Refer to event id DCUR12 Based on observation, interview and record review, the facility failed to ensure staff treated one resident (Resident #35) in a review of nine sampled residents, with dignity and respect when Certified Nurse Assistant (CNA) C performed a Covid (Coronavirus-infectious disease) test on the resident without talking with the resident prior to administering the test to request permission, to educate to the rationale or preparation for testing, or to ensure privacy of the resident when tested. The census was 52.

Refer to event id DCUR12 Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, remained free from misappropriation of property when the resident's iPad (an electronic tablet/computer) came up missing and was presumed stolen. The facility census was 52.

Refer to event id DCUR12 Based on observation, interview and record review, the facility failed to follow professional standards of practice when Certified Nurse Assistant (CNA) C performed a Covid (Coronavirus-infectious disease) test (an invasive procedure where a cotton swab is inserted in a resident's nasal passages and a sample collected for testing) on one resident, (Resident #35), in a review of nine sampled residents. Resident #35 had not been assessed by a licensed nurse to determine the resident had symptoms that necessitated testing. Instead, CNA C performed the test without any professional basis for testing and without documented training to show he/she received appropriate training to perform the test. The facility census was 52.

Refer to event id DCUR12 Based on observation, interview and record review, the facility failed to provide incontinent care for one additional resident, (Resident #29), of nine sampled residents. The census was 52.

Refer to event id DCUR12 Based on observation, interview and record review, the facility failed to ensure one newly hired nurse assistant (NA) (NA B), of one NA employee file reviewed, obtained their certification within the required four month time frame. The census was 52.

Refer to event id DCUR12 This deficiency is uncorrected. For previous examples, refer to Statement of Deficiencies dated 11/17/23. Based on observation, interview and record review, the facility failed to ensure staff utilized appropriate personal protective equipment (PPE) during nasal swab testing (cotton swab up both nostrils) for one resident, (Resident #35), in a review of one resident tested for COVID-19 (an infectious disease caused by severe acute respiratory syndrome). The census was 52.

Based on observation, interview and record review, the facility failed to ensure staff treated one resident (Resident #35) in a review of nine sampled residents, with dignity and respect when Certified Nurse Assistant (CNA) C performed a Covid (Coronavirus-infectious disease) test on the resident without talking with the resident prior to administering the test to request permission, to educate to the rationale or preparation for testing, or to ensure privacy of the resident when tested. The census was 52. The facility did not provide a policy regarding dignity when requested. Review of the booklet, Resident Rights For Long-Term Care in Missouri, showed residents should be treated with consideration and respect and with full recognition of dignity and individuality. 1. Review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility, dated 10/6/23, showed the following: -Adequate hearing; -Clear speech; -Sometimes understands others; -Severely impaired cognition; -Short and long term memory problem; -No rejection of care. Review of the resident's care plan, last revised 10/18/23 showed the following: -Risk for changes in psychosocial well being related to safety measures required by the CDC to decrease risk of Covid-19; -The resident will need time and patience from you when attempting to make needs known. Review of the resident's Physician Order Sheet (POS) dated 1/2024 showed the following: -Diagnoses included Alzheimer's disease (a progressive disease which destroys memory and other mental functions); -May have Covid testing as needed (PRN) (8/17/21). Review of the resident's progress notes showed the following: -On 12/6/23, 12/28/23 and 1/2/24 resident tested for Covid 19 antigen with negative results; -On 1/3/24 no signs or symptoms of Covid, resident up eating his/her meals. Observation of the resident on 1/4/24 at 11:44 A.M. showed the following: -The resident sat in his/her recliner in the common area with his/her head resting on the right arm of the chair and his/her eyes closed; -Two other residents sat in their recliners and three residents sat at the table in the same room; -Certified Nurse Aide (CNA) C entered the common area with a packaged nasal swab and applied gloves; -He/She walked over to the resident, inserted the swab into the resident's nasal passages, moved it around and then spoke the resident's name and quietly spoke a few words, five at most. CNA C did not speak to the resident or explain that he/she was going to perform a Covid test prior to completing the test; -The resident repeated no and attempted to move away from the CNA as the CNA performed the test. During interview on 1/4/24 at 11:50 A.M., CNA C said the following: -No one had directed him/her to perform a Covid test on the resident; -He/She did not think the resident felt good so he/she wanted to test him/her; -He/She would report the findings to his/her charge nurse; -He/She said it would have been a dignity issue if he/she had not been discreet, (his/her back to the rest of the room, blocking others from seeing). During interview on 1/5/24 at 11:41 A.M., Licensed Practical Nurse (LPN) A said the following: -He/She believed the resident to be at baseline and had not suspected any reason for the resident to be Covid tested; -He/She was not aware that CNA C Covid tested the resident and he/she did not direct him/her to do so; -CNA C did not report any Covid test results to him/her; -Prior to conducting a Covid test, staff should educate the resident and explain the procedure. During an interview on 1/11/24 at 3:21 P.M., the Director of Nursing (DON) said the following: -He/She would expect staff to ideally provide privacy when performing Covid testing; -It would probably be best not to test Resident #35 as it would be traumatic for him/her either way. During interview on 1/5/24 at 3:32 P.M., the Administrator said the following: -The nurse should make the decision as to when a resident should be tested for Covid; -They would expect for the CNA to get consent from the nurse before testing a resident and inform the nurse of the test results after the testing; -If the nurse had not assessed the resident, had not instructed the CNA to perform a Covid test on the, and the CNA then failed to report the findings of the test to the nurse, this would be an unnecessary traumatic event for the resident. MO228693

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, remained free from misappropriation of property when the resident's iPad (an electronic tablet/computer) came up missing and was presumed stolen. The facility census was 52. On 1/5/23, the administrator was notified of the past noncompliance which occurred on 12/25/23. On 12/26/23 the administrator identified Certified Nurse Aide (CNA) D as misappropriating Resident #1's ipad (electronic tablet/computer) after review of facility camera footage. Upon discovery, CNA D was suspended, the facility conducted an investigation and notified appropriate parties, including local law enforcement. Inservicing of staff was conducted where the abuse and neglect policy, which included misappropriation of resident property, was reviewed and the facility reported they planned to replace the resident's ipad. The deficiency was corrected on 1/5/24. Review of the undated facility policy, Prevention of Abuse & Neglect and Misappropriation of Residents Property, showed the following: -The facility will make every effort to protect the resident's personal belongings by doing a completed inventory of personal belongings on admission and again annually. Any lost belongings will be reported to the charge nurse or social services director and every effort will be made to find them; -Prevention of Misappropriation of Resident Property: Residents, their families and staff will receive information on how to and whom to report concerns, incidents and grievances without the fear of retribution. Staff members will receive this policy by way of annual review information on orientation, yearly and as needed in-services. Review of the booklet, Resident Rights For Long-Term Care in Missouri, showed residents have the right to be free from misappropriation of resident property and exploitation. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 9/15/23, showed the following: -Very important to take care of his/her personal belongings/things; -Very important to do favorite activities; -Somewhat important to listen to music he/she liked. Review of the resident's care plan dated 10/11/23 showed the following: -Resident has periods of confusion and forgetfulness; -Resident prefers things to be a certain way. Attempt to keep his/her schedule and belongings the same. Review of the resident's quarterly MDS, dated [DATE] showed the following: -Severely impaired cognition; -Adequate hearing and speech. During interview on 1/4/24 at 1:35 P.M., CNA E said he/she knew the resident had a tablet which the resident would use to listen to music. He/She reported that it was missing to the charge nurse. Review of the time card report for CNA D showed he/she worked 12/22/23 from 1:30 P.M. to 4:24 A.M. on 12/23/23. Review of the facility investigation for the resident's missing iPad, dated 1/4/24, showed the facility interviewed staff and residents about the missing iPad and any other items they could have missing. The Administrator contacted the resident's family and the replacement cost of the iPad would be around $400.00 to $500.00. The facility had viewed video footage dated 12/22/23 and 12/23/23 which showed suspicious behavior on the part of CNA D, including carrying a white charger cord out of the resident's room, attempting to conceal it and carrying it to the break room. CNA D's last date to work was 12/24/23. Review of the theft report, provided by law enforcement, dated 12/27/23 at 9:21 A.M., showed the following: -The administrator contacted him/her regarding a missing iPad which belonged to Resident #1; -The iPad had been seen recently by staff in the resident's room; -The administrator had located video footage of CNA D entering and exiting the resident's room with laundry under his/her arm with what appeared could be something folded inside the laundry. The Administrator said this would be unusual, as all dirty laundry was removed from a resident's room in a laundry hamper. Review of the facility surveillance video, on 1/4/24 at 2:10 P.M., showed the following: -On 12/22/23 at 1909 (7:09 P.M.) the resident walked with staff (not CNA D) to the shower room. He/She wore black pants, a white shirt and a black vest; -At 1938 (7:38 P.M.) the resident walked with staff (not CNA D) back to his/her room. He/She wore cream sweat pants and a black vest; -At 2223 (10:23 P.M.) CNA D entered the resident's room (call light was on) and exited the room with a small white object in a white trash bag in his/her right hand and a pair of blue pajamas tucked under his/her left arm with part of them hanging down. He/She walked and entered the soiled utility room and exited carrying nothing. CNA D looked around and walked to the breakroom at 2234 (10:34 P.M.) and then to the smoke room; -On 12/23/23 at 0213 (2:13 A.M.) CNA D entered the resident's room without knocking (call light was not on) and at 0214 (2:14 A.M.) exited holding a white charging cord, which he/she quickly rolled up to conceal, (keeping it in his/her hand) and walked to and entered the break room. During interview on 1/4/24 at 2:10 P.M., the administrator said the following: -The resident's family had gifted him/her the iPad with his favorite music downloaded for him/her to listen to; -Staff were aware and assisted the resident at different times with the iPad; -He/She was first made aware of the missing iPad on 12/25/23 after the family had notified the Director of Nurses; -They watched video surveillance which showed CNA D entering and exiting the resident's room carrying clothes, a bag and a charger. They believed CNA D had carried the iPad out wrapped up in the clothes he/she carried out and then returned for the charger. -They planned to replace the resident's missing iPad. MO229263

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure an alleged injury of unknown origin was reported to the State Survey Agency (SSA) in a timely manner for one of three (Residents (R) 19) residents reviewed for reporting allegations to the SSA in a timely manner. The census was 52. Findings include: Review of the admission Record in the electronic medical record (EMR) under the Profile tab revealed R19 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbances. During an observation on 11/14/23 at 3:06 PM, R19 was in the activity room and had bruising on his/her neck. Review of the Progress Notes dated 11/16/23 revealed R19 had two small bluish reddish bruises to the right side of his/her neck. The note indicated the nurse talked to R19's family member and both agreed that R19 slept in unusual positions either in bed or in the recliner and he/she could have bruised him/herself. The resident was unable to say how the bruising on his/her neck got there due to his/her cognition. During an interview on 11/16/23 at 3:54 PM Certified Nursing Assistant in Training (CNAT) 5 revealed he/she first saw bruising to R19's neck on 11/13/23 and reported the bruising to the nurse on duty. During an interview with the Director of Nursing (DON) on 11/16/23 at 4:48 PM she confirmed CNAT5 reported the bruising to the nurse on 11/13/23, however, the nurse did not report the incident to the Administrative staff. The DON confirmed the bruising (injury of unknown origin) should have been reported to the SSA (state agency) in a timely manner and it was not. The DON further confirmed she reported the injury of unknown origin on 11/16/23 and the bruising was first noted and reported on 11/13/23. During an interview on 11/16/23 at 4:46 PM the administrator said she did not know about the bruise until today (11/16/23). She said she would have reported it immediately if she had known. Review of the facility's policy, Abuse, Neglect and Exploitation policy (undated) revealed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: the allegation involve abuse or result in serious bodily injury, or injury of unknown origin. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to complete a significant change assessment for one of 24 sampled residents (Resident (R) 21) after R21 suffered a cerebral vascular accident (CVA) which resulted in R21 needing a feeding tube due to being unable to take food or fluids by mouth. The census was 52. Findings include: Review of R21's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R21 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, atrial fibrillation, and essential hypertension. Review of R21's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/02/23 and located under the RAI tab of the EMR, revealed R21 did not have a feeding tube. Review of R21's Dietary Quarterly Note dated 05/12/23 at 7:13 PM and located under the Resident tab of the EMR, revealed the resident was on a regular/mech [mechanical] soft diet. The resident eats in the east activity area and is assisted by staff with meal choices. The resident likes to have a pancake and scrambled eggs with syrup for breakfast. The resident likes coffee and cranberry/apple juice and desserts and sweet foods. Review of R21's Progress Note dated 07/12/23 at 5:15 PM and located under the Resident tab of the EMR, revealed the resident was brought to nurses station by CNA [Certified Nurse Aide], who stated the resident had choked on broccoli and apple juice. The resident had a little bit of food in his/her mouth that they removed, staff removed the resident's dentures to see if that would help make sure everything was out of his/her mouth, resident sounds like he/she had fluid in his/her throat, was having trouble trying to cough, and swallow when asked to. Left sided facial droop noticed, the resident's voice had a garbled sound to it, when asked to lift arms, left arm was drooping, could not grip with left side. Review of R21's Progress Note, dated 07/24/23 at 5:15 PM and located under the Resident tab of the EMR, revealed Resident was re-admitted for CVA and stroke, resident is NPO [nothing by mouth] currently has a peg [feeding] tube placed and receives continuous peg tube feedings. Review of R21's MDS 3.0 Resident Assessments list, located under the RAI tab of the EMR, revealed the facility did not complete a significant change assessment following R21's hospitalization for a CVA which resulted in R21 needing a feeding tube due to being unable to take food or fluids by mouth. During an observation on 11/16/23 at 9:00 AM, R21's feeding tube insertion site was observed. CNA3 confirmed R21 did not take any food or fluids by mouth. During an interview on 11/16/23 at 9:33 AM, the MDS Coordinator (MDSC) confirmed she did not complete a significant change assessment for R21 after the resident returned to the facility following hospitalization for a CVA and placement of a feeding tube. The MDSC said R21 should have had a significant change assessment completed. On 11/17/23 at 2:02 PM, the MDSC stated the facility used the RAI manual as the facility policy for completing significant change assessments.

Based on observation, interview and record review, the facility failed to follow professional standards of practice when Certified Nurse Assistant (CNA) C performed a Covid (Coronavirus-infectious disease) test (an invasive procedure where a cotton swab is inserted in a resident's nasal passages and a sample collected for testing) on one resident, (Resident #35), in a review of nine sampled residents. Resident #35 had not been assessed by a licensed nurse to determine the resident had symptoms that necessitated testing. Instead, CNA C performed the test without any professional basis for testing and without documented training to show he/she received appropriate training to perform the test. The facility census was 52. During interview on 1/11/24 at 3:21 P.M., the Director of Nursing (DON) said the facility did not have a policy for Covid testing. Review of the undated facility job description for CNA's showed the following: -Immediate Supervisor: charge nurse; -General responsibilities to the facility: 1. Follow company policies and procedures; 2. Greet all visitors, staff and most importantly, the residents with a prompt courteous approach; 3. Adhere to the philosophies, goals and objectives of the facility; 4. Cooperate and be able to work with all departments cohesively for the betterment of the facility and residents; 5. Adhere to professional standards, follow policy and procedures and abide by federal, state and local requirements; -Specific Responsibilities: 1. Provide direct care to all residents to include but not limited to: Bathing, dressing, toileting, ambulating, transferring, shaving, nail care and oral care; 2. Conduct bed checks at least every two hours; 3. Do walking rounds with the on-coming shift. Be sure to check all residents, shower room, dirty utility room, etc.; 4. Assist in the dining room (getting menus, passing plates); 5. Assist residents with all meals; 6. Make beds; 7. Pass ice water and snacks; 8. Catheter care and emptying catheters; 9. Obtain accurate intakes and outputs; 10. Maintain residents' room (keep them stocked and tidy); 11. Pick up resident clothing and take to laundry; 12. Clean bed pans, urinals and commodes; 13. Wash wheel chairs/geri chairs; 14. Be able to change out oxygen tanks; 15. Assist residents to and from activities; 16. Assist residents with smoking; 17. Answer call lights in a timely manner; 18. Document daily on provided tablets and on the kisoks; 19. Be responsible to carry and maintain your pagers (sign them in and out every shift); 20. Attend care plan meetings; 21. Obtain resident vital signs and weights; 22. Report changes in resident condition to the charge nurse. 1. Review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility, dated 10/6/23, showed the following: -Adequate hearing; -Clear speech; -Sometimes understands; -Severely impaired cognition; -No rejection of care. Review of the resident's care plan, last revised 10/18/23 showed the following: -Risk for changes in psychosocial well being related to safety measures required by the CDC to decrease risk of Covid-19; -The resident will need time and patience from you when attempting to make needs known. Review of the resident's Physician Order Sheet (POS), dated 1/2024, showed the following: -Diagnoses included Alzheimer's disease (a progressive disease which destroys memory and other mental functions); -May have Covid testing as needed (PRN) (8/17/21). Review of the resident's progress notes showed the following: -On 12/6/23, 12/28/23 and 1/2/24 resident tested for Covid 19 antigen with negative results; -On 1/3/24 no signs or symptoms of Covid, resident up eating his/her meals. Observation of the resident on 1/4/24 at 11:44 A.M. showed the following: -The resident sat in his/her recliner in the common area with his/her head resting on the right arm of his/her chair and his/her eyes closed; -CNA C entered the common area with a packaged nasal swab and applied gloves; -CNA C walked over to the resident, inserted the swab into the resident's nasal passages, moved it around and then spoke the resident's name and quietly spoke a few words, five at most. CNA C did not speak to the resident or explain that he/she was going to perform a COVID test prior to completing the test; -The resident repeated no and attempted to move away from the CNA during the procedure. During interview on 1/4/24 at 11:50 A.M., CNA C said the following: -No one had directed him/her to perform a Covid test on the resident; -He/She did not think the resident felt good so he/she wanted to test him/her; -He had not been trained to perform Covid testing but read the instructions on the box; -He/She would report the findings to his/her charge nurse. Review of CNA C's employee file showed no documentation he/she had been trained on how to perform a COVID test on him/herself or residents. During interview on 1/5/24 at 11:41 A.M., Licensed Practical Nurse (LPN) A said the following: -He/She believed the resident to be at baseline and had not suspected any reason for the resident to be Covid tested; -He/She was not aware that CNA C Covid tested the resident and he/she did not direct him/her to do so; -Covid testing would not be within CNA C's scope of practice; -CNA C did not report any Covid test results to him/her; -Prior to conducting a Covid test, staff should educate the resident and explain the procedure. During interview on 1/5/24 at 3:32 P.M., the Administrator and the Infection Preventionist said the following: -They had not trained staff to perform Covid testing on residents, however they did train them to test themselves so they would know how; -All residents have a standing order for Covid testing as needed; -A nurse should perform an assessment on the resident and request a CNA test a resident before the test is done; -The nurse should make the decision as to when a resident should be tested for Covid; -They would expect for the CNA to get consent from the nurse before testing a resident and inform the nurse of the test results after the testing.

