**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to report an allegation of neglect of care to the state agency (SA) for 1 of 3 residents (R1) reviewed who alleged neglect of care.R1's Resident Face Sheet indicated she admitted to the facility on [DATE]. R1's diagnosis included atrial fibrillation, adult failure to thrive and hypertension. R1's Individual Resident Care Plan dated 6/19/25, indicated she required assistance with repositioning, toileting and wheelchair mobility and displayed no behaviors. R1's Progress Note dated 6/22/25, indicated R1's family spoke with nurse regarding R1's condition. R1's family insisted R1 be sent to the emergency department because they felt facility's care of R1 was poor. R1 had not been eating or drinking much and refusing to take her medications. Family asked for boxes to pack up R1's belongings and said they would not be bringing R1 back to the facility. R1's Progress Note dated 6/23/25, indicated social services designee (SSD) called and spoke with R1's family member (FM)-A to discuss the weekend happenings. FM-A said the lack of care was neglect and everyone could see R1 had not been doing well. FM-A said, this was uncalled for, poor care/neglect. Later in the afternoon, SSD spoke with hospital staff who reported R1 was dehydrated and throwing up on arrival to the hospital. A facility Grievance Form dated 6/23/25, indicated R1's family expressed concerns about her care and condition. R1 was sent to the hospital for evaluation and facility informed facility she would not be returning.During interview on 7/16/25 at 1:46 p.m., the SSD stated she thought the allegation of neglect from the family was because R1 was not getting enough to drink or food. The SSD said R1's FM-A had reported neglect to her and said she did not believe it had been reported to the SA.During interview on 7/16/25 at 1:57 p.m., licensed social worker (LSW)-A stated the allegation of neglect was not reported to the SA because the facility did not feel neglect had occurred. LSW-A said the facility felt the family was unhappy that staff had not sent R1 to the hospital.During interview on 7/16/25 at 3:11 p.m., licensed practical nurse (LPN)-A stated he had worked with R1 over the weekend. LPN-A said R1 seemed okay on Friday when she admitted to the facility. LPN-A said on Sunday the family was really upset and talked about the care at the facility being poor and that R1 would not be coming back. During interview on 7/16/25 at 3:38 p.m., the administrator stated the allegation of neglect had not been reported to the SA. The administrator said she had not been aware of any concerns until Sunday night after some of the owners had spoken with the family. The administrator stated her understanding had been that family was upset about care and the facility wanted to talk to them and ask what the issues had been. Facility policy Abuse Prevention/Prohibition Program dated 4/23/24, defined neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotions distress. The policy indicated allegations of neglect would be reported within two hours if neglect resulted in serious bodily injury and within 24 hours if the neglect did not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to utilize assistance devices (transfer belt) and provide a hazard free environment as care planned for 3 of 4 residents (R1, R3, R4) reviewed for falls. Findings include: R1's Resident Face Sheet indicated she admitted to the facility 8/21/24, with diagnosis that included fracture of left scapula, weakness, moderate dementia and back pain. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she had upper extremity impairments to one side. The MDS indicated R1 required substantial to maximal assistance to transfer and stand and indicated ambulation was not attempted due to medical condition or safety concerns. R1's MDS indicated she had sustained two or more falls since the prior assessment with no injury and two or more falls with minor injury. R1's care plan dated 6/5/25, identified a risk for falls and decreased physical mobility related to left shoulder injury, muscle weakness and inability to ambulate. Care plan interventions included extensive assitance from one to two staff to transfer from recliner and assistance from one staff with gait belt on/off the toilet. 5/22/25, Event Report indicated at 4:00 a.m., R1 was being assisted to sit down in the chair, suddenly felt a bit dizzy and hit the floor. R1 was face down on the floor and had hit her head. Progress Note dated 5/22/25, indicated nurse was called into R1's room. R1 was seen face down on the ground with no transfer belt around her waist. nursing assistant (NA) stated she was trying to assist R1 into the recliner chair when she fell forward on her face. During observation and interview on 6/10/25 at 10:38 a.m., R1 was seated in a wheelchair in her room. R1 had a bump on her forehead that was purple in color along with dark purple bruising under both eyes, on both sides of her mouth and under her chin, covering the upper part of her neck. R1 said NA-A had assisted her to the bathroom and said on the way back, NA-A was walking behind her and she fell. R1 stated NA-A had not used the transfer belt and said, she remembered her head hitting the floor. R1 said, I heard it just pop. R3's Resident Face Sheet indicated she admitted to the facility 2/25/25, with diagnosis that included dementia, history of fracture, osteoporosis and anxiety. R3's quarterly MDS dated [DATE], identified severe cognitive impairment The MDS indicated she required substantial to maximal assistance for transfers and ambulation and had no falls since the prior assessment. R3's care plan dated 6/5/25, identified a self care deficit related to right hip and wrist fractures, cognitive deficits and decreased physical mobility with potential for falls. Resident Care Sheet dated 6/6/25, indicated R3 was a fall risk. Interventions included, do not leave bed remote with R3. The care sheet further directed staff to transfer R3 using assistance from two staff and a transfer belt. Event Report and correlating Progress Notes indicated on 6/2/25 at 12:00 a.m., nurse was called to R3's room where she was sitting on the floor next to her bed. The bed was in the highest position. R3 reported she had hit her head. Staff had been in the room [ROOM NUMBER] minutes prior and the bed had been in the lowest position. Staff believed R3 was on the remote control which caused the bed to raise resulting in the fall. During observation on 6/11/25 at 7:44 a.m., R3 was laying in bed. The control for the bed was in reach of R3 next to her head. During observation and interview on 6/11/25, at 7:51 a.m., NA-B reviewed the care sheet and said staff were not to leave the remote in reach of R3. NA-B verified placement of the remote and said the overnight shift had been the last ones in the room. R4's Resident Face Sheet indicated she admitted to the facility 5/23/25, with diagnosis that included hemiplegia and hemiparesis, cerebral infarction (stroke), weakness of upper and lower extremities and disorder of bone density. R4's admission MDS dated [DATE], identified intact cognition and indicated she had upper extremity impairment on one side. The MDS indicated R4 required partial to moderate assistance for transfer and ambulation and had not fallen since admission. R4's Individual Resident Care Plan dated 5/23/25, indicated she transferred with assistance from one staff using a transfer belt and was receiving therapy. Resident Care Sheet dated 6/6/25, indicated R4 required assistance from two staff using a transfer belt for transfers and ambulation. During observation on 6/11/25 at 7:36 a.m., NA-C was walking with R4 down the hall past the nurses station. NA-C was not using a transfer belt. At 7:41 a.m., NA-C was interviewed about the transfer belt. NA-C said R4 was supposed to have a transfer belt and said, it bothers her and I couldn't find it. During interview on 6/11/25 at 8:58 a.m., registered nurse (RN)-A stated based on the care plan and the care sheet, a transfer belt should have been used when transferring R4. R4's therapy Ambulation Recommendations to Caregivers dated 6/4/25, directed staff to ambulate R2 twice daily with four wheeled walker and assistance from two staff. During interview on 6/11/25 at 9:07 a.m., the director of nursing (DON) stated staff were expected to follow the care sheets. The DON said staff should be able to pick up the care sheet and take care of any of the residents. The DON further stated R4's bed remote could be locked but not all the staff were aware so she directed them not to place the remote within R4's reach. During interview on 9/11/25 at 9:15 a.m., physical therapy assistant (PTA)-A stated the transfer belt enabled staff to control a residents movement while walking with them at their center of gravity. PTA-A said if a resident started to fall, the transfer belt allowed staff to correct the movement and/or assist with lowering the resident to the floor. PTA-A stated therapy recommended a transfer belt as it was the easiest and safest way to control a resident. During interview on 6/11/25 at 9:43 a.m., NA-B stated she was not aware the bed remotes could be locked. NA-B said she used the remote to adjust the bed when completing cares. During interview on 6/11/25 at 9:45 a.m., family member (FM)-A stated R3 had sustained two falls since she admitted to the facility. FM-A said the second fall happened when she fell out of bed. FM-A said she was told the bed could not be controlled by the remote. FM-A said when staff transferred R4, sometimes staff used a transfer belt and sometimes they did not. FM-A said the order was for two staff and a transfer belt and said sometimes it's two and no belt, sometimes one and no belt and sometimes a belt. FM-A stated it would help if the staff looked at their sheets (care sheets). Facility policy Transferring of Residents dated 5/2025, indicated residents who are unable to transfer themselves independently or with minimum assistance shall be transferred following the principles of this policy to allow for maximum safety during transfer. -Transferring resident with single assist, assure transfer belt is in position on resident. - Transferring resident with double assist, assure transfer belt is in place on resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure flooring was maintained in a safe manner for 1 of 1 resident (R49) reviewed for environment. Findings include: R49's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and had non-Alzheimer's dementia. During observation on 2/11/25 at 8:42 a.m., the floor in R49's room had a black substance built up on the seams between the flooring tiles in the room which covered approximately 50 percent of the floor. When walking on the black substance between the seams would stick to your shoes. During an interview on 2/12/25 at 11:44 a.m., housekeepers (HSK)-A and HSK-B stated R49's room was cleaned about three days a week and included sweeping and mopping the floor. They stated the stuff coming up between the tiles was sticky and not sure if it was cleanable. HSK-A and HSK-B stated sometimes they can get a little bit of it to come off, but within a couple of days more sticky stuff would come up through the seams. During an interview on 2/12/25 at 11:58 a.m., the maintenance director (M)-A stated he was aware of the substance coming between the seams in R49's room and sated it was probably the glue from the tiles. M-A stated the resident resident's floor was replaced in the past year, and after the resident moved into the room is when the glue started to come out. About mid-summer R49 was moved out of his room and the floor was scraped and rewaxed. Within a week more of the glue was coming out from between the seams. M-A stated the floor needed to be replaced in the room, but the resident would need to be moved out of the room before they could do it; however, there was not a current plan in place to replace the flooring. During an interview on 2/12/25 at 12:40 p.m., licensed practical nurse (LPN)-A, the infection preventionist, stated she was aware of the substance on R49's floor and stated it was sticky and tacky to touch and the floor could not be cleaned thoroughly because of the substance being sticky. Further, the floor in R49's room would need to be replaced. During an interview on 2/12/25 at 1:20 p.m., the administrator stated it was unacceptable for R49 to be in the room with a floor in that condition and it needed to be replaced. A policy for maintenance of flooring was requested, but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to accurately code a significant weight loss on the Minimum Data Set (MDS) for 1 of 3 residents (R30) reviewed for nutrition Findings include: R30's quarterly MDS dated [DATE], identified R30 had a severe cognitive impairment and diagnoses t included diabetes, hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), chronic kidney disease, dysphasia (difficulty swallowing food or liquids) and aphasia (a comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain). R30's weight was 153 pounds (lbs.) and R30 had no loss of 5% or more in the last month or loss of 10% or more in last 6 months. R30's medical records identified the following weights: - 7/14/24 172.5 lbs. - 1/3/25 153.3 lbs. Which is a 11.13 percent decrease in weight in 180 days. R30's Mini Nutrition assessment dated [DATE], identified the registered dietician would continue R30's current plan of care and monitor weights monthly. Intake would be assessed regularly to ensure that nutrient needs were being met. Laboratory values would be reviewed for trends, and interventions would be adjusted as necessary. R30 would not trigger for any significant weight changes as evidenced by a 5% change in 30 days or 10% change in 180 days. The RD would continue to monitor weights monthly and reassess quarterly or as needed if significant changes in weight, intake, or health status occurred. During an interview with the RD-A and dietary manager (DM)-A on 2/11/25 at 1:10 p.m., the RD stated she just did the quarterly assessment on R30 and R30 was not a significant weight loss. Upon review of R30's weights, the RD stated her initial report did not identify R30's 180-day weight for some reason it did not pull that. R30 should have been triggered on the MDS as a significant weight loss. During an interview on 2/12/25 at 9:33 a.m., registered nurse (RN)-D stated her role was the facility's MDS coordinator. The RD completed the nutrition assessment, and that information was pulled into section K of the MDS. RN-D stated R30's quarterly MDS dated [DATE] was coded incorrectly. Coding of the MDS was important because it affected reimbursement, quality reports, and R30 could have had further weight loss because the appropriate interventions were not put into place. During an interview on 2/12/25 at 12:21 p.m., the director of nursing (DON) stated R30 should have been recognized as a significant weight loss in 6 months. During an interview on 2/12/25 at 1:05 p.m., the administrator stated assessments were expected to be completed accurately to ensure accurate care planning and interventions were implemented to either stabilize weight and/or to prevent further weight loss. The facility policy Resident Assessment Minimum Data Set (MDS revised 1/2025, identified assessments will be completed by staff qualified and knowledgeable to assess a specific care area. Assessments would be coded accurately to correctly assess medical, functional, and psychosocial problems and strengths to develop person-centered care plans and interventions to maintain and improve status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to develop a baseline care plan to ensure immediate resident needs were identified and addressed for 1 of 4 residents (R211) whom were newly admitted . Findings include: R211's Discharge summary dated [DATE], identified R211 was hospitalized for acute blood loss anemia and acute knee pain due to gout. R211's bleeding resolved and was restarted on anticoagulant medications as well as gout medications to treat his left knee pain. R211's progress note dated 1/24/25, identified R21 arrived at the facility to be admitted . R21 had a foley catheter in place, which would remain until his urology appointment in March. R21 had experienced a lot of falls at home prior to admission and would need assist of one and walker with ambulation. On 2/11/25, at 8:14 a.m. R211 was observed sitting in a recliner watching television in his room. The door to the room was open and R211's foley catheter bag was visible attached to the side of his recliner. R211's medical record lacked evidence a baseline care plan had been developed to ensure staff were knowledgeable in R211's care needs despite R211 having an indwelling foley catheter, need for enhanced barrier precautions, and need for assistance with activities of daily living (ADLs) and mobility. When interviewed on 2/12/25, at 12:43 p.m. the director of nursing (DON) stated they were unable to locate a baseline care plan for R211. It was the facility's practice to have a baseline care plan completed for all residents within 48 hours of their admission. A baseline care plan was important as it identified a resident's care needs and how to care for each resident. The facility's undated Baseline Care Plan policy, identified the facility would develop a baseline care plan within 48 hours of admission. The care plan would include at minimum initial goals, physician orders, dietary orders, therapy services, social services, PASARR recommendations, instructions to provide effective and person centered care, address resident health and safety concerns to prevent decline or injury and identify needs for supervision, behavioral interventions and assistance with ADL's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed identify enhanced barrier precautions (EBP) interventions for 1 of 1 resident (R18) reviewed with a surgical wound. Findings include: R18's admission minimum data set (MDS) dated [DATE], identified R18 was admitted on [DATE], was cognitively intact and was receiving surgical wound care. R18's orders report dated 1/24/25, identified staff were to monitor R18's dressing placement and for signs and symptoms of infection such as increased redness, warmth, swelling, drainage, or generalized fever over 101. Staff were to notify the charge nurse so they could notify the provider. R18's care plan revised 2/12/25, identified R18 recently had a hip replacement and required staff to complete dressing changes and monitor and report any signs or symptoms of infection. The plan further identified R18 required assist of one staff for transfers, toileting and dressing. However, the plan failed to address R18's need for EBP. During observation on 2/10/25 at 7:06 p.m., there was no personal protection equipment (PPE) cart near or inside R18's room. Further, there was no sign directing staff to wear PPE during dressing changes or cares. On 2/12/25 at 7:33 a.m., RN-C was observed in R18's room and changing R18's dressing. Observation of the dressing identified a dark red spot, approximately 1-inch in diameter in the middle area of the outside of the dressing. While wearing gloves, RN-C removed R18's dressing and stated there was an area on the distal end of the incision that appeared to be a fluid filled bubble/blister. RN-C stated the skin around the distal end appeared to be darker red although was not warm to touch. RN-C cleansed and reapplied a dressing to the wound. RN-C stated the wound looked worse than the other day and thought it may be starting to get infected. RN-C did not apply or wear a gown during the dressing change. On 2/12/25 at 12:32 p.m., RN-C stated upon R18's admission she was told by the infection preventionist, staff did not need to wear PPE while providing wound care. RN-C stated she worked with multiple residents during the day and had the potential to carry bacteria on her clothing. RN-C stated wearing PPE would help prevent the spread of bacteria to/from herself and the resident. RN-C stated she had not worn PPE including a gown when she cared for the wound or changed R18's dressing. The Care Plan policy reviewed 4/2015, identified a care plan started on the day of admission, was reviewed every 90 days and would be updated as needed. The care plan included what kind of services were needed, who provided the services and how the care plan would help the resident reach their goals of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to revise and update a comprehensive care plan for 1 of 3 residents (R10) reviewed for weight loss. Findings include: R10's quarterly minimum data set (MDS) dated [DATE], identified R10 was cognitively intact and required set-up assistance for eating, and had a weight loss that was not a physician-prescribed weight-loss regimen. R10's progress notes, identified the following: - 10/16/24, registered dietician (RD)-A identified R10 weighed 115 lbs. and had been drinking a nutritional supplement daily. RD-A's recommendations included staff to offer and provide high calorie, high protein shakes. - 11/5/24 RD-A identified R10's weight had been stable for one week and recommendations included high caloric foods per patient request and continue to follow up and monitor weights. - 11/12/24 RD-A identified staff were to provide alternate meals upon request, offer high calorie/high protein shakes, food items to help promote weight gain, and to monitor intake and weights weekly. R10's care plan dated 4/3/24, identified R10 had a potential for alteration in nutrition. Interventions included staff to offer a regular diet, thin liquids and assist with meal set up. Further interventions included weights as ordered, offer food alternatives as needed, and offer snacks two times per day. The plan failed to identify individualized interventions for weekly weights, weekly intake documentation and options for high calorie, high protein foods to help promote weight gain as recommended by the RD. On 2/11/25 at 12:42 p.m., RD-A stated in R10 weighed 125 lbs. on August 9, 2024 and had lost by November 18, 2024 10 weighed 110 lbs., a weight loss of 15 lbs. in 3 months. RD-A stated a significant change assessment was completed on 10/16/24. RD-A had talked with R10 about a plan to increase her weight and recommendations included higher calorie/higher protein shakes and continue with the nutritional supplement. RD-A stated in December 2024, documentation of weekly meal intakes and weights were recommended. R10's care plan failed to identify the recommendations. During an interview on 2/12/25 at 1:05 p.m., the administrator stated staff were expected to complete accurate assessments to aid in care planning and implementing interventions to either stabilize weight or to prevent loss. The Care Plan policy reviewed 4/2015, identified a care plan started on the day of admission, was reviewed every 90 days and would be updated as needed. The care plan included what kind of services were needed, who provided the services and how the care plan would help the resident reach their goals of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a bed was kept in the low position to prevent falls for 1 of 2 residents (R40) reviewed for falls. Findings include: R40's Falls Risk assessment dated [DATE], identified R40 was at high