**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to get 1 of 2 residents (R36) out of bed when requested.Findings include:R36's quarterly Minimum Data Set (MDS) dated [DATE], identified R36 had diagnoses which included quadriplegia, fracture of surgical neck of left humerus with routine healing, anxiety, and depression. R36's MDS identified R36 was moderately cognitively intact, had no rejections of care, and was dependent on staff for bed to wheelchair transfers. R36's care plan dated 5/21/25, identified R36 had the potential for calling 911 if her call light was not answered fast enough or if she dropped something on the floor. Interventions included to try to answer the call light as soon as possible if not able to answer call light immediately to let R36 know when would be back (to give a length of time). In addition, R36's care plan dated 2/1/25, identified R36 had an activity of daily living (adl) self-care performance and required a mechanical lift with substantial maximal assistance of one staff for transfers. On 6/24/25 at 2:52 p.m., R36 waved writer in and said can you help me? She said she wanted to get up out of bed, she was asked if she had pushed her call button, which she then did. The room number showed on the call light scroll bar in the hallway. -at 2:55 p.m., nursing assistant (NA)-A entered R36's room with linens, the call light was shut off and NA-A exited the room and went to the next room.-at 3:05 p.m., the call light was back on, NA-A entered the room and could be heard asking what she could get for R36. The call light was shut off and NA-A exited the room. R36 was not assisted out of bed. During an interview on 6/24/25 at 3:24 p.m., R36 said NA-A told her that her partner didn't show up so she couldn't get her up. During an interview on 6/24/25 at 3:30 p.m., NA-A stated she told R36 twice that she couldn't get her up because she couldn't find her partner. NA-A offered that R36 gets up on days. Then stated, oh there's my partner. NA-A did not approach NA-B to ask for help in getting R36 up. During an interview on 6/24/25 at 3:48 p.m., licensed practical nurse (LPN)-B verified they had not been approached by any NAs for help in getting R36 up. During an interview on 6/24/25 at 3:49 p.m., NA-B stated they were not informed by NA-A that R36 wanted to get up. During an interview on 6/26/25 at 11:18 a.m., registered nurse (RN)-B verified R36 had been wanting to get up in her chair more often. RN-B verified she would expect staff to get her out of bed even if she didn't want to stay up for very long. RN-B stated not getting R36 up could have been related to staffing, said too much work to do, offered that the unit used to have three nursing assistants but has gone down to two even though the census hadn't changed, the unit remained full, so there were two NAs to care for 25 residents. During an interview on 6/26/25 at 12:50 p.m., the director of nursing (DON) verified she would expect staff to help a resident out of bed as requested. The DON offered if they couldn't find their partner they should find another staff. The Combined Federal and State [NAME] of Rights dated 2/1/17, identified under Self-Determination, The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure residents were comprehensively assessed for self-administration of medications for 1 of 2 residents (R20) reviewed for self-administration of medication.Findings include:R20's significant change Minimum Data Set (MDS) dated [DATE], identified R20 had intact cognition with diagnoses that included heart disease, hypertension, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the protective layers covering the brain), Parkinson's disease, chronic atrial fibrillation, type 2 diabetes, congestive heart failure, chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), anxiety, osteoarthritis, and dysphagia (difficulty swallowing).R20's provider orders reviewed on 6/25/25, included the following orders:-Advair Diskus inhalation aerosol powder breath activated 250-20 micrograms per actuation (mcg/act), inhale one puff orally two times a day related to COPD, rinse mouth after use, ok to self admin after nurse set up-Ipratropium-albuterol inhalation solution 0.5-2.5 (3) milligrams per 3 milliliters (mg/3mL) inhale one vial orally via nebulizer two times a day for shortness of breath (SOB) related to COPD, ok to self admin after nurse set up-Ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3mL inhale one vial orally via nebulizer every 4 hours as needed (PRN) for SOB related to COPD, ok to self admin after nurse set up-Proventil HFA inhalation aerosol solution 108 (90 Base) mcg/act inhale 2 puffs orally every 4 hours PRN for SOB related to COPD, ok to self admin after nurse set upR20's Medication Self Administration assessment dated [DATE], indicated R20 being able to self-administer inhalant medications and nebulizer medications. Review of R20's medical record showed no other medication self-administration assessments from 5/23/24 to 6/25/25.During interview on 6/26/25 at 12:28 p.m., licensed practical nurse (LPN)-A verified R20's provider orders as listed. LPN-A stated for residents that can self-administer medications the nurse would bring the medication to the resident, fill the nebulizer if needed, and give to the resident. LPN-A identified R20 as being cognitively able to self-administer medications, and was able to turn off nebulizer when the treatment was complete.During interview on 6/26/25 at 12:33 p.m., registered nurse (RN)-A verified R20's provider orders as listed. RN-A stated in order for a resident to self-administer medications an assessment would be done to make sure resident understood how to self-administer safely. RN-A stated these assessments were completed quarterly and if there was a change in the resident's condition. RN-A confirmed R20 had an assessment done on 5/23/24 and had not been assessed since that time.During interview on 6/26/25 at 12:37 p.m., director of nursing (DON) verified R20's provider orders as listed. DON explained residents had to be assessed for ability to safely self-administer medications and needed to be reassessed periodically and if the resident's condition had changed. DON confirmed R20 had assessment done on 5/23/24 and had not been reassessed since that time.Self-Administration of Medication by Residents policy reviewed on 2/27/24, indicated If the resident wishes to self-administer medications, they will be assessed for their ability to safely self-administer their medications. The assessment will include cognitive status, physical status, which medications are appropriate. Policy continued to say A periodic re-assessment by the IDT of the continued appropriateness of the self-administration will be completed, and the decision to continue the self-administration of medications will be based on changes in the resident's medical and decision-making status

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure bathing preferences were honored for 1 of 1 resident (R10) reviewed for choices.Findings include:R10's significant change Minimum Data Set (MDS) dated [DATE], indicated R10 was cognitively intact with the diagnoses of congestive heart failure, diabetes and end stage renal disease. Section GG. indicated R10 required partial/moderate assistance with shower/bathing. R10's Care Plan Report last revised 5/7/25, identified R10 required partial/moderate assistance of one with bathing/showering. R10's care plan lacked identification of R10's preferences for personal hygiene and bathing.During an interview on 6/23/25 at 4:41 p.m., R10 stated they would like to have a shower two times a week. They didn't feel very clean by mid-week and felt like they were smelling a little. They really wished it could be two times a week, but nobody would do it. During an observation on 6/25/25 at 9:03 a.m., R10 was at the nurse station asking when they would get their bath. R10 was told they were behind. R10 propelled themselves to their room. During an interview on 6/25/25 at 9:05 a.m., R10 stated they were supposed to get their shower this a.m., but they had been told staff were running late. R10 stated when they were at home, they took a shower every day and now they only got a shower once a week, every Wednesday. When they arrived, they had not been asked about bathing preferences, they were just told their day was Wednesdays. R10 stated they wished they could get a shower more frequently because after a couple days they started to feel dirty. They had told a few different nurses, how they felt and asked for a second shower, but nobody had listened or helped them. They really looked forward to Wednesdays because their body just didn't feel good when they felt like they smelled bad. During an interview on 6/26/25 at 11:34 a.m., RN-A stated if a resident had expressed, they wanted a shower two times a week, then their request should be honored.During an interview with on 6/26/25 at 2:04 p.m., the director of nursing (DON) stated the facility tried to honor resident bathing preferences and if a resident requested a shower two times a week, they would do their best to honor that. They would expect staff to bring forward resident requests and preferences for bathing frequency so that the team could address them in the care plan. The facility policy Person Centered Care Planning dated 12/18/23, listed the care partner team will work to replicate resident's preferences for daily routine and incorporate person centered language into the plan of care. The self-determination section included resident/family representative should be involved, informed and have input in decisions about their care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the us of as-needed (PRN) psychotropic medication was limited to 14 days or extended to a certain date with supporting rationale provided by the medical provider for 1 of 5 residents (R20) reviewed for unnecessary medication use.Findings include:R20's significant change Minimum Data Set (MDS) dated [DATE], identified R20 had intact cognition with diagnoses that included heart disease, hypertension, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the protective layers covering the brain), Parkinson's disease, chronic atrial fibrillation, type 2 diabetes, congestive heart failure, chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), anxiety, osteoarthritis, and dysphagia (difficulty swallowing).R20's provider order sheet reviewed on 6/25/25, identified order for gabapentin oral tablet 100 milligram (mg) to be given by mouth PRN for anxiety. This order started on 5/9/25 and did not have an end date.During interview on 6/26/25 at 12:28 p.m., registered nurse (RN)-C verified R20 had an order for gabapentin PRN and the order did not have an end date. During interview on 6/26/25 at 12:33 p.m., RN-A verified R20 had an order for gabapentin PRN and the order did not have an end date. RN-A stated the order needed an end date as it was a PRN psychotropic medication.During interview on 6/26/25 at 12:37 p.m., director of nursing (DON) verified R20 had an order for PRN gabapentin and the order did not have an end date. DON stated the order should have an end date due to it being PRN psychotropic medication.Psychotropic Medications policy last issued 5/21/25, indicated PRN psychotropic medications ordered will be limited to 14 days. The prescribing practitioner will evaluate and document the medications necessity, benefits, and improvement (expressions, indications of distress). If the physician deems it appropriate to extend beyond the 14-day limit, supporting rationale must be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the baseline care plan did not cover the required elements for 1 of 2 residents (R110) reviewed for care plans.Findings include:R110's admission Minimum Data Set (MDS) dated [DATE], was in progress. R110 was admitted [DATE]. R110's provider orders dated 6/26/25, identified R110 had diagnoses which included acquired absence of right leg below knee, diabetes mellitus, lymphedema (swelling, most often in an arm or leg, caused by a lymphatic system blockage), and reduced mobility. R110's orders included the following:-Consistency CHO (carbohydrate) diet Regular texture, Thin consistency, limit of potassium to 2000 mg (milligram) dated 6/11/25-Apply Sequential Compression Device to left leg QD (every day) for 1 hour one time a day related to LYMPHEDEMA dated 6/12/25-Observe closely for side effects of Diuretic medication including decreased PO (oral) intake, acute confusion, agitation, delusions, aggression, lethargy, decreased sweating, tachycardia, hypotension, orthostasis, generalized weakness, sunken eyes every shift dated 6/11/25-Observe for s/s (signs and symptoms) of Hypoglycemia, cold clammy skin, fainting, irritability, shaking, change in LOC (level of consciousness), confusion, trembling, headache, hunger, rapid pulse,nausea. Hyperglycemia increased thirst, confusion, agitation, weight loss, increase urination, drowsiness, every shift dated 6/11/25R110's care plan dated 6/16/25, identified R110 had the potential for significant change in medical condition and addressed advance directive preferences. Limited mobility dated 6/19/25, identified R110 was wheel chair dependent, did not include how R110 transferred (however physical therapy had a transfer care plan inside the closet door). Discharge plans dated 6/16/25, plan was return to home. Skin impairment dated 6/11/25, interventions included to follow facility protocols for treatment of injury, and pressure reducing cushion in wheel chair and pressure reducing mattress. Trauma related to loss of leg dated 6/18/25, was addressed. Vulnerable adult was also addressed dated 6/16/25. R110's care plan did not include activities of daily living (ADLs), diabetes mellitus, consistent carbohydrate diet, side effect monitoring for diuretic, hypoglycemia, and use of sequential compression device. During an interview on 6/25/25 at 11:34 a.m., registered nurse (RN)-B verified the care plan in the computer was missing information on diabetes mellitus, ADLs, diet, and medication. RN-B verified the care plan in the computer flowed to the Kardex, which the nursing assistants would have access to. During an interview on 6/26/25 at 1:11 p.m., the director of nursing (DON) verified the care plan in the computer was missing information on diabetes mellitus, ADLs, diet, and medication which would flow to the Kardex, which the nursing assistants had access to. During an interview on 6/26/25 at 1:45 p.m., the DON stated the 48 hour care plan was paper and there were all kinds of those care plans on the nursing unit. The DON verified the 48 hour care plan was located at the central nursing unit in the hard chart (not on the resident's nursing unit). The DON stated the charge nurse would have one and the nursing assistants would have the paper care plan as well. A review of R110's nursing unit with the DON was unable to find any paper 48 hour care plans. The DON verified the NAs would only have access to the Kardex which was generated from the computer care plan not the 48 hour care plan. The policy Person Centered Care Planning dated 4/20/23, identified the care plan would include the minimum healthcare information necessary to properly care of the resident to include: physician orders, dietary orders, activities of daily living (ADLs). In addition, If the goals and interventions change from the baseline care plan, due to a change in the resident's goals or physical, mental or psychosocial functioning, those changes must be incorporated into an updated summary and provided to the resident and his or her