Based on observation, interview and record review, the facility failed to provide incontinent care for one additional resident, (Resident #29), of nine sampled residents. The census was 52. Review of the facility policy, Perineal Care, last revised 2/2018 showed the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 1. Review of Resident #29's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/2/23, showed the following: -Diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions); -Occasionally incontinent of bladder and bowel; -Required partial to moderate assist for toileting and personal hygiene. Review of the resident's care plan, dated 12/13/23, showed the following: -Incontinent of bladder and bowel at times; -Resident will be clean and free of odors; -Resident required staff assist to go to the restroom. Provide pericare with incontinent episodes. Observation of the resident on 1/4/24, at 11:46 A.M., showed the following: -The resident sat in a recliner in the dining room; he/she wore long pants and a sweat shirt; -Nurse Assistant (NA) B assisted the resident to stand and walk to the dining table; -The backside of the resident's pants and sweatshirt (bottom and lower back) were noticeably wet and saturated with urine; -NA B led the resident to the dining table and had him/her sit in the chair. NA B noted the soaked clothing and said sometimes we fall short but we got to get back up; -The resident said It makes me feel terrible and cold; -NA B served the resident his/her lunch tray and the resident ate lunch; (NA B did not call other staff for help or provide the resident incontinent care after the resident had been incontinent of urine). During interview on 1/5/24, at 11:25 A.M., NA B said the following: -He/She was the only staff scheduled on the unit but would call for help as needed; -He/She should be working with a Certified Nurse Assistant (CNA); -He/She really could not do anything without a CNA; -He/She had changed the resident at 10:15 A.M.; -He/She should have changed and dried the resident when it was noted the resident was wet with urine and before the resident ate lunch. During interview on 1/5/24, at 3:32 P.M., the Administrator said the following: -Residents should be checked and changed every two hours and as needed; -If residents are observed wet with saturated clothing, they would expect staff to change the resident at that time; -They would not have expected staff to assist a resident with soiled/wet clothing to the dining table for a meal without addressing and changing the resident first; -NA's can provide resident care; -If they needed help they could push the panic button they carry in their pockets. MO228093 MO228693

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pressure ulcer prevention measures were completed per facility policy and consistent with professional standards of practice, for one resident out of a sample of two residents (Resident (R) 16) reviewed for pressure ulcers. The facility failed to conduct thorough weekly skin assessments, which included measurements, descriptions, and stage of a right heel wound to be able to identify a decline or an improvement, or new skin conditions. These failures had the potential to delay identification and treatment of any new wounds the resident might develop. The census was 52. Findings include: Review of R16's EMR located under the Resident tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of a document provided by the facility titled Braden Scale for Prediction of Pressure Sore Risk dated 09/02/22, indicated R16 scored 15 and was identified to be at risk for the development of pressure ulcers. The document directed staff to continue with the plan of care. The facility provided no additional Braden Scale assessments prior to the end of the survey. Review of R16's EMR titled Orders located under the Resident tab dated 04/26/23 indicated skin prep was to be applied to the resident's right heel twice a day until area resolved. Review of R16's EMR titled Medication Administration Record (MAR) located under (eMAR [electronic MAR] tab indicated the resident was being treated for a right heel pressure ulcer from 04/23 to 11/23. Review of R16's EMR titled nursing Progress Notes dated 05/01/23 to 11/14/23, failed to show staff completed consistent weekly skin assessments, for the resident's right heel which included stage, measurements, and description of the wound. Further review revealed weekly skin assessments were not completed for the following weeks: 05/09/23, 05/16/23, 06/06/23, 06/13/23, 07/04/23, 07/11/23, 08/01/23, 08/08/23, 08/29/23, 09/12/23, 09/19/23, 10/03/23, 10/10/23, 10/17/23, 10/24/23, 10/31/23, and 11/07/23. Review of a document provided by the facility titled quarterly MDS with an ARD of 07/10/23 indicated staff could not determine a Brief Interview for Mental Status (BIMS) score and indicated R16 had short- and long-term memory problems. The assessment indicated the resident was totally dependent on bed mobility of one staff member and totally dependent on two staff for transfers. The assessment indicated the resident had no pressure ulcers. Review of documents provided by the facility titled Skin Checks identified the following for R16's condition of her skin. On this document was a human diagram, front and back showed the following: -On 03/18/23, the skin assessment indicated the resident had an old area on his/her right heel. There were no measurements or a description of the right heel. There was no stage to the right heel identified; -On 03/24/23, the skin assessment indicated the resident had an old area on his/her right heel. There were no measurements or a description of the right heel. There was no stage to the heel identified; -On 04/01/23, the skin assessment indicated the resident had no new areas and did not identify the condition of the resident's right heel. There was no stage to the heel identified; -On 04/07/23, the skin assessment indicated the resident had no new areas and indicated the resident had a scab on his/her right heel. There were no measurements or a description of the right heel. There was no stage to the heel identified; -On 04/22/23, the skin assessment indicated the resident had no new areas and there was a scabbed right heel. There were no measurements or a description of the right heel. There was no stage to the heel identified; -On 04/29/23, the skin assessment indicated the resident had no new areas and there was no mention of the resident's right heel. There was no stage to the heel identified; -On 05/04/23, the skin assessment indicated the resident had a scabbed right heel. There were no measurements or a description of the right heel. There was no stage to the heel identified; -On 05/12/23, the skin assessment indicated the resident had a sore on the right heel which continued. There were no measurements or a description of the right heel. There was no stage to the heel identified; -On 05/18/23, the skin assessment indicated the resident had a scab on the right heel which continued. There were no measurements or a description of the right heel. There was no stage to the heel identified; -On 05/24/23, the skin assessment made no mention of the resident's right heel. There was no stage to the heel identified; -On 06/02/23, the skin assessment indicated the resident's right heel continues. There were no measurements or a description of the right heel. There was no stage to the heel identified; -On 06/06/23, the skin assessment made no mention of the resident's right heel. There was no stage to the heel identified; On 06/16/23, the skin assessment indicated the resident's right heel had scab that continues. There were no measurements or a description of the right heel. There was no stage to the heel identified; -On 06/24/23, 06/30/23, 07/06/23, 07/14/23, 07/21/23, 07/24/23, 08/05/23, 08/21/23, 08/30/23, 09/06/23, 09/13/23, 09/27/23, and 10/05/23 the skin assessments made no mention of the resident's right heel. There was no stage to the heel identified. Review of R16's EMR titled Care Plan located under the RAI tab, dated 08/22/23, indicated the resident was incontinent of bowel/bladder and staff were to monitor for skin changes to turn and reposition the resident every two hours. In addition, the staff were to apply heel protectors while the resident was in bed. During an interview on 11/15/23 at 10:52 AM, Certified Nursing Assistant Training (CNAT) 2 stated they were not sure if the resident had a pressure ulcer on the heel. CNAT 1 stated the resident was total care. During an interview on 11/15/23 at 11:01 AM Certified Nursing Assistant (CNA) 3 stated she was not aware if R16 pressure ulcer on her heel was healed or not. During an interview on 11/15/23 at 1:15 PM, Infection Control Nurse (ICP)/Quality Assurance (QA) Nurse stated R16 was at risk for the development of pressure ulcers. The ICP/QA Nurse stated a scabbed area cannot be staged. During an interview on 11/16/23 at 11:17 AM, Licensed Practical Nurse (LPN) 1 stated R16 had a scab on his/her right heel, and it was not open and stated the resident continued with skin prep to treat her right heel. LPN 1 stated it was important to measure a pressure ulcer weekly to see if there was improvement or deterioration in the wound. During an interview on 11/16/23 at 12:10 PM, the MDS Coordinator (MDSC) stated if an area was scabbed over it would be unstageable. The MDSC stated that it was the facility's belief that R16's right heel had healed and there was just a scab on it. The MDSC stated pressure ulcers should be measured and a description provided of the area. The ICP/QA Nurse was also present during this interview. During an interview on 11/17/23 at 10:10 AM, the Director of Nursing (DON) stated R16's right heel wound should be measured on a weekly basis. The ICP/QA Nurse who was present during this interview stated the right heel could not be staged since it was scabbed over. A request was made for additional and more current Braden Scales to be produced and weekly skin audits during this interview. No additional information was provided by the facility prior to the end of the survey. Per the RAI manual showed it is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Throughout this section, terminology referring to healed versus unhealed ulcers refers to whether or not the ulcer is closed versus open. When considering this, recognize that Stage 1. Deep Tissue Injury (DTI), and unstageable pressure ulcers although closed (i.e., may be covered with tissue, eschar, slough, etc.) would not be considered healed. Facilities should be aware that the resident is at higher risk of having the area of a closed pressure ulcer open up due to damage, injury, or pressure, because of the loss of tensile strength of the overlying tissue. Tensile strength of the skin overlying a closed pressure ulcer is 80% of normal skin tensile strength. Review of a policy provided by the facility titled Pressure Ulcers/Skin Breakdown Clinical Protocol dated 04/18 indicated nursing staff and the practitioner will assess and document an individual's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and history of pressure ulcer(s). In addition, the nurse shall describe and document/report a full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Review of a policy provided by the facility titled Additions to Pressure Ulcer Risk Assessment Policy dated 02/2014, indicated all pressure areas will be measured weekly, and measurements will be placed into the Wound Tracking Book. All licensed nurses will be assigned weekly skin assessments by the DON. Skin assessments will be completed and turned into the Quality Assurance Nurse. Any new pressure areas will be measured and put in the Wound Tracking Book and any new interventions to the Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interviews, and facility policy review, the facility failed to assess nutritional status after a significant weight gain/weight loss, and failed to take corrective action after the facility determined the weight gain and loss was an error for two (Resident (R) 6 and R43) of four residents reviewed for nutrition in a total sample of 24 residents. Findings include: 1. Review of R6's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE] with diagnoses that included unspecified dementia and anorexia. Review of R6's EMR titled Vitals located under the Resident tab revealed the resident had a significant weight gain from 09/02/22 to 10/03/22 of 45.5 pounds. There was no evidence in the clinical record that a re-weigh was obtained nor was there evidence the resident's weight was taken during the month of 11/22. On 12/07/22 the resident weight was 178.5 and then lost 41.7 pounds by 01/25/23. Again, there was no evidence in the clinical record that a re-weigh was obtained. Review of a document provided by the facility titled Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/13/22 indicated the staff could not determine R6's Brief Interview for Mental Status (BIMS) score. The assessment indicated the resident was not nutritionally at risk. Review of R6's EMR titled Care Plan located under the RAI [Resident Assessment Instrument] tab, dated 09/13/23, indicated R6 ate a regular diet with fortified foods and a Registered Dietician (RD) consultant would be provided as needed. Review of documents provided by the facility titled .Dietetic Consultation Service completed by the former RD, dated 11/09/22, 12/07/22, 02/09/23, 03/07/23, failed to identify R6's significant weight gain/loss. Review of a document provided by the facility titled RD Recommendations dated 01/2023 failed to identify R6's significant weight gain/loss. An observation was conducted on 11/15/23 at 11:25 AM R6 was sitting in the main dining room and began to eat her lunch meal. The resident was served meatloaf, mashed potatoes, and corn. The resident was observed to use her right hand and began to feed herself. The resident ate the entire serving of meatloaf and corn during this observation and left the mashed potatoes. During this observation, an interview took place with Certified Nursing Assistant Training (CNAT) 4 stated the resident was able to feed herself and did well with eating. During an interview on 11/15/23 at 11:30 AM, Dietary 1 stated R6 stated the resident was able to feed herself and ate well and never remembered the resident to have a poor appetite. During an interview on 11/15/23 at 1:15 PM, the Infection Control Nurse (ICP)/Quality Assurance (QA) was presented with R6's weights from the end of 2022 and stated the staff must not have subtracted the weight of the resident's wheelchair. The ICP/QA Nurse stated if there was a five percent variance of loss/gain the practice was to re-weigh the resident. During an interview on 11/15/23 at 1:45 PM, the Dietary Manager (DM) stated she mentioned the irregularities of R6's weight in previous weight meetings but she confirmed there was no documentation to support this statement. During an interview on 11/16/23 at 2:21 PM, the current RD stated if a resident had fluctuating weight, he would ask that the resident be re-weighed to verify the weights. The current RD stated he attends the monthly weight meetings, and any variance would be discussed. 2. Review of R43's Face Sheet, located under the Resident tab of the electronic medical record (EMR) revealed R43 was admitted to the facility on [DATE] with diagnoses that included heart failure and essential hypertension. Review of R43's Orders, dated 06/30/23 and located under the Resident tab of the EMR, revealed staff was to obtain R43's weight each week on Wednesdays. Review of the facility's Food & Nutrition Recommendation Sheet, dated 07/05/23 and provided by the Certified Dietary Manager (CDM), revealed the Registered Dietician (RD) had assessed R43 to have a significant weight loss during the previous three months. Review of R43's Weekly Weights, for the month of July 2023 and located under the Resident tab of the EMR, revealed R43's weight was not obtained on 07/05/23, 07/12/23, and 07/19/23. It was recorded the weights were not obtained due to condition. Review of R43's Progress Notes, dated 07/05/23, 07/12/23, and 07/19/23 and located under the Resident tab of the EMR, revealed no documentation to show why R43's weights were not obtained. Review of R43's Weekly Weights, for the month of August 2023 and located under the Resident tab of the EMR, revealed R43's weight was not obtained on 08/02/23, 08/16/23, and 08/23/23. It was recorded the resident either refused or the weight was not obtained due to condition. Review of R43's Progress Notes, dated 08/02/23, 08/16/23, and 08/23/23 and located under the Resident tab of the EMR, revealed no documentation to show why R43's weights were not obtained. Review of R43's Weekly Weights, for the month of September 2023 and located under the Resident tab of the EMR, revealed R43's weight was not obtained on 09/06/23 or 09/13/23. It was recorded the resident either refused or the weight was not obtained due to condition. Review of R43's Progress Notes, dated 09/06/23 and 09/13/23 and located under the Resident tab of the EMR, revealed no documentation to show why R43's weights were not obtained. Review of R43's Orders, dated 09/20/23 and located under the Resident tab of the EMR, revealed staff was to obtain R43's weight daily due to chronic kidney disease. Review of R43's Daily Weights, for the month of October 2023 and located under the Resident tab of the EMR, revealed R43's weight was not obtained on 18 out of 31 days. It was recorded R43's weight was not obtained due to either R43 refused, was sleeping, was done by prior shift, or due to condition. It was recorded R43 weighed 143 lbs. on 10/04/23 and 152.5 lbs. on 10/06/23. It was recorded R43 weighed 155.5 lbs. on 10/25/23 and 160.5 lbs. on 10/29/23. Review of R43's Daily Weights, for 11/01/23 through 11/02/23 and located under the Resident tab of the EMR, revealed R43 weighed 211 lbs. on 11/01/23 and 150.5 lbs. on 11/02/23. During an interview on 11/16/23 at 9:52 AM, Certified Nurse Aide (CNA) 3 stated all staff were responsible for obtaining weights. CNA3 stated she did not think staff was required to weigh R43 daily. CNA3 stated if a resident refused to be weighed or if staff had difficulty in obtaining a resident's weight, the staff should come back later to try again or find someone else to try. CNA3 stated if one shift was unable to obtain a weight, it should be reported to the next shift so they could try. During an interview on 11/16/23 at 10:05 AM, Registered Nurse (RN) 1 confirmed R43 was supposed to be weighed daily but stated that R43 often refused. RN1 stated the facility had identified a concern with monthly weights and had assigned one staff member to obtain all monthly weights but the nurses and aides were responsible for obtaining daily weights. During an interview on 11/16/23 at 11:48 AM, the Director of Nursing (DON) stated the consultant dietician monitored residents' weights. The DON confirmed that if there was a big discrepancy in weights, the staff was supposed to reweigh the resident. The DON stated she thought the staff was reweighing residents, as necessary. The DON stated staff was not provided any training related to weighing residents and were not monitored to ensure they were using the scales correctly. The DON reviewed R43's weights and confirmed the resident should have been weighed per orders and reweighed when there were large discrepancies. During an interview on 11/17/23 at 11:06 AM, the administrator and Infection Preventionist (IP), who was the facility's QAPI lead, were asked if the facility had identified any concerns related to obtaining accurate weights before the survey. The IP stated they had started a new system of having one person obtain the monthly weights because the weights had been inconsistent. The IP was asked if daily and weekly weights had been included in the new system and if those weights were monitored for accuracy. The IP stated, No. The IP stated, We trust our nurses to look back [monitor]. Review of a policy provided by the facility titled, Weight Assessment and Intervention, dated 03/22, indicated .Any weight change of 5 % or more since the last weight assessment is retaken the next day for confirmation.If the weight is verified, nursing will immediately notify the dietitian in writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one newly hired nurse assistant (NA) (NA B), of one NA employee file reviewed, obtained their certification within the required four month time frame. The census was 52. Review of the undated facility policy, Lewis County Nursing Home Job Description-Nursing, showed: -Position: Certified Nurse Assistant (CNA); -Qualifications: Must be [AGE] years old. Must be certified (non-certified personnel will be offered classes at the facility and must become certified within the specified guidelines); -General Responsibilities to the facility: Follow company policies and procedures. Adhere to professional standards, follow policy and procedures and abide by federal, state and local requirements. Review of a undated document provided by the facility, titled Job Description Report by Department, showed NA B's original hire date and current hire date were both 6/13/23. He/She was employed full time as a CNAT (Certified Nurse Assistant in Training). His/Her class start date was 8/3/23. Review of the nursing schedule for 12/10/23 to 12/23/23 showed NA B was scheduled to work 12/11/23 through 12/14/23 and from 12/16/23 through 12/20/23. Observations on 1/4/24 at 11:12 A.M. and 11:46 A.M. showed the following: -NA B stood in the common area of the locked dementia unit, where residents sat in recliners and at the dining table; -NA B talked with residents as they sat in the common/dining area; -NA B assisted residents to stand and walk to the dining table and served them their lunch trays; (There was no other staff present at the time and NA B worked the locked unit without supervision. He/She phoned staff from outside the unit when he/she needed assistance with checking and changing residents). During an interview on 1/4/24 at 11:13 A.M. and 1/5/24 at 11:25 A.M., NA B said the following: -He/She had been working as an NA at the facility since the end of May 2023; -He/She began CNA classes the beginning of October; -He/She was not certified at this time; -He/She should be working with a CNA; -He/She was the only staff scheduled on the unit; -The nurse for the unit was Licensed Practical Nurse (LPN) A who was working the other side (unit); -He/She had changed (provided incontinence care) for a resident at 10:15 A.M.; -When he/she needed help changing someone he/she called for assistance and someone would come over. During interview on 1/5/24, at 3:32 P.M., the Administrator said the following: -NA's can provide resident care; -If they needed help they could push the panic button they carry in their pockets; -They did not see an issue with an NA working alone in a locked unit anymore than they would a CNA; -NA's should receive their certification within four months from the date of hire.