risk for falls. R40's quarterly Minimum Data Set (MDS) dated [DATE], identified R40 had moderate cognitive impairment and a diagnosis of unspecified convulsions. R40 required substantial/maximal assistance to roll left and right. R40's care plan revised 12/19/24, identified R40 had decreased physical mobility with potential for falls related to lower extremity weakness, impaired mobility related to general muscle weakness and poor coordination manifested by inability to transfer, wheel self, turn and reposition self, sit up, lie down or get feet and legs into bed independently. R40 was unable to ambulate. The care plan directed to follow fall interventions as listed in nursing orders. R40's nursing order dated 2/6/25, identified R40's fall interventions included a contour mattress with cutout, low bed, mats at bedside and anti-tip bars to wheelchair. During an observation on 2/11/25 a 9:04 a.m., registered nurse (RN)-B and nursing assistant (NA)-A transferred R40 into bed using a full body mechanical lift. The bed was approximately 3.5 feet (ft) high. NA-A pulled R40's privacy closed and began assisting R40's roommate on the other side. RN-B pulled the full body mechanical lift from the room. However, R40's bed was left in an elevated position and was not in the view of staff. - At 9:14 a.m., NA-B stepped into the room and asked NA-A if she needed help. NA-B stated NA-A could provide incontinence care to R40. NA-B looked into R40's dresser drawer for supplies and stated she needed to leave the room to find more. However, R40's bed remained in an elevated position and was not in view of staff. - At 9:19 a.m., NA-B returned to the room and provided incontinence care to R40. R40's bed was lowered to the floor and R40 was given her call light. During an interview on 2/11/25 at 9:29 a.m., NA-B stated R40 was kind of high risk for falls. R40 rolled out of bed and staff thought it was because R40 had a seizure. NA-B stated she had never seen R40 roll ever but R40 should not have been left unattended in an elevated bed because she could have another seizure. During an interview on 2/12/25 at 8:44 a.m., RN-C stated R40 was a fall risk due to a history of seizures. R40 was care planned for a low bed and floor mats to prevent falls and/or injury. R40 should not have been left unattended in an elevated bed. During an interview on 2/12/25 at 12:17 p.m., the director of nursing (DON) stated R40 should not have been left unattended in an elevated bed for safety to prevent falls. During an interview on 2/12/25 at 1:01 p.m., the administrator stated staff were expected to follow care planned intervention for safety. The facility policy Fall Prevention revised 3/2022, identified the facility would identify residents who were at high risk for falls and develop individual fall precautions for those residents to prevent falls and fall related injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to prevent weight loss for 1 of 3 residents (R30); and failed to implement assessess nutrition interventions to prevent further weight loss for 1 of 3 residents (R10) reviewed for nutrition. Findings include: R30: R30's quarterly MDS dated [DATE], identified R30 had severe cognitive impairment and diagnoses included diabetes, hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), chronic kidney disease, dysphasia (difficulty swallowing food or liquids) and aphasia (a comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain). R30's weight was 153 pounds (lbs) and R30 had no loss of 5% or more in the last month or loss of 10% or more in last 6 months. R30's Mini Nutrition assessment dated [DATE], identified the registered dietician would continue R30's current plan of care and monitor weights monthly. Intake would be assessed regularly to ensure that nutrient needs were being met. Laboratory values would be reviewed for trends, and interventions would be adjusted as necessary. R30 would not trigger for any significant weight changes as evidenced by a 5% change in 30 days or 10% change in 180 days. The RD would continue to monitor weights monthly and reassess quarterly or as needed if significant changes in weight, intake, or health status occurred. R30's care plan revised 2/7/25, identified R30 had a potential for alteration in nutrition related to diabetes, hemiplegia of right side, heart disease and depression. The care plan directed to provide a regular diet, set up tray, open and pour liquids, butter bread, cut meat and arrange food then R40 was independent in eating. Weigh as ordered. Offer alternates as needed. Offer snacks two times a day. R30's weights identified the following: - 7/14/24 172.5 lbs - 7/21/24 157.6 lbs - 7/28/24 154.7 lbs - 7/30/24170.6 lbs - 8/9/24 171 lbs - 8/16/24 171 lbs - 8/23/24 167.2 lbs - 8/30/24 164 lbs - 8/30/24 207 lbs - 9/6/24 164.4 lbs - 9/13/24 162.8 lbs - 9/20/24 162 lbs - 9/27/24 165 lbs - 10/11/24 164 lbs - 10/18/24 165 lbs - 10/25/24 164.6 lbs - 11/1/24 164 lbs - 11/15/24 162.2 lbs - 11/22/24 160 lbs - 12/6/24 158 lbs - 12/13/24 156.7 lbs - 12/20/24 156 lbs - 1/3/25 153.3 lbs - 2/7/25 146.8 lbs This identified R30's weight loss was 25.7 lbs or 14.89 percent (%) in 6 months. R30's Nutrition assessment dated [DATE], failed to identify weight Loss of 5% or more in the last month or loss of 10% or more in last 6 months. R30's meal intakes identified the following: - 7/14/24 dinner 76-100% - 7/15/24 breakfast 26-50% and dinner 26-50% - 7/16/24 breakfast 51-75% and 26-50%; dinner 1-25% - 7/17/24 breakfast 1-25%, dinner 1-25% - 7/20/24 breakfast 1-25%, dinner 1-25% - 7/21/24 breakfast none, dinner 1-25% - 7/23/24 breakfast 26-50% - 7/24/24 breakfast 26-50%, dinner 76-100% - 7/25/24 breakfast 26-50%, dinner 1-25% - 7/26/24 breakfast 51-75%, dinner 1-25% -7/27/24 breakfast 51-75% - 7/29/24 breakfast 51-75%, dinner 1-25% - 7/30/24 breakfast 51-75%, dinner 1-25% - 8/2/24 breakfast 51-75%, lunch 1-25%, dinner 76-100% - 8/8/24 dinner 76-100% - 8/9/24 breakfast 1-25%, lunch 51-75% and dinner 1-25% - 8/13/24 lunch 1-25%, dinner 26-50% - 8/14/24 breakfast 51-75%, lunch 1-25%, dinner 1-25% - 8/19/24 dinner none - 8/20/24 dinner 51-75% - 8/21/24 breakfast 1-25% - 8/22/24 lunch none - 8/23/24 breakfast 26-50%, lunch 1-25% - 8/24/24 breakfast 26-50%, lunch 1-25% - 8/28/24 breakfast 26-50% - 8/31/24 dinner 1-25%- - 9/1/24 breakfast 1-25%, lunch 26-50% - 9/3/24 dinner 1-25% - 9/3/24 dinner 1-25% - 9/5/24 breakfast 76-100% - 9/8/24 breakfast 1-25% - 9/13/24 breakfast 1-25%, lunch 76-100% - 9/18/24 dinner 26-50% - 9/23/24 dinner 51-75% - 9/26/24 dinner 76-100% - 9/27/24 breakfast 1-25% - 9/29/24 dinner 51-75% - 10/1/24 dinner 76-100% - 10/6/24 breakfast 51-75% - 10/10/24 breakfast 51-75% - 10/17/24 lunch 51-75% -10/18/24 dinner 26-50% - 10/20/24 dinner 26-50% - 10/25/24 dinner 26-50% - 10/30/24 breakfast 26-50%, lunch 76-100% -11/2/24 breakfast 1-25% - 11/9/24 breakfast 26-50%, lunch 26-50% - 11/10/24 breakfast 76-100% - 11/18/24 breakfast 1-25%, lunch 51-75% - 11/19/24 lunch 26-50% - 11/21/24 dinner 51-75% - 11/22/24 dinner 26-50% - 11/26/24 breakfast 51-75%, lunch 76-100% - 11/27/24 breakfast 76-100% - 11/29/24 breakfast 1-25% - 11/30/24 breakfast 26-50% - 12/1/24 breakfast 51-75%, lunch 51-75% - 12/4/24 lunch 76-100% - 12/9/24 breakfast 76-100%, lunch 76-100% - 12/10/24 breakfast 26-50% - 12/11/24 breakfast 1-25%, dinner 1-25% - 12/12/24 breakfast 76-100%, lunch 1-25%, dinner 51-75% - 12/13/24 breakfast 51-75%, lunch 76-100% - 12/14/24 breakfast 76-100%, lunch 26-50% - 12/15/24 breakfast 51-75%, lunch 1-25% - 12/16/24 breakfast 26-50%, lunch 26-50%, dinner 51-75% - 12/17/24 breakfast 51-75%, lunch 51-75% - 12/18/24 breakfast 51-75%, lunch 51-75% - 12/19/24 lunch 51-75% - 12/20/24 breakfast 1-25%, lunch 1-25% - 12/23/24 breakfast 51-75%, lunch 26-50% - 12/24/24 breakfast 51-75% - 12/25/24 breakfast 51-75%, lunch 26-50% - 12/26/24 dinner 76-100% - 12/27/24 breakfast 51-75%, lunch 26-50% - 12/28/24 lunch 1-25%, dinner 26-50% - 12/29/24 breakfast 76-100%, lunch 51-75% - 12/30/24 breakfast 26-50%, lunch 1-25% - 12/31/24 breakfast 51-75% - 1/2/25 breakfast 51-75%, lunch 26-50% - 1/3/25 breakfast 51-75%lunch 26-50% - 1/4/25 dinner 1-25% - 1/5/25 lunch 51-75% - 1/6/25 breakfast 1-25% - 1/10/25 lunch 76-100% - 1/11/25 breakfast 26-50% - 1/14/25 dinner 76-100% - 1/15/25 breakfast 1-25% - 1/17/25 breakfast 1-25%, lunch 26-50% - 1/18/25 breakfast 51-75%, lunch 26-50% - 1/21/25 breakfast 51-75%, lunch 76-100% - 1/24/25 breakfast 51-75%, lunch 51-75% - 1/26/25 breakfast not taken - 1/27/25 breakfast 1-25% - 1/29/25 breakfast none, dinner 51-75% - 1/30/25 breakfast 26+-50%, - 1/31/25 breakfast none, lunch 1-25% - 2/1/25 breakfast 1-25% - 2/2/25 breakfast 1-25% - 2/725 breakfast none, lunch 26-50% - 2/10/25 breakfast 51-75%, lunch 1-25%, dinner 51-75% - 2/11/25 breakfast 76-100%, lunch 26-50% - 2/12/25 breakfast 1-25% During an observation on 2/10/25 at 11:59 a.m., R30 was assisted in her wheelchair to the dining room to wait for her lunch meal. R30 was given a cup of tea, a glass of milk and a glass of water. - At 12:41 p.m., R30 was served her lunch meal of chicken ala king over a buttered biscuit, parsley carrots and fruit salad. R30 had tea, water and milk to drink. - At 12:47 p.m., trained medication aide (TMA)-A asked R30 if she was going to eat. R30 shook her head no and TMA-A stated ok and walked away. - At 12:49 pm., nursing assistant (NA)-C asked R30 if she would at least eat her dessert. R30 nodded her head yes and NA-C brought R30 a cup of fruit salad. R30 ate the fruit salad but no other part of her meal. During an observation on 2/10/25 at 6:10 p.m., R30 was sitting in her wheelchair at the dining room table but R30 was asleep. R30 dinner meal of fried potatoes, hamburger steak and peas with carrots was in front of R30. R30 had eaten the peas with carrots but other part of her meal. NA-D approached R30 and asked if she was done eating. R30 nodded yes and NA-D assisted R30 from the dining room. NA-D did not encourage R30 to eat more or offered to assist R30. During an observation on 2/11/25 at 12:22 p.m., R30 was sitting in her wheelchair at the dining room table. R30 had her lunch meal of shepherd's pie, peas and pudding in front of R30. R30 had eaten a few bites of her meal. No staff offered to assist R30 or encouraged R30 to eat more. During an interview with the registered dietician (RD)-A and dietary manager (DM)-A on 2/11/25 at 1:10 p.m., RD-A stated she was unable to speak with R30 for R30's quarterly assessment so RD-A spoke with staff about R30. R30 had difficulty with self-feeding and the nursing assistants explained they didn't always help R30, but they were always watching R30 from a distance. If R30 had difficulty with a meal, the nursing assistant would approach R30 and offer assistance. Limited self-feeding happened so staff needed to be there proactively. RD-A stated when she pulled the report for R30's weights, it did not show R30 had a significant weight loss. RD-A stated weight entries were not documented consistently, and this played a factor as well. Inconsistency was also identified with meal intakes. For example, if a resident did not want breakfast but requested a banana, staff should not document the resident ate 100% of their meal. RD-A stated the weekly weights and meal intakes were so important because the assessment would not be accurate due to either a lack of information or inaccurate information. RD-A stated she has explained this to nursing through email and during R30's care conference. If I see something I let them know, but if they do it or not is out of my control. RD-A stated she relied on nursing staff to also identify weight loss or gain when entering weight into the medical record and to obtain a re-weigh. RD-A stated finger foods were also recommended for R30, and shepherd's pie would be harder for R30 to eat independently. Staff wanted to encourage the nursing assistants to monitor meals and make sure every resident received foods that would allow the most independence. Residents could not or would not always verbalize the need for help. RD-A stated she did bring R30 to the quality assurance and performance improvement (QAPI) meeting because R30's weights were constantly fluctuating, however, RD-A stated she did not recognize R30 had had a significant weight loss. During an interview on 2/12/25 at 8:47 a.m., RN-C stated the facility changed the process of weights from weekly to monthly at the beginning of the year. Some residents were weekly depending on need, and some were daily. Nursing and dietary monitored residents' weights to ensure no resident had either lost or gained too much weight in a period. The nursing assistants collected the meal percentages. They wrote the percentages on a sheet and then the nurse entered it into the computer. RN-C stated she knew R30 lost about 30 lbs since her admission and staff did try to assist R30 but R30 was just a picky eater and would only eat what R30 wanted to eat. RN-C stated the percentage of the meal eaten reflected what was gone from the resident's plate. For example, if the resident only wanted a banana that was 100% of the meal. During an interview on 2/12/25 at 9:33 a.m., RN-D stated R30 did have a significant weight loss that should have been recognized, and interventions care planned to either stabilized R30's weight or to prevent further weight loss. During an interview with the director of nursing (DON) and RN-A on 2/12/25 at 12:21 p.m., the DON stated, staff should have recognized R30's significant weight loss and implemented interventions to either promote the stabilization of R30's weight or to prevent further loss. R10: R10's quarterly MDS dated [DATE], identified R10 was cognitively intact, required set-up assistance for eating, and had a weight loss that was not a physician-prescribed weight-loss regimen. R10's mini nutritional assessment dated [DATE], identified a nutritional risk score of 6.0 and identified R10 as malnourished. Risk factors included weight loss of 3.2 and 6.6 lbs. during the last 3 months, no change in food intake, was bed or chair bound, had suffered psychological stress or acute distress in the past months, and had a BMI less than 19. R10's weights identified the following: - 1/6/25 108 lbs. - 12/30/24 107 lbs. - 12/23/24 107 lbs. - 12/2/24 110 lbs. - 11/25/24 110 lbs. - 11/18/24 110 lbs. - 11/11/24 112 lbs. - 11/4/24 112 lbs. - 10/21/24 109 lbs. - 10/14/25 115 lbs. - 10/12/24 115 lbs. - 10/11/24 114 lbs. - 10/10/24 115 lbs. - 9/30/24 114 lbs. - 9/23/24 112 lbs. - 9/20/24 111 lbs. - 9/19/24 114 lbs. - 9/2/24 114 lbs. - 8/30/24 116 lbs. - 8/29/24 117 lbs. - 8/28/24 118 lbs. - 8/27/24 119 lbs. - 8/26/24 117 lbs. - 8/25/24 118 lbs. - 8/23/24 118 lbs. - 8/21/24 119 lbs. - 8/20/24 120 lbs. - 8/19/24 121 lbs. - 8/16/24 122 lbs. - 8/15/24 123 lbs. - 8/9/24 125 lbs. - 8/8/24 126 lbs. - 8/4/24 123 lbs. R10's Nutrition MDS assessment dated [DATE], identified R10 weighed 107 lbs. and had a weight loss of 5% or more in the past month, or a loss of 10% or more in the last 6 months and was not a physician-prescribed weight-loss regimen. R10's progress notes, identified the following: - On 10/16/24, registered dietician (RD)-A identified R10 weighed 115 lbs. and had been drinking a nutritional supplement daily. RD-A's recommendations included staff to offer and provide high calorie, high protein shakes. - On 11/5/24 RD-A identified R10's weight had been stable for one week and recommendations included high caloric foods per patient request and continue to follow up and monitor weights. - On 11/12/24 RD-A identified staff were to provide alternate meals upon request, offer high calorie/high protein shakes, food items to help promote weight gain, and to monitor intake and weights weekly. R10's care plan dated 4/3/24, identified R10 had a potential for alteration in nutrition. Interventions included staff to offer a regular diet, thin liquids and assist with meal set up. Further interventions included weighs as ordered, offer food alternatives as needed, and offer snacks two times per day. The plan failed to identify individualized interventions for weekly weights, weekly intake documentation and options for high calorie, high protein foods to help promote weight gain as recommended by the RD. On 2/12/25 at 9:29 a.m., R10 was seated at a dining room table and had the morning meal in front of her that included two slices of toast and a glass of juice. At 10:01 a.m., R10 was observed leaving the dining room. R10 had eaten 3/4th of the toast and drank the juice. On 2/12/25 9:25 a.m., licensed practical nurse (LPN)-C stated she would document morning meal intake for the residents that ate in the dining room. LPN-C stated she knew what the residents normally ate for their morning meal and would mark the intakes accordingly. LPN-C stated R10 usually had two slices of dry toast and juice every morning and would mark 100% intake when R10 ate all her meal. On 2/11/25 at 12:42 p.m., RD-A stated in R10 weighed 125 lbs. on August 9, 2024 and had lost by November 18, 2024 10 weighed 110 lbs., a weight loss of 15 lbs. in 3 months. RD-A stated a significant change assessment was completed on 10/16/24. RD-A had talked with R10 about a plan to increase her weight and recommendations included higher calorie/higher protein shakes and continue with the nutritional supplement. RD-A stated in December 2024, documentation of weekly meal intakes and weights were recommended. R10's care plan failed to identify the recommendations. On 2/12/25 at 9:58 a.m., nursing assistant (NA)-I stated the nurses would let NAs know when a resident needed to be weighed. The NA's told the nurses the weight and the nurses would document in the chart. On 2/12/25 at 11:50 a.m., LPN-B stated weights used to be done on bath days but that had recently changed and was uncertain why. LPN-B stated when a resident needed to be weighed, she would let the NAs know, they would weigh the resident and report the weight back to the nurse. If there was a 5 lb. weight difference from the previous weight LPN-B stated she would re-weigh the resident herself and would contact the provider if needed. On 2/12/25 at 12:05 p.m., LPN-A residents used to be weighed on bath days but that had recently changed. LPN-A stated she was uncertain why it had changed. LPN-A stated the nurse that received the weight would document in the resident's chart and follow up as needed. LPN-A stated the RD would follow the resident's weight whenever there was a weight loss. The RD would recommend interventions including nutritional supplement, high protein/high calorie shakes and/or supplements ans sometimes snacks between meals. The RD would communicate the recommendations to the unit manager. The unit manager would add the recommendations to the care plan and notify staff. LPN-A was uncertain if any of these interventions were recommended for R10. Further, LPN-A stated R10's weight should have been monitored weekly. During an interview with the DON and RN-A on 2/12/25 at 12:21 p.m., the DON stated staff were expected to collect weights per facility policy, and to document meal intakes accurately. During an interview on 2/12/25 at 1:05 p.m., the administrator stated staff were expected to collect weights according to facility policy, accurately document meal intakes and to complete accurate assessments to aid in care planning and implementing interventions to either stabilize weight or to prevent loss. The Interventions for Unintended Weight Loss policy dated 2019, identified unintended weight loss or gradual weight loss would be identified and monitored so that appropriate and individualized interventions could be implemented. The facility policy Weighing a Resident revised 1/20/25, identified all residents would be weighed on admission and at least monthly while they are in the nursing home. Monthly weights will be done the first seven days of each month. A. Tell the resident what you are going to do. B. Take the resident to the scale or bring Medi-lift to resident's room. C. Check to be sure the scale is balanced. (Allow the scale time to balance - wait until the scale reads 0) If using the Media-lift scale, balance the scale to zero with sling prior to getting resident into sling. D. Ask the resident to step on the scale. Read the weight indicated on the screen of the scale. If you use Medi-lift scale, press the weight button after resident is in sling. E. Record the weight in the designated spot. NOTE: 1. If it is necessary to weigh a resident with braces, an artificial limb, or clothing, a note should be made on the record that the brace or clothing is included in the weight. 2. A resident may be weighed in a WC or on a platform balance scale. In this case, weigh the chair first and write down the weight. Then weigh the resident in the chair. Write this down. Take the weight of the resident and the chair and subtract the weight of the chair to get the weight of the resident. 3. When weighing a resident in a WC it is important that the WC is wheeled forward enough so that the platform is off the floor. 4. If the resident has oxygen or anti-rollback on their W/C it should be noted as well. 5. If a resident's weight needs to be monitored more closely, they will be set up as indicated. Such as weekly weights for weight loss or daily weights for fluid status monitoring. The facility policy Interventions for Unintended Weight Loss dated 2019, identified uintended weight loss or gradual weight loss will be identified and monitored so that appropriate and individualized intervention can be implemented. Patients/residents will be weighed upon admission or readmission, weekly for the first 4 weeks after admission, and at least monthly thereafter to help identify and document weight trends. Weekly weights may be ordered due to a significant change in condition, if food intake has declined and persisted (e.g., for more than a week), or there is other evidence of altered nutritional status or fluid and electrolyte imbalance. Factors that may impact weight and the significance of apparent weight changes include: a. Usual weight through adult life b. Current medical condition c. Therapeutic diet d. Calorie restricted diet or calorie-enhanced diet e. Recent changes in food or fluid intake f. Edema g. Dehydration Staff will follow a consistent approach to weighing and use an appropriately calibrated and functioning scale (e.g., wheelchair scale or bed scale). Since weight varies throughout the day, a consistent process and technique (e.g., weighing the patient/resident wearing a similar type of clothing, at approximately the same time of the day, using the same scale, either consistently wearing or not wearing orthotics or prostheses, and verifying scale accuracy) can help make weight comparisons more reliable. The facility policy Method To Determine Percent of Meal Eaten reviewed 4/2015, identified the following: 1. Count the number of nutritious items served at the meal. Do not count: desserts (unless fruits), coffee, tea, Jello, Jello salad, broth, donut, sweet roll, cake, and pie. 2. Figure the amount of food consumed of each item that counts from above: None eaten = 0 points ¼ eaten = .25 points ½ eaten = .5 points ¾ eaten = .75 points All eaten = 1 point 3. Total the number of points eaten. 4. Divide the number of points eaten by the number of points served and multiple by 100 to obtain the percentage of the meal eaten.