representative, (if applicable), until the comprehensive care plan is developed. The policy identified Care plans are available to staff using the electronic medical record (EMR) system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure to develop a comprehensive care plan for 2 of 6 residents (R13, R33) reviewed for care planning. Findings include:R13:R13's admission Minimum Data Set (MDS) dated [DATE], indicated R13 was cognitively intact with the medical condition of fractures and other multiple traumas with the diagnoses of hip fracture and lymphedema. MDS Section N. indicated R13 received opioid pain medication and a diuretic. Section GG. indicated R13 was dependent for showering, toileting, transfers, and required maximal assistance for dressing. R13's care plan date last revised 6/2/25, included the following:ADL self-care performance focus identified R13 required assistance of one with for dressing, oral care, and one to two staff for bed mobility. Personal hygiene and toilet use read I require (specify assistance) by (x) staff for both areas. R13's care plan did not identify nor include focus areas and interventions for hip fracture/weight bearing status, pain management/opioid use, diuretic medication, anticoagulant medication, self-administration, or lymphedema management.R13's Order Summary Report as of 6/26/25, included: ---Morphine sulfate and hydromorphone for pain as needed (opioid medication)---Eliquis 2.5 mg two times a day (anticoagulant) and ---Lasix 40 mg daily for lymphedema (diuretic)---Observation for anticoagulant side effectsR13's orders did not include observation for side effects from opioid pain medications and/or diuretic medication. R13's N Adv-Clinical admission dated with effective date 6/24/25 at 9:22 p.m., section AS_8. Cardiovascular assessment was documented as: Skin warm and pink with brisk capillary refill (< 3 seconds). No edema present. No Edema issues.Sequential N Adv-Skilled Evaluation assessments documented under AS_8. Cardiovascular were documented as: Skin warm and pink with brisk capillary refill (< 3 seconds). No edema present, No Edema issues on the following dates: 5/29/25, 5/30/25, 6/1/25-6/7/25, 6/9/25-6/14/25, 6/16/25-6/18/25, and 6/21/25-6/24/25.admission and ongoing assessments lacked evidence to show R13's chronic lower extremity edema had been identified on admission and assessed for worsening on an ongoing basis. During an interview on 6/23/25 at 5:31 p.m., R13 was in bed wearing a hospital gown, legs and feet were uncovered and edematous from the thigh down. A catheter bag was attached at the foot of the bed. R13 stated they were taking a water pill (diuretic) that had just been increased for the swelling in their legs and indicated they had the catheter because the water pill made it so they couldn't make it to the bathroom. R13 stated they were getting therapy in their room for a broken leg. It was noted R13 had two inhalers located on their bedside table.During an observation on 6/24/25 at 12:57 p.m., R13 was in bed with legs directly on bed, no compression or elevation of legs. Extremities were edematous from the thigh down. R13 stated they had mostly been doing strengthening exercises because they couldn't bear weight on their leg yet. During an interview on 6/25/25 at 2:17 p.m., PT-A stated they were familiar with R13. R13 had chronic lymphedema and was toe touch weight bearing on the left leg due to fractures. PT-A reviewed OT notes and stated OT had been doing strengthening and bed mobility with R13. PT-A indicated the main focus for R13 had been to get R13 moving, but that had been difficult due to R13's pain and limited ability to bear weight on their left leg. PT-A stated they did not see any lymphedema treatments.During an interview on 6/25/25 at 3:47 p.m., RN-A stated R13 had an order entered on 6/10/25, that stated R13 could have inhalers at bedside. A Self med-assessment was completed on 6/24/25, which indicated R13 was safe to have their inhalers kept at the bedside. RN-A confirmed self-medication administration was not on the care plan. During an interview on 6/26/25 at 12:34 p.m., OT-A stated they had worked with R13 today and had wrapped R13's left leg and elevated it on a pillow because the left leg edema had been getting worse. R13's legs should be elevated on pillows to help with the edema. OT-A stated compression was also good for lymphedema and indicated OT-B had fitted R13 for tubi-grips on 5/31/25, but usually an order had to be obtained for the resident to wear them. During an interview on 6/26/25 at 11:25 a.m., RN-A stated OT primarily managed care for lymphedema however nurses were to assess for edema, skin issues, and pain related to lymphedema. RN-A stated nursing had gotten R13's diuretic increased on 5/28/25, due to increased edema. RN-A opened R13's electronic medical record (EMR) and stated R13's skilled assessments documented no edema issues. The assessments should have identified edema issues and indicated the severity of the edema. The use of diuretics and lymphedema should have been incorporated into R13's care plan. RN-A confirmed their care plan process also included planning for fractures/weight bearing, therapy, and/or other special precautions staff would need to know to care for the resident. During an observation on 6/26/25 at 12:18 p.m., R13's left leg was ace wrapped and elevated on a pillow. R13's right leg was edematous and directly on the bed. During an interview on 6/26/25 at 12:55 p.m., OT-B stated there had not been orders placed for them to see R13 for lymphedema, they had only been seeing R13 for ordered occupational therapy. Therapy goals had been slow moving due to R13's non-weight bearing status and pain levels. OT-B stated R13 had managed their lymphedema at home with ace wraps before admit. OT-B had not yet recommended OT orders for lymphedema manual treatments, but they had shown R13 some exercises R13 could do to help with their leg edema. OT-B stated they had also fitted R13 for tubi-grips but had not notified nursing because at the time R13 had gotten them on independently. OT-B was aware R13 had not been wearing the tubi-grips though. OT-B thought it may be because it was too difficult for R13 to put them on when in pain.During an interview on 6/26/25 at 2:13 p.m., the director of nursing (DON) stated lymphedema should be addressed on R13's care plan and if R13 had been fitted for tubi-grips that information should be communicated to nursing so it could be incorporated into the nursing plan of care. The care plan should also include medical diagnoses, pain management, and medications like anticoagulants and diuretic use. The DON confirmed these items were not included in R13's care plan and stated the reason for admission, therapy, and weight bearing status should also be on the care plan. The DON indicated they would expect nurses to measure the level of edema as plus one, plus two etc. when they completed assessments so clinical changes in edema could be identified and followed up on. R33:R33's significant change MDS dated [DATE], indicated R33 was cognitively intact with the diagnoses of hypertension, thyroid disorder, stroke, and seizure disorder. R33's Care Plan Report last updated on 6/2/25, lacked evidence to show a plan of care with goals and interventions had been developed for R33's seizure disorder. R33's undated Order Summary included the following orders: ---Observe closely for significant side effects of Anticonvulsant medication including drowsiness, ataxia, nystagmus, dizziness, blurred vision, nausea, rash, gum enlargement, ---Keppra Oral Solution 100 MG/ML (Levetiracetam) Give 5 ml by mouth two times a day related to OTHER seizures During an interview on 6/26/25 at 11:24 a.m., RN-A, stated nursing had a standard guide they followed for care planning which identified certain medications and side effect monitoring that should be included in the care plan. RN-A indicated pain was a standard part of the care plan and identified seizure medication and monitoring should also be included in the care plan. During an interview on 6/26/25 at 1:49 p.m., the DON stated a seizure disorder would be important to include on the care plan. The DON identified R33 was on Keppra and stated they expected medication monitoring for Keppra and seizure disorder to be part of the care plan. The policy Person Centered Care Plan dated 4/20/23, instructed for each resident to have a comprehensive person-centered care plan developed with resident/representative input consist with resident rights that was to include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified through comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to revise the care plans to reflect current care needs for 2 of 6 residents (R37, R52) reviewed for care planning. Findings include:R37:R37's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and hospice care. Diagnoses for R37 included hemiplegia and hemiparesis following a cerebral hemorrhage affecting the right side, diabetes mellitus, pneumonia, chronic kidney disease stage three, and chronic gout.R37's care plan didn't indicate a hospice status or contain coordination of care with St. Croix Hospice. During an interview on 6/26/25 at 8:47 a.m., the HUC stated she didn't keep hospice paperwork for St. Croix, any documents they had should be in the hard chart. During an interview on 6/26/25 at 10:20 a.m., the DON would expect there to be a hospice care plan for R37.R52:R52's quarterly MDS dated [DATE], identified limited range of motion (ROM) in both lower extremities. Was dependent on assist of two for toilet hygiene, personal hygiene, lower body dressing, and transfers. R52 needed maximum assistance of two for showers and bed mobility. Section H identified R52 was always incontinent of bowel and bladder. Diagnoses included a current urinary tract infection (UTI), psoriasis, delusional disorder, hallucinations, severe major depressive disorder with psychotic symptoms, depression, and adult failure to thrive. R52's care plan dated 2/2/25, identified an activities of daily living (ADL) self-care deficit with a goal to maintain her current level of function with an intervention to provide an assist of two staff to transfer R52 in and out of the bath or shower, and an assist of one to complete bathing tasks. The care plan didn't address refusal of care or planned follow-up approaches. Review of R52's electronic medical record (EMR) on 6/26/25, identified in the month of June bathing was charted as completed for R52 on 6/11 and 6/18/25. Review of R52's progress notes didn't reveal refusals of care in June 2025. During an observation on 6/23/25 at 6:17 p.m., R52 was sitting on her bed, her hair appeared wet and stringy, white facial hair was noted on her chin, and there was a red rash around her mouth and chin. During an observation on 6/25/25 at 8:25 a.m., R52 was sitting on her bed eating breakfast, her hair appeared wet and hung in clumps. During an interview on 6/25/25 at 2:19 p.m., nursing assistant (NA)-E stated R52 just got a bed bath because she didn't like to get out of bed. During an interview on 6/25/25 at 2:56 p.m., NA-F stated R52 had mostly bed baths because she didn't like getting out of bed, she really hated it. They try and take it day by day with R52. NA-F stated there were shampoo caps for washing hair when doing a bed bath, and they only shaved her face when it wasn't broke out from her psoriasis but she refused her cream (treatment for psoriasis) all the time too. During an interview the week of 6/23 to 6/26/25, an unidentified employee (UE)-A stated they can't get their work done, checks and changes (for incontinent care) didn't get done on time, and they are expected to get one bath done on a shift, but typically wasn't possible. UE-A stated they were able to chart about 75% of the time. UE-A added they used to have a restorative aid, but because of staffing issues that person had to go back to NA work, and sometimes they have a bath aid. UE-A provided an example for a unit having seven two-person transfers while there were two NAs and one nurse during a day shift. UE-A confirmed R52 did refuse cares, they would give her some time and then re-approach. During an interview on 6/26/25 at 7:38 a.m., licensed practical nurse (LPN)-D confirmed she was familiar with R52, and she often refused bathing, hair washing, and the prescription cream for her face and then would refuse to shave because her face would be broken out. LPN-D explained you had to take it day to day with R52 because some days she was delusional, you had to try get things done for her on days she was willing. During an interview on 6/26/25 at 10:14 a.m., the DON stated they just keep trying when R52 refused care, try a different staff, or call her husband and he may be able to get her to do it. The DON's expectation would be for the refusal of care to be on the care plan. A policy, Person Centered Care Planning dated 4/20/23, identified its purpose was to provide guidance to care center staff on developing/establishing the resident's person-centered care plan. The policy indicated care plan development will include an assessment of needs to identify and support what is important to the person as well as including preferences for when how, and by whom direct are partner support is provided, and the interdisciplinary team will review the care plan quarterly, with significant changes and as needed to determine if the care plan reflects current resident needs and choices. An undated Hospice Respite Care Agreement between [NAME] Heritage Manor and St. Croix Hospice, identified the facility shall participate in any meetings, when requested, for the coordination, supervision and evaluation by Hospice of the provision of Respite Care. