**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, the facility failed to further assess and intervene after a change in mental status after a fall for 1 of 4 residents reviewed for assessment and intervention (Resident #2). The facility reported a census of 42 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated [DATE], listed diagnoses for Resident #2 which included high blood pressure, stroke, respiratory failure, insomnia, and cognitive communication deficit. The MDS stated the resident was independent with walking and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. A [DATE] Care Plan entry stated the resident was independent with walking in his room. A [DATE] Family Practice clinic note stated the resident had no cognitive impairment and no disorientation to person, place, or time. A [DATE] at 12:30 a.m. untitled nursing note stated staff found the resident on the floor. The resident stated he was trying to get up and sustained a hematoma (bruise) to the right eyebrow and skin tears to the right eyebrow, right elbow, and right hand and an abrasion to the right knee. Nurse charting revealed the facility conducted neurological assessments at the following times with normal results: [DATE] 1:30 a.m. [DATE] 2:30 a.m. [DATE] 3:30 a.m. [DATE] 9:09 a.m. [DATE] 11:28 a.m. [DATE] 11:13 p.m. [DATE] 3:26 a.m. A [DATE] 9:27 a.m. untitled nursing note stated the resident was alert and oriented x 2 and stated the town was Channel 9. A [DATE] 3:14 p.m. untitled nursing note stated the resident was alert and oriented to self and month. A [DATE] 7:30 p.m. untitled nursing note stated staff went into the room to administer medications and the resident responded but did not open his eyes. A [DATE] 8:10 p.m. untitled nursing note stated the resident sat in the recliner and frothed at the mouth with apneic spells (periods of not breathing). The resident had blue hands and was sluggish with fixed pupils. Staff was unable to obtain a blood pressure and obtained an order to send the resident to the hospital. The resident had a pulse when the ambulance arrived but when they listened to the apical pulse(a pulse point on the chest at the bottom tip of the heart), it was absent and the resident had no respirations. The paramedics initiated Cardiopulmonary Resuscitation(CPR). The resident's pulse and blood pressure were restored at the hospital. A [DATE] 11:22 p.m. untitled nursing note stated the facility was notified at 10:52 p.m., that the resident passed away. The facility lacked documentation of provider notification or further assessment and intervention after the resident had a mental status change during the [DATE] 9:27 a.m. and [DATE] 3:14 p.m. assessments. The undated facility policy Charting Protocol directed staff to notify the physician when a behavior change occurred. On [DATE] at 1:05 p.m., the Director of Nursing (DON) was queried with regard to her expectations if a resident had a change from alert and oriented x 4 (person, place, time, and situation) to not being able to state the town. She stated that if there was a change, she would expect staff to notify the physician. On [DATE] at 10:11 a.m., via phone, Staff C Doctor of Medicine (MD) stated he would have wanted staff to inform him and the resident's family of the resident's mental status changes.

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to ensure staff utilized a gait belt in accordance with the care plan for 1 of 3 residents reviewed for transfers(Resident #1). The facility reported a census of 42 residents. Findings include: 1. The Annual Minimum Data Set(MDS) assessment tool, dated 4/4/24, listed diagnoses for Resident #1 which included heart failure, arthritis, and Alzheimer's disease. The MDS stated the resident required supervision or touching assistance with toileting hygiene and toileting transfers. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 13 out of 14, which indicated intact cognition. The facility Gait Belt Policy, reviewed 1/5/24, directed staff to utilize a gait belt with all residents who required any physical assistance to stand, transfer, or ambulate, unless contraindicated as identified on the care plan. Each staff member will have a gait belt readily available for use when on duty. A gait belt will be provided to staff upon hire. A 2/20/24 at 1:21 a.m. Progress Note documented the resident was on her back on the floor and fell trying to reach her tissues. A 3/2/24 11:23 p.m. Progress Note stated the resident was on the floor and tried to pick up tissue paper from the floor and lost her balance. A 3/11/24 Progress Note stated the resident sat on the floor next to her bed and stated she reached for a mint when she slid out of bed. A 4/6/24 untitled nursing progress note stated the resident was seated on the toilet and staff attempted to assist her to a standing position when the resident sat back down after only raising up approximately an inch. The resident stated she would need more help than that and staff used more effort in the next assist. The resident was unable to straighten her knees and moved