Based on interview, record review, and facility policy review, the facility failed to ensure pharmacy recommendations were acted upon/responded to in a timely manner for monthly medication regimen reviews for one of five sampled residents (Resident (R) 43) reviewed for unnecessary medications. The census was 52. Findings include: Review of R43's Consultant Pharmacist Communication to Physician, dated 06/28/23 and provided by the Director of Nursing (DON), revealed, New regulations in effect November 28, 2017, require all PRN [as needed] psychotropic medications (including Ativan) to be limited 14 days. Therefore, in order for the facility to remain compliant, the PRN order for Ativan needs to be discontinued. Please review and consider DISCONTINUING the PRN order for Ativan. Hand-written on the communication was re-eval [re-evaluate] q [every] 7 days. The communication contained no physician response to the recommendation. Review of R43's Consultant Pharmacist Communication to Physician, dated 09/26/23 and provided by the DON, revealed, In order for the facility to remain compliant, the PRN order for Ativan needs to be discontinued. Please review and consider DISCONTINUING the PRN order for Ativan. Hand-written on the communication was [change] to re-eval q 7 days. The communication contained no physician response to the recommendation. Review of R43's Consultant Pharmacist Communication to Physician, dated 09/26/23 and provided by the DON, revealed, GRADUAL DOSE REDUCTION FOR PSYCHOTROPIC AGENTS REGARDING ABILIFY 400 MG [milligrams] IM [intramuscularly] Q MONTH, SEROQUEL 25 MG PO [by mouth] BID [twice daily], and BUSPIRONE 15 MG PO TID [three times daily] As you are aware, there are various CMS-related drug usage requirements related to the use of ALL psychoactive medications. This recommendation is a reminder to conduct an evaluation in an attempt to establish the lowest effective dose with the fewest number of medications through periodic reduction and/or discontinuation and does not necessarily reflect my clinical judgment or opinion regarding the discontinuation or reduction. Please review for the possibility of a trial dose reduction or taper to discontinuation. NOTE: Abilify and Seroquel include a BLACK BOX WARNING regarding the increased risk of mortality in elderly dementia patients. The communication contained no physician response to the recommendation. During an interview on 11/16/23 at 11:48 AM, the DON said the pharmacy consultant came monthly, reviewed the residents' medication regimens, and sent reports to her. She reviewed the reports and then presented them to the physician, and the physician would write on them whether they wanted to follow the recommendation or not. The DON said this process should be completed in 30 days. The DON said the medication regimen reviews had last been sent to the physicians in July 2023. The DON confirmed it was her writing on the communications for R43. During an interview on 11/17/23 at 9:55 AM, the Pharmacist confirmed he had requested a GDR for R43's Seroquel, buspirone, and Abilify during September 2023. The Pharmacist stated he did not have a reply yet for those recommendations. The Pharmacist confirmed he had requested the facility reduce or stop R43's use of Ativan multiple times. The Pharmacist confirmed his recommendation was that a resident use PRN Ativan no longer than 60 days. The pharmacist stated he had made the recommendation to reduce or stop the Ativan during March, June, and then again in September 2023. The Pharmacist stated the facility responded to his recommendations by saying they would continue the seven-day re-evaluation. Review of the facility's policy titled Antipsychotic Medication Use, revised December 2016, revealed antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Review of the facility's undated, Pharmacy Recommendation Review Policy, provided by the DON, revealed Pharmacy recommendations will be reviewed by the DON. The DON will add nursing recommendations and fax to the physician within one week of receiving them. The physician will have ten working days to respond. If no response, the DON will have physician or Nurse Practitioner review and sign recommendations when they do round, monthly. Pharmacy recommendations will be done within one month of receiving them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review, the facility failed to ensure two residents (Resident (R) 51 and R43) of five residents reviewed for unnecessary medication were being monitored for behaviors while taking psychotropic medications, additionally, failed to identify an indication for the use of a psychotropic medication, and failed to attempt Gradual Dose Reductions (GDRs) or document a rationale for the reason not to attempt a GDR. Findings include: 1. Review of a document provided by the facility titled Assisted Living Physician Orders dated 08/26/23, indicated R51 was prescribed Haldol 1 milligram (mg) to be administered by mouth at bedtime for agitation. Review of R51's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R51's EMR titled Physician Orders dated 10/31/23, indicated the resident was to be administered Haldol 1 mg by mouth at bedtime. Review of documents provided by the facility titled admission Minimum Data Set (MDS)with an Assessment Reference Date (ARD) of 11/06/23, indicated R51 had a Brief Interview for Mental Status (BIMS) score of five out of 15 which revealed the resident had severe cognitive impairment. The assessment revealed the resident had no behavior(s) nor was identified as a risk to self or to other residents. A review of R51's EMR titled Nursing Progress Notes, from 10/31/23 forward, did not contain evidence of behavior monitoring. There was no indication for the use of the Haldol. An attempt was made on 11/15/23 at 9:22 PM, to interview R51. The resident was in bed on her right side, eyes were open, and she did not respond to questions. During an interview on 11/15/23 at 10:52 AM, Certified Nursing Assistant Training (CNAT) 2 stated R51 was more of a night person and slept during the day. CNAT2 stated the resident did not yell out constantly and did not refuse care. CNAT stated the resident did not hit out either. During an interview on 11/15/23 at 11:02 AM, Certified Nursing Assistant (CNA) 3 stated R51 was not aggressive and was not verbally abusive with others. CNA 3 stated the resident only wanted to remain in bed. During an interview on 11/15/23 at 1:15 PM, the Infection Control Preventionist (ICP)/Quality Assurance (QA) Nurse stated R51 was on Haldol prior to her admission. During an interview on 11/16/23 at 11:25 AM, Licensed Practical Nurse (LPN) 1 stated R51 was given Haldol at night. LPN1 stated the resident had no behaviors other than voicing she wants to go to bed. During an interview on 11/17/23 at 9:39 AM, the Consultant Pharmacist stated R51 was a new admission and would be reviewing his/her medications. The Consultant Pharmacist stated he looks for an appropriate diagnosis for the use of any psychotropic medication and would typically request a gradual dose reduction (GDR) within the first quarter for the use of an antipsychotic medication. The Consultant Pharmacist stated it was difficult to locate behaviors, in resident clinical records, related to the use of psychotropic medication. During an interview on 11/17/23 at 10:10 AM, the Director of Nursing (DON) confirmed there was no indication for the use of Haldol. The ICP/QA Nurse was present during this interview and stated the resident had agitation. 2. Review of R43's Face Sheet, located under the Resident tab of the EMR revealed R43 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified atrial fibrillation, and heart failure. Review of R43's Orders dated 12/18/22 and located under the Resident tab of the EMR, revealed R43 was to receive Ativan (lorazepam), an anxiolytic medication, 0.5 milligrams (mg) by mouth three times daily as needed (PRN). It was recorded to re-evaluate the need for the PRN Ativan every seven days. There was no indication for the use of the Ativan. Further review of R43's Orders and Progress Notes, dated 12/18/22 through 08/22/23 and located under the Resident tab of the EMR, revealed the order for Ativan, 0.5 mg three times daily PRN was renewed after each evaluation period. There was no documentation of the physician's rationale for continuing the PRN order. Review of R43's quarterly MDS with an ARD of 08/22/23 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed R43 had long and short-term memory problems, behaviors of inattention, disorganized thinking, and wandering and received antipsychotic and antidepressant medications on seven of the preceding seven days. Review of R43's Medication Administration Records (MARs), dated September 2023 and located under the Reports tab of the EMR, revealed R43 received Ativan 0.5 mg as follows: -09/01/23 - 6:35 PM for anxiety; -09/02/23 - 11:12 PM for anxiety; -09/03/23 - 9:05 AM for restlessness and 6:14 PM for anxiety; -09/05/23 - 6:47 PM for anxiety; -09/06/23 - 2:56 PM for a behavior issue; -09/09/23 - 7:06 PM for anxiety; -09/10/23 - 6:27 PM for anxiety; -09/11/23 - 7:10 AM for anxiety; -09/18/23 - 6:18 PM for anxiety; -09/20/23 - 6:47 AM for anxiety; -09/21/23 - 8:12 PM for anxiety; -09/24/23 - 6:45 PM for anxiety; -09/26/23 - 11:44 PM for anxiety; and -09/29/23 - 3:00 PM with no reason documented. Review of R43's Progress Notes, dated 09/01/23 through 09/30/23 and located under the Resident tab of the EMR, revealed no documentation of any non-pharmacological interventions attempted by the staff to reduce R43's anxiety before administering the Ativan on any day. Review of R43's MARs, dated October 2023 and located under the Reports tab of the EMR, reviewed R43 received Ativan 0.5 mg as follows: -10/01/23 - 9:45 AM and 6:41 PM for anxiety; -10/06/23 - 1:17 AM and 6:40 PM for anxiety; -10/08/23 - 6:57 PM for anxiety; -10/11/23 - 7:26 AM for anxiety; -10/13/23 - 6:36 PM for anxiety; -10/21/23 - 6:37 PM for anxiety; -10/22/23 - 6:49 PM for anxiety; -10/24/23 - 4:40 PM for a behavior issue; -10/26/23 - 1:55 PM for a behavior issue and 4:40 PM for air hunger. Review of R43's Progress Notes, dated 10/01/23 through 10/26/23 and located under the Resident tab of the EMR, revealed no documentation of any non-pharmacological interventions attempted by the staff to reduce R43's anxiety before administering the Ativan on any day. There was no documentation of what R43's behaviors had been. Review of R43's Progress Note, dated 10/26/23 at 5:06 PM and located under the Resident tab of the EMR, revealed R43 was showing signs and symptoms of a respiratory infection. It was recorded that the nurse practitioner ordered R43 to receive an antibiotic, a nebulizer treatment, and an increase in the Ativan dose to 1 mg three times daily as needed. Review of R43's MARs, dated October 2023 and located under the Reports tab of the EMR, reviewed R43 received Ativan 1.0 mg as follows: -10/27/23 - 10:18 PM for anxiety; -10/29/23 - 10:13 AM for a behavior issue. Review of R43's Progress Notes, dated 10/27/23 through 10/29/23 and located under the Resident tab of the EMR, revealed no documentation of any non-pharmacological interventions attempted by the staff to reduce R43's anxiety before administering the Ativan. There was no documentation of what R43's behaviors had been. Review of R43's MARs, dated 11/01/23 through 11/12/23 and located under the Reports tab of the EMR, reviewed R43 received Ativan 1.0 mg as follows: -11/04/23 - 7:58 PM for anxiety; -11/06/23 - 3:59 PM for anxiety; -11/07/23 - 3:21 PM for a behavior issue; -11/09/23 - 2:53 PM for a behavior issue; and -11/12/23 - 9:47 AM and 5:59 PM for restlessness. Review of R43's Progress Notes, dated 11/01/23 through 11/12/23 and located under the Resident tab of the EMR, revealed no documentation of any non-pharmacological interventions attempted by the staff to reduce R43's anxiety before administering the Ativan. There was no documentation of what R43's behaviors had been. Review of R43's MARs and Progress Notes, dated 12/22/22 through 11/14/23, revealed no documentation of target behaviors related to the use of Ativan and no monitoring for adverse consequences. Review of R43's Care Plan, dated 11/14/23 and located under the RAI tab of the EMR revealed a focus related to behaviors. The care plan noted the resident has socially inappropriate/disruptive behavioral symptoms as evidenced by wandering yelling and being aggressive toward staff. Approaches included to assess whether the behavior endangers the resident and/or others. Intervene if necessary. Convey an attitude of acceptance toward the resident. When [R43] begins to become socially inappropriate/disruptive, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc). Remove him/her from other residents' rooms and unsafe situations. Allow the resident to have control over situations, if possible. Allow the resident to make decisions, to set schedules, to set realistic goals, to meet challenges, to participate in self-care. Observe and report socially inappropriate/disruptive behaviors when around others. [R43] is on medications for his/her behaviors but doesn't like to be 'bossed' Make suggestions as to what he/she is supposed to be doing vs [versus] telling him/her what to do. Further review of R43's Care Plan revealed a focus related to antipsychotic medications. It showed the resident receives antipsychotic medication due to behavioral symptoms and anxiety. Approaches included, to monitor [R43]'s behavior and response to medication. Assess if his behavioral symptoms present a danger to the himself/herself and/or others. Intervene as needed. Quantitatively and objectively document the behaviors. Pharmacy consultant review. Complete AIMS [abnormal involuntary movements] every quarter. The care plan did not address target behaviors or other adverse consequence monitoring. Review of R43's Orders, dated 12/18/22 and located under the Resident tab of the EMR, revealed R43 was to receive Seroquel (quetiapine), an antipsychotic medication, 25 mg one tab twice daily for unspecified dementia, unspecified severity with agitation. Review of R43's MARs dated 01/01/23 through 11/14/23 and located under the Resident tab of the EMR, revealed R43 received the Seroquel as ordered by the physician. Review of R43's Resident tab of the EMR revealed no documentation of any attempts to reduce the use of Seroquel. There was no documentation of adverse consequence monitoring related to the use of Seroquel. There was no documentation of target behaviors related to the use of Seroquel. Review of R43's Orders, dated 06/30/23 and located under the Resident tab of the EMR, revealed R43 was to receive Abilify (aripiprazole) 400 mg intramuscularly every third Saturday of each month for unspecified dementia, unspecified severity with agitation. Review of R43's MARs, dated 07/01/23 through 11/14/23 and located under the Resident tab of the EMR, revealed R43 received Abilify as ordered by the physician. Review of R43's Resident tab of the EMR revealed no documentation of any attempts to reduce the use of Abilify. There was no documentation of adverse consequence monitoring related to the use of Abilify. There was no documentation of target behaviors related to the use of Abilify. Review of R43's Orders, dated 12/12/22 and located under the Resident tab of the EMR, revealed R43 was to receive buspirone (Buspar), an anti-anxiety medication, 15 mg three times daily for unspecified dementia, unspecified severity with agitation. Review of R43's MARs, dated 01/01/23 through 11/14/23 and located under the Resident tab of the EMR, revealed R43 received buspirone as ordered by the physician. Review of R43's Resident tab of the EMR revealed no documentation of any attempts to reduce the use of buspirone. There was no documentation of adverse consequence monitoring related to the use of buspirone. There was no documentation of target behaviors related to the use of buspirone. During an interview on 11/15/23 at 3:41 PM, Nurse Aide (NA) 1 said the resident did not have behaviors, would get a little mad but was not aggressive. During an interview on 11/16/23 at 9:52 AM, CNA 3 stated she brought snacks to R43 to help redirect him. CNA3 stated, Most days are good. CNA3 stated she learned what nonpharmacological interventions to use with R43 by reading R43's Care Plan, through reports from other aides, and from the nurses. CNA3 confirmed she had not read R43's Care Plan in a few months. During an interview on 11/16/23 at 10:05 AM, Registered Nurse (RN) 1 stated R43 had exit seeking behaviors, was non-cooperative due to his dementia, and did not understand. RN1 was asked what individualized, non-pharmacological interventions had been identified to help reduce any behaviors or anxiety for R43 before administering PRN Ativan. RN1 stated staff made sure to keep a visual check on R43 and tried to keep him occupied. RN1 stated what staff attempted depended on R43's behavior. RN1 stated if R43 was really anxious, staff would administer the PRN Ativan. RN1 stated that happened just once in a while. RN1 stated R43 received the PRN Ativan when he [R43] is very combative and that isn't often or when he is exit seeking. RN1 stated if R43 became real agitated, staff should try to redirect him, and get him interested in other things. RN1 stated the only documentation required before administering the PRN Ativan to R43 was just say he's angry and uncooperative and give him his Ativan. RN1 stated that hopefully the individualized non-pharmacological interventions for R43 were documented on R43's Care Plan. RN1 stated, We take him in the [activity] room but when he starts being uncooperative, hitting staff, running over people's toes, when he/she is being anxious. RN1 confirmed staff did not complete behavior monitoring. RN1 stated, they did not do that every day because that was part of the resident's dementia, and his/her normal behavior. RN 1 confirmed staff completed adverse consequence monitoring through observations but did not document the monitoring. RN1 stated when a resident was put on a new medication, staff document side effect monitoring for one month and then stop. During an interview on 11/16/23 at 11:48 AM, the DON stated R43 had very aggressive behaviors when first admitted to the facility. The DON stated R43 would go down the hallways, refuse care, disrobe, go in and out of rooms, and had no regard for others' safety. The DON stated they did not see that behavior as much as they used to. The DON stated R43 had been placed on Abilify and that helped a lot. The DON confirmed her expectation was for staff to make sure R43's needs were being met first before medicating him with the PRN Ativan. The DON stated R43 could be very impulsive and confirmed R43's behaviors were part of his disease process. The DON stated the pharmacist completed recommendations for R43's medication regimen. The DON stated staff needed to know what side effects and adverse consequences to monitor for and then document if anything was noted. The DON confirmed there was no daily check sheet for monitoring behaviors or adverse consequences. The DON confirmed R43 had been receiving Seroquel and Buspar since admission to the facility. The DON stated Haldol had been added to R43's medication regimen because R43 had some very aggressive physical behaviors, but it was changed to Abilify following a pharmacist recommendation. The DON confirmed R43 had been receiving Ativan PRN since admission to the facility. The DON was asked if any GDR had been attempted for any of the medications. The DON confirmed, Not for a while. The DON confirmed that her expectation was for staff to attempt non-pharmacological interventions before administering the PRN Ativan and to document those interventions. During an interview on 11/17/23 at 9:35 AM, the Nurse Practitioner (NP), who was providing coverage for the Medical Director, confirmed staff should be assessing R43 and trying other modalities (non-pharmacological interventions) prior to medicating R43 with the PRN Ativan. The NP stated she had ordered the increase in the Ativan dosage during October 2023 because R43 was experiencing trouble breathing and the family had requested R43 not be sent to the hospital and not for behaviors or anxiety. The NP confirmed in her professional opinion that many of R43's behaviors were part of his disease process. During an interview on 11/17/23 at 9:55 AM, the Pharmacist confirmed he had requested a GDR for R43's Seroquel, buspirone, and Abilify during September 2023. The pharmacist stated he did not have a reply yet for those recommendations. The pharmacist stated he had asked for an appropriate diagnosis for the use of Seroquel in December 2022. The Pharmacist stated since R43 had continued to receive Seroquel when the Abilify was ordered, he would not have requested a GDR right away because the resident must not be stable for some reason. The Pharmacist confirmed he had requested the facility reduce or stop R43's use of Ativan multiple times. The Pharmacist confirmed his recommendation was that a resident use PRN Ativan no longer than 60 days. The Pharmacist stated he had made the recommendation to reduce or stop the Ativan during March, June, and then again in September 2023. The Pharmacist stated the facility responded to his recommendations by saying they would continue the seven-day re-evaluation. Review of the facility's policy titled, Behavioral Health Services, revised March 2019, revealed, non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. When medications are prescribed for behavioral symptoms, documentation will include the rationale for use and other approaches and interventions tried prior to the use of antipsychotic medications, specific target behaviors and expected outcomes and monitoring for efficacy and adverse consequences. Review of a document provided by the facility titled Antipsychotic Medication Use, dated 12/16 indicated antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. Residents who are admitted from the community, who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for three (Resident (R) 51, R6 and R16) of 24 sampled residents reviewed for quality-of-care issues. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. The census was 52. Findings include: 1. Review of R51's electronic medical records (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R51's EMR titled nursing Progress Notes, located under the Resident tab indicated the resident sustained a fall on 11/02/23. Review of a document provided by the facility titled admission MDS with an Assessment Reference Date (ARD) of 11/06/23 failed to identify R51 sustained a fall. During an interview on 11/16/23 at 12:34 PM, the MDS Coordinator (MDSC) confirmed the error for R51 and missed the fall the resident sustained on 11/02/23. 2. Review of R6's EMR titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R6's EMR titled Vitals located under the Resident tab revealed the following weights: 09/02/22 the resident weighed 133.5 pounds; 10/03/22 the resident weighed 179 pounds; there was no weight documented for 11/22/22; 12/07/22 the resident weighed 178.5; and, on 01/25/23 the resident weighed 136.8 pounds. Review of documents provided by the facility titled MDS with the following ARD revealed the following: -The resident's quarterly assessment with an ARD of 12/20/22 showed the resident weighed 179 pounds and had no significant weight gain (gain of 5% or more in the last month or gain of 10% or more in last 6 months). However, R6 was noted to have weighed 133.5 pounds three months prior. -The resident's annual MDS, with an ARD of 06/13/23, showed the resident weighed 134 pounds and had no or unknown weight loss. The resident was noted to have a weight of 178.5 pounds on 12/07/22. During an interview on 11/16/23 at 12:34 PM, the MDSC confirmed the errors for R6's weights in the MDS assessments. 3. Review of R16's EMR located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R16's EMR titled Orders located under the Resident tab dated 04/26/23 indicated skin prep was to be applied to the resident's right heel twice a day until area resolved. Review of R16's EMR titled Medication Administration Record (MAR) located under eMAR [electronic MAR] tab indicated the resident was being treated for a right heel pressure ulcer from 04/23 to 11/23. Review of a document provided by the facility titled quarterly MDS with an ARD of 07/10/23 indicated R16 had no pressure ulcers. Review of a document provided by the facility titled quarterly MDS with an ARD of 10/09/23 indicated R16 had no pressure ulcers. Review of R16's EMR titled MAR dated 11/23 indicated the resident still received treatment to the right heel. During an interview on 11/15/23 at 1:15 PM, Infection Control Preventionist (ICP)/Quality Assurance (QA) Nurse stated the resident had a scabbed area (referencing R16's right heel) that could not be staged. During an interview on 11/16/23 at 11:17 AM, Licensed Practical Nurse (LPN) 1 stated R16 still had a scab on his/her right heel and continued to receive treatment to the area. During an interview on 11/16/23 at 12:10 PM, the MDSC stated R16 had a scabbed area on her right heel and assumed the area under it was healed therefore did not place it on the MDS.