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure oxygen tubing and supplies were properly managed for 1 of 1 resident (R211) who was reviewed for oxygen use. Findings include: R 211's admit Minimum Data Set (MDS) dated [DATE], indicated R211 was mildly cognitively impaired with the diagnoses of emphysema and congestive heart failure.R211's Care Plan Report last revised 6/8/25, included R211's use of humidified oxygen of 1 to 4 liters related to diagnoses of congestive heart failure and emphysema.R211's Treatment and Medication Administration Record dated between 6/1/25 and 6/24/25, did not include documented oxygen tubing and/or bubbler changes. During an observation on 6/23/25 at 6:48 p.m., R211 was wearing oxygen tubing that was connected to an oxygen concentrator with bubbler (container with water to add moisture to received oxygen). Neither the oxygen tubing or bubbler were dated. R211 stated they were not sure when their oxygen tubing had last been changed.During an observation on 6/24/25 at 11:59 a.m., R211 was seated in their wheelchair with oxygen tubing on. Neither the tubing or the bubbler were dated. During an observation on 6/25/25 at 8:57 a.m., R211 was seated on their bed with their oxygen on. Neither the tubing or the bubbler were dated. During an interview on 6/25/25 at 3:49 p.m., registered nurse (RN-A) reviewed R211's electronic medical record (EMR) and confirmed there was not any documentation to show when R211's oxygen tubing had last been changed, nor did R211 have an order for oxygen tubing to be changed. RN-A went into R211's room and confirmed R211's tubing was not dated. RN-A stated they could not determine when R211's tubing had last been changed because it was not labeled, nor was there documentation in R211's EMR. RN-A stated it was policy to date tubing when it was changed, their normal process was to have an order for oxygen tubing changes. Nurses were expected to sign off on the order and date the tubing when changed so that others could tell it had been changed. During an interview on 6/26/25 at 1:52 p.m., the director of nursing stated all residents at the facility should have an order to have their oxygen tubing changed every Sunday. The tubing should be dated when it is changed. The tubing should be changed for infection preventions reasons. The facility Oxygen Policy dated 4/14/21, directed oxygen tubing and cannula or mask should be labeled with the date and changed every week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to follow dialysis orders for 1 of 1 resident (R111) reviewed for dialysis care. Findings include:R111's admission Minimum Data Set (MDS) dated [DATE], identified R111 had diagnoses which included dissection of thoracoabdominal aorta, anxiety, dependence on renal dialysis, and seizures. In addition, R111's MDS identified she was moderately cognitively intact, had no rejections of care and was receiving dialysis. R111's Order Summary report identified the following:Daily weights, update medical doctor for weight gain more than two pounds per day or five pounds per week. Dated 6/9/25.Ensure the dressing on the double lumen right internal jugular tunneled-site is intact. If comes loose re-secure, or replace dressing with a Tegaderm. Keep dressing clean and dry and lumens covered. Two times a day. Dated 6/9/25.R111's electronic treatment administration record (eTAR) identified the following:Daily weights missing on 6/13/25, 6/16/25, 6/18/25, 6/20/25, 6/25/25Dressing check twice daily missing morning check on 6/13/25, 6/19/25, 6/20/25, 6/25/25R111's care plan dated 6/9/25, identified R111 needed dialysis related to renal failure. Interventions included to check dressing daily at access site, to document, to re-secure or change dressing if it became loose or fell off. To ensure lumens were covered. On 6/26/25 at 3:12 p.m., R111 returned from dialysis, she was using a wheeled walker and walked to the kitchenette and drank two glasses of juice. R111 said she felt shaky so she had some orange juice. She said the nurses never do anything when she would get back and said she still had her paperwork from the morning, said she had forgotten to give it to them at the dialysis center. R111 said her family picked her up and took her to dialysis and brought her back. During an interview on 6/26/25 at 11:00 a.m., registered nurse (RN)-B reviewed the documentation and verified the missing documentation for weights and dressing checks. RN-B stated she would expect staff to follow orders as written, said she was not sure if they were short on those days. RN-B verified it was important to weigh R111 daily and to report the changes in weight to the MD as medication may have need to be changed. RN-B verified the dressing on R111's access site needed to be checked twice daily and said missing documentation was related to staffing, had often been told by staff they don't have time to document cares. During an interview on 6/26/25 at 2:19 p.m., the director of nursing (DON) verified she would expect staff to follow and document orders as written. Said concern with missing weights could mean fluid overload and the need to diurese (remove fluid) the resident. During an interview on 6/26/25 at 3:20 p.m., RN-E stated R111 stopped at the nurses station and asked for a glass and nothing more, she was not aware R111 was feeling shaky. RN-E said she would check R111's dialysis site/dressing at bedtime and check a blood sugar at 4:00 p.m RN-E stated she had not had any training on taking care of residents who were on dialysis and stated she was supposed to be in training, but there was a call in so she was pulled from training to work on the cart. RN-E stated communication from dialysis center went to the charge nurse. During an interview on 6/26/25 at 3:26 p.m., RN-A stated the paperwork from the dialysis center would be faxed around supper time and stated if there were concerns or problems the dialysis center would call them directly. During an interview on 6/26/25 at 3:39 p.m., the DON stated she would expect a resident returning from dialysis to have the nurse perform an assessment to include checking the dialysis site, review the paperwork and check a set of vitals. During an interview on 6/26/25 at 3:48 p.m., RN-F stated she was not sure if they received dialysis education in the annual training. The policy Dialysis Management dated 2/19/18, identified the purpose of the policy was to provide guidance to care center staff for residents requiring dialysis services. The policy identified the dialysis center and the facility would exchange information on medical, nursing issues, dietary concerns, psychosocial concerns, and any lab values. The policy did not address what steps the facility staff would take when the resident returned from their dialysis appointment or care of the dialysis site if it was not a graft or fistula. The training for RNs caring for dialysis residents was requested but not provided.

**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 4 residents (R37, R48) observed to receive medication. A total of three errors out of 34 opportunities were identified resulting in a facility error rate of 8%. Findings include: R37:R37's significant change Minimum Data Set (MDS) dated [DATE] identified intact cognition and hospice care. Diagnoses for R37 included hemiplegia and hemiparesis following a cerebral hemorrhage affecting the right side, diabetes mellitus (DM), pneumonia, chronic kidney disease stage three, and chronic gout. R37's medication administration record (MAR) for June 2025, identified an order on 4/2/25 for tart cherry ultra oral capsules 1200 milligrams (mg), give two capsules by mouth two times per day related to gout. During an observation and interview on 6/25/25 at 9:09 a.m., licensed practical nurse (LPN)-E was preparing R37's medications for administration and noted there was only one capsule of the cherry ultra capsules left. LPN-E stated it had been ordered but wasn't here yet, so she documented a partial dose and made a note explaining the medication was on order from the pharmacy. During an interview on 6/25/25 at 2:03 p.m., LPN-E stated the medication had not come in yet, but they might get it with delivery tonight. During an interview on 6/26/25 at 10:10 a.m., the director of nursing (DON) stated LPN-E could have called the pharmacy to see if more of the cherry tabs were coming or notify the provider of a partial dose and have them ok it. The DON stated it would be a medication error. R48:R48's admission MDS dated [DATE], identified intact cognition and diagnoses of Parkinson's disease, hypothyroidism and gastro-esophageal reflux disease (GERD). R48's provider orders identified the following orders: -On 4/10/25, omeprazole delayed release capsule 40 mg, give one capsule by mouth one time per day before meal for acid reflux. Do not crush medication. -On 6/24/25, carbidopa-levodopa 25-100 mg, give one-half tablet by mouth two times per day related to Parkinson's. During an observation and interviews on 6/25/25 at 9:34 a.m., LPN-C prepared and administered the above-noted medications to R48. LPN-C stated they had a fall on the unit this morning so they were behind, and typically she wouldn't give omeprazole after a meal because it was important to help prevent GERD. LPN-C further stated it was important to administer carbidopa-levodopa at the same time every day. During an interview on 6/25/25 at 2 p.m., R48 stated he had breakfast about 8:30 a.m. this morning, before he got his morning pills. During an interview on 6/25/25 at 1:26 p.m., pharmacist (PH)-T stated it was best to give medications like carbidopa-levodopa and omeprazole at the same time every day. For the omeprazole, it would be best to give a half-hour before a meal to help avoid the symptoms of GERD. During an interview on 6/26/25 at 2:31 p.m., the director of nursing (DON) stated she expected medications to be given on time and would have expected the nurse to call for help. A policy, Heritage Manor Ordering and Receiving Medications dated 11/2017, identified requests for refills of current medications were either written on a medication re-order form or to pull the sticker from the bottle and place on the re-order form provided by the pharmacy for this purpose. Reorder medications three to five days in advance of the need to assure an adequate supply was on hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the hospice medical record for 1 of 1 resident (R37) reviewed for hospice care. Findings include:R37's significant change Minimum Data Set (MDS) dated [DATE] identified intact cognition and hospice care. Diagnoses for R37 included hemiplegia and hemiparesis following a cerebral hemorrhage affecting the right side, diabetes mellitus, pneumonia, chronic kidney disease stage three, and chronic gout.R37's care plan didn't indicate a hospice status or contain coordination of care with St. Croix Hospice. During an observation and interview on 6/26/25 at 8:38 a.m., R37's St. Croix Hospice binder was stored at the central nurse's station, it didn't contain any information. R37's hard chart was also stored at the nurse's station, and that chart didn't contain any hospice information. The hospice binder had sections for hospice contact information, admission documentation, charting forms for nursing assistants (NA)s, nurses, and care plans, all of which were blank forms. Registered nurse (RN)-A confirmed the absence of hospice documentation in the hard chart and stated St. Croix provided their own binders for the hospice documentation. RN-A stated the case manager had to give them a new binder because R37's wife took the other one. RN-A stated the admission paperwork, and interdisciplinary team (IDT) care plans were with the health unit coordinator (HUC). During an interview on 6/26/25 at 8:47 a.m., the HUC stated she didn't keep hospice paperwork for St. Croix, any documents they had should be in the hard chart. During observations and interview on 6/26/25 at 9:01 a.m., the director of nursing (DON) stated St. Croix did a binder and that was in R37's room, but the hospice nurse needed to chart in Point Click Care (PCC, electronic health record), and just the NA just charted in the binder. R37's wife wanted the book in his room so she could look at it. At 9:10 a.m., the DON talked to R37, and he didn't know where the book was. The DON walked to the nurse's station on the 100s unit and checked the file cabinet and medication room but didn't find it there. The DON then checked with licensed practical nurse (LPN)-D, the nurse for the unit, and she didn't know where it was. During an interview on 6/26/25 at 12:21 p.m., St. Croix Hospice case manager (HCM) stated the hospice admission nurse normally brought the binder to the facility at admission and it contained the certificate of terminal illness (CTI), care plan and every 2 weeks after IDT the care plans get faxed over every 2 weeks, he puts them in the St. Croix binder. Not sure if the consents/agreements. The HCM stated R37's binder was in his room, but last Friday the hospice aid had said she couldn't find it. Would typically provide the forms that are, they don't do stickers on the hard charts. Main contact for [NAME] it is usually [NAME] the charge nurse. He would say that information should be in the chart, so that people know the info they need. During an interview on 6/26/25 at 10:20 a.m., the DON would expect there to be a hospice care plan for R37. The DON stated she called R37's wife and she hadn't seen the binder either and didn't know where it was. The DON added she had contacted St. Croix Hospice to let them know they didn't have a hospice binder here. An undated Hospice Respite Care Agreement between [NAME] Heritage Manor and St. Croix Hospice, identified the facility shall participate in any meetings, when requested, for the coordination, supervision and evaluation by Hospice of the provision of Respite Care. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to have infection control measures in place for a resident colonized with a multi-drug-resistant bacteria (MDRO, bacteria resistant to one or more classes of antimicrobial agents) for 1 of 1 resident (R41) reviewed for infection control. Findings include: R41's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of obstructive and reflux uropathy, benign prostatic hyperplasia (BPH, non-malignant swelling of the prostate), and extended-spectrum beta-lactamase (ESBL, enzymes produced by certain types of bacteria that make them resistant to many common antibiotics) resistance, and urinary tract infection (UTI). The MDS also indicated R41 was occasionally incontinent of urine and had no catheter or toileting plan. R41's care plan dated 1/31/25, identified an activities of daily living (ADL) self-care performance deficit with interventions to assist with toilet use and hygiene when R41 requested. The care plan also identified intermittent bladder incontinence with an intervention for enhanced barrier precautions (EBP) due to a history of ESBL. R41's electronic medical record (EMR) included a banner identifying enhanced barrier precautions (EBP) were in place related to ESBL. Review of R41's progress notes identified a note on 4/14/25, from the assistant director of nurses (ADON) and infection preventionist noted the final urinary culture results received and uploaded into chart, the report indicated greater than 100,000 colony-forming units (CFU) per milliliter (mL) klebsiella pneumoniae (a type of bacteria) present. A note from 6/16/25 identified R41 returned from a urology appointment and received new orders to continue changing depends (incontinent brief) every three to four hours and as needed. Start timed voiding every two hours. Bacteriuria (bacteria in urine without signs of infection) in R41 due to colonization with a very resistant strain of klebsiella and will defer treatment since he is asymptomatic. If symptomatic (fevers, dysuria, confusion, flank pain, etc.) will need intravenous antibiotics and infectious disease consult. During an observation and interview on 6/23/25 at 5:19 p.m., R41 stated he had UTIs one after the other. It was observed there were no EBP in place in R41's room, no sign on or near the door, and no personal protective equipment (PPE) in the room. During an interview on 6/24/25 at 1:27 p.m., nursing assistant (NA)-E stated R41 needed help once in a while with brief changing and incontinence care. NA-E stated they didn't need to wear PPE when helping him. NA-E looked at R41's door and stated, no he didn't have precautions.During an interview on 6/24/25 at 1:49 p.m., NA-H stated they did have to help R41 in the bathroom sometimes when he needed help cleaning up after an incontinent episode. During an interview on 6/24/25 at 1:53 p.m., the assistant director of nurses (ADON) and infection preventionist stated R41 was colonized with ESBL and should have EBP because it was important to help prevent the spread of ESBL. A policy, Enhanced Barrier Precautions dated 8/20/24, identified its purposed was to provide guidelines to staff in the application of EBP to safely care for residents colonized or infected with MDROs. The procedure identified EBP shall be used when providing high-contact care to residents who are infected or colonized with an MDRO when other precautions don't apply. The procedure identified transferring, hygiene care, toileting, incontinent care and dressing as high-contact activities for which EBP should be worn. Posted signage on the resident's door and chart should indicated appropriate use of PPE.