Based on interview and document review, the facility failed to ensure a complete medical record was maintained to include the physician reviewed orders, treatments and care plans during routine visits for 1 of 2 residents (R7) reviewed during medication administration. Findings include: R7's undated Resident Face Sheet identified admission date 6/13/24. Diagnoses included epilepsy, diabetes, pain, autistic disorder, fibromyalgia and chronic kidney disease. R7's Physician Order Report dated 10/7/24 to 1/7/25, lacked complete orders. The signed physician order report identified 12 ordered medications on page one and two of the documents. Of the 12 orders, only nine were legible as the document had faded and incomplete printed areas over the pages. R7's activities of daily living (ADL) order with start date 8/15/20, appeared to order a non-pharmaceutical intervention for pain, however, was illegible as the scanning was faded and incomplete in areas. Pages three and four of the order report were not available. When interviewed on 2/12/25, at 11:52 a.m. the medical records staff member (MR)-F stated she was unable to locate the full four-page Physician Order Report dated 10/7/24 through 1/7/25. MR-F usually checked the documents after she scanned them into the resident's medical records to ensure the document was legible. MR-F stated she must have missed checking R7's physician report and she was unsure why only two pages of the four-page document was scanned. It should have been the full four pages as there were more orders on the missing pages. During interview on 2/12/25, at 12:00 p.m. the director of nursing (DON) confirmed they were unable to locate the complete four-page Physician Order Report for R7's medical record. The facility policy Doctors Review and Renewal Policy revised 4/2015, identified the physician's progress notes would be stamped each visit, and the physician would sign that the plan of care was reviewed, including resident care plan, medications, treatments and all other orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R39: R39's quarterly MDS dated [DATE], identified R39 had a severe cognitive impairment and included a diagnosis of dementia. R39 exhibited no hallucinations, delusions or behaviors during the assessment period. R39's medical record identified R39 was evaluated by a medical provider on 6/25/24, 8/21/24, 11/5/24 and 1/15/25. During an interview on 2/12/25 at 12:00 p.m., MR-F stated she was responsible for the facility's medical records. MR-F stated she was responsible to figure out when a resident was last seen then schedule a follow up visit every 60 days with the resident's provider. There was a 10-day grace period as well, but the resident must be seen by day 70. R39 was seen on 8/21/24 but not again until 11/5/24 which was 76 days. MR-F stated she did not start her role until January 2025 and could not say why R39 was not seen timely. After 11/5/24, R39 was seen again on 1/15/25 which was 71 days. MR-F stated R39 was scheduled on 1/8/25 but for some reason that was cancelled. MR-F stated she was new to her role at that time and must have mistakenly counted days when the appointment was rescheduled for 1/15/25. It just slipped through my fingers. During an interview on 2/12/25 at 12:31 p.m., the DON stated the facility needed to ensure timely physician visits occurred to ensure appropriate resident care was provided. During an interview on 2/12/25 at 1:14 p.m., the administrator stated staff were expected to ensure timely physician visits occurred. The facility policy Doctors Review and Renewal Policy revised 4/2015, identified the following: A. The resident must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The physician's progress notes should be stamped each visit and the physician sign that he has reviewed the plan of care including resident care plan, meds, treatments, and all other orders. B. A physician visit will be considered timely if it occurs not later than 10 days after the date the visit was required. C. If any resident is receiving physical therapy, they must be seen by their physician every 30 days and orders reviewed. D. If a resident is on Medicare they must be seen by their physician every 30 days and orders reviewed. E. Medications, orders and plan of care must be RENEWED by the physician at least every 90 days. The computer sheet will be generated at these times and the physician will review, sign, and date to renew the orders. F. On new admits and hospital returns all MD orders are to be computer generated the first time the MD rounds. Based on interview and document review, the facility failed to ensure long term residents received routine physician visits every 60 days as required for 2 of 2 residents (R7, R39) reviewed during medication administration. Findings include: R7: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition. Diagnoses included epilepsy, diabetes, pain, autistic disorder, polyneuropathy, fibromyalgia, conduct disorder, and chronic kidney disease. R7's medical record identified R7 had physician visits for his primary care on 7/26/24 and 1/8/25. R7's medical record lacked documentation of routine 60 day visits for 165 days, from 7/26/24 to 1/8/25. During interview on 2/12/25, at 11:52 a.m. the medical record staff (MR)-F stated she was only able to find documentation of physician visits July 25, 2024 and January 8, 2024. It appeared a visit had been scheduled in September and November 2024, however the visits were not completed or billed. MR-F thought they must have been canceled for some reason. A joint interview was conducted with consultant registered nurse (RN)-A and the director of nursing (DON), 2/12/25, at 12:00 p.m. RN-A stated R7's primary physician stopped rounding at the facility and had also canceled R7's medical appointments the facility had scheduled. R7 had agreed to change to a different primary physician and then was seen by that physician in January, so the facility hoped to continue regularly scheduled visits from that point on. RN-A stated R7 had not been seen for recertification visits every 60 days and it was the facility's usual practice to have established residents seen every 60 days to be re-certified as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to comprehensively assess and implement interventions for identified behaviors for 1 of 3 residents (R17) reviewed for dementia care. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 had a severe cognitive impairment, R39 used antipsychotic medication daily and exhibited no hallucinations, delusions or behaviors during the assessment period and had a diagnosis of dementia. R39's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 8/21/24, identfiied R38 was unable to complete BIMS interview. R39 was at risk for alteration in thought process with potential for anxiety, falls, and decreased mobility related to cognitive decline secondary to unspecified dementia.Would proceed to anticpate R39 needs and intervene when making poor decisions. R39's care plan revised 11/26/24, identified R39 had alteration in thought process with potential for anxiety related dementia and nursing home placement manifested by impaired cognition. Staff were directed to reorient and validate as needed. Staff would anticipate and meet needs, provide cues and supervision when making poor decisions, and intervene as needed. R39 was not to leave facility unattended. Explain all procedures before doing them. Approach in an unhurried calm manner. Offer information regarding schedules, routines, locations, and services as R39 and family need. Encourage family and or friends to visit or maintain usual contact. R39's nursing progress notes identified the following: - 1/21/25 at 3:06 a.m., R39 had been yelling out all night. When asked if R39 needed anything R39 stated get out of my room you b**ch. R39 continued to yell you b**ch over and over for about half an hour after this nurse left the room. When the aide went in to try calm R39, R39 yelled at her to get out as well. R39 was unable to be consoled and continued to yell in her room despite every effort to give her what she could need. - 1/21/25 at 11:39 a.m., R39 slapped a staff member across the face with cares. R39 had been yelling at staff constantly - 1/22/25 at 2:23 a.m., R39 was awake most of the night yelling out. When staff entered the room, R39 told her to get out of my room! R39 had had her as needed (PRN) Zyprexa (an antipsychotic medication) earlier in the day and was not available to give again. This behavior continued throughout the night until around 3:00 a.m. - 1/22/25 at 1:51 p.m., R39 got up for breakfast without complaint. R39 then stayed up in her wheelchair and wheeled herself around with some talking to herself. Between 11:00 a.m. to 12:00 p.m., R39 was yelling to herself in her room I want to lay down but no one to help me. Help. R39 was not using the call light at this time. The nursing assistant (NA) asked to bring R39 to lunch and R39 said no. Writer asked R39 again about 15 minutes later and R39 still did not want to come to lunch. R39 was assisted to lie down, and staff saved her lunch meal for when R39 was hungry. - 1/23/25 at 2:25 a.m., R39 was awake yelling out again tonight. Attempted to talk with R39 and asked if R39 was hungry, R39 stated that she was and that she would like some toast. This nurse made R39 some toast and gave R39 some apple juice. R39 continued to yell, appearing to be talking to people in the room trying to get them to try the toast as it was the best thing R39 had tasted in years. R39 was upset that they wouldn't try the toast. (There was no one in the room with her) After R39 finished her toast and juice R39 continued to yell out. PRN Zyprexa was given. Will continue to monitor. - 1/23/25 at 4:54 a.m., R39 finally settled and fell asleep around 4:00 a.m. - 1/28/25 at 2:59 a.m., R39 slept fairly well. R39 did holler out a few times during the night and was talking loudly. R39 had a shower last night on the evening shift and was very upset. - 1/30/25 at 2:43 p.m., R39 did not need her PRN Zyprexa this shift. R39 got up for both meals. R39 was yelling for help in room between breakfast and lunch, writer helped R39 change sweaters, that was what R39 was asking for help with. R39 then went to music at activities for a short time. R39 yelled out loud to herself minimally this shift. - 2/2/25 at 2:31 a.m., R39 refused her bedtime medication. PRN Zyprexa given. R39 too half the medication and refused to finish. R39 kicked and pinched staff. - 2/4/25 at 2:39 a.m., R39 was very agitated and hollering out. Talking about going to school and R39 would be late if she did not get to the bus. Unable to redirect R39. PRN Zyprexa given for agitation. - 2/4/25 at 5:08 a.m., R39 sleeping. Was no longer hollering out or agitated about 30 minutes after PRN Zyprexa was given. - 2/6/25 at 4:54 a.m., R39 slept well all night. Continued to holler at staff when they come in to give medication or reposition/change her, but as soon as staff left, R39 was calm and quiet again. - 2/8/25 at 3:10 a.m., R39 was yelling out all shift. PRN Zyprexa was attempted to be administered but R39 refused to take. - 2/11/25 at 5:29 a.m., R39 slept well throughout the night. R39 started hollering nonstop at around 5:00 a.m. this morning. Unable to redirect. R39 was given PRN Zyprexa. R39's medical record lacked any assessment into R39's distress and behaviors and implementation of specific interventions. R39's Physician orders identified the following: - 12/18/24, identified Zyprexa (olanzapine) (an antipsychotic medication) 5 milligram (mg) tablet. Give 1 tablet by mouth once a day in the morning. - 1/21/25, Zyprexa 2.5 mg tablets. Give 2.5 mg by mouth once a day as needed. Used for behaviors. Add note when given. Okay to stand until next face to face visit. - 1/21/25, Zyprexa 2.5 mg tablets. Give 2.5 mg by mouth once a day as needed. Used for behaviors. Add note when given. Okay to stand until next face to face visit. Saff were to monitor behavior and document every shift. R39 needed her PRN Zyprexa put a note In for the doctor. If R39 was lethargic, notify the charge nurse. - 1/28/25, Zyprexa 5 mg tablet. Give 1.5 tablet by mouth once a day in the evening. R39's electronic medication administration record (EMAR) dated January 2025, identified R39 received Zyprexa 2. 5mg PRN on the following days; - On 1/23/25 at 2:36 a.m. for other - On 1/25/25 at 4:13 p.m. for behavior issues yelling at table R39's EMAR dated February 2025, identified R39 received Zyprexa 2.5 mg PRN on the following days: - On 2/1/25 at 11:37 p.m. for behavior issue refused all bedtime (HS) meds - On 2/4/25 at 2:38 a.m. for other agitation - On 2/11/25 at 5:40 a.m. for other agitation at 5 am. There was no evidence of non pharmological interventions attempted prior to the administration of Zyprexa and what the result was of the medication. During a continuous observation on 2/10/25 at 6:15 p.m., R39 was sitting in her room in her wheelchair next to her bed with an overbed table against the wall in front of her. R39 had her hairbrush in her hands and was pulling on the bristles. R39 repeatedly stated I don't care. breakfast, whatever. R39 was wearing a dark blue cardigan sweater over a gown, black slippers and a blanket across her lap. - At 6:19 p.m., R39 loudly sang I don't know what that is and oh my bra they took it off because I don't need one. R39 could be clearly heard five rooms away. - At 6:40 p.m., R39 turned her wheelchair to face her bed. R39 repeatedly stated I want my bed, I don't know, are you helpless?, yes, yes, I am, I don't want the chair over there I want it over here where I can sit on it, I don't know who put it over there, I don't know what's going on. I have nothing on my feet besides my shoes. I have socks but I don't know how to put them on and you should, yes, you should. - At 6:42 p.m., well I just don't I have socks right here and I just don't know how to put them on, didn't you ever dress yourself?, I don't know, do you know nothing? - At 6:44 p.m., help me get my socks on, are you helpless?, yes, I am. R39 began weeping. Oh, I don't like it either. I don't like being helpless. - At 6:50 p.m., R39 continued hollering. Trained medication aide (TMA)-B pushed the medication cart up against the wall outside R39's door but did not redirect R39. R39 loudly sang ooohhhhhhh, I don't know what to dooooooo. Cooome and help meeeeeeeeeee. Take my shoes off. TMA-B was directly outside R39's room and did not respond. Oh, are you that helpless!?! Yes, I am. Didn't you ever dress yourself? No, my mother dressed me. - At 6:52 p.m., TMA-B administered R39 her bedtime medication. However, TMA-B did not offer R39 toileting, repositioning or to lie down. TMA-B exited the room and R39 began hollering again. - At 6:56 p.m., What do I got to do now? Go to bed in your clothes. What do you know? Nothing! - At 6:56 p.m., R39 was crying. I don't know how to do things. Who put you to bed last night? Nobody. I didn't go to bed. Are you helpless? Yes, I am. My mother never showed me how. You poor child. - At 7:04 p.m., the social worker (SS)-A approached R39 and stated Hi, did you have any chocolate today? SS-A continued to reminisce with R39 about family. SS-A offered R39 a drink of water and R39 took a drink. SS-A asked R39 if she wanted to lie down and R39 stated yes. SS-A turned on R39's call light, reassured R39 someone would assist her to bed and left the room. - At 7:09 p.m., R39 began hollering. How did I get so helpless? Have you always been so helpless? I guess so. My mother did everything. - At 7:11 p.m., just climb into bed. I'll fall on my face in between. No, you won't. How do you know that? You're not that bad. - At 7:14 p.m., NA-E entered R39's room and asked R39 if she needed something because R39's call light was on. I don't know. NA-E turned off R39's call light and told R39 if she remembered what she needed to press her call light. NA-E left the room. R39 immediately started hollering. Oh, my legs hurt. I just want to go to bed. - At 7:23 p.m., NA-F entered R39's and assisted R39 to bed. R39 was quiet after lying down. During an interview on 2/10/25 at 7:33 p.m., NA-F stated R39 hollered a lot. R39 was impatient and would holler out when R39 wanted something. NA-F stated she was too busy, and this was the first chance she had to assist R39 to bed. R39 did not get along with a lot of people and NA-F was responsible to put her to bed that shift. R39 would swat you. R39 didn't mean it but would hit. NA-F stated once R39 laid down R39 would be quiet the rest of the night. During an interview on 2/10/25 at 7:38 p.m., TMA-B stated R39 hollered like that every day. R39 hallucinated all day long and R39 believed she was sitting with people and talking to them. R39 sang I don't know all day long. Staff tried to talk to her and bring her to activities or to watch tv but R39 didn't like that stuff. R39 liked to stay in bed but staff had to get her up for meals. TMA-B During an interview on 2/11/25 at 10:16 a.m., NA-G stated R39 yelled a lot. Staff could ask R39 what she wanted and sometimes R39 would say and other times R39 wouldn't. During an interview on 2/11/25 at 4:14 p.m., TMA-B stated R39 did have a PRN dose of Zyprexa that could be used once a day for R39's behaviors. Before giving, TMA-B had to talk to the charge nurse who assessed R39. The charge nurse could give the PRN dose of Zyprexa but most of the time the charge nurse told the TMA to do it. TMA-B stated there were no non-pharmacological interventions to try first. Staff just needed to tell the charge nurse what was going on so the charge nurse could assess the behavior. During an interview on 2/11/25 at 4:16 p.m., RN-E stated, for behaviors, she would assess the situation and try to diffuse the R39's agitation. If that didn't work, RN-E would check to see the last time the PRN Zyprexa was used and would administer the medication. RN-E redirect like conversation, find something common, calm, reminiscing, RN-E did not know R39 well and would have to ask the staff who would know R39 better what interventions worked best. RN-E stated R39's care plan really didn't direct specific interventions about R39's behaviors. As an employee, RN-E stated she expected the care plan be more resident centered and have triggers and interventions identified to either prevent behaviors or to calm R39 so R39 would not need that PRN medication. During an interview on 2/12/25 at 7:13 a.m., NA-H stated R39's behaviors had no rhyme or reason that NA-H could think of. If R39's son came to visit, R39 would be calm but then got worked up again when he left. You can try every intervention you can think of and then if you try too long, R39 would become combative. R39 had a stuffed puppy that she liked and would help R39 stay calm. Also, if a man came into the dining room, R39 would scream at him to leave. During an observation in the dining room on 2/12/25 at 7:27 a.m., R39 was reading aloud from the conversational starter on her table. A male resident from another unit came into the dining room to talk to another female resident and R39 yelled you get out of here! The male resident did not respond but left the dining room shortly after. During an interview on 2/12/25 at 8:55 a.m., RN-C stated there was no rhyme or reason to R39's behaviors. RN-C stated there were no unique resident-centered interventions care planned R39's behaviors and staff should attempt non-pharmacological interventions before giving an antipsychotic medication. Staff were also expected to document all behaviors and attempts at redirection for monitoring. During an interview on 2/12/25 at 12:31 p.m., the director of nursing (DON) stated staff were expected to find something for R39 to do, go on walks, out of her room, get her up or lie her down. The behaviors often occurred in the dining room prior to meals and R39 was in the dining room way before the meal started. Staff should offer a snack, a drink. The DON stated R39's care plan should have interventions that are individualized to R39's behaviors so staff could identify triggers and have resources to try to prevent R39's behaviors or to calm R39. During an interview on 2/12/25 at 1:14 p.m., the administrator stated the care plan should show specific resident centered care plan to promote non-pharmacological interventions to prevent behaviors. Staff were expected to follow the care plans. A facility policy regarding dementia care was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure as needed medication from facility standing orders were transcribed and administered appropriately to reduce the risk of complications for 1 of 1 resident (R56) reviewed for loose stools. Findings include: R56's admission Minimum Data Set (MDS) dated [DATE], identified R56 had mild cognitive impairment and was continent of both bowel and bladder with no constipation present. A diagnosis of diarrhea was included. R56's Medication Administration Record (MAR) dated 2/1/25 to 2/10/25, identified loperamide (an antidiarrheal) OTC (over the counter) medication was added on 2/5/25. Instructions were for loperamide 2 milligrams (mg) to be administered four times per day for diarrhea. Special instructions instructed to give 2 mg of the medication after each loose stool, not to exceed 8 mg in a 24-hour period. The medication was scheduled to be given every day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. Staff initialed the medication administration as administered as follows: - 2/5/24 at 12:00 p.m. the 4:00 p.m. and 8:00 p.m. scheduled doses were documented as resident refused. - 2/6/25, the medication was administered at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. - 2/7/25, the medication was administered at 8:00 a.m. The 12:00 p.m., 4:00 p.m., and 8:00 p.m. scheduled doses were documented as resident refused. - 2/8/25, the medication was administered at 9:00 p.m. The 8:00 a.m., 12:00 p.m., and 4:00 p.m., scheduled doses were documented as resident refused. - 2/9/25, the medication was administered at 8:00 a.m., and 12:00 p.m. with the 4:00 p.m. and 8:00 p.m. scheduled doses refused. A notation was made in the MAR, R56 had stated she should not be taking loperamide four times per day and did not want it. - 2/10/25, the medication was refused at 8:00 a.m., 12:00 p.m., and 4:00 p.m. The medication was discontinued after 4:00 p.m. R56's bowel monitoring record identified R56 had four bowel movements on 2/5/25, a medium bowel movement on 2/6/25, and two medium bowel movements on 2/9/25. When interviewed on 2/10/25, at 5:57 p.m. R56 stated she had loose stools on 2/5/25, then her stools were fairly normal. R56 stated she only took the loperamide two times after the first loose stool on 2/5/25 and that did the trick. The nurses mentioned something about taking it four times per day and R56 told the nurse there was no way she was taking it that often. R56 told the nurses she should not be taking loperamide like that and should only take it when it was needed after a loose stool. R56 indicated she never took any more of the loperamide after the two initial doses on 2/5/25 and refused it after that. During interview on 2/11/25, at 4:47 p.m. licensed practical nurse (LPN)-B stated the loperamide order was transcribed from the facility standing orders and should not have scheduled times for administration. The medication was to be given for a loose stool and so should have been transcribed on to the MAR as a one-time order from standing orders. Then if needed to be given again, would need to be re-entered onto the MAR again and each time it was needed. R56 did not have a physician order for as needed (PRN) loperamide and so when taking it from the facility's standing orders would be a one-time only medication administration. When interviewed on 2/11/25, at 5:05 p.m., the director of nursing (DON) stated she had spoken with R56 who denied having loose stools and so the DON questioned why R56 was still receiving scheduled loperamide. The DON contacted R56's primary provider and had the medication discontinued. The DON stated if the loperamide order was transcribed from the facility's standing orders, the medication should not have been scheduled with administration times. The medication should have been identified as PRN on the resident's MAR. The medication was transcribed to the MAR incorrectly and therefore, lead to medication errors as well. Medication errors occurred each time the medication had been given on the scheduled times. If R56 had been experiencing loose stools for that amount of time, the provider should have been notified. It was the facility's policy to notify the provider if a resident was having four or more loose stools in a 24-hour period. When interviewed on 2/12/25, at 9:30 p.m., LPN-D stated on 2/5/25, she had entered the loperamide order on R56's MAR from the facility's standing orders in order to administer R56 the medication for complaints of loose stools. LPN-D indicated the medication should have been identified as PRN and not scheduled four times per day. LPN-D thought she must not have pressed the PRN button and so the medication had not been recorded on R56's MAR correctly. The facility's policy Medication Discrepancies revised 4/2015, identified a goal to ensure safe administration of all medications to residents. Medication discrepancies included medications given at the wrong time, a PRN medication given sooner than the physician's stated order, or an order transcribed incorrectly,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations were acted upon, addressed, and documented in the medical record for 1 of 5 residents (R51) reviewed for unnecessary medication use. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 had intact cognition. Diagnoses included paroxysmal atrial fibrillation, heart disease, and secondary hypertension. R5's Physician Order Report signed 10/9/24, identified R5's current medication regimen with their corresponding start dates and included the following: Eliquis (an anticoagulant) 2.5 milligrams (mg) two times per day, aspirin (reduces the formation of blood clots) 81 mg every day, and Diltiazem (to prevent chest pain) 120 mg every day. R5's Consultant Pharmacist's Medication Review dated August 2024, identified R5's medication regimen had been reviewed by the consulting pharmacist (CP) and listed an irregularity regarding the medication Diltiazem. The CP comment included concomitant use of Diltiazem with oral anticoagulants such as Eliquis was associated with higher bleeding risk. A suggested course of action was listed to consider reassessing risks vs. benefits of using Diltiazem. There was no recorded response from the physician on either accepting the recommendation or rejecting it despite the follow up implementation time frame for the physician to address ASAP (as soon as possible) but no later than 30 days. R5's Consultant Pharmacist's Medication Review dated October 2024, identified R5's medication regimen had been reviewed by the consulting pharmacist (CP) and listed an irregularity regarding the medication Diltiazem. The CP comment included concomitant use of Diltiazem with oral anticoagulants such as Eliquis was associated with higher bleeding risk. An additional comment was added the CP had not found a response to his August recommendation and so was renewing the recommendation again. A suggested course of action was listed to consider reassessing risks vs. benefits of using Diltiazem. There was no recorded response from the physician on either accepting the recommendation or rejecting it despite the follow up implementation time frame for the physician to address ASAP (as soon as possible) but no later than 30 days. R5's medical record lacked evidence the consulting pharmacist's recommendation on R5's Diltiazem dose irregularity had been forwarded, reviewed and/or acted upon by the physician despite the recommendation being made both in August and October and R5 continued to receive the medication which had been identified as a potential for increased risk of bleeding, with need for close monitoring for signs of bleeding. When interviewed on 2/12/25, at 12:00 p.m. the director of nursing (DON) stated she was unable to find the provider's response to the CP's recommendations. The DON was responsible to ensure the physician reviewed the recommendations. When pharmacy recommendations were received, she sorted them into physician rounding and fax for non-rounding physicians. Sometimes the physician would take the CP recommendation forms back to the clinic for further review and did not always return them. The DON was working on a new process to ensure recommendations were being followed up on. The expectation was to have the physician address all pharmacy recommendations within 14 days. The facility policy Pharmacy Service Medication Regimen Review dated 10/2022, identified the consultant pharmacist would review the medication regimen of each resident at least monthly to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications. The pharmacist would provide a written report to the DIN within 3 business days of completing the monthly review. Copies of the report would be provided to the DON, the patient's attending physician and the facility's medical director. Recommendations would be acted upon and documented by the facility staff and/or the prescriber. The physician would accept and act upon suggestions or reject and provide an explanation for disagreeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide a face-to-face provider evaluation for continued use of a as needed (PRN) psychotropic medication for 1 of 2 residents (R39) reviewed for mood/behavior. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 had severe cognitive impairment. R39 used antipsychotic medication daily and exhibited no hallucinations, delusions or behaviors during the assessment period. R39 had a diagnosis of dementia. R39's Physician order dated 1/21/25, identified Zyprexa (olanzapine) (an antipsychotic medication) 2.5 milligram (mg) tablets. Give 2.5 mg by mouth once a day as needed. Used for behaviors. Add note when given. Okay to stand until next face to face visit. R39's electronic medication administration record (EMAR) dated January 2025, identified R39 received Zyprexa 2. 5mg PRN on the following days; - On 1/23/25 at 2:36 a.m. for other - On 1/25/25 at 4:13 p.m. for behavior issues yelling at table R39's EMAR dated February 2025, identified R39 received Zyprexa 2.5 mg PRN on the following days: - On 2/1/25 at 11:37 p.m. for behavior issue refused all bedtime (HS) meds - On 2/4/25 at 2:38 a.m. for other agitation - On 2/11/25 at 5:40 a.m. for other agitation at 5 am. R39's medical record 1/22/25 through 2/12/25, failed to identify R39's physician failed to document the rationale and duration of need for PRN antipsychotic medication. During an interview on 2/11/25 at 5:05 p.m., the director of nursing (DON) stated PRN antipsychotic medications should be re-evaluated by the physician every 14 days with a documented rationale and duration for use. During an interview on 2/12/25 at 1:14 p.m., the administrator stated staff were expected to ensure PRN antipsychotic medication rationale and duration for use was clearly documented to ensure appropriate use. The facility's Psychotropic Medication Monitoring Policy and Procedure reviewed 6/2023, identified orders for PRN psychotropic medications would be given only for specific, clearly documented circumstances. PRN psychotropic medications require a face-to-face assessment by the prescribing provider 14 days after initiating of the new medication. Specific target behaviors and interventions will be listed for PRN psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 1 resident (R211) reviewed for catheter care; and 1 of 1 resident (R18) reviewed with a surgical wound. Findings include: A CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) manual, dated 7/2022, identified MDRO transmission within a nursing home was common and contributed to substantial resident morbidity and mortality. The feature outlined EBP were defined as, . expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The feature identified several examples of high-contact resident care activities including dressing, bathing, providing hygiene, transferring, changing linens or briefs, and wound care. R211: R211's admission Minimum Data Set (MDS) dated [DATE], identified R211 was cognitively intact. R211 required maximum assistance with dressing and transfers and moderate assistance with toileting. R211 had an indwelling foley catheter with a diagnosis of retention of urine. R211's care plan with revision date 2/12/25, identified enhanced barrier precautions were needed due to the indwelling foley catheter. On 2/10/25 at 6:15 p.m., R18's room was observed and there was no personal protective equipment (PPE) cart in or near R18's room. Further, there was no sign posted outside R18's room identifying R18 was on EBP. On 2/10/25, at 6:45 p.m. R211 was observed seated in a recliner in reclined position in his room. Nursing assistant (NA)-J entered the room and assisted R211 to stand and ambulate to the side of his bed. NA-J with gloved hands transferred, removed clothing, assisted to wash up and position R211's catheter leg bag on to the bed. At no time did NA-J wear a gown. On 2/10/25, at 7:37 p.m. registered nurse (RN)-F entered R211's room. RN-F stated the facility did not allow residents to sleep at night with leg bags as the urine would not drain properly. RN-F changed R211's beg bag to a leg bag maintaining proper hand hygiene ; however, RN-F failed to wear a gown for EBP requirements. When interviewed on 2/10/25, at 7:45 p.m. RN-F stated it was not the facility's practice to initiate EBP with standard catheter care. EBP would only be initiated if the resident had some type of infection. The facility initiated EBP with all residents with wounds or supra pubic catheter care, but not for standard catheter care, or colostomies. If staff were required to do EBP with resident care, there would be signage on the resident's door to indicate that and R211 did not have any signage in his room. On 2/11/25, at 2:55 p.m. NA-J assisted R211 with toileting cares. Although NA-J used proper hand hygiene with glove use, NA-J failed to wear a gown when assisting R211 with toileting cares. When interviewed on 2/11/25, at 3:00 p.m. NA-J stated she had not worn EBP when she had assisted R211 to the bathroom. Staff only had to wear EBP when working with R211's catheter or when providing peri care. NA-J assisted R211 to the bathroom but had not grabbed a washcloth and washed him up, so had not really provided peri care. NA-J had wiped R211's peri area with toilet paper to clean after his bowel movement when she assisted him off the toilet. That may have constituted peri care, and she should have been wearing a gown while assisting him with toileting. During interview on 2/12/25, at 8:56 a.m. infection preventionist licensed practical nurse (LPN)-A stated EBP was required for all residents with wounds, gastrostomy tubes, and foley catheters. The residents did not have signage on their doors to identify if EBP was required. Staff knew which residents required EBP as it was identified on the resident's care sheet and was also passed along during shift report. Staff were required to wear gown and gloves for EBP whenever working with a resident's foley catheter and should have been wearing EBP when changing a foley catheter leg bag to a collection bed bag. During interview on 2/12/25, at 12:00 p.m. the director of nursing (DON) stated it was the facility's expectation for staff to use EBP for foley catheter care as well as peri care with all residents with wounds or invasive medical devices. Staff were trained on EBP during their orientation on hire and at all staff meetings. Residents who required EBP during care were identified on staff care sheets and a gown was required for all close contact personal care. R18: R18's admission MDS dated [DATE], identified R18 was admitted on [DATE], was cognitively intact and was receiving surgical wound care. R18's care plan revised 2/12/25, identified R18 recently had a hip replacement and required staff to complete dressing changes and monitor and report any signs or symptoms of infection. The plan further identified R18 required assist of 1 staff for transfers, toileting and dressing. However, the plan failed to address R18's need for contact and/or EBP. R18's orders report dated 1/24/25, identified the following: - Right hip: monitor dressing placement and monitor for any signs and symptoms of infection such as increased redness, warmth, swelling, drainage, or generalized fever over 101. Notify charge nurse if noted so that provider can be notified. During observation on 2/10/25 at 7:06 p.m., there was no PPE cart near or inside R18's room. Further, there was no sign directing staff to wear PPE during dressing changes or cares R18's orders report dated 1/24/25, identified staff were to monitor R18's dressing placement and for signs and symptoms of infection such as increased redness, warmth, swelling, drainage, or generalized fever over 101. Staff were to notify the charge nurse so they could notify the provider. R18's care plan revised 2/12/25, identified R18 recently had a hip replacement and required staff to complete dressing changes and monitor and report any signs or symptoms of infection. The plan further identified R18 required assist of one staff for transfers, toileting and dressing. However, the plan failed to address R18's need for EBP. During observation on 2/10/25 at 7:06 p.m., there was no personal protection equipment (PPE) cart near or inside R18's room. Further, there was no sign directing staff to wear PPE during dressing changes or cares. On 2/11/25 at 10:10 a.m., registered nurse (RN)-C was in R18's room and assisted R18 to lay down in bed. Wearing gloves, RN-C assessed the area around R18's surgical dressing by touching and stated the dressing was intact with no drainage outside of the dressing. The skin around the dressing was a little warm to touch. RN-C failed to wear a gown while assessing R18's surgical wound. On 2/12/25 at 7:33 a.m., RN-C was observed in R18's room and changing R18's dressing. Observation of the dressing identified a dark red spot, approximately 1-inch in diameter in the middle area of the outside of the dressing. While wearing gloves, RN-C removed R18's dressing and stated there was an area on the distal end of the incision that appeared to be a fluid filled bubble/blister. RN-C stated the skin around the distal end appeared to be darker red although was not warm to touch. RN-C cleansed and reapplied a dressing to the wound. RN-C stated the wound looked worse than the other day and thought it may be starting to get infected. RN-C did not apply or wear a gown during the dressing change. On 2/12/25 at 12:15 p.m., licensed practical nurse (LPN)-A stated staff were to wear PPE during direct patient care for residents that had catheters, tubes and open wounds that required a dressing change, including surgical wounds. LPN-A stated R18 should have been placed in EBP because the wound was open and draining. Further, LPN-A stated all staff should wear a gown and gloves when providing direct patient care or working with or changing a wound dressing. On 2/12/25 at 12:32 p.m., RN-C stated upon R18's admission she was told by the infection preventionist, staff did not need to wear PPE while providing wound care. RN-C stated she worked with multiple residents during the day and had the potential to carry bacteria on her clothing. RN-C stated wearing PPE would help prevent the spread of bacteria to/from herself and the resident. RN-C stated she had not worn PPE including a gown when she cared for the wound or changed R18's dressing. The facility Enhanced Barrier Precautions policy dated 11/2024, identified EBP expanded the use of PPE and referred to the use of gown and gloves during high-contact resident care activities that provided opportunities for transfer of multidrug-resistant organisms (MDRO)'s to staff hands and clothing. MDRO's may be indirectly transferred from resident to resident during high contact care activities. Residents with wounds and indwelling medical devices are at an especially high risk of both acquisition of and colonization with MDRO's. The policy further identified EBP would be implemented for residents with wounds and/or indwelling medical devices during high-contact resident care activities regardless of MDRO infection or colonization. High risk care activities included device care or use, and wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to have a system in place to ensure water temperatures were maintained a comfortable temperature for 2 of 13 residents (R22 ,R45) who resided on Maple Lane unit reviewed for complaints of cold-water temperatures. This had the potential to affect all 13 residents residing who resided on Maple Lane unit. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], identified R22 had severe cognitive impairment and was dependent on staff for bathing, dressing and grooming. R45's quarterly MDS dated [DATE], identified R45 had moderate cognitive impairment and was independent with dressing and grooming and required supervision with bathing. During interview on 2/10/25, at 1:45 p.m. family member (FM)-H stated R22 did not have hot water in his room. Staff had to take R22 to another wing in the facility for his showers as there wasn't any hot water on the wing R22 resided. FM-H felt it was terrible the residents had to wash up in cold water and were carted down two halls half naked for their showers. During interview on 2/10/25, at 6:23 p.m. R45 stated the water never got hot in their sink. It was always lukewarm at best. They washed up the best they could and had to take their showers on the other wing. On 2/11/25, at 8:14 a.m. licensed practical nurse (LPN)-B was observed running water at the end of the resident hallway in the facility's sunshine conference room. LPN-B stated running the water in the sink helped to get hot water going to the resident rooms in the wing. At 9:15 a.m. the continuously running water in the sink remained a cool tepid temperature to the touch. During interview on 2/11/25, at 3:48 p.m. maintenance director (M)-A stated the facility installed a new hot water heater in November 2024 alongside the exiting water heaters, and he thought that had corrected the problem until now. M-A had only just learned of the lack of hot water on the Maple Lane unit the day prior and had called a local heating and plumbing to come out, however, they would not be able to come until the following week. M-A had done a few water temperatures that day and had ranged 93 to 98 degrees, so the temperatures were a little under what they should be. M-A stated hot water temperatures should be at maximum temperature of 115 degrees. M-A did not have a consistent process for monitoring the water temperatures. On 2/11/25, at 5:09 p.m. LPN-B stated she reported the cold-water issues to maintenance a few times over the past couple of months. Staff filled out their requests to maintenance in the maintenance logbook on each wing. The maintenance staff would pick up the forms and she did not know what happened to them after that. There were no copies made of the requests. The current maintenance book for the wing was reviewed and had several blank maintenance requests forms, however, no current requests were documented. The maintenance book failed to identify staff requests for hot water on Maple Lane. On 2/12/25, at 8:32 a.m. M-A was observed testing the water temperature at the end of resident's hall Maple Lane. The hot water had been running five minutes prior to test. The temperature of the running hot water at the sink registered 89.7 degrees. M-A stated he only did hot water tests when he had complaints about the hot water, and he had only gotten complaints two days prior. M-A stated he thought the aides had been bringing residents from Maple Lane to another resident wing to take their showers as the showers on Maple Lane did not work. Hot water issues had been coming up from time to time. MD-A thought the old plumbing was causing the issues and so the facility kept getting sporadic cold water that showed up for a day or so. During interview on 2/12/25, at 12:00 p.m. the director of nursing (DON) stated the facility had ongoing hot water issues on the south wing and were doing their best to correct the problem. DON thought it was something to do with the piping and would possibly requiring tearing into some walls to fix the plumbing. A joint interview was conducted with administrator, owner and registered nurse (RN)-A on 2/12/25 at 1:56 p.m., the administrator stated there were ongoing concerns with the water temperature that were discussed during the quality assurance and performance improvement (QAPI) meeting. A new water heater had been installed but that had not resolved the issue. They called in the previous facility director who had also given them some direction on what to try to resolve the issue. Also, the administrator had started a new process for maintenance requests because it had become apparent staff were making verbal requests that could not be verified. A binder was placed on each unit for maintenance requests. That way, the administrator was able to audit those requests and ensure they were followed up on. A policy on water temperature management was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to notify the physician of a change in condition for 1 of 3 residents (R1) who was sleeping more than usual, not eating and not taking medications. Findings include: R1's Resident Face Sheet identified diagnosis that included dementia with behavioral disturbance, depression, hypertensive kidney disease, open wound and agitation. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she displayed no rejection of care behaviors during the basement period. The MDS indicated R1 was able to eat independently after set up and weighed 116 pounds. R1's care plan dated 3/25/24, identified a self care deficit related to dementia and decreased physical mobility. The care plan indicated R1 did not ambulate and required assist of two staff for transfers. The care plan identified an alteration in nutrition related to a poor appetite at times, pain and cognitive dysfunction. The care plan indicated R1 was able to feed herself after set up and directed staff to assist with eating and cues as needed, weigh as ordered and protein shakes with every meal. R1's Resident Progress Notes indicated the following: -5/24/24, R1's family member (FM)-A called in regard to R1 and her medications. FM-A stated she did not like the way R1 was on her current medication (Zyprexa) and would like to have it discontinued or changed to something else. FM-A stated that she was not able to understand R1's speech, and that she was not eating. Discussed in morning meeting where it was stated that they should probably have a care conference for R1 with FM-A to discuss further. Spoke to administrator who said next week. -5/25/24, R1's FM-A was in to visit and left immediately upset that she was in her room sleeping. Spoke to all staff about it and it was reported that she had been sleeping most of the day. Staff reported that the day staff said R1 wouldn't wake up even during cares and licensed practical nurse said R1 wouldn't wake up to take her medication that morning and it had been attempted multiple times. R1 was not up for lunch. When writer went in with staff R1 woke up and was cooperative with her brief change which had a small BM and the brief was dry. She had not received any medications due to sleepiness. 