Based on interview and record review, the facility failed to revise their pneumococcal vaccine policy to reflect current pneumococcal vaccination guidelines. This failure increased the risk for residents to not be vaccinated per current guidelines and contract pneumonia. The census was 52. Findings include: Review of the CDC recommendations, revised on 02/09/23, indicated the CDC recommends pneumococcal vaccination for all adults 65 years or older If PCV20 is used, a dose of PPSV23 is NOT indicated. For adults 65 years or older who have only received PPSV23 [Pneumococcal polysaccharide vaccine], CDC recommends giving 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, the CDC recommends you either give 1 dose of PCV20 at least 1 year after PCV13, or give 1 dose of PPSV23 at least 1 year after PCV13. Review of a policy provided by the facility titled Pneumococcal Vaccine, dated 08/16 indicated all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. There were no current guidelines reflected in the policy on the newest CDC/APIC guidelines for pneumococcal vaccines. During an interview on 11/17/23 at 10:10 AM, the Director of Nursing (DON) and the Infection Control Preventionist (ICP/Quality Assurance (QA) Nurse both stated they were not aware of the CDC's newest recommendations regarding the pneumococcal vaccinations.

Based on interview and record review, the facility failed to implement their Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect 52 of 52 residents who resided at the facility. Findings include: During an interview on 11/17/23 at 11:06 AM, the Administrator and Infection Preventionist (IP), who was the facility's QAPI Lead, stated the facility did not have a QAPI Council. The Administrator stated that the facility's QA (Quality Assurance) committee were the same people involved in the QAPI program. The IP was asked if minutes were kept of the QAPI meetings. The IP stated, I haven't sat down and had a formal meeting in quite some time. The IP stated it was difficult to get staff together for a QAPI meeting. The IP stated she gathered information from the fall committee, the weekly antibiotic report, and fall worksheets and reviewed that information to identify any concerns. The IP stated that information was reviewed during meetings and taken back to the floor staff. The IP was asked how she developed benchmarks for measuring improvement in Performance Improvement Plans (PIPs). The IP stated she just wrote out what the problem was, how it was identified, and what the solution would be. The IP confirmed there were no benchmarks by which to measure improvement of any identified PIPs. The IP was asked how pharmacy consult reports were used in the QAPI program. The IP stated the pharmacist came to the QA meetings every month, and if he saw anything he questioned before then, he could contact the Director of Nursing (DON). The IP was asked how the facility was following its' QAPI plan without having meetings, using benchmarks, and using data from consultant reports. The IP stated the plan probably needed to be changed. The IP stated there was not enough time to implement the QAPI program because most of the nursing leadership had to work to the floor. Continuing with the interview on 11/17/23 at 11:06 AM, the Administrator and IP were asked if the facility had identified any concerns related to obtaining accurate weights before the survey. The IP stated they had started a new system of having one person obtain the monthly weights because they had been inconsistent. The IP was asked if daily and weekly weights had been included in the new system and if those weights were monitored for accuracy. The IP stated, No. The IP stated, We trust our nurses to look back [monitor]. The IP was asked if any concerns related to unnecessary medications and drug regimen reviews had been identified prior to the survey. The IP stated the pharmacist did his reviews and would let them know if there was anything that shouldn't be there. The IP stated the physician did a medication regimen review as well. The IP and Administrator were asked if there had been any concerns identified with the Infection Control Program and Antibiotic Stewardship prior to the survey. The Administrator stated, No. Review of the facility's undated Quality Assurance Improvement Plan, provided by the Administrator, revealed, our nursing home has a Performance Improvement Program which systematically monitors, analyzes, and improves its performance to improve resident/patient outcomes. The QAPI plan addresses Clinical Care, Quality of Life and Resident Choice. Review of State/National and past facility measures will be used to benchmark for improvement in all areas. These benchmarks will be reviewed at least monthly, and reported to the QAPI Committee on a quarterly basis. The QAPI Council provides the backbone and structure for QAPI. This group includes all of the Executive Leadership team plus additional staff members. This group of people work together to communicate and coordinate QAPI activities. Currently QAPI Council meets once a month. Information gathered is analyzed and compared to benchmarks and/or targets established by the facility. Consultant reports are compared to goals on a monthly basis. QAPI teams analyze data regularly as part of their project assignments. Minutes of all meetings - QAPI Lead is responsible for maintaining documentation.

Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility. The facility failed to update their infection control policies on an annual basis. The facility also failed to provide assistance with eating in a manner to potentially prevent cross-contamination for two of 24 sampled residents (Resident (R) 19 and R24) observed during dining. The census was 52. Findings include: 1. Review of a document titled, Centers for Disease Control (CDC) National Healthcare Safety Network (NHSN) Long Term Care Facility Component Tracking Infections in Long-Term Care Facilities dated January 2020, indicated, surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility infection prevention and control (IPC) program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents, staff, and visitors. Information collected during surveillance activities can be used to develop and track prevention priorities for the facility. When conducting surveillance, facilities should use clearly defined surveillance definitions that are collected in a consistent way. This method ensures accurate and comparable data regardless of who is performing surveillance. During an interview on 11/17/23 at 10:10 AM, the Infection Control Preventionist (ICP) and the Director of Nursing (DON), stated the ICP just began mapping in 10/23 and prior to this there was not a way to identify clusters of potential infections other than to review the daily reports collected from the units. The ICP and DON both stated the facility was small and they knew the care needs of each resident. The DON stated there was no proof that the facility's infection control policies were being reviewed on an annual basis. 2. During an observation of the noon meal on 11/14/23 at 12:08 PM, Certified Nurse Aide in Training (CNAT) 4 was observed feeding R24. CNAT4 was not wearing gloves. At 12:11 PM, CNA4 got up from her seat, and without performing hand hygiene, gave R19 a bite of food and touched R19's shoulder and upper chest. R19 had been touching her own utensils. CNAT4 then returned to R24 and assisted her with a bite of food without performing hand hygiene. At 12:12 PM, R19 dropped her beverage glass onto her plate. CNAT4 got up from her seat, removed the glass from R19's plate, and without performing hand hygiene, returned to R24, and continued to feed her. During an interview on 11/14/23 at 4:00 PM, CNAT4 stated she did not remember if she had performed hand hygiene while feeding R24 and R19. During an interview on 11/17/23 at 11:38 AM, the Infection Preventionist (IP) stated it was her expectation for staff to perform hand hygiene between feeding different residents. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2015, revealed, the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situation before and after assisting a resident with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. The failure to have a system in place that monitored antibiotic use in accordance with established protocols has the potential to affect all 52 residents of the facility. In addition, the facility failed to ensure one Resident (R41) had appropriate clinical indications for the use of an antibiotic. The census was 52. Findings include: 1. Review of a CDC document undated titled, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use'. All nursing homes should take steps to improve antibiotic prescribing practices and reduce inappropriate use. Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Process measures include tracking how and why antibiotics are prescribed and tracking any adverse outcomes. Review of a policy provided by the facility titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, dated 12/16 indicated Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. The lP [Infection Preventionist], or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics.Therapy may require further review and possible changes if the organism is not susceptible to the antibiotic chosen, the organism is susceptible to narrower spectrum antibiotic, therapy was ordered for prolonged surgical prophylaxis, therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include the resident name and medical record number, unit and room number, date symptoms appeared, name of antibiotic (see approved surveillance list), start date of antibiotic, pathogen identified (see approved surveillance list), site of infection, stop date. Total days of therapy and outcome. Review of a document provided by the facility titled, Antibiotic Tracking Sheet from 06/02/23 to 11/11/23 revealed residents were identified, along with the associated infection. The symptoms of the infection associated with the antibiotic were not identified, the pathogens were not identified, the laboratory tests and if a culture and sensitivity was ordered was not identified on these logs. 2. Review of a policy provided by the facility titled Antibiotic Stewardship dated 12/16, indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. When a culture and sensitivity (C&S) or chest x-ray is ordered labs or results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of a policy provided by the facility titled Antibiotic Stewardship - Orders for Antibiotics, dated 12/16 indicated appropriate indications for use of antibiotics included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending. Review of R41's electronic medical record (EMR) titled Resident Face Sheet indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility for R41 titled Physician Order Report dated 10/18/23 indicated the resident was prescribed ciprofloxacin (Cipro - an antibiotic) 500 milligrams (mg) to be administered twice a day until 10/24/23. Review of R41's EMR titled Orders located under the Resident tab dated 11/02/23 indicated the resident was prescribed Cipro 250 mg to be administered twice a day as a preventative measure for urinary tract infections. Review of a document provided by the facility for R41 titled Suspected UTI (urinary tract infection) SBAR (Situation, Background, Assessment, and Recommendation [a standardized form to communicate the condition of a resident] Form, undated, indicated the resident had met criteria, proceed with contacting provider for urinalysis with urine culture and sensitivity for symptoms listed above. In a box on the right side of the document it indicated the resident had back or flank pain. In addition, the criteria were not met since the resident did not have a temperature above 100 degrees Fahrenheit (F), as directed by the SBAR. There were no other symptoms identified. Review of R41's EMR failed to provide evidence of symptoms of a UTI nor was there evidence to show any clinical documentation to support the use of Cipro. There was no evidence the facility implemented a urinalysis or a culture and sensitivity of the urine sample. During an interview on 11/17/23 at 9:39 AM, the Consultant Pharmacist stated he participated in the antibiotic stewardship program and stated he reviewed the antibiotic usage. The Consultant Pharmacist stated it was difficult to get a buy in from the facility and family and the use of antibiotics prophylactically and not to do so. During an interview on 11/17/23 at 10:10 AM, the Infection Control Preventionist (ICP) and the Director of Nursing (DON) were asked about the prophylactic use of Cipro and R41. Both staff stated a family member of the resident was being hateful to her and this was an indication the resident had a UTI. Both the ICP and DON stated the resident has not been seen by a urologist and had no violent behaviors to others. During this interview, the DON stated there was a positive SBAR so the criteria must have been met for the resident to be prescribed an antibiotic. The ICP stated she had no reason why there were no dates associated with the prophylactic use of antibiotics and never placed the pathogens on the tracking forms. During an interview on 11/17/23 at 2:01 PM, the Minimum Data Set (MDS) Coordinator confirmed there was no urinalysis or culture and sensitivity for the use of R41's antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide necessary treatment and services consistent with standards of practice to promote healing of existing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction), when the facility failed to consistently and accurately assess and monitor pressure ulcers and prevent new ulcers from developing for one resident (Resident #1) in a review of five sampled residents. The facility census was 44. Review of the Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, provided by the National Pressure Ulcer Advisory Panel (NPUAP), dated 2009, showed the ongoing assessment of the skin is necessary to detect early signs of pressure damage. Review of the facility policy Pressure Ulcer Risk Assessment, revised February 2014, showed the following: -The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers; -Review the resident's care plan to assess for any special needs of the resident; -If pressure ulcers are not treated when discovered, they have the potential to become larger, painful and infected; -Once a pressure ulcer starts it can be extremely difficult to heal; -Pressure ulcers are a serious skin condition for the resident; -Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs of developing pressure ulcer to the supervisor; -Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated; -Staff will perform routine skin inspections with (daily care); -Nurses are to be notified to inspect the skin if skin changes are identified; -Because a resident can develop pressure ulcer within two to six hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to prevent pressure ulcers. The admission evaluation helps define those initial care approaches and interventions; -Once inspection of the skin is completed proceed to the admission assessment or weekly skin integrity tool (depending on whether this is a new admission or an existing resident) and complete the documentation findings; -If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in the skin; -Proceed to care planning and interventions individualized for the resident and their particular risk factors. 1. Review of Resident #1's admission body observation completed by Registered Nurse (RN) G, dated 12/14/22 showed the following: -Stage II pressure ulcer (partial thickness loss of the dermis presenting as a shallow ulcer with a red or pink wound bed) to the right buttock; -He/She had a small open area on his/her bottom and his/her coccyx (a small, triangular bone at the base of the spinal column), is irritated, incontinent at times with urine; -RN G did not document pressure ulcer measurements upon admission, physician notification of the pressure ulcer or any orders obtained for treatment. Review of the resident's Braden scale (tool used to determine risk of pressure ulcer development), completed by the facility staff dated 12/14/22 showed the following: -At mild risk for pressure ulcers; -Interventions included, pressure reducing cushion for chair and bed and pressure ulcer/injury care. Review of the resident's baseline care plan dated 12/14/22 showed the following: -Independent with be mobility; -Required assist of two staff members with transfers, walking, and toileting; -Equipment used wheelchair and walker; -RN G documented the skin was intact; -A hand written note by RN G showed house cream (a skin protectant used to prevent skin irritation) to bottom related to irritation and a small open area. During interview on 2/9/23 at 12:45 P.M. Registered Nurse G said the following: -He/She completed the admission assessment on the resident; -The resident had an open area, but it was very small, it was not measured because it was so small; -The CNAs (certified nurse assistant) just put barrier cream on the open area; -Wounds are to be measured weekly by the nurse; -The CNAs do a good job of monitoring the skin and will report to the nurses if there was any skin changes or concerns. Review of the resident's CNA Skin Report (completed during showers/bathing) dated 12/16/22 showed the CNA documented nothing new to skin for old and new areas. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument assessment required to be completed by facility staff, dated 12/21/22 showed the following: -Diagnoses of heart failure (a condition in which the heart doesn't pump blood as well as it should) and cerebral palsy (a congenital disorder of movement, muscle tone, or posture); -Cognition intact; -No rejection of care; -Limited assistance of one staff member with bed mobility, transfers, walking in room and locomotion on and off the unit, dressing and toileting; -Personal hygiene setup help only; -Functional limitation of upper and lower extremities on both sides; -Occasional bowel and bladder incontinence; -At risk for pressure ulcers; -One or more stage one pressure ulcer (an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness) or higher indicated none; -Pressure reducing device for chair and bed. Review of the resident's nursing note dated 12/22/22 at 12:55 P.M., showed the following: -The resident reports his/her bottom hurts; -He/She has a small open area on his/her right cheek near the center that measures 2 cm (centimeters) x 1.5 cm and had a moist small area one on top of the buttock crease, but it is not open; -The resident reported he/she had these (open areas) before arriving here; -Applied antifungal powder (used to treat fungal infections of the skin) and Z guard (helps to treat minor skin irritations and works by forming a barrier on the skin to protect it from irritants and moisture). Review of the resident's physician order sheet dated 12/22/22 showed apply fungal/powder, Z-guard to open areas on buttocks BID (twice a day) until healed. Review of the resident's treatment administration dated 12/22/22 showed apply fungal/powder, Z-guard to open areas on buttocks BID (twice a day) until healed. Review of the resident's CNA Skin Report (completed during showers/bathing) dated 12/23/22 showed under old and new areas the CNA documented bruises on both arms, scabs on both knees, old areas. Review of the resident's CNA Skin Report dated 12/25/23 the CNA documented no new areas or old areas. Review of the resident's CNA Skin Report dated 1/6/23 showed the CNA documented no new or old areas. Review of the the resident's medical record showed no documentation licensed nursing staff assessed the skin status/open area on a weekly basis. Review of the resident's wound tracking sheet dated 1/10/23 showed the following: -Wound located on left buttock cheek; -RN G documented he/she did not know if the area was better or worse than previously assessed; -The area was moist; -The area had no drainage; -The resident was admitted with the area; -Encourage the resident to keep it clean and dry and make frequent position changes; -Nurse description 1cm x 2 cm, pale edges, and wound bed being treated. Continue current treatment. Review of the resident's progress notes dated 1/12/23 at 10:55 A.M. showed the following: -The resident has an open area on the right (buttock) cheek near center; -The area measures 2 cm x 1.5 cm, and no depth or drainage noted; -The open area is drying up; -Antifungal cream/powder and z-guard mixed together and applied to the area twice a day; -No documentation the physician was notified of the increase in size of the pressure ulcer or additional orders obtained. Review of the resident's CNA Skin Report dated 1/13/23 showed the CNA documented no new or old areas. Review of the resident's CNA Skin Report dated 1/15/23 showed open area on his/her bottom. Treatment to bottom completed by the nurse. Review of the resident's progress note dated 1/17/23 at 9:05 A.M. showed the following: -The resident has a stage II (partial thickness loss of the dermis presenting as a shallow ulcer with a red or pink wound bed) pressure ulcer on right inner buttock near the crack that measures 1cm x 1.5 cm, no drainage noted; -Some discomfort noted during treatment; -The resident encouraged to stay in bed at night off of his/her bottom. Review of the resident's physician order sheet dated 1/17/23 showed apply calcium alginate (a dressing that helps maintain a moist wound healing environment, promoting the healing process) and then Mepilex (absorbent soft silicone foam dressing) to open area on right buttock check daily until healed. Review of the treatment administration record dated 1/17/23 showed apply calcium alginate and then Mepilex to open area on right buttock cheek daily until healed. Review of the resident's care plan dated 1/18/23 showed the following: Problem start date 1/18/23: Pressure ulcer, the resident is at risk of pressure ulcers related to wheelchair use and positioning while in bed and wheelchair, as evidenced by area to bottom present on admission; -Resident is incontinent of bowel and bladder and needs you to monitor skin for changes; -Resident tends to sleep in his/her recliner verses the bed at times; -Resident has poor positioning due to cerebral palsy; -Staff completes skin assessments with showers and reports any changes during showers or personal cares; -Apply barrier creams as needed and please report changes to the nurse for assessment. The nurse will report changes to the physician and the family. Review of the resident's CNA Skin Report dated 1/20/23 showed the resident refused the shower. Review of the resident's wound tracking form dated 1/24/23 showed the following: -Wound location, the resident's bottom; -The area was worse than previously assessed; -The area has no drainage or odor; -Measurements are 2 cm by 2 cm; -Resident educated to stay off his/her back. There was no documentation found in the resident's record to show the physician was notified of the increase in size to the wound or new orders obtained or new interventions put in place. Review of the resident's CNA Skin Report dated 1/27/23 was blank. Review of the resident's progress note dated 1/29/23 at 10:36 A.M. showed the following: -Treatment provided to the coccyx as ordered; -New area to the coccyx (tailbone) measures 0.5 cm x 1 cm with three satellite areas (are small peripheral areas that are centered around a larger area) on the right lower side 0.5 cm, 1 cm and 0.5 cm calcium alginate applied, New order to do this twice a day; -The resident is requiring assistance with all care, spoke to the resident about staying dry. Record review of the resident's discharge MDS assessment dated [DATE] showed the following: -The resident had one or more stage one pressure ulcers at stage one or higher; -Number of stage one pressure ulcers was two; -Number of stage one pressure ulcers present at admission was one. Review of the resident's progress note dated 1/30/23 at 2:16 P.M. showed the resident was transported by ambulance to the hospital for evaluation and treatment. Review of the hospital emergency department note dated 1/30/23 at 2:58 P.M. showed the resident had three distinct stage II sacral (located below the lumbar spine and above the tailbone which is known as the coccyx) ulcers. During interview on 2/2/23 at 3:10 P.M. CNA E said the following: -He/She provided showers for Resident #1 routinely while he/she was in the facility; -The resident had a lot of scratches and some scabs and other areas but he/she thought the nurses were aware of all the areas; -He/She did not know the resident had any open areas on his/her bottom; -If he/she noted something really bad he/she would report it to the nurse; -He/She tried to complete the showers very quickly; -He/She only documented new areas on the shower sheet or old areas that were worse. During interview on 2/7/23 at 10:30 A.M. the resident said he/she had one open area when he/she arrived at the facility, but now he/she had three open areas. He/She was so weak at the facility and was in bed a lot. He/She felt staff ignored him/her. During interview on 2/7/23 at 1:45 P.M. the MDS Coordinator/RN H said the following: -The resident didn't have a pressure ulcer when the admission MDS was completed; -He/She just had an order for barrier cream; -Care plans are updated quarterly with any new interventions. During interview on 2/2/23 at 3:45 P.M., 2/7/23 at 1:40 P.M. the Director of Nursing said the following: -She would expect the charge nurse to complete a full body skin assessment on all new residents upon admission and obtain a physician order for any skin issues. CNAs were not to provide treatment on open areas; -With any skin issues identified, the charge nurse should obtain appropriate orders from the physician and those orders need to be on the TAR; -Any skin issues identified are to be measured and documented weekly on the weekly tracking form; -She would expect the physician to be notified if a wound was worse than previously assessed; -She would expect the CNAs to document on each resident's CNA skin condition report sheet after each shower, any new areas or old areas; -She would expect any new areas be reported to the charge nurse so the areas could be evaluated and appropriate orders obtained. During interview on 2/9/23 at 3:15 P.M. the administrator said the following: -She would expect weekly wound tracking forms be completed on any residents with skin issues; -Any skin areas of concern should be reported to the charge nurse so the areas of concern can be assessed and orders obtained; -She would expect a full skin assessment be completed on all residents at admission including measurements of any skin issues identified and orders obtained. MO213460