Based on observation and interview, the facility failed to ensure resident call lights were within reach from the bathroom floor in resident bathrooms for 4 of 4 residents (R36, R47, R111, R6) reviewed for call light accessibility.Findings include:During an observation on 6/23/25 at 2:33 p.m., the bathroom call light cord in R6's room was approximately three feet from the bathroom floor. During an observation on 6/23/25 at 5:31 p.m., the bathroom call light cord in R111's room was approximately three feet from the bathroom floor. During an observation on 6/23/25 at 6:18 p.m., the bathroom call light cord in R36's room was approximately three feet from the bathroom floor. During an observation on 6/24/25 at 9:14 a.m., the bathroom call light cord in R47's room was approximately three feet from the bathroom floor.On 6/24/25 at 12:08 p.m., maintenance director (M)-A went to each bathroom (405, 407, 410, 413) and verified the call lights were too short, M-A stated the call light cord should be reachable from the floor in case of fall in the bathroom. On 626/25 at 12:48 p.m., the director of nursing verified the call light cords should be reachable from the floor in case a resident fell in the bathroom. The policy Call Light dated 10/23/17, did not address call light cord length in resident bathrooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure there were sufficient numbers of staff to ensure all resident cares including getting residents out of bed when requested for 1 of 2 resident (R36) reviewed for choices, monitoring for and treating constipation for 1 of 2 (R16) and monitoring residents receiving dialysis for 1 of 1 resident (R111) reviewed for dialysis care. This had the potential to affect all residents residing in the facility. Findings include:Staff and Resident Interviews/Observations:On 6/23/25 at 2:53 p.m., R110 stated she had taken herself to the bathroom (said she had already waited 40 minutes) and was fearful of soiling self. R110 was tearful during the interview and further stated she had put on her artificial leg on to complete the transfer (even though she had not been cleared by therapy to do so). On 6/24/24 at 8:30 a.m., family member (FM)-F stated therapy had told them at the beginning of May there were only two nursing assistants for the entire building. FM-F stated they had a camera in their family member's room and on 5/4/25, between 2:00 p.m., and 3:00 p.m., one staff used the mechanical lift to put R35 into bed. At 8:00 p.m., two staff lifted R35 under the arms and pivot transferred her to bed (no lift was used).During an interview on 6/24/25 at 11:33 a.m., the medical director (MD) was asked about the concerns brought forward by family and residents (long waits, transferring themselves to the bathroom, not using the mechanical lift for transfers or one staff using the mechanical lift instead of two staff, cold food) the MD stated the root cause of the concerns listed would be related to not having enough staff. The MD stated he did not know what the number would be where the facility can't or shouldn't take any admissions. The MD stated the corporation thinks the facility should fill all the beds even though it might not have enough staff to take care of the residents.On 6/25/25 at 12:56 p.m., during the resident council interview, R20, R33, and R41 stated it sometimes took a long time to get their call light answered, they stated when there was a long wait, they assumed staff were busy and stated waits could be up to 40 minutes long. R20 stated when asked how long it took to get their call light answered, as long as it takes. During an interview 6/25/25 at 3:20 p.m., scheduler (S)-H explained the assignment sheets and stated the second nurse on the night shift hadn't been being filled for a couple of years. The assignment sheets identified one nurse and three nursing assistants for the entire building for nights. During an interview on 6/26/25 at 8:41 a.m., NA-C stated they worked on call so worked to fill in for call ins. NA-C stated sometimes had a bath aide, but not always, sometimes showers have to be skipped, and would be left for the next shift. During an interview on 6/26/25 at 8:43 a.m., NA-D stated would sometimes need to skip showers if it was very busy and would tell the next shift the showers weren't done. During an interview on 6/26/25 at 10:31 a.m., anonymous staff (AS)-G stated some days were really rough because of call ins, sometimes the staff for the shift would be one licensed person and two nursing assistance with new admits, falls, and hospice residents who would need medications every two hours. AS-G stated it was a big building with residents spread out. AS-G stated during the COVID-19 outbreak the second staff for nights was taken away (said this was supposed to be a temporary solution to lack of staff). AS-G stated their concerns have been brought to the director of nursing (DON) several times. Stated about six weeks ago started having an RN on call. AS-G stated with residents in the facility for short term rehabilitation after surgery they often need two staff to transfer them and require a lot of as needed pain medication. AS-G stated when working would try to run the bowel list but often no time to do it. AS-G stated two-hour turns are often late, many times the staffing was not safe when only three staff in the building. AS-G stated they would not mandate a third nursing assistant to stay for night call ins, leaving two NAs and a nurse. During an interview on 6/26/25 at 11:46 a.m., S-H verified on nights they would not mandate a nursing assistant to stay if one of the three NAs called in, leaving two NAs for the building. During an interview that occurred between the dates of 6/23/25, to 6/26/25, AS-O stated they were passing medications for 18 to 20 residents which was manageable. However, when scheduled with just one nursing assistant it was difficult to get medications passed on time. On those days, in addition to medication pass, they also had to work the floor helping to get people up, passing meal trays, answering call lights, toileting, and completing check and changes. AS-O stated they probably worked a quarter of their shifts short one nursing assistant. Residents did not get the same level of care when short staffed. Medications get delayed for cares, and residents wait longer for things like call lights, toileting, and repositioning. AS-O didn't think residents were neglected or any had had a seriously bad outcome while short staffed, but they did feel like they couldn't give the residents the quality of care they would like to. Between the dates of 6/23/25, and 6/26/25, an anonymous resident's (AR)-R family member (FM)-S asked to share information about their family member's care. They stated staffing was a real issue at the facility. There were many times staff worked short and when that happened the quality of care suffered. FM-S shared notes that showed AR-R had frequently gone 10 days between bath and one time 20 days had lapsed between bath days. FM-S stated they assisted AR-R with things like shaving, brushing teeth etc. when they were visiting but when they were not there, these things did not get done for AR-R. On several occasions they have found AR-R dressed in the same shirt as the day before. When gone for a weekend, when they got back, they would see AR -R had not been shaved. At a care conference a routine for AR-R had been developed, but staff were not following it. AR-R also has a medication that needs to be taken at the same time every day to be effective per AR-R's doctor and neurologist, but the medication is not being given as ordered and has been given as much as 2 hours later than ordered. The nurses are great, and they try, but they get pulled to do cares and then the medication gets late. FM-S stated they had brought their concerns to the director of nursing and the administrator. The administrator had said they were working on filling vacant positions but did not give any indication if they thought staffing was or wasn't good. Staff here are good people, they want to do good, they work really hard, and things are not getting done for lack of trying they don't have enough time to get everything done for resident because of staff levels. During an interview that occurred between the dates of 6/23/25, to 6/26/25, AS-N stated they were very concerned about staffing at the facility. The area they were working had residents that required two staff for transfers, however they only had one nursing assistant assigned. When this happened, they had to wait for another staff to be freed up to assist, or the nurse would have to help when there wasn't an NA. AS-N stated they would not transfer a resident by themselves if it was unsafe, so often when they worked short and family or residents would get mad because they ended up having to wait longer to get up or transfer to the bathroom. Check and changes suffered when they were short staffed as well. AS-N stated they worked short staffed more than they worked with full staff, at least 4 to 5 times in a pay period. This made it very challenging to do safe care because they were spread thin, and many residents needed assistance of two for some of their care. During an interview that occurred between the dates of 6/23/25, to 6/26/25, AS-Q stated some days staffing was not very good. Last weekend they had had only four nursing assistants for the whole building until 6:30 p.m., and then only three for the rest of the afternoon shift. AS-Q stated they felt rushed to get their work done, but they didn't feel like residents were neglected, they just couldn't do as much as they would like for residents. Sometimes they had bath aides, but bath aides often got pulled to the floor, so that made it really hard to get everyone's bath in, and baths often got bumped to another day. AS-Q stated most residents just got shaved on bath days, but if a resident asked to be shaved on another day, they would do their best to get that done. Rights:see also F550R36's quarterly Minimum Data Set (MDS) dated [DATE], identified R36 had diagnoses which included quadriplegia, fracture of surgical neck of left humerus with routine healing, anxiety, and depression. R36's MDS identified R36 was moderately cognitively intact, had no rejections of care, and was dependent on staff for bed to wheelchair transfers. R36's care plan dated 5/21/25, identified R36 had the potential for calling 911 if her call light was not answered fast enough or if she dropped something on the floor. Interventions included to try to answer the call light as soon as possible if not able to answer call light immediately to let R36 know when would be back (to give a length of time). In addition, R36's care plan dated 2/1/25, identified R36 had an activity of daily living (ADL) self-care performance and required a mechanical lift with substantial maximal assistance of one staff for transfers. On 6/24/25 at 2:52 p.m., R36 waved writer in and said can you help me? She said she wanted to get up out of bed, she was asked if she had pushed her call button, which she then did. The room number showed on the call light scroll bar in the hallway. -at 2:55 p.m., nursing assistant (NA)-A entered R36's room with linens, the call light was shut off and NA-A exited the room and went to the next room.-at 3:05 p.m., the call light was back on, NA-A entered the room and could be heard asking what she could get for R36. The call light was shut off and NA-A exited the room. R36 was not assisted out of bed. During an interview on 6/24/25 at 3:24 p.m., R36 said NA-A told her that her partner didn't show up so she couldn't get her up. During an interview on 6/24/25 at 3:30 p.m., NA-A stated she told R36 twice that she couldn't get her up because she couldn't find her partner. NA-A offered that R36 gets up on days. Then stated, oh there's my partner. NA-A did not approach NA-B to ask for help in getting R36 up. During an interview on 6/24/25 at 3:48 p.m., licensed practical nurse (LPN)-B verified they had not been approached by any NAs for help in getting R36 up. During an interview on 6/24/25 at 3:49 p.m., NA-B stated they were not informed by NA-A that R36 wanted to get up. During an interview on 6/26/25 at 11:18 a.m., registered nurse (RN)-B verified R36 had been wanting to get up in her chair more often. RN-B stated she would expect staff to get her out of bed even if she didn't want to stay up for very long. RN-B stated not getting R36 up could have been related to staffing, said too much work to do, and stated that the unit used to have three nursing assistants but has gone down to two even though the census hadn't changed, the unit remained full, so there were two NAs to care for 25 residents. During an interview on 6/26/25 at 12:50 p.m., the director of nursing (DON) verified she would expect staff to help a resident out of bed as requested. The DON offered if they couldn't find their partner they should find another staff. The Combined Federal and State [NAME] of Rights dated 2/1/17, identified under Self-Determination, The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.Constipation:see also F684R16's significant change MDS dated [DATE], identified R16 had diagnoses which included osteoarthritis of knee, postconcussional syndrome (a set of symptoms that can persist for weeks, months, or years after a concussion or traumatic brain injury), depression, muscle weakness, trigeminal neuralgia (a chronic pain condition affecting the trigeminal nerve in the face), constipation, and diabetes. R16's MDS identified R16 was cognitively intact, had impaired vision, had no rejections of care and required substantial to maximal assistance with activities of daily living (adls). In addition, R16's MDS identified R16 was always continent of bowel.R16's Order Summary Report identified the following orders:-daily during each shift monitor for side effects of opioids (lethargy, sedation, constipation, dizziness,nausea, vomiting) dated 1/25/25-ok for standing house orders unless noted otherwise dated 1/16/25-Magnesium Citrate Oral Solution (Magnesium Citrate) give 1 dose by mouth one time a day every 3 day(s) for constipation dated 6/10/25-MiraLax Oral Powder 17 GM (gram)/SCOOP (Polyethylene Glycol 3350) give 17 gram by mouth one time a day for constipation dated 5/29/25-Morphine Sulfate (Concentrate) Solution 20 MG (milligram)/ML (milliliter) give 0.5 ml by mouth every 4 hours as needed for Pain 10 mg =(0.5 ml) dated 6/23/25-Senna Plus Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) give 2 tablets by mouth two times a day related to CONSTIPATION dated 5/29/25-Ultram Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth four times a day for pain dated 6/23/25R16's care plan identified the following: - constipation related to decreased mobility, interventions included to encourage to sit on the toilet for bowel evacuation, to follow the bowel management program, to record bowel movement (BM) daily. A review of R16's bowel report 5/1/25-6/26/25, identified the following:5/1/25-5/10/25, no BM documented (10 days)5/12/25-5/17/25, no BM documented (5 days)5/19/25-5/27/26, no BM documented (9 days) out of the facility from 5/27/25-5/29/255/30/25-6/4/25, no BM documented (6 days) A review of R16's electronic medical record medication administration (eMAR) revealed the following:5/1/25-5/10/25:refused senna plus twice on 5/1/25refused senna plus once on 5/3/25, 5/4/25, 5/5/25, 5/6/25, 5/7/25, 5/8/25, 5/10/25milk of magnesia 30 milliliters given on 5/2/255/12/25-5/17/25: refused senna plus twice on 5/17/25refused senna plus once on 5/12/25, 5/13/25, 5/14/25, 5/15/25, 5/16/255/19/25-5/27/25:refused senna plus once on 5/19/25, 5/20/25, 5/21/25, 5/23/25, 5/24/25, 5/25/25, 5/26/255/30/25-6/4/25: refused senna plus once on 6/2/25, 6/4/25A review of R16's progress notes dated 5/1/25-6/26/25, identified the following:5/7/25 9:37 p.m., 0 BM for multiple days. Bowel sounds active x4. Abdomen soft and none-distended at this time. Has been receiving laxatives per protocol.This was not documented in R16's eMAR. 5/8/25 3:28 p.m., residents' abdomen is soft, non-distended, when palpated, resident denies any discomfort, bowel sounds are present in all 4 quadrants let resident know that charting says she has not had a bm for 2 weeks around, residents stated that that could not be, she said I for sure had one lately. No indication that a provider was notified. 