R59 continued on amoxicillin for UTI. The evaluation section on the Observation Report/Post Fall Assessment form dated 5/18/11, indicated R59 was confused, got up on her own without using the call light. The nursing notes and Observation Report/Post Fall Assessment failed to include the time the fall occurred, if the alarm sounded, what the resident had been doing prior to the fall, when the resident had last been to the bathroom, or if the new medications were being monitored for effectiveness or side effects. Social services notes dated 5/19/11, indicated the IDT (inter-departmental team) met and R59 would be moved to a room closer to central area due to risk of falling. However, documentation indicated no other new interventions were initiated at that time to try minimize the risk for further falls. 2. An Event Report dated 5/24/11, indicated R59 fell at 2:31 p.m. R59 was found sitting on the floor in the bathroom. The report indicated R59 had been sitting in her wheelchair (w/c) in her room prior to the fall. No injuries were noted. A w/c alarm was indicated as being in use at the time of the fall, however, the Event Report and nursing notes failed to indicate if the alarm sounded to alert staff. The Event form identified the interventions of chair alarm and bed alarm as "somewhat effective" and "resident non-compliant with alarms." The Event Report and nursing notes also failed to address when the resident had last been assisted to the bathroom. However, documentation was lacking to indicate appropriate care plan interventions had been developed and implemented by staff to try minimize the risk for further falls. The nursing assistants (NA) daily forms used to record continence/incontinence status for those residents on a toileting schedule were requested from 5/9-5/28/11, and R59 had not been included on those forms. An IDT note by social services dated 5/26/11, indicated staff had been trying to have R59 sit out in the living room area more because she was trying to get up and transfer herself when in her room by herself. 3. An Observation Report/Post Fall assessment dated [DATE], indicated R59 fell at 6:00 a.m. The documentation included, "At 6 a.m. resident's alarm sounded. Staff found her lying on floor beside bed, she stated she had been up to bathroom and was going back to bed when she fell ." The report indicated R59 was barefooted and had pajama pants pulled only halfway up. R59 complained of right hip pain and an ambulance was called. Nursing notes dated 5/28/11, indicated R59 sustained a right hip fracture which required surgery. Nursing notes dated 6/1/11, indicated R59 returned to the facility on [DATE]. On 6/8/11, at 2:55 p.m. NA-B stated everyone was on a 2 hour toileting schedule, and R59 had been on an every 2 hour toileting schedule since admit. She added at first it was just to remind the resident, but now it was to help her. She stated R59 does not try to get up out of bed or out of the chair at all anymore. On 6/10/11, at 8:00 a.m. LPN-C stated R59 had been frequently getting up without assistance. LPN-C stated R59 would forget she had a CVA and would attempt to get up and walk, and 2 minutes later staff had to remind her again. LPN-C stated R59 was not steady, and had needed to be assisted with one staff for transfers. On 6/9/11, at 7:25 a.m. RN-A stated R59 was confused upon admit, and would forget right after staff would tell her something. RN-A stated weakness was the main cause of R59's falls. RN-A stated R59 was not on a scheduled toileting program, but should have been since, "she obviously wasn't calling for help very good." RN-A stated they had considered the fact that R59 was on new meds but, "didn't take the time to monitor for side effects" and added staff know residents are going to need to urinate more when they are on a diuretic. However, when RN-A was asked if they had considered scheduled toileting as a fall intervention, RN-A stated maybe R59 should have been toileted more than every two hours. She added if the resident was asking more frequently to go, she maybe should have been on an hourly schedule because she was going that often. At 8:05 a.m. RN-A stated she did not know if staff were toileting R59 every 2 hours or not, and did not know what exactly staff were doing on the night shift. RN-A stated R59 should have been on the toileting schedule right away as she was confused and obviously did not use her call light. RN-A added, "That's where she fell too." (in the bathroom on 5/24/11). RN-A stated R59 should have been "at least on the NA care plan to be checking every 2 hours," but verified that information was not on the care plan or NA care plan. RN-A stated, she had not paid "close enough attention" to which residents were on the toileting schedule. RN-A verified all causal factors had not been considered after R59's falls on 5/18, and 5/24/11. She added, the post fall assessment forms did not ask about toileting, so they had not been considering that. On 6/10/11, at 8:50 p.m. RN-A and RN-B were interviewed. RN-B stated upon admit, the resident's daughter (D-A) told him R59 had no history of falls. RN-B stated R59 had needed extensive assistance with toileting as she could not get her pants back up. RN-B stated normally if someone needs extensive assist they would be on the toileting list. RN-A stated she thought R59 did not ask to go to the