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or resident representative when five residents (Resident #13, #47, #50, #52 and #54), in a review of 17 sampled residents, were transferred to the hospital or another facility. The facility census was 56. Review of the undated facility policy, Transfer or Discharge Notice, showed the following: -A resident and/or his/her representative (sponsor) will be given a 30-day written notice of an impending transfer or discharge from our facility; -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of the individuals in the facility is endangered; d. The health of individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility; f. An immediate transfer or discharge is required by the resident's urgent medical needs; g. The resident has not resided in the facility for 30 days; and/or h. The facility ceases to operate. -The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. A statement of the resident's rights to appeal the transfer or discharge, including: (1) The name, address, email and telephone number of the entity which receives such requests; (2) Information about how to obtain, complete and submit an appeal form; and (3) How to get assistance completing the appeal process; e. The facility bed-hold policy; f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; g. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); h. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); and i. The name, address and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. -A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. -The reasons for the transfer or discharge will be documented in the resident's medical record. -If the information in the notice changes prior to the transfer or discharge, the recipients of the notice will be updated as soon as practicable. 2. Review of Resident #13's medical record showed the following: -He/She was admitted to the facility on [DATE]; -He/She was transferred to an area hospital on 5/9/21 and re-admitted to the facility on [DATE]; -There was no evidence to show the facility provided a written discharge notice to the resident or resident representative. 3. Review of Resident #47's medical record showed the following: -He/She was admitted to the facility on [DATE]; -He/She was transferred to an area hospital on 1/21/21 and re-admitted to the facility on [DATE]; -There was no evidence to show the facility provided a written discharge notice to the resident or resident representative. 4. Review of Resident #50's medical record showed the following: -He/She was originally admitted to the facility on [DATE]; -He/She was transferred to an outside facility for evaluation and treatment of a medical condition on 4/14/21 and 5/10/21; -There was no documentation to show the facility notified the resident's representative of the transfer. 5. Review of Resident #52's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's nurses' notes dated 4/20/21 showed at 4:48 P.M. received phone call from orthopedic physician's office saying they were sending the resident to the ER (emergency room) since they could not get his/her left shoulder into socket without sedation. Review of the resident's nurses notes dated 4/21/21 at 12:00 A.M. showed the resident was being admitted to the hospital for dehydration, left shoulder contusion (blood or bleeding under the skin due to trauma of any kind; typically black and blue at first, with color changes as healing progresses), left hand fracture, and chest wall contusion. Review of the resident's medical record showed no evidence facility staff notified the resident's representative in writing of the transfer. 6. Review of Resident #54's medical record showed an admission date of 11/15/19. Review of the resident's progress notes dated 4/19/21 showed the following: -At 4:23 A.M., staff received a call from 911 stating the resident had called them and complained of being bullied. Staff checked on the resident and he/she said there were either people outside his/her room or in his/her head; -At 9:00 A.M., the social services director and administrator talked to the resident about him/her calling 911. The resident said the voices in his/her head told him/her to call 911; -At 9:15 A.M., the resident's Durable Power of Attorney (DPOA) was notified by phone call of the resident calling 911 and that the resident will be set up for a psychiatric evaluation for hearing voices; -At 3:03 P.M., the social services director spoke to the resident about him/her acceptance at a regional hospital for psychiatric evaluation. His/Her questions were answered and he/she was reminded that he/she would have his/her room available upon return. Review of the resident's progress notes dated 4/20/21 at 6:15 A.M. showed the resident left the building with social services for transportation to the hospital for admission for a psychiatric evaluation. Review of the resident's progress noted dated 4/30/21 at 1:18 P.M. showed the resident returned to the facility. Record review showed no documentation a letter was provided to the resident and resident's DPOA notifying them of the resident's transfer to the hospital and the reason for the transfer. 7. Review of Resident #55's medical record showed an admission date of 3/01/21. The resident was discharged to another facility on 3/12/21. There was no evidence to show the facility provided a written discharge notice to the resident or the resident's guardian. 8. Review of Resident #57's medical record showed an admission date of 3/15/21. The resident was discharged to the hospital on 3/29/21, with symptomatic cardiac changes. There was no evidence to show the facility provided a written discharge notice to the resident or resident representative. During an interview on 5/21/21 at 10:30 A.M., the administrator said staff were to provide a written notice of transfer to the resident and/or resident representative upon transfer and/or discharge from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform residents and resident representatives of their bed hold policy at the time of transfer to the hospital for five residents (Resident #13, #47, #50, #52 and #54), in a review of 17 sampled residents, who were transferred to the hospital or another facility. The facility census was 56. 1. Review of the undated facility policy Transfer or Discharge Notice showed the following: -A resident, and/or his or her representative (sponsor), will be given a 30-day written notice of an impending transfer or discharge from our facility. -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of the individuals in the facility is endangered; d. The health of individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility; f. An immediate transfer or discharge is required by the resident's urgent medical needs; g. The resident has not resided in the facility for thirty (30) days; and/or h. The facility ceases to operate. -The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; d. A statement of the resident's rights to appeal the transfer or discharge, including: (1) the name, address, email and telephone number of the entity which receives such requests; (2) information about how to obtain, complete and submit an appeal form; and (3) how to get assistance completing the appeal process; e. The facility bed-hold policy; f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; g. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); h. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); and i. The name, address and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. 2. Review of Resident #13's medical record showed the following: -He/She admitted to the facility 4/1/2013; -He/She transferred to the hospital on 5/9/21; -He/She readmitted to the facility on [DATE]. Review of the resident's record showed no documentation the resident or resident's representative was informed in writing of the facility's bed hold policy at the time of transfer on 5/9/21. 3. Review of Resident #47's medical record showed the following: -He/She was originally admitted to the facility on [DATE] and had a readmission on [DATE]; -He/She discharged to an outside facility for evaluation and treatment of a medical condition on 1/21/21; -He/She readmitted to the facility on [DATE]; -There was no documentation to show the facility notified the resident's legal representative of the facility's bed hold policy at the time he/she was transferred. 4. Review of Resident #50's medical record showed the following: -He/She originally admitted to the facility on [DATE]; -He/She transferred to an outside facility for evaluation and treatment of a medical condition on 4/14/21 and 5/10/21; -There was no documentation to show the facility notified the resident's legal representative of the facility's bed hold policy at the time he/she was transferred. 5. Review of Resident #52's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's nurses' notes dated 4/20/21 showed at 4:48 P.M. received phone call from orthopedic physician's office saying they were sending the resident to the emergency room since they could not get his/her left shoulder into socket without sedation. Review of the resident's nurses notes dated 4/21/21 at 12:00 A.M. showed the resident was being admitted to the hospital for dehydration, left shoulder contusion (blood or bleeding under the skin due to trauma of any kind; typically black and blue at first, with color changes as healing progresses), left hand fracture and chest wall contusion. Review of the resident's medical record showed no documentation facility staff notified the resident's legal representative of the facility's bed hold policy at the time he/she transferred to the hospital. 6. Review of Resident #54's medical record showed the following: -He/She admitted to the facility 11/15/19; -He/She transferred to the hospital on 4/20/21; -He/She readmitted to the facility on [DATE]. Review of the resident's record showed no documentation the resident or resident representative was informed in writing of the facility's bed hold policy at the time of transfer on 4/20/21. During interview on 5/21/21 at 10:15 A.M., the Social Service Designee said the following: -Staff shared responsibility of providing bed hold policies to residents and/or resident representatives upon transfer to the hospital; -Procedure was to contact the representatives by phone and mail them a copy of the policy to sign and send return to facility; -Sometimes letters did not get signed because residents were sent out on an emergent situation and resident was to be taken care of first; -She had no documentation to show Residents #13, #52, #50, #54, and #47 and/or the residents' representatives received a written copy of facility's bed hold policy. During an interview on 5/21/21 at 10:30 A.M., the administrator said a copy of the facility's bed hold policy was supposed to go with the resident when a resident transferred out of the facility. A copy of the policy should be provided to a resident's representative if the resident was incapable of understanding the policy. Residents' representatives were expected to sign and return a copy of the signed policy to the facility. During an interview on 5/21/21 at 10:40 A.M., Registered Nurse (RN) A said bed hold policies were provided to residents and/or resident representatives only when residents were admitted to the hospital. He/She did not provide a copy of bed hold policy when a resident was sent to the emergency room. During interview on 5/21/21 at 2:07 P.M. the Director of Nurses said the following: -The bed hold policy was at the nurses stations; -It was the responsibility of the nurses transferring to fill out the bed hold sheet and if the resident was able to sign obtain their signature; -If the resident was unable to sign, the nurse should obtain verbal consent for the bed hold with the resident or over the phone with the resident's representative; -Social services would send a copy of the bed hold to obtain a signature from the legal representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being for four residents (Residents #8, #32, #33, and #47), in a review of 17 sampled residents, and for six additional residents (Residents #1, #9, #10, #14, #25 and #46). Staff failed to ensure weekend and evening activities were provided for residents. The facility census was 56. Review of the undated facility policy Activities showed the following: CONDUCTING ACTIVITIES: It is the policy of this facility that the activity director/coordinator be responsible for overseeing activity programs; Procedure: 1. The activity coordinator is responsible for overseeing all activity programs; 2. Resident seating arrangements are planned through the activity coordinator so that residents can achieve their maximum viewing and hearing potential; 3. The activity coordinator shall welcome all visitors and help them in finding seating arrangements; 4. Once the program is ready to start, the activity coordinator shall begin the program with brief introductory remarks and then turn the program over to the person in charge of the activity; 5. A representative of the activity department shall remain in the activity area to assure that any resident needing assistance can be readily cared for or removed from the activity if necessary or the resident wishes. 1. Review of the facility's activity calendar, dated October 2020, showed the following: -There were no scheduled activities past 2:00 P.M. Monday through Friday; -There was one scheduled activity on Saturdays at 10:00 A.M.; -There were no activities scheduled on Sundays. Review of the facility's activity calendar, dated December 2020, showed the following: -There was one activity scheduled on 12/1-12/4, 12/7/20, 12/9-12/11, 12/14-12/17, 12/21/20, 12/23/20, 12/24/20, 12/28/20, 12/30/20, 12/31/20; -There were no activities scheduled past 1:30 P.M. except for on 12/8/20, 12/22/20 and 12/29/20; -There were no activities scheduled for any Saturday or Sunday; -There were no activities scheduled for Christmas. Review of the facility's activity calendar, dated January 2021, showed the following: -There were no activities scheduled past 3:00 P.M. Monday through Friday; -There were no activities scheduled on Saturdays or Sundays. Review of the facility's activity calendar, dated February 2021, showed the following: -There were no activities scheduled past 3:00 P.M. Monday through Friday; -There were no activities scheduled on Saturdays or Sundays. Review of the facility's activity calendar, dated March 2021, showed the following: -There were no activities scheduled past 3:00 P.M. Monday through Friday; -There were no activities scheduled on Saturdays or Sundays. Review of the facility's Special Care Unit (SCU) activity calendar, dated March 2021, showed the following: -There was one activity scheduled on Mondays, Tuesdays, Thursdays and Fridays with no time the activity would occur; -There were no activities scheduled on Wednesdays, Saturdays or Sundays. Review of the facility's activity calendar, dated April 2021, showed the following: -There were no activities scheduled past 3:00 P.M. Monday through Friday; -There were no activities scheduled on Saturdays or Sundays. Review of the facility's Special Care Unit (SCU) activity calendar, dated April 2021, showed the following: -There was one activity scheduled on Mondays, Tuesdays, Thursdays and Fridays with no time the activity would occur; -There were no activities scheduled on Wednesdays, Saturdays or Sundays. Review of the facility's activity calendar, dated May 2021, showed the following: -There were no activities scheduled past 3:00 P.M. Monday through Friday; -There were no activities scheduled on Saturdays or Sundays. Review of the facility's Special Care Unit (SCU) activity calendar, dated May 2021, showed the following: -There was one activity scheduled on Mondays, Tuesdays, Thursdays and Fridays with no time the activity would occur; -There were no activities scheduled on Wednesdays, Saturdays or Sundays. 2. Review of Resident #10's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated 11/24/20, showed the following: -Cognitively intact; -He/She considered it very important to do things with groups of people, do his/her favorite activities, and go outside when weather permits. Review of resident's activities plan, last reviewed on 5/24/21, showed the following: -He/She enjoyed coming to activities of his/her choosing; -Staff were to ensure resident was aware of activities and ensure he/she was able to choose activities he/she would like to attend; -He/She enjoyed exercise class as well as outdoor activities. During group discussion on 5/19/21 at 1:07 P.M., the resident said the following: -There were no activities in the evening or after supper, and no activities on the weekends; -He/She would like to have something to do, it would break the boredom; -He/She would prefer to participate in activities similar to those conducted on weekdays on the weekends and evenings. 3. Review of Resident #14's admission MDS, dated [DATE], showed the following: -He/She was cognitively intact; -He/She considered it very important to do things with groups of people, do his/her favorite activities, and go outside when weather permits. Review of resident's activities care plan, last reviewed on 3/25/21, showed the following: -He/She would tell you what he/she liked/disliked and which activities he/she preferred; -He/She would continue to make his/her own choices; -He/She loved listening to music, word puzzles, coloring and watching TV; -He/She was adjusting to changes in his/her environment with making this his/her home and needed reassurance that he/she was doing okay. Staff were to make him/her aware of what activities were going on and remind as needed. During group discussion on 5/19/21 at 1:07 P.M. the resident said the following: -There were no activities in the evening or after supper, and no activities on the weekends; -He/She would like to have something to do, it would break the boredom; -He/She would prefer to participate in activities similar to those conducted on weekdays on the weekends and evenings. 4. Review of Resident #25's annual MDS, dated [DATE], showed the following: -Cognitively intact; -It was very important for him/her to read books/newspapers/magazines, listen to music, be around animals, do things with groups of people, do favorite activities, go outside to get fresh air with weather is good, and participate in religious services/practices; -It was somewhat important for him/her to keep up with the news. Review of the resident's care plan , last reviewed/revised on 4/1/21, showed the following: -He/She was able to make his/her own decisions on what he/she wanted to do daily; -He/She enjoyed staying in his/her room; -He/She watched TV and did crossword puzzles daily; -He/She enjoyed visiting with family, friends and staff; -He/She liked keeping up with the news with local papers; -He/She attended Bingo activities. During interview on 5/18/21, at 10:26 A.M., the resident said the following: -He/She liked to read a lot; -He/She enjoyed playing Bingo; -He/She went to many activities. During group discussion on 5/19/21, at 1:07 P.M. the resident said the following: -There were no activities in the evening or after supper, and no activities on the weekends; -He/She would like to have something to do; -He/She would prefer to participate in activities similar to those conducted on weekdays on the weekends and evenings. 5. Review of Resident 46's annual MDS, dated [DATE], showed the following: -He/She was cognitively intact; -He/She considered it very important to do things with groups of people, do his/her favorite activities and go outside when weather permits. Review of resident's activities care plan, last reviewed on 5/6/21, showed the following: -He/She enjoyed visiting with family and friends and coming to Bingo; -He/She would attend activities of his/her choice. During group discussion on 5/19/21, at 1:07 P.M., the resident said the following: -There were no activities in the evening or after supper, and no activities on the weekends; -He/She would like to participate in activities similar to those conducted on weekdays on the weekends and evenings. 6. Review of Resident 1's significant change MDS, dated [DATE], showed the following: -He/She was cognitively intact; -He/She considered it very important to do things with groups of people, do his/her favorite activities and go outside when weather permits. Review of resident's activities care plan, last reviewed on 5/21/21, showed the following: -He/She liked to visit and socialize, but did have concerns of his/her tremors and needed encouragement with activities; -He/She attended some activities, but required assistance with some activities such as bingo; -He/She preferred passive activities due to tremors, but staff were to continue invite/inform him/her of what activities were going on. During group discussion on 5/19/21, at 1:07 P.M., the resident said the following: -There were no activities in the evening or after supper, and no activities on the weekends and he/she would like to have something to do on the weekends. 7. Review of Resident 9's annual MDS, dated [DATE], showed the following: -He/She was cognitively intact; -He/She considered it very important to do things with groups of people, do his/her favorite activities, and go outside when weather permits. Review of resident's activities care plan, last reviewed on 5/20/21, showed the following: -He/She attended and participated in activities of his/her choice; -He/She enjoyed special events, Bingo, art class, nail care, music, daily newsletter, and correspondence with friends of high school days; -Staff were to encourage him/her to attend out of room activities. During group discussion on 5/19/21, at 1:07 P.M. the resident said the following: -There were no activities in the evening or after supper, and no activities on the weekends; -He/She would like to have activities on the weekends. 8. Review of Resident 8's annual MDS, dated [DATE], showed the following: -He/She was cognitively intact; -He/She considered it somewhat important to do things with groups of people, do his/her favorite activities, and go outside when weather permits. Review of resident's activities care plan, last reviewed on 3/4/21, showed the following: -He/She was able to inform staff of his/her preferences to activities and was being encouraged with activities; -His/Her main activity was smoking and playing games on his/her phone; -He/She liked to watch TV and visit with other residents; -He/She liked to play bingo and would participate with this and offered options and choices. During an interview on 5/20/21 at 2:23 P.M., resident said the following: -There were no activities on weekends; -He/She would participate in activities on weekends if provided and he/she was interested in what was scheduled. 9. Review of Resident #33's significant change MDS dated [DATE] showed it was very important for the resident to listen to music he/she liked, be around animals such as pets, to do things with groups of people, do his/her favorite activities, go outside for fresh air and participate in religious services or practices. Review of the resident's care plan, last revised 4/26/21 showed the following: -He/She enjoyed being busy and he/she liked to visit with others; -He/She was able to make his/her own choices for activities; -He/She lived in the SCU and participated in activities of his/her choosing; -He/She had a hearing deficit; -He/She liked TV, music, gardening, kickball, noodle with beach ball, animals and of course snacks. Observation of the resident on 5/18/21 at 10:25 A.M. showed the resident sat in a recliner in the TV room with the TV on. He/She held a purple bear. During interview on 5/20/21 at 1:15 P.M Nurse Aide (NA) K said the following: -He/She was the only aide on the special care unit; -The activity person would take a couple of the residents out of the unit occasionally for activities, but did not usually provide activities on the unit; -In the past he/she would have a few of the residents gather at the table and color but it had been too busy with the new resident who wandered. Observation on 5/20/21 at 1:15 P.M. showed the resident sat in a recliner in the day room with the TV on. Observation on 5/20/21 at 1:35 P.M. showed activity staff and residents in the activity room with BINGO being played. There were no special care residents participating in the activity. 10. Review of Resident #47's care plan dated 2/24/21 showed the following: -He/She enjoyed visiting with staff and other residents in the special care unit; -He/She enjoyed activities of dancing, tossing and kicking of beach ball or hitting balloons with noodles. Review of the resident's annual MDS, dated [DATE], showed that it was very important for the resident to listen to music he/she liked and to do his/her favorite activities. It was somewhat important to to keep up with the news, do things with groups of people, go outside for fresh air and participate in religious services or practices. Observations of the resident showed the following: -On 5/18/21 at 10:24 A.M. the resident lay in a recliner in the day room with his/her eyes closed and the TV on; -On 5/19/21 at 2:34 P.M. the resident sat in a recliner in the day room with the television on; -On 5/20/21 at 1:15 P.M. the resident sat in a recliner in the day room with the TV on. During interview on 5/19/21 at 2:34 P.M. Certified Nurse Aide (CNA) N said that after he/she arrived to work, they (staff) usually put a movie on. During interview on 5/20/21 at 1:15 P.M. NA K said residents either watched TV or would go to their rooms. 11. Review of Resident's #32's care plan, last reviewed/revised on 4/14/21, showed the following: -He/She was able to make his/her own decisions on what he/she wanted to do daily; -He/She liked to play games; -He/She enjoyed playing Bingo; -He/She liked to play games; -He/She liked to exercise; -He/She enjoyed staying in his/her room watching TV; -He/She enjoyed visiting with family and friends. During interview on 5/20/21, at 11:46 A.M., the resident said the following: -There were no activities in the evening or after supper, and no activities on the weekends; -He/She would like to have something to do; -He/She would like to have something to do on the weekends; -He/She liked to play games, play Bingo and went to church services when offered. 