5/26/24, received order from physician to send R1 for evaluation, lethargic and not eating. R1's Resident Transfer Form dated 5/26/24, indicated unscheduled discharge to hospital due to level of consciousness decline. Hospital paperwork dated 5/26/24 indicated R1 presented to the emergency department after FM noted she was more somnolent and deconditioned. FM stated the nursing home told her R1 had been significantly more drowsy over the last several days/weeks, had been sleeping longer and refusing to eat or drink any water. The History and Physical identified encephalopathy likely secondary to chronic hypernatremia as well as deconditioning and sever calorie protein . and UTI. Urinalysis showed many bacteria, significant change from prior. The following lab work was performed: Sodium level of 162 milliequivalents per liter (mEq/L), A normal blood sodium level is between 135 and 145 (mEq/L). (Symptoms of hyponatremia can include nausea and vomiting, loss of energy and confusion. Serious hyponatremia can cause seizures, coma and even death.) Acute Kidney Injury (AKI), which is significant for her (AKI is defined as an abrupt (within hours) decrease in kidney function, which encompasses both injury (structural damage) and impairment). During interview on 5/31/24 at 11:31 a.m., FM-A said at baseline R1 could communicate and said she was not always accurate but could be understood and R1 could eat independently. FM-A said she had called the facility and kept saying something wasn't right. FM-A stated she felt R1 was not feeding herself because of the medication and the facility had not been feeding her. FM-A stated last Thursday (5/23/24) she went to the facility and R1 looked near death and said she looked so bad FM-A knew something wasn't right. FM-A said that was in the evening and nobody knew anything so she called Friday and was told they would do a care conference on Tuesday. FM-A said she she went back to the facility on Saturday evening and R1 was in bed and said the staff told her R1 had been in bed since the staff member had gotten there at 2:00 p.m. FM-A stated she went back again on Sunday and R1 was in her chair and could not hold her own head up. FM-A said she told the nurse something was wrong and the nurse asked her if she wanted R1 sent to the hospital, then told her the hospital would just say it was R1's dementia causing the decline. FM-A said when R1 got to the hospital she was seriously dehydrated and her sodium level was through the roof. During interview on 6/4/24 at 7:31 a.m., physician (P)-A stated the last time she had seen R1 was on 4/9/24 for a hospital discharge follow up and said her lab work was fine at that time. P-A stated R1's labs always seemed to be perfect and said in general R1 slept in the mornings because her nighttime routine was a little skewed. P-A reviewed R1's hospital record and said all her labs were skewed and she could tell she was severely dehydrated. P-A said typically when R1 was up she was very social and said when R1 was healthy she saw her eat. P-A stated maybe the facility had been seeing a decline but it didn't give them the okay to not address safety, not getting up and not eating or drinking. P-A said she had not heard anything about R1's status since she had last seen her in April other than behaviors. During interview on 6/4/24 at 1:56 p.m., trained medication aide (TMA)-A stated R1's intake was poor and she only took bites here and there but she received a supplement that she was good about drinking. TMA-A said recently R1 had been sleeping a lot more and not waking for her medications. During interview on 6/4/24 at 2:20 p.m. registered nurse (RN)-A stated R1 had been declining over the last month and said, more behaviors. RN-A said R1 was sleepy but sated that was not abnormal. RN-A stated FM-A had come to the facility on Sunday and had also been there the day before. RN-A said staff had been utilizing an as needed medication regularly and said she felt like it may have been making R1 a little more sleepy. RN-A stated she felt FM-A was so upset because she had a hard time coming to terms with the health decline. On 6/4/24 at 4:36 p.m. the director of nursing (DON) and administrator were interviewed. The DON stated RN-A had noticed R1 had a change of condition on Friday and asked what she should do. The DON said she had said they should set up a care conference. The administrator stated RN-A talked about R1 pouring her drinks in her food and said it was unusual and said R1 was discussed in the morning interdisciplinary team meeting. The administrator stated she had been seeing a big change in R1 also. The DON stated when staff identified R1's change of condition they should have updated the provider. Facility policy Notification to Physician/Family/Responsible Representative, dated 10/17/21, indicated physicians, responsible family members or legal representatives shall be notified, in a timely manner, of any changes in the resident's condition. The policy indicated when there is a change in resident status or condition, the charge nurse must evaluate the resident, obtain vital signs, and document findings in the resident's electronic medical record. The charge nurse will notify the assistant director of nursing or DON on call of the situation or change in condition as soon as possible. The physician will be notified as follows: If the change requires the immediate care of a physician, attempts will be made at contacting the primary care provider or on call Provider for treatment recommendation or, an order to transfer to the ER if the resident change in not life threatening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to identify and assess for a change of condition for 1 of 3 residents (R1) who began sleeping more, missing medications due to sleep and not drinking/eating regularly. Additionally, R1's family member had to voice concerns regarding deteriorating health condition for initiation of hospital transfer. Findings include: R1's Resident Face Sheet identified diagnosis that included dementia with behavioral disturbance, depression, hypertensive kidney disease, open wound and agitation. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she displayed no rejection of care behaviors during the basement period. The MDS indicated R1 was able to eat independently after set up and weighed 116 pounds. R1's care plan dated 3/25/24, identified a self care deficit related to dementia and decreased physical mobility. The care plan indicated R1 did not ambulate and required assist of two staff for transfers. The care plan identified an altered thought process and directed staff to encourage family to voice questions and concerns. The care plan further identified and alteration in nutrition related to a poor appetite at times, pain and cognitive dysfunction. The care plan indicated R1 was able to feed herself after set up and directed staff to assist with eating and cues as needed, weigh as ordered and protein shakes with every meal. R1's Resident Progress Notes indicated the following: -5/24/24, R1's family member (FM)-A called in regard to R1 and her medications. FM-A stated she did not like the way R1 was on her current medication (Zyprexa) and would like to have it discontinued or changed to something else. FM-A stated that she was not able to understand R1's speech, and that she was not eating. Discussed in morning meeting where it was stated that they should probably have a care conference for R1 with FM-A to discuss further. Spoke to administrator who said next week. -5/25/24, R1's FM-A was in to visit and left immediately upset that R1 was in her room sleeping. Spoke to all staff about it and it was reported that R1 had been sleeping most of the day. She did have cares completed and was dressed on top but had her brief on the bottom. Staff reported that the day staff said R1 wouldn't wake up even during cares and licensed practical nurse said R1 wouldn't wake up to take her medication this morning and it was attempted multiple times. R1 was not up for lunch. When writer went in with staff R1 woke up and was cooperative with her brief change which had a small BM and the brief was dry. She had not received any medications due to sleepiness. -5/26/24, received order from physician to send R1 for evaluation, lethargic and not eating. R1's Resident Transfer Form dated 5/26/24, indicated unscheduled discharge to hospital due to level of consciousness decline. Care Conference Review dated 5/28/24, indicated family member (FM)-A was frustrated because R1 had significantly declined in the past two weeks and she had received very little communication. FM-A advocated for R1 to be sent to the emergency department on Saturday and felt the staff working didn't think she should send her. R1's Hospital admission History and Physical Note dated 5/26/24, indicated R1 presented to the emergency department after FM noted she was more somnolent and deconditioned. FM stated the nursing home told her R1 had been significantly more drowsy over the last several days/weeks, had been sleeping longer and refusing to eat or drink any water. The H and P identified encephalopathy likely secondary to chronic hypernatremia as well as decondition and sever calorie protein . and UTI. Urinalysis showed many bacteria, significant change from prior. The following lab work was performed: Sodium level of 162 milliequivalents per liter (mEq/L), A normal blood sodium level is between 135 and 145 (mEq/L). (Symptoms of hyponatremia can include nausea and vomiting, loss of energy and confusion. Serious hyponatremia can cause seizures, coma and even death.) Acute Kidney Injury (AKI), which is significant for her (AKI is defined as an abrupt (within hours) decrease in kidney function, which encompasses both injury (structural damage) and impairment). During interview on 5/31/24 at 11:31 a.m. FM-A stated for the past month facility staff had been claiming R1's behaviors were increasing and they wanted to put her on behavior medication. FM-A stated she told them she was concerned that R1 would be in a zombie state. FM-A said at baseline R1 could communicate and said she was not always accurate but could be understood and R1 could eat independently. FM-A stated the facility kept increasing her doses and R1 was not feeding herself. FM-A said she called the facility and kept saying something wasn't right. FM-A stated she felt R1 was not feeding herself because of the medication and said the facility had not been feeding her. FM-A stated last Thursday (5/23/24) she went to the facility and R1 looked near death and said she looked so bad FM-A knew something wasn't right. FM-A said that was in the evening and nobody knew anything so she called Friday and was told they would do a care conference on Tuesday. FM-A said she she went back to the facility on Saturday evening and R1 was in bed and said the staff told her R1 had been in bed since the staff member had gotten there at 2:00 p.m. FM-A stated she went back again on Sunday and R1 was in her chair and could not hold her own head up. FM-A said she told the nurse something was wrong and the nurse asked her if she wanted R1 sent to the hospital, then told her the hospital would just say it was R1's dementia causing the decline. FM-A said when R1 got to the hospital she was seriously dehydrated and her sodium level was through the roof. During interview on 6/4/24 at 7:31 a.m., physician (P)-A R1 was 80 some years old and had a significant wound on her hip. P-A stated the last time she had seen R1 was on 4/9/24 for a hospital discharge follow up and said her lab work was fine at that time. P-A stated R1's labs always seemed to be perfect and said in general R1 slept in the mornings because her nighttime routine was a little skewed. P-A reviewed R1's hospital record and said all her labs were skewed and she could tell she was severely dehydrated. P-A said typically when R1 was up she was very social and said when R1 was healthy she saw her eat. P-A stated maybe the facility was seeing a decline but said it didn't give them the okay to not address safety, not getting up and not eating or drinking. P-A said she had not heard anything about R1's status since she had last seen her in April other than behaviors. P-A said R1 weighed 106 pounds when she admitted to the hospital. During interview on 6/4/24 at 1:56 p.m., trained medication aide (TMA)-A stated R1's intake was poor and she only took bites here and there but she received a supplement that she was good about drinking. TMA-A said recently R1 had been sleeping a lot more and not waking for her medications. During interview on 6/4/24 at 2:20 p.m. registered nurse (RN)-A stated R1 had been declining over the last month and said, more behaviors. RN-A said R1 was sleepy but sated that was not abnormal. RN-A stated FM-A had come to the facility on Sunday and had also been there the day before. RN-A said she told FM-A they could send R1 to the hospital but told her it may not change the outcome. RN-A said staff had been utilizing an as needed medication regularly and said she felt like it may have been making R1 a little more sleepy. RN-A stated she felt FM-A was so upset because she had a hard time coming to terms with the health decline. On 6/4/24 at 4:36 p.m. the director of nursing (DON) and administrator were interviewed. The DON stated RN-A had noticed R1 had a change of condition on Friday and asked what she should do. The DON said she had said they should set up a care conference. The administrator stated RN-A asked about R1 pouring her drinks in her food and said it was unusual and said R1 was discussed in the morning interdisciplinary team meeting. The administrator stated she had been seeing a big change in R1 also. The DON stated when staff identified R1's change of condition they should have updated the provider and said they had a hard time determining if it was her medication or her dementia that was causing the changes. The DON acknowledge there was no evidence of an assessment following the change of condition or after FM-A voiced concerns. Facility policy Notification to Physician/Family/Responsible Representative, dated 10/17/21, indicated when there is a change in resident status or condition, the Charge Nurse must evaluate the resident, obtain vital signs, and document findings in the resident's electronic medical record. The charge nurse will notify the assistant director of nursing or DON on call of the situation or change in condition as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to assess the use of a wedge cushion used to keep a resident (R1) in bed as a potential restraint for 1 of 3 residents reviewed for rights. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. The MDS indicated R1 had two or more falls since the last assessment date and did not use restraints. R1's care area assessment (CAA) dated 12/6/23, identified multiple falls and indicated after medication adjustments R1 was more alert and moved around more. The CAA indicated R1 was restless and liked to fidget with things. The CAA identified fall interventions that included a contour mattress, low bed against the wall and a wedge cushion to position in bed. R1's care plan dated 3/18/24, identified decreased physical mobility with potential for falls. The care plan identified general weakness, poor coordination, restlessness and impulsive behaviors. The care plan indicated R1 was unable to turn or reposition himself, sit up, lie down or get his feet and legs into bed independently. The care plan directed staff to use a wedge when in bed to prevent falls. R1's Physician Order Report dated 4/14/24 through 5/14/24, identified the following fall interventions: Bariatric bed with contour mattress, low bed and bed against wall. R1's Resident Progress Note dated 5/2/24, indicated he had an unwitnessed fall, had rolled out of bed and was found face down on the floor by nursing assistant (NA). R1 sustained several skin tears and had a red mark on his face. A correlating Event Report dated 5/7/24, indicated R1's fall mat and wedge were not in place at the time of the fall. During observation and interview on 5/9/24 at 11:22 a.m., R1 was seated in his wheel chair with family member (FM)-A. R1 had a bandage on his elbow and steri strips on his arms. FM-A stated R1 did not stay in bed and said R1 used to walk several miles a day and had a lot of strength in his arms and legs. FM-A said she had seen R1 swing his legs out of bed and said she thought he got his legs out of bed and got carried over by the momentum. FM-A said R1 had a bed that went all the way down to the floor and a mat on the floor. FM-A stated when staff put R1 in bed they put him as close to the wall as they could and used a wedge cushion and pillows to keep him wedged toward the wall. During interview on 5/9/24 at 11:16 a.m., trained medication aide (TMA)-A stated she was told R1 got anxious at night and scooted around in bed. TMA-A said R1's falls occurred on the evening and night shift. TMA-A said the wedge cushion was in place to make sure R1 could not roll onto the floor. NA-A was present and said the wedge cushion had a thing that he laid on so he could not get it (the wedge) out. NA-A stated R1 had a different wedge cushion previously but he had been able to remove it, so he got a new one. During observation and interview on 5/9/24 at 2:12 p.m., R1's wedge cushion was observed with NA-B. The cushion had an attachment that NA-A said was slid under R1's hips to hold the wedge in place. NA-A said the wedge was used to keep R1 facing the wall and prevent falls. During interview on 5/9/24 at 2:20 p.m., the nurse consultant stated they had identified that R1 was very restless in the evenings and at night and said most of his falls had occurred when he was in bed. The nurse consultant said pillows and the wedge were implemented to help position R1 for comfort and was not a restraint. The nurse consultant stated R1 would probably not be able to remove the wedge himself and said she was not familiar with the type of wedge being used. The nurse consultant stated R1 had not been assessed for a potential restraint. Facility Policy Physical Restraints, dated 4/2015, indicated: - Prior to using a restraint, an assessment will be conducted determining the need and benefit/risk relationships. The physical restraint elimination form will be completed. If a resident scores as a priority for reduction the restraint shall not be started. For a resident who scores good or poor for reduction, therapy will be consulted for an evaluation and a restraint may be started once risk verses benefits of the restraints are discussed and documented. - Three principles will guide the decision making process when physical restraints are determined to be the best course of intervention: a. The least restrictive device, applied the least amount of time possible to achieve its stated purpose. b. The benefit of use has been considered and outweighs any potential risk. c. A plan has been develop to minimize/prevent complications and risk factors from materializing considering the circumstances and specific type of restraint to be used. - For residents with a device which they can remove themselves, i.e. front release lap belt, lap tray, lap buddies, etc., the nurse will have the resident demonstrate, each month, the ability to remove the device and will record this on the treatment sheet. When the resident can no longer remove the device it will be considered a restraint and the above policy will be in effect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure nursing staff observed medication administration for 1 of 1 residents (R30) observed to self-administer a nebulizer treatment who was not assessed to be able to do so. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30's diagnoses included aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), asthma, anxiety, depression, and morbid obesity. R30's MDS identified her as severely cognitively impaired, with behaviors (verbal/vocal symptoms, disruptive sounds), rarely/never was understood, and rarely understood others. R30's current Physician Order Report dated 4/5/24, identified R30 had an order for albuterol sulfate solution (used to treat wheezing and shortness of breath caused by breathing problems such as asthma) for nebulization 2.5 milligrams (mg) per 3 milliliters (ml) for inhalation for moderate persistent asthma three times daily started on 11/16/23. R30's care plan dated 11/29/21, did not address nebulizer treatments. R30 did not have an assessment for self administration of medications. During an observation on 4/3/24 at 10:05 a.m., trained medication aide (TMA)-A brought R30 to her room and prepared R30's nebulizer with albuterol sulfate. TMA-A placed the nebulizer mask onto R30's face and gave her the call light and said she would be back to check on her and exited the room. TMA-A did not stay with R30 while the nebulizer treatment was in progress. During an observation on 4/3/23 at 10:16 a.m., TMA-A returned to R30's room, removed the nebulizer mask, took it apart, rinsed it in the bathroom sink, and placed the nebulizer set up on a paper towel and left R30 seated in her wheelchair in her room. During an interview on 4/3/24 at 10:18 a.m., TMA-A stated she had been taught that it was okay to leave a resident alone during a nebulizer treatament as long as they had their call light within reach. TMA-A stated she was not sure if R30 had ever been assessed for self administration of medications. During an interview on 4/5/24 at 10:03 a.m., corporate registered nurse (CRN) stated R30 had not been assessed for self administration of medications. Self-Administration Medications dated 4/2015, identified residents who chose to self-administer medications would be assessed by the interdisciplinary team to determine if they were cognitively and physically able to self-administer medications. The policy further identified the facility would obtain a written order for self-administration of medications from the prescriber. The policy identified the ability to safely self-administer medications would be reviewed quarterly and as needed based on changes in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure conflicting directives for emergency care and treatment were clarified to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 15 residents (R28) reviewed for advanced directives. Finding include: R28's significant change Minimum Data Set (MDS) dated [DATE], identified R28 had diagnoses which included anxiety, depression, bipolar disorder, and secondary Parkinsonism (when symptoms similar to Parkinson disease are caused by certain medicines, a different nervous system disorder or another illness). In addition, R28's MDS identified she was cognitively intact, was understood by others and was able to understand others and further identified she had no rejections of care, delusions, or hallucinations. On [DATE] at 12:36 p.m., R28's electronic medical record (EMR) identified her as do not resuscitate (DNR) on her face sheet. On [DATE] at 12:37 p.m., a review of R28's Uniform Code Level Directions for Cardiopulmonary Resuscitation Havenwood Care Center dated [DATE], located in her EMR identified the following: Code Level 1: All available reasonable technology is used in the event of cardiac respiratory arrest. The facility document titled Resident Care Sheet dated [DATE], identified R28 as DNR. A progress note dated [DATE] at 4:25 p.m., identified the facility staff visited with R28 and she informed them she wanted to live and wanted her code status to be full code. During an interview on [DATE] at 1:12 p.m., R28 stated when she first got to the facility she didn't want anything done, but then changed her mind and would want them to do everything. During an interview on [DATE] at 3:48 p.m., licensed practical nurse (LPN)-A stated any staff who were cardiopulmonary resuscitation (CPR) trained could perform CPR. LPN-A stated in the event of an emergency he would check the face sheet in the computer to see what a resident's code status was. LPN-A checked R28's and verified the code status was listed as DNR, he then checked the scanned documents and verified the document titled Uniform Code Level for R28 dated [DATE], identified R28 as a code level 1 meaning CPR should be performed in the event of a cardiac respiratory arrest. LPN-A verified the documents did not match and had conflicting information. During an interview on [DATE] at 3:54 p.m., licensed social worker (SW)-A stated staff could look for code status on the nursing assistant care guides and the clipboards located next to the automated external defibrillators (AEDs). The assistant director of nursing (ADON) stated the code status was also located in the computer on the resident's profile page. SW-A verified R28's scanned document identified R28 wanted CPR performed in the event of a cardiac respiratory arrest. SW-A stated code status was reviewed at each care conference and if a resident changed their mind on code status the uniform code level document should have been updated, signed and scanned into the EMR. During an observation on [DATE] at 9:30 a.m., the clipboard next to the automated external defibrillator (AED) had a sheet dated [DATE], which identified R28 as DNR During an interview on [DATE] at 9:30 a.m., the assistant director of nursing (ADON) was updating the code clipboard and stated the night staff were supposed to run a report at least weekly, but would prefer it if they ran the report daily after midnight. R28 was now listed as full code, meaning All available reasonable technology is used in the event of cardiac respiratory arrest. The facility policy Code Status Auditing dated [DATE], identified the facility would assure residents' choices for their code status would be accurately communicated throughout the medical record/organization by completing audits upon new admission, hospital return and monthly. The policy further identified the code status would be addressed during the quarterly care conference. During the monthly audits medical records would run a report from Matrix (the electronic medical record) and would compare this with the orders , the care plan and the care sheet. Any concerns or discrepancies would be brought to the director of nursing and clarified with the resident and/or resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the long term care ombudsman was notified of resident transfers for 1 of 2 residents (R26) reviewed for hospitalization. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had diagnoses which included dementia, hemiplegia (paralysis on one side of the body), seizure disorder, and depression. R26's MDS identified she was cognitively intact. R26's progress notes revealed the following: -11/16/23, identified R26 was sent to the hospital at approximately 7:05 p.m -1/13/24, identified R26 was sent to the hospital at approximately 4:15 p.m R26's medical record lacked evidence notification was sent to the state ombudsman's office regarding the transfers to the hospital. An email communication from the ombudsman dated 4/4/24, indicated the ombudsman's office had not received any communications regarding hospitalizations since 4/2021. During an interview on 4/4/24 at 1:56 p.m., social worker (SW)-A stated the facility did not notify the ombudsman's office of hospitalizations or discharges unless the hospitalization or discharge was contested. A policy on notifying the ombudsman's office of hospitalizations and/or transfers was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide the resident or their representative a written bed hold notice for 1 of 2 residents (R26) reviewed for hospitalization. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had diagnoses which included dementia, hemiplegia (paralysis on one side of the body), seizure disorder, and depression. R26's MDS identified she was cognitively intact. R26's progress notes revealed the following: -11/16/23, identified R26 was sent to the hospital at approximately 7:05 p.m -1/13/24, identified R26 was sent to the hospital at approximately 4:15 p.m R26's medical record lacked evidence written notification was given to the resident or the resident's representative for either hospitalization. During an interview on 4/4/24 at 12:46 p.m., nurse consultant (NC)-A stated residents would sign a bed hold on admission to designate if they would want their bed held in the future. During an interview on 4/4/24 at 1:38 p.m., social worker (SW)-A stated all residents sign a bed hold upon admission as the owner wants the residents to be able to return to the facility without worrying about any charges. SW-A stated residents and families are informed their bed will be held without a charge. They only ask residents and families to let them know if they are not planning to return to the facility. SW-A verified the bed hold form had language that identified the bed would be held with no charge for up to 18 consecutive days. SW-A verified the importance of having a resident or family member sign a bed hold is to notify them of potential charges to determine if they want their bed held. The Resident Handbook dated 6/2001, identified the following: BED-HOLD DURING ABSENCE FROM THE NURSING HOME- It is the responsibility of a resident receiving Medicare benefits, a private paying resident, or responsible party acting on their behalf, to pay the per diem rate during their absence from the facility in accordance with the current Minnesota Department of Human Services policy on reserve bed days. If the bed is to be held beyond 18 days a charge equal to one -half of the full per diem rate will be assessed. Until such time as the facility is notified that the room is no longer required, it will be reserved for the resident and billed accordingly. The facility will issue a notice of transfer or discharge, which outlines the bed-hold policy, when a transfer or discharge is to take place. The facility Bed Hold Policy dated 3/2005, identified the following: When the facility transfers a resident to a hospital or a resident goes on a therapeutic leave, the facility will provide written information on the bed hold policy to the resident and / or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure residents who were at risk for pressure ulcers were repositioned timely as directed by the residents care plan for 1 of 2 residents (R30) reviewed for pressure ulcers. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30's diagnoses included aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), asthma, anxiety, depression, and morbid obesity. R30's MDS identified her as severely cognitively impaired, with behaviors (verbal/vocal symptoms, disruptive sounds), rarely/never was understood, and rarely understood others. In addition, R30's MDS identified she was at risk for pressure ulcers and was always incontinent of bowel and bladder. R30's care plan dated 11/29/21, identified R30 had an alteration in elimination. Interventions included to check for incontinence every two to three hours. R30's care plan indicated R30 was at risk for alteration in skin integrity related to decreased physical mobility. R30's care plan identified she was unable to to turn and reposition herself. Interventions included staff to provide turning and repositioning every two to three hours. R30's resident care sheet dated 4/5/24, directed staff to check and change R30 every two to three hours and as needed. In addition, to reposition every two to three hours. On 4/3/24, R30 was continuously observed from 8:15 a.m. to 11:54 a.m. -at 8:15 a.m., R30 was observed seated in her wheel chair in the dining room seated at a table with one other resident. -at 8:19 a.m., R30 had her head down and staff gently woke her when she brought her the breakfast meal. -at 8:47 a.m., staff removed R30's clothing protector and brought her to an area with a television, there were several other residents in the area. -at 8:54 a.m., a staff member approached her and asked her if she wanted to go to her room and lie down, she declined. -at 9:54 a.m., an activities staff stated you usually like to hang out here and then left the area. -at 10:05 a.m., trained medication aide (TMA)-A brought R30 to her room for a nebulizer treatment. -at 10:16 a.m., TMA-A returned to the room removed the nebulizer treatment mask, did not offer to check and change or reposition her. R30 remained seated in her wheel chair in her room. -at 11:23 a.m., R30 had two visitors enter her room and visit with her. -at 11:44 a.m., one of the visitor asked R30 if she needed to use the bathroom before lunch and told R30 they should put the light on, but they did not. -at 11:54 a.m., staff were asked to check and change R30, nursing assistant (NA)-B stated sitting in one position for almost four hours was too long for R30. -at 11:56 a.m., visitors started to bring R30 out of her room, NA-B stated they wanted to change R30 prior to lunch and returned her to her room. -at 11:57 a.m., NA-B, NA-C, and licensed practical nurse (LPN)-B assisted R30 into bed by removing the foot rests, placing a transfer belt on R30 and instructing R30 to stand take a couple of steps, and then to sit on the bed. They assisted R30 by lifting her legs into bed. All three staff performed hand hygiene prior to putting gloves on. NA-B removed R30's brief wearing gloves, and NA-C wiped R30 front to back using pre-packaged wipes. R30 was rolled to her side and peri-care was performed again using different wipes, R30's brief was wet, a new brief was placed, R30 started to cough and voided in the new brief, the process was repeated ending with a new brief. R30's skin was intact with no open areas. During an interview on 4/3/24 at 1:30 p.m., NA-E verified R30 had not been repositioned since she got her up that morning and she should have been repositioned and checked and changed every two to three hours. During an interview on 4/5/24 at 10:05 a.m., nurse consultant (NC)-A verified R30 should have been checked and changed and repositioned every two to three hours as per the care plan. NC-A stated this would be important to prevent skin breakdown. Skin Care policy dated 6/2023, identified the resident care plan would be updated to address pressure relief, bowel and bladder incontinence, and treatment. The policy further indicated care plans would be individualized to address resident specific needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure nebulizer and tubing were changed in a timely manner for 1 of 1 residents (R30) reviewed for respiratory care. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30's diagnoses included aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), asthma, anxiety, depression, and morbid obesity. R30's MDS identified her as severely cognitively impaired, with behaviors (verbal/vocal symptoms, disruptive sounds), rarely/never was understood, and rarely understood others. In addition, R30's MDS identified she was receiving oxygen therapy. R30's care plan dated 11/29/21, did not address respiratory care and/or nebulizer treatments. R30's Physician Order report dated 3/5/24-4/5/24, did not address care and changing of nebulizer and tubing. R30's medical record lacked direction and/or documentation for nebulizer and tubing changes. During an observation on 4/2/24 at 12:08 p.m., R30's nebulizer set up was on R30's bedside table. The set up was all connected and the tubing was undated. During an interview on 4/3/24 at 10:18 a.m., trained medication aide (TMA)-A stated R30's nebulizer set up should be rinsed after each use and left to dry on a paper towel. She was unsure when the nebulizer set up and tubing was last changed but thought it came up as a task for the nurse. TMA-A verified the set up was undated. During an interview on 4/5/24 at 10:03 a.m. nurse consultant (NC)-A stated the nebulizer set up and tubing changes should have shown as being changed in the medication administration record. NC-A reviewed R30's record and verified there were no documented nebulizer and tubing changes for R30. NC-A stated it was important to change the tubing to prevent infection. The policy Quality of Care dated 10/2023, identified the following: Havenwood Care Center will ensure that a resident, who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive care plan, the residents' goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders for 2 of 6 residents (R30, R39) observed to receive medication. A total of two errors out of 27 opportunities were identified resulting in a facility error rate of seven percent. Findings include: R30: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30's diagnoses included aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), asthma, anxiety, depression, and morbid obesity. R30's MDS identified her as severely cognitively impaired, with behaviors (verbal/vocal symptoms, disruptive sounds), rarely/never was understood, and rarely understood others. R30's current Physician Order Report dated 4/5/24, identified R30 had an order for albuterol sulfate solution (used to treat wheezing and shortness of breath caused by breathing problems such as asthma) for nebulization 2.5 milligrams (mg) per 3 milliliters (ml) for inhalation for moderate persistent asthma three times daily started on 11/16/23. R30's care plan dated 11/29/21, did not address nebulizer treatments. R30 did not have an assessment for self administration of medications. During an observation on 4/3/24 at 10:05 a.m., trained medication aide (TMA)-A brought R30 to her room and prepared R30's nebulizer with albuterol sulfate. TMA-A placed the nebulizer mask onto R30's face and gave her the call light and said she would be back to check on her and exited the room. TMA-A did not stay with R30 while the nebulizer treatment was in progress. During an observation on 4/3/23 at 10:16 a.m., TMA-A returned to R30's room, removed the nebulizer mask, took it apart, rinsed it in the bathroom sink, and placed the nebulizer set up on a paper towel and left R30 seated in her wheelchair in her room. During an interview on 4/3/24 at 10:18 a.m., TMA-A stated she had been taught that it was okay to leave a resident alone during a nebulizer treatament as long as they had their call light within reach. TMA-A stated she was not sure if R30 had ever been assessed for self administration of medications. During an interview on 4/5/24 at 10:03 a.m., corporate registered nurse (CRN) stated R30 had not been assessed for self administration of medications. R39: R39's admission Minimum Data Set (MDS) dated [DATE], identified end-stage renal (kidney) failure with hemodialysis (a treatment where a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do it adequately). R39's physician orders dated 3/8/24, included calcium acetate (a mineral used to prevent high blood phosphate levels in people who are on dialysis due to severe kidney disease) 667 milligrams, three times daily with meals. During an observation on 4/2/24 at 7:04 p.m., trained medication aid (TMA)-B provided R39 with her medication, including calcium acetate, which was to be given with meals, at a time when R39 had not recently had a meal. During an interview on 4/2/24 at 7:12 p.m., TMA-B stated she knew the calcium acetate was supposed to be given with meals, but she was not able to get it to R39 at that time. TMA-B stated she had mentioned this to a nurse manager (unidentified) because R39 often receives this medication late or not at all due to her dialysis times conflicting with medication administration times. During an interview on 4/5/24 at 10:47 a.m., registered nurse (RN)-A stated the calcium acetate for R39 should be given with meals as directed, so the medication works as it was supposed to. During an interview on 4/5/24 at 10:57 a.m., the assistant director of nursing (ADON) would expect the medication to be given as directed, following the six rights of giving medications. A document, general policies in administering medications dated 12/2023, identified the purpose was to ensure all RNs, licensed practical nurses (LPN)s, TMAs at Havenwood Care Center would be trained to do medication pass according to industry standards using the six rights of medication pass: right medication, dose, resident, time, method, documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications with a shortened expiration period were labeled with an opened-on date and failed to ensure expired medications were disposed for one of two medication carts in the facility. This practice had the potential to affect all residents with medications stored in the facility. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and a diagnosis of multiple sclerosis. R2's provider orders dated 5/6/22, identified an order for Flonase Allergy Relief, one spray to each nostril two times per day related allergic rhinitis. R13's quarterly MDS dated [DATE], identified moderately intact cognition and a diagnosis of chronic obstructive pulmonary disease (COPD). R13's provider orders dated 5/3/23, identified an order for albuterol sulfate inhaler 90 micrograms (mcg) per actuation. Gve one to two puffs every four to six hours as needed for shortness of breath. During an observation on 4/5/24 at 9:58 a.m., the North medication cart contained a bottle of Flonase for R2, without an opened-on date and with a manufacturer expiration date of 2/2024. The North cart also contained an albuterol sulfate inhaler for R13 dispensed on 3/19/24, with no opened-on date and whose dose-meter read 202. During an interview on 4/5/24 at 9:58 a.m., trained medication aid (TMA)-C stated she would normally go through her cart every couple of weeks for expired medications, or whenever she had time. TMA-C stated it was important to date medications when opened and to remove expired medications from use so the medications work like they should. During an interview on 4/5/24 at 10:05 a.m., the assistant director of nursing (ADON) stated pharmacy consultant did a medication cart audit every three months. It was her expectation not to have expired medications in the medication cart, and to put an opened-on date for medications like inhalers. This was important so the medications were effective. A document, Thrifty [NAME] Pharmacy - Pharmacy Services, storage of medications dated October 2022, identified medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Medication storage conditions are monitored daily by nursing staff and corrective action taken if problems are identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure allegations of abuse were reported for 1 of 6 residents (R28) reviewed for abuse. This had the potential to affect residents who he provided care for. Findings include: R28's significant change Minimum Data Set (MDS) dated [DATE], identified R28 had diagnoses which included anxiety, depression, bipolar disorder, and secondary Parkinsonism (when symptoms similar to Parkinson disease are caused by certain medicines, a different nervous system disorder or another illness). In addition, R28's MDS identified she was cognitively intact, was understood by others and was able to understand others, and further identified she had no rejections of care, delusions, or hallucinations. R28's care plan dated 4/20/20, identified R28 as a vulnerable adult, one of the listed interventions was to invite designated family to care conferences, encourage family and resident to voice question or concerns. During an interview on 4/1/24 at 3:32 p.m., R28 stated there was a guy who touched her inappropriately. R28 stated he rubbed her vagina too long and it made her uncomfortable. She thought this occurred about five months ago or less. R28 stated she told staff about it the next day. On 4/1/24 at 3:51 p.m., this allegation was reported to the administrator and director of nursing (DON). Both stated they would check the grievance log and stated this was the first they had heard about the allegation. The facility Grievance Log revealed on 12/12/23, R28 filed a resident care concern (activities of daily living/cares). It was not reported to the State Agency (SA) or the police department. During an interview on 4/3/24 at 2:09 p.m., social worker (SW)-A recalled the assistant director of nursing (ADON) was working a night shift in December of 2023, and a nursing assistant approached her and asked her to go talk to R28. SW-A told the ADON to ask the resident if she thought the allegation was abuse, she recalled R28 said it wasn't abuse but she no longer wanted that particular staff to do any cares for her. SW-A stated at the time of the event they did not further investigate or report the allegation. During an interview on 4/3/24 at 2:21 p.m., the ADON recalled the night in December and that she called SW-A during the night shift for advice regarding what was reported to her by R28. She recalled R28 said she thought the care she received from nursing assistant (NA)-A was inappropriate during peri-cares. R28 stated she no longer wanted that particular staff to do any cares for her. The ADON was not sure what NA-A was told about the matter but thought he was told not to go into R28's room after the reported allegation. SW-A stated the NA-A was not working the night it was reported but had worked the previous night. No one knew if NA-A was given any remedial training on performing cares. A review of NA-A's personnel file did not reveal any education/training on performing cares after the allegation. During an interview on 4/3/24 at 3:30 p.m., NA-A stated he had recently been placed on a suspension related to an allegation regarding cares with a resident. NA-A stated previous to his suspension there were a few residents he was not allowed to provide cares for. NA-A stated his orientation was hands on training with another NA. NA-A listed four residents who did not want him to do any cares and added he thought they did not want any males to take care of them. When asked if he recalled an event in December of 2023, he stated he did recall he was not supposed to do any cares with R28. He recalled he was told she wasn't comfortable with him because of care he provided in December. When asked if he received any remedial training after December on providing personal cares he stated he had not. During an interview on 4/4/24 at 7:26 a.m., NA-B recalled R28 had complained about a staff touching her. NA-B recalled the resident didn't like how the person had changed her. NA-B stated she immediately contacted the ADON via the walkie talkie asking her to come to R28's room to talk to the resident. NA-B recalled R28 stated the staff was NA-A and R28 stated he touched her in a way she didn't like during cares and said it was uncomfortable to her. NA-B stated she didn't wait a minute and told the ADON right away. During an interview on 4/5/24 at 9:57 a.m. SW-A stated they did not investigate further in December because R28 said it wasn't abuse when she was asked that specific question. The facility policy Abuse Prevention/Prohibition Program dated 8/1/22, identified the facility would promptly and immediately report any incident or suspected incident of resident abuse or neglect. The policy identified allegation would be reported as required by Stated and Federal regulation as soon as possible but no later than two hours for suspected abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure allegations of abuse were investigated for 1 of 6 residents (R28) reviewed for abuse. This had the potential to affect residents who he provided care for. Findings include: R28's significant change Minimum Data Set (MDS) dated [DATE], identified R28 had diagnoses which included anxiety, depression, bipolar disorder, and secondary Parkinsonism (when symptoms similar to Parkinson disease are caused by certain medicines, a different nervous system disorder or another illness). In addition, R28's MDS identified she was cognitively intact, was understood by others and was able to understand others and further identified she had no rejections of care, delusions, or hallucinations. R28's care plan dated 4/20/20, identified R28 as a vulnerable adult, one of the listed interventions was to invite designated family to care conferences, encourage family and resident to voice question or concerns. During an interview on 4/1/24 at 3:32 p.m., R28 stated there was a guy who touched her inappropriately. R28 stated he rubbed her vagina too long and it made her uncomfortable, she thought this occurred about five months ago or less. R28 stated she told staff about it the next day. On 4/1/24 at 3:51 p.m., this allegation was reported to the administrator and director of nursing (DON). Both stated they would check the grievance log and stated this was the first they had heard about the allegation. The facility Grievance Log revealed on 12/12/23, R28 filed a resident care concern (activities of daily living/cares), it was not reported to the State Agency (SA) or the police department. During an interview on 4/3/24 at 2:09 p.m., social worker (SW)-A recalled the assistant director of nursing (ADON) was working a night shift in December of 2023, and a nursing assistant approached her and asked her to go talk to R28. SW-A told the ADON to ask the resident if she thought the allegation was abuse, she recalled R28 said it wasn't abuse but she no longer wanted that particular staff to do any cares for her. SW-A stated at the time of the event they did not investigate further or report the allegation. During an interview on 4/3/24 at 2:21 p.m., the ADON recalled the night in December and that she called SW-A during the night shift for advice regarding what was reported to her by R28. She recalled R28 said she thought the care she received from nursing assistant (NA)-A was inappropriate during peri-cares. R28 stated she no longer wanted that particular staff to do any cares for her. The ADON was not sure what NA-A was told about the matter but thought he was told not to go into R28's room after the reported allegation. SW-A stated the NA-A was not working the night it was reported but had worked the previous night. No one knew if NA-A was given any remedial training on performing cares. A review of NA-A's personnel file did not reveal any education/training on performing cares after the allegation. During a telephone interview on 4/3/24 at 3:30 p.m., NA-A stated he had been placed on a suspension related to an allegation regarding cares with a resident. NA-A stated previous to his suspension there were a few residents he was not allowed to provide cares for. NA-A stated his orientation was hands on training with another NA. NA-A listed four residents who did not want him to do any cares and added he thought they did not want any males to take care of them. When asked if he recalled an event in December of 2023, he stated he did recall he was not supposed to do any cares with R28. He recalled he was told she wasn't comfortable with him because of care he provided in December. When asked if he received any remedial training after December on providing personal cares he stated he had not. During an interview on 4/4/24 at 7:26 a.m., NA-B recalled R28 had complained about a staff touching her. NA-B recalled the resident didn't like how the person had changed her. NA-B stated she immediately contacted the ADON via the walkie talkie asking her to come to R28's room to talk to the resident. NA-B recalled R28 stated the staff was NA-A and R28 stated he touched her in a way she didn't like during cares and said it was uncomfortable to her. NA-B stated she didn't wait a minute but told the ADON right away. During an interview on 4/5/24 at 9:57 a.m. SW-A stated they did not investigate further in December 2023, because R28 said it wasn't abuse when she was asked that specific question. The facility policy Abuse Prevention/Prohibition Program dated 8/1/22, identified the facility would complete a timely, thorough and objective investigation of all allegations of abuse, neglect or mistreatment. The policy identified the investigation would be conducted by the administrator or director of nursing but could be designated to another individual to complete the investigation if needed. The investigation would include the name of the resident involved, date and time of incident, nature of the injury/illness, circumstances, were event took place, observation of the environment, determination to further report, names of witnesses, injured persons account of event, notification of residents physician, notification of person's family, condition of resident, corrective action taken, review by quality assurance.