5/21/25 2:35 p.m., MOM 30ml given PSO for no BM multiple days. No indication that a provider was notified. 526/26 at 3:08 a.m., Unable to determine last bowel movement however resident did receive mom on evening shift. No indication that a provider was notified. 5/26/25 9:29 p.m., CNAs stated res had an emesis that looked like bm. CNAs did not save it. Res told this writer and the charge nurse that it was bile. No indication that a provider was notified. 5/27/25 12:09 p.m., note identified the wound clinic called and informed them the resident was sent to the emergency room for altered mental status. 5/27/25 2:10 p.m., Resident was admitted to the hospital with colitis. A review of the Bowel Regulation/Protocol - Constipation per the standing orders did not indicate dietary interventions were taken, milk of magnesia given daily, Dulcolax suppository given, fleets enema given, Miralax given, or provider notified for bowel regimen need or refusals of bowel medication. In addition, R16's eMAR did not reflect medications given per Bowel Regulation/Protocol - Constipation.A review of R16's hospitalization from 5/27/25-5/29/25, revealed the following:R16 was admitted from the wound clinic with altered mental status, nausea and vomiting, stercoral colitis (a rare sore that develops in the colon due to prolonged and severe constipation), and a primary diagnosis of fecal impaction in the rectum. According to R16's hospital notes general surgery was consulted and made a recommendation for enemas three times daily which was ordered. Subsequently she did go to the operating room for manual disimpaction by a physician. During an interview on 6/25/25 at 9:45 a.m., registered nurses (RN)-A and RN-B stated they had not run a report to identify which residents had not had BM in the last three days. RN-A stated the night shift should have run a report for the day shift. Licensed practical nurse (LPN)-C stated they would run the report around 12:30 p.m. or 1:00 p.m LPN-C showed an alert on her electronic screen medication screen, and said it would show alerts for example vital signs out of range and no BM for longer than three days. Both RN-A and RN-B were unable to run the BM report on the computer. During an interview on 6/25/25 at 10:20 a.m., both RN-A and RN-B confirmed they currently had no way of knowing when the last BM report had been run or which residents had not had a BM in the past three days. When asked if the process for monitoring BMs was working, LPN-C stated emphatically no. A three day BM report was run which identified 16 residents who had not had a BM in the last 3 days, one third of the residents. During an interview on 6/25/25 at 11:18 a.m., LPN-C ran a seven day report which showed different information. The 16 residents on the three day report were showing they'd had a BM on the 22nd, yesterday or today. LPN-C could not explain why the two reports were different. LPN-C stated she had no idea if any other staff ran the seven day report. LPN-C said the night shift was supposed to run a BM report and highlight the residents who would need bowel medication per the house standing orders bowel regulation/protocol - constipation. LPN-C could not confirm when the report was last run. During an interview on 6/26/25 at 9:30 a.m., RN-D stated nights had not run a bowel list. RN-D stated they had no idea which residents had not had a BM in the past three days. RN-D stated they did not know how to run the report and would have to ask the charge nurse to run the report. RN-D stated R16 was one of the residents who typically had trouble with constipation and that she had recently been hospitalized with a bowel problem. RN-D stated magnesium citrate was a new medication since she returned. R16 was supposed to take the medication every three days if she hadn't had a BM but offered, she always refuses. RN-D stated she would mark it as refused and tell the charge nurse. She stated she was not sure when R16's last BM was. A review of R16's eMAR and corresponding progress note revealed the following:-Magnesium citrate oral, give one time a day every three days for constipation.-refused on 6/17/25, omitted on 6/20/25, refused on 6/23/25, and not given 6/26/25, see progress note.-6/26/25 10:10 a.m., res would take 3 sips, ref the rest. states it tastes too horrible.-No indication the provider had been notified. On 6/26/25 at 10:27 a.m., RN-A stated she was asked to run a bowel report for R16 but not for the entire unit. During an interview on 6/26/25 at 11:22 a.m., RN-B stated the bowel report should be run for the entire unit, stated it was important to know which residents had not had a BM in the past three days to prevent impaction and bowel obstruction. RN-B stated when R16 returned from the hospital magnesium citrate was a new order, she thought R16 had been going regular. She was not aware R16 was refusing the magnesium citrate. RN-B verified the facility system for monitoring bowel movements was not working. RN-B stated they worked short a lot (nursing assistants and nurses) get pulled to work on the medication cart, help on the floor. Stated when working short can't look into other concerns. During an interview on 6/26/25 at 12:42 p.m., MD verified when R16 had a report of an emesis that looked like BM, the staff on duty should have consulted with the charge nurse and called the provider. MD stated it might have indicated a bowel obstruction and R16 may have needed to go to the emergency room that night. During an interview on 6/26/25 at 12:53 p.m., the DON verified she would expect staff to utilize the house standing orders for bowel protocol, involve the charge nurse and call the provider. The DON verified it was important for residents to have BMs every three days, don't want residents to become impacted or have a bowel rupture. The DON stated in a perfect world the nurse on every shift would run a bowel report and stated it was an old idea to have the night shift RN the bowel report. House Standing Orders dated 7/17/23, identified the following: Bowel Regulation/Protocol - Constipation 1. If the resident has not had a BM in the last 24 hours may receive dietary interventions, such as prune juice of fiber2. Milk of magnesia or equivalent 30 milliliters orally every day as needed for constipation 3. Dulcolax suppository or equivalent one rectally every day as needed for constipation4. Fleets enema or equivalent one rectally every day as needed for constipation. If no results within two hours after enema, notify the medical doctor or nurse practitioner.5. Miralax 17 grams oral as needed per package instructions6. If as needed bowel meds are used more than twice in one week, assess for routine bowel regimen need. 7. Senna two tablets orally every day at bedtime as needed for three days. Dialysis care:see also F698R111's admission Minimum Data Set (MDS) dated [DATE], identified R111 had diagnoses which included dissection of thoracoabdominal aorta, anxiety, dependence on renal dialysis, and seizures. In addition, R111's MDS identified she was moderately cognitively intact, had no rejections of care and was receiving dialysis. R111's Order Summary report identified the following:-Daily weights, update medical doctor for weight gain more than two pounds per day or five pounds per week. Dated 6/9/25.-Ensure the dressing on the double lumen right internal jugular tunneled-site is intact. If comes loose re-secure, or replace dressing with a Tegaderm. Keep dressing clean and dry and lumens covered. Two times a day. Dated 6/9/25.R111's electronic treatment administration record (eTAR) identified the following:-Daily weights missing on 6/13/25, 6/16/25, 6/18/25, 6/20/25, 6/25/25-Dressing check twice daily missing morning check on 6/13/25, 6/19/25, 6/20/25, 6/25/25R111's care plan dated 6/9/25, identified R111 needed dialysis related to renal failure. Interventions included to check dressing daily at access site, to document, to re-secure or change dressing if it became loose or fell off. To ensure lumens were covered. On 6/26/25 at 3:12 p.m., R111 returned from dialysis, she was using a wheeled walker and walked to the kitchenette and drank two glasses of juice. R111 said she felt shaky, so she had some orange juice. She said the nurses never do anything when she would get back and said she still had her paperwork from the morning. She had forgotten to give it to them at the dialysis center. R111 said her family picked her up and took her to dialysis and brought her back. During an interview on 6/26/25 at 11:00 a.m., RN-B reviewed the documentation and verified the missing documentation for weights and dressing checks. RN-B stated she would expect staff to follow orders as written, said she was not sure if they were short on those days. RN-B verified it was important to weigh R111 daily and to report the changes in weight to the MD as medication may have need to be changed. RN-B verified the dressing on R111's access site needed to be checked twice daily and said missing documentation was related to staffing, had often been told by staff they don't have time to document cares. During an interview on 6/26/25 at 2:19 p.m., the DON verified she would expect staff to follow and document orders as written. Said concern with missing weights could mean fluid overload and the need to diurese (remove fluid) the resident. During an interview on 6/26/25 at 3:20 p.m., RN-E stated R111 stopped at the nurses' station and asked for a glass and nothing more, she was not aware R111 was feeling shaky. RN-E said she would check R111's dialysis site/dressing at bedtime and check a blood sugar at 4:00 p.m. RN-E stated she had not had any training on taking care of residents who were on dialysis and stated she was supposed to be in training, but there was a call in so she was pulled from training to work on the cart. RN-E stated communication from dialysis center went to the charge nurse. During an interview on 6/26/25 at 3:26 p.m., RN-A stated the paperwork from the dialysis center would be faxed around supper time and stated if there were concerns or problems the dialysis center would call them directly. During an interview on 6/26/25 at 3:39 p.m., the DON stated she would expect a resident returning from dialysis to have the nurse perform an assessment to include checking the dialysis site, review the paperwork and check a set of vitals. During an interview on 6/26/25 at 3:48 p.m., RN-F stated she was not sure if they received dialysis education in the annual training.The policy Dialysis Management dated 2/19/18, identified the purpose of the policy was to provide guidance to care center staff for residents requiring dialysis services. The policy identified the dialysis center and the facility would exchange information on medical, nursing issues, dietary concerns, psychosocial concerns, and any lab values. The policy did not address what steps the facility staff would take when the resident returned from their dialysis appointment or care of the dialysis site if it was not a graft or fistula. The training for RNs caring for dialysis residents was requested but not provided.Facility Assessment: A review of the Facility assessment dated [DATE], identified the facility mission statement as Expressing [NAME] love by providing care that values every human life. The average daily census was listed as 65. The facility assessment identified they would accept residents with renal insufficiency, renal failure, and end state renal disease. In addition, residents with digestive concerns, colitis, inflammatory bowel disease and bowel incontinence. The facility assessment identified they could support and care for those who needed assistance with bathing/showers, mobility support and bowel/bladder toileting programs. Included behavioral support such as dealing with anxiety. The staffing plan identified the following:licensed nurses providing direct care - three on days / evenings and one on nightsnursing assistants six on days / evenings and three on nightsWeekend were the sameA review of the day/afternoon/night assignment sheets and nurse staffing report for the following days revealed the following staffing: 5/1/25, census 59day - no NA for Windy Hill or Park evening - no NA for Lakeview5/2/25, census 59evening - no charge nurse / no NA for Central5/3/25, census 59day - no second NA for Windy Hill, no NA for Lakeview, NAs from Park to cover Lakeview at 10:30 a.m. and Park, NA pulled from Lakeview to cover Windy Hillevening - no charge nurse5/4/25, census 59day - no NA for Windy Hillevening - no charge nurse5/5/24, census 59evening - no charge nurse, no NA for Central or Lake (NAs form Windy Hill and Park had to cover Central and Lake) 5/7/25, census 58evening - no charge nurse5/8/25, census 59evening - no second NA for Windy Hill Central to help5/9/25, census 58evening - no charge nurse, no NA for Central5/10/25, census 60 day - no NA for Lakeviewevening - no charge nurse5/11/25, census 59day - no NA for Lakeviewevening - no charge nursenight - no NA for Central/Lakeview5/14/25, census 58evening - no charge nurse5/15/25, census 57evening - no charge nurse5/16/25, census 59evening - no charge nurse, Lakeview had NA from 4:00 p.m.-8:00 p.m. (partial shift)5/17/25, census 59evening - no charge nurse/ no LPN after 6:30 p.m., for Windy Hill, no NA for Lakeview until 6:30 p.m. 5/18/25, census 59evening - no charge nurse / no NA for Lakeview5/19/25, census 59day - no NA for Central5/20/25, census 58day - no NA for Central5/21/25, census 58day - no NA for Lakeviewevening - no charge nurse5/22/25, census 59day - no NA for Lakeviewevening - no charge nurse5/23/25, census 58evening - no NA for Central5/24/25, census 58 evening - no nurse for Central / Lakeview5/25/25, census 57day - no NA for Central or Lakeview5/27/25, census 57day - no NA for Central5/28/25, census 57evening - no charge nurse5/29/25, census 59eve - no charge nursenight - no NA for Park 5/30/25, census 59day - no NA for Lakeviewevening - no charge nurse / no NA for Lakeview5/31/25, census 59eve - no charge nurse / no second NA until 8:30 p.m.night - no NA for Windy Hill after midnight Administration Interview: During an interview on 6/26/25 at 1:01 p.m., the DON stated the staffing was adequate and one nurse and three NAs over night was okay. The DON verified an NA would not be mandated to stay if one of the three NAs for nights called in, leaving one nurse and two NAs for the building. The DON stated, barring any events it should be manageable.

