**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure allegations of financial exploitation were reported to the State Agency (SA) within 24 hours for four of five residents (R1, R2, R3, and R4) reviewed for allegations of financial exploitation. Findings include:Findings include:R1R1's facesheet dated 7/9/25, indicated he admitted to the facility on [DATE] and was his own responsible party. R1's emergency contact was his spouse, R4.R1's care plan dated 6/11/25, identified he was a vulnerable adult. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.Nursing Home Incident Report #360867 was submitted to the SA on 6/17/25 at 2:57 p.m. The report identified an allegation of financial exploitation for resident R1. The business officer manager (BOM) was the initial reporter and became aware of the incident on 6/17/25 at 2:00 p.m. Details included, facility found out that resident's bank statement has unauthorizes purchases which is linked to employee's address. Description included, On June 12, 2025, facility identified $4,047.67 in unauthorized transactions on resident [R1's] bank account, occurring between May 16 through June 12, 2025. [R1] did not approve these charges. Today, we confirmed the address linked to the transaction belongs to a facility employee.During a joint interview on 6/30/25 at 3:42 p.m., the BOM stated she assisted R1 monthly to check his bank account and print the statement. She noticed unusual activity on R1's bank statement on 6/12/25 and notified administration right away. The administrator in training (AIT) stated he filed a Minnesota Adult Abuse Reporting Center (MAARC) report initially and then when the facility later noticed that some of the transactions were linked to employee names, an Office of Health Facility Complaints (OHFC)/State Agency (SA) report was filed.During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility first became aware of concerns regarding suspicious activity on R1's bank account on 6/12/25 when the facility identified $4,047.67 in unauthorized charges. A police report and MAARC report were filed on 6/12/25 but the report to the SA was not filed until 6/17/25 when addresses linked to the transactions were identified as belonging to employees. She was not present on 6/12/25 and did not know why it was not reported to the SA at that time, she would expect the allegations to have been reported to the SA on 6/12/25. The administrator stated alleged financial exploitation should be reported to the SA within 24 hours. R2R2's facesheet dated 7/9/25, indicated he admitted to the facility on [DATE] and had a financial power of attorney.R2's care plan dated 5/20/25, identified he was a vulnerable adult. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.Investigation Report with submission date 6/23/25 at 4:06 p.m., was submitted to the SA as the follow-up for Nursing Home Incident Report #360867 regarding R1. The investigation report noted similar incidents had been identified including a case involving R2. Unauthorized transactions had been discovered on R2's bank account beginning around 5/15/25. The BOM had confirmed this with R2's power of attorney (POA), POA-A. Police were notified and investigation ongoing.Nursing Home Incident Report #360946 was submitted to the SA on 6/25/25 at 11:48 a.m. The report identified an allegation of financial exploitation for resident R2. The BOM was the initial reporter and became aware of the incident on 6/20/25 at 1:30 p.m. Description included, upon review/investigation of an open OHFC [report] relating to financial exploitation, business office manager reviewed resident's bank statement and discovered suspected fraudulent activity.During an interview on 7/1/25 at 1:07 p.m., the BOM stated she became aware of the concerns when POA-A spoke to the social services director (SSD) who came and got her. The SSD told her POA-A noticed some things on R2's bank statement. The BOM reviewed the bank statement with POA-A and identified concerns for fraudulent activity like that seen on R1's account.During an interview on 7/7/25 at 7:55 a.m., POA-A stated she identified concerns with R2's credit card on 6/19/25 when she tried to use the card to obtain a storage unit for R2 and it was declined due to fraudulent activity. POA-A went to the facility the next day on 6/20/25 and mentioned this to the SSD. R2 had his bank statements, which POA-A reviewed with facility staff who stated there was an investigation going on and this had happened to another resident. The facility notified the police, who came and spoke with R2 regarding the fraudulent activity. During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility became aware of concerns about financial exploitation related to R2 on 6/20/25 when his bank statement was reviewed with the BOM and suspected fraudulent activity identified. This was reported to the SA on 6/23/25 when it was included in the investigation report submitted as follow-up on the allegations of financial exploitation of R1. A separate report specific to R2 was then submitted to the SA on 6/25/25. The administrator stated the facility was aware of the allegations regarding financial exploitation of R2 on 6/20/25 and she would expect this to have been reported to the SA within 24 hours. She confirmed this should have been reported right away and should have been filed as a separate report, not included in the follow-up investigation report for R1. R3R3's facesheet dated 7/9/25, indicated she admitted to the facility on [DATE] and was her own responsible party.R3's care plan focus dated 6/17/25, identified she was a vulnerable adult. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.Investigation Report with submission date 6/23/25 at 4:06 p.m., was submitted to the SA as the follow-up for Nursing Home Incident Report #360867 regarding R1. The investigation report identified similar incidents had been identified including a case involving R3. R3 reported a missing bank card but experienced no financial loss and had cancelled the card.Nursing Home Incident Report #360948 was submitted to the SA on 6/25/25 at 12:17 p.m. The report identified an allegation of financial exploitation for resident R3. The report identified the social services designee (SS) was the initial reporter and became aware of the incident on 6/24/25 at 12:00 p.m. Description of the incident included, during facility investigation of open OHFC relating to financial exploitation, resident informed social services of missing debit card 6/16/25. Debit card found 6/24/25 and resident confirmed there was no fraudulent activity on the account.Untitled facility resident interview document dated 6/18/25, indicated an interview was conducted with R3 by facility staff with note that R3 admitted to the facility on [DATE]. Question Have you noticed any unusual transactions on your bank account recently? had answer No. Froze card. Question Have you noticed any missing valuables, money, checks, credit cards, or debit cards recently? had answer Debit card is missing - lost since first day here. Froze Card. [Bank name] - blue debit card. Had it when she left hospital. Says son doesn't have it. R3's progress note dated 6/18/25, indicated the AIT followed up with R3 regarding her missing card. R3 stated she cancelled the card and there were no unauthorized charges.During an interview on 7/7/25 at 10:44 a.m., the administrator stated she became aware of concerns regarding financial exploitation of R3 on 6/20/25 when she received an email for R3's son stating her debit card had gone missing but then it showed up the following morning on 6/21/25 and there were no fraudulent charges on the account. R3 was included in the investigation report for R1 submitted 6/23/25 and then filed as a separate report with the SA on 6/25/25. The administrator then reviewed R3's progress notes and confirmed the facility was aware of R3's missing debit card on 6/18/25, stated this should have been reported to the SA within 24 hours, and confirmed it had not been reported within that time frame.R4R4's facesheet dated 7/9/25, identified she admitted to the facility on [DATE], and her spouse R1 was her responsible party and emergency contact.R4's care plan dated 5/5/25, identified she was at risk for abuse and or neglect. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed.During a joint interview on 6/30/25 at 3:42 p.m. the AIT stated R4 was R1's spouse and R1 made financial decisions for her, though was not her power of attorney. The AIT stated the facility became aware R4's name was on the same account as R1's so they filed a MAARC report as part of the process of trying to obtain a financial conservator for them both. The BOM stated the fraudulent charges linked to R1's debit card were on a checking account shared by both R1 and R4 and the money in the account belonged to them both.During an interview on 7/1/25 at 9:11 a.m., the SSD stated she submitted a MAARC report regarding R4 after the facility found out R1's account was shared with R4. She was made aware of this and submitted the report on 6/26/25. The SSD confirmed the concern for R4 was an allegation of financial exploitation as the money in the account belonged to both R1 and R4 who were financially independent. The SSD stated she only knew how to file MAARC reports, and the administrators were responsible for filing reports to the SA.During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility became aware of allegations of financial exploitation of R4 on 6/26/25 during a monthly billing-related review phone call with the corporate business office. R1 was discussed and the BOM brought up R4 and stated a hold needed to be placed on her collection to the facility until the fraudulent charges from R1's card were reimbursed by the bank. The administrator had not previously realized R1's bank account was shared with R4 and given that they were on the same account the financial exploitation affected R4 too. The administrator reviewed a copy of R1's bank statement dated 5/30/25 provided to the surveyor by the facility and confirmed both R1 and R4's names were listed. The administrator stated R4's name was clearly on the account and she would expect allegations of financial exploitation of R4 to have been identified and reported to the SA on 6/12/25 when the facility identified fraudulent activity on the account. The administrator confirmed allegations of financial exploitation were also not reported within 24 hours of the facility becoming aware of the allegations for R1, R2, and R3. The allegations needed to be reported because all residents were vulnerable adults and any alleged or confirmed abuse or any sort needed to be reported to the SA within two hours if there was physical harm or 24 hours for all others.Facility policy titled Abuse Prohibition/Vulnerable Adult Policy dated 4/2025, identified the purpose of the policy included to promptly report, document, and investigate all incidents of alleged or suspected abuse/neglect. All staff were responsible for reporting any situation that was considered abuse or neglect. The policy identified incidents that must be reported to the State Agency including: mistreatment (inappropriate treatment or exploitation of a resident), misappropriation of resident property, and financial exploitation (including but not limited to: residents provide gifts to staff or volunteers, residents or families provide any payment in cash or checks to staff or volunteers, having residents sign over POA to staff). Section titled How and when to report to the Minnesota Department of Health (MDH)/ Office of Health Facility Complaints (OHFC) included, 2.) Suspicion of Neglect, Exploitation, or Misappropriation of resident property must be reported to OHFC online reporting process not later than 2 hours if the incident resulted in serious bodily injury. 3.) If the suspected Neglect, Exploitation, or Misappropriation of resident property did not result in serious bodily injury, the reports must be made within 24 hours. 6.) Notify the Minnesota Department of Health (MDH) on the notification website immediately after discovery of incident. Additional direction included Utilizing the Minnesota Adult Abuse Reporting Center (MAARC). The policy directed the following scenarios should be reported directly to MAARC: a.) If the Vulnerable Adult is not a facility resident. b.) The Vulnerable Adult discharges from facility against medical advice, including residents who do not return from a Leave of Absence. *All discharges that are against medical advice need to be reported to MAARC within 24 hours. c.) The alleged maltreatment occurred prior to facility admission.

