**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 3/18/25, 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide toileting cares in a dignified manner for 1 of 1 resident (R12) reviewed for dignity. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 was severely cognitively impaired and R12 was dependent (helper performed all the effort and resident does none of the effort to complete the activity) for toileting and bed to chair transfers. R12 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene. R12's care plan dated 8/9/24, identified R12 was cognitively impaired and required assist of two staff for ceiling lift transfers. 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. 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 stated she 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 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 two with ceiling lift transfers. Residents were being left alone in the lifts in the bathrooms 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 nor was it dignified.R12 had a history of depression as well. During an interview on 10/30/24 at 9:44 a.m., NA-C stated the facility was always short staffed. NA-C stated she had heard about an incident where R12 was left alone in the bathroom because staff were answering call lights because there wasn't enough staff. During an interview on 10/30/24 at 1:25 p.m., NA-B stated R12 reported the bathroom incident to her, and NA-B reported it to the nurse. After that, NA-B didn't know what happened. During an interview on 10/30/24 at 2:39 p.m., the social worker designee (SWD)-A stated she was informed of R12's bathroom incident and staff were expected to not leave residents unattended in the bathroom to ensure resident's safety and to provide comfort to the resident. However, there was no documented grievance for R12's concerns or follow up. During an interview on 10/30/24 at 6:21 p.m., the administrator stated staff were expected to provide cares in a dignified manner to maintain the resident's individuality and to provide comfort. A facility policy regarding dignity was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed ensure a voiced grievance was acted upon; and provide a written policy for how the facility would handle grievances for 1 of 1 resident (R20) reviewed for missing property Findings include: R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 was cognitively intact and demonstrated no delusional behavior and/or thinking. The facility 8/7/24, resident council minutes identified R20 was missing a long white, [NAME] nightgown that had been gone for an undetermined length of time. On 10/30/24 at 9:58 a.m., during a resident council discussion R20 stated she reported a missing night gown a few months ago at a resident council meeting. R20 stated she asked staff about the gown a couple weeks ago but had not received any follow up. An interview was completed on 10/30/24 at 2:45 PM, with environmental services manager (EVS) and laundry aide (LA)-A. LA-A stated in August 2024, the facility changed the laundry process, and all personal and facility laundry was done in the large laundry room and not on the units as previously done. Staff and/or family were instructed to label all the residents clothing and any unlabeled and/or unclaimed items were folded/hung on the cart and brought to the units for the nurses, residents, and family to look through and identify. EVS stated residents/families/staff notified the laundry staff of missing items. Residents also voiced concerns of missing items during resident council and laundry staff were notified to watch for the item/s. After an undetermined amount of time, the concern would be discussed with administration to make a decision regarding compensation. During interview on 11/4/24 2:32 p.m., nursing assistant (NA)-E stated staff would search for any missing items and notify the nurse and laundry staff. NA-E was unaware that R20 was missing a night gown and was uncertain if there was a form to fill out for missing items. During interview on 11/4/24 at 1:52 P.M., the activities director (AD) stated when missing items were brought to resident council meetings she would make a note in the minutes, highlights the concern, and placed a copy of the minutes in the appropriate manager's mailbox as well as the director of nursing (DON)'s for follow up. If the concern came up again at future resident council meeting would make another note in the minutes and place a highlighted copy in the administrator's mailbox. The AD stated once the copies were placed in the appropriate mailbox, the AD would not follow up any further. Missing items were discussed at the interdisciplinary meeting but did not recall that R20's missing night gown had been discussed. On 11/4/24 at 2:16 p.m., EVS stated she was unaware of R20 having any missing clothing items and if it had been prior to 8/24, the nursing staff would have tracked and followed through with the item. A facility grievance policy was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure allegations of potential sexual abuse were reported or timely reported to the administrator and state agency (SA) for 1 of 1 resident (R39) reviewed for abuse involving 2 of 2 residents (R6, R31) with cognitive impairment, who was observed inappropriately touching other residents' multiple times, Findings include: 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. R31's quarterly 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. R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 diagnoses included dementia, psychotic disturbance, mood disturbance and anxiety. 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's progress notes identified the following: - 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. - 9/25/24, R39 was observed fondling R31's breast. Staff intervened and separated the two residents. - 10/15/24, R6 was found in R39's room with 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 behavior was not appropriate. R6 stated the incident made her uncomfortable and R39 had been squeezing her breast pretty hard. The director of nursing (DON) and social services designee (SWD) were notified. During interview on 10/29/24, at 1:00 p.m. LPN-A stated on 9/6/23, she had observed R39 approach R31 from behind, placing his arms on either side of R31 in a bear hug and was just going to grab R31's breasts, when LPN-A intervened. LPN-A stated R39 had just come up behind R31 and she did not think R31 had even heard R39 coming. R31 had gotten scared and startled. During interview on 10/29/24, at 2:00 p.m. RN-A stated she had been working on 10/14/24 and witnessed R39 reaching 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. When interviewed on 10/29/24, at 1:30 p.m. SWD stated she had been notified of some incidents with R39's behavior toward residents. SWD received a call from RN-A on 10/14/24, and on 10/15/24, from the DON regarding incidents of R39 inappropriate sexual touching of other residents. SWD discussed the incidents regarding R31's behavior with the DON and they determined there were no non-consensual type of feelings. The residents had not seemed upset, so it was felt to be ok to just document the incidents when they occurred. The DON notified SWD of the incident when R39 was fondling R6's breasts because staff had called the DON first. It was the facility's policy to file a vulnerable adult (VA) report when resident to resident incidents occurred, but assessments had not been completed for any of the residents involved. SWD did not think the facility had done any follow up after receiving reports on R39's behavior toward other residents. SWD did feel a reasonable person would be upset when approached from behind and breasts grabbed, and a VA report should have been filed. - The interdisciplinary team (IDT) and SWD was just trying to figure out the core regulations and what needed to be reported, as the previous DON would never let them report anything. The facility had so much going on with the covid outbreak and administrative changes, many days she came and just hit the floor to give care to residents due to staffing. Just trying to catch up and survive. SWD was notified of R39's behaviors but was not the first person notified and had already put in 70 hours, so SWD just assumed someone else would look into it. If SWD had been the first one notified of the behaviors, she would have handled it differently. 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 had 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 did not need to be reported. Typically, when the DON received a report of resident-to-resident incidents, she entered it into risk management and then communications, depending on what the incident was. The DON would read through the report and made sure the facility staff were not culpable and then the report went to SWD. The DON reviewed the reports with SWD, and they had felt because the residents were vulnerable and did not know any better, and there was no malicious intent or culpability, that the incidents did not have to be reported. None of R39's allegations of sexual abuse toward other residents had been reported to the state agency as required. 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 on 10/29/24, around 3:00 p.m. or 4:00 p.m. If the administrator been made aware of the behaviors, he would have reported the incident and investigated. 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. High Risk Monitoring Household: Pine dated 11/4/24, identified a grid of 30-minute time slots for 5 residents including R31 and R39. At 1:00 p.m., the form identified R39 grabbed R31 and NA-B initials. The facility reported event dated 11/4/24 at 11:32 p.m., identified at approximately 1:30 p.m. on 11/4/24, it was reported R39 grabbed R31 by her side. The witness redirected R39 right away. R31 was assessed and R31 was busy talking about going home to Ohio and did not mention the incident with R39. Upon inspection of R31's side, no injury and marks noted, and R31 told author, Don't do that even though author informed R31 about what was going to happen. Author spoke with the witness, witness stated she only saw R39 grabbing R31's side. Incident report to the SSD. R31's son notified of the incident. Plan of care on going. However, the report failed to identify previous incidents between R39 and R31, interventions implemented to prevent further incidents nor if the care plans were being followed. During an interview on 11/4/24 at 3:54 p.m., with the DON and administrator, the DON stated she was told by nursing assistant (NA)-B that LA-A just saw R39 come up behind R31. 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 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. R39 did not touch R31's breasts, it was more like he was trying to surprise R31. LA-A stated NA-B was in a room and R39 was unattended. The facility's Resident Abuse Prohibition Policy with revision date 6/7/23, identified an employee must report abuse immediately to supervisor in house. The supervisor would then immediately notify the administrator. If an incident or allegation was considered reportable the administrator or designee would make a report to the Minnesota Department of Health (MDH) online reporting web site immediately, but no later than two hours after the allegation was made, if the allegation involved abuse or resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide immediate protection and investigate allegations of resident-to-resident sexual abuse for 2 of 2 residents (R31, R6) reviewed for abuse, who were abused by R39. Findings include: 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. R31's quarterly 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. R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 diagnoses included dementia, psychotic disturbance, mood disturbance and anxiety. 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's progress notes identified the following: R39's progress notes identified the following: - 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. - 9/25/24, R39 was observed fondling R31's breast. Staff intervened and separated the two residents. - 10/15/24, R6 was found in R39's room with 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 behavior was not appropriate. R6 stated the incident made her uncomfortable and R39 had been squeezing her breast pretty hard. The director of nursing (DON) and social services designee (SWD) were notified. During interview on 10/29/24, at 1:00 p.m. LPN-A stated on 9/6/23, she had observed R39 approach R31 from behind, placing his arms on either side of R31 in a bear hug and was just going to grab R31's breasts, when LPN-A intervened. LPN-A stated R39 had just come up behind R31 and she did not think R31 had even heard R39 coming. R31 had gotten scared and startled. During interview on 10/29/24, at 2:00 p.m. RN-A stated she had been working on 10/14/24 and witnessed R39 reaching 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. The facility was unable to produce any investigation file on the above incidents including, staff and resident interviews and observations and record review. When interviewed on 10/29/24, at 1:30 p.m. social worker designee (SWD) stated she had been notified of some incidents with R39's behavior toward residents. SWD was called on 10/14/24, by registered nurse (RN)-A and on 10/15/24, by the DON regarding incidents of inappropriate touching. The reported incidents that occurred with R39 had not been investigated because they had determined both participants were willing and did not seem upset. 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. The facility staff did not investigate any of the resident-to-resident incidents beyond reviewing the initial reports called to them by staff. DON had not been aware of all the incidents or near miss incidents and had not been aware there were so many. 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 on 10/29/24, around 3:00 p.m. or 4:00 p.m. Had he been made aware of the behaviors he would have reported the incidents, notified the POA's of the residents, notified the physician and the ombudsman and investigated. Administration should have been notified and the incidents investigated. The facility's Resident Abuse Prohibition Policy with revision date 6/7/23, identified a nurse would begin the investigation of reports of abuse immediately. A root cause investigation and analysis would be completed and given to the administration. The investigation would include who was involved, residents' statements, involved staff and witness statements of events, a description of the residents' behavior and environment at the time of the incident, injuries present, observation of resident and staff behaviors during the investigation, environmental considerations, and resident skin checks. Administration would investigate the incident to consist of a review of the completed complaint report, an interview with the person reporting, interviews with any witnesses, a review of the resident medical record, interviews with staff members having contact with the resident during relevant periods of the alleged incident, interviews with the resident's family and visitors if applicable, and a root cause analysis of all circumstances surrounding the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 3 residents (R7) reviewed for catheters. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 had severely impaired cognition and an indwelling urinary catheter. Diagnoses included multiple sclerosis (MS), type 2 diabetes, and history of urinary tract infection (UTI). The MDS failed to identify R7 had a multi-drug resistant organism (MDRO). R7's care plan revised 8/9/24, identified R7 needed total assistance with toileting needs and catheter management. The care plan failed to identify R7 had an MDRO. 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 interview on 10/30/24 at 10:06 a.m., the director of nursing (DON) stated staff were expected the staff to document and submit the MDS timely and accurately to ensure resident care was provided accurately and safely. Additionally, the facility's reimbursement depended on an accurate MDS submission. During an interview on 10/31/24 at 1:10 p.m., registered nurse (RN)-D stated you wouldn't know a resident's history of having an MDRO unless you were digging in their charts. RN-D had just found out the other day R7 was colonized for MRSA. During an interview on 11/6/24 at 2:34 a.m., registered nurse (RN)-C stated she did conduct and submit R7's MDS assessment, however, did not review R7's MDRO status because the MDS was related to R7's COVID-19 diagnosis. RN-C stated she guessed she missed it. RN-C could not say why an accurate MDS could affect a resident's care nor why the accurate MDS was important. I don't understand what you mean. A facility policy regarding MDS assessments was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R99's admission MDS dated [DATE], identified R99 had moderate cognition and diagnoses including neurogenic bladder, Alzheimer's disease, and dementia. R99 required intermittent catheterization and did not participate in a bladder program. R99's care plan dated 10/22/24, failed to identify a care plan goal and measurable objectives for straight catheterizing R99. R99's Bowel and Bladder Comprehensive assessment dated [DATE], identified R99 required intermittent catheterization performed by nursing staff every shift and as needed. On 10/30/24 at 1:55 p.m., stated R99 required staff to use a straight catheter to empty his bladder. Observed while licensed practical nurse (LPN)-A used a straight catheter to empty R99's bladder. LPN-A wore gloves and used sterile technique but failed to wear a gown. LPN-A stated she had failed to wear a gown during R99's catheter cares. LPN-A stated she should have worn a gown to protect herself, other residents and R99 from splashing of urine and the potential spread of bacteria causing an infection. During interview on 11/6/24 1:13 p.m. the DON resident care plans should be updated timely and accurately and to ensure the staff knew what to provide and to ensure the resident received resident-centered care. A facility policy regarding care planning was requested but not received. Based on interview and document review, the facility failed to develop a comprehensive care plan for 1 of 2 residents (R7, R99); and failed to involve family during the care conference and document the care conference fully for 1 of 2 residents (R7) reviewed for catheters. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE], identified R7 had severely impaired cognition and an indwelling urinary catheter. Diagnoses included multiple sclerosis (MS), type 2 diabetes, and history of urinary tract infection (UTI). However, the MDS failed to identify R7 had a multi-drug resistant organism (MDRO). R7's care plan revised 8/9/24, identified R7 needed total assistance with toileting needs and catheter management. The care plan failed to identify R7's preferences for family involvement with her care nor to identify R7 had an MDRO. 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). R7's Care Conference Summary New dated 6/26/24, identified a nursing, dietary and activities summary. T The note failed to identify when the care conference was held, who attended and/or who was invited to attend. R7's Care Conference Summary New dated 10/3/24, identified an activities summary. The note failed to identify when the care conference was held, who attended and/or who was invited to attend. R7's Care Conference Summary New dated 10/21/24, identified an activities summary. The note failed to identify when the care conference was held, who attended and/or who was invited to attend. During an interview on 10/28/24 at 3:54 p.m., family member (FM)-A stated the facility was supposed to notify R7's daughter by text with the date and time of R7's care conference so R7's daughter could participate. After all the changes in staff, that just did not happen anymore. FM-A stated he did get a letter but preferred R7's daughter be involved too. That's what the plan always was. Why can't they continue to do it that way? If R7's daughter received a text, R7's daughter could show her employer and the employer was good to give R7's daughter the time off to attend the care conference. During an interview on 10/31/24 at 1:10 p.m., registered nurse (RN)-D stated staff were expected to follow the facility's catheter care policy to prevent the spread of infection, however, RN-D did not update R7's care plan to direct staff regarding enhannced barrier precautions during catheter care. During an interview on 11/4/24 at 2:27 p.m., the social worker designee (SWD) stated RN-C did all the MDS assessments, scheduled the care conference meetings, documented the care conference notes and the care coordinator updated the care plan. The care coordinator was out of the building and unavailable during survey. The SWD stated she could not find where R7's history of MRSA was care planned and/or R7's completed care conference notes were completed. During an interview on 11/4/24 at 2:34 p.m., RN-C stated she only scheduled the care conference meetings but did not attend them because she wasn't always onsite. Because of this, RN-C did not document the care conference note. RN-C updated the MDS calendar and sent that to the nurses, activities, and the SWD. Who updated the care plan and/or notified R7 or R7's family was between the care coordinator and SWD. During interview on 11/6/24 1:13 p.m. the director of nursing (DON) stated the previous care coordinator was really good about texting and communicating with residents' families regarding changes in condition and/or care conferences. The care coordinator had left the facility prior to the DON taking her role at the facility. That's just what I've been told. However, the DON stated she was aware that was no longer taking place and communication needed to improve. Resident care plans should be updated timely and accurately, and care conference documentation needed to be complete to ensure the staff knew what to provide to ensure the resident received resident-centered care. A policy regarding resident care conferences and/or care planning was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to follow provider's orders for intermittent catheterization for 1 of 1 resident (R99); and failed to ensure catheter care was provided in a manner to prevent potential urinary tract infection (UTI) for 1 of 3 residents (R7) reviewed for catheters. Findings include: R99's admission Minimum Data Set (MDS) dated [DATE], identified R99 had moderate cognition. R99 required intermittent catheterization and did not participate in a bladder program. Diagnoses included neurogenic bladder, Alzheimer's disease and dementia. R99's interagency transfer orders signed 10/24/24, identified orders for staff to perform scheduled straight catheterizations 4 times a day; If staff were consistently draining >500 mL per catheterization, then add a scheduled catheterization. R99's Bowel and Bladder Comprehensive assessment dated [DATE] identified R99 required intermittent catheterization every shift and as needed, requires extensive assist from staff with transfers on/off the toilet and peri cares. Intermittent catheterization performed by nursing every shift and as needed. R99's care plan 10/22/24, failed to identify R99's catheterization. R99's October electronic treatment administration record (TAR), directed staff to straight catheterize R99 every shift or as requested by resident, related to neuromuscular dysfunction of bladder, with a start date 10/24/24 at 3:00 p.m., signed by care coordinator (CC)-G. CC-G was out of the office and unable to be interviewed during the survey dates. 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. There were individually wrapped sterile straight catheters and sterile glove kits on the bathroom counter. On 10/30/24 at 7:04 a.m., licensed practical nurse (LPN)-A stated staff assisted resident with straight catheterization every shift because R99 was not able to complete it himself. On 10/30/24 at 4:48 p.m., LPN-B stated R99 was unable to urinate on the toilet and staff were using a straight catheter to empty R99's bladder three times per day; although, the original orders dated 10/24/24, were as follows: straight catheterizations 4 times a day; If staff are consistently draining >500 mL per catheterization, then add a scheduled catheterization. LPN-B stated the orders entered into the computer system on 10/24/24, for intermittent catheterization every shift and as needed were incorrect and not as originally ordered. On 10/30/24 at 5:18 p.m., the director of nursing (DON) stated R99 had been using a straight catheter to empty his bladder since before admission. The DON reviewed the original order and the order that was entered by the nursing staff and stated the orders entered by the staff were incorrect and staff should have assisted R99 with catheterization 4 times per day and as ordered by the doctor on 10/24/24. The risk of incorrectly completing the orders as directed were a high risk for infection. On 10/30/24 at 6:03 p.m., the medical doctor stated he was not notified that staff were only assisting R99 with catheterization once per shift and not four times daily as originally ordered. R99's medical record did not identify any pain or hospitalizations related to not providing catheterization four times a day as ordered. R7's significant change MDS dated [DATE], identified R7 had severe cognitive impairment with diagnoses of multiple sclerosis (MS), type 2 diabetes, history of UTI, and peripheral vascular disease. 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. 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. During an observation on 10/29/24 at 10:17 a.m., nursing assistant (NA)-B was providing morning cares for R7. R7's catheter bag was uncovered and lying on the floor. During an interview on 10/29/24 at 10:34 a.m., NA-B stated yea, the catheter bag was on the floor, but NA-B had just wiped it down with alcohol. NA-B stated she guessed there could be residual urine on the catheter bag that could soil the floor. NA-B also guessed there was dirt on the floor and there could be germs in the dirt that could potentially cause a UTI. 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. During an interview on 10/29/24 at 10:39 a.m., LPN-A stated a catheter bag should never touch the floor due to infection control because it can lead to an infection. During an interview on 10/31/24 at 1:10 p.m., registered nurse (RN)-A stated staff were expected to follow the facility's catheter care policy. During an interview on 10/31/24 at 2:18 p.m., DON stated staff were expected to provide catheter care per facility policy and to demonstrate understanding of infection control to prevent the spread of microorganisms in the facility to prevent possible infections. The facility policy Suprapubic Catheter Placement dated 3/1/17, identified the purpose of this procedure was to relieve the retention of urine in the bladder in a resident who required a permanent or long-term catheter. However, the policy/procedure failed to address catheter care after placement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. Findings include: 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, identified R7 had a RNP. Restorative Therapy nursing assistant would monitor R7's progress and tolerance daily and document. RT staff were to report concerns to nursing and/or physical therapy/occupational therapy for assessment and recommendations. Staff were directed 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. During an observation on 10/29/24 at 12:30 p.m., R7 did not have visible contractures and was able to lift/extend arms during a ceiling lift transfer. R19's quarterly Minimum Data Set (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. During an observation on 10/29/24 at 1:22 p.m., NA-C and licensed practical nurse (LPN)-A transferred R19 to the toilet using the ceiling lift. R19 had no visible contractures and was able to extend her upper and lower extremities. 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 care plan dated 6/23/23, identified R22 had chronic pain related to arthritis and lumbago with sciatica. Staff were to monitor and report any decrease in range of motion (ROM). 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. During observation on 11/4/24 at 1:58 p.m., R22 was sitting in her wheelchair and there we no visible contractures. R22 was able to move hands and feet without restriction. 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 observation on 11/4/24 at 1:54 p.m., R43 was sitting in her recliner in her room scrolling through her phone. R43 had no visible contractures. During an interview on 11/4/24 at 11:51 a.m., restorative therapy (RT)-A stated not applicable in the Range of Motion task documentation meant a resident was not offered RNP services. RT-A stated when a resident was admitted to the facility, they're asked if they wanted to participate in exercise. If so, the physical therapist did an evaluation and entered the orders in the resident's chart. RT-A followed those orders during RNP services. 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. - The residents were welcome to come down to the RT department and get on the machines and do exercises. The door was always open, and the residents had access if they wanted. Because of limited time, RT-A started with residents who had contractures to prevent worsening and ambulatory residents. RT-A stated there were 37 residents who had an RNP program ordered, and RT-A was getting to 18-20 per day. I just can't complete it. RT-A stated she had not reported any refusals and/or inability to complete RNP services so the residents were re-evaluated and/or RNP orders changed. 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. A policy regarding restorative therapy was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 [NAME] dated 10/29/24, directed staff to provide assist of one with transfers using the ceiling lift. However, the [NAME] 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 his bladder. LPN-A used a straight catheter to empty R99's bladder. LPN-A wore gloves and used sterile technique but failed to wear a gown. LPN-A stated she had failed to wear a gown during catheterization and should of to protect herself, other resident. As splashing of urine could potentially spread bacteria causing an infection. On 10/31/24 at 2:18 p.m., the DON stated staff were expected to follow the Center for Disease Control (CDC) precautions guidance for personal protective equipment during catheter care. Further, the DON stated the facility policy directed staff to demonstrate understanding of infection control to prevent the spread of microorganisms in the facility to prevent possible infections. The Standard Precautions policy revision 2009 identified all resident blood, body fluids, excretions, and secretions other than sweat were considered potentially infections and standard precautions would be used for all residents. The policy further identified gowns/aprons (fluid resistant) should be worn when there was a potential for soiling clothing with blood/body fluids. The facility policy Standard and Transmission Based Precautions revised 4/4/24, identified Transmission-based precautions must be used when a resident developed signs and symptoms of a transmissible infection, arrived with symptoms of an infection (pending laboratory confirmation), or has a laboratory confirmed infection and was at risk of transmitting the infection to other residents. The diagnosis of many infections is based on clinical signs and symptoms, but often required laboratory confirmation. However, since laboratory tests {especially those that depend on culture techniques) may require two or more days to complete, transmission-based precautions may be implemented while test results were pending, based on the clinical presentation and the likely category of pathogens. Nurses would identify the type (i.e., contact, droplet, airborne) and duration of the transmission-based precautions required, depending upon the infectious agent or organism involved. Contact Precautions Contact precautions are intended to prevent transmission of infections that were spread by direct (e.g., person-to-person) or indirect contact with the resident or environment, and required the use of appropriate PPE, including a gown and gloves upon entering the room. Prior to leaving the resident's room, the PPE was removed, and hand hygiene was performed. Contact precautions were indicated for gastrointestinal illnesses such as C. difficile or norovirus, infected draining wounds, or secretions. Policies: A review of the facility infection control policies identified the following policies were not reviewed or updated in the past year: The Standard Precautions policy revision 2009, Multidrug Resistant Organisms (MDROs) policy dated 2009, Infectious Disease Outbreak Policy last revised 10/23/20, Infection Preventionist Responsibilities revised 7/25/17, Infection Control Plan revision date 3/10/20, C. Difficile policy dated 8/17/18, Antimicrobial Stewardship Program dated 12/4/18, Hand Hygiene dated 3/10/20, Personal Protective Equipment-using gloves dated 7/25/17, Personal Protective Equipment- using protective eyewear dated 7/25/17, Personal Protective Equipment- using face masks dated 7/25/17, Influenza, Prevention and Control of Seasonal Influenza dated 7/25/17, Infection Control Education dated 7/25/17, Pneumococcal Vaccination dated 4/14/17, and Long Term Care and Assisted Living Response Plan for Supporting COVID-19 Testing dated 9/1/20. The facility lacked documentation their infection control policies had been reviewed annually as required. When interviewed on 10/31/24, at 10:15 a.m. RN-A stated she had never updated any of the facility policies or procedures as she had just taken over her position a few weeks prior. There was only so much a person could do and RN-A was just trying to complete what she could. During interview on 10/31/24, at 2:40 p.m. the DON stated infection control policies should be updated annually. Updating infection control policies should have been completed by the DON or infection preventionist. It was important to update infection control policies because things changed so much within the infection control program. The facility's Infection Prevention Plan Policy, dated 3/10/20, identified an annual review would be conducted to review the Infection Prevention and Control Program and the program would be updated as necessary, including necessary updates as national standards changed. 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. 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. 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 ass[TRUNCATED]

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 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 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 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 provide mandatory training on the facility specific Quality Assurance and Performance Improvement (QAPI) program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program for 5 of 10 employees (DON, RN-E, LPN-C, NA-B, NA-I) reviewed for training requirements. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including quality assurance. - Registered nurse (RN)-E did not complete staff education including quality assurance. - Licensed practical nurse (LPN)-C last completed quality assurance training 4/20/23. - Nursing assistant (NA)-B did not complete staff education including quality assurance - NA-I did not complete staff education including quality assurance 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 QAPI 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 QAPI, Survey Preparedness A facility policy related to staff training/education was requested but not provided.