Based on observation, interview, and document review, the facility failed to maintain controlled medication accounting for facility stock medication and for 1 of 1 resident (R262) reviewed for medication side effects. The facility failed to ensure residents were free from medication errors for 1 of 1 resident (R262) who didn't receive their medication as ordered. In addition, the facility failed to remove expired facility stock medication which had to potential to affect any resident needing facility stock medication. Findings include: R262's admission Record dated 6/26/25, identified an admission date of 6/17/25 and a diagnosis of irritable bowel syndrome (IBS-D, a condition characterized by stomach pain, cramping and diarrhea).R262 had a provider order dated 6/17/25, for the medication eluxadoline (trade name Viberzi, a schedule IV-controlled substance used to treat IBS-D) oral tablet 75 milligrams (mg) two time per day. Review of R262's medication administration record (MAR) for June 2025, identified the number 9 appeared on 6/19 and 6/25 for the 7 p.m. dose, and on 6/23 for the 7 a.m. dose for the medication eluxadoline. Progress notes for R262 identified the following entries regarding eluxadoline oral tablet 75 mg: 6/19/25 at 4:54 p.m., cannot locate medication. 6/23/25 at 6:08 a.m., drug not available. 6/25/25 at 10:08 p.m., cannot locate medication. During an interview on 6/24/25 at 12:27 p.m., licensed practical nurse (LPN)-E stated the number nine identified on the MAR meant the medication couldn't be found. LPN-E searched the drawers of the 100s unit medication cart and found the bottle of eluxadoline for R262. LPN-E thought it was a controlled substance because there was a C on the bottle. LPN-E was going to notify the charge nurse, add this medication to the narcotic count book and lock it in the narcotic box in the medication cart. At 1 p.m., LPN-E found a second person to count and record the eluxadoline. LPN-E stated they had received 60 tablets on 6/18/25, nine doses were given and LPN-E counted 51 pills remaining. LPN-E further explained the pharmacy usually delivers in the afternoons, and they do give a slip with the medications that the receiving nurse would need to find. LPN-E stated she will be updating the director of nursing (DON).During an interview on 6/25/25 at 1:26 p.m., pharmacist (PH)-T stated controlled medications (those that need to be counted) were on a list separate from the non-controlled medications and both required a signature from the facility on deliver. At 1:48 p.m., PH-T stated he did find the signed list from the facility receiving the eluxadoline on 6/18/25 at about 5:30 p.m. However, the pharmacy technician didn't realize it was a controlled substance and grouped it with the other medications. During an interview on 6/26/25 at 10:08 a.m., the DON stated they counted controlled substances schedules two through five. The DON stated it would be a medication error if a medication couldn't be found.During an observation and interview on 6/26/25 at 12:37 p.m., the unit one nurse's station medication refrigerator in the medication room had an unopened 30 mL bottle of lorazepam intensol (an oral liquid concentrate of lorazepam, a benzodiazepine medication used for anxiety). RN-A explained this was for the facility emergency kit, the rest of the kit was in a locked cabinet in the same medication room. The kit was observed to be locked with a numeric-coded tag. There was a clipboard with loose pieces of paper on it for counting the emergency kit controlled substances. RN-A indicated this was where the lorazepam, which was a schedule IV-controlled medication, would be counted but the papers hadn't been filled out for any of the emergency kit items since 6/22/25. RN-A stated the risk of not counting it would be for the whole bottle to go missing. During an observation and interview on 6/26/25 at 12:57 p.m. the medication cart in the 400's unit had an open bottle of facility-stock Tussin (generic cough syrup) with a manufacturer's expiration date of 02/25. Registered nurse (RN)-D stated the night nurse checked for expired medications, but she wasn't sure when that was done. RN-D explained the controlled substances were counted before and after each shift but wasn't sure which nurse (out-going or in-coming) read from the cards or the book. During a follow-up interview on 6/26/25 at 2:20 p.m., RN-D clarified there was no count sheet for the lorazepam intensol, it hadn't been recorded when it was delivered. During an interview on 6/26/25 at 2:32 p.m., the DON stated they usually did a weekly audit for expired medications, the risk of administering expired medication was that it might not be effective anymore. The DON also stated the emergency kit controlled substances were counted on a sheet that needed to be counted and signed-off shift to shift. The DON stated the risk of not counting the controlled substances would be that the whole kit could be lost, and acknowledged doing the count on loose pieces of paper would run the risk of losing those pieces of paper and not having a record. A document, Heritage Manor Health Center Emergency Medication Kit Unit 1 dated 6/21/25, identified the other controlled substances contained in the emergency kit:Lorazepam 1 mg tabs, 2 tabsOxycodone 5 mg tabs, 6 tabsUltram 50 mg, 6 tabsRoxanol 10 mg/0.5 mL, 6 oral syrnigesMorphine 10 mg/mL, 8 syringesHydrocodone 5/325 mg, 6 tabsA document, Medication Storage Policy dated 4/11/23, identified nursing staff will conduct weekly audits of the medication storage room and destroy any expired medications and moisturizers. A document, Controlled Medications dated 2/27/24, identified its purpose to provide care center staff direction for providing resident use of controlled substances related to acquisition, storage, disposal, and documentation to prevent the diversion of controlled substances. Controlled Substances are medications categorized into five schedules dependent on how dangerous and/or addictive the substances are and to what extent they have accepted medical uses. Schedule I Medications have no accepted medical use in treatment in the United States and is the most addictive with the highest potential for abuse. Schedule II Medications are substances accepted for medical use in treatment in the United States and have a high potential for abuse with the greatest potential for physical and psychological dependence of FDA-approved pharmaceutical controlled substances. For this reason, Schedule II controlled substances are subject to the highest levels of controls among FDA-approved controlled substances. Schedule III-V Medications are substances accepted for medical use in treatment in the United States and have a lower addictive dependency and potential for abuse than Schedule II medications. Receipt of Controlled Medications from the Pharmacy-Upon receipt of controlled medications from the pharmacy, the Charge Nurse or TMA must check them into the Medication Room. -Remove stickers from the substance and apply one to a separate count sheet in the bound book. -If no sticker is available, record information including the resident name, name of medication, form of the substance, number of units or volume in each container, dispensing directions and route and record in the bound book.Recording Usage-All Schedule II-V controlled substances are regulated by using drug administration record sheets. -All Schedule II-V controlled substances will be recorded in the care center's bound book immediately following preparation of each medication.-The following information must be recorded:i. Date and time.ii. Dose administered.iii. Route of administration.iv. Nurse's signature.v. Amount remaining.Auditing Usage.A controlled medication count audit must be completed at each shift change. i. The Nurse or TMA going off the shift counts all controlled substances within the controlled substance lock box with the Nurse or TMA coming on the shift. ii. The controlled substance count must be conducted with a minimum of one licensed personnel. iii. Together with the Nurse or TMA coming on the shift, the Nurse or TMA going off physically counts the controlled substances on hand. The count should match the recorded balance on the individual count sheet in the bound book. 1. During the count the oncoming Nurse or TMA will count the controlled substance while the outgoing Nurse or TMA verifies the number/count on the count sheet in the bound book. 2. The outgoing Nurse or TMA will use the ledger in the front of the bound book to tell the oncoming Nurse or TMA the number of the card, cassette, or bottle. 3. The oncoming Nurse or TMA should then count the substance according to pharmacy packaging (dose). 4. The outgoing Nurse or TMA should verify that this is the correct number of substances left using specific page number and verify to the incoming Nurse or TMA verbally with yes or no.-Each Nurse and/or TMA that is counting will sign the count sheet for that date and shift.

Based on observation, interview, and document review the facility failed to ensure food was stored in accordance with professional standards for food service safety by failing to maintain safe food storage temperatures. This practice had the potential to affect all residents consuming food at the facility. OR Based on observation, interview, and record review, the facility failed to ensure beverages including milk were maintained and served at a safe temperature of less than 41 degrees Fahrenheit (F). In addition, the facility failed to ensure dishwasher temperatures were maintained for proper sanitization of dishes. These deficient practices had the potential to impact all residents residing at the facility Findings include: The facility form Weekly Temp Logs included at the bottom of the form: Temperature danger zone is 41 to 140 F. All food has to be held above or below this until meal service is complete. The breakfast section of the form did not include a section to record beverage temperatures. The lunch and dinner sections had a place to record dessert and milk temperatures. Temp logs for the month of June 2025, were requested and reviewed. Hot food temperatures were recorded each day, but all spaces for milk and dessert temperature documentation were empty. An invoice from Genesis Refrigeration dated 6/26/25, included the following:-all systems operating normally. Room temperature 36 degrees. Product tested at 38 degrees.-set room temp down two degrees-recommend moving more sensitive items away from the door and removing food from boxes if possible. The undated facility policy Food Handling Section F. included: Cold foods shall be held at 40 degrees or below until served. Nursing and Dietary Services will establish procedures such that delivery of food to serving areas that accommodate this requirement. The undated facility policy Food Temperature line item three instructed temperatures should be taken periodically to ensure hot foods stay above 135 degree F and cold foods stay below 41 degree F.During an observation on 6/25/25 at 11:35 a.m., milk, assorted juices including prune juice, and almond milk were contained in a two stack of metal bins on a cart parked at the intersection of the 200 and 300 hallways. During beverage temperature checks that started on 6/25/25 at 11:59 a.m., the dietary manager (DM) performed a temperature check of main dining room milk and stated the milk temperature was 49.1 degrees F. The DM identified the milk temperature as being high and rechecked the milk with a second thermometer. The DM confirmed the second thermometer read 50.7 degrees F. The DM removed the milk from the serving area and returned with milk from the back cooler. The milk temperature of new milk read 41.5 degrees F. The DM stated they would need to remove the milk from service and replace it. The DM went into the dining room and collected milk cups from three residents who had been served milk. The DM stated they kept beverages cold during meal service by storing it in double stacked bins with ice between the bins. The DM confirmed they did not regularly check temperatures of beverages before serving them to residents during meal service.-At 12:09 p.m., the DM confirmed beverage temperatures for the following located at the intersection of the 200 and 300 hallways: ---milk: 51.4 degrees F---almond breeze milk: 59 degrees F---apple juice: 66.4 degrees F-at 12:12 p.m., the DM asked RN-A to determine who had milk in the 200 and 300s. -at 12:15 p.m., the DM returned with a new gallon jug of milk from the main cooler and reported the milk temperature was 41.5 degrees F. The DM put the milk on the beverage cart and requested a staff bring the cart of beverages to the kitchen and instruct staff not to put any of the beverages away. -At 12:19 p.m., the milk from dining service on the 400s unit had already been returned to the unit fridge. The DM removed the milk from the 400s unit fridge and confirmed the milk temperature was 52.7 degrees F. The refrigerator temperature was confirmed at 36 degrees F. The DM removed the milk from the fridge and stated it would need to be dumped. -At 2:23 p.m., the DM removed two cartons of milk from the 100s unit fridge. The DM confirmed the milk temperatures were 43.2 degrees F and 43.3 degrees F. The unit fridge temperature was confirmed at 38 degrees F. The DM removed both gallon jugs from the fridge.During an interview at 6/25/25 at 12:39 p.m., the administrator stated they had just discussed the milk situation and had decided they would dump and replace the milk that was temping at greater than 41 degrees. On 6/25/25 at 1:34 p.m., The dietary manager reported they had dumped all of teh milk and then provided a resident list for 6/25/25, lunch service which identifed:-100s hallway: two residents received milk.-200s hallway: three residents received juice.-300s Unit: two residents received juice.-400s Unit: nine residents had received milk, and one resident had received almond milk.During an interview on 6/26/25 at 8:47 a.m., the assistant director of nursing (ADON) stated it was concerning that beverages, especially milk were reaching temperatures greater than 41 to 51 degrees F during meal service. The ADON explained as milk warmed, bacteria could grow, and this created a risk for food borne illness. The practice of beverages potentially sitting and warming and then returning to refrigeration until another meal service was also a concern for the same reason. The ADON reported the facility had had residents with gastrointestinal illness, but the facility had not found a pattern of illness or an incident where multiple residents had experienced gastrointestinal symptoms at the same time. During an interview on 6/26/25 at 10:15 a.m., the dietary manager (DM) stated milk temperatures should be maintained between 33 to 40 degrees to prevent bacteria growth and food borne illnesses. Safe temperatures should be maintained because the risk for bacteria growth and food borne illness increased the longer milk remained at a temperature of 41 degrees or greater. The DM stated they had modified their milk storage and placed ice around the beverages. Temperatures were done at 7:22 a.m., and milk had been 38 and when it was returned to the fridge it was less than 40 on each unit at 8:37 a.m.During an interview on 6/26/25 at 12:42 p.m., the facility administrator stated it was their expectation that the facility policy was followed and that beverages that required cold storage were not let to sit out longer than 4 hours in the danger zone. The administrator explained 51 degrees was still a cool serving temp for milk however the facility tried to keep it cooler. Milk can be warmer and out for 4 hours at a time, but not beyond that. The administrator confirmed they felt it was okay for the facility to re-refrigerate milk with temperatures of 41 to 51 degrees F as long as it had not been out for more than 4 hours in the danger zone. The administrator stated beverages at the facility were never out for more than a half hour, so the facility milk temperatures were okay and complaint with the FDA (Food and Drug Administration) four-hour rule. DishwasherDuring an observation of the dishwashing area on 6/23/25 at 2:00 p.m., dietary aide (DA-A) was running dishes through the dishwasher and DA-B was taking washed dishes and placing them on drying racks. A temperature log in the washing area included temperature recordings and handwritten temperature ranges: wash 140 to 160, final rinse 180. The log instructed staff to notify DM and environmental service manager if out of range. DA-A stated they had forgotten to do a temperature check earlier and proceeded to check wash and rinse temperatures and record them on the log. DA-A verified the final rinse temperature was 140 degrees F and stated that didn't seem right, that they would run check it again in a few minutes. On the next check, DM-A confirmed the wash temperature was 152 degrees F, and the final rinse was 140 degrees F. DA-B continued to put dishes from dishwasher on drying racks. --At 02:07 p.m. DA-A verified the