Based on interview and document review, the facility failed to identify and protect all residents at risk of financial exploitation during investigations into 4 of 4 residents (R1, R2, R3, R4) reviewed who made allegations of financial exploitation. This had the potential to affect all 67 other residents who were residing in the facility, including R5, whose representative subsequently identified and reported additional allegations of financial exploitation. Findings include:Untitled resident questionnaire documents dated 6/17/25 and 6/18/25, included dates, resident names, interviewer signatures, and three questions. Questions included: have you noticed any unusual transactions on your bank account recently; Have you noticed any missing valuables, money, checks, credit cards or debit cards recently; and do you know how to report facility concerns, lost, missing, or damaged items. Questionnaires were completed for 29 residents. One questionnaire had a resident name written down and crossed out with no further information, and one questionnaire had a resident name, R5, date of 6/17/25, and note at the bottom indicating R5 was hospitalized /on a leave of absence. Facility document titled Attendance Record dated 6/18/25, identified it was for resident education on storing valuable items. The record included resident names/signatures or staff signatures on behalf of residents unable to sign and resident room numbers. The record identified education was completed with 47 residents, per listed room numbers. Facility document titled Resident Education Regarding Valuables in the Facility undated, was a one-sheet page with printed information. The information included, It is important to be aware that while residing in the facility, there will be multiple staff that frequently enter and exit residents' private living spaces. Checkbooks, cash, credit cards, and valuable jewelry should not be left unsecured in residents' private living space. Residents may wish to obtain a lockbox to secure items should they decide to keep these items at the facility. It is recommended that valuables be kept with family if possible. It is important to be aware that physical credit cards do not need to be taken, thieves have taken pictures of credit cards and used the images to permit theft. You should never share your financial PIN [personal identification number] numbers or passwords with anyone. If you suspect a crime has occurred, report it immediately to staff. During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility first became aware of allegations of financial exploitation on 6/12/25 when the facility identified $4,047.67 in unauthorized charges/suspicious activity on R1's bank account statement reviewed by the business office manager (BOM). On 6/17/25, the facility identified addresses linked to the transactions belonged to employees. The facility became aware of concerns regarding financial exploitation of R3 on 6/18/25, when an interview was conducted with R3 who reported her debit card was missing but had no fraudulent transactions because she had cancelled the card. The facility became aware of concerns about financial exploitation related to R2 on 6/20/25 when his bank statement was reviewed with facility staff and suspected fraudulent activity identified. The facility became aware of concerns about financial exploitation related to R4 on 6/26/25 when they realized R1's bank account was shared with R4, her spouse. The administrator would expect the allegations of financial exploitation of R4 to have been identified on 6/12/25 when the facility identified the fraudulent activity on the account because R4's name was clearly on the bank statement/account. In a follow-up interview at 3:32 p.m., the administrator stated the fraudulent charges on R2's account totaled $709.97. During a joint interview on 6/30/25 at 3:42 p.m., the administrator in training (AIT) stated after the facility identified potential financial exploitation of R1 was linked to employee addresses and names via transactions, identified staff members were suspended. In addition, the facility checked in with other residents who managed their own finances to see if they had issues. The social services director (SSD) stated she completed this along with the social services designee and the receptionist. This was a list of questions, a safety questionnaire, she discussed with about 20 to 30 residents. The AIT stated this was when R3 notified the facility she had a missing bank card. During an interview on 7/1/25 at 9:11 a.m., the SSD stated after the BOM noticed fraudulent activity on R1's bank account, staff including herself completed questionnaires with residents and asked them if they had noticed anything similar. Education was provided that if they wished to purchase a lock box they could. She stated secure storage for resident valuables was not offered to residents unless they asked for it, and the admission contract contained information about storage of valuables. During a follow-up interview on 7/7/25 at 12:11 p.m., she confirmed safety questionnaires were completed on 6/17/25 and 6/18/25. She was advised to complete them only with residents who oversaw their own finances. Staff also rounded with an educational paper given to all residents about lock boxes and keeping personal items safe. It did not notify residents of the financial exploitation concerns or need to check their finances for potential fraudulent charges. The SSD stated all residents were probably not capable of understanding this education and she had not followed up with any families or representatives of the residents educated. She did not know of other actions taken to notify all residents and representatives of the concerns. During an interview on 7/7/25 at 10:44 a.m., the administrator stated she was aware of concerns related to financial exploitation for four residents, R1, R2, R3, and R4. An all-staff meeting was held on 6/30/25 with education about the facility's abuse prohibition and vulnerable adult policy but was not mandatory. She was unable to articulate what was done to follow up with staff not present at the meeting. Staff rounded with residents on 6/17/25 and 6/18/25 to complete safety questionnaires. She thought this should have been done with every resident. Questionnaire papers indicated rounding was done with 31 residents and she did not know how they were selected. She identified one completed with a resident with dementia who might not understand the questions and whose family should have been notified, and one with a resident (R5) who was in the hospital at the time. The administrator was not aware of follow-up completed with these residents and their representatives. She stated there were at least 40 residents (those who did not get questionnaires) who were not talked to about concerns for financial exploitation or were talked to but not documented. She was unable to articulate what was done to protect these residents from potential financial exploitation. To protect residents, she would expect every resident in the building and their family/representatives to have been notified of the concerns as soon as the facility found out there was a second resident involved in the alleged financial exploitation. The administrator stated all residents should have been followed up with because even if someone had a POA (did not manage their own finances) they could still have something (such as a credit or debit card) at the facility that could be utilized to make unauthorized purchases. She had not yet notified all families of the potential financial exploitation and did not see evidence all residents had been informed. She would expect safety interviews with residents, meetings with residents if they wanted assistance reviewing bank statements, and communication with families and POA's to see if they had noticed fraudulent activity for all residents. Additionally, staff interviews and all staff education. During a follow-up interview on 7/7/25 at 12:20 p.m., the administrator stated the education sheet provided to all residents communicated it was important to be aware of personal items, but it did not say the facility had something like this happen. Further, all residents were not capable of understanding the information as presented and regardless of if a resident was their own representative, the facility should have followed up with every resident to ensure they understood. Residents would not be aware of the risk of potential financial exploitation if the facility did not explain it. During an interview on 7/7/25 at 3:26 p.m., the AIT stated he had spoken to the police detective (PD) handling the financial exploitation investigations that morning. The PD notified the facility of another resident, R5, who was a potential victim of financial exploitation as R5's family had notified the PD she had a missing bank card. The SSD followed up with R5's family who confirmed her credit card was missing. During a joint interview on 7/8/25 at 8:22 a.m., the administrator stated R5's POA, POA-B, indicated R5's credit card went missing on 6/27/25 and there were about $500 in fraudulent charges. The administrator confirmed the safety questionnaire for R5 completed on 6/17/25 indicated she was in the hospital at the time. The administrator did not see any follow-up completed with R5 or her family/representatives to provide the information in the questionnaire. The regional director of operations (RDO) stated the facility had initially determined to notify only residents who managed their own credit cards of the concerns. He confirmed residents who did not manage their own finances could also have cards in the facility. He confirmed every resident was not able to understand and follow up on the information presented in the resident education sheet and facility would have followed up with POA's for these residents. He was not able to identify evidence of this follow up. During an interview on 7/8/25 at 1:42 p.m. POA-B stated she was R5's family member and POA. POA-B stated R5's credit card was missing and had fraudulent charges on the account. She identified this on 6/28/25 when reviewing R5's credit card statement. She cancelled the card right away, went to the facility and noted the card was missing from R5's wallet, and reported it to the police. She did not know when the card went missing, but the fraudulent charges were between 6/5/25 and 6/11/25, totaling $497.95. The detective, PD, had informed POA-B on 7/2/25 that she was already working on an investigation and working with the facility, so POA-B did not notify the facility because she thought they knew about R5. POA-B stated she spoke to facility staff yesterday and they had not known about R5. POA-B stated she received an automated voice message from the facility that morning regarding financial fraudulent activity in the facility, but had not received previous communication from the facility notifying her about potential concerns. POA-B stated she did not know when the facility became aware of the concerns, but thought they should have let people know sooner if they knew sooner. During an interview on 7/3/25 at 1:41 pm., POA-C stated she was R2's family member and one of his POA's. Fraudulent charges were identified on R2's card on 6/19/25 when she and R2's other POA, POA-A, tried to use the card's information for a transaction and it was declined and marked fraud. POA-C stated she thought the facility was going to send out a letter or communication to all guardians or individuals this financial exploitation pertained to, and she had received nothing. This was concerning. There were vulnerable people at the facility who didn't have someone like herself or POA-A watching their backs and some didn't have the capacity to do so on their own. This made her sick as there was nothing sicker in her mind than elder abuse and what happened was criminal. During an interview on 7/7/25 at 7:55 a.m., POA-A stated she identified the fraudulent activity on R2's card on 6/19/25 and notified the facility on 6/20/25. At the time, she had no idea the fraudulent activity involved anyone at the facility. When she notified the facility, the SSD informed her there was an investigation as this had happened to other residents. POA-A gathered an employee was responsible for the fraud. POA-A was informed the facility would send a letter to all residents that these activities were going on. POA-A had not received such communication. POA-A stated people needed to know this was happening so they could check their funds and be aware. It has been two weeks since she first notified the facility of the activity on R2's account and she thought this communication should have gone out. POA-A was concerned this may have happened to other residents and thought the facility should notify every resident because, otherwise, how would residents and guardians know to look at bank statements. POA-A stated if she had not stopped by the facility on 6/20/25 and mentioned the fraudulent activity on R2's card to staff, she would never have known it was connected to the facility, no one had contacted her. POA-A stated she was upset and felt very strongly about this as she would still have no idea what was going on if she hadn't happened to mention it to the SSD on 6/20/25. During an interview on 7/7/25 at 8:33 a.m., the police detective (PD) handling the investigation into multiple reports of financial exploitation at the facility stated the investigation was on-going. The first case was reported to the police by the facility on 6/12/25. The PD had enough evidence to file charges against two employees of the facility related to the financial exploitation. She stated there were currently three residents who were victims but felt there could be more cases. She thought it would be good for the facility to get something out to notify people to make sure they were checking their bank accounts often in case there were additional victims. Facility policy titled Abuse Prohibition/Vulnerable Adult Policy dated 4/2025, identified the purpose of the policy, including To protect residents against abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse, to promptly report, document and investigate all incidents of alleged or suspected abuse/neglect, and to identify and remedy any potentially abusive situations. Policy interpretation and implementation section indicated all staff were responsible for reporting any situation considered abuse, neglect, injuries of unknown origin, misappropriation of resident property, or involuntary seclusion. Further, A supervisor will be notified immediately and will assess the situation to determine if any emergency treatment or action is required. Immediately, upon learning of the incident, staff will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury while the matter is being investigated. Investigation/protection section included, Staff will take immediate and appropriate actions to prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress, and The facility will provider proper follow up communication related to the incident across all shifts and to practitioners and resident representatives as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure four of five residents (R1, R4, R2, and R5) reviewed for financial exploitation were free from misappropriation of personal property and financial exploitation when facility staff stole resident credit/debit cards or card information and made unauthorized transactions totaling over $5,000. This had the potential to affect all residents residing at the facility. Findings include:R1R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had moderately impaired cognition and required partial to substantial assistance from staff for most activities of daily living (ADL's). R1's facesheet dated 7/9/25, indicated he was his own responsible party and his emergency contact was his spouse, R4. R1's diagnoses included unspecific dementia. R1's care plan dated 6/11/25, identified he was a vulnerable adult and at risk for decreased cognitive and physical abilities. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. R1's progress note dated 6/12/25, indicated the business office manager (BOM) alerted the social services direct (SDD) of suspicious activity on R1's banking statement and a large amount of missing money. R1 stated he had not given his banking information to anyone or made any new purchases. BOM and R2 called the bank and communicated there were many purchases on the account R1 didn't make. The bank put a stop on the account. Police were called and a report filed. Police spoke to the bank and stated a bank employee would come to the facility to assist R1 with filling out paperwork related to the fraudulent purchases. R1's bank form titled Cardholder Statement of Disputed Items dated 6/12/25, included a list of disputed transactions with dates, dollar amounts, and merchants for cardholder name of R1. Disputed transactions marked as unauthorized/counterfeit transactions (cardholder did not authorize or engage in the transaction) dated 5/19/25 through 6/11/25. There were 65 disputed transactions totaling $4,040.18. R1's bank statement dated 5/30/25, included the following transactions:- $279.61 on 5/23/25 to LULULEMONCOM- $136.56 on 5/27/25 to VALLEYFAIR ONLIN[E]- $168.00 on 5/27/25 to LULULEMONCOM R1's bank statement dated 6/30/25, included the following transactions:- $75.06 on 6/4/25 to eBay- $108.00 on 6/6/25 to Nike.com- $225.00 on 6/6/25 to Nike.com- $39.99 on 6/9/25 to SUGARBABYCARE- $69.80 on 6/9/25 to SUGARBABYCARE- $129.00 on 6/9/25 to LULULEMONCOM- $168.00 on 6/9/25 to LULULEMONCOM- $263.80 on 6/9/25 to Nike.com- $223.45 on 6/10/25 to VF Outdoor, LLC (a subsidiary of VF Corporation, an apparel, footwear, and accessories company that owns brands including Timberland)- $27.75 on 6/11/25 to TIKTOK SHOP- $35.94 on 6/11/25 to eBay- $168.00 on 6/11/25 to LULULEMONCOM- $198.00 on 6/11/25 to VF Outdoor, LLC- $198.00 on 6/11/25 to VF Outdoor, LLC a second time- $65.76 on 6/12/25 to eBay Nursing Home Incident Report submitted to the state agency (SA) dated 6/17/25, identified an allegation of financial exploitation for R1. Description of the incident included, On June 12, 2025, facility identified $4,047.67 in unauthorized transactions on resident [R1's] bank account, occurring between May 16 through June 12, 2025. [R1] did not approve these charges. Today, we confirmed the address linked to the transaction belongs to a facility employee. Alleged perpetrators identified in the report included one nursing assistant (NA), NA-A. Investigation follow-up report submitted to the SA dated 6/23/25, identified NA-A was interviewed after a Valley Fair (local amusement park) purchase made with R1's card was traced to NA-A's first name and a separate purchase from Sugar Baby Crush was linked to the same street address as NA-A's documented address, but with a one-digit difference in the apartment number. NA-A denied involvement in the transactions. NA-B was interviewed when online orders under his name were linked to the unauthorized use of another resident, R2's, financial information with shipments sent to NA-B's address on file. NA-B stated this was his previous address and he now lived at the address linked to the Sugar Baby Crush on R1's bank statement. NA-B denied involvement. Staff members with linked address were suspended pending further investigation. Investigation conclusion noted, the allegation was verified based on evidence collected during the investigation. During an interview on 7/1/25 at 11:16 a.m., R1 stated he was not sure of the exact amount, but people had taken his money without him knowing or authorizing this. His card was not taken, but money was taken out of his associated checking account some way or another. He previously kept his card in his wallet and wallet in his pocket or on the dresser. Now he kept it in a lockbox. R1 had worried this would continue to happen, but now had a new card. He was upset that his money was disappearing without him knowing and worried he might try to go shopping and have his card declined. He did not realize anyone was using the card prior to the BOM telling him about it, she ran the account statement and showed him. During a joint interview on 6/30/25 at 3:42 p.m., the BOM stated she noted unusual transactions on R1's bank statement on 6/12/25. She saw purchases from that day and assisted R1 with cancelling his card immediately. The administrator in training (AIT) stated staff later noticed some of the purchases were related to an address of a staff member. The AIT stated NA-A was the name that appeared on one transaction and NA-B, who worked at the facility through a staffing agency, had an order shipped in his name from another transaction. Both were suspended. The facility called places where transactions occurred to get associated names and addresses. Staff were suspended as soon as they were identified. 