Based on interview and record review the facility failed to ensure staff were educated on infection control policies and procedures for 4 of 10 staff (DON, RN-E, LPN-C,NA-B) who's training records were reviewed and 3 of 3 staff (NA-B, NA-C, LPN-A) who identified they were not educated in procedures for standard, transmission-based and enhanced barrier precautions (EBP). This had the potential to impact all 46 residents who reside in the facility. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including infection prevention. - Registered nurse (RN)-E did not complete infection prevention training. - Licensed practical nurse (LPN)-C last completed infection prevention education 4/20/23. - Nursing assistant (NA)-B completed no assigned staff education including infection prevention in 2024. During an interview on 10/29/24 at 10:17 a.m., NA-B was unable describe to differentiate between the different types of precautions and/or when to use them. During an interview on 10/29/24 at 12:23 p.m., NA-C stated she had never been provided education regarding enhanced barrier precautions nor been told why sometimes staff wore personal protective equipment 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 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 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 were expected to follow Centers for Disease Control and Prevention (CDC) guidance to prevent the spread of infection. However, staff needed education regarding precautions. RN-A could not verbalize what education, if any, had been provided to staff prior to the start of survey. 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. The DON could not verbalize what education, if any, had been provided to staff prior to the start of survey. The Facility Assessment 2023 dated 12/18/23, identified staff training/education and competencies that were necessary to provide the level and types of support and care needed for the residents. General orientation was provided upon hire and annually. General orientation included education/training related infection control, blood borne pathogens and emerging infectious disease. However, the assessment failed to identify staff education requirements related to transmission-based precautions. Infection Prevention Plan Policy revised 4/4/24, identified would designate one individual as the infection preventionist (IP) who is responsible for the facility's IPCP. The infection preventionist would complete specialized training in infection prevention and control. However, the plan failed to identify the staff eduation/training required for infection prevention and/or regarding transmission-based precautions.

Based on interview and document review, the facility failed to ensure 4 of 10 staff (DON, RN-E, LPN-C, NA-B) received annual training on behaviors in Alzheimer's disease or related disorders, problem solving with challenging behaviors, and communication skills. 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 compliance and ethics. - Registered nurse (RN)-E did not complete compliance and ethics training. - Licensed practical nurse (LPN)-C last completed compliance and ethics traninig 4/20/23. - Nursing assistant (NA)-B completed no assigned staff education including compliance and ethics 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 compliance and ethics 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. However, the facility assessment failed to identify the need for staff education/training related to behavioral health. A facility policy related to staff training/education was requested but not provided.

Based on interview and document review, the facility failed to ensure 12 hours of annual in-service training was completed for 2 of 5 nursing assistants (NA-A, NA-B) reviewed for in service requirements. This had the potential to affect all 46 residents residing in the facility. Findings include: Review of personnel records identified the following: - Nursing assistant (NA)-I did not complete 12 hours of continuing education. - NA-B did not complete 12 hours of continuing education. 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 assigned staff education now. RN-C assigned the annual training for staff and presented some of the general orientation education. The annual training was according to staff hire date: - 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 was 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 was responsible for staffing training and was aware staff were not compliant with staff education requirements including compliance and ethics 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 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. 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 interview and document review, the facility failed to ensure 3 of 10 staff (DON, RN-E, NA-B) received annual training on behaviors in Alzheimer's disease or related disorders, problem solving with challenging behaviors, and communication skills. Findings include: Review of personnel records identified the following: - Director of nursing (DON) completed no assigned staff education including behavioral health. - Registered nurse (RN)-E last completed behavioral health training 8/3/23. - Nursing assistant (NA)-B completed no assigned staff education including behavioral health in 2024. During an interview on 11/6/24 at 12:42 p.m., human resources (HR)-A stated she used to assigned the annual staff education but registered nurse (RN)-C assigned staff education now. RN-C assigned the annual training for staff and presented some of the general orientation education. The annual training was according to staff hire date: - DON: HR-A stated the DON did not complete any of the new hire trainings. - 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. - 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 was responsible for staffing training and was aware staff were not compliant with staff education requirements including behavioral health 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. However, the facility assessment failed to identify the need for staff education/training related to behavioral health. A facility policy related to staff training/education was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to thoroughly investigate an injury of unknown origin for 1 of 3 residents (R1) reviewed who sustained significant unexplained bruising. Findings include: R1's admission Record identified diagnosis that included Alzheimer's disease, dementia and age related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she had upper extremity impairments on both sides. The MDS indicated R1 required substantial/maximal assistance from staff for toileting and transfers and did not ambulate. R1's care plan dated 1/19/24, identified vulnerabilities related to functional limitations and Alzheimers disease. R1's facility Progress Note (PN) dated 6/20/24, indicated writer was summoned to R1's room by nursing assistant (NA) at 6:50 p.m. who stated R1 had bruising to her left side. Writer entered R1's room and noted bruising on left axillary (armpit) area. Bruising measured 24 centimeters (cm) x 17 cm. Bruising also noted between breasts and measured 3 cm x 3 cm. Writer asked R1 what happened to which R1 stated, I don't know what happened. Writer then asked R1 if she fell and R1 stated, No, I didn't fall. When asked if anyone hurt her, R1 stated oh god, no, no one hurt me, I haven't been anywhere at all, I just stay here. R1's emergency department (ED) notes dated 6/22/24, indicated R1 presented with shoulder pain and bleeding/bruising. The note indicated the bruising to the left chest was shallow and obviously occurred approximately one week prior. The bruising under the left and axial chest walls were blue and red and occurred much more recently. R1 had significant deformity to her upper left humerus which raised issue about a possible fracture that may have resulted in the bruising. Extensive document review showed left humerus fracture had occurred in August 2023. Discussed with facility nurse the possibility of staff utilizing the arm for lifting, turning, etc. may have contributed to the bruising. Also discussed R1 used the arm for pulling herself up or forward which may have resulted in bleeding into the axillary and chest walls. A physician Visit Note dated 6/28/24, indicated R1 had known Alzheimer's type dementia and was unable to give a good story. Concern for possible trauma, but no known fall or injury. Of note, the findings on the x-ray were all old. A report to the state agency (SA) dated 6/21/24, indicated R1 had a bruise noted to her left lateral side. Area measured 24 cm x 17 cm. R1 was also was noted to have a 3 cm x 3 cm bruise to her sternum. R1 expressed she had no recollection of bruising or how it happened or occurred. The facility investigation indicated the brushing was noted to be caused by previous fracture 12 or more months prior, along with atrophy of the end of the left humerus. Emergency department (ED) diagnosis indicated superficial bruising of chest wall, left, initial encounter. A facility investigation undated indicated three staff who worked on 6/20/24 and 6/21/24, were interviewed. The investigation lacked evidence of additional staff interviews in an effort to determine if an incident occurred that may have resulted in the injury. Further, no staff or resident interviews had been performed in and effort to rule out abuse. During interview on 7/17/24 at 11:18 a.m., R1's physician (P)-A stated he had seen R1 after she had been to the ED due to her bruising. P-A stated the ED physician had blamed the bruising on in injury from R1's shoulder. P-A stated the brushing was not related to the shoulder injury as the shoulder injury was old. P-A stated when he saw R1 there had been no fall reported. P-A said he felt the injury was a result of R1 hitting her side on a sink or other object during a transfer. P-A stated elderly people had thin skin and the muscle could break and cause the bleeding and said he did not think R1 would have had to hit something really hard to cause the injury. During interview on 7/17/24 at 12:41 p.m., registered nurse (RN)-A stated she had accompanied R1 to the ED after the bruising had been discovered. RN-A stated the ED physician said R1's humeral head had atrophied and when she was transferring she may have pulled on something and started the bruising. RN-A stated when she looked at the notes it did not make sense because the notes indicated the atrophy had occurred last fall. RN-A stated she had asked R1's physician (P)-A who said he did not think it had any relation to the bruising at all. RN- A said P-A told her he thought R1 might have been injured on a bath rail or side rail while transferring. RN-A said if R1 had fallen she would not have been able to get herself up without help. During interview on 7/17/24 at 1:05 p.m., the director of nursing (DON) stated R1 was not a good historian and said she had been sent to the ED to rule out a potential fracture. The DON stated the ED performed x-rays that picked up an an old fracture and said the facility was unable to determine what led to the bruising. The DON acknowledged no further interviews had been completed in an effort to determine how the injuries may have occurred. Facility Policy And Procedure On Reporting And Internal Review Of Maltreatment And Injuries Of Unknown Origin dated 7/1/24, indicated when the facility had knowledge of an injury of unknown origin an internal review will be completed. The internal review will include an evaluation of whether there is a need for corrective action to protect the health and safety of the vulnerable adult, assess services and care plan, assessment due to an incident and if there is a need for additional staff training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to perform assessment to determine potential causal factors of extensive bruising for 1 of 3 residents (R1) reviewed for non-pressure related skin concerns. In additional the facility failed to implement interventions to prevent further injury. Findings include: R1's admission Record identified diagnosis that included Alzheimer's disease, dementia and age related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she had upper extremity impairments on both sides. The MDS indicated R1 required substantial/maximal assistance from staff for toileting and transfers and did not ambulate. R1's care plan dated 1/19/24, identified impaired cognitive functioning related to dementia and a potential for alteration in skin integrity and directed staff to observe skin daily with cares and notify nurse of new or worsening skin concerns. The care plan further identified a self care deficit and indicated she used half upper side-rails to maximize independence with turning and repositioning in bed and needed limited assistance with transfers in and out bed, wheelchair and toilet. The care plan further identified R1 had contractions and limitations to bilateral shoulders. R1's facility Progress Note dated 6/20/24, indicated writer was summoned to R1's room by nursing assistant (NA) at 6:50 p.m. who stated R1 had bruising to her left side. Writer entered R1's room and noted bruising on left axillary (armpit) area. Bruising measured 24 centimeters (cm) x 17 cm. Bruising also noted between breasts and measured 3 cm x 3 cm. Writer asked R1 what happened to which R1 stated, I don't know what happened.Writer then asked R1 if she fell and R1 stated, No, I didn't fall. When asked if anyone hurt her, R1 stated oh god, no, no one hurt me, I haven't been anywhere at all, I just stay here. R1's Skin Observation Tools identified the following: 6/17/24, Skin warm, dry and intact. 6/21/24, R1 noted to have bruising in-between breast which measured 3 cm x 3 cm and left axillary area which measured 24 cm x 17 cm. 6/25/24, Bruising noted down left side of torso, side of left breast and left arm. 7/2/24, Bruising noted down left side of torso, side of left breast and left arm is still present but stating to fade. 7/8/24, No alterations noted. 