wash temperature was 149 and the final rinse was 158 degrees F. DA-A stated normally the wash was right on 160 degrees and the final rinse was 180 degrees. DA-A stated it had never happened to them to have the final rinse cycle so low, they knew others had had that happen, but they didn't know what to do about it. DA-A stated they were not concerned about the low temperatures, they planned to wash the rest of the dishes. When asked again, DA-A stated they were not concerned but they would ask others. C-A stated they did not work with the dishwasher, so they did not know much about it. NA-B stated they worked the other side of the dishwasher, and the dishes were scalding hot when they came out, so they were not concerned about the temperature readings. NA-A and NA-B stated they felt they could continue to wash dishes. NA-B turned a crank on the dishwasher and stated it might help raise the temperatures of the dishwasher. NA-A continued to prepare silverware for washing. On 6/23/25 at 2:17 p.m., the administrator was notified there was a concern related dish sanitization in the kitchen. On 6/23/25 2:32 p.m., the administrator stated they had just returned from the kitchen and the staff had descaled and cleaned the dishwasher. While there he had seen the final rinse read at 180 degrees F. The administrator stated staff had followed protocol and cleaned the dishwasher and hooked up the chemical wash for low temperature washing because of the low temperatures. All the log entries had looked good except for today's entry which may have been an error. During a follow up interview on 6/23/25 at 2:39 p.m., DA-B stated they had noticed the dishwasher chemical bins were empty, so they had replaced them. DA-B confirmed they had not switched to low temperature washing solution, they had just replaced the high temperature wash solutions as soon as they had noticed they were empty. DA-B stated they used wash and rinse solutions all the time with the dishwasher. -at 2:49 p.m., DA-B confirmed the final rinse temperature was 180 degrees F, and the wash temperature was 145 degrees F. DA-B explained when they drained and cleaned the dishwasher of debris, it often raised wash and rinse temperatures. DA-B stated they had called their supervisor, and they had instructed them to switch to the yellow sanitizer (DA-A had the jug in hand). DA-B stated they would be re-washing all of the dishes they had washed before. During an observation on 6/23/25 at 6:07 p.m., the dishwasher was hooked to the regular rinse and wash solutions. DA-C was in the dishwashing area cleaning off dishes and placing them in a rack. -at 6:10 p.m., DA-C confirmed the wash temperature was reading 149 and the rinse temperature was 150 degrees F. The DM came over to the dishwashing area and stated the dishwasher final rinse gauge needed to be read as the dishes were actually going through the final rinse not after the gauge had been sitting. --at 6:13 p.m., the DM read the final rinse cycle as 170 and instructed DM-C to re-wash 3 racks of dishes on the clean side of the dishwasher. --at 6:16 p.m., the DM confirmed the final rinse cycle was 180 and the wash cycle was 160 degrees F. DA-C then proceeded to wash dishes. DM stated the wash cycle needed to be 140 or greater and the final rinse needed to be at least 180 degrees F. During an observation on 6/26/25 at 9:04 a.m., the dishwasher sanitizing solutions were not empty. The final rinse was verified to be at 180 degrees F and the wash at 160 degrees F. During an interview on 6/26/25 at 10:15 a.m., the DM stated they had always used the 140 to 160 degrees F for the dishwasher wash temperature and indicated it was in their policy. The DM reviewed the manufacture instructions and stated the high temperature ranges were listed as 150 F to 160 F for the wash, and 180 F to 195 F for the final rinse cycle. DA then went to the dishwasher and confirmed the placard on the dishwasher read wash 150 F and final rinse 180 F. The DM stated they must have missed updating the wash cycle temperatures on the temperature log and policy when they switched for a low heat to a high heat dishwasher. The DM explained staff could not just check and record dishwasher temperatures once, they were expected to perform ongoing temperature monitoring while washing dishes because temperatures could fluctuate out of range. It was important for wash and final rinse cycles were to be maintained so that were dishes were properly sanitized to prevent the risk or food borne illness. The dishwasher was serviced on 6/24/25, and it was in working order. Dishes being washed at too low of temperatures on 6/23/25, was operator error. Past staff education has included how to run the dishwasher, monitor the gauges, and actions to be taken when out of range, but there will need to be re-education done. During an interview on 6/26/25 at 12:42 p.m., the administrator stated it was their expectation that staff monitored dishwasher temperatures and notified someone if temperatures remained out of range. The CMA Dish Machine EST-44 High Temperature Low Temperature Conveyor Dish Machine manufacturer instructions dated 2020, listed the high dish wash temperature ranges as 150 F to 160 F for the wash, and 180 F to 195 F for the final rinse cycle.The facility form Dishwasher Temperature Log had instruction at the top: please record temperature of wash and rinse cycle when washing dishes. The log included a place to document wash and rinse temperatures each day for breakfast, lunch and supper and actions taken. The bottom of the log instructed staff to notify the dietary manger and environmental director immediately when temperatures were outside of acceptable range. Identified temperature ranges were wash 140-160 and final rinse 180. Logs from 12/2024, to 6/23/25, were reviewed. Temperatures were consistently documented as wash 160 and rinse 180-182. The undated facility policy Dishwasher Temperature Monitoring Logs identified the purpose of the log was to ensure dishwasher temperatures were properly monitored and controlled. The policy instructed temperatures must be maintained at 140F-160F for washing, 165 F at rack level and 180F at final rinse. Temperatures below required levels were to be reported to service director, dietary team leader or maintenance staff immediately for correction of problem before dishwashing was continued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform an elopement risk assessment for 1 of 1 (R1) resident reviewed for elopement. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and included diagnoses of Alzheimer's disease, dementia without behavioral or psychotic disturbance, major depressive disorder, recurrent, severe with psychotic symptoms. R1's provider orders dated 4/12/24, identified an order for staff to check placement and function of a wanderguard located on R1's right ankle, using a hand-held device to check the battery function each shift and to ensure R1 had not removed the device. R1's care plan dated 8/21/23, identified a risk for wandering with interventions to have a wander guard in place to right ankle, move closer to nurse's station for supervision due to wandering, encourage to attend activities during highest wandering times. R1's medical record did not contain an assessment for elopement risk. During an interview on 5/16/24 at 1:09 p.m., the director of nursing (DON) stated the only elopement risk assessment found in R1's record was one they started in August 2023. The DON further stated they did a trial removal of the wanderguard recently and then one day she got up in the common area and tried to walk, so they added it back and an assessment was not done at that time. DON thinks they should probably do a new one, and they are in the process of doing a new elopement risk assessment right now. St. [NAME] Health Services of [NAME] document, Elopement dated 8/1/22, identified its purpose was to provide guidance to staff to protect residents at risk for elopement. The document defined elopement as being when a resident who is cognitively, physically, mentally, emotionally and/or chemically impaired wanders away, walks away, runs away, escapes or otherwise leaves a care center or environment, unsupervised, unnoticed and/or prior to their scheduled discharge. The document further identified each resident would be assessed on admission for risk of wandering or elopement and at any time a resident was identified at risk for elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to implement occupational therapy (OT) orders for proper wheelchair positioning for 1 or 2 residents (R31) reviewed for positioning. Findings include: R31's quarterly minimum data set (MDS) dated [DATE], identified R31's diagnoses include Dementia, generalized muscle weakness, and hemiplegia (paralysis of one side of body). R31 was severely cognitively impaired, used a wheelchair, and required substantial/maximum assistance with dressing, grooming, and transferring. R31's care plan dated 6/23/22, identified to keep side supports in wheelchair when resident up in wheelchair to prevent leaning to the left. Therapy progress note dated 3/6/24, states evaluation for wheelchair positioning completed. Resident was provided with lateral side wedges to further prevent leaning to left side. Please keep side supports in wheelchair when resident up in chair. During observation's on 5/14/24 from 1:03 p.m. to 6:31 p.m., R31 was observed hunched forward and deeply leaning to left side while in wheelchair. No lateral side wedges were placed in wheelchair. On 5/15/24 8:20 a.m., R31 was observed deeply leaning to the left while in wheelchair with no lateral side wedges placed. During observation's on 5/15/24 between 10:30 a.m. to 3:24 p.m., R31 was observed leaning to the right side while in wheelchair. One lateral side wedge was placed on the left side. On 5/16/24 at 3:15 p.m., R31 was observed leaning to the left while in wheelchair with one lateral side wedge placed on left side. On 5/17/24 at 8:31 a.m., R31 was observed deeply leaning to the left while in wheelchair with no lateral side wedges placed. On 5/17/24 at 8:50 a.m., R31 remains in wheelchair with one lateral side wedge placed on left side. R31 continues to lean towards the left while in wheelchair. During interview on 5/17/24 at 9:40 a.m., occupational therapist (OT) confirmed having completed R31's wheelchair positioning assessment on 4/6/24. States order was written for 2 lateral side wedges, placed on both left and right side, while R31 was up in wheelchair. Orders are communicated to the facility via a progress note in the electronic health record and by the completion of a caregiver sheet which will be posted in residents' closets to communicate orders to nursing assistants. During interview on 5/17/24 at 9:57 a.m., nursing assistant (NA)-D confirmed caregiver sheets are posted in resident closet's to communicate therapy orders. NA-D was aware of R31's order to have lateral wedges placed while up in wheelchair but does not recall ever using 2 wedges for R31. During interview on 5/17/24 at 10:06 a.m., registered nurse (RN)-B confirmed therapy orders are communicated to the facility via a caregiver sheet and progress note. Facility nurses use the caregiver sheet to update the care plan. RN-B confirmed R31's care plan identified the use of 2 lateral side wedges while R31 was up in wheelchair. States does not ever recall using/seeing 2 lateral wedges for R31. During interview on 5/17/24 at 10:11 a.m., director of nursing (DON) states having the expectation care plans and therapy orders are followed. DON reviewed R31's care plan and consulted with OT and confirmed 2 lateral side wedges should be used when R31 was up in wheelchair. DON does not recall R31 ever using 2 lateral side wedges and plans to obtain a second lateral side wedge from therapy. DON states it was important to follow the care plan and therapy orders to ensure proper positioning and resident safety. Adaptive and Positioning Equipment policy dated 7/27/23, listed purpose was to provide adaptive equipment that allows residents to achieve their highest most practicable level of functioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain safe positioning for a resident with a feeding tube, while the tube feeding was running for 1 of 1 resident (R37) reviewed for tube feeding care. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of Parkinson's disease with dyskinesia (uncontrollable, uncoordinated movements), respiratory failure, pneumonitis due to inhalation of food and vomit, and dysphagia (a swallowing disorder). R37 was dependent on staff for oral hygiene, needed maximum assistance for bed mobility, and had a feeding tube. R37's provider orders dated 2/9/24, identified a nothing by mouth order, to provide medications via feeding tube only, and to keep head of bed (HOB) at 45 to 60 degrees for all feedings and flushes. Feeding times were 3 a.m., 9 a.m., 3 p.m., and 9 p.m. at 85 milliliters (mL) per hour. R37's care plan dated 4/27/23, identified R37 received nutrition through a feeding tube with an intervention for HOB to be elevated 45 to 60 degrees for all feedings and to leave elevated for one hour after. During an interview on 5/13/24 at 2:29 p.m., family member (FM)-A stated R37 moved around in the bed and didn't stay upright enough and that was how she recently got aspiration pneumonia. On 5/14/24, R37 was observed during the following times: -12:34 p.m., R37 was lying in bed, HOB at about 15-20 degrees, resident's head is about 1.5 feet below the head of the bed. -6:40 p.m., the feeding pump was beeping, and the bag appeared to be empty, R37's HOB was approximately 10 degrees, and her neck was hyperextended. On 5/15/24, R37 was observed during the following times: -8:58 a.m., tube feeding running at 85 mL per hour, R37's shoulders are at the area where the bed bends, feet are at foot board, and she is fidgeting her feet at a fast pace. -9:34 a.m., same position, fidgeting hands around blanket, eyes open and tube feeding running. -11:04 a.m., HOB about 10 degrees, R37 was further up in the bed laying on her left side tracing her fingers down the wall, tube feeding was running. -2:41p.m., HOB about 10 degrees and R37 was laying on her left side. The feeding pump was running at 85 mL per hour. During an interview on 5/15/24 at 2:45 p.m., nursing assistant (NA)-E stated she wasn't sure what R37's HOB should be, she didn't touch it and thought it was usually at about the same level. During an interview on 5/15/24 at 3:47 p.m., licensed practical nurse (LPN)-B stated R37 was checked on every two hours to reposition, and they would check on her then. There was no set schedule for checking on her. LPN-B confirmed R37's HOB was about 15 degrees, and the orders were for 45 to 60 degrees as noted on a sign taped to her over-the-bed table. LPN-B stated it was important to keep her HOB up so she didn't aspirate (inhale fluid into the lungs). During an interview on 5/15/24 at 3:54 p.m., the director of nursing (DON) stated she would expect R37's HOB to be at 45 to 60 degrees as the care plan and orders said as this was important, so she didn't aspirate. St. [NAME] Health Services of [NAME], Enteral Feeding Tube Usage policy dated 4/1/19, identified its purpose was to provide guidance to licensed nursing staff in providing enteral feeding tube care and services. The policy further identified to elevate the head of the bed (HOB) to at least 30 degrees and keep it elevated during feeding and for a minimum of 1 hour following feeding (if resident can tolerate). If resident cannot tolerate HOB elevation of at least 30 degrees, they should be assessed on an individual basis to determine elevation height they can tolerate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed in a timely manner for 1 of 1 residents (R17) reviewed for respiratory care. Findings include: R17's significant change Minimum Data Set (MDS) dated [DATE], included diagnoses of heart failure, anxiety, type 2 diabetes, and a thyroid disorder. R17's physician orders dated 12/20/23, identified staff should change oxygen tubing weekly on Monday night shift. During observation on 5/14/24 at 12:22 p.m., oxygen tubing did not have a date. During observation on 5/17/24 at 9:12 a.m., oxygen tubing did not have a date. R17's treatment record indicated oxygen tubing was not changed in April or in May. During interview on 5/17/24 at 10:10 a.m., certified nursing assistant (CNA)-A stated nurses are responsible for changing oxygen tubing per orders. CNA-A confirmed there was no date on the oxygen tubing. During interview on 5/17/24 at 10:40 a.m., licensed practical nurse (LPN)-A stated nurses are responsible for changing oxygen tubing per orders. LPN-A confirmed there was no date on the oxygen tubing. During interview on 5/17/24 at 11:05 a.m., director of nursing (DON) stated it was expected staff would complete resident cares on their shift and for cares to be charted. Oxygen Administration policy dated 9/12/23, identifies tubing and cannula or mask should be labeled with date and changed every week.