14 or 15 people had been suspended pending investigation. Statements were taken from the suspended staff members who all denied involvement. The investigating police detective provided the facility with photographs of people at Valley Fair traced back to the Valley Fair transaction. The facility reviewed the images and identified three staff members. The facility was not sure how staff got access to R1's card because it was not missing, it could potentially have been added to Apple Pay as this is what R2's bank reported happened with his card. During an interview on 7/7/25 at 10:44 a.m., the administrator stated nursing assistant in training (NAIT)-B's employment was terminated because of the Valley Fair footage, the Valley Fair tickets being sent to his email address, and because his home address fit with other purchases made. That information came from the police detective (PD). NA-B was barred from working at the facility through the staffing agency because a purchase made on R1's account was sent to NA-B's address. NAIT-B did not respond when contacted for interview. During an interview on 7/8/25 at 2:44 p.m., NA-B stated he had picked up a few shifts at the facility through a staffing agency and his last shift was on 4/28/25. There was currently an investigation going on about fraud at the facility and he was now suspended from picking up shifts through the agency. NA-E stated a friend working at the facility, NAIT-B, had come around their friend group saying he had a way to get clothes and stuff like that and something had happened with a credit card. NAIT-B put card information into an application used to buy clothes from [NAME] gear on NA-B's cell phone. NA-B stated NAIT-B never told him he was not using his own money so NAIT-B made purchases not knowing the card belonged to someone else. NA-B used the card for transactions at [NAME], Nike Tech, and shoes and stated those were the three items he bought. NA-B was working with police and gave them the purchased items. NA-B stated police informed him the card belonged to a resident at the facility and he did make purchases with the card but was unaware the card belonged to a resident at the time. He endorsed making at least three purchases with the card for clothes and shoes from approximately June 12th through June 15th. R4R4's quarterly MDS assessment dated [DATE], indicated R4 had moderately impaired cognition and was dependent on staff or required substantial staff assistance for most ADL's. R4's facesheet dated 7/9/25, indicated her spouse, R1, was her responsible party and emergency contact. R4's diagnoses included unspecified dementia, disorientation, other signs and symptoms involving cognitive functions and awareness, and adjustment disorder with depressed mood. R4's care plan dated 5/5/25, identified she was at risk for abuse and or neglect and at risk for decreased cognitive and physical abilities. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. R4's progress note dated 6/16/25, indicated the SSD followed up with R4 due to the [NAME][n]cial concern and she had no further questions or concerns. Bank statements for period ending 5/30/25 and 6/30/25 identified the statements were for an account under both R1 and R4's names. The account number was the same as the account number on R1's Cardholder Statement of Disputed Items. During an interview on 7/1/25 at 10:48 a.m., R4 stated a good amount of money was taken out of her and R1's account. She was not sure when or how this happened, but it was scary and overwhelming. She was tearful and concerned about her husband, she felt more sorry for him than herself. It bothered him and she worried about him. R1 was a veteran and had worked hard for his money, he went through hell and high water in the war. She had noticed him crying in his sleep and this hurt her to hear. R4 stated stealing was one of the lowest things a person could do and she hoped the people who took their money without authorization were kicked out of the facility. During a joint interview on 6/30/25 at 3:42 p.m. the AIT stated R4 was the spouse of R1 and R1 made financial decisions for her, though was not a power of attorney. The AIT stated the facility became aware R4's name was on the same account as R1's. The BOM stated the fraudulent charges linked to R1's debit card were on a checking account shared by both R1 and R4 and the money in the account belonged to them both. During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility became aware of allegations of financial exploitation of R4 on 6/26/25 during a monthly billing-related review phone call with the corporate business office. R1 was discussed and the BOM brought up R4 and stated a hold needed to be placed on her collection to the facility until the fraudulent charges were reimbursed by the bank. The administrator stated she had not previously realized R1's bank account was shared with R4 and given that they were on the same account the financial exploitation affected R4 too. The administrator reviewed a copy of R1's bank statement dated 5/30/25 provided to the surveyor by the facility and confirmed both R1 and R4's names were listed on the account. R2R2's quarterly MDS assessment dated [DATE], indicated R2 had moderately impaired cognition and required supervision/touching assistance to no assistance from staff with most ADL's. R2's facesheet dated 7/9/25, indicated he had a financial power of attorney (POA). R2's diagnoses included Parkinson's disease. R2's care plan dated 5/20/25, identified he was a vulnerable adult and at risk for decreased cognitive and physical abilities. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, adult protection, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. R2's progress note dated 6/20/25, indicated the AIT assisted R2 and POA with a meeting with the police regarding unauthorized transactions on R2's bank account. A police case was filed, bank card was cancelled, and bank initiated the refund process. R2's bank statement dated 5/16/25, identified transactions from the previous 30 days. Notations on the statement identified the following: on 5/4/25 the card was added to Apple Pay (mobile payment and digital wallet service), on 5/15/25 a Cash App (an application for peer-to-peer money transfers) transaction included NA-B's first name, on 5/15/25 the card was blocked by the bank, the bank would send a letter about fraud/amount reimbursed and a new debit card in 10 days, and fraudulent charges totaled $709.97. Cash App transactions listed as CASHAPP*[NA-B's first name]* included eight separate transactions on 5/15/25 for amounts of $10 and $15 totaling $110 in charges. Additional transactions included:- $82.18 on 5/7/25 to Nike.com- $50.80 on 5/12/25 to WAL-MART Investigation follow-up report submitted to the SA dated 6/23/25, was the follow-up report for the Nursing Home Incident Report about R1. It identified there was now an additional case regarding R2. NA-E was interviewed after online orders under his name were linked to the unauthorized use of R2's financial information with shipments sent to his address on file with the staffing agency. He denied involvement. R2's POA, POA-A, had confirmed there were purchases on R2's account that he did not authorize beginning around 5/15/25. Police were notified, bank contacted, and card cancelled. Nursing Home Incident Report submitted to the SA dated 6/25/25, identified an allegation of financial exploitation for R2. Description of the incident noted suspected fraudulent activity was identified on review of R2's bank statements. Alleged perpetrators identified in the report included seven NA's (NA-A, NA-C, NA-D, NA-E, NA-F, NA-G, and NA-H) and three NAIT's (NAIT-A, NAIT-B, and NAIT-C). During an interview on 7/1/25 at 2:10 p.m., R2 stated his debit card information was taken and someone took money out of his account. Someone used his card and a police report had been filed. The bank noticed some funny transactions and previously put a stop on his account. He was not sure how much money was taken, but thought it was around $740 in charges. He was told the suspected perpetrators worked at the facility and the police had a suspect, but he did not know who it was. R2 stated he had his wallet and checkbook at the facility, but did not recall getting any information about how to protect his valuables. He used to keep his wallet in his pocket or on his nightstand, but now kept it in a lock box. He did not like that his money was taken, felt a little upset, and felt the perpetrators invaded his personal space. During an interview on 7/3/25 at 1:41 p.m., R2's family member and POA, POA-C, stated fraudulent charges were identified on R2's card on 6/19/25 when she and R2's other power of attorney, POA-A, tried to use the card's information to obtain a storage unit for R2. The card was declined and marked as fraud. POA-A went to the facility the next day and notified the SSD of the fraud issue. POA-C stated R2's bank statement had a facility staff name on it and apparently the person used Apple Pay which could be done using a picture of the card without the card itself. The bank had previously texted a fraud alert to R2 but R2 did not text and never saw it. The fraudulent charges looked like they went from 5/5/25 through 5/16/25. POA-C's understanding was the charges were made by someone who worked at the facility. During an interview on 7/7/25 at 7:55 a.m., R2's friend and POA, POA-A, stated she identified the fraudulent activity on R2's card on 6/19/25 and notified the facility the next day on 6/20/25. At the time, she had no idea the fraudulent activity involved anyone at the facility. When she notified the facility, the SSD informed her there was an investigation as this had happened to other residents. POA-A gathered an employee was responsible for the fraudulent charges because you could see the name on the bank statement. Fraudulent activity was identified on the statement from 5/4/25 when Apple Pay was added through 5/15/25 when the bank shut off the card. R2 now had a lock box for his valuables but POA-A had taken his checkbooks and new debit card received from the bank because POA-C didn't want it there, lacked trust, and just didn't know what was going on. During a joint interview on 6/30/25 at 3:42 p.m., the BOM stated the bank reported R2's card was put on Apple Pay. The SSD stated the facility found out about the fraudulent charges when POA-A stopped by her office and said they saw some suspicious activity on his bank statement. The SSD noted the card had been cancelled on the 15th by the bank due to unusual purchases. During an interview on 7/7/25 at 10:44 a.m., the administrator stated the facility identified unauthorized charges on R1's account with transaction information linked to employees. Upon becoming aware of concerns of financial exploitation of R2 on 6/20/25, R2's bank statement was reviewed and the facility identified similar charges as those on R1's statement, such as transactions at the same merchants. Some staff were suspended because they were identified by name in bank statement transactions, were identified in footage provided by the police, or had an associated address. NA-B was barred from working at the facility through the staffing agency because Cash App payments were sent in his name on R2's account. During an interview on 7/8/25 at 2:44 p.m., NA-B stated he made transactions using Cash App with payment to himself. This was done utilizing a photo of a credit card sent to him by NAIT-B which NAIT-B said he found on the ground. NA-B used the photo to enter the card's information into Cash App on his phone and transferred $150 to himself. NA-B did not remember the name on the photographed card but noted it was not NAIT-B's name, the card was blue, and he no longer had the photo. He wasn't really thinking about the name on the card at the time he transferred the money, he just put the information in. He had already made other purchases using this card because NAIT-B entered the card information into NA-B's phone. NA-B stated NAIT-B had convinced him he had a place to buy good quality clothes and stuff for low prices and NA-B was blindsided by everything apart from the Cash App payments. NA-B denied awareness when he made fraudulent transactions of the misappropriation of resident property or financial exploitation of residents. The cops told him the card belonged to a resident, but he did not know who. NA-B stated he made transactions using card information from NAIT-B from approximately 6/12/25 to 6/15/25. R5R5's significant change MDS assessment dated [DATE], indicated R5 was cognitively intact, receiving hospice care, and was dependent on staff for most ADL's. R5's facesheet dated 7/9/25, indicated she had a financial POA. R5's diagnoses included encounter for palliative care, major depressive disorder, need for assistance with personal care, and dependence on enabling machines and devices. R5's care plan dated 7/8/25, indicated she was a vulnerable adult and at risk for decreased cognitive and physical abilities. Interventions included: staff will continue to follow the facility vulnerable adult and abuse reporting policy; and local ombudsman, police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. R5's progress note dated 7/7/25, indicated her POA, POA-B, was called. POA-B stated she took R5's bills home and noticed charges that shouldn't be there on a bank statement. POA-B had only used the card for two medical rides for R5. POA-B stated the card went missing on 6/27/25 and she called the bank and had the card stopped. She was aware of $500 in fraudulent charges and took R5's valuables home. POA-B notified police and police stated the facility was aware of what was going on, so POA-B did not inform the facility at that time. POA-B had not made R5 aware of the situation as R5 was at the end of life and POA-B and family did not want R5 upset and thinking about who stole from her while she is here. R5's bank statement dated 5/21/25 through 6/19/25, included a list of 22 transactions with total purchases and charges of $651.95. Charges dated 5/29/25 and 6/12/25 were for $77 each to School Services. Additional transactions included:- $28.62 on 6/6/25 to Target- $7.49 on 6/6/25 to KWIK TRIP (a gas station)- $49.32 on 6/7/25 to SPEEDWAY (a gas station)- $1.60 on 6/7/25 to KWIK TRIP- $5.99 on 6/7/25 to KWIK TRIP- $47.05 on 6/10/25 to CASEY'S (a gas station)- $37.30 on 6/10/25 to CASEY'S- $45.00 on 6/10/25 to FAMS BARBERSHOP AND A Faribault- $52.84 on 6/11/25 to KWIK TRIP Nursing Home Incident Report submitted to the SA dated 7/7/25, identified an allegation of financial exploitation for R5. Description noted the police detective (PD) informed the facility R5's family member reported a missing credit card that went missing on 6/27/25 with approximately $500 in unauthorized charges. The facility followed up with the family member, POA-B who noted she had previously reported the incident to the police and planned to submit the bank statement to the facility the following day. There were no identified alleged perpetrators. During an interview on 7/7/25 at 3:26 p.m., the AIT stated he spoke to the PD handling the financial exploitation investigations that morning. The PD notified the facility of another resident, R5, who was a potential victim of financial exploitation as R5's family notified the PD she had a missing bank card. The SSD followed up with R5's family who confirmed her credit card was missing. During an interview on 7/9/25 at 7:50 a.m., the administrator stated she had met with POA-B who provided a copy of R5's bank statement. POA-B indicated the charges from School Services were authorized charges for medical rides, but did not identify any other authorized charges on the statement. Total unauthorized charges were $497.95. The administrator reviewed the bank statement and transactions and noted merchants were the same or similar as those seen on the statements for R1, R2, and R4's accounts. The transactions were also from the same time frame at the beginning of June and ended when the facility identified concerns about R1's card. Charges made to a gas station and two fast food restaurants were especially similar, and the administrator thought the same people made the purchases with R5's card as did so with R1 and R2's cards. During an interview on 7/8/25 at 1:42 p.m., R5's family member and POA, POA-B stated R5's credit card was missing and there were fraudulent charges on the account. POA-B had taken R5's bills home to review and looked through the credit card statement and saw all this fraud. On 6/28/25 she cancelled the card, went to the facility and noted the card was missing from R5's wallet, and reported it to the police. She did not know when the card went missing, but the fraudulent charges were between 6/5/25 and 6/11/25, totaling $497.95. There were two legitimate charges on the card from medical rides with a transport company that showed as School Services. There were no further fraudulent charges on the account after the date on the statement. She guessed the card was stolen around 6/5/25. The detective, PD, had informed