in a forward motion. The staff member was able to slow the resident's motion but was unable to prevent the resident from kneeling on the floor in front of the toilet. On 4/16/24 at 2:23 p.m., staff walked the resident from her room to the shower room utilizing a gait belt. On 4/16/23 at 3:00 p.m., Resident #1 stated on the night of the fall, she had to go to the bathroom and a staff member kept pulling on her arm to get her off the toilet. She stated she ended up falling on the floor in her own urine. She didn't know the staff member's name but stated she was never rough or unkind but she was in a hurry. She stated she did not feel the staff member was intentionally being mean but stated she was supposed to utilize a gait belt and did not. The current undated Care Plan as of 4/17/24 stated the resident required the assistance of 1 staff with ambulation and transfers. On 4/17/24 at 10:47 a.m., via phone, Staff A Certified Nursing Assistant (CNA) stated Resident #1 required the assistance of 1 staff and could be a difficult transfer. On 4/18/24 at 10:54 a.m., via phone, Staff B Registered Nurse (RN) stated on the night of the fall, the resident was in bed and needed to go to the bathroom. She reported the resident started walking to the bathroom with her walker. Staff B assisted the resident to pull down her pants and sit on the toilet. She stated when she was finished she (Staff B) took the resident under her arm in order to attempt to help her stand up and the resident could not. Staff B stated the resident then looked at her and stated she needed more help than that. Staff B stated (on the second attempt) the resident's knees did not unbend and instead of standing, the resident went forward almost head first and she could not prevent her from going to the floor. Staff B reported she assessed her for possible injuries and then other staff members assisted her off the floor. Staff B stated that the resident required the assistance of 1 staff with a walker and stated she would normally use a gait belt with her. She stated she did not use a gait belt with the resident on the night of the fall because she did not have one with her. On 4/18/24 at 1:05 p.m., the Director of Nursing (DON) stated if a resident required the assistance of staff for transfers, staff should utilize a gait belt. She stated if staff did not have a gait belt, they should locate one to use in the transfer.

Based on clinical record review, observations, staff interviews and policy review the facility failed to provide complete perineal (groin and bottom) cares in a way to prevent contamination following an incontinent episode for 1 of 3 residents observed for incontinent cares (Resident #12). The facility reported a census of 37 residents. Finding Include: The Minimum Data Set (MDS) Assessment for Resident #12 completed on 9/07/23, included diagnoses of non-Alzheimer's Dementia, Diabetes Mellitus, and renal insufficiency/renal failure/end-stage renal disease. The Brief Interview for Mental Status (BIMS), revealed score of 2 out of 15 indicating severe cognitive impairment. The MDS identified the resident required total dependence with two or more staff assistance for toileting and extensive assistance of one staff for dressing and personal hygiene tasks. The MDS documented the resident always incontinent of urine and frequently incontinent of bowel. Resident #12's Care Plan, revised 9/18/23, revealed focus areas for alterations in elimination: bowel incontinence and bladder incontinence and focus area for self-care deficit. On 10/03/23 at 10:06 AM, Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA transferred Resident #12 to the toilet. Staff B removed Resident #12's brief soiled from urinary incontinence. Staff A and B removed gloves, performed hand hygiene, and applied new gloves. Staff A helped stand Resident #12, Staff B wiped bottom and continued to use the same wipe multiple times after wipe become soiled with bowel movement (BM). Staff B failed to complete incontinent cares on Resident #12's front (groin) area following urinary incontinence. Staff B continued to wear same gloves after cleaning BM to apply a clean brief, manage resident clothing, and move the stand lift towards wheelchair. On 10/03/23 at 10:15 AM, Staff B, CNA, reported hand hygiene and glove change are expected when entering and exiting a resident room and after removing a soiled brief. Staff B confirmed urinary incontinence to be the reason she removed the original brief. On 10/05/23 at 10:45 AM, the Director of Nursing (DON) stated she expected the staff to change gloves and perform hand hygiene after touching soiled surfaces or when gloves become contaminated, before a clean brief and clothing is touched. The DON stated that she expected wipes to be thrown away after one use, not used multiple times following contamination. Facility provided a document titled, Nurse Aide Skills Checklist: Provide Incontinent Care, dated 7/2007, which instructed to remove gloves and reapply if soiled with BM or vaginal discharge and to change cloth or cloth surface with each wipe.