Based on document review and interview the facility failed to verify nurse aide registration for 1 of 5 nursing assistants (NA-A) prior to allowing the individual to serve as a nurse aide and work directly with residents in the facility after the 4 month training period. This had the potential to affect residents who he provided care for. Findings include: Review of NA-A's personnel file identified date of hire as 10/23/23, and placed on an investigatory suspension on 4/1/24. No verification of NA-A nursing assistant certification was located in the personnel file. A search of the nursing assistant registry revealed he was not currently registered. During an interview on 4/5/24 at 9:22 a.m., the administrator stated NA-A took his nursing assistant skills test on 12/22/23, but did not take his knowledge test related to a communication misunderstanding between the testing site and the facility. NA-A showed the facility proof of passing the skills test after the testing date. The administrator stated it was an expectation that after the four month training period a nursing assistant would take the test and become a registered nursing assistant. Abuse prevention/prohibition program dated 8/1/22, identified all applicants would be screened through the State of Minnesota Department of Human Services. In addition, prior to employment, all applicants for the position of Certified Nursing Assistant would be screened with the Minnesota Nursing Assistant Registry to ensure the applicant was eligible for employment in that capacity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure nutrient and/or calorie substantive snacks were offered and readily available for 3 of 6 residents (R6, R50, R308) who voiced concern at a resident council meeting. This had the potential to affect all residents residing at the facility. In addition, the facility failed to prevent a greater than 14-hour lapse between dinner and breakfast meals and without offering a snack in the evening. Findings include: During a resident council meeting on 4/3/24 at 2:00 p.m., the following residents stated concerns with recent changes to the snack cart: R6, whose quarterly Minimum Data Set (MDS) dated [DATE] identified intact cognition, stated the facility hardly ever comes around with snacks. They used to, but the cart went away. R308, whose admission MDS dated [DATE] identified moderately impaired cognition, added they didn't come around at all with the snack cart. R50, whose quarterly MDS dated [DATE] identified moderately impaired cognition, stated the facility said it was due to temperatures (safety) and infection control. During an interview on 4/4/24 a 8:56 a.m., NA-G stated she didn't think there was a snack cart anymore and she wasn't sure why not. During an interview on 4/4/24 at 8:59 a.m., NA-D stated there was a snack cart in the kitchenette between meals, the residents would have to ask for a snack to be able to get one. They passed water at 2 p.m. and 10 p.m., but there was no offering of snacks at that time. During an interview on 4/4/24 at 9:01 a.m. nursing assistant (NA)-F stated they used to have a snack cart that was out all the time, but too many people took too much stuff off it and now they didn't have it anymore. During an interview on 4/4/24 at 1:44 p.m., the certified dietary manager (CDM) confirmed dinner was served at 5 p.m. and breakfast at 8 a.m. and that was a total of 15 hours. The CDM also confirmed the resident snack cart was not available in the evenings or anytime there were not dietary staff in the unit kitchenettes. Once meal service was over, the dietary staff put the snack carts back in the locked kitchenettes, including after dinner. The CDM explained residents pouring their own coffee was a safety hazard, and family/guests pouring juice was an infection control hazard. So, the residents had to ask if they wanted a cup of coffee or juice, and staff would go get it for them. The CDM stated offering snacks was important because the residents could be hungry. During an interview on 4/5/24 at 8:42 a.m., the administrator stated she recognized the hours between meals were too many and that their snack offering didn't meet the requirements for needing a substantial snack. The administrator further stated this was important to help residents keep consistent weights and not lose weight. A document, Havenwood Resident Council Meeting Minutes dated 3/27/24, identified an announcement The snack carts, drink carts and coffee carts will be going away. The mock survey to prepare dietary for our next state survey revealed this is an infection control issue as well as a safety issue. Moving forward, a staff member will have to pour and serve you your drinks. A snack/drink cart will be passed mid-afternoon around the 3:00 p.m. mark. A document, Mealtimes and Frequency dated 10/2019 identified the mealtimes for breakfast at 8 a.m., lunch at 12 p.m., and dinner at 5 p.m. Taking into consideration there may not be more than 14 hours between meal services unless a substantial bedtime snack is offered, all residents will have available to them, a bedtime snack. Adequacy of the snack would be determined by individuals in the group and evaluation of the overall nutritional status of those in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to assess 1 of 3 residents (R4) reviewed for nursing care assessment. While receiving assistance with a transfer, staff heard an audible tear which was not assessed by nursing staff on duty at the time of the incident. Findings include: R4's quarterly Minimum Data Set, dated [DATE], identified severe cognitive impairment and indicated she required total assistance from two staff to complete bed mobility and transfers. R4's care plan dated 4/11/23, identified impaired physical mobility related to Multiple Sclerosis, obesity and an inability to transfer. The care plan directed staff to provide assistance from two staff for bed mobility and provide total assistance from two staff for transfers using a bariatric ceiling lift. A report to the state agency (SA) dated 6/22/23, indicated on the morning of 6/22/23, nursing staff reported to unit manager that R4 appeared to have some swelling and increased pain to her right shoulder. Unit manager assessed R4 and determined that her shoulder was swollen with pain and decreased range of motion (ROM).Unit manager called writer to report a possible injury related to a transfer that had occurred on 6/20/23. Unit manager reported that on 6/20/22, two nursing assistants (NA)'s reported that they had heard a noise and thought they had ripped residents clothing when removing the sling from under her after being assisted to bed with the Hoyer lift. Unit manager, her orientee and the director of nursing did assess resident on that day and didn't find any rips in clothing, sling or injury/changes in residents ROM or pain at that time. Upon reports of change in condition, the unit manager requested resident be seen by the nurse practitioner (NP) who was rounding the morning of 9/22/23. The NP believed that R4 obtained an anterior right shoulder dislocation. A second report to the SA dated 6/27/23, indicated on 6/20/2023, around 1:00 p.m. two NA's were removing a transfer sling from under R4 when an audible ripping/tearing sound was heard. NA's questioned whether R4's clothing had ripped. Unsure if clothing was assessed following the above, as nothing was mentioned/documented. Writer reviewed facility documentation in R4's medical record and late entries noted regarding above. Writer was notified of the above two days after the incident occurred. R4 was assessed by writer and had visible deformity and discoloration noted to anterior right shoulder, acromion process (bony process on the shoulder blade) and proximal humerus (largest bone in the upper arm). The report indicated R4 was currently on Hospice Care and had been stable. However, this added trauma/injury led to undue suffering for R4. R4's medical record lacked evidence an assessment was completed at the time of the incident. R4's Resident Progress Notes identified the following: 6/21/23, R4 had a shower this afternoon. Skin assessment completed. Right shoulder upper chest appeared to have some edema/erythema. Neckline had redness as well which did occur. Skin intact to this area, no increased warmth at this time. 6/22/23, Right shoulder pain noted and swollen on top with decreased ROM and pain. Physician to assess. 6/22/23, back dated to 6/20/23, Staff reported to unit charge manager and orientee that clothes may have ripped during a transfer. This writer and orientee assessed ROM to bilateral lower extremities and no decrease in ROM noted at time of assessment. This writer touched left arm and R4 stated ow, writer touched right shoulder/arm and R4 reported same ow with no Wong-Baker (a self-assessment tool that can help people communicate about their physical pain. It uses a combination of faces, numbers, and words) pain noted. Regular pain reported as R4 had chronic pain. Will observe for changes in condition. 6/22/23, back dated to 6/20/23, NA's reported to writer that while removing sling from under resident, it appeared residents elbow got stuck on the sling, leaving a red mark on the elbow. Writer went to R4's room to assess arm for any other signs of injury. R4 had contractures and ROM was difficult to assess for any change due to the contracture. R4 did yell when being touched on any area of her upper extremities, which was her normal response. Writer assessed left shoulder and elbow, resident did yell ow, writer assessed right shoulder and elbow and resident yelled ow which was her normal response. Writer did not believe there was any injury present due to no change in R4's typical behavior. Staff education to be provided on proper removal of Hoyer sling. 6/22/23, Per hospice nurse who was at the emergency department with R4, R4 had a proximal humerus fracture, non-operable. Plan to place sling, limit movement, gowns and nothing with sleeves and no rolling onto right shoulder. During interview on 9/21/23, at 4:33 p.m. licensed social worker (LSW)-A stated she remembered the incident and said two days after the incident occurred a NA who frequently worked with R4 reported R4's arm was flaccid which was unusual for R4. LSW-A stated the NA knew right away something was wrong and the NP happened to be in the facility so she assessed R4 and felt the shoulder had been dislocated. Facility policy Resident Incidents/Change In Resident Health Status dated January 2003, indicated upon discovery of an incident and after the resident's immediate safety has been assured; the charge nurse shall be notified. For purposes of internal review only, details of the incident will be recorded on a Resident Incident Report. A progress note will be made in the resident's medical record with the details of the incident as well as family and physician notification. Following a fall, injury or acute illness, the resident will be observed and charted on at least once each shift for 24 hours. The RN supervisor will assess the situation & implement & care plan changes needed for the safety of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to the facility failed to ensure a resident's bedtime routine preferences were honored for 1 of 1 residents (R49) who voiced concerns about bedtime routines. Findings include: R49's annual Minimum Data Set (MDS) dated [DATE], identified R49 was cognitively intact and required extensive assistance with dressing, personal hygiene and was totally dependent on staff for transfers. Further, it was somewhat important to R49 to choose her bedtime. R49's care plan dated 4/27/22, identified R49 was unable to care for herself. R49's personal and psychosocial needs would be met with assistance from staff. The staff were to include R49's personal preferences for care and services. During an interview on 5/24/23 at 1:50 p.m., R49 stated she needed to adjust her evening visits with family, so she can get washed ready for bed by 7:30 p.m. I have had to learn their [facility staff] routine. If she wanted to visit with her family past 7:30 p.m. she would have to wait until they could get her ready for bed, and didn't know how long that would be. You wait until they can put you to bed and felt helpless. During an interview on 5/24/23, at 2:55 p.m. nursing assistant (NA)-B stated they started putting residents to be around 7:00 p.m. in the evening. R49's family visited almost every night and that made it hard to get R49 ready. R49 might have to wait for help because when she goes out, she might return during a window for getting ready for bed because R49 needs twos staff for assistance. R49 routinely waited more than an half hour for assistance, if she was not ready prior to 7:30 p.m. that's just how the cookie crumbled. During an interview on 5/24/23 at 2:57 p.m. the acting administrator stated leadership did not want residents changing their routines to meet staffing patterns or concerns. Nursing should have a process to assess and care plan preferences. The facility policy Quality of Life - Dignity reviewed 6/2/22, identified each resident should be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity meant the resident would be assisted in maintaining and enhancing his or her self-esteem and self-worth. Residents would be groomed as they wished. Residents would be assisted in attending the activities of their choice, including activities outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure triggered Care Area Assessments (CAAs) on an annual and on a significant change in status Minimum Data Set (MDS) were completed to ensure a comprehensive resident assessment for 1 of 3 residents (R45) reviewed for assessments. Findings include: R45's annual MDS dated [DATE], identified R45 diagnoses of dementia, psychotic disturbance, mood disturbance, anxiety and dysphasia. R45 received antidepressant medications daily and was on a mechanical altered diet. Under Section V of the MDS, the triggered CAA(s) to be completed included Psychosocial Well being, and Mood State, and Nutritional Status. R45's medical record lacked evidence the triggered CAAs for R45's psychosocial well being, mood state or nutrition were completed. R45's significant change in status MDS, dated [DATE], identified R45 MDS had triggered Cognitive Loss/Dementia, Visual Function, Urinary Incontinence and Indwelling Catheter, Behavioral Symptoms, Falls, Nutritional Status, Pressure Ulcer, and Psychotropic Drug Use Care Areas for further assessment. A notation made for each of the triggered care areas to refer to R45's annual MDS CAAs completed on 11/10/22. R45's medical record lacked evidence any triggered CAAs were assessed or completed for the significant change in status MDS. When interviewed on 5/23/23, registered nurse (RN)-A stated CAAs were completed on admission, annual and with significant change in status. RN-A notified the responsible persons to complete their triggered CAA's for R45's annual MDS and they did not get them completed. RN-A closed out the 11/18/23, MDS and so those CAA areas were missed. R45's significant change in status CAA from 2/25/23, were not completed due to the significant change was related to therapy being discontinued. RN-A was completing a number of MDS's on residents due to changes in their therapy and was difficult to keep up with the work load. R45's CAAs for the significant change on 2/25/23, must not have been completed due to time constraints. The facility policy Resident Assessment For RAI Process, dated 4/2015, identified nursing, social services, activities and dietary would complete identified portions of the MDS for initial, change in status and annual RAI process. The RN would generate a triggered Resident Assessment Protocol (RAP or CAA) summary form to determine the RAP's to be completed. A summary of the RAP will be written to include on the RAP findings form: Nature of condition, cause, onset/duration of the the problem, complications and risk factors, factors that must be considered in developing care, need for referrals and reason to proceed to the care plan. The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2019, identified the RAI helps nursing home staff gather information on each resident to help ensure care plans are developed and revised. The manual outlined, under Chapter 4: Care Area Assessment (CAA) Process and Care Planning, the RAI consisted of three components which includes the MDS, the CAAs, and the RAI Utilization Guidelines. The manual identified CAAs were required to be completed for OBRA comprehensive assessments (i.e. admission, annual, significant change in status, or significant correction of a prior comprehensive).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R61's discharge MDS dated [DATE], identified R61 was discharged to a hospital. R61's progress notes dated 3/31/23, identified R61 left with is wife to go home at 1:00 p.m. R61's Discharge summary dated [DATE], identified R61 had discharged home with his wife. During an interview on 5/24/23 at 1:04 p.m., RN-A stated R61 discharged home on 3/31/23, the discharge MDS dated [DATE] was incorrect. R61 was not discharged to the hospital, but was discharged home. The facility policy Resident Assessment for RAI Process reviewed 4/2015, directed the facility established a consistent measurement of each resident's functional capacity. Each resident would have initial, periodical, annual and significant change in status comprehensive accurate standardized assessment completed. Based on interview and document review the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 3 residents (R51) reviewed for pressure ulcers and 1 of 2 residents (R61) reviewed for discharge status. Findings include: R51's care plan dated 2/28/23, identified R51 had an alteration in skin integrity related to pressure ulcers on both heels. Staff were directed to perform wound care/dressing changes as ordered with an egg crate pad placed under sheets at the foot of R51's bed for pressure relief and to educate R51 on the importance of keeping his dressings on. R51's quarterly Minimum Data Set (MDS) dated [DATE], identified R51 had no pressure ulcers. R51's Wound Observation notes dated 2/16/23 through 5/24/23, identified R51 had a left heel pressure ulcer which was identified on 2/16/23. During an interview on 5/23/23 at 4:16 p.m., registered nurse (RN)-A stated she completed all the assessments required for the MDS process. RN-A stated R51's look back period for his 4/19/23 quarterly MDS was 4/13/23-4/19/23. RN-A completed all the assessments required for MDS; however R51's pressure ulcer was not coded on his 4/19/23 quarterly MDS because she just missed it. During an interview on 5/24/23 at 12:44 p.m. the acting administrator stated RN-A reported the error in R51's MDS and was already making corrections. MDS assessments should be accurate not only for care planning but also for facility reimbursement. RN-A was missing not sure if administrator or RN-A reported to leadership that she reviewed R51's quarterly MDS dated [DATE], and missed several items in section M.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to implement physician orders to promote the healing of pressure ulcer for 1 of 3 residents (R16) reviewed for pressure ulcers. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had a Stage 4 pressure ulcer (Stage 4 pressure ulcers are the most serious. These sores extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments. In more severe cases, they can extend as far down as the cartilage or bone.). R16's care plan revised 3/15/23, identified R16 had decreased physical mobility with potential for altered skin integrity related to artificial right hip and knee, congestive heart failure (CHF), cognitive impairment, spinal stenosis, chronic bruising on right hip, right hip ulcer and arthritis. R16 was unable to ambulate. Staff were directed to apply treatment to right hip as ordered. Update the physician with signs and symptoms of infection or worsening of wound. R16's physician orders dated 4/20/23, directed staff to pack the wound superficially with dry gauze, do not cut gauze into pieces, followed by ABD (also known as an abdominal pad, is a type of medical dressing used to cover and protect wounds on the abdomen or other areas of the body. ABD pads are typically made from a soft, absorbent material that can be easily wrapped around a wound and secured in place with adhesive tape or a bandage.), and secure with tape. Apply zinc oxide cream to the peri wound area with dressing changes. Irrigate wound with normal saline every Monday, Wednesday and Friday. R16's Treatment Administration Record (TAR) dated May 2023, identified registered nurse (RN)-B completed R16's dressing change on the evening of 5/21/23. On 5/22/23 at 9:08 a.m., licensed practical nurse (LPN)-A set up supplies to change R16's right hip wound dressing. LPN-A stated R16's skin was fragile and very little tape was required to secure the ABD pad to prevent skin breakdown. LPN-A stated a soft cloth surgical tape was also needed to prevent skin breakdown. LPN-A pulled back R16's blankets and revealed a absorbent foam bordered dressing was covering R16's wound. One side of the dressing had loosened to allow a large amount of greenish colored drainage to leak onto R16's incontinent brief. LPN-A stated do you see what's wrong there? That's the wrong dressing. The dressing on R16 identified RN-B's initials and was dated 5/21/23. LPN-A removed the dressing and proceeded to apply the correct ordered dressing. During an interview on 5/23/23 at 10:18 a.m., RN-C stated R16's skin could not handle a form border dressing because R16's skin was to fragile for that kind of dressing. RN-C stated RN-B was a new to the facility; however RN-C went over R16's wound orders with RN-C before leaving for the day on 5/21/23., RN-B was given the opportunity to ask questions. RN-C stated she did not know why RN-B used a foam border dressing because she had to remove the old dressing. The facility always had enough dressing supplies but, if not, you should call R16's wound care physician for guidance. During a telephone interview on 5/24/23 at 10:29 a.m. RN-B stated was a nurse for more than 40 years and followed standards of practice. RN-B refused to answer further questions regarding the wound care RN-B provided to R16 on 5/21/23. During an interview on 5/24/23 at 10:35 a.m., the director of nursing (DON) stated RN-C was the charge over the weekend. RN-C went through all the dressing orders with RN-B during shift change. The physician order should always be followed to promote wound healing. The facility policy Skin Care implemented 3/2022, identified the facility would ensure proper identification of residents at risk for skin breakdown, prevention of development of pressure ulcers, and determining appropriate treatment of pressure ulcers and/or skin for residents. Quality assurance audits would be performed periodically per the DON's discretion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a resident was reassessed for continued use of an as needed (PRN) antipsychotic medication (medication used for a variety of mental health disorders), beyond the 14 days for 1 of 5 residents (R55) who received an as needed psychotropic (mood altering) medication reviewed for unnecessary medications. Findings include: R55's admission Minimum Data Set (MDS) dated [DATE], identified R55 had moderate cognitive impairment and demonstrated no physical, verbal or behavioral symptoms. R55 used psychotropic medication 6 out of 7 days during the assessment period. R55's diagnoses included dementia, anxiety, and dysthymic disorder (persistent depression). R55's Physician Order Report dated 4/27/23 through 5/24/23, directed staff to give 0.5 milligrams (mg) of lorazepam twice daily as needed for anxiety or agitation. The completed order listed a start date of 5/3/23, however, did not list a stop date for the PRN dosing of the psychotropic medication, as required. R55's Medication Administration Record (MAR) dated 4/27/23 through 5/24/23, identified R55 continued to have an active, current order for the PRN lorazepam which listed the start date of 5/3/23. R55 had received one dose of the as needed psychotropic on 5/6/23 through 5/9/23, 5/16/23, 5/18/23, 5/20/23 and 5/22/23. R55 received two doses of the as needed psychotropic on 5/14/23, 5/15/23, 5/17/23, and 5/19/23. The medical record lacked a new order with rationale for continuing with the PRN lorazepam past 14 days. During interview on 5/23/23 at 9:37 a.m., registered nurse (RN)-D stated PRN lorazepam should only be ordered for 14 days and then should be renewed by the provider. RN-D stated R55's lorazepam 0.5 mg 1 tab twice daily PRN was ordered on 5/3/23 and should have been but was not re-ordered after 14 days, as required. During interview on 5/23/23 at 9:56 a.m., the director of nursing (DON) stated R55's PRN lorazepam 0.5 mg order was received on 5/3/23 and was not renewed after 14 days, as required. During interview on 5/23/23 at 10:05 a.m., the nurse practitioner (NP) stated she was aware that residents using as needed antipsychotic medications were required to be reassessed every 14 days and a new order including the rationale for use must be obtained. The NP stated R55 was evaluated on 5/14/23, but had not received a new order for PRN lorazepam. The Psychotropic Medication Monitoring policy reviewed 2/22, identified PRN psychotropic medications will be given only for specific, clearly documented circumstances. The policy further directed residents with orders for PRN psychotropic medications require a face-to-face assessment by the prescribing provider 14 days after initiating of the new medication.