POA-B on 7/2/25 she was already working on an investigation and working with the facility, so POA-B did not notify the facility because she thought they knew about R5. The PD reported the suspects had already been suspended from the facility and were going to be charged and the police had video footage of a suspect. POA-B noted R5 was not aware of the financial exploitation concern. POA-B and R5's significant other had decided not to tell R5 because she was declining, in the end days of life, and would be so upset and was starting to get confused. They did not want her to know and POA-B was sure she would be upset thinking someone in the facility that was there to care for her was actually stealing from her. She used to keep her purse with checkbook and credit cards in it on the nightstand which POA-B had removed from the facility. POA-B thought R5's sense of trust would probably be impacted by the events and she would always be wondering if whatever aide came in to help her was the person that stole from her. R5 would expect her valuables to be safe and it would be upsetting because she trusts people and someone violated her personal belongings. During an interview on 7/7/25 at 8:33 a.m., police detective (PD) stated she was the detective handling the investigation into financial exploitation cases at the facility. PD stated that, due to the open nature of the investigation, she could not share victim or suspect names at this time. The PD stated she had two suspects, the facility had suspended multiple staff members, and she was confident the suspects were not currently working at the facility. She had three victims. The first victim was reported to the police on 6/12/25 by the facility, second victim reported on 6/20/25 by the facility, and third victim reported by their POA on 6/28/25. The PD stated she had more than enough evidence and would be filing charges against the two suspects. The fraudulent charges for all three victims stopped on either 6/11/25 or 6/12/25. All the fraudulent charges were made in May and June. The first and second victims had photos taken of their cards, whereas the third victim's physical card was taken. It was undetermined who had taken the card, but she thought it was one of the suspects who shared the card and card information with a bunch of people. The PD identified the two suspects as facility staff. So far, she had determined one suspect was connected to all three victims' cases and the second suspect was connected to two victims' cases. During a follow-up interview on 7/17/25 at 10:52 a.m., PD stated she had completed her suspect interviews and would be closing the case and filing charges. There were three victims, R1, R2, and R5. PD was not aware R1's card used for fraudulent charges was linked to a bank account shared with R4. Estimated totals in fraudulent transactions for the victims were approximately $4,000 for R1, $550 for R2, and $497 for R5. The PD identified three suspects, two of whom were facility employees, NAIT-B and NA-B. The PD had interviewed both NAIT-B and NA-B multiple times. During the interviews, NAIT-B informed the PD of the following: NAIT-B took a picture of a card identified by the PD as belonging to R1; NAIT-B used the card for purchases of [NAME] Lemon, sweatshirts, Valley Fair tickets, and ordering food with NA-B and the third suspect. NAIT-B reported the third suspect used the card for eBay purchases; NAIT-B took a picture of a card identified by the PD as belonging to R2. NAIT-B put the card into Apple Pay and used it at Walmart; NAIT-B took a picture of and took a card identified by the PD as belonging to R5. The card was used to buy stuff at gas stations and NAIT-B confirmed his identity in video footage the PD obtained from Kwik Trip associated with the transactions. NAIT-B also used the card at Target and a barbershop; NAIT-B sent pictures of R1 and R5's cards to NA-B, and of R1's card to the third suspect. During interviews, NA-B informed the PD of the following: NA-B received pictures of cards from NAIT-B identified by the PD as belonging to R1 and R2; NA-B used R1's card for multiple purchases including Sugar Baby Care, [NAME] Lemon, Nike, Timberland shoes, and TikTok. NA-B stated NAIT-B purchased and sent him a ticket for Valley Fair; NA-B used R2's card for Cash App transactions made to himself of about $250; NA-B stated he did not have information about a third card. The PD stated she had no suspicions that anyone else was knowingly involved and did not think anyone else spent money on R1, R2, and R5's cards other than the three suspects. Both NAIT-B and NA-B were to be charged with felony level financial transaction card fraud. Facility policy titled Abuse Prohibition/Vulnerable Adult Policy dated 2/2023, identified the purpose included to protect residents against abuse by anyone including but not limited to facility staff and staff of other agencies serving the individual. Incidents to be reported to the state agency noted a list including mistreatment - inappropriate treatment or exploitation of a resident, misappropriation of resident property, and financial exploitation including but not limited to residents providing gifts to staff or volunteers, residents or families providing any payment in cash or checks to staff or volunteers, and having residents sign over POA to staff. Facility policy titled Resident Right Policy dated 1/2024, identified it was the practice of the facility to uphold the rights of all residents. Residents had access to these rights including via a copy of the Combined Federal and State [NAME] of Rights provided in the admission process. Facility document titled Combined Federal and State [NAME] of Rights with State Agency logo dated 6/18/19, included The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on interview and document review, the facility failed to implement its policy to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of property when pre-employment background screening procedures were not completed for one of 11 staff members reviewed for background screening. This had the potential to affect all 71 residents residing in the facility as the staff member worked on all units. Findings include:Findings include:Untitled undated facility personnel document, identified nursing assistant in training (NAIT)-A was a new hire for position of NAIT with start date of 1/29/25. NAIT-A's employee status was full time.Criminal Background Study Information form undated, contained personal and demographic information required to complete a criminal background study for NAIT-A. A box on the form labeled office use only contained date results received space for date to be written in. This space was blank.Review of NAIT-A's employee file did not identify a completed pre-employment background screening.Review of NAIT-A's timesheets indicated she worked shifts at the facility from 1/29/25 through 6/24/25.During an interview on 7/8/25 at 11:26 a.m., NAIT-A stated she began working at the facility at the end of January as an NAIT. She stated she worked everywhere including the facility's unit on the second floor and both units on the first floor. During an interview on 7/1/25 at 1:26 p.m., the director of nursing (DON) stated keeping residents safe included the hiring process. Background screening was done and references checked to ensure whoever was brought into the facility to care for residents was cleared. This was part of the hiring process for everyone in the facility.During an interview on 7/7/25 at 2:33 p.m., the administrator stated the requested background clearance for NAIT-A could not be located. She noted NAIT-A had completed a background study form online but never went for fingerprinting, so there was no background clearance in NAIT-A's file. The administrator was not previously aware NAIT-A's background screening procedure was not completed, and facility procedure was to complete this prior to an employee starting work. This needed to be done to ensure the facility brought in individuals who were competent, safe, and allowed to work in healthcare.Facility policy titled Abuse Prohibition/Vulnerable Adult Policy dated 4/2025, identified the purpose of the policy included protecting residents against abuse by anyone, including facility staff. The Prevention section included employee screening and noted, The Minnesota Department of Health requires Criminal Background Studies to be completed on all facility employees (Sections 144.40 to 144.58). Potential employees are screened for a history of abuse, neglect, or mistreating residents. Licensing verification checks, and Nursing Assistant Registry checks are completed on facility employees when indicated.Facility policy titled Background Study Policy dated 12/2016, identified it was the facility's policy to complete criminal background studies on all employees. Upon hire or facility transfer, employees completed a facility background study form. The Human Resources Director would verify the information was correct and submit an online background study request. Further, The employee may not begin working until the results of the request are received and indicate the applicant is not disqualified or may work unsupervised while a study is being completed. If an employee was not disqualified, the applicant could then be scheduled to work and results were filed in employee personnel file. Staff personnel files containing study results were maintained by the [NAME] President of Human Resources.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 2 of 2 residents (R54, R74) who utilized urinary catheters. Findings include: R54 R54's annual Minimum Data Set (MDS) dated [DATE] identified R54 with intact cognition, impairment of both lower extremities, dependent on staff for toileting hygiene and lower body dressing and had an indwelling catheter (tube for urine collection from bladder to a bag outside of the body). During observation on 4/28/25 at 1:42 p.m., R74 was lying in bed with an uncovered large urine drainage bag attached to side of bed visible to the hallway. During observation on 4/28/25 at 2:39 p.m., R74 was lying in bed with an uncovered large urine drainage bag attached to side of bed visible to the hallway. Two staff walked past the room. At 5:13 p.m., a staff member pushed a meal cart past R74's room. At 5:15 p.m., one staff member was observed inside the room speaking to R74 and left the room. During observation and interview with R74 on 4/28/25 at 6:35 p.m., R74 was lying in bed with an uncovered large urine drainage bag attached to side of the bed visible to the hallway. R74 stated, staff have never asked me if I wanted a cover on my urine bag. And I imagine other people would not feel comfortable looking at my urine in this bag. I guess I would not like to see anyone else's urine in their bag if I think about it. During observation and interview on 4/29/25 at 8:39 a.m., registered nurse (RN)-B was obtaining medications from the medication cart which was located across the hall from R54. RN-B observed the uncovered partially filled large urine drainage bag from hall and stated, catheter bag should be covered for dignity and decency. R74 R74's admissions MDS dated [DATE] identified R74 with intact cognition, required substantial to maximal assist with toileting hygiene and lower body dressing, and had an indwelling catheter. During observation on 4/29/25 at 8:03 a.m., R74 wheeled self around hallway seated in wheelchair with large urine drainage bag attached to underside of wheelchair. R74 wheeled self to nursing station where four residents were eating a meal at tables adjacent to the nursing station. The urine bag was visible and uncovered. During observation and interview on 4/29/25 at 8:31 a.m., licensed practical nurse (LPN)-A observed R74 wheel past her as she was obtaining medications from medication cart and stated, that [urine bag] should be covered for dignity. During interview with R74 on 4/30/25 at 10:04 a.m., R74 stated, It [catheter drainage bag] was never covered until yesterday when they [staff] came in and put one[sic] cover on it. I don't want to see another person's pee[urine]. I should be more respectful. During interview with director of nursing (DON) on 4/30/25 at 10:48 a.m., DON stated, Foley [catheter] need to be covered and stated the uncovered catheter bags were a concern for infection control and dignity. Facility policy for dignity was requested and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a sanitary and homelike environment for 1 of 1 residents (R40) whose tube feeding pole and equipment had dried, white substance on it. Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], identified R40 with intact cognition and diagnoses of depression, anxiety, chronic respiratory failure resulting in oxygen dependence, and a history of head and neck cancer with all nutrition through a percutaneous endoscopic gastrostomy (PEG) tube (soft flexible feeding tube inserted through the abdominal wall into the stomach). During observation on 4/28/25 at 5:07 p.m., R40's tube feeding (TF) pole was coated with dried white substance on entire surface of the pole and all five legs of the base. The TF unit/machine had greasy smeared substance on the entire front programming screen. During interview with licensed practical nurse (LPN)-A on 4/29/25 at 1:03 p.m., LPN-A stated the nursing staff was responsible for wiping down and cleaning tube feeding equipment if there were spills or visible soil on the unit and pole. During observation on 4/29/25 at 1:06 p.m., R40's tube feeding (TF) pole was coated with dried white substance on the entire surface of the pole and all five legs of the base. The TF unit/machine had greasy smeared substance on the entire front programming screen. During observation and interview with registered nurse (RN)-B on 4/29/25 at 1:18 p.m., RN-B stated everyone is responsible for making sure patient care equipment was clean. If we see if it is dirty we should clean it so the gunk doesn't dry like concrete. During observation and interview with RN-B on 4/29/25 at 1:21 p.m., RN-B looked at R40's TF pole and machine and stated, that is horrible. RN-B stated the white substance appeared to be TF solution that was not wiped up after nurses prepared to administer the solution and following disconnecting the feedings from R40. During interview with R40's spouse on 4/29/25 at 1:22 p.m., R24 stated the pole was soiled in appearance and, It is not good to look at. No one wipes up their spills or messes. During interview with R40 on 4/29/25 at 2:07 p.m., R40 stated the TF pole and machine is always cruddy looking. R40 stated he had never seen any staff member clean or wipe up the TF solution or wipe down the feeding equipment before or after attaching the feeding to his PEG. During interview with director of nursing (DON) on 4/29/25 at 10:50 a.m., DON stated expectation of nursing staff to be cleaning and wiping the machine, pole, and the base of the pole if there is spillage or visible soil on them. DON stated it was a concern for infection control and dignity for the resident. Facility policy requested for environmental cleaning of patient care equipment and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure grievances were sufficiently acted upon for 1 of 1 resident (R53) reviewed for grievances. Findings Include: R53's quarterly Minimum Data Set (MDS) dated [DATE], indicated R53 was cognitively intact. During an interview on 4/28/25 at 4:28 p.m., R53 stated approximately two months ago, during an evening shift a nursing assistant entered her room and attempted to change an incontinent brief. R53 was concerned because she didn't wear incontinent briefs, and the aid was unkind during the encounter. The following morning R53 reported the incident to staff. During a subsequent interview on 4/29/25 at 1:28 p.m., R53 stated she filed a grievance approximately two months ago and requested the nursing assistant not return to the unit. R53 confirmed that no one from the facility followed up with the results of the grievance. R53 stated the aid did work on the unit after staff was made aware of the incident and told residents he had been off for two weeks having a party. R53's progress notes failed to mention an incident which occurred on or around February 2025 through March 2025. Facility Report of Grievances/Complaints/Care Concerns 2024-2025 contained a list of grievances related to care concerns and lost items. The list lacked indication R53 filed a grievance. During an interview on 4/29/25 at 2:21 p.m., nursing assistant (NA)-D stated the completed grievance forms were kept on file in the social workers office. The process would be if a resident had a concern, staff would talk to the charge nurse. Grievance forms were completed by the residents, or a social worker could assist with the forms. During an interview on 4/29/25 at 2:46 p.m., registered nurse (RN)-D stated all grievances were given to social services and resolved using an electronic software, Med Trainer. RN-D stated R53's grievance was unfamiliar, but whomever was working should have filed a grievance immediately. During an interview on 4/30/25 at 9:13 a.m., social services (SS)-A stated when a resident filed a grievance, social services, the DON, and the Administrator would start collecting staff and resident statements. If the grievance fell under nursing, nursing aids, or resident cares the DON would follow-up. Grievances were manually entered into Med Trainer and once the hard copy was scanned into the program, the paper could be discarded. All statements, education, or resolutions were scanned into Med Trainer. SS-A was not 100% familiar with R53's grievance but remembered hearing about a concern with an employee. During an interview 4/30/25 at 9:15 a.m., Administrator in Training (AIT) called the DON who stated the previous social services director, SS-B, was involved in addressing the concern. During an interview 4/30/25 at 9:31 a.m., Activities Director(A)-A stated R53 asked why the facility didn't follow up with the grievance form. A-A then reported her concern to facility leadership. During an interview 4/30/25 at 9:48 a.m., (SS)-B stated no involvement in R53's grievance in February or March of 2025. During an interview 4/30/25 at 9:53 a.m., Administrator stated on or about 3/7/25, a nursing assistant entered R53's room without checking the [NAME], the aid started to do cares, R53 said to stop, and he left the room. The administrator indicated the issue was addressed with the aid, however was unable to locate the grievance form, or any written resolution provided to R53. Administrator confirmed someone was aware of the incident and it was investigated but there was no resolution or follow up by the facility provided to R53 at that time. Facility Policy titled Complaint and Grievance, revised 9/2023 stated, a grievance form should be completed when a complaint has been given to any employee of the facility. All completed grievance forms will be kept on record at the facility for a period of no less than three years.