7/15/24, Red marks on back, lotion applied. During observation on 7/16/24 at 4:07 p.m., nursing assistant (NA)-A assisted R1 to transfer from her wheelchair to the toilet. R1 placed her arms on the arm rests of the wheelchair to push herself up and reached for the grab bars on the toilet. R1 asked for help and NA-A assisted R1 to place her hands on the grab bars. R1's left flank was observed to have extensive dark purple bruising. R1 then used her right arm to reach over and grab the wheelchair to pull herself up from the toilet. NA-A assisted R1 to turn and sit in the wheelchair by placing her hands under R1's buttocks and assist to maneuver her into the chair. NA-A had not used a transfer belt when assisting R1. NA-A stated the observed transfer was typical for R1. During interview on 7/17/24 at 9:53 a.m. NA-B stated R1's bruising had been present for about three weeks. NA-B stated, I'm pretty sure they said she had fallen. NA-B said R1's transfers depended on the day and said sometimes she would ring for assistance. NA-B indicated R1 was able to sit up on the side of the bed using the grab bars but some days she needed assistance to stand. NA-B added, R1's cognition was pretty good but said she was not good about remembering details. During interview on 7/17/24 at 12:41 p.m. registered nurse (RN)-A stated she had accompanied R1 to the emergency department (ED) after the bruising had been discovered. RN-A stated the ED physician said R1's humeral head had atrophied and when she was transferring she may have pulled on something and started the bruising. RN-A stated when she looked at the notes it did not make sense because the notes indicated the atrophy had occurred last fall. RN-A stated she had asked R1's physician (P)-A who said he did not think it had any relation to the bruising at all. RN-A said P-A told her he thought R1 might have been injured on a bath rail or side rail while transferring. RN-A said if R1 had fallen she would not have been able to get herself up without help. RN-A stated after the injury she had place a referral for occupation therapy to evaluate R1 but said they had not evaluated her transfer ability. RN-A stated R1 was stand by assist during transfer so staff did not use a transfer belt. RN-A stated she had not performed any reassessment of R1's transfer ability after the injury occurred, nor were any new interventions implemented. During interview on 7/17/24 at 1:05 p.m. the director of nursing (DON) stated the facility did not know what had led to R1's bruising. The DON stated there was no evidence R1 had been assessed for transfer safety following the injuries because staff assisted R1 with her transfers. A policy related to non-pressure related skin injuries was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to report an injury of unknown origin within 24 hours of it being identified to the State Agency (SA) for 1 of 3 residents (R1) reviewed for potential abuse. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had a severe cognitive impairment and a diagnosis of Alzheimer's disease. R1 was dependent on staff for all care areas. R1 exhibited physical and verbal behaviors towards others. R1's WSLC Skin Incident Report dated 11/29/30, identified staff reported bruising to R1's hand/arm/finger. It was reported R1 was combative during cares the evening prior. A bruise to the left wrist measured 8 centimeters (cm) by 26 cm. The top of hand bruise measured 4 cm x 3.4 cm. The right index finger bruise measures 6.2 cm from knuckle. Interventions included a physician order was obtained to get an x-ray, nurse assessment, and taping of the finger if R1 allowed. R1's Skin/Wound note dated 11/29/23 at 10:46 a.m., identified R1 had bruising to the left wrist and right hand. Area to left wrist measured 8 x 2.6 cm. The top of the right hand measured 4 x 3.4 cm and her right index finger measured 6.2cm from her knuckle. R1 was noted to have combative behaviors during cares per staff. R1 offered no complaints or signs/symptoms of pain or discomfort. R1 had range of motion within normal limits and utilized hand/finger when eating and holding objects. Orders were obtained to have an x-ray of R1's finger. R1's family was notified. However, the note did not identify when R1's bruising was identified. R1's Vulnerable Adult Maltreatment Report dated 12/1/23, identified the facility filed a report to the State Agency on 11/30/23 at 1:40 p.m. During an interview on 12/5/23 at 12:09 p.m., nursing assistant (NA)-A stated during morning to evening shift change on 11/28/23, the day shift nurse reported R1's hand was swollen and all red in color. During an interview on 12/5/23 at 2:35 p.m., NA-B stated she worked with R1 on 11/28/23. R1's hand was swollen and R1's left arm was bruised, but her right hand was really red, and swollen. During an interview on 12/5/23 at 2:42 p.m., LPN-B stated LPN-B was told about it during report on 11/29/23. Because the injury was reported to LPN-B, she believed everything was done so LPN-B did not report the injury nor document in R1's electronic medical record (EMR). R1 had an x-ray of her finger later that afternoon on 11/29/23, and we were told on 11/30/23, R1 had a small fracture in her finger. During an interview on 12/5/23 at 2:52 p.m., RN-B stated during morning to evening report on 11/28/23, LPN-C told RN-B they had to do something with R1's hand. RN-B did not know what LPN-C was referring to, so RN-B went to assess R1 on 11/28/23. RN-B saw R1's hand was very swollen, red and bruised and went to LPN-D to ask what RN-B needed to do. RN-B stated she was instructed by LPN-D to obtain measurements of R1's injury and LPN-D would take care of it. LPN-D needed to talk to LPN-C to figure out what was going on. During an interview on 12/5/23 at 3:38 p.m., LPN-C stated she was unaware of R1's injury until the high risk meeting the morning of 11/29/23, but the injury should have been reported as soon as it was identified. During an interview on 12/5/23 at 4:33 p.m., LPN-D stated she recalled someone said something to her in passing on 11/28/23, about R1's bruise. LPN-D could not exactly recall what was said, but gave instruction to measure, document and LPN-D would look at it the next day. It wasn't told to me in a way that made sense. LPN-D didn't think anything of it because there were two nurses on the floor. LPN-D should have reported R1's injury to the State Agency (SA) on 11/28/23, and documented in R1's electronic medical record (EMR) when she was notified on 11/28/23. During an interview on 12/6/23 at 6:20 a.m., RN-C stated she was informed of R1's injury on 11/28/23, during shift change. RN-C worked with R1 on 11/27/23, but R1 was wearing long sleeves. R1 did not do anything new. R1 always cried out or was combative, so RN-C stated she didn't think anything of it. When RN-C arrived at the facility on 11/28/23, RN-B stated did you see all those bruises on R1. RN-C assessed R1 and observed a large bruise to R1's left arm and R1's right hand was swollen and red. When RN-C touched R1's arm it was evident R1 was having discomfort. That morning, RN-C had another registered nurse look at it. However, RN-C did not file a report to the SA nor documented the injury in R1's EMR. During an interview on 12/6/23 at 8:47 a.m., NA-E stated R1's right hand was swollen, red and bruised the morning of 11/28/23. NA-E immediately notified RN-B. On 11/28/23, at approximately 11:30 a.m., NA-E observed RN-B measure R1's bruises with a tape measure. When RN-B pulled up R1's left sleeve there was a large purple bruise to R1's left forearm. R1's arm looked horrible and R1's right index finger was puffy, and it couldn't be missed. During an interview on 12/6/23 at 9:55 a.m., LSW stated she was informed of R1's injury on 11/28/23, and it should have been reported to the SA when discovered. During an interview on 12/6/23 at 12:45 p.m., the DON stated she assessed R1's injuries as soon as she was notified and insisted an x-ray be obtained. The DON was unaware staff identified R1's injury on 11/28/23. Staff were expected to assess, document and report according to facility policy. The facility policy Resident Abuse Prohibition Policy revised 6/7/23, defined injuries Of Unknown Source as follow: a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and, b. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. The policy identified clinical indicators of physical abuse included fractures, especially on non-ambulatory adults. The policy directed an owner, licensee, administrator, licensed nurse, employee, contracted provider, or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat, or harmfully neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, or misappropriation shall immediately but no later than two hours, report concern to either a care coordinator, DON, or LSW. The administrator will then be immediately notified of allegation and a report made to the state agency by the person who received report. The Nursing Home Administrator or designee will report abuse/allegations of mistreatment or suspected abuse immediately to the SA per State and Federal requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to thoroughly investigate an injury of unknown source to ensure resident safety and appropriate interventions were implemented for 1 of 3 residents (R1) reviewed for potential abuse. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had a severe cognitive impairment and a diagnosis of Alzheimer's disease. R1 was dependent on staff for all care areas. R1 exhibited physical and verbal behaviors towards others. R1's WSLC Skin Incident Report dated 11/29/30, identified staff reported bruising to R1's hand/arm/finger. It was reported R1 was combative during cares the evening prior. A bruise to the left wrist measured 8 centimeters (cm) x 26 cm. The top of hand bruise measured 4 cm x 3.4 cm. The right index finger bruise measures 6.2 cm from knuckle. Interventions included a physician order was obtained to get an x-ray, nurse assessment, and taping of the finger if R1 allowed. R1's Skin/Wound note dated 11/29/23 at 10:46 a.m., identified R1 was noted to have bruising to left wrist and right hand. Area to left wrist measured 8 x 2.6 cm. The top of the right hand measured 4 x 3.4 cm and her right index finger measured 6.2 cm from her knuckle. R1 was noted to have combative behaviors during cares per staff. R1 offered no complaints or signs/symptoms of pain or discomfort. R1 had range of motion within normal limits and utilized hand/finger when eating and holding objects. Orders were obtained to have an x-ray of R1's finger. R1's family was notified. However, the note did not identify when R1's bruising was identified. R1's Vulnerable Adult Maltreatment Report dated 12/1/23, identified the facility filed a report to the State Agency on 11/30/23 at 1:40 p.m. The Warroad Senior Living Center Staffing Hours form dated 11/26/23 through 11/28/23, identified the following staff members were working and had opportunity to have contact with R1: RN-C, RN-D, RN-E, LPN-A, LPN-B, NA-A, NA-D, NA-E, NA-G, NA-H, and NA-J. The facility investigation was requested and identified the following: R1's Vulnerable Adult Internal Investigation Form updated 6/9/23, identified on 11/30/23 at 1:32 p.m., R1 was noted to have a bruise to her left wrist/forearm and the top of her right hand. She was also suspected to have a fractured finger. R1 was noted to be combative during standing lift transfers prior. The form identified the care plan was followed. A ceiling lift was assessed for R1 by a licensed practical nurse, registered nurse, and restorative therapist. R1 was comfortable and safe, no hollering or lashing out. R1's family agreed to switch to ceiling lift transfers. Other case notes: Nursing Assistant (NA)-D was terminated on Tuesday, 11/28/23. NA-D worked with R1 in the days prior to her termination and NA-D was observed to transfer R1 without following the care plan appropriately. The following staff interviews were included: licensed practical nurse (LPN)-B, LPN-A, NA-E, NA-F, and registered nurse (RN)-B. The form failed to identify all staff, with possible interaction with R1 nor other residents with contact with NA-D, were interviewed to determine if an injury occurred during a transfer when the care planned was not followed. Nor did the investigation identify any observation of care provided. During an interview on 12/5/23 at 12:09 p.m., NA-A stated during morning to evening shift change on 11/28/23, the day shift nurse reported R1's hand was swollen and all red in color. NA-A stated she was not interviewed regarding R1's bruising. During an interview on 12/5/23 at 2:35 p.m., NA-B stated she worked with R1 and R1's hand was swollen. R1's left arm was bruised, but her right hand was really red and swollen. NA-B stated she was not interviewed regarding R1's bruising and was not aware of what happened. During an interview on 12/5/23 at 2:42 p.m., LPN-B assumed R1 hit her hand on the standing lift during a transfer. Where else would it come from? During an interview on 12/5/23 at 3:49 p.m., NA-C stated she worked with R1 on 11/28/23. R1 was behavioral and NA-C could not calm her down. NA-C stated R1 hit, punched, kicked, and NA-C had to ask LPN-D for assistance. NA-C did not believe R1 injured herself, but LPN-D sat with her. If a resident did hurt themselves, NA-C would ask for the nurse immediately. NA-C stated she not was interviewed regarding R1's bruising. During an interview on 12/5/23 at 4:33 p.m., LPN-D stated she recalled someone said something to her in passing on 11/28/23, about R1's bruise. LPN-D could not exactly recall what was said, but gave instruction to measure, document and LPN-D would look at it the next day. LPN-D didn't think anything of it because there were two nurses on the floor. Staff were busy, but it was passed on in the morning during report. On 11/29/23, LPN-D brought her concerns to the director of nursing (DON) and the social worker (SW)-A. LPN-D then stated she as aware of R1's injury on 11/28/23, and also a nursing assistant had been let go that day due to unsafe practices. Staff reported the nursing assistant had not wanted to listen to direction and LPN-D witnessed an unsafe resident transfer; however, there was no evidence to identify any injury occurred during the transfer During an interview on 12/6/23 at 6:20 a.m., RN-C stated she was informed of R1's injury on 11/28/23, during shift change. RN-C worked with R1 on 11/27/23, but R1 had been wearing long sleeves. R1 did not do anything new. R1 always cried out or was combative, so RN-C stated she didn't think anything of it. When she arrived at the facility on 11/28/23, RN-B stated did you see all those bruises on R1. RN-C assessed R1 and observed a large bruise to R1's left arm and R1's right hand was swollen and red. When RN-C touched R1's arm it was evident R1 was having discomfort. That morning, RN-C had another registered nurse look at it RN-C stated R1 hit out during cares and R1 would try to hit you just by talking to R1. RN-C stated she was told NA-D transferred R1 without using a lift and NA-D was terminated on 11/28/23. RN-C stated she was not interviewed by leadership regarding R1's bruising. During an interview on 12/6/23 at 8:47 a.m., NA-E stated R1's right hand was swollen, red and bruised the morning of 11/28/23. NA-E observed a large purple bruise to R1's left forearm. R1's arm looked horrible. R1's right index finger was puffy. NA-E stated NA-D performed R1's cares that morning. NA-E told LPN-D of NA-D transferring R1 without using a lift and NA-E was terminated later that day at the end of her shift; however, there was no evidence to identify any injury occurred during the transfer. During an interview on 12/6/23 at 9:55 a.m., SW-A stated she was informed of R1's injury on 11/28/23. Staff found out that R1 was transferred without the care planned interventions by NA-D on 11/28/23 and NA-D was terminated later that day, although there was no evidence and injury occured during the transfer. SW-A stated she did not interview all staff who had potential contact with R1 nor spoke with NA-D. During an interview on 12/6/23 at 12:45 p.m., the director of nursing (DON) stated she assessed R1's injuries as soon as she was notified and insisted an x-ray be obtained. The DON was unaware staff had identified R1's injury on 11/28/23. The investigation should include who, what, when and where to determine the resident and the other residents were safe. The follow up investigation had been completed and submitted to the SA. Staff were expected to investigate according to facility policy. The facility policy Resident Abuse Prohibition Policy revised 6/7/23, defined injuries Of Unknown Source as follow: a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and, b. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. The policy identified clinical indicators of physical abuse included fractures, especially on non-ambulatory adults. The policy directed the investigation would consist of at least the following: a. A review of the completed complaint report b. An interview with the person or persons reporting the incident. c. Interviews with any witnesses to the incident d. A review of the resident medical record if indicated. e. An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident. f. Interviews with the resident's family members, and visitors (if applicable) g. other residents in the staff's care. h. A root cause analysis of all circumstances surrounding the incident. i. Investigation of involuntary seclusion should include: - Symptoms that led to the consideration of the separation - Investigation into whether the symptoms were caused by failure to meet resident needs, provide meaningful activities or manipulation of the resident environment - Was the cause of the symptom removed? - Were alternatives attempted prior to separation? - Was the separation for the least amount of time necessary? - Was the family/legal representative involved in the care planning and informed choice regarding the separation? - Is there evidence of monitoring and adjustments in care to reduce negative outcomes and attempt to determine less restrictive alternatives? j. While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to the resident. Visits may only be made in designated areas, supervised by staff after approval by the Administrator. k. The Administrator will keep the resident or his/her representative informed of the progress of the investigation. l. The results of the investigation will be recorded and attached to the report. m. The Administrator or designee will complete a copy of the investigation materials. n. The Administrator or designee will inform the resident and/or his/her representative of the results of the investigation and corrective action taken. m. Inquiries made concerning abuse reporting and investigation must be referred to the Administrator or to the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to assess for dementia related behaviors and implement individualized resident centered interventions to managed the dementia symptoms for for 2 of 3 residents (R3, R1) reviewed for potential abuse. Findings include: R3 R3's annual Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and a diagnosis of dementia. R3 exhibited physical and verbal behaviors toward others. R3's cognitive Loss/Dementia CAA dated 9/22/23, identified R3 demonstrated behavioral symptoms during the review period, including physical and verbal. R3 had a diagnosis of dementia which was the primary contributing factor to her cognitive function decline and behavioral symptoms. R3 also had a diagnosis of major depressive disorder that may contribute to her symptoms. R3 had a WanderGuard in place to reduce risk for elopement. Staff would continue with current interventions related to cognitive impairment and proceed to care plan. R3's care plan revised 11/27/23, identified R3 exhibited delusions, accusations, statements of depression and confusion. Interventions included dementia approach, redirection, 1:1 with staff, family support and reassurance. R3 had a history of bearing down when getting on/off toilet and voiding having a bowel movement on staff. The care plan failed to identified the resident centered intervention for specific behaviors. During an observation on 12/5/23 at 10:50 a.m., licensed practical nurse (LPN)-A attempted to assist R3 with her morning cares and the room was quiet. R3 was lying in bed on her back with a t-shirt on without pants. A throw blanket was covering R3 from the waist down. LPN-A approached R3 holding a lift sling, bent over R3, approximately 6 inches from R3's face, and stated loudly to R3 let's get you up for the day. R3 became angry and stated quit spitting in my face! LPN-A laughed and stated she wasn't spitting, she was talking to R3. R3 attempted to punch LPN-A, but LPN-A stepped out of the way. R3 stated to LPN-A leave me alone! LPN-A tossed the lift sling into R3's wheelchair and laughingly stated I guess we will try again later. LPN-A shrugged her shoulders and stated R3 was dry and she just didn't know what to do with R3. During an interview on 12/5/23 at 10:58 a.m., R3 stated I just hate it here. I ask them to leave and they don't they just keep on. I'm all locked up. R3 pointed to her lower abdomen and shrugged. They think it's funny. I hate them. I just want to be left alone. During an interview on 12/5/23 at 2:32 p.m., nursing assistant (NA)-B stated R3 was always good with her because R3 liked Elvis and NA-B sang with R3. NA-B stated other staff told her R3 refused cares, but R3 had never done that with NA-B. R3 had to have an incentive,and make it worth her while to do something. R3 loved music so NA-B always turned on the music before starting cares and R3 would cheer up. During an interview on 12/6/23 at 11:12 a.m., NA-E stated R3 was combative with NA-E once, but NA-E was told it happened a lot. R3 seemed to be crankier lately as well. R3 didn't like to be cold or get out of bed. It had to be her idea to. You had to ask and if R3 said no, you go back in 15 minutes and try again. Staff needed to turn on R3's music before you left the room too. R3 liked Elvis or 50-60's music. It just improved R3's mood. During an interview on 12/5/23 at 4:27 p.m., LPN-D stated R3's care plan did not identify specific behavior triggers nor resident centered interventions for the behavioral triggers. R1 R1's significant change MDS dated [DATE], identified R1 had a severe cognitive impairment and a diagnosis of Alzheimer's disease. R1 was dependent on staff for all care areas. R1 exhibited physical and verbal behaviors towards others. R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/10/23, identified R1 had severe cognitive impairment. R1 would sometimes respond to the interview questions but responses were nonsensical. R1 demonstrated inattention, disorganized thinking; and behavioral symptoms including physical and verbal symptoms towards others. Primary factor related was her diagnosis of Alzheimer's type dementia. R1 also had a diagnosis of unspecified mood (affective) disorder and adjustment disorder with mixed anxiety and depressed mood. Non-pharmacological interventions are also included in her care plan to help prevent and manage her symptoms. R1's cognitive impairment did affect her ability to participate in ADL's, activities, and daily decision making. R1 had more difficulty with communicating and comprehending than she had in the past related to disease progression, as well as decline in physical abilities. R1's care plan would continue to include interventions to promote as much participation as possible with the above with support and assistance as necessary. R1's care plan revised 10/13/23, identified R1 displayed the following target behavioral symptoms: irritability, agitation, teary eyed, crying, lashing out at staff verbally and physically, refusal of cares, loss of interests. Interventions included non-pharmacological interventions of: one to one staff, family support, interaction with husband, activities of choice, distraction, reassurance, use dementia approach: facial expressions that sparkle, get below eye level, introduce yourself,offer handshake, offer endorphin booster, explain what is going to happen next. Use seven words or less in a sentence, speak low and slow, no questions, no up talking. Avoid saying no to the resident and offer snack. When resident was overstimulated and agitated, place resident out of arms distance from other residents. The care plan failed to identified the resident centered intervention for specific behaviors and how to approach the resident with her cares. R1's [NAME] dated 12/5/23, identified R1 exhibited behaviors. The [NAME] directed staff to: - Monitor behavior episodes and attempt to determine underlying cause. - Consider location, time of day, persons involved, and situations. - Document behavior and potential causes. The [NAME] failed to identify R1's behavior triggers nor provided resident centered interventions. R1's Behavior Symptoms AR dated 11/6/23 through 12/6/23, identified R1 exhibited frequent crying, repetitive movements, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching, spitting, biting and rejection of care 22 out of 30 days. The non-pharmacological interventions used were other individualized approach per resident care plan/[NAME], dementia approach, ensure safety, redirection, and reassurance. The documentation did not provide a description of the incidents nor if the non-pharmacological interventions were effective. During a telephone interview on 12/5/23 at 8:51 a.m., family member (FM)-A stated R1 was unable to express herself due to the progression of her dementia which was worsening over the past year. Staff reported to FM-A, R1 frequently lashed out at staff, especially during cares and FM-A observed R1 to lash out at staff as well. FM-A was usually not at the facility when R1 was assisted to bed, but FM-A could see how R1's cognition worsened as the day went on, so behaviors would too. During an observation on 12/5/23 at 10:24 a.m., LPN-A and LPN-B provided cares to R1. R1 was in bed, lying on her left side with her eyes closed. LPN-A pulled back R1's blankets and stated, hey dolly. R1 did not respond. LPN-A stated R1's incontinent product was soaked through and soiled the reusable incontinent pad under R1. LPN-B attempted to wake R1, but R1 made no response. LPN-A rolled R1 to the left and R1 suddenly opened her eyes and yelled out Hey! and began to reach out to LPN-A. LPN-A stepped back and stated hey, don't pinch. then stated, it's not bad unless she gets the fat of your arm. R1 began to weep and LPN-B stroked R1's shoulder and whispered, don't cry. R1 continued to have facial grimacing and wept. LPN-A began cleaning feces from R1's side and removed R1's soiled incontinent product. LPN-A stated oh, we have a mess today. I guess that's better than not working. LPN-A then told LPN-B just watch her hands so she doesn't get me. LPN-B continued to hold R1's hands while R1 crossed her arms over her chest. - LPN-A rolled R1 to the right. LPN-A took a disposable wipe and wiped feces from R1's bottom. LPN-A then said to R1 I'm going to wipe you, dolly. R1 attempted to kick LPN-A with her left leg but LPN-A stepped out of the way. LPN-A stated R1 was just not happy, and LPN-A did not know how to fix her anymore. LPN-A rolled R1 to the left, then stated I'm going to turn you now. R1 yelled out oh no! LPN-A continued to roll R1 who yelled Cut it out! R1 attempted to hit LPN-A, but LPN-B held her hands. LPN-B stated to R1 let's make it all better. LPN-A cleaned between R1's thighs without saying anything to R1. R1 yelled No! LPN-B whispered to R1 that it was ok, they just needed to get R1 clean down there. LPN-A and LPN-B repositioned R1 in her bed by lifting R1 by the reusable incontinent pad without saying anything to R1. R1 yelled Oh! and pinched LPN-B. LPN-B stated to R1 you got the love roll there after stepping out of R1's reach. R1's yelled out daddy, help me! LPN-A rolled to R1 to the right while LPN-B tucked a pillow behind R1's back for comfort. LPN-B stated to R1 you're ok. We're done traumatizing you for a little bit here. LPN-A and LPN-B exited R1's room. LPN-B stated that it just breaks your heart. During an observation on 12/05/23 at 3:36 p.m., R1 was lying in bed and RN-A repositioned R1 for comfort. RN-A repeatedly explained each step in a calm, low volume to R1 before beginning the step. R1 remained calm. R1 was wearing long sleeves and RN-A assessed R1's right hand and right index finger bruising. RN-A stated R1's right index finger was slightly swollen, bruising, dark purple to the second knuckle, all the way around the finger. R1 did not withdraw from RN-A touch. During an interview 12/5/23 at 12:09 p.m., (NA)-A stated R1 was aggressive. R1 didn't understand what was going on so her first reaction was to attack someone. The biggest thing was one person held R1's hands because she hit and pinched. The other person undressed her and stuff. If R1 said no, staff usually took a small break. If R1 started to cry staff stopped, NA-A still held her hand and let R1 see NA-A. NA-A talked until R1 calmed down. Most likely R1 hit out. The nursing assistants were supposed to tell the nurse when R1 was combative during cares. During an interview on 12/5/23 at 1:42 p.m., LPN-B stated R1 was so fast. R1 went from zero to sixty in a flash. Once, LPN-B was assisting R1 to eat ice cream and R1 said no, but was still eating the ice cream. LPN-B kept giving her spoonfuls and, suddenly, R1 stated I said no! and LPN-B had supplement all over me. You just don't see it coming. LPN-B stated she used to think it was pain, but wasn't sure anymore. R1's medications really didn't seem to make a difference and LPN-B stated she didn't know how to help R1. It was one thing when R1 was combative. Combative meant get out. The nursing assistants should always report that to the nurse and it should be documented. During an interview on 12/5/23 at 2:35 p.m., NA-B stated R1 usually wasn't combative with her. You have to go really slow and repeatedly tell R1 what your' e doing. During an interview on 12/5/23 at 2:45 p.m., RN-A stated R1 could become combative, refuse medications, grab and pull away. If R1 refused cares, RN-A would do as much as she could without escalating the situation. You do what you can and call it a day. Refusal of care or combative behaviors should be documented. During an interview on 12/5/23 at 2:52 p.m., RN-B stated R1 can be combative: hit, punch, kick, spit and/or bite. Loud noises would set R1 off. R1 didn't like to be surrounded by large groups. Combative behaviors should be assessed and documented. During an interview on 12/5/23 at 3:49 p.m., NA-C stated R1 would hit and kick. R1 could potentially hurt herself or you. NA-C would try to talk to R1 to calm her down or let the nurse know. During an interview on 12/5/23 at 4:27 p.m., LPN-D stated R1 exhibited behaviors: hitting out, combativeness, hollered out, and more so whenever staff tried to do stuff with R1. Loud noises sometimes would bother R1, sometimes not. Sometimes R1 would be out at the table and did well and other times she struggled more. Staff usually assisted R1 to eat in quiet places. Bed time and sleeping were the worst times. R1 liked hymns and quieter music. LPN-D stated R1's care plan did not identify R1's possible behavior triggers nor directed staff how to prevent the behaviors. During an interview on 12/6/23 at 6:20 a.m., RN-C stated R1 lashed out during cares, but it didn't have to be cares. R1 would try to punch someone just for talking to her. R1's dementia was severe and R1 could not remember what was happening. Staff needed to continually cue R1. During an interview on 12/6/23 at 8:47 a.m., NA-E stated she had to go painfully slow with R1. The nurses would get mad with NA-A because it took too long. NA-E continually told R1 what was happening. If you didn't, R1 would get startled, doesn't understand and lashed out. NA-E stated she had never been hit by R1 but had been told by many that R1 was combative. Staff just pulled back the blankets and start. I wouldn't want that, would you? During an interview on 12/6/23 at 12:37 p.m., the director of nursing (DON) stated she identified in the five weeks she was at the facility the nursing staff did not document as expected. The DON had not had time to educate the staff but had a nursing staff meeting scheduled for the near future. The DON expected nursing to assess behaviors and to create a resident centered care plan to minimize the behaviors. A facility policy regarding mood/behavior assessment and care planning was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure residents did not self-administer medications as assessed for 1 of 1 residents (R39) observed to self administer medication after staff set up. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 had moderate cognitive impairment and diagnoses included dementia, high blood pressure, and renal insufficiency. R39's Initial Evaluation of Ability of Resident to Self-Administer Drugs dated 2/27/23, identified R39 was not cognitively or physically able to self-administer medications. On 11/29/23 at 7:50 a.m., licensed practical nurse (LPN)-A dispensed the following medications into a medication cup: acetaminophen ES 500 milligrams (mg) 2 tabs (pain reliever), Calcitriol 0.25 micrograms (mcg) (a medication that treats low calcium levels caused by kidney disease), calcium 600 mg with Vitamin D3 10 mcg (a supplement that prevents low levels of calcium and vitamin D, Chlorthalidone 50 mg (a water pill), ferrous sulfate 325 mg (iron supplement used to treat or prevent low blood levels of iron)., Memantine 10 mg (a medication for dementia), Valsartan 320 mg (a medication for high blood pressure), vitamin C 1000 mg (helps to protect cells and keeping them healthy. maintaining healthy skin, blood vessels, bones and cartilage) At 7:53 a.m.-A delivered the med cup to R39 while R39 was sitting at the dining room table for breakfast. LPN-A placed the med cup next to R39, then stated R39 took her medications while she ate. LPN-A returned to the medication cart and went about her duties with other residents. LPN-A did not approach R39 until she picked up her empty medication cup from the table. LPN-A did not observe R39 to ensure R39 took all of her medications. During an interview on 11/29/23 at 9:33 a.m., LPN-A stated she always thought R39 was able to self-administer her medications because R39 had always been independent with her medications. During an interview on 11/29/23 at 12:58 p.m., LPN-B stated R39 was not able to self-administer mediations and staff should ensure R39 took her medications before stepping away. During an interview on 11/29/23 at 3:04 p.m., the director of nursing (DON) stated staff should follow the resident assessment and care plan for self-administration of medications. The facility policy Self-Administration of Medication Policy revised 11/2022, identified a Self-Administration of Medication Assessment would be completed. Once complete, appropriate notation must be documented in the resident's medical record and care plan. A interdisciplinary team (IDT) reviewed the assessment to determine that the practice of self-administration was clinically appropriate. If self-administration was determined to be unsafe, the IDT should consider, based on the resident's abilities, options that allowed the resident to actively participate in the administration of their medications to the extent that it was safe. The ability to self-administer medications would be assessed quarterly and/or with a significant change in condition and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review, the facility failed to assess, monitor and implement mental health interventions for 1 of 1 resident (R28) who had identified behavior needs. Findings include: R28's significant change Minimum Data Set (MDS) dated [DATE], identified R28 had moderate cognitive impairment and diagnoses that included dementia and malnutrition. R28 exhibited no depression or behavioral symptoms during the lookback period. R28's care plan revised 10/20/23, failed to identify R28's interventions for any behaviors. R28's psychosocial note dated 11/10/23, identified family member (FM)-A was updated on the subarachnoid hemorrhage in R28's parietal lobe. Discussed behavioral concerns and patterns R28 displayed when FM-A left the facility. FM-A explained R28 and FM-A got into an argument earlier in the week, FM-A told R28 she wouldn't be in to visit for awhile and R28 knew she was dog sitting this weekend. FM-A expected R28 would do something to create a fall as per FM-A, this was something R28 had done for years. Discussed the safety of R28's lift recliner chair, FM-A expressed that she wanted that out of R28's room as he had done this before when he was acting out. FM-A expressed that she would purchase R28 a normal recliner chair that would not lift him up as this one did. FM-A expressed further concerns and issues R28 had a history of, prior to his admission to the facility and prior to his initial brain injury. During an observation on on 11/28/23 at 9:18 a.m., R28 was sitting in his wheelchair in the living room in front of the tv. R28 look around the room and occasionally looked at the movie on the tv, but did not speak nor make any movement of his arms, trunk or legs. At 10:33 a.m., FM-A approached R28 who lit up in a smile and instantly began talking to FM-A in a slow, deliberate speech. FM-A assisted R28 to his room. During an interview on 11/28/23 at 3:37 p.m., FM-A stated R28 was very ornery and manipulative. R28 had a motorcycle accident in his late 20's-early 30's. R28 had several motor vehicle accidents as well. During the motorcycle accident, R28 went over the handlebars, without a helmet, down an embankment into a forested area. R28 had a head injury and also hurt his shoulder. R28 has a history of being volatile to the point FM-A was fearful for her life. R28 has told FM-A he wanted to end his life and FM-A stated she felt, one of these days, R28 would do it. R28 had thrown himself from his recliner. R28 was an intelligent man, had been through military training and was very manipulative especially when she made plans away from the facility. FM-A stated R28 threw himself from his recliner on purpose, when she was away from the facility. FM-A stated R28 was bullheaded and stubborn. You think he's weak, but he's stronger than you think he is. Additionally, there were things in his childhood, physical and verbal abuse. FM-A stated R28 was impulsive, and hell bent. FM-A had reported this to social services (SS)-A but had gone into greater detail on 11/10/23. R28's medical record lacked evidence the behaviors were assessed, identified and interventions implemented for R28's behaviors. During an interview on 11/28/23 at 4:04 p.m., nursing assistant (NA)-A stated R28 could get snarky. R28 would laugh with a strange look on his face and could be demanding. During an interview on 11/28/23 at 4:31 p.m., licensed practical nurse (LPN)-C stated staff tried to keep him in the living room more to supervise because R28 was a fall risk. R28 would try to climb out of his wheelchair or his bed if FM-A was gone. During an interview on 11/29/23 at 8:32 a.m., NA-C stated people had to give R28 time to talk. Yes or no questions were better but sometimes R28 just wouldn't talk. FM-A was usually here every day and NA-C just knows that R28 liked his recliner and if R28 closed his eyes, NA-C took that as leave me alone. R28 could be a stinker. If FM-A was gone, R28 would throw a fit so FM-A had to come. Usually, R28 threw himself on the floor. During an interview on 11/29/23 at 8:41 a.m., LPN-A stated R28 startled easily. R28 was more of an attention seeker, especially when FM-A was gone. For example, one weekend, he turned on his call light every five minutes. We'd go in, he'd smile, we'd turn off the call light, and he'd turn it right back on, or R28 would throw himself on the floor. During an interview on 11/29/23 at 11:31 a.m., social services (SS)-A stated they discussed resident behaviors during IDT meetings and the daily high risk meeting. SS-A had been working with R28 and FM-A. FM-A had a conversation with SS-A when FM-A was upset with R28, FM-A disclosed way more than she ever had before. R28's behavior had been erratic and been hurting others and/or himself since he was in his 30's. We have never seen him aggressive with staff nor with FM-A while he's been at the facility. In the past R28 held FM-A at gunpoint. Normally, she doesn't go into detail. SS-A puts in a summary in R28's chart but SS-A did not put in these statements because they were allegations. It was a fine line because SS-A did not have anything to show for that. We know R28 had attention seeking because that's when he had more falls. Its when R28 was alone. R28 wanted to have engagement with others and staff. SS-A stated she did not know how to care plan this for R28 without making it an assumption because this had all came since his last fall on 11/9/23. Even on good terms, we know R28 fell more when FM-A was not here but staff had not connected this was on purpose. FM-A reported she walked into R28's room and R28's had his feet on his dresser trying to push himself over. FM-A had never said R28 wanted to end his life but she reported that if R28 wasn't hurting himself, he wanted to hurt others. SS-A stated FM-A described it more like a mind game. R28 knew if he had a fall, staff called FM-A to either come or take time away from what she was doing. SS-A stated she knew talking about self harm in care plans was bad and wanted to document that clearly. R28 had been doing great in the living room because everyone was saying hi to him. Behaviors were important to care plan because it communicated to other staff how to care for R28. During an interview on 11/29/23 at 12:27 p.m., LPN-B stated R28 was very dependent on FM-A, who was at the facility every day. FM-A set up appointments, etc., to go around R28's nap time etc. LPN-B stated she knew there was an argument before R28's last fall between R28 and FM-A, but R28 was good with the staff. It was hard because his impulsivity was hard to differentiate between impulsivity and/or intentional. Was it his brain injury? Was he trying to do something and didn't understand? LPN-B had not seen a pattern where R28 tried to hurt himself permanently, but had been more impulsive previous to his fall because he did not have that ability anymore. LPN-B stated she was involved in R28's care conferences but R28's behaviors had not been addressed. During an interview on 11/29/23 at 2:47 p.m., the director of nursing (DON) stated there was no behavior care plan for R28. There's just things we need to get on track here. There was no documentation to reflect R28's behavior and/or mood assessment because the DON had looked for it herself. The DON was very aware the facility needed to make changes in their care planning and documentation. A facility policy regarding mood/behavior assessment and care planning was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to offer and provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 5 of 5 residents (R7, R25, R34, R39, R43) reviewed for immunizations. This had the potential to affect all residents who were eligible for the pneumococcal booster. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 was [AGE] years old and had diagnoses of Parkinson's disease and breast cancer. R7's immunization record dated 11/29/23, identified R7 received the pneumococcal polysaccharide vaccine (PPSV23) on 6/17/15, and received the pneumococcal conjugated vaccine (PCV-13) on 5/22/17. R7's medical record did not include evidence R7 or R7's representative received education regarding pneumococcal vaccine booster and there was no indication R7 was offered the pneumococcal vaccine per CDC guidance. R25's significant change MDS dated [DATE], identified R25 was [AGE] years old and had diagnoses of dementia and heart failure. R25's immunization record dated 11/29/23, identified R25 received the PPSV23 on 7/25/17, and received the PCV-13 on 12/19/14. R25's medical record did not include evidence R25 or R25's representative received education regarding pneumococcal vaccine booster and there was no indication R25 was offered the pneumococcal vaccine per CDC guidance. R34's annual MDS dated [DATE], identified R34 was [AGE] years old and had a diagnosis of dementia. R34's immunization record dated 11/29/23, identified R34 received the PPSV23 on 11/6/03, and received the PCV-13 on 11/9/16. R34's medical record did not include evidence R34 or R34's representative received education regarding pneumococcal vaccine booster and there was no indication R34 was offered the pneumococcal vaccine per CDC guidance. R39's quarterly MDS dated [DATE], identified R39 was [AGE] years old and had a diagnosis of dementia. R39's immunization record dated 11/29/23, identified R39 received the PPSV23 on 11/14/05, and received the PCV-13 on 12/5/16. R39's medical record did not include evidence R39 or R39's representative received education regarding pneumococcal vaccine booster and there was no indication R39 was offered the pneumococcal vaccine per CDC guidance. R43's quarterly MDS dated [DATE], identified R43 was [AGE] years old and had a diagnosis of dementia. R43's immunization record dated 11/29/23, identified R43 received the PPSV23 on 2/12/03, and received the PCV-13 on 10/16/15. R43's medical record did not include evidence R43 or R43's representative received education regarding pneumococcal vaccine booster and there was no indication R43 was offered the pneumococcal vaccine per CDC guidance. During an interview on 11/29/23, at 12:00 p.m. the infection preventionist (IP) stated they were familiar with the updated guidelines regarding pneumococcal vaccinations. At this time the facility had not handed out any education regarding the updated pneumococcal guidelines and had not offered any resident pneumococcal vaccinations. The facility's Pneumococcal Vaccination policy dated 10/24/22, identified the purpose is to ensure each resident is offered pneumococcal vaccinations per recommendations from the Centers for Disease Control and Prevention (CDC).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to assess for and failed to ensure 1 of 2 residents (R4) was free from the use of physical restraints when placed in recliner chairs that prevented rising independently. Findings include: 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. 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 had not been using assessment to determine restraint use. The DON stated if a resident was totally dependent on staff the facility should look at rights, talk to family and the residents and care plan accordingly. The DON stated there was no criteria for determining if a device was a restraint. Facility Policy Restraints dated 4/4/23, indicated a facility must not impose physical restraints for purposes of discipline or convenience. The facility is prohibited from obtaining permission from the resident, or resident representative, for the use of restraints when the restraint is not necessary to treat the resident's medical symptoms.