bathroom, waited too long, and then tried to go on her own on the morning of 5/28/11. At 9:00 a.m. RN-B stated R59 had attempted to get up and walk and go to the bathroom on her own. RN-A then stated she did not know how long R59's alarm had been going off the morning of 5/28/11. RN-A stated it happened at 6:00 in the morning and the charge nurse was usually around then. RN-A stated at that time of the day there was 1 NA for both wings and normally there was a float NA that came in at 5:00 a.m., but that person had not come in, so they were short that day. RN-A stated the fall could have been due to lack of supervision. On 6/9/11, at 7:57 a.m. the DON stated prior to R59's hospitalization , she was supposed to walk with assistance, but her mental status had not been good so she would get up and attempt to go on her own. The DON added she thought R59 had some bladder incontinence because she wore a pad and stated, "typically anyone who wears a pad is toileted every two hours." The DON stated they did not have a NA care plan from the time-frame of the falls as they were up-dated every night. The DON verified R59 had needed extensive assist for ADLs to ensure her safety. On 6/10/11, at 10:15 a.m. the DON stated R59's root cause of the falls was that she had a UTI and was probably more confused. The DON stated R59 was not calling for help before going to the bathroom and she should have been on a toileting schedule. When asked about additional interventions such as supervision, the DON stated the facility was unable to provide "1:1's" for supervision unless it was for a resident with behavior R26 was identified through a comprehensive falls assessment to require an alarming seat belt alarm. However, the alarming seat belt was not observed to be utilized through out the survey. R26 was diagnosed with [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R26 had cognitive impairment and required extensive assistance from staff with toileting and mobility. The MDS further identified R26 did not have any falls since the last assessment period. The Falls Risk assessment dated [DATE], indicated R26 was at risk for falling due to history of falls, [DIAGNOSES REDACTED]. On 6/8/11, at 2:50 p.m. no alarming seat belt observed attached to R26. At this time, R26 stated she does not utilize a seat belt in her wheelchair. On 11/23/10, at 7:10 p.m. the safety event (a review of the fall) indicated R26 had fallen in her room when she fell out of her wheelchair. No injury was sustained and R26's wheelchair alarm was functioning appropriately at the time. On 11/24/10, the fall review committee documentation determined after an assessment of the fall, an alarming seat belt would be appropriate as a fall intervention for R26. No additional interventions were implemented at that time. The record did not indicate the alarming seat belt was utilized at that time. On 5/12/11, at 3:39 p.m. the safety event indicated R26 was found in the floor of her bathroom. No injury was sustained and R26's wheelchair alarm was functioning appropriately at the time. On 5/18/11, the fall review committee documentation determined after an assessment of the fall, an alarming seat belt would be reapplied. No additional interventions were implemented at that time. No documentation in the record indicated the alarming seat belt was ever applied. In addition, the plan of care was not revised regarding the use of the alarming seat belt. On 6/8/11, at 2:56 p.m. nursing assistant (NA)-E stated the interventions to prevent falls for R26 were bed and chair alarms and a 2 hour toileting program. She stated R26 is often attempting to self transfer to the toilet and sets off her chair alarm during the day. She added R26 does often remember to use the call light, but not always. On 6/9/11, at 9:31 a.m. NA-A stated he recalled R26 utilizing an alarming seat belt in the past, but added he thought it was maybe a year ago. NA-A stated R26 did not utilize an alarming seat belt at this time. He added R26 attempted to self transfer to the bathroom frequently. NA-A stated R26 will use the call light, but often sets off her chair alarm when attempting to self transfer. At 11:16 a.m. registered nurse (RN)-B stated he was unaware of R25 utilizing an alarming seat belt and he did not ever remember her having one. He stated R26 frequently attempts to self transfer to the bathroom. At 12:24 p.m. RN-A stated she participates in the fall committee at times but could not remember the discussion related to the use of an alarming seat belt for R26. She added she does not think she ever had one and verified it was not on the plan of care. At 1:46 p.m. the director of nursing (DON) stated usually an RN is at the falls committee and she would expect them to implement the interventions determined by the committee. The DON recalled the falls committee, consisting of occupational therapy (OT) and nursing, felt the alarming seat belt would be a reminder for R25 to call for help because she often does remember to call. The DON stated she felt the alarming seat belt would work for R26. The DON stated she told NA-A to place the alarming seat belt. She verified the alarming seat belt was not care planned or implemented. She stated she should have followed up on it. The DON added she felt this was an appropriate intervention determined by assessing R26's falls and should be implemented.