Based on interview, observation, and documentation review, the facility failed to ensure a comprehensive care plan was developed and maintained to ensure appropriate care was provided for 1 of 1 resident (R51) reviewed for smoking. Findings include: R51's admission Minimum Data Set (MDS) assessment, dated 2/19/25, indicated R51 had intact cognition with no hallucinations or delusions present and no behaviors. Section J: Health Conditions indicated R51 currently used tobacco. Section O: Special Treatments and Programs indicated R51 used oxygen. R51's admission Record, printed 5/1/25, identified R51's admission date to the facility as 2/13/25. Furthermore, it identified the following relevant diagnoses: nicotine dependence, emphysema (chronic lung disease that progressively damages the tiny air sacs in the lungs), and congestive heart failure (condition where the heart doesn't pump blood as efficiently as it should). During an interview on 4/28/25 at 6:54 p.m., R51 stated she smoked cigarettes. R51 stated she had smoked for a long time. R51 stated the facility assessed me to make sure I am ok to smoke. R51 stated she had smoked since she has been at the facility and staff had been aware of her smoking. R51 stated she currently used oxygen at night only and did not wear it during the day. R51 stated she never wore her oxygen when she smoked. R51's care plan, reviewed on 4/28/25, lacked evidence of R51 being a current cigarette smoker. Furthermore, the care plan lacked the identification of safety interventions needed during the smoking assessments (i.e., ensuring resident removes oxygen while smoking). R51's Smoking Evaluations, dated 2/13/25, 2/17/25 and 4/14/25, identified R51 as a current smoker. During interview on 4/30/25 at 10:41 a.m., registered nurse (RN)-B verified they work with and were familiar with R51. RN-B stated R51 currently smoked and had smoked since admitting to the facility. RN-B reviewed R51 electronic medical record (EMR) and verified three smoking assessments had been completed. RN-B stated if a resident was identified as a smoker it should be on the care plan as everything should be on the care plan. RN-B verified R51 lacked identification that R51 was a smoker. RN-B verified they were adding it to the care plan during the interview, stating, it should be on there. During an interview on 5/1/25 at 8:48 a.m., registered nurse manager (RN)-D stated when a resident admitted to the facility, a smoking assessment was to be completed which included observing the resident smoke, and assessing for safety risks and concerns. RN-D stated if a resident was a smoker it needs to be added to the care plan. RN-D stated R51 currently smoked. RN-D reviewed R51's EMR and verified smoking assessments completed on 2/13/25, 2/17/25, and 4/14/25. RN-D reviewed R51's care plan and stated, I might be wrong, but it shows a date initiated 4/30/25, for smoking but I am not sure if I am looking at it right. During an interview on 5/1/25 at 9:29 a.m., director of nursing (DON) reviewed R51's EMR. DON verified R51 was a current smoker, had smoked since admission, and the care plan had not been updated until 4/30/25 (two days after survey entrance). DON stated it was important to have a comprehensive care plan as that is how you care for the resident. A facility policy titled Care Planning, dated 11/2024, indicated The care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purposes of providing care or services to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed ensure the care plan was updated and revised to reflect current interventions for 1 of 1 resident (R62) reviewed for positioning and mobility. Findings include: R62's quarterly Minimum Data Set (MDS) dated [DATE], identified R62 as independent with mobility, had no upper extremity impairment (shoulder, elbow, wrist, hand), and used a walker. R62's Occupational Therapy Discharge summary dated for services March 12, 2025, through April 9, 2025, indicated therapy was provided seven times for muscle weakness. R62's therapy involved improved strength for the left wrist, and R62 was given a brace on 4/9/25. Therapy directed R62 to wear the brace as tolerated. R62's care plan with a review date of 3/17/25, indicated a walking program of 200 feet one to three times per day with an assist of one during ambulation, bed movements, and transfers. The care plan lacked updates after R62 was discharged from therapy to walk independently with his walker and given a brace for his left wrist. R62's progress note dated 4/11/25, indicated R62 had a diagnoses of chronic kidney disease, type two diabetes, orthostatic hypotension, dehydration, and a failure to thrive (gain weight). R62's medications were noted as increasing a risk for falls and that R62 was an assist of one with transfers and mobility and with all activities of daily living. R62's progress note dated 4/17/25, indicated R62 was seen by the medical doctor and no new orders or changes to the current plan of care. R62 was also seen by the nurse practitioner on 4/16 no new orders or changes to the current plan of care. During observation and interview on 4/28/25 at 4:10 p.m., R62 was wearing a black brace on his left wrist. R62 stated the brace was for significant pain but was unable to explain the reason for its use or where it came from. During an interview on 4/30/25 at10:54 a.m., director of therapy (DOT)-A stated that R62 had recently undergone therapy for hand weakness and joint pain in the thumb, with therapy sessions from March 12, 2025, through April 9, 2025. DOT-A also confirmed that R62 had participated in therapy on three separate occasions in 2024. Additionally, DOT-A confirmed that the brace on R62's left hand was used for joint pain and the brace was applied intermittently with R62 being independent with its use, and continued use was recommended. R62 discharged with independent use of a walker and self-cares. DOT-A stated R62 needed no supervision with the walker or the brace at the time of discharge and managed these items independently. Nursing managed any care plans or concerns related to their use. R62 was given a green card and walked the entire facility. DOT-A confirmed R62's care plan stated he was on a walking program of 200 feet one to three times a day with staff assist and acknowledged the care plan needed to be revised. Licensed practical nurse (LPN)-D, who shared a desk with therapy, joined the interview, reviewed R62's care plan, and acknowledged R62 was now independent with his walker and was no longer on the walking program. Additionally, LPN-D stated the wrist brace wasn't care planned because R62 was independent with its use and the walking proram was a standing order and did not need revision. During an interview on 4/30/25 at12:26 p.m., registered nurse (RN)-D stated all braces and splits should be care planned and positioning should be checked under skin to make sure it is intact. RN-D reviewed R62's care plan and confirmed the care plan did not mention the brace worn on the left wrist. RN-D stated it was important to put braces on the care plan to monitor for alteration of skin integrity and skin breakdown. A policy titled Care Planning revised on 11/2024 and stated the care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purposes of providing care or services to the resident. The plan of care will be utilized to provide care to the resident. The care plan is to be modified and updated as the condition and care needs of the resident changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to reassess a resident with known constipation to determine what, if any, new interventions could be put in place to prevent constipation for one of one resident (R28) reviewed for constipation. Findings include: R28's quarterly Minimum Data Set (MDS), dated [DATE], indicated R28 was cognitively intact, was frequently incontinent of bowel without a bowel program, and required substantial to maximum assistance with toileting. R28's diagnoses, dated 3/7/25, indicated R28 had several medical diagnoses including Parkinson's Disease in which constipation is a common symptom. R28's bowel movements document in April indicated R28 often went three or more days in between bowel movements. R28's first documented bowel movement in April was 4/10/25, indicating 10 days without a bowel movement. R28 also did not have a bowel movement between 4/17/25 and 4/20/25 indicating three days between bowel movements, between 4/20/25 and 4/26/25 indicating 6 days between bowel movements, and between 4/20/25 and 4/29/25 only 1 small bowel movement was documented. R28's Orders indicated R28 had an order for Polyethylene Glycol Powder (Miralax) 17 grams by mouth two times a day for constipation, dated 1/22/25, and Senna- Docusate Sodium 8.6-50 milligrams (ml) two tablets two times a day for constipation, dated 12/3/24. R28's most recent Bowel Evaluation, dated 11/13/24, indicated R28 was continent of bowel but lacked any further assessment of R28's typical bowel movement patterns, what was normal or abnormal for her, and interventions attempted, or in place, to prevent constipation. R28's progress notes, dated 4/1/25 - 4/28/25, lacked any notes of R28's constipation or intervention used to promote bowel movements. On 4/29/25, it was documented R28 reported constipation to the nursing assistant (NA) and was offered milk of magnesia and an additional Senna in addition to her scheduled Miralax and Senna. It was also documented on 4/29/28, that R28 was also given prune juice by the nurse. During an interview on 4/28/25 at 5:15 p.m., R28 stated she had not had a complete bowel movement in over a week, stating she was often constipated due to her diagnosis of Parkinson's disease and was starting to have stomach pain due to her constipation. During an interview on 4/30/25 at 9:48 a.m., NA-E stated it was expected that the NAs document each shift if a resident had a bowel movement, stating the NAs did not do any of the tracking of bowel movements but that the nurses should be tracking when a resident had a bowel movement last to determine if they needed additional interventions to promote a bowel movement. NA-E stated R28 struggled with constipation but was unsure what the nurses did to help her manage her constipation. During an interview on 4/30/25 at 10:43 a.m., licensed practical nurse (LPN)-E stated it was expected that bowel movements were tracked, stating the NAs should let the nurses know if a resident had not had a bowel movement and that the clinical manager also tracked bowel movements. LPN-E stated most residents were already on Senna or Miralax but if it gets bad and a resident does not have a bowel movement in 3-4 days then a suppository should be given. LPN-E stated Milk of Magnesia was also available to give to residents as needed and any interventions used to promote a bowel movement should be documented in progress notes. LPN-E stated R28 seemed to struggle with constipation and reported that the Miralax was not effective for her so LPN-E would offer her milk of magnesia. During an interview on 4/30/25 at 12:42, nurse manager and registered nurse (RN)-D confirmed R28 struggled with constipation and stated the expectation was that on day three of no bowel movement the nurses should be offering prune juice or Milk of Magnesia, and if there is no bowel movement by bedtime that day the nurses should be offering to administer a suppository. RN-D stated R28 at times would toilet herself independently and the NAs should be asking R28 each shift if she had a bowel movement. During a follow up interview on 5/1/25 at 7:58 a.m., RN-D stated bowel assessments were completed on admission, annually, with a significant change in condition and as needed. RN-D confirmed R28 should be reassessed to determine what changes could be made to her bowel regiment to prevent frequent episodes of constipation and that she had reached out to the provider yesterday. A policy on constipation management was requested and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to follow-up and implement treatment for improved hearing for 1 of 1 resident (R62) who had complaints of hearing loss which were not addressed. Findings include: R62's admission Minimum Data Set (MDS) dated [DATE], identified R62 as highly impaired with the absence of useful hearing, did not wear hearing aids, and had a diagnosis of unspecified sensorineural hearing loss. R62's care plan initiated 9/23/24, indicated the use of a pocket talker to aid in communication, but failed to mention the use of R62's hearing aids. R62's most recent care plan with a review date of 3/24/25 indicated sensorineural hearing loss bilaterally. The care plan indicated the use of a pocket talker to aid in communication as needed and to speak clearly and distinctly to the resident, but failed to mention R62's hearing aids. R62's physician's note dated 12/12/24, indicated R62 wore hearing aids. R62's quarterly Minimum Data Set (MDS) dated [DATE], identified R62 had no cognitive impairment. Further, R62 had moderate difficulty with hearing and did not wear hearing aids. R62's treatment administration records (TAR) were reviewed from December 2024 through April 2025. The TAR failed to list any type of hearing device for R62 during this timeframe, and included orders started 4/29/25 to place and remove hearing aids. R62's quarterly MHM Hearing and Vision Form V3 dated 2/27/25, selected moderate difficulty for ability to hear and indicated R62 did not use hearing aids. During observation and interview on 4/28/25 at 5:52 p.m., R62 indicated he could not hear, had difficulty communicating his needs, and wanted to know if the facility was going to help with hearing aids. R62 was observed with no hearing aids. During an interview on 4/29/25 3:25 p.m., nursing assistant (NA)-B stated NAs carried care sheets to determine what residents had adaptive equipment but failed to have a care sheet readily available. NA-B located a care sheet from an office down the hall dated 4/18/25, and confirmed no hearing aids were listed for any of the residents on the unit which included R62. NA-B stated residents should tell staff if they wear hearing aids, but the care sheets should be updated with that information in case the resident couldn't inform the aid. NA-B confirmed the treatment administration record in the computer identified residents who needed hearing aids placed in the morning and removed at night. NA-B confirmed R62's care sheet and care plan did not indicate hearing aids, but R62 had a new order dated 4/29/25 to remove hearing aids. Nursing assistant (NA)-C also confirmed the care sheets were not accurate for the residents on the unit since there were two other residents who both also wore hearing aids. During an interview on 4/30/25 at 8:40 a.m. nursing assistant (NA)-D stated R62 had hearing aids for years but hasn't worn them frequently until this morning. NA-D stated the activities director (A)-A found batteries and A-A mentioned having R62 wear his hearing aides today, 4/30/25, but NA-D could not confirm. During an interview on 4/30/25 at 8:48 a.m., A-A reported that during a conversation with R62 on 4/29/25, R62 mentioned having difficulty hearing and was offered a pocket talker. R62 also noted that he had hearing aids in the closet but hadn't worn them in a while. R62 then removed two hearing aids from a tote, and A-A assisted with inserting new batteries. During interview on 4/30/25 at 12:17 p.m., registered nurse (RN)-D confirmed completing the quarterly MHM Hearing and Vision Form V3 dated 2/27/25. RN-D talked with R62 and confirmed moderate difficult hearing and stated R62 denied having hearing aids in his ears nor were any on the bedside table. RN-D asked the on-duty nursing assistant who indicated R62 did not wear hearing aids, although RN-D could not recall who the aid was working during the assessment. RN-D stated. RN-D confirmed R62 did have difficulty hearing during the assessment and did not have a consent on file for a referral for hearing aids. RN-D noted a refusal in the R62's electronic medical record that he did not want a referral for hearing aids, dated 9-20-24. Medication and Treatment Policy, revised 2/24 stated orders for medications and treatments will be transcribed accurately and in a timely fashion. The policy failed to directly mention hearing