Based on interview and document review the facility failed to timely report an allegation of abuse to the state agency (SA) and administrator for 1 of 1 resident (R1) who alleged employee to resident abuse. Findings include: A report to the SA dated 7/10/23, at 3:29 p.m. indicated on 7/9/23, at 9:00 a.m. R1 had been tearful when a nursing assistant (NA) was assisting her to the bathroom. When asked what was wrong, R1 stated the girl last night had hit her. R1 said she had been hit in the chest, then showed the NA by smacking her own chest. R1 then told the NA she broke it pointing to her lamp. R1 also described the incident to her family member (FM) and registered nurse (RN) and said the staff was mean to her and hit her. R1 then demonstrated what the staff member had done to her at which time R1 grabbed the RN's wrists, then pushed the RN away by his wrists. During interview on 7/19/23, at 8:51 a.m. licensed social worker (LSW)-A stated staff had become aware of the allegation on 7/9/23, when R1 reported it to the NA. LSW-A said the NA then reported it to the nurse on duty who told her the call the clinical coordinator if she had concerns. LSW-A stated the NA reached out to the clinical coordinator at 7:00 p.m. on 7/9/23, via text message. LSW-A stated she received a call around 8:00 p.m. on 7/9/23, and said she should have reported to the SA at that time but she did not have her laptop with her. During interview on 7/19/23, at 2:12 p.m. the DON stated if an allegation of abuse was reported after hours or on a weekend, the person who learned of the incident should tell the charge nurse, clinical coordinator or LSW-A. The DON stated she was also available and was on call 24/7. The DON stated no one had called and reported the incident to her. The DON stated she was not aware of the allegation until 7/10/23, in the morning and said the administrator was notified at that time. Facility policy Resident Abuse Prohibition Policy dated 6/7/23, indicated Employees must report abuse immediately to supervisor in house or designee. Supervisor in house or designee must then notify the Administrator immediately. The facility must designate a facility staff member on each shift responsible for receiving complaints and conducting complaint investigations. The policy further indicated if an incident or allegation is considered reportable, the administrator or designee will make a report to the SA online reporting web site immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to thoroughly investigate an allegation of staff to resident abuse and failed to ensure protection for vulnerable adults pending the investigation results for 1 of 1 residents (R1) who alleged staff to resident abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she required assistance of one staff for activities of daily living. The MDS indicated R1 did not display hallucinations or delusions. R1's care plan dated 3/1/23, indicated R1 was vulnerable due to the following factors: Communication, difficulty making needs known, disoriented to place an time, functional limitations, confusion and repetitive vocalizations. The care plan indicated R1 may be easily exploited. A report to the SA dated 7/10/23, at 3:29 p.m. indicated on 7/9/23, at 9:00 a.m. R1 had been tearful when a nursing assistant (NA) was assisting her to the bathroom. When asked what was wrong, R1 stated the girl last night had hit her. R1 said she had been hit in the chest, then showed the NA by smacking her own chest. R1 then told the NA she broke it pointing to her lamp. R1 also described the incident to her family member (FM) and registered nurse (RN) and said the staff was mean to her and hit her. R1 then demonstrated what the staff member had done to her at which time R1 grabbed the RN's wrists, then pushed the RN away by his wrists. A facility Vulnerable Adult Internal Investigation dated 7/10/23, indicated no safety plan was needed to ensure the safety of R1 and indicated not verified. The facility investigation included interviews with residents and staff however, only two of the eight staff who worked the evening and night of the alleged incident were interviewed. During interview on 7/19/23, at 8:51 a.m. the licensed social worker (LSW)-A stated the NA who R1 reported the allegation to had spoken to the nurse on the unit but did not give her the full story. LSW-A said the nurse on duty was only told about the broken lamp. On 7/19/23, at 12:19 p.m. RN-A stated R1's communication varied and said her words were typically very jumbled but when she got upset she was more able to get words out. RN-A said she had received a text message from staff on 7/9/23, and staff reported R1 had said another staff had poked her in the chest and had broken her lamp. RN-A said R1 had described to her family member staff grabbing her hands and pushing her. RN-A stated the lamp was broken, and said the shade cracked in half. One of the NA's who worked the night of the allegation said R1 had caught the cord with her walker and the lamp fell and broke. On 7/19/23, at 2:12 p.m. the director of nursing (DON) stated on 7/10/23, interviews were completed with the nurse who had worked the night shift on 7/8/23, and the nurse that worked the following evening because he had been working when R1's FM came to the facility. The DON stated she and LSW-A had spoken to only one of the NA's that worked the night of 7/8/23. The DON confirmed only two staff that worked the night of the alleged incident had been interviewed. Facility policy Resident Abuse Prohibition Policy dated 6/7/23, indicated when an incident or suspected incident of abuse, neglect or other maltreatment is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The policy indicated the investigation will consist of interviews with staff members having contact with the resident during the relevant periods or shifts of the alleged incident. The policy further indicated ensuring safety and well-being for the vulnerable adult is of utmost priority. Safety, security and support of the resident if applicable and other residents with the potential to be affected will be provided. This should include as appropriate: Remove resident/patient from situation. If it is determined that a resident could be at risk in the same environment, the situation will be evaluated and options will be considered. Employees accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and document review, the facility failed to thoroughly investigate an allegation of employee to resident physical abuse for 1 of 3 residents (R1) who were reviewed for allegations of abuse. Findings include: R1's quarterly minimal data set (MDS) dated [DATE], indicated R1 had a diagnosis of Alzheimer's Disease and had severely impaired cognition. R1 did not exhibit behaviors. Review of facility report number 352377 to the State Agency (SA) dated 5/19/23, R1 had reported nursing assistant (NA)-A grabbed R1 hard on her arms and NA-A threw R1's call light under the bed. Review of facility 5-day investigation submitted to the SA dated 5/22/23, indicated all residents with BIMS 8 and higher or moderately impaired cognition were interviewed during the week of 5/8/23 through 5/10/23 (prior to the allegation of abuse) and revealed no abuse concerns. Facility investigation lacked evidence of other residents, who were under the care of NA-A on 5/19/23, were interviewed or assessed to ensure safety. During an interview on 5/25/23, at 3:17 p.m. social services (SS)-A confirmed other residents, who NA-A cared for on the day of the allegation, were not interviewed due to facility completing safety assessments during the week of 5/8/23. Further, SS-A indicated interviewing other residents would have been important due to the severity of R1's allegation to ensure other resident's safety as well as ensuring no additional incidents had occurred with NA-A. During an interview on 5/25/23, at 4:43 p.m. director of nursing (DON) indicated on 5/19/23, the day of R1's allegation, NA-A was assigned to two wings. DON confirmed other residents under NA-A were not interviewed, however would be important as part of the investigation to ensure other residents were protected from abuse. Review of facility policy titled Resident Abuse Prohibition Policy revised 5/5/23, indicated the investigation will consists of at least the following: review of completed complaint report, interviews with the person reporting the incident, interviews with witnesses, interviews with staff members having contact with the resident during the alleged period, interviews with roommate, family, and visitors. The policy lacked evidence of interviewing other residents who were under the direct care of the alleged perpetrator during the alleged period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to immediately report potenential allegations of staff to resident abuse to the facility administrator and/or the state agency (SA) for 1 of 5 residents (R5) reviewed for abuse. Findings include: R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 had severe cognitive impairment and required assist of two staff for ADL's. An untitled document dated 2/25/23, identified NA-E was forcefully pulling R5's body back by his shoulders and yelling get back or just sit down and was verbally and physically rough with R5. During interview on 4/4/23, at 8:14 a.m. NA-D stated R5 was wheelchair bound, unable to walk and would attempt to throw himself out of his wheelchair and/or bed. The last weekend of February 2023, R5 was seated in his wheelchair and NA-E was standing behind the wheelchair. R5 would attempt to stand and NA-E would firmly push on his shoulders from behind, try to sit him down and stated no stop it and sit down, sit down. NA-D talked to LPN-C about how NA-E was treating R5 and was asked to write it up and put the note in the DON's mailbox. NA-D stated she left the note for the DON. During an interview on 4/4/23 10:09 a.m., the administrator stated he was not aware of any allegations of employee to resident abuse until after survey entrance on 4/3/23. There should have been a report file and a documented investigation conducted. Any allegation not determined reportable, documentation was still required because they would still need to work through their processes to ensure resident safety During interview on 4/4/23, at 10:45 a.m. the DON stated R5 had a lot of behaviors, was a very difficult resident and had a 1:1 staff assigned while awake.The DON stated received a phone call regarding R5's behaviors, aggression, and NA-E had her hands on the residents shoulders. The DON denied being told NA-E had forcefully pushed on R5's shoulders and stated she had not received any notes or documentation regarding NA-E's alleged rough treatment of R5. The DON was not able to to provide the communication she received regarding the incident. The facility policy Resident Abuse Prohibition Policy revised 1/17/23, identified an owner, licensee, Administrator, licensed nurse, employee, contracted provider, or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or harmfully neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, or misappropriation shall immediately report to the Nursing Home Administrator or designee. The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements. - External Reporting: initial reporting of allegations: if an incident or allegation was considered reportable, the Administrator or designee would make a report to the state agency online reporting web site immediately, but not later than two hours after the allegation was made. If the even that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure staff treated residents with respect and dignity during provisions of care for 1 of 1 residents (R1) reviewed who was dependent on staff for assistance with activities of daily living. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and indicated she did not display behaviors. The MDS indicated R1 required extensive assistance from staff for bed mobility and transfers and total dependence on staff for toileting. R1's care plan updated 2/21/23, identified a self care deficit. The care plan directed staff to provide assistance from one to two staff to turn and reposition in bed and directed the use of a lift to complete perineal cares and lower body dressing. Facility Progress Notes indicated the following: 1/31/23, R1 refused to roll to left or right and stated she got too dizzy. Staff encouraged R1 to go slow but R1 declined. 2/1/23, R1 was on an antibiotic for bilateral ear infections. R1 continued to refuse to turn from side to side leaving staff to use a mechanical lift to perform cares. 2/6/23, R1 continued to complain of dizziness when turning from side to side. 2/6/23, R1 had a decent amount of emesis after lunch. R1 indicated she was scared if she moved she would have another emesis. 2/17/23, Staff spoke with R1's family member (FM)-A regarding incident on 2/16/23. FM-A reported R1 called her and was very upset, in tears and requested FM-A come to the facility. FM-A stated upon arrival to the facility, R1 was in tears and it took two hours to calm her down. FM-A stated staff were attempting to provide evening cares to R1 and were insisting she turn side to side instead of providing R1 with the mechanical lift that had been requested due to R1's preference related to her complaints of dizziness with turning. 2/17/23, Staff discussed the events of the previous evening with R1 while accompanied by another staff member. R1 verbalized that while staff did not physically force her to turn she felt as though they would not let it go. R1 reported staff member talked about other residents who refused cares and ended up with skin concerns. R1 stated it was very upsetting and she did not want to be forced to do anything she did not want to do. During interview on 2/28/23, at 1:24 p.m. R1 stated she had an inner ear infection that had lasted awhile and caused her to be dizzy and feel nauseated. R1 stated she had asked not to be turned rapidly because it caused her to feel like she was going to vomit and said it made me sick. R1 said on the evening of 2/16/23, nursing assistant (NA)-A had been assisting her with cares and said apparently it was too much for her to use the lift and said she didn't want to be bothered with it. R1 stated it had happened more than once with NA-A and another individual and said they acted like she was making a big deal out of nothing. R1 stated the previous incident had been reported to RN-A. R1 said she did not like to be made to feel that way and said, I know what I was feeling. R1 said it definitely caused her discomfort to roll side to side and said she did not like feeling that way. R1 further stated it was upsetting to her to be disregarded. During interview on 2/28/23, at 2:10 p.m. registered nurse (RN)-A stated R1 had recently complained of headaches and dizziness when turning side to side and had been diagnosed with ear infections and vertigo. RN-A stated on 2/17/23, FM-A had sent her a message requesting a phone call. RN-A stated FM-A told her R1 had called her the night before and had been upset and crying. FM-A stated R1 had told her NA-A was trying to get her to turn side to side and R1 would not do it so they eventually got the lift to assist her. RN-A said FM-A had talked to RN-B on the evening of 2/16/23, after the incident occurred and said RN-B told her the NA's went to her and reported R1 had been upset and was crying. RN-A stated it was decided that NA-A would no longer care for R1 and acknowledged it was no the first time this had occurred between R1 and NA-A. During interview on 2:39 p.m. NA-B stated he was in the room when the incident occurred between NA-A and R1 on 2/16/23. NA-B stated NA-A was having difficulty getting R1 to turn from side to side. NA-B said he thought NA-A was being polite enough but maybe let it go on too long. NA-B stated NA-A spent approximately 10 minutes trying to convince R1 to turn even after R1 requested to use the mechanical lift. During interview on 2/28/23, at 3:01 p.m. the director of nursing (DON) stated she heard about the incident between NA-A and R1 the next morning. The DON stated when she asked what had upset R1 she was told staff had not respected R1's wishes and it had taken FM-A two hours to calm R1 down afterward. The DON stated RN-A and the director of household life (DHL) had spoken to R1 who reported she had been upset because she requested the use of the lift and NA-A did not respect her wishes. The DON stated she was not aware there had been a previous incident between R1 and NA-A. During interview on 2/28/23, at 3:12 p.m. the DHL stated RN-A had asked her to be part of the conversation when she spoke to R1. The DHL said R1 stated she had been very upset because the two NA's had bullied, or tried to bully her into turning and she refused. The DHL said R1 told her the NA's had been lecturing her. The DHL stated R1 named NA-A and said she felt NA-A had overly lectured her and she had told NA-A she could make her own choices. The DHL said R1 told her she had been so upset she called her daughter. During interview on 2/28/23, at 3:21 p.m. RN-B stated on the evening of 2/16/23, she went to R1's room to give her medications and NA-A and NA-B were in the room providing cares. RN-B stated R1 was trying to tell the NA's something and she felt like NA-A was confused. RN-B said she told NA-A, I think she is trying to tell you she wants to use the lift. RN-B said the NA's got the lift and she exited the room. RN-B stated she did not know how long the NA's had been in the room when she entered. RN-B said a while later NA-A told her FM-A was there and wanted to talk to her. RN-B said when she got to R1's room, R1 was crying and was upset because NA-A wanted her to roll over but she couldn't because of her ears. RN-B said FM-A was upset and said there had already been two conversations about using the lift already and felt this incident should not have happened. During interview on 2/28/23, at 3:33 p.m. FM-A stated her sister called her on 2/26/23, and asked if she could call R1 or if she had heard from her. FM-A stated she called R1 who was crying and she had difficulty understanding her. FM-A stated she went to the facility and R1 was still upset. FM-A stated when R1 calmed down she said NA-A had been downright mean and said this was the third incident related to the lift and turning. FM-A said initially they had written a note requesting staff use the lift and when that did not work she had met with RN-A. FM-A stated NA-A was the staff taking care of R1 when she had