12. During an interview on 05/20/21 at 12:55 P.M., the activity director said the following: -The last daily activity was scheduled for 3:00 P.M.; -When activity staff were not present, residents could watch movies, and puzzles were located in the activity room along with a basket of towels to fold; -Residents could help themselves to whatever they wished to do; -There were no activity staff available to provide activities on weekends, but movies, puzzles, games, and folding towels were available in the activity room for a resident to request; -He/She was the facility's only activity staff, but there had been someone hired. He/she did not think new activity staff member would be working weekends; -Sometimes CNAs sit and talk with residents, and maybe provide nail care when they had a chance on weekends; -The SCU had a separate activity calendar; -He/She conducted activities in the SCU every day except Wednesdays (and weekends), but there were puzzles, colors, movies, and other things on the unit that staff could do with the residents; -Residents had voiced concerns about no activities on weekends, but he/she was the only activity staff and needed more help to provide weekend activities; -The previous activity director quit the end of October, he/she was hired in November, but did not start until mid-December; -There were no activities performed regularly from October until mid-December; -He/She was out of the facility from 12/6/20 until the end of December and other staff were supposed to fill in, but not all December activities were completed. He/She didn't know what was completed and who attended; -The administrator (who was in different role at the time) tried to conduct activities, but also had to do his/her job as well. 13. During interview on 5/21/21 at 10:30 A.M., the administrator said activities were held intermittently from October until December if they had time. There was no true schedule for activities. The previous activity director resigned and they had put out ads, but had few responses. The receptionist filled the activity director role, but then they had to find someone to replace him/her before he/she could assume the activity role. There were no activity calendars for SCU for October 2020, December 2020, January 2021, or February 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to consistently implement, evaluate, and modify interventions, in accordance with current standards of practice, as necessary to reduce the risk of falls for three residents (Resident #23, #52, and #54) in a review of 17 sampled residents. Resident #52 fell multiple times from 3/24/21-4/17/21 and ultimately sustained a dislocated shoulder ( an injury that occurs when the top of upper arm bone pops out of the socket in the shoulder blade) and fractured finger. The facility staff failed to use proper technique during gait belt (canvas belt placed around the resident's waist to assist with ambulation and transfers), transfers for two residents (Resident #4 and #31), when the resident did not bear weight, or bore only minimal weight, during transfers. The facility census was 56. Review of the undated facility policy Falls and Fall Risk, Managing showed the following: Falls and Fall Risk, Managing: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; Policy Interpretations and Implementation: Definition: According to the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, a fall is defined as: -Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is ground on the floor, a fall is considered to have occurred; -Challenging a resident's balance and training him/her to recover from loss of balance is an intentional therapeutic intervention. The losses of balance that occur during supervised therapeutic interventions are not considered a fall; Fall Risk Factors: 2. Resident conditions that may contribute to the risk of fall include: a. fever; b. infection; c. delirium and other cognitive impairment; d. pain; e. lower extremity weakness; f. poor grip strength; g. medication side effects; h. orthostatic hypotension; i. functional impairments; j. visual deficits; i. incontinence; 3. Medical factors that contribute to the risk of falls include: a. arthritis; b. heart failure; c. anemia; d. neurological disorders; e. balance and gait disorders; etc.; Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls; 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., try one or a few at a time, rather than many at once); 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc; 4. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period; 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant; 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling; 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficiency and staff will respond to alarms in a timely manner; Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each residents response to interventions intended to reduce falling or the risks of falling; 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved; 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified; 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls; Review of the undated facility policy Gait Belt and Transfer Policy showed the following: Purpose: To ensure the safety of residents and staff during transfers; Policy: All necessary staff shall be provided with transfer/gait belts upon employment to be utilized during patient care; Procedures: The staff members shall be responsible for using the transfer/gait belts at all times indicated during patient transfers; -Physical contact shall be maintained with all patients who are less that independent in their mobility skills; -Gait belts shall be secured before transfers begin; -All staff shall use good body mechanics during all aspects of transfers. Review of the Nurse Assistant in a Long Term Care Facility manual, revised 2001, showed the following: -The nurse assistant should never transfer or ambulate residents by grasping their upper arms or under their arms; -Such a transfer could result in skin tears, damage to nerves and arteries, and possible dislocation of the shoulder; -The gait belt increases the comfort and safety of the resident during the transfer procedure; -The gait belt is applied over the resident's clothing to avoid injury from the buckle and possible pinching the skin; -The gait belt prevents injury to the resident that could be caused by pulling on his/her arms, shoulders, or wrist; -If a resident is non-weight bearing the certified nurse assistant (CNA) should transfer him/her using a mechanical lift; -A gait belt is required when repositioning a resident in a chair. 1. Review of Resident #52's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's copy of fall risk (acuity) dated 3/5/21 showed a score of 16. A score of 10 or higher represents a high risk for falls. Review of the resident's undated baseline care plan showed the following: -Safety: History of falls, history of fall related injury; -Transfer: staff assist of two; -Walking: Not applicable (N/A); -Scheduled toileting every two hours. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/21 showed the following: -Cognitively intact; -No behaviors; -Required extensive assist of two or more staff for transfers and toilet use; -Walk in room did not occur; -Totally dependent on staff assist of one for locomotion on unit; -Frequently incontinent of bladder and bowel; -Diagnoses of hypertension, diabetes, arthritis, osteoporosis and depression; -Fall in last month prior to admission; -Fall in last two to six months prior to admission; -Fracture related to a fall in six months prior to admission; -Moving from seated to standing position-not steady, only able to stabilize with staff assistance; -Walking did not occur; -Moving on and off toilet-not steady, only able to stabilize with staff assistance; -Surface to surface transfer-not steady, only able to stability with staff assistance. Review of the resident's fall event report dated 3/24/21 showed the following: Fall location: resident room; -Resident was sitting in wheelchair prior to fall; -The fall was witnessed; -Location of injury: Was a controlled fall-resident could no longer stand and was slowly slid to floor-only injury was a lightly abraded quarter size area to left knee; -Care plan reviewed; -Notes: Resident was being assisted in bathroom to transfer from wheelchair to toilet. Gait belt on and resident told staff he/she could not stand any longer-staff assisted him/her to the floor slowly-while slowly sitting him/her to the floor his/her left leg rubbed the wall and has a small abraded area quarter size on outer part. Assisted up off floor by two aides and gait belt back into wheelchair-had urinated on floor. Bedtime care was given and assisted into bed-Betadine (antiseptic) applied to abraded area on left knee. Will continue to monitor. Call light in reach. Review of the resident's baseline care plan dated 3/24/21 showed the resident was lowered to the floor by the aide in a controlled fall. Received left knee abraded area quarter size. Family and physician notified. The resident's baseline care plan showed no documentation regarding interventions to prevent further falls. Review of the resident's care plan revised 3/26/21 showed the following: -Resident has a history of falls and fall with fracture with recent fall and needs for therapy. Lowered to the floor on 3/24 with knee abraised; -Resident is at the facility for therapy as when he/she was home he/she did have an event of falling. He/She has a history of falls and falls with fractures. He/She is needing staff to help him/her at this time to achieve his/her goal to go home. He/She is using a wheelchair for mobility for distances with assist of one but can propel him/herself for very short distances. He/She is ambulating for short distances with assist of one and wheeled walker. If staff happen to notice he/she is assisting him/herself and may need assistance please do so. Review of the resident's fall event report dated 4/12/21 showed the following: Fall location: resident room; -The resident was sitting in his/her wheelchair prior to fall; -The fall was not witnessed; -No injury noted; -Immediate interventions taken: none of the above; -Describe measures if necessary: Resident request to get in bed-said that was what he/she was trying to do-get his/her pajamas on; -Care plan reviewed; -Notes: Resident was found on floor in his/her room beside closet with wheelchair in back of his/her and commode in front of him/her sitting on his/her buttocks with legs outstretched. Is able to move lower and upper extremities without complaints. Resident was trying to change into his/her pajamas when he/she said he/she fell off his/her wheelchair, went down on bottom. Resident assisted up with gait belt and two aides. Resident is able to bear weight but is refusing to walk at this time, said he/she just can't. Resident was incontinent of urine at the same time. Assisted resident with bedtime care and into bed. Review of the resident's care plan revised 4/12/21 showed resident found on floor. No injuries. Contacted family and physician. No evidence facility staff evaluated current interventions or implemented new interventions to prevent further falls. Review of the resident's fall event report dated 4/15/21 showed the following: Fall location: resident room; -The resident was transferring him/herself from the commode to bed, didn't make it into the bed; -The fall was not witnessed; -Immediate measures taken: Asked resident to turn on his/her light whenever he/she transfers, needs stand by assist; -Care plan reviewed. Review of the resident's care plan revised 4/15/21 showed resident found on floor. No injuries. Contacted family and physician. No evidence facility staff evaluated current interventions or implemented new interventions to prevent further falls. Review of the resident's fall event report dated 4/17/21 showed the following: Fall location: resident bathroom; -The resident was transferring him/herself to the toilet; -Fall was witnessed; -No injury noted; -Immediate measures taken: none of the above; -Care plan reviewed; -At 6:45 P.M. CNA notified this nurse resident was on the floor. Upon entering bathroom noted resident sitting on floor in front of toilet with legs out in front of him/her. CNA said she was pulling down the resident's brief when the resident went dead weight and he/she lowered the resident missing the toilet and the resident landing on the ground. Resident is starting physical therapy/occupational therapy Monday (4/19/21). Review of the resident's care plan revised 4/17/21 showed fall witnessed. No injuries. No evidence facility staff evaluated current interventions or implemented new interventions to prevent further falls. Review of the resident's nurses' notes dated 4/19/21 showed the following: -At 1:45 P.M. received order per request of therapist for a left shoulder and left hand X-ray. Portable X-ray already here so X-ray was completed; -At 3:38 P.M. received results of X-ray of left shoulder, shows suggestive of left anterior shoulder dislocation, recommend axillary view or CT study to better evaluate if warranted. Physician notified; -At 7:20 P.M. received phone call from family member. Family wants resident taken to the emergency room (ER) to have his/her should put back in. Resident said he/she did not want to go to the ER. Resident told family member he/she does not want to go to the ER and wants to go to bed. Family member agreeable to wait until tomorrow. Review of the resident's nurses' notes dated 4/20/21 showed the following: -At 6:50 A.M. resident up in wheelchair in lobby area. Skin warm, dry and pale with continued bruising noted to left hand/wrist area also edematous (swollen) at this time. Resident complaints of pain to left shoulder at this time. As needed (PRN) Ultram (pain medication)/Tylenol (pain medication) administered per PRN orders; -At 4:48 P.M. Received phone call from orthopedic physician's office saying they were sending the resident to the ER since they could not get his/her left shoulder into the socket without sedation. Review of the resident's nurses notes dated 4/21/21 at 12:00 A.M. showed called hospital for update. Resident is being admitted for dehydration, left shoulder contusion, left hand fracture and chest wall contusion. Review of the resident's hospital history and physical dated 4/21/21 showed the following: -Resident's chief complaint is dehydration, shoulder dislocation and left hand fracture; -History of present illness: Resident present to the emergency department with complaints of left shoulder pain onset five days ago. Resident currently resides in the facility where they found him/her again between the commode and his/her bed. He/She has a known left shoulder dislocation and X-ray confirmed these findings. Multiple skin tears and contusions to his/her left arm and chest wall noted. Investigative procedures included an X-ray of the left should with anterior shoulder dislocation X-ray of the humerus negative for acute fracture. There is a moderately displaced oblique fracture through the fifth metacarpal bone on the left hand. Resident was sedated and shoulder was reduced of dislocation. CT chest abdomen and pelvis revealed a moderate left anterior chest wall hematoma fracture of the left coracoid (a short projection from the shoulder blade, to which part of the biceps is attached) process and multiple acute appearing bony fragments in the region of the left glenohumeral joint (a ball-and-socket synovial joint between the head of the humerus and the glenoid cavity (a shallow cavity which articulates with the head of the bone of the upper arm, the humerus, to form the shoulder joint of the scapula), consistent with recent trauma. Review of the resident's hospital orthopedic consultation note dated 4/21/21 showed the following: -Radiology: X-rays show anterior shoulder dislocation with coracoid process fracture; -Orthopedic assessment and plan: The resident's left shoulder fracture was reduced in the emergency department. He/she also has a left hand fracture that was placed in a splint in the emergency department. The resident is non-operable. During interview on 5/21/21 at 9:50 A.M. Certified Nurse Aide (CNA) G said when the resident was first admitted to the facility he/she would assist with transfers and ambulation, then his/her family came in, the resident refused therapy, started to fall and hurt his/her arm. Mentally the resident was pretty good but he/she does have some confusion. Now the resident does not assist with transfers, can't use his/her left arm to weight bear, doesn't use his/her legs and won't plant his/her feet. The resident injured his/her shoulder and fingers during his/her last fall. During interview on 5/21/21 at 9:10 A.M. Registered Nurse (RN) A said the process after a resident falls is obtain vital signs, first aid, assist up if able, look at current interventions in place to prevent falls and see if any new interventions could be added to prevent falls. During interview on 5/21/21 at 2:08 P.M. the Director of Nursing (DON) said the following: -She didn't know whether the resident had a pattern to his/her falls; -The charge nurse should do an event report and put his/her initials, date and that the resident had a fall on the care plan; -The charge nurse should look at the current fall interventions and see if there is anything else that could be done to prevent falls; -There were not any fall intervention on the resident's baseline care plan; -Staff should write fall interventions on the care plan after each fall; -No interventions were added to the baseline care plan after the 3/24/21 fall; -For the falls on 4/12, 4/15, and 4/17 staff did not indicate on the care plan whether interventions were evaluated or new interventions were added to prevent further falls; -On 4/20, the resident went to the hospital and had a dislocated shoulder and fractured finger; -Orthopedics tried to reduce the shoulder dislocation in the office but couldn't so they sent the resident to the ER and he/she was admitted for sedation during the reduction. 2. Review of Resident #31's significant change MDS dated [DATE] showed the following: -Rarely/never understands verbal content; -Short and long term memory problems; -Moderately impaired cognitive skills for daily decision making; -Totally dependent on two or more staff for transfers; -Walk in room did not occur; -Surface to surface transfer-not steady, only able to stabilize with human assistance; -Diagnosis of dementia; -Weight 87 pounds. Review of the resident's care plan dated 4/29/21 showed the following: -The resident requires assist of one to two with ADLS and cares; -Transfers with mechanical lift with two or with assist of two and may use sheet technique for transfers. Observation on 5/20/21 at 7:10 A.M. in the resident's room showed the following: -The resident lay on his/her back in bed; -CNA H and CNA I assisted the resident to sit on the side of the bed; -CNA I applied a gait belt around the resident's waist; -CNA H and CNA I lifted the resident up by holding onto the gait belt; -The resident's knees were bent at the knees and the resident's feet slid across the floor during the pivot transfer; -The resident did not bear weight; -CNA H and CNA I assisted the resident into the wheelchair by picking him/her up with the gait belt and by lifting up under the resident's thighs. During interview on 5/20/21 at 7:15 A.M. CNA H said the following: -The resident did not bear weight during the transfer; -It depends on the day whether or not the resident can bear weight; -The resident cannot follow simple commands; -Staff have talked about changing the resident to a mechanical lift transfer. 3. Review of Resident #4's care plan dated 3/11/21 showed the following: -The resident is able to inform staff when he/she is needing staff assistance with assist of one with needs; -The resident is using the wheelchair for mobility with assisting him/herself with very short distances and staff assistance with distance, and ambulating with a gait belt and assist of one. Review of the resident's quarterly MDS dated [DATE] showed the following: -Moderately impaired cognition; -No rejection of care; -Required staff assist of one for transfers, walk in room and toilet use; -Moving from seated to standing-not steady, only able to stabilize with human assistance; -Walking (with assistive devices if used)-not steady, only able to stabilize with human assistance; -Moving on and off toilet-not steady, only able to stabilize with human assistance; -Surface to surface transfer-not-steady, only able to stabilize with human assistance. Observation on 5/20/21 at 8:50 A.M. in the resident's room showed the following: -The resident sat in his/her recliner; -RN A entered the room and applied a gait belt around the resident's waist; -With the use of his/her lift chair, the resident stood up very slowly; -RN A did not place his/her hands on the gait belt during the transfer; -The resident walked slowly to his/her bathroom with the use of his/her walker; -RN A did not place his/her hands on the gait belt during ambulation; -The resident sat down on the toilet seat hard; -The lid of the toilet tank clanged when the resident sat; -RN A did not place his/her hands on the gait belt during surface to surface transfers or ambulation. During interview on 5/20/21 at 11:45 A.M. RN A said the following: -He/She put the gait belt on the resident but the resident can walk by him/herself so he/she didn't need to hold onto the gait belt; -If a resident does not bear weight staff should transfer the resident by mechanical lift. He/She was not aware Resident #31 was not bearing weight. During interview on 5/20/21 at 9:05 A.M. RN E/ Quality Assurance (QA) Nurse said staff should have their hands on the gait belt during transfers and ambulation. At times the resident has problems walking. During interview on 5/21/21 at 2:08 P.M. the Director of Nurses (DON) said the following: -She would expect staff to hold onto the gait belt during gait belt transfers and ambulation; -If a resident is unable to bear weight staff should use a mechanical lift. 4. Review of Resident #23's significant change MDS dated [DATE], showed the following: -Cognitively intact; -Minimal depression; -Extensive assistance of one staff member for bed mobility, transfers, walking in room, walking in corridor, locomotion off the unit, toilet use and bathing; -Balance is not steady; -Two or more falls with no injury since last assessment; -One fall with injury since last assessment; -Antidepressant medication used five out of seven days during the look back period; -Care area assessment identified areas of concern to include falls. Review of the resident's care plan, dated 4/1/21, showed the following: -Resident has history of falls with needs for assistance with transfers; -He/She is able to use the call light but will generally not use the call light for transfer assistance needs; -Bed in lowest position with floor mats with events of wiggling self out of bed. Review of the resident's care plan, updated 4/20/21, showed the resident rolled out of bed with no injuries, interventions (hand written with no evidence of interventions used). Review of the resident's nurses notes dated 4/20/21 showed no documentation regarding the resident rolling out of bed as indicated on the care plan. Review of the resident's nurses notes dated 4/23/21, at 1:07 A.M., showed the resident was found sitting on the floor beside his/her bed. Assisted back to bed. Review of the resident's care plan, updated 4/23/21, showed the resident sat on side of bed on 4/23/21 precautions in place and evaluated (hand written with no indication of precautions used). 5. Review of Resident #54's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Modified independence in decision making; -Delusion present; -Independent for bed mobility, transfers, ambulation in room, locomotion in room and corridors, hygiene and toileting; -Independent with supervision/set up help for eating; -Limited assistance of one staff member for dressing and ambulation in the corridor; -Extensive assist of one staff member for bathing; -Limited range of motion one side upper extremity; -Assistive devices for mobility include walker and wheelchair; -Balance during transitions and walker is unsteady, but able to stabilize without staff assistance; -One fall with no injury since last assessment; -Two falls with injury, not major, since last assessment. Review of the resident's care plan, dated 4/14/21, showed the following: -He/She has a history of falls with a diagnosis of post polio (a virus that may cause paralysis) and Parkinson's (a long-term degenerative disorder of the central nervous system that mainly affects the motor system); -He/She does not like to wait and will go ahead and help him/herself which can be unsuccessful, as evidenced by falls on 2/04/21, 3/25/21, and 4/3/21; -He/She has a bed cane to help with bed mobility with sitting on the side of the bed; -He/She has diagnosis that can inhibit his/her ability to get his/her body to move like he/she wants it to, which can lead to needed assistance and risk for falling, so if staff see he/she is needing help please stop and do so or call for assistance as he/she can be impatient. Review of the resident's nurses notes dated 5/14/21, at 2:00 P.M., showed the resident fell in his/her room while ambulating. Review of the resident's care plan, updated 5/14/21, showed the resident fell in room, all safety measures in place (handwritten and initialed with no indication of what safety measures were in place). During an interview on 6/2/21, at 9:47 A.M., the care plan coordinator said the following: -She would expect the care plan to be updated after falls with with the date of the fall, interventions to be noted as effective or not, and if new interventions were initiated what they were; -If no new interventions put into place the care plan should indicate the care plan was reviewed and by whom; -The interventions are monitored for effectiveness by RN E/ QA nurse. During interview on 6/1/21, at 3:05 P.M., RN E / QA Nurse said the following: -After a fall the care plan is evaluated by the charge nurse to see if there are appropriate interventions in place for the resident to maintain safety; -If there is an intervention that has not been used yet the intervention will be added to the care plan by writing it on the care plan, dating the intervention and initials of who added the intervention; -If there are no interventions to add, reviewed and by whom is added to the care plan. During interview on 5/21/21, at 2:08 P.M., the DON said the following: -She would expect charge nurses to update the care plan with interventions after an event such as a fall; -She would expect the interventions to be listed with a date and initial and what interventions were used; -By looking at Resident #23's care plan it was unclear what interventions were put in place after falls on 4/20/21 and 4/23/21. MO 184288 MO 184303