aids or adaptive devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively reassess and, if needed, determine or develop proactive interventions to help address pressure injury risk and development after a new pressure injury was identified (i.e., change of condition) for 1 of 2 residents (R13) reviewed whom had active pressure injuries. Findings include: The Centers for Medicare (CMS) State Operations Manual (SOM) Appendix PP, dated 2/2023, identified definitions for pressure ulcer care and treatment. This included guidance provided on the several stages of injury definition which included, Stage 3 Pressure Ulcer: Full-thickness skin loss . subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible . depth of tissue damage varies by anatomical location . Undermining and tunneling may occur . R13's quarterly Minimum Data Set (MDS), dated [DATE], identified R13 had intact cognition along with multiple medical conditions including heart failure, high blood pressure, and multiple sclerosis (MS). The MDS outlined R13 consumed multiple high-risk medications including opioids, diuretics and antiplatelets. Further, the MDS identified R13 was at-risk for pressure injury development and had one current stage IV pressure injury which had not been present upon admission. On 4/28/25 at 3:05 p.m., R13 was observed lying in bed while in her room. R13 had an air-alternating pressure mattress (APM) on her bed and was interviewed. R13 stated she had a sore on my butt which staff did a dressing change on multiple times a day. R13 stated she felt the wound was slowly healing but would likely never resolve. R13 stated she obtained the wound from sitting in her wheelchair for extended periods and reiterated it would likely never heal adding, No matter what I do, it will never go away. R13 denied concerns with the wound and requested to end the interview due to feeling unwell. R13's [NAME] Northwestern Hospital Wound Clinic Progress Note, dated 4/10/25, identified R13 was seen in the office for a wound check. R13's past medical history of her wounds was outlined within the note. This identified R13 presented in August 2024, for initial evaluation of the sacrum wound which had been present for . a few weeks and that it began without a clear cause. A section labeled, Treatment Course, identified each visit and subsequent information of the wound and it's progress. On 1/27/25, the note recorded R13 was seen by a plastic surgeon and an MRI was ordered. R13 was recorded as being on protein supplement daily and having wound cares done . one or two times daily. On 4/10/25, the note recorded R13 was identified to have a new wound to the right IT [ischial tuberosity] today. R13 was listed as continuing to get up in her wheelchair for approximately four hour increments every other day, still smoking, and still using protein supplement. The note recorded R13's new wound as, Pressure Injury Stage [blank space] Stage 3, and listed it as having some slough present and being 3.4 X 1.5 X 0.1 (cm) in size. R13's care plan, printed 4/30/25, identified R13's actual or potential medical and/or care-related problems and corresponding interventions to address them. The care plan identified R13 had an alteration in skin integrity and required extensive assistance with bed mobility adding, Resident runs the show . The care plan listed multiple interventions to address R13's skin risk and concerns including limiting her time seated in the powered wheelchair, monitoring skin integrity with cares, and using an air mattress. The last time the interventions were revised prior to the onsite survey was recorded as, 09/27/2024, with multiple interventions being added and/or revised on 4/29/25 and 4/30/25 (after survey started). R13's MHM (Monarch Healthcare Management) Skin Evaluation and Skin Risk Factors V-2, loaded 10/20/24, was identified with dictation present, In Progress. However, the entire evaluation was left blank and not completed. There were no additional Skin Evaluation and Skin Risk Factors V-2 evaluations loaded or completed in the record. On 4/29/25 at 12:36 p.m., nursing assistant (NA)-A was interviewed, and verified they had cared for R13 prior adding, [I've] worked with her many times. NA-A explained they often helped the nurses complete R13's wound care and stated R13 rarely got up from her bed due to her own choice. NA-A stated R13 would also, at times, refuse meals and seemed not not really want you in there much. NA-A stated R13 used an air mattress and nurses would mix medications into her mashed potatoes. NA-A stated they were unsure how long R13 had the sacral pressure wound but added, Since I started [working there]. NA-A described R13 as being somewhat dismissive and independent with her cares adding, She knows what she wants. R13's dietary progress note, dated 4/24/25, identified a nutrition follow-up was completed due to R13's weight and wound adding, Discussed resident at IDT [interdisciplinary team] wound meeting. R13's weight was outlined as stable and added, Will discuss with nurse manager about increasing protein powder to 2 scoops per serving to better meet protein needs which would provide ~24 gm [grams] protein. However, the note lacked evidence of what, if any, other factors the IDT had reviewed which could contribute to pressure ulcer risk or skin breakdown (i.e., mobility, medication use, continence) to determine what, if any, interventions were needed to reduce the risk of skin breakdown and promote healing since R13 developed a new pressure injury on 4/10/25. When interviewed on 4/29/25 at 1:37 p.m., registered nurse (RN)-A stated they had worked with R13 multiple times prior. RN-A explained R13 did not like to get up from bed and would only get into her electric wheelchair like every 3rd day which was usually just so she could smoke outside. RN-A verified R13 had an active wound on her sacrum and expressed it was larger sized than an orange (fruit) adding oh, it's bigger. RN-A stated the wound was slow to heal due to R13 being resistive with interventions and getting out of bed adding R13 had super, super fragile skin. RN-A stated they were aware of R13 having a second wound now, however, RN-A stated they felt it was a little tiny one and due to bandage-tape being pulled off the skin. RN-A stated they felt the wounds were both getting better just slowly adding aloud, It's really slow to heal. RN-A stated the nurse manager would like know more about the wounds as they tracked it and measure it. On 4/30/25 at 9:36 a.m., licensed practical nurse manager (LPN)-C was interviewed, and verified they had a chance to review R13's medical record. LPN-C verified R13 had two active pressure injuries which both developed in-house, and explained R13 beats to her own drum with cares and interventions. LPN-C stated the wound was checked for measurements and status every week, and R13 was also being seen by an outside wound clinic for it at times. LPN-C stated R13 had been educated on the risks of not allowing repositioning and being so specific with what interventions she would allow. LPN-C explained the right IT pressure injury was new and recorded as a stage three pressure area from the wound clinic. LPN-C verified the first recorded evidence of the wound was on 4/10/25 from the wound clinic note, and explained when a new wound developed the staff wanted to obtain treatment orders, update the provider, and then the plan of care needed to be updated. LPN-C stated R13's wound treatments were tweaked due to the new wound. LPN-C stated the facility' skin evaluation evaluation (i.e., MHM Skin Evaluation and Skin Risk Factors V-2) was just an extra tool to help review someone adding the comprehensive part of the review could be more within the IDT discussion which happened every morning. LPN-C then provided a Microsoft Word document which had IDT notes listed on it. The untitled page, undated, identified R13's name along with, New Wound Right IT. The page outlined, IDT discussed and reviewed Care Plan and orders for any changes to interventions. Resident continues 'to run the show' and does not allow [hospital] wound clinic repositioning direction. Uses pillows. New Orders for wound healing, dietician involved, provider updated, Resident involved. However, the provided document lacked evidence what, if any, other interventions were considered, offered, refused despite R13 having multiple wounds and being resistive to recommendations. Further, R13's medical record was reviewed and lacked documented evidence R13 had been comprehensively reassessed for pressure wound risk or what, if any, interventions were considered, adopted or agreeable despite R13 developing another wound with some interventions, such as monitoring and an air mattress, already in place prior to the right IT wound developing. At this time, the director of nursing (DON) joined the interview via telephone. DON explained a new wound should be assessed and photographed, then the provider and family should be updated. DON stated the IDT would then discuss the wound and review the care plan. DON stated they felt everything was in place for R13 and reiterated R13 likes to do her own thing with cares she will allow. DON stated the skin evaluation form was just a tool and expressed they didn't feel completing one was necessarily required for a new wound development adding, We don't have a policy for that. LPN-C verified R13's medical record lacked evidence of a comprehensive reassessment being done in the evaluations or progress notes. DON acknowledged the actual medical record possibly lacked evidence of the IDT' discussion on R13's new pressure injury adding aloud, I see what you're saying. DON stated having the documentation in the medical record was important to promote continuity of care. A facility-provided Skin Assessment & Wound Management policy, dated 2/2025, identified a pressure ulcer risk assessment (Braden Scale) would be completed per an established schedule and, Skin Evaluation and Skin Risk Factors Form is completed before initial MDS, annually, and upon significant change. A section labeled, New Skin Problem, outlined a series of steps to be completed for developed pressure injuries which included notifying the provider, completing education with the resident, and initiating the Skin and Wound Evaluation (i.e., weekly monitoring). However, the policy section lacked direction or guidance on how a comprehensive reassessment process would look or be documented within the medical record.

Based on observation, interview and record review, the facility failed to provide services to maintain and/or prevent loss of range of motion and contracture care for 1 of 1 residents (R51) reviewed for limited range of motion. Findings include: R51's admission Minimum Data Set (MDS) assessment, dated 2/19/25, indicated R51 had intact cognition with no hallucinations, delusions, behaviors or rejection of care. In addition, R51 had no impairment in function limitation in range of motion, utilized a wheelchair for mobility, dependent on staff for lower body dressing and dependent on staff for transfers. R51's admission Record, printed 5/1/25, indicated the following relevant diagnoses: chronic pain, abnormalities of gait and mobility, dorsalgia (back pain), muscle weakness, disease of spinal cord, restless sleep syndrome and cervicalgia (neck pain). During an interview on 4/28/25 at 6:51 p.m., R51 stated she was not getting physical therapy (PT). R51 stated she had been getting occupational therapy (OT) but hadn't received any OT in probably at least two weeks. R51 expressed frustration stating, this is the whole reason I am here, and I am not getting therapy. R51 stated one of the therapy staff had told her that the nursing staff could work with my legs in bed but they aren't doing that. R51 stated she can no longer straighten her left leg which she could do prior to coming to the facility and indicated she currently used a Hoyer lift (a medical device used to transfer individuals, who cannot bear weight, with limited mobility from one place to another, such as a bed to a wheelchair). A Nursing Order-External Facility note, dated 3/4/25, indicated Patient is cleared to toe touch during transfer while wearing a Darco shoe. A Nursing Order-External Facility note, dated 4/15/25, indicated It is also recommended that the patient participate in physical therapy daily at the facility, while maintaining non-weight bearing status to the left heel, but can do to-touch transfers on the left foot. Darco shoes were provided during a previous appointment for this reason. A Nursing Order-External Facility note, dated 4/22/25, indicated It is also recommended that the patient participate in physical therapy daily at the facility, while maintaining non-weight bearing status to the left heel, but can do to-touch transfers on the left foot. Darco shoes were provided during a previous appointment for this reason. R51's care plan, printed 5/1/25, lacked evidence of a restorative nursing program. Furthermore, lacked evidence of PT recommendations or recent assessments. During an interview on 4/30/25 at 10:39 a.m., registered nurse (RN)-B stated that nursing and therapy work together to coordinate care for residents. RN-B stated therapy would update nursing when there were changes to how residents ambulated, transferred or were new to the program. RN-B reviewed R51's electronic medical record (EMR) and verified R51 was discharged from OT on 4/16/25. RN-B verified R51 was not receiving any restorative nursing services after reviewing R51's EMR and three-ring binder that contains information on exercises for residents participating in the restorative nursing program. RN-B verified R51 was not receiving PT services, and stated R51 relied heavily on caregiver assistance. During an interview on 4/30/25 at 11:04 a.m., registered nurse manager (RN)-D reviewed R51's EMR. RN-D stated they reviewed communication with outside providers and had reviewed Nursing Order-External Facility Notes listed above. RN-D stated she had talked to therapy about changing R51 to toe touch. RN-D stated she could not remember when she had talked to therapy, did not have documentation regarding the conversation, and stated she thought it was when she had reviewed the first note during stand up (interdisciplinary team meeting). RN-D verified R51 should have been assessed by therapy. During an interview on 4/30/25 at 11:11 a.m., director of therapy (DOT)-A stated all residents had standing orders for therapy evaluations. DOT-A stated nursing communicated to therapy when a resident needed to be assessed or reassessed. DOT-A verified R51 was currently not getting any therapy (PT/OT) services. DOT-A stated R51 had PT services from 2/16/25 to 3/13/25, and OT services from 2/16/25 to 4/16/25. DOT-A stated R51 had not been reassessed for PT services since being discharged , and stated he had been given a copy of one of the Nursing Order-External Facility notes, did not remember exactly when it was, but did verify it was after R51 had discharged from PT services. DOT-A reviewed R51's EMR and verified there was no restorative nursing program. DOT-A stated R51 had not been able to move her legs on her own since admission, and we tried to get her to move her legs, but she always asked for help. DOT-A verified R51 transferred with a Hoyer lift since admission. DOT-A verified that a PT assessment should have been completed for R51. DOT-A stated R51 might not be able to bear weight, but it would be important to prevent any contractures. During a follow up interview on 5/01/25 at 8:56 a.m., RN-D verified R51 did not receive and had not received any restorative nursing services. During an interview on 5/01/25 at 9:34 a.m., director of nursing (DON) stated he had reviewed R51's EMR. DON stated R51 should have been reassessed by therapy. DON stated it was important to work with therapy and have a restorative nursing program to see how we can improve your life and prevent things that shouldn't happen and live a better life. DON stated R51 was going to be reassessed by therapy today, and he had followed up with R51 that morning. DON had assessed R51 that morning (5/1/25) and stated R51 did not have any contractures in lower or upper extremities, decrease in extension of legs and therapy would complete a full reassessment this day. A