Based on observation, interview and document review, the facility failed to secure 1 of 2 treatment carts in the facility that contained medication. Findings include: During an observation on 5/21/23, at 4:38 p.m., registered nurse (RN)-B obtained a glucometer from the [NAME] way treatment carts bottom drawer, but stated she did not have key for the treatment cart. RN-B turned the cart so the drawers were against the wall and walked away leaving the cart unattended. - At 4:47 p.m., RN-B returned to the treatment cart to obtain insulin. RN-B again turned the cart so the drawers were against the wall and walked away leaving the cart unlocked and unattended. - At 4:54 p.m., RN-B returned to the cart, but again turned the unlocked cart so the drawers were against the wall. RN-B then left the unit to go to the other unit to perform treatments. During an observation on 5/21/23 at 5:37 p.m. the treatment cart remained unlocked with the drawers turned to the wall. RN-B was not on the unit and the cart was left unattended nor was in view of staff. During an interview on 5/21/23 at 5:39 p.m. trained medication aide (TMA)-A stated the treatment cart contained insulins and prescribed topicals like nystatin (an antifungal powder), Voltaren gel (analgesic) and insulins. TMA-A stated she assumed RN-B did not have cart keys because another staff member took them home. Normally, the nurses had keys for the treatment cart and it was locked when not in use. During an interview on 5/21/23 at 5:49 p.m., the consultant director of nursing (DON) and the DON stated nursing had keys to the treatment carts. The DON stated the keys worked for both carts and no keys were reported missing that day. The treatment and medications carts were expected to be locked when not in use to ensure safety of medications. During observation on 5/22/23 at 4:52 p.m., licensed practical nurse (LPN)-B was standing at the unlocked treatment cart on [NAME] Way unit prepping supplies for a residents blood sugar check. After collecting supplies from inside the treatment cart, LPN-B walked away without locking the cart. LPN-B walked to the dining room, talked with a resident and wheeled the resident to their room, all while the treatment cart was unlocked and unattended. - At 5:00 p.m. LPN-B returned to the unlocked treatment cart, reached inside and grabbed an insulin syringe, prepped the residents insulin, locked the cart and walked away. During interview on 5/24/23 at 3:41 p.m., the DON stated staff were expected to lock the medication/treatment carts prior to walking away from the cart. Staff were expected to keep the carts locked whenever they were unattended. The facility policy Storage of Medications revised October 2022, identified medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on interview and document review, the facility failed to be in-compliance with the supplemental nursing service agency (SNSA) requirements; the facility obtained nursing services from Rock Medical staffing agency, an SNSA, which was not registered with the commissioner as required per the MN State Statute §144A.71 Subdivision 1. This had the potential to affect all 58 residents of the facility who received services from the supplemental staff. Findings include: During review of staff schedules dated 5/16/23 through 5/23/23, it was verified Rock Medical provided supplemental regisered nurse staffing to the facility. Rock Medical was not identified as being a SNSA registered with the State Agency. During review of an e-mail dated 5/23/23 at 2:33 p.m., the acting administrator identified RN-B was employed by Rock Medical and her start date at the facility was 5/15/23. RN-B worked 2:30 p.m. to 10:00 p.m. the following days: 5/15/23, 5/16/23, 5/18/23, 5/19/23, 5/20/23, and 5/21/23. The shifts on 5/19/23, 5/20/23 and 5/21/23, RN-B was on her own per se, but there were always at least one other RN or licensed practical nurse (LPN) in the building with her for support and supervision. During joint interview with the acting administrator and the director of nursing (DON) on 5/23/23 at 1:47 p.m., the acting administrator stated the facility had not received approval for Rock Medical staffing agency, an SNSA, who provided RN-B to work at the facility. RN-B had worked for two weeks. The policy on staffing was requested and not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed ensure appopriated disinfecting of glucometers to prevent transmission of a bloodborne pathogen when staff used the incorrect glucometer for 1 of 4 residents (R43) observed during glucometer checks. Findings include: R43's quarterly Minimum Data Set (MDS) dated [DATE], identified R43 had diagnoses that included diabetes mellitus. R43's physician orders dated 3/11/22, identified R43 was to have glucometer checks four times daily. During an observation on 5/21/23 at 4:38 p.m., registered nurse (RN)-B pulled open the bottom drawer of the treatment cart and pulled out a small, plastic bin containing a glucometer, strips and alcohol wipes. - At 4:42 p.m. RN-B obtained R43's blood glucose reading of 247 using the glucometer. - At 4:54 p.m. RN-B returned the the treatment cart where she turned over the glucometer. On the underside of the glucometer, a piece masking tape clearly identified the glucometer belonged to another resident (R53) and not R43. RN-B stated oh no. I'm sorry. RN-B attempted to find R43's glucometer in the treatment cart, but stated she was unable. RN-B then used an alcohol swab to wipe down R53's glucometer and put the basket back into the bottom drawer of the treatment cart. During an interview on 5/21/23 at 4:57 p.m., RN-B stated it was important to ensure individual glucometers were used to prevent the spread of infection. During an interview on 5/21/23, at 5:49 p.m., the director of nursing (DON) and consultant DON stated they were unaware of any inappropriate usage of a glucometer and expected to be informed. The consultant DON stated individual glucometers were used in the facility to decrease the risk of transmission of a bloodborne pathogen. Staff were directed to use an approved sanitizing wipes because alcohol was not a sanitizing agent During an interview on 5/24/23 at 12:46 p.m. the acting administrator stated the inappropriate use of a glucometer was like a medication error and it should have been reported as soon as it was found in order to ensure appropriate procedures were followed for resident safety. The facility policy Disinfection of Blood Glucose Monitors revised 12/29/17, identified residents would have individual glucometers stored in their room for individual use; however, if a glucometer was used out of the cart for a as needed or emergency glucose check disinfection would be completed to reduce and prevent the spread of infection and potentially infectious agents between residents, the glucometers would be disinfected after each use. Staff were directed to follow manufacturer's recommendations and disinfect using a desigantated wipe.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 commercial dishwashing machines used in the main production kitchen was kept in good repair to prevent food-born illness. This had the potential to affect all 58 residents, staff and visitors who consumed meals from the main production kitchen. Findings include: On 5/21/23, dishwashing was observed in the main production kitchen. Dietary aide (DA)-A was observed running several hard plastic trays filled with dirty dishes into the single CMA EST44 dish machine. Two front gauges were observed on the machine, one labeled wash and the other rinse. The wash temperature gauge measured 119 degrees and the rinse temperature gauge measured 140 degrees. DA-A stated he did not recall ever having checked the temperatures on the dishwasher machine. During tour with the dietary manager (DM) on 5/21/23, DM observed the dishwasher cycle and reported the wash temperature was reading 119 and rinse temperature was 170. DM stated the wash needed to reach 150 and the rinse temperature needed to reach 180 in order to clean and sanitize the dishes. DM did not know how long the dishwasher was running cold and there were no records of the dishwashing temperatures; however, DM noticed the low temperatures a few days previously but forgot to notify the maintenance department. On 5/22/23, the maintenance mechanic (MM)-A stated he checked the dishwasher gauges every morning, but frequently the machine was not running when he checked them. The gauges in the back of the machine were not accurate, just the two gauges in the front of the machine. MM-A kept a log of the temperatures of the wash and rinse. 26 wash and rinse temperatures were recorded on the log from 4/15/23 through 5/19/23. Wash temperatures ranged 110 to 130 degrees and rinse temperatures ranged 140 to 170 degrees. MM-A observed a dishwashing cycle and reported the final rinse gauge at the back of the machine indicated 170 to 175 degrees. The wash gauge in front of the machine indicated 110 degrees and the rinse gauge 138 degrees. DM ran a digital thermometer through the dishwashing cycle, which indicated a maximum temperature of 172 degrees. The front two gauges in front of the dishwasher did not move. MM-A stated they did not appear to be functioning. On 5/22/23, the acting administrator stated she was made aware the dishwasher was not getting up to the required temperature. They had a repair man coming the next day to fix it. In the meantime, the facility would use disposable dishware until the dishwasher could be repaired. On 5/23/23, a dishwasher repair mechanic (DRM) was observed checking the dishwasher's operation. DRM stated he ran the dishwasher a few times and the final rinse was not getting hot enough. The front gauges on the machine were not functioning. The only functioning gauge was the final rinse gauge at the back of the dishwasher. The dishwasher element was not working. DRM checked the dishwater at the bottom of the machine during the wash cycle and it was 130 degrees. DRM thought the dishwasher was washing dishes somewhere around 130 degrees. The rinse cycle was getting to 170 degrees. DRM stated there was no way to tell how long the dishwasher was not functioning. On 5/23/23, DM stated she planned to schedule a mandatory in-service for the dietary staff. She was going to have the gauges on the dishwasher fixed and had temperature plates on order. DM stated she would train the dietary staff to run the temperature plate through the dishwasher at every meal and monitor and record dishwasher temperatures on a log once the dishwasher was functioning properly. An undated Model EST44 CMA Dish machines manual was provided. A section labeled Operation identified the required steps to begin operation of the dish machine. Step 3 instructed to allow the dish machine to come to temperature and identified the wash temperature at 150 degrees minimum, and the final rinse temperature at 180 to 195 degrees. A section labeled Regular Service and Maintenance Checklist directed staff to check wash tank temperature 150 degree minimum, check power rinse tank temperature 160 minimum and check final rinse temperature 180 to 195 degrees. The facility policy Dish Machine Temperature Log dated 2019, indicated staff would monitor dish machine temperatures through out the dishwashing process. Staff would be trained to report any problems with the dish machine to the director of food and nutrition services as soon as they occurred. the director of food and nutrition services would promptly assess any dish machine problems and take action immediately to assure proper sanitation of dishes.

Based on observation, interview and document review, the facility failed to monitor 1 of 1 dishwasher wash and rinse water temperatures to ensure dishes and silverware were properly cleaned and sanitized. In addition, the facility failed to ensure cold foods were held at the appropriate temperature prior to meal service. This had the potential to affect 58 of 58 residents, staff and visitors who consumed food prepared in the kitchen. Findings include: Dishwasher Machine Temperatures On 5/21/23, an initial kitchen tour was conducted. Dishwashing was observed in the main production kitchen. Observation of three cycles of dishes revealed gauges on the front of the dishwasher, one labeled rinse and the second labeled wash. The wash gauge registered 119 degrees and the rinse temperature registered 140 degrees. Dietary aide (DA)-A stated he did not recall ever checking the temperatures on the dishwasher. During kitchen tour on 5/21/23, the dietary manager (DM) observed dishwashing and stated the dishwasher temperature was running at 119 degrees during the wash cycle and 170 degrees during the rinse cycle. DM-A indicated the wash cycle needed to reach 150 degrees and the rinse cycle 180 degrees to properly sanitize the dishes. DM did not know how long the dishwasher was running cold as there was no record or log of the dishwasher temperatures. DM noticed it was running cold a couple days prior but she forgot to notify maintenance. On 5/22/23, DA-B stated he never recorded temperatures for the dishwasher. DA-B did not think the gauges in front of the dishwasher worked but thought the bigger gauge in the back of the machine recorded the rinse temperature and the smaller one in the back recorded the wash temperature. DA-B ran a load of dishes through and checked both gauges, and reported both gauges identified 160 degrees and that was the temperature the dishwasher needed to be run at. DA-B didn't record and dishwasher temperatures on logs, but thought they used to several months back. The facility policy Dish Machine Temperature Log dated 2019, indicated staff were to monitor dish machine temperatures throughout the dishwashing process. Staff were to record dish machine temperatures for the wash and rinse cycles at each meal. The director of food services would spot check the logs to assure temperatures were appropriate and staff were correctly monitoring dish machine temperatures. The director of food services would promptly assess any dish machine problems and take action immediately to assure proper sanitation of dishes. An undated Model EST44 CMA Dish machines manual was provided. A section labeled Operation identified the required steps to begin operation of the dish machine. Step 3 instructed to allow the dish machine to come to temperature and identified the wash temperature at 150 degrees minimum, and the final rinse temperature at 180 to 195 degrees. A section labeled Regular Service and Maintenance Checklist directed staff to check wash tank temperature 150 degree minimum, check power rinse tank temperature 160 minimum and check final rinse temperature 180 to 195 degrees. Food Temperatures On 5/22/23, at 11:25 a.m. dietary cook (DC)-A was observed setting out food in preparation of lunch service. DC-A removed a tub of commercial potato salad from the refrigerator and spooned a large amount into a blender. After blending the potato salad to a puree consistency, DC-A spooned the pureed potato salad into a hotel pan, covered with plastic wrap and returned it to the refrigerator. DC-A continued to dish up food into pans to send out to the facility wings for service. DC-A setup food on to two individual carts, the temperature of the food was taken as he set each pan of food on the carts. DC-A took two containers of pureed potato salad from the refrigerator and placed one on each cart. After taking the temperature of the potato salad, DC-A stated it was 43.2 degrees. DC-A stated cold foods needed to be 45 degrees or colder to serve. During continuous observation on 5/22/23, between 11:25 a.m. through 12:10 p.m. the pureed potato salad on the south wing was observed to remain on the metal kitchen cart without ice or refrigeration. On 5/22/23, at 12:10 p.m. DA-A was observed to take the temperature of the food on the south wing prior to dishing up individual residents their lunch. The temperature of the pureed potato salad was 49 degrees and the pureed chicken salad temperature was 46 degrees. DA-A stated cold foods should be between 30 to 40 degrees. It was not their practice to put the salads on ice when they left the kitchen, but the food was usually never much above 40 degrees, and the facility rarely served salads. DA-A would just serve them. - DA-A was observed to open a can of soup from the cupboard for a resident's alternative request. He placed the soup in a bowl and in the microwave, setting the microwave at 30 seconds. After 30 seconds of heating in the microwave, DA-A placed the bowl on a tray and gave to a nursing assistant (NA) to serve to the resident, making no attempt to monitor the temperature of the food. When requested to check the temperature of the soup, the soup registered 100 degrees. DA-A stated it should be 130 degrees for service and returned the soup to the microwave to warm for additional time. DA-A stated he did not routinely temp the soup when heating it for resident. They just knew how long it needed to be in the microwave to get it hot. On 5/22/23, at 12:15 p.m. DM was notified of the temperature of the salads and stated that was time/temperature abuse. DM removed the pureed salads from service. The dietary food temperature logs May 1 through May 22, 2022 indicated food temperatures were recorded 25 out of 66 opportunities prior to service. Food temperature logs for March 2023 and April 2023 could not be provided. On 5/24/23, DM stated the facility did not have a policy of when to check the temperature of food for service. DM now instructed the staff take the temperature of all the food prior to every meal service. The facility policy General HACCP (Hazard Analysis and Critical Control Point, a system to prevent food safety hazards) Guidelines for Food Safety dated 2019, indicated food must be held at greater than 135 degrees or lower than 41 degrees. The United States Public Health Service Food and Drug Administration Food Code 2022, section 3-202 Specifications for Receiving Food, identified refrigerated food should be at a temperature of 41 degrees or below when received. Section 4-204, Warewashing Machines, Temperature Measuring Devices, identified a warewashing machine should be equipped with a temperature measuring device that indicated the temperature of the water at each wash and rinse tank and as the water enters the hot water sanitizing final rinse manifold.

Based on observation, interview and document review, the facility failed to ensure the kitchen floors, refrigerators, stove, oven, food warming cart, dishwashing area, and counters were kept in a clean, sanitary manner to reduce the risk of cross contamination in 1 of 1 main production kitchens and 1 of 2 kitchenettes. This had the potential to affect all 58 residents, staff and visitors who consumed food prepared in and/or served from the kitchen. Finding include: On 5/21/23, an initial kitchen tour was completed. The kitchen floor in the kitchen preparation and cooking areas as well as the dishwashing area were covered with dried food and spills on the ceramic tiles and through out the grout between the tiles. The kitchen dish washing area had pans of dried up bars on the counter, dried hard dinner rolls, and a tub full of lettuce salad with dressing that was wilted, dry, and discolored. Dietary aide (DA)-A stated the kitchen was like that when he came on shift that morning, the food sitting out was from the day before. - Dietary cook (DC)-A stated the night shift was to wash the floors and it was obvious they had not done so. DC-A was too busy to wash them before he started his shift. DC-A would clean the stove and counters after his lunch service was done. The food in the kitchen area and the dirty dishes in the dish washing area was from the night before and they should have put the food away and washed their dishes but the previous shift did not. During subsequent observations of the kitchen with dietary manager (DM)-A on 5/21/23 and 5/22/23, the kitchen floor remained sticky with visible food and spills through out the kitchen preparation, cooking and dishwashing areas. Dried food and liquid spills were on the outside panels of the kitchens refrigerators. The back splash of the stove and the hoods were covered with food and grease splatters. Burned food debris and grease were in the oven drip trays which were brown in color. DM-A stated the trays should appear clean and silver in color. The warming unit near the stove had dried food spills covering both sides and in the bottom inner trays. It was not clean and would probably function better if it were clean and had water in the bottom pan. - The garbage can was positioned next to the kitchen stove and flat top area, and was overflowing with garbage, no cover for the can was visible. DM-A stated the staff were told to take the garbage out every shift and not just one time per day. - Food spills and food crumbs were spattered over the walls near the garbage and the stove. Food spills and liquid spills were in the bottom cupboards where clean pots and bowls were being stored. Several open boxes of grocery food items were on the floor of the kitchen's walk in cooler .DM-A indicated the kitchen areas should be cleaned on a regular basis and had the potential to attract pests or grow mold. - The sink in the dishwashing area was full of cold and food laden, scummy water. - The south kitchenette counters had visible food crumbs over the counters. Bread was opened and undated. A hotel pan on a lower counter shelf was full of cold, dirty water on a shelf with food prep utensils. The Resident Council Minutes dated 4/19/23, identified residents reported frequently receiving dirty silverware and felt dietary staff may need to be re-educated on how to properly wash and inspect silverware before setting the tables. Floors in the dining rooms were not always cleaned and may need to talk to dietary staff about spot cleaning if maintenance could not attend to them right away. During interview on 5/24/23, DM-A stated she had recently started at the facility and needed to train the staff on how to put food away and initiate a cleaning routine. DM-A was aware of the resident council complaints and had attended their last meeting to discuss their issues. The facility policy Cleaning Instructions dated 2019, indicated the food and nutrition staff would maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The director of food and nutrition services would determine all cleaning and sanitation tasks needed for the department. Tasks should be designated to be the responsibility of specific positions the department. A cleaning schedule would be posted for all cleaning tasks and staff would initial the tasks as completed. Staff would be held accountable for cleaning assignments.