Based on observation, interview, and record review, the facility failed to provide licensed nursing staff on a 24 hour basis for 8 days in the first quarter of fiscal year 2024. Findings include: The facility's certification and survey provider enhanced report (CASPER) identified 20 days between October 1st 2023 and December 31st 2023 when there was no licensed nursing staff in the facility. During interview on 5/17/24 at 10:52 a.m., director of nursing (DON) stated the facility was staffed well now and the gaps in the CASPER were a result of their payroll software not working correctly. The facility's payroll records confirmed the following days included gaps of 6 hours or more with no licensed nursing staff: -10/7/23, gap in coverage on night shift -10/15/23, gap in coverage on night shift -10/22/23, gap in coverage on night shift -11/5/23, gap in coverage on night shift -11/11/23, gap in coverage on night shift -11/18/23, gap in coverage on night shift -11/19/23, gap in coverage on night shift -12/17/23, gap in coverage on night shift Information on payroll software problem 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 complete all sections on the Minimum Data Set (MDS) for 2 of 15 residents (R40, R38) reviewed for resident assessment. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Resident Facility Assessment Instrument (RAI) 3.0 User's Manual dated 10/2019, OBRA-required comprehensive assessments include the completion of both the MDS and the CAA process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. Section O: identified special treatment, procedures, and programs. The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods. Section E: behavior. The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Behaviors include those that are potentially harmful to the resident himself or herself. The emphasis is identifying behaviors, which does not necessarily imply a medical diagnosis. Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems from those that are not problematic. Once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. This section focuses on the resident's actions, not the intent of his or her behavior. Because of their interactions with residents, staff may have become used to the behavior and may underreport or minimize the resident's behavior by presuming intent (e.g., Mr. A. doesn't really mean to hurt anyone. He's just frightened.). Resident intent should not be taken into account when coding for items in this section. R40's admission Minimum Data Set (MDS) dated [DATE], indicated R40 had diagnoses which included anemia, hypertension, endstage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hyperlipidemia, and anxiety. R40's admission MDS dated [DATE], section O-special treatment, procedures, and programs revealed the following: O. 0100 Special treatments and programs Z. none of the above was checked (dialysis was not checked). R38's significant change MDS dated [DATE], indicated R38 had diagnoses which included anemia, hypertension, hyperlipidemia, arthritis, seizures, and depression. R38's Face Sheet dated 3/9/23, indicated R38 had major depressive disorder, recurrent, severe with psychotic symptoms and dementia. R38's significant change MDS dated [DATE], revealed the following: E. 0100 Z. none of the above was checked (which were hallucinations and delusions). During an interview on 3/8/23, at 1:59 a.m. registered nurse (RN)-A verified R40 was receiving dialysis three times a week and that it was not listed in his MDS dated [DATE]. RN-A said it would have been important to note he was receiving dialysis treatments on the MDS as it would have been used to develop his care plan and it was necessary for payment. During an interview on 3/9/23, at 10:15 a.m. the director of nursing (DON) verified dialysis was missing as a treatment on R40's MDS dated [DATE]. She said it would have been important to note it on the MDS as it would have been used to develop R40's care plan, for example weights and directing staff to monitor his dialysis access site. The DON verified R38's MDS should have noted she was having hallucinations and delusions. The DON stated this would have justified the medications R38 was taking and would have been needed to develop her care plan. The policy titled MDS 3.0 assessment dated [DATE], directed staff to conduct comprehensive, accurate and standardized assessments of each resident, using the Resident Assessment Instrument (RAI) manual and Regulations and Rules specified by the Centers for Medicare and Medicaid and the State of Minnesota.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to complete morning cares for 1 of 3 residents (R26) reviewed for personal cares. Findings include: R26's health conditions dated 3/9/23, indicated R26's diagnoses included low back pain, major depressive disorder, and weakness. R26's significant change Minimum Data Set (MDS) dated [DATE], indicated R26 was severely cognitively impaired and required extensive assistance with personal hygiene, dressing, and toilet use. R26's care plan dated 6/24/22, indicated R26 required extensive assistance with grooming and personal hygiene. Staff were directed to encourage R26 to start grooming tasks and to assist with completion if he was unable. On 3/8/23, at 7:18 a.m. until 7:47 a.m. R26 was continuously observed. R26 was observed lying in bed with his eyes open, wearing oxygen running at two liters per minute. His feet were bare and were sticking out from under his covers. He was wearing a regular shirt. He was able to push his soft touch call light. - At 7:25 a.m. nursing assistant (NA)-A knocked, entered his room, said good morning and said she would be right back with a pal. - At 7:28 a.m. NA-A returned with a mechanical lift and NA-B. Both NA's performed hand hygiene and put on gloves, they removed R26's oxygen, gathered his clothing, and a new brief. They put his socks on, put on his sweat pants pulling them up to his knees, and put on his shoes. During this time they were talking to R26 telling him what was going to happen. They assisted him to a seated position on the side of his bed, brought the mechanical lift close to him and attached the straps, he gripped the machines handles and they brought him to a standing position and then brought him into the bathroom, and lowered him to the toilet seat. His old brief was removed by NA-A who then removed her gloves and washed her hands, then put on new gloves. NA-B made his bed. -at 7:37 a.m. NA-A asked R26 if he was done, he said he was and NA-A placed the new brief, he was raised to a standing position and moved out of the bathroom and lowered into his wheelchair. His old shirt was removed, a new shirt was put on, he was given his glasses, and his hat and brought to the common area where the administrator said she would bring him to breakfast. During an interview on 3/8/23, at 10:36 a.m. NA-A stated morning cares included taking residents to the bathroom, helping them wash their face and hands, helping them with brushing their teeth or brushing their dentures for them, and helping them to put on clean clothes. NA-A verified none of that was done for R26. During an interview on 3/8/23, at 10:41 a.m. NA-B said morning cares included peri-care, washing face and hands, taking them to the bathroom, helping them get dressed and making sure their teeth were brushed. NA-B verified this was not done for R26. During an interview on 3/8/23, at 10:45 a.m. licensed practical nurse (LPN)-A stated morning cares included washing a residents face, hands, bottom, making sure they had clean clothes, and that oral care was completed. During an interview on 3/9/23, at 10:25 a.m. the director of nursing (DON) stated she would expect staff to help a resident wash their face, hands, under their arms, and peri-care as part of morning cares. The DON stated brushing teeth was an expectation as part of morning cares as well. The policy A.M. Cares no date, directed the staff to complete the following steps: 1. Introduce self and explain procedure to the resident. 2. Adjust windows and draw the drapes. 3. Offer or take the resident to the bathroom. If unable to toilet, check incontinent product and change as needed. 4. Provide assistance with perineal care per the resident plan of care. 5. Resident shaved per the plan of care. 6. Allow resident to brush teeth, or assist with oral hygiene if he/she is not able. 7. Wash resident's face, hands and underarms and dry well. Encourage resident participation. 8. Straighten and/or change all bed linen, blankets and spread as needed. 7. Position the resident comfortably. 8. Put call light within easy reach. 9. Prepare bedside stand to receive breakfast if eating in room. 10. Leave bedside area clean and resident comfortable. 11. Report unusual or abnormal conditions and symptoms to nurse.

Based on observation, interview, and record review the facility failed to ensure proper sanitary storage of resident medications within the medication cart and that expired medications were removed from surplus stock supply. In addition, the facility failed to ensure only authorized personnel had access to keys to get at drugs and biologicals stored in the medication room and the medication cart. Findings Include: On 3/8/23, at 10:59 a.m. licensed practical nurse (LPN)-A locked the medication cart located in front of the nurse's station, placed medication keys on cart surface and walked over to fridge to get milk while the keys remained on the cart. At 11:00 a.m. LPN-A proceeded into resident room with milk to administer pills. At 11:02 a.m. LPN-A returned to the medication cart and sanitized hands. On 3/8/23, at 11:14 a.m. the medication cart was parked across from the nurse's station. The medication cart keys were hanging on the cart computer arm. LPN-A was not in sight. Continuous observation of cart initiated. On 3/8/23, at 11:19 a.m. unknown staff used a different set of medication keys to access the medication cart. LPN-A's keys remained hanging on the computer arm. On 3/8/23, at 11:22 a.m. LPN-A returned to the mediation cart and picked up medication keys. On 3/8/23, at 11:37 a.m. LPN-A confirmed the keys left on the cart gained access to the medication room, medication cart, and the locked boxes within the cart containing narcotics. LPN-A stated normally if I go far away from the cart, I grab the medication keys, but if I go into a resident room, I have left the keys on the cart. LPN-A stated it was not okay to leave the keys unattended, the keys should always be kept on the medication nurse's person. On 3/8/23, 02:43 p.m. the director of nursing (DON) stated medication keys should not be left on top of the cart, or anywhere unattended, the keys should be always kept with the medication nurse in a pocket. On 3/8/23, at 11:23 a.m. the bottom drawer of the medication cart contained a handled bin with resident topical medications stored in plastic bags. A second bin contained medical tape and supplies for measuring and staging wounds. The bin also contained two unbagged Nystatin topical powders. (Nystatin powder is a medication used to treat fungal infections of the skin). LPN-A removed the powders from the wound bin and stated the powders should not be in the cart without being in a plastic bag, and the powders should be stored in the handled bin with the other topical medications (already in bags). LPN-A verbalized concern about using the wound measuring supplies after the nystatin powder had been mixed in with the supplies. The smaller bottom drawer contained a compartment of resident topical ointments and creams in plastic bags stored together. One tube of diclofenac sodium topical gel 1% was not stored in a bag. LPN-A stated the cream should be in a bag and stated she would be bagging all items as soon as she got some bags. On 3/8/23, at 2:22 p.m. LPN-B confirmed the medication stock supply contained four bottles of expired Mylanta dated 1/2023 and seven Vesta daily Moisturizer tubes with an expiration date of 2/2023. Registered nurse (RN)-B was also in the medication room and stated the person that orders stock medications does a review of expiration dates before an order is placed and typically pulls expired mediations from stock if anything was expired. In addition, night nurses check stock medications for expiration dates. On 3/8/23, 2:43 p.m. the DON stated stock medications were ordered twice a month. During the ordering process, current stock medications were reviewed to determine what needs to be ordered. At this time expired stock medications would be removed from inventory. Nurses also looked at stock medications and disposed of items that were expired. Facility policy Medication Storage instructed the following: The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. The medication cart is to be locked at all times when the licensed nurse is not present and medication cart keys shall be kept with the licensed nurse. The keys for the medication room are to be kept with the licensed nurse. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.