facility policy titled Medication and Treatment Orders, dated 2/24, indicated Orders for medications and treatment will be transcribed accurately and in a timely fashion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure a resident with a catheter had medical justification for continued use and failed to attempt a trial removal, if recommended, for one of one resident (R35) reviewed for indwelling catheter. Findings include: R35's quarterly Minimum Data Set (MDS), dated [DATE], indicated R35 had moderate cognitive impairment, required supervision with toileting and moderate assistance with bathing and had an indwelling catheter in place. R35's admission MDS, dated [DATE], indicated R35 was admitted with an indwelling catheter in place. R35's Diagnoses, dated 5/16/22, indicated R35 had several medical diagnoses related to potential need for an indwelling catheter including other obstructive and reflex uropathy which can hinder the normal flow or urine, unspecified retention of urine, renal hypoplasia (a congenital condition in which one or both kidneys are underdeveloped), benign prostatic hyperplasia with and without lower urinary tract symptoms (a non-cancerous enlargement of the prostate gland), and infection and inflammatory reaction due to indwelling urethral catheter. However, the electronic medical record (EMR) failed to demonstrate duration of the retention, attempts (if any) to manage without a catheter, and medical justification for why the catheter was necessary on an ongoing basis (i.e neurogenic bladder). The EMR further lacked any evidence of post void residual (PVRs) to determine the extend of R35's urine retention. A urology note for R35, dated 7/28/22, stated anticipate SP (suprapubic catheter - a urinary catheter that is surgically inserted through the abdominal wall directly into the bladder) on 8/17/22. The EMR lacked any evidence of follow up on this order or potential for a SP catheter to be placed. During an interview on 4/3025 at 9:41 a.m., R35 stated he believed he had his catheter since coming to Minnesota years ago to prevent urine leaking on the plane. R35 stated it has had an indwelling catheter since then because he has only had 2-3 urinary tract infections with the indwelling catheter in place. During an interview on 4/30/25 at 12:42 p.m., nurse manager and registered nurse (RN)-D stated she emailed R35's provider that day about an appropriate catheter diagnosis, stating I don't believe we have [one]. RN-D further stated the facility had not attempted to remove R35's catheter since his admission to the care facility to assess the extent of his urine retention or if it could be managed without an indwelling catheter. During a follow up interview on 4/30/25 at 2:33 p.m., RN-D stated R35 had an appointment with urology on 5/1/25, and she would follow up on the goal for his catheter, including a proper diagnosis, order for a removal attempt, or a supra pubic placement, stating it was not clear what the goal for his indwelling catheter currently was. A facility policy titled Indwelling Catheter Care Procedure was provided, however it only spoke to proper care of a residents catheter while in place i.e. peri care with a catheter, emptying catheter bags and ensuring they are draining properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and document review the facility failed to comprehensively reassess a resident for pain who was hospitalized for concerns with her pain medication and had pain medication changes, and who still reported frequent pain for one of one resident (R1) reviewed for pain. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact and independent with most activities of daily living (ADLs). The MDS further indicated during the look back period R1 received scheduled pain medication, no PRN (as needed) pain medications, and was in pain almost constantly which effected R1's sleep and day to day activities. R1's Orders indicated R1 had several medications for pain including: Buprenorphine HCl Sublingual Tablet Sublingual, give 2 milligrams (mg) sublingually one time a day for chronic pain syndrome, dated 4/11/25; Oxycodone HCl Oral Tablet 5 mg, give 1 tablet by mouth every 6 hours as needed for Chronic pain/Nonacute pain and give 2 tablets by mouth every day with wound care, dated 4/2/25; Pregabalin Oral Capsule 150 mg, give 150 mg by mouth three times a day for pain, dated 3/12/25; and Acetaminophen Oral Tablet, give 1000 mg by mouth as needed for pain three times a day, dated 2/19/25. The orders also contained an order to monitor for pain daily, dated 5/30/24, and to document any non-pharmacological pain interventions every shift, dated 10/15/24: 0: No intervention needed 1: Ice 2: Heated blankets 3: Massage 4: Repositioning 5: Music 6: Essential Oils 7: Food/Drink 8: Relaxation Breathing. R1's most current comprehensive pain assessment, dated 2/21/25, indicated R1 reports constant pain to BLEs [bilateral lower extremities] and reported 10/10 pain. R1's medication administration record (MAR) for April 2025 indicated R1 received as need Tylenol 10 times and as needed Oxycodone 15 times in the month of April. A hospital note for R1, dated 4/10/25, indicated R1 was hospitalized for concerns regarding over sedation due to changes to her pain medication buprenorphine. The note indicated more changes were made to her pain medication in the hospital including stopping buprenorphine film and patch and adding buprenorphine 2 mg sublingual tablet. The note also indicates changes were made to Pregabalin (a medication used to treat nerve and muscle pain). R1 electronic medical record (EMR) lacked evidence that R1 was comprehensively reassessed since having changes to her pain medications to see what, if any additional medications or pain interventions could be added to promote pain control despite R1 still frequently reporting uncontrolled pain. During observation and interview on 4/28/25 at 2:24 p.m., R1 was sitting in her room in her wheelchair, with tears in her eyes stating she had almost constant pain in her knees and shoulders. During an interview on 4/30/25 at 9:48 a.m., R1 stated her left leg was in excruciating pain. During an interview on 4/30/25 at 9:48 a.m., nursing assistant (NA)-E stated R1 would complain of pain at times, and she would let the nurses know, though she did not work with R1 often. During an interview on 4/30/25 at 10:43 a.m., licensed practical nurse (LPN)-E stated R1 had been having issues with her legs and often had pain. LPN-E stated they would assess R1's pain level and need for non-pharmacological pain interventions prior to administering PRN pain medications but that she was not responsible for comprehensive pain assessments. During an interview on 4/30/25 at 12:42 nurse manager and registered nurse (RN)-D stated comprehensive pain assessments would be expected to be completed quarterly and with a change in condition, stating a hospitalization would be considered a change in condition and she would have expected a comprehensive pain reassessment to be completed with R1 after her hospitalization with pain medication changes. RN-D confirmed R1 had not been comprehensively assessed for pain since 2/21/25. A facility policy on pain was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure the three-compartment dish sink was of proper sanitization parts per million (ppm) which had the potential to affect all 76 residents who received meals from the main kitchen. Furthermore, the facility failed ensure employees wore beard restraints to prevent hair from contacting food. Findings Include: A report titled Diet/consistency Rollup printed on 4/30/25, categorized each diet and had total meals served out of the main kitchen as 76. During the initial kitchen walk through conducted on 4/28/25 at 1:22 p.m., an area over the three-compartment sink had logs for documentation of water sanitization for April 2025, completed for April 1-24th. Above the sink were two large bottles held by a wire rack with two tubes that ran down into the three compartment sink, both were empty. The bottle on the left was labeled quaternary sanitizer and the one on the right was labeled pot/pan detergent and sanitizer. A large bottle of Dawn dishwashing detergent sat on the far right of the three-compartment sink. A cook was wearing a navy-blue baseball cap and had a beard that extended from the chin approximately 1. During an interview on 4/28/25 at 2:11 p.m., culinary services director (DOC)-A confirmed hair nets were available for employees and donned one himself. DOC-A stated employees needed to either wear a hat or a hairnet. DOC-A then stated if a beard was too big they need to wear a cover or shave it, and after a couple of days beards should be shaved or covered or else it could fall into the resident's food. DOC-A could not recall a facility policy on beards in the kitchen, but said employees would be written up if they didn't wear a beard restraint. DOC-A confirmed beard restraints were not available for employees at the kitchen entrance or in the office on 4/28/25. During an observation on 4/29/25 at 11:43 a.m., The pots/pan detergent and sanitizer bottle above the three compartment sink had approximately 1 inch of a blue bubbly solution. On the right hand of the three-compartment sink was a large bottle of Dawn dish detergent. During an observation and interview on 4/29/25 at 12:07 p.m., cook (C)-A removed a puree mixer lid and blade from the drying rack located on the left of the three-compartment sink. C-A stated the puree mixer was hand washed with Dawn and often Dawn detergent was added to the pots/pans bottle above the sink. Dawn and water were then mixed and the sink was filled to wash pots, pans, and kitchen utensils. During an interview on 4/29/25 at 2:08 p.m., dietary aid (DA)-A stated the three-compartment sink area was used for pots and pans. The pots and pans were scrubbed with Dawn and then used to cook. All resident dishware was put through dishwasher. During an observation on 4/30/25 at 12:41 p.m., Dawn dish detergent was used to wash a clear/gray plastic top to the puree mixer. The top was rinsed off and set on the side of the sink to dry. These items were rinsed less than 30 seconds. During an interview on 4/30/25 at 12:43 p.m. C-A stated no thermometer was available to check the water coming out of the sink and confirmed a puree blender top were hand washed with Dawn and other kitchen utensils. During an observation on 5/1/25 at 9:44 a.m., a three-compartment sink had a large bottle of Dawn dish soap. During an interview on 5/1/25 at 10:31 a.m., DOC-B stated the facility policy allowed for manually washing dishes in the three-compartment sink, but all dishes needed to be sent through the dishwasher to be sanitized. DOC-B stated he was not aware the cooks were manually washing and reusing the items without sending the items through the dishwasher and replied, oh no, they can't do that to which the nearby DOC-A responded, yes we talked about that. DOC-B also confirmed beards should be no longer than a ½ for all Monarch facilities and that C-A should wear a beard cover. Facility Policy titled Sanitization, revised October 2008, #9 Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing. C: Sanitize with hot water or chemical sanitizing solution. Chemical sanitizing solution may consist of: Chlorine, Iodine, Quaternary ammonium. Facility Policy titled Cleaning and Disinfection, revised September 2012, Mixer bowls, beaters, grinders, pots, pans, roasters, electric knife, blades, food thermometers, etc. 1. Wash in 3 compartment sink or dishwasher: a. 1st compartment-soap and water (110-120 degrees Fahrenheit). B. 2nd compartment-clear water for rinsing (120 degrees Fahrenheit). c. 3rd compartment-Detergent/disinfectant (170 degrees Fahrenheit for 2 minutes). 2. Allow to remain wet for 10 minutes to air dry. Facility Policy titled Food Preparation and Service, revised April 2019, Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food

Based on observation, interview, and document review, the facility failed to ensure soiled personal laundry and linens were bagged (i.e., contained) at the point-of-use and transported in a manner to reduce the risk of cross-contamination and potential infectious spread in 1 of 1 main washrooms and 2 of 2 units (70's, 90's) reviewed. This had potential to affect all 75 residents within the care center. Findings include: On 4/29/25 at 7:57 a.m., the campus' main laundry washroom was toured with housekeeper (HSK)-A present. HSK-A explained they were the primary person who completed laundry for the care center, and they then provided a tour of the laundry process and the machines used. The soiled linen receiving area and washroom were located on one side of the hallway and folding area (clean) on the opposite. However, in the hallway between these areas were a series of mobile, off-white colored hard plastic bins including one labeled, Soiled Linen Only, in black paint. The bin was covered with a light-blue colored cloth covering which was lifted exposing it's contents which was soiled white linens and personal clothing, much of which was not bagged but rather loose in the bin causing articles to touch. HSK-A verified the items were not bagged and expressed they should have been prior to transport. HSK-A stated the bin was likely brought down last evening by the nursing assistant (NA) staff. HSK-A stated they had, at times, noticed soiled laundry items to be coming down to the main washroom not bagged adding aloud on occasion, yes. HSK-A stated they had talked about the issue with the care center administrator in the past, however, added, But not as frequently as maybe I should have, to be honest. HSK-A then verified they had not collected any soiled linen from the units today yet. A tour of the '70's Unit' was then completed. The soiled utility room was opened with HSK-A present which, inside, had three mobile, off-white containers similar to the one observed by the washroom. HSK-A stated two were used for trash and one was used for soiled linens and personal clothing. The laundry container had a balled-up light-blue cloth cover inside the corner of the container and, again, nearly all of the soiled laundry inside was not bagged. HSK-A stated they items should be bagged at the point-of-use and not transported loosely like it appeared had happened adding aloud, [They should be] bagging in, bagging out. HSK-A stated most of the personal laundry and linens were laundered by the care center adding, Pretty much [yes]. HSK-A stated the soiled linen should be bagged to help prevent cross contamination between the garments. Following, a tour of the '90's Unit' was then completed. The soiled utility room was opened with HSK-A present which, inside, had multiple mobile, off-white containers similar to the one observed by the washroom and '70's unit.' The container for soiled linens and laundry was uncovered and, inside, nearly all of the garments and linens were not bagged. Further, sitting on top of the soiled laundry was two yellow-colored bags which had markings on them to indicate potential bio-hazard (i.e., isolation room, active infection). HSK-A verified the items were not covered or bagged and stated aloud, That will be addressed today. HSK-A stated they did complete audits of laundry care which included walking around with the administrator and observing general cleanliness. HSK-A stated they would provide these for review. A series of three Monthly Facility Tour Form(s), dated 12/27/24 to 3/28/25, were provided. These outlined various areas of the care center and provided spacing to record a score (0 to 10) of cleanliness of the corresponding area. A section was listed, Laundry/Linen, which outlined three specific areas to review including linen closets, personals, and laundry room. The spacing provided to write-out any comments was left blank and no concerns were written. However, the provided audits all lacked evidence the soiled utility rooms (where soiled linens were kept until transport to the washroom) were included in the review or audit process. On 4/30/25 at 10:01 a.m., the interim director of nursing (DON) was interviewed, and they verified they were the campus' infection preventionist (IP). DON explained they have educated staff through staff meetings and such about the need to bag soiled