vomited after being rolled. FM-A stated her concern was the lack of self-determination and. FM-A further stated it had taken 45 minutes to calm R1 and said that was not typical. Following exit, during interview on a return phone call on 3/1/23, at 1:56 p.m. NA-A stated on 2/16/23, she had gone into R1's room to provide cares. NA-A said R1 had refused cares earlier in the shift and said she had asked R1 to roll and she refused . NA-A stated she explained some of the risks of not repositioning. NA-A stated RN-B came into the room and asked them to weigh R1 so they got the lift and completed R1's cares. NA-A stated she felt the incident was a normal interaction to her. Further, NA-A denied knowledge of a similar incident between herself and R1. When asked why she did not get the lift as requested by R1, NA-A stated R1's care plan at the time said to encourage her to roll as much as possible. NA-A acknowledged she was aware it was okay to use the lift for R1. Facility policy Resident Rights dated 8/28/19, indicated each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure nursing staff observed medication administration for 1 of 1 residents (R44) observed to self-administrating a nebulizer treatment and was not assessed to be able to do so. Findings include: R44's quarterly Minimum Data Set (MDS) dated [DATE], identified R44 had severe cognitive impairment and diagnoses included chronic obstructive pulmonary disease (COPD) (a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.) R44's Initial Evaluation of Ability of Resident to Self-administer Drugs dated 6/16/22, identified R44 was cognitively able to self-administer medications, but was not physically capable nor desired to self-administer medications. R44's vision was poor and R44 preferred assistance. R44's Order Summary Report revised 10/26/22, identified Albuterol Sulfate Inhalation Nebulization Solution 0.63 milligram (mg)/3 milliliter (mL) inhale 1 vial orally via nebulizer two times a day related to COPD. During an observation on 10/24/22, at 4:33 p.m. licensed practical nurse (LPN)-A prepared R44's nebulizer with Albuterol Sulfate. LPN-A placed the nebulizer mask onto R44 and exited the room. LPN-A did not stay and observe R44. - At 4:53 p.m. R44 pulled off the nebulizer mask and laid it in his lap. - At 4:54 p.m. R44 attempted to lay the nebulizer mask onto his bed, but it was out of his reach. R44 then tipped the nebulizer mask over as if he was pouring the medication onto the floor and shook it several times. - At 4:56 p.m. LPN-A walked past R44's room door; however, LPN-A did not look in on R44 to ensure his nebulizer was working properly. - At 4:58 p.m. R44 flung his nebulizer mask onto his bed. - At 5:01 p.m. nursing assistant (NA)-A walked past R44's room, saw his nebulizer mask was off and entered R44's room. NA-A picked up the nebulizer mask and placed it onto R44's face and stated there's a little bit left to R44. NA-A stated no one ever instructed them to make sure R44 was wearing the nebulizer mask but she knew he needed it. NA-A exited R44's room. - At 5:05 p.m. R44 removed the nebulizer mask and flung it onto his bed. - At 5:08 p.m. LPN-A returned to R44's room, picked the nebulizer mask off R44's bed and held the mask to R44's face for approximately 30 seconds before shutting it off. During an interview on 10/24/22, at 5:10 p.m. LPN-A stated R44 was left alone with his nebulizer all the time. R44 was able to eat on his own and only needed supervision for eating and because of this, R44 could administer his own nebulizer treatment. LPN-A did not know if R44 was assessed to determine if R44 was safe to self-administer medications. During an interview on 10/25/22, at 5:07 p.m. registered nurse (RN)-D stated the staff normally left residents to self-administer nebulizer treatments. The nurse would set a timer for ten minutes and look in the room every time staff walked by. The only time staff would not do this was if they had been told otherwise. For example, if a resident had dementia. During an interview on 10/26/22, 3:08 p.m. RN-C stated staff stayed in the vicinity and set a time for ten minutes to make sure staff shut off the nebulizer machine. A resident with dementia would never be left alone. R44 would not have an assessment to determine if he could self-administer his nebulizer because the staff prepped the nebulizer and watched R44 self-administer. During an interview on 10/26/22, at 3:26 p.m. RN-B stated all residents should have a self-administration assessment in their paper chart. Upon review of R44's self-administration assessment dated [DATE], it identified R44 should not self-administer medications. At that time, RN-B stated R44 should not have been left with his nebulizer alone. During an interview on 10/26/22, at 3:49 p.m. the director of nursing (DON) stated R44 should have better supervision during his nebulizer treatment. At least, the nurses should have stayed in visual range and observed him. During an interview on 10/26/22, at 3:59 p.m. the administrator stated staff were expected to follow facility policy and practice standards regarding medication administration and self-administration of medications. The facility policy Self Administration of Medication reviewed 3/10/22, identified if a resident requested to self-administer medication(s), member of the interdisciplinary team (IDT) would determine that it was safe before the resident exercised that right. A resident may only self-administer after the IDT had determined which medications may be self-administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to report an incident of neglect of care with serious bodily injury was reported within 2 hours to the State Agency (SA) and adminstrator for 1 of 1 resident (R30) who fell and fractured femur when staff were not following the care plan. Findings include: R30's WSLC Post Fall Investigation Report dated 10/18/22, at 6:45 a.m. identified staff entered room [ROOM NUMBER]-A and found R30 lying on her side. Immediately, staff tried to comfort resident but due to the amount of pain R30 was experiencing, an ambulance was called. R30's Night Shift: Pine Toileting and Repositioning form dated 10/18/22, identified R30 required every 30-minute checks. 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 next to every half-hour mark indicating R30's location and condition were check ok hourly. R30's Post Fall Questions dated 10/18/22, identified 30+ minutes had passed since R30 was last checked. R30's progress note dated 10/18/22, at 9:12 a.m. 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 CNA comforted her while author went and called the ambulance. During an interview on 10/27/22, at 9:57 a.m. registered nurse (RN)-C stated she assumed R30 was checked every 30 minutes all shift. I just assumed they were both ok. R30 fell at approximately 6:40 a.m. and was last checked at 5:30 a.m. prior to her fall. R30 was not in her bed and did not have a bed alarm as care planned. RN-C considered reporting R30's fall to the SA but RN-C realized R30 was not in her bed and believed only the 6:00 a.m. check was missed. During an interview on 10/27/22, at 10:58 a.m. the director of nursing (DON) stated she was not informed R30 did not receive every 30-minute checks prior to her fall. The staff were not following R30's care plan and her fall with major injury should have been reported to the SA timely. During an interview on 10/27/22, at 11:33 a.m. the administrator stated staff were expected to follow care planned fall interventions and R30's fall with major injury should have been reported to the adminstrator and SA. The facility policy Resident Abuse Prohibition Policy revised 9/9/21, defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy directed if an incident was considered reportable, the administrator or designee would make a report to the SA immediately, but not later than two hours after the allegation was made, if the event that cuase the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to complete a significant change in status assessment (SCSA) when two or more areas of change in resident status were identified for 1 of 1 resident (R20) reviewed for activities of daily living. Findings include: R20's annual Minimum Data Set (MDS) dated [DATE], identified R20 had moderate cognitive impairment and diagnoses included Alzheimer's disease, dementia, heart disease and diabetes. R20 required limited assistance with bed mobility, grooming and dressing. R20 required extensive assist with transfer, ambulation, and toileting and was independent with eating after setup. R20's quarterly MDS dated [DATE], and 8/11/22, indicated a severe cognitive impairment. R20 required extensive assistance with bed mobility, dressing, grooming and eating and was unable to ambulate. Review of the above assessments identified a significant decline in functional status in activities of daily living in five areas, as well as a cognitive decline. When interviewed on 10/26/22, at 10:00 a.m. registered nurse (RN)-A stated R20 had a decline with functional ability, which was why R20 was moved from the memory care unit to her unit in January. A significant change MDS should have been completed. RN-A didn't have much training on how to complete the MDS since starting her position and was still learning. It would be important to complete significant change MDS when changes were identified so interventions could be added to the care plan and increase care needs could be identified. During interview on 10/26/22, at 11:00 a.m. the director of nursing (DON) stated she met with care coordinators every Monday and changes in resident status were discussed, as well as determining if a significant change MDS was warranted. She was surprised the significant change for R20 was not recognized. DON reviewed the MDS and identified R20 was more dependent with her activity of daily living and was no longer ambulating. It would be important to recognize significant changes when it occurred with residents so the care plan could be updated with more interventions and the nursing assistants could provide more assistance. A facility policy for MDS assessments was requested, however, none was received. The Minimum Data Set 3.0 Manual V1.17.1 dated 10/19, identified assessment Management Requirements and Tips for Significant Change in Status Assessments: A SCSA is appropriate when: There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident current status to the most recent comprehensive assessment and any subsequent quarterly assessments; and The resident's condition is not expected to return to baseline within two weeks. Guidelines for Determining a Significant Change in Resident Status: The final decision what constitutes a significant change in status must be based upon the judgment of the IDT (interdisciplinary team). MDS assessments are not required for minor or temporary variations in resident status - in these cases, the resident's condition is expected to return to baseline within two weeks. However, staff must note these transient changes in the resident status in the resident's record and implement necessary assessment, care planning, and clinical interventions, even though an MDS assessment is not required. Some Guidelines to Assist in Deciding If a Change is Significant or Not: Decline in two or more of the following: Any decline in an ADL physical functioning area where a resident is newly coded as extensive assistance, total dependence, or activity did not occur; Resident incontinence pattern changes or there was placement of an indwelling catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure transmission based precautions (TBP) were implemented when displaying signs of symptoms of COVID-19, until COVID-19 could be ruled out for 1 of 3 residents (R44) reviewed for COVID-19 practices. Findings include: R44's quarterly Minimum Data Set (MDS) dated [DATE], identified R44 had severe cognitive impairment. and a diagnosis of chronic obstructive pulmonary disease (COPD) (long standing inflammatory lung disease that causes obstructed airflow from the lungs making it hard to breathe.) R44's progress note dated 10/13/22, identified R44 had a productive cough and was spitting up brown-tinged sputum. R44 had coarse lung sound in both upper lobes. When R44 woke he was having a hard time breathing, a temperature of 99.8, oxygen saturation of the blood of 90%. R44 stated he felt terrible. During an interview on 10/26/22, at 2:33 P.M. registered nurse (RN)-B stated the increase in R44's productive cough was identified, and concerns were talked about possibility of COVID-19. They did not place him on transmission-based precaution (TBP) at that time because they did not have any COVID-19 in the building even though R44 displayed coarse lung sounds, a temperature and low blood saturation. They decided to test resident for COVID-19 but did not place R44 on TBP. The results of the first COVID-19 test was negative, and then tested for COVID-19 two days later to confirm R44 did not have COVID-19. During the time of testing RN-B stated they should of started R44 on TBP to protect the other residents from possible exposure to COVID-19. She stated TBP precautions were not started because the employees and residents were getting tired of COVID-19 and use of TBP. During an interview on 10/27/22, at 8:55 A.M. the director of nursing (DON) stated residents who had symptoms of COVID-19 would be placed on TBP. Residents would have had two tests for COVID-19 two days apart and if both were negative the resident would have been taken off TBP. The DON would have expected R44 to be placed on TPB when symptoms started. The facility's Infectious Disease Policy dated 10/24/22, identified residents who were suspected or had tested positive for COVID-19 would be placed on TBP and confined to their room with the door closed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to conduct outbreak testing as required upon identification of a positive COVID-19 resident (R32) residing in the facility. In addition, the facility failed to ensure COVID-19 testing results were documented in the residents medical record for 1 of 3 residents (R44) reviewed for COVID-19 practices This had the potential to spread COVID -19 to all residents who resided at the facility. Findings include: The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations For Healthcare Personnel During the Coronavirus Disease 2019 Pandemic, updated September 23, 2022, indicated a single new case of COVID-19 infection in any healthcare worker or resident should be evaluated to determine if others in the facility could have been exposed. Facilities are directed to perform an outbreak investigation with contact tracing or a broad-based approach. Facilities are directed to perform testing for all residents and health care personnel identified as close contacts or on affected unit if using a broad based approach, regardless of vaccination status. R32's admission Record dated 8/24/22, identified an admission date of 8/24/22. Diagnoses included hypertension, edema, heart disease, open wounds and diabetes. R32's care plan dated 9/20/22, indicated R32 was usually independent with transfers and used a four wheel walker and manual wheelchair for locomotion in the facility. R32's progress notes dated 8/24/22 to 8/30/22, included the following: -8/24/22, at 9:46 p.m. R32 was noted to have been in a pleasant mood for the shift. He went out to the main dining area and ate 100% of his meal. He returned to his room and sat in his recliner before going to bed. -8/29/22, at 12:26 p.m. R32 exhibited nasal congestion and an intermittent semi-productive cough. He complained of feeling weak and tired. A COVID-19 antigen test was performed and was positive for COVID-19. R32 was placed on transmission based precautions and quarantined to his room. When interviewed on 10/27/22, at 12:00 p.m. the director of nursing (DON) stated the last time the facility tested residents for outbreak testing was in January 2022. The facility did not conduct outbreak testing when R32 tested positive because he had only been in the facility a few days and she was not aware he ever left his room after he was admitted . The DON did not realize R32 had been eating his meals in the dining room with other residents. When the facility had a new positive resident or staff, it was the facility's practice to do outbreak testing on all staff and residents until there were no more positive cases for COVID-19 for fourteen days. The facility logs did not identify any symptomatic or positive resident or staff cases following R32's COVID positive status. The facility's policy Long Term Care and Assisted Living Response Plan for Supporting COVID-19 Testing dated 9/1/20, indicated the facility administration would determine the best course of action for testing its staff and residents while taking into consideration testing recommendations from Minnesota Department of Health (MDH), Centers for Disease Control (CDC) and other state and federal departments. Pandemic/Epidemic testing triggers were identified as one or more residents confirmed to have COVID-19. R44's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and included a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) (long standing inflammatory lung disease that causes obstructed airflow from the lungs making it hard to breathe.) During an interview on 10/26/22 registered nurse (RN)-B stated R44 started to develop symptoms of COVID-19 on 10/12/22, and was then tested for COVID-19 using a rapid test on 10/13/15, and 2 days later 10/15/22. The results of both tests were negative. She stated the testing, and the results were passed along in change of shift reports and sometimes placed in the progress notes. There was not a process in place in recording testing and results. RN-B stated the testing was completed by her and was not documented anywhere. During an interview on 10/27/22 at 9:56 A.M. the director of nursing (DON) stated when R44 was tested for COVID-19 the results and the dates the testing was done should have been documented in R44's medical record. The DON was aware at times staff just do the test quick and forget to chart them. The expectation was for the staff to document all the testing and results. The facility's Plan for Supporting COVID-19 Testing dated 9/1/20, identified the facility would ensure that records and maintained regarding the testing process, resident consent for testing, and test results. Follow facility policy and procedure for entering results for residents into each resident's medical record.