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer residents a daily bedtime snack for one resident (Resident #8), in a review of 17 sampled residents, and for four additional residents (Residents #9, #10, #14, and #25), who participated in group interview and reported bedtime snacks were not offered on a routine basis at the facility. The facility census was 56. Review of the undated facility policy, Serving Snacks (Between Meal and Bedtime), showed the following: Purpose: The purpose of this procedure is to provide the resident with adequate nutrition. Preparation: 1. Review the resident's care plan and provide for any special needs of the resident; 2. Assemble equipment and supplies needed; 3. Check the tray before serving the snack to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow; 4. Ensure that the necessary non-food items (i.e., flexible straw, special devices, etc.) are on the tray. Report or replace missing items; Steps in the Procedure 1. Place the snack on the over bed table or serving area. Be sure the over bed table is adjusted to a comfortable position and height for the resident. Arrange the supplies so that they can be easily reached by the resident; 2. Assist the resident to a nearly upright position; 3. Arrange the snack so that it can be easily reached by the resident; 4. Place beverages within easy reach. Open beverage cartons as necessary; 5. Assist the resident as necessary. However, encourage the resident to feed himself or herself as much as possible; 6. Place the call light within easy reach of the resident. 7. Once the resident has received the adequate assistance, exit the room and allow the resident to eat his or her snack. 1. Review of Resident #10's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated 11/24/20, showed the following: -He/She was cognitively intact; -His/Her diagnoses included diabetes (elevated blood sugars); -He/She considered it very important to have snacks available between meals. During interview on 5/19/21 at 1:00 P.M., the resident said he/she was not offered and/or provided bedtime snacks. 2. Review of Resident #14's admission MDS, dated [DATE], showed the following: -He/She was cognitively intact; -He/She considered it very important to have snacks available between meals. During interview on 5/19/21 at 1:00 P.M., the resident said he/she was not offered and/or provided bedtime snacks. 3. Review of Resident #25's annual MDS, dated [DATE], showed the following: -He/She was cognitively intact; -His/Her diagnoses included diabetes; -He/She considered it very important to have snacks available between meals. During interview on 5/19/21 at 1:00 P.M., the resident said he/she was not offered and/or provided bedtime snacks. 4. Review of Resident #9's annual MDS, dated [DATE], showed the following: -He/She was cognitively intact; -His/Her diagnoses included diabetes; -He/She considered it very important to have snacks available between meals. During interview on 5/19/21 at 1:00 P.M., the resident said he/she was not offered and/or provided bedtime snacks. 5. Review of Resident #8's annual MDS, dated [DATE], showed the following: -He/She was cognitively intact; -His/Her diagnoses included diabetes; -He/She considered it somewhat important to have snacks available between meals. During interview on 5/12/21 at 2:23 P.M., the resident said staff did not offer bedtime snacks. He/She could get snacks from the snack basket located on the ice cart, but staff did not bring snacks to him/her. He/She was an insulin dependent diabetic. He/She had an occasional low sugar episode that required a snack. He/She purchased snacks and kept them in his/her room. 6. During an interview on 5/19/21 at 5:10 P.M., Nursing Assistant (NA) C said he/she worked 2:00 P.M. until 10:00 P.M. He/She did not offer and/or pass bedtime snacks unless residents asked for one. During an interview on 5/19/21 at 5:10 P.M., Certified Nursing Assistant (CNA) B said he/she worked 2:00 P.M. until 10:00 P.M. He/She did not offer and/or pass bedtime snacks unless residents asked for one. He/She was unsure about what was done for diabetic residents. During an interview on 5/21/21 at 2:10 P.M., the director of nursing (DON) said CNAs begin assisting residents to bed for the night right after supper. Staff were to place snacks in the nursing medication carts so the nurses could offer snacks because the CNAs were busy with night routines. There were snacks on the special care unit staff were to offer. She expected staff to offer bedtime snacks to every resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure safe transfers techniques for two residents (Resident #26 and#40) when the residents did not bear weight during gait belt (canvas belt placed around the resident's waist to assist with ambulation and transfers) transfers and staff failed to lock the resident's wheelchair during the transfer to prevent accidents for one additional resident (Resident #16). The facility census was 54. 1. Review of the undated facility policy titled Gait Belt and Transfer Policy showed it was the policy of the facility to use gait belts for the transferring of residents who were unable to transfer independently, unless it was deemed necessary that the resident must be lifted mechanically for their and the facilities staff. 2. Review of the facility policy titled Safe Lifting and Movement of Residents, revised July 2017, showed the following: -In order to protect the safety and well-being of staff and residents and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents; -Manual lifting of residents shall be eliminated when feasible; -Nursing staff, in conjunction with rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the resident's mobility (degree of dependency), resident size, weight-bearing ability, cognitive status, whether the resident is usually cooperative with staff and the resident's goals for rehabilitation, including restoring or maintaining functional abilities; -Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary; -Safe lifting and movement of residents is part of an overall facility employee health and safety program which involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies, addresses reports of workplace injuries, provides training on safety, ergonomics and proper use of equipment and continually evaluates the effectiveness of workplace safety and injury-prevention strategies. 3. Review of the most current Nurse Assistant in a Long Term Care Facility student reference manual, dated 2001, under Lesson Plan 3, transferring the Resident, showed the following: -Section II-Safety Measures-Caution: NEVER transfer a resident by lifting him/her under the arms! This can cause nerve damage, fractures and shoulder dislocation; (C) for a resident who is weak, you must have control of the shoulders and hips during the transfer; (E) all wheelchairs (w/c) or geri-chairs (g/c) should have locks that are locked during transfer; a slight movement of the w/c or g/c could cause a fall; -Section III-Equipment for Transfer Activities (A) Gait belt (1) (a special belt that is placed around the resident's waist and provides the nurse assistant with a handle to hold onto for those who require assistance during transfers, ambulation or repositioning); (2) the purpose of using a gait belt (a) to ensure optimum safety and comfort for the resident (b) to minimize the risk of injury to the resident and/or nurse assistant(s) (c) to facilitate proper body mechanics of the nurse assistant. It allows for better control of the resident while transferring; (3) the nurse assistant should not transfer or ambulate residents by grasping their upper arms or under their arms. Such a transfer could result in skin tears, damage to nerves and arteries and possible dislocation of the shoulder. The gait belt increases the comfort and safety of the resident during the transfer procedure and prevents injury to the resident that could be caused by pulling on his/her arms, shoulders or wrist; (8) the nurse assistant grasps the belt on both sides of the resident's waist; -Section V- Positioning the Resident in a Chair (B) (1) apply gait belt (2) use two people. They should stand on opposite sides of the resident. Each grasps the belt in back and places one hand under the thigh in front. On the count of three, lift and move the resident back in the chair (3) an alternate method using two people, as follows: (a) one should stand in front of the resident and one behind the resident (b) the nurse assistant in front of the resident places his/her hands under the resident's thighs. The nurse assistant behind the resident places his/her arms around the resident and grasps the gait belt in the front (c) on the count of three, they lift and move the resident back in the chair. 4. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/6/19, showed the following: -Brief interview for mental status (BIMS) of three indicating cognitive impairment (BIMS scores range from 0-15, the higher the score, the lower the impairment to the cognitive response); -Transfers required extensive assistance of two plus staff for physical assistance; -Balance during transitions was not steady; -Functional limitation in range of motion; impairment of upper and lower extremities; -Used a wheelchair for mobility; -Weight 109 pounds. Review of the resident's care plan, dated 2/14/19 showed the following: -Diagnoses included Alzheimer's dementia, muscle weakness, abnormal posture, reduced mobility and need for assistance with personal care; -Requires assistance with transfers and mobility; -Has Alzheimer's and weakness with arms and legs. Observation on 4/10/19 at 3:00 P.M. showed the following: -The resident sat in a recliner in the facility day area; -The resident's wheelchair sat to the right of the resident; -Certified Nurse Assistant (CNA) D applied a gait belt around the resident's waist and stood to the resident's left side; -Registered Nurse (RN) A stood in front of the resident; -RN A took both of the resident's hands in his/her hands and instructed the resident to stand; -The resident made no attempt to get up from the recliner; -RN A pulled the resident up out of the recliner by his/her arms. RN A did not use the gait belt to transfer the resident; -The resident said Oh, oh during the transfer; -CNA D moved to the resident's right side and beside the resident's wheelchair; -RN A pivoted the resident to his/her right side and sat the resident down in the wheelchair; -The wheelchair was not locked and the wheelchair slid backwards as the resident sat down; -The resident sat on the edge of the wheelchair seat and was not properly positioned in the wheelchair; -CNA D moved behind the resident's wheelchair, placed his/her arms under both of the resident's arm pits and with an upward motion, pulled the resident back in the chair; -Staff did not lock the wheelchair prior to the resident transfer and did not properly perform the transfer or repositioning of the resident using the gait belt. During interview on 4/10/19 at 3:10 P.M. CNA D said the following: -He/she thought the resident was a one person assisted transfer; -He/she had been trained on how to properly transfer and reposition residents; -He/she knew the wheelchair should be locked for a safe transfer; he/she was unaware the resident's wheelchair was not locked; -He/she had repositioned the resident in the wheelchair without using the gait belt because he/she just reacted quickly because the wheelchair had slipped backwards during the transfer and he/she did not want the resident to fall; he/she probably should have used the gait belt to reposition the resident. During interview on 4/10/19 at 3:15 P.M. RN A said the following: -He/she thought the resident would stand when instructed and he/she always guided the resident by using his/her arms instead of the gait belt; he/she thought it was okay to transfer the resident this way; -The resident was usually anxious with transfers and that is why he/she thought the resident was saying Oh, oh; -He/she knew the wheelchair should be locked for a safe transfer; -He/she had not locked the wheelchair locks prior to the transfer; he/she was not aware the locks had not been applied. 5. Review of Resident #26's quarterly MDS, dated [DATE], showed the following: -Sometimes understands others; -Required extensive assistance of two plus staff for transfers and toileting; -Not steady, but able to stabilize with staff assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfers; -Mobility devices included a walker and a wheelchair; -Diagnosis included dementia; -Weight 117 pounds. Review of the resident's care plan, dated 2/27/19 showed the following: -Diagnoses included low back pain and osteoporosis; -Needs assist of two staff to use bathroom; -May use wheeled walker and assist of two but will generally use the wheelchair; -Requires assist of one or two with activities of daily living (ADLs) and cares; -Needs help with daily needs and it might be you and a buddy to do this but this does depend at times at how he/she might like you. He/she can help you at times especially if he/she likes you today and he/she might even walk with you but usually he/she is needing use of a wheelchair to get to his/her favorite spot in the commons area in his/her recliner and watch what is going on. Review of the resident's physician order sheet (POS), dated 3/11/19 through 4/11/19 showed the following: -Activity level - up ad lib (as desired); -Weight bearing as tolerated. Observation on 4/10/19 at 3:19 P.M., showed the following: -The resident sat in a recliner in the common area; -CNA K applied a gait belt around the resident's waist and stood on the resident's left side; -CNA L stood on the resident's right side; -CNA K grasped the gait belt in his/her left hand and the resident's pants waistband in his/her right hand. CNA L grasped the gait belt with his/her right hand and pulled the resident up out of the recliner; -The resident did not bear weight as his/hers toes touched the floor but his/her heels did not touch the floor; -CNA K and CNA L pivoted the resident with just the resident's toes on the floor and sat the resident in his/her wheelchair; -Staff propelled the resident in his/her wheelchair to the shower room; -CNA K and CNA L grasped the gait belt and transferred the resident to the toilet with the resident's knees bent during the transfer; -Following toileting, CNA K and CNA L grasped the gait belt and pivot transferred the resident to his/her wheelchair; -The resident's knees remained bent during the pivot transfer and his/her feet slid across the floor. During interview on 4/10/19 at 3:23 P.M., CNA L said the resident bears some weight but not all. Staff get him/her up and the resident can't pivot. During interview on 4/10/19 at 3:32 P.M., CNA K said the resident does not bear full weight. The resident is partial weight bearing and bends his/her knees. 6. Review of Resident #40's significant change MDS dated [DATE], showed the following: -Diagnosis included osteoporosis (a disease in which bone weakening increases the risk of broken bone. It is the most common reason for a broken bone among the elderly); -Extensive assist of one staff for transfers, bed mobility, and toileting; -Used a wheelchair; -Not steady, only able to stabilize with staff assistance; -Weight 96 pounds. Review of the resident's medical record showed the resident returned from the hospital on 4/8/19. Review of the resident's care plan, last revised on 4/10/19 showed the following: -Dementia and cognitive loss; -At risk for falls with fractures; -The resident needed one to two staff assistance with transfers; -Staff were not to use a gait belt due to the resident's fragile skin. Review of the resident's care plan used by the CNAs and kept in the resident's closet, last updated 4/10/19 showed the following: -The resident required one or two staff assistance with transfers; -Resident's condition declining which included ADL status. Observation on 4/10/19 at 6:14 A.M., showed the following: -CNA/RA (restorative aide) G held the resident by the gait belt on the side of the bed; -The resident's buttocks slid off the bed; -The resident's feet slid out from under him/her; -The resident's torso was bent over to his/her knees; -The resident was not following directions from CNA/RA G; -CNA/RA G said the resident was heavier than he/she thought; -Certified Medication Aide (CMT) H entered the resident's room and assisted CNA/RA G to reposition the resident; -CNA C entered the resident's room; -CNA C and CNA/RA G held the gait belt and attempted to stand the resident; -The resident's torso bent and his/her head went toward his/her knees, the resident's knees buckled; -CNA C and CNA/RA G lifted the resident off the ground using the gait belt and put the resident in the geri-chair (a reclining chair on wheels). Observation on 4/10/19 at 4:44 P.M. showed the following: -Nursing assistant (NA) J and CNA D entered the resident's room; -NA J placed a gait belt around the resident's waist; -NA J stood on the resident's right side. CNA D stood on the resident's left side; -NA J and CNA D attempted to stand the resident; -The resident's feet slid across the floor and his/her knees buckled; -NA J and CNA D lifted the resident with the gait belt and sat the resident in the geri-chair. During an interview on 4/10/19 at 4:58 P.M. NA J said: -They got report the resident had declined, staff were not to use a gait belt because of the resident's skin being fragile, but staff always used a gait belt; -He/she did not know the resident did not bear weight; -The resident did not bear weight during the transfer and did not follow directions; -The resident needed to be transferred with a mechanical lift; -He/she reported the resident not bearing weight to RN A. During an interview on 4/10/19 at 4:58 P.M. CNA D said the resident did not bear weight during the transfer and did not follow directions. During an interview on 4/11/19 at 10:40 A.M. CNA/RA G said the following: -The resident had declined since readmission from the hospital; -The resident did not bear weight or follow directions; -The resident needed to be a mechanical lift transfer; -He/she reported the resident not bearing weight and decline to RN A. During an interview on 4/11/19 at 10:45 A.M. CNA C said the following: -The resident used to be a gait belt and one person transfer; -The resident had declined since his/her hospitalization; -The resident needed to be a full lift with the mechanical lift; -He/she reported the resident's decline to the RN A. 7. During an interview on 4/11/19 at 9:54 A.M. the physical therapist assistant said the following: -A person needs to bear weight for staff to perform a gait belt transfer; -It was unsafe to lift a resident with a gait belt or not use a gait belt at all and transfer a resident; -If a resident wasn't bearing weight or had too fragile skin to put a gait belt on, that resident should be a mechanical lift transfer. During an interview on 4/11/19 at 10:53 A.M. the Director of the facilities rehabilitation center said the following: -She would expect staff to report decline in a resident's status to her; -Staff had not reported a decline in Resident #40's ability to transfer; -Resident #40 just got back from the hospital she had not received a order for the resident to be screened for transfer or any therapy; -A resident needed to be cognitively intact enough to follow directions and bear 50% of weight to be transferred with a gait belt; -If a resident's knees buckle and/or slide across the floor with a transfer that is an indication the resident is not bearing weight and may need to be changed to a mechanical lift transfer; -Staff should never lift or pull on a resident's arms, lift the resident off the floor or transfer a resident without a gait belt because it could harm the resident and the staff; -The staff should always lock the brakes on the wheelchair during transfers. During interview on 4/11/19 at 12:30 P.M. the Director of Nursing said the following: -If the resident does not bear weight staff should use a mechanical lift for transfers; -She would expect staff to report a decline in a resident's status to her; -Staff had not reported decline in Resident #40's status to her; -Staff should not pull, lift on the resident's body and or lift the resident with the gait belt as it could crack a rib or bone and harm the staff and the resident; -She would expect staff to ensure wheelchair brakes were locked prior to transfer to provide a safe transfer; -She expected staff to utilize the gait belt and not pull on the resident's arms during a transfer and repositioning; -She thought Resident #16's care plan instructed staff to transfer the resident by using his/her arms and not the gait belt.