items where collected, and he verified soiled laundry and linens should be bagged prior to transport. This was important to do as staff could spread infections from one place to another. DON added, We will continue to do staff education and follow-up with the staff. A facility-provided Infection Prevention and Control Program policy, dated 11/2024, identified the facility would establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment. The policy outlined several steps taken with this program including infection surveillance, antibiotic stewardship and data analysis; however, the policy lacked information on soiled linen handling or transportation. A separate, facility-provided Skill 6. Gown, Glove, and Bag Linen protocol, undated, identified a checklist for staff to implement with gown removal and soiled item collection in an isolation room. This identified, 5. Remove the soiled linen. Keep the linen contained during removal and place in the appropriate bag/receptacle. A facility' policy on soiled laundry handling and transportation was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately assess a resident after a change in condition for one of one resident (R1). License practical nurse (LPN)-A noticed a change in condition at 8:00 a.m. on 3/4/25, started taking vital signs at 10:30 a.m., and emergency medical services (EMS) was not called until 11:33 a.m. Findings include: R1's face sheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of acute cystitis with hematuria. R1's additional diagnoses included chronic obstructive pulmonary disease, acute kidney failure, hallucinations, chronic respiratory failure, dependence on supplemental oxygen, and chronic obstructive pulmonary disease with exacerbation. R1 was discharged from the facility on 3/4/25. R1's admission hospital medical records indicated R1 was admitted to the hospital from [DATE] to 2/25/25 due to covid-19, urinary tract infection, and encephalopathy. It was noted during her admission that her skin was warm and dry. No skin concerns were noted. R1's Initial Data Collection assessment dated [DATE], indicated R1's skin was dry and pale but was not cyanotic, oily, mottled, jaundiced, or clear. There were eleven bruises, and their locations noted, and one area of redness noted. No other skin concerns were noted. R1's Brief Interview for Mental Status (BIMS) assessment dated [DATE], indicated R1 scored eight, which indicated R1 was moderately cognitively impaired. R1's care plan dated 2/25/25, indicated R1 had alterations in skin integrity. Staff was to monitor skin integrity daily during cares, monitor for skin breakdown for signs/symptoms of infection and to report to the provider, and document on skin condition and keep the provider informed of changes. R1's Provider Orders for Life-Sustaining Treatment (POLST) dated 2/25/25, indicated R1 requested resuscitation to be attempted. R1 requested full medical treatment if necessary. The POLST was signed by R1, but not by the provider. R1's Minimum Data Set (MDS) dated [DATE], indicated R1 had one or more unhealed pressure ulcers, but no other skin concerns noted. R1's Skin Evaluation and Skin Risk Factors assessment dated [DATE], did not indicate R1 had a gray tint to her skin. R1's progress note dated 3/4/25 at 11:18 a.m., indicated R1's vital signs were unstable, a change of condition was noted, and R1 was not responding to stimuli. R1's pulse was ranging from the fifties to one hundred and twenty beats per minute, blood pressure was seventy-three over forty-nine, reparations were twenty-six breaths per minute, and her oxygen was at eighty-two percent on two liters of oxygen. The nursing staff raised R1's oxygen to four liters of oxygen via nasal cannula. R1 was breathing heavily and was not responding to verbal commands or sternal rubs. It was recommended that R1 be sent to the emergency department for further evaluation. FM-B was present in the facility at the time. R1's progress note dated 3/4/25 at 12:00 p.m., indicated the writer was notified that R1's blood pressure was seventy-three over forty-nine, pulse was ranging from fifty-five, one hundred-eight, one hundred thirty-eight, and forty-nine. R1's respirations were twenty-six breaths per minute with shallow breathing, temperature was ninety-seven point four, and her oxygen was eighty-two percent on two liters of oxygen but increased to eighty-nine percent on four liters of oxygen. R1 was hard to arouse. The nursing staff performed a sternal rub and R1 was heard moaning in a low voice and was able to respond with eyebrow movement when asked how she was doing. The writer of the progress note called FM-B, updated him on the status of R1, and recommended R1 be sent to the emergency department. FM-B reported that he was on his way to the facility to discharge R1 home with hospice services, not to send R1 to the emergency department, and FM-B would have R1 evaluated once she was discharged . The writer called FM-B again to update R1's POLST to do not resuscitate (DNR) if he was not approving to send R1 to the emergency department, but FM-B was already at the facility and wanted to keep R1 a full code. FM-B later approved to send R1 to the emergency department. R1's progress note dated 3/4/25 at 12:40 p.m., indicated at about 12:21 p.m. the writer gave a report to a nurse in the emergency department. R1 had a bed bath between 7:00 a.m. and 8:00 a.m. that morning. R1 was noted to be sleepy and snoring, but that she typically sleeps in the morning. FM-B informed staff not to send R1 to the hospital or activate EMS as R1 was going to be discharged on hospice that day. FM-B indicated he was on his way to the facility, arrived four minutes later, refused to change R1's code status, and then approved of R1 going to the emergency department. The assigned RN indicated R1 was at her baseline prior to the change in condition, prompting an assessment, follow up call to the provider, family, the interdisciplinary team (IDT), and EMS. R1's progress note dated 3/4/25 at 1:06 p.m., indicated R1 was responsive the entire time before R1 was taken via EMS by sternal rub and speaking with R1. R1 would respond by moaning and raising eyebrows when writer would ask questions. Writer went into R1's room and RN-A was getting R1's vital signs. R1's temperature was ninety-seven point three and oxygen was eighty-two precent on two liters of oxygen. Nursing staff increased R1's oxygen to three liters of oxygen via nasal cannula and oxygen saturation remained under ninety percent, so nursing staff increased oxygen to four liters of oxygen via nasal cannula and oxygen saturations raised to ninety percent. R1's pulse ranged from the forties to one hundred-thirty beats per minute. R1's pulse would increase quickly at eighty beats per minute, to one hundred-twenty beats per minute, and then sixty beats per minute. The nursing staff took blood pressures and pulse from the beginning to when R1 left with EMS. The following vitals signs were in order from the beginning: blood pressure sixty-eight over thirty-nine with pulse seventy three beats her minute, blood pressure sixty-four over thirty-five with pulse eighty beats per minute, blood pressure seventy-three over forty-nine with pulse fifty beats per minute, blood pressure seventy-eight over forty-two with pulse seventy-five beats per minute, blood pressure seventy-one over forty-one with pulse fifty-two beats per minute, blood pressure fifty-one over thirty-one with pulse eighty-two beats per minute, blood pressure fifty-six over twenty-nine with pulse seventy-eight beats per minute, and blood pressure sixty over thirty-seven with pulse seventy-nine beats per minute. R1 was transferred to the hospital via EMS. R1's vital sign documentation indicated blood pressures ranging from one hundred-twelve over sixty-one to one hundred eighty-nine over seventy-seven. R1's oxygen ranged from eighty-nine percent on oxygen via nasal cannula to ninety-six percent via nasal cannula. R1's pulse ranged from sixty-nine beats per minute to one hundred nine beats per minute. R1's respirations ranged from fourteen breaths per minute to twenty breaths per minute. R1's temperatures range from ninety-six point three to ninety-eight point zero. R1's EMS report indicated the facility called EMS on 3/4/25 at 11:33 p.m., and arrived at the facility on 11:38 a.m. where R1 had shallow respirations. Staff stated R1 had been unresponsive for about four hours before calling EMS. Staff also stated R1 was transitioning back home that same day and was going on hospice, but family had been in the room requesting R1 to be a full code. R1 had been laying down and was on four liters of oxygen when she is normally only on two liters of oxygen. The report stated R1 was given a sternal rub which R1 responded with a moan, but did not open her eyes or talk. No skin abnormalities noted. R1's hospital medical records dated 3/4/24, indicated R1 presented to the emergency department by EMS for evaluation of decreased level of consciousness. R1 had been unresponsive for four hours. R1 would occasionally groan but was not speaking. R1 presented with agonal respirations, lethargic, minimally responsive, but no skin concerns. R1's blood pressure at the facility was seventy over twelve but increased to one hundred-thirty over sixty on the way to the hospital. Medical records indicated R1 was going on hospice to get better in-home services so R1 could leave the facility. During this admission, R1 was intubated, and was transferred to another hospital via EMS. R1's medical records dated 3/4/25, indicated R1 presented to the intensive care unit (ICU) with shock. R1 was too critically ill to participate in any cares. During her admission, R1 had acute encephalopathy, septic shock due to UTI, severe acute kidney injury due to acute tubular necrosis in setting of septic shock, and acute on chronic hypoxemic and hypercapnic respiratory failure. R1 was still in the hospital as of 3/11/25. During an interview on 3/11/25 at 2:20 p.m., family member (FM)-A stated R1 was still in the transitional care unit (TCU) at the hospital. Hospital staff removed R1's intubation tube on 3/9/25. An interview was attempted with FM-B on 3/11/25 at 2:38 p.m. and 3:14 p.m. but was not successful. During an interview on 3/11/25 at 3:21 p.m., LPN-A stated she has been working at the facility for about four weeks. LPN-A stated when R1 was first admitted to the facility on [DATE], LPN-A had completed her admission assessment. LPN-A noted no skin concerns or discoloration at that time. On 3/3/25, LPN-A had seen R1 while working with R1's roommate and R1 was sleeping and did not have any skin discoloration or concerns at that time. On 3/4/25 around 7:00 a.m. or 8:00 a.m., FM-A was visiting and LPN-A stated R1 is usually awake during the night, and sleeps most of the day. FM-A stated R1 was to be discharged on hospice that same day. LPN-A stated she noticed R1's facial coloring was not at her baseline. LPN-A stated that she had mentioned R1's gray tint to FM-A but FM-A stated R1 had looked like that before. LPN-A stated she considered that to be a change of condition. LPN-A stated she was not concerned about R1 because FM-A stated R1 had looked like this before. LPN-A stated R1 would respond to her by raising her eyebrows or by moaning, but R1 did not open her eyes or talk. R1's baseline was talking and opening her eyes. LPN-A told FM-A that she would be talking to the interdisciplinary team (IDT) in their morning meeting about R1's condition. LPN-A stated the IDT meeting ended around 10:30 a.m. and had asked the NA's to get a set of vital signs from R1 but could not recall the name of the NA. RN-A was in R1's room while the NA was attempting to get R1's vital signs. RN-A had left R1's room and it was only LPN-A and one of the NA's in R1's room at the time. LPN-A stated she would perform sternal rubs on R1 and R1 would respond by raising her eyebrows and moaning quietly. When R1's blood pressure was low, R1 would not respond at all but still had a pulse. RN-A told LPN-A that registered nurse (RN)-C had talked to FM-B and FM-B did not want R1 sent to the emergency department right away and that he would be at the facility in a couple of minutes. Once FM-B got to the facility, the facility staff were able to call EMS. When EMS got to the facility, LPN-A gave report stating R1 was responsive by raising her eyebrows and moaning quietly. LPN-A stated she told EMS that R1 had a gray tint to her face for about four hours. LPN-A stated she also told another EMS staff that R1 had been in this condition for four hours. LPN-A stated any resident who had a gray tint to their face or body would be concerning. During an interview on 3/11/25 at 3:53 p.m., FM-A stated she did not tell licensed practical nurse (LPN)-A that R1 facial color had been gray or that a gray facial color was R1's baseline. During an interview on 3/11/25 at 4:24 p.m., RN-A stated on the morning of 3/4/25, he saw the nursing assistants (NA's) give R1 a bed bath and she was very sleepy. RN-A stated her baseline was being very tired due to being awake at night and sleeping during the day. RN-A could not recall what time he saw the NA's give R1 her bed bath. R1 would make a moaning sound during her bed bath. R1's blood pressure was low. R1 was not really responding at all. RN-A state he kept getting R1's vital signs and got the crash cart ready in case R1 did not have a pulse. RN-A stated RN-C called FM-B, updated him on R1's condition, and had recommended she be sent to the emergency department for further evaluation. FM-B said he was only minutes away from the facility and to wait to call EMS. When FM-B got to the facility, he wanted EMS called right away. When EMS got to the facility, R1 was not responsive, but had a pulse and blood pressure. During an interview on 3/12/25 at 8:11 a.m., RN-C stated herself and LPN-A admitted R1 into the facility. RN-C stated she could not recall R1's facial color when she admitted . On 3/4/25, R1 was going to be discharging home on hospice services. Around 11:00 a.m., RN-C was called into R1's room by RN-A and LPN-A and said R1's vitals were not ok. RN-C noticed that R1 was sleeping. RN-C noted her oxygen saturation to be low, so the RN-C increased R1's oxygen via nasal cannula. RN-C did not look or assess R1's facial coloring. RN-C called FM-B and gave an update on R1's condition and had recommended R1 be sent out to the emergency department for further evaluation. FM-B said that he was on his way to the facility and not to call EMS until he got to the facility. RN-C walked back into R1's room and FM-B had arrived and said that R1 needed to be sent to the emergency department right away. EMS was called and EMS suggested to get the crash cart if needed. RN-C asked FM-B wanted to change R1's POLST code to DNR instead of her full code. FM-B did not want to change R1's code status. EMS arrived and transferred R1 to the emergency department. RN-C gave a nurse-to-nurse report to the hospital nurse and the hospital nurse stated R1 had been unconscious for four hours in which RN-C said that was not true because when staff at the facility did a sternal rub, R1 would moan and raise her eyebrows. RN-C stated she would expect when a licensed nursing staff noticed a change in condition, they would immediately call and update the provider. If they get ahold of the provider, they would give their recommendations and follow the providers orders. If they did not get ahold of the provider, there are instances where they could send the resident to the hospital without a provider's orders. RN-C stated it would not be appropriate to wait two hours or more to assess a residents change in condition. RN-C stated if she saw a resident have a gray facial color that was not at the resident's baseline, she would call EMS right away. RN-C stated if the license nurses waited over two hours to assess a resident's change in condition, the facility failed. During an interview on 3/12/25 at 8:29 a.m., the director of nursing (DON) stated on 3/4/25 RN-A told the DON that R1 had a bed bath in the morning but could not recall the time that took place. DON stated RN-A went to give R1 her medications and check her vitals around 11:00 a.m. DON stated RN-A called him because he was not in the facility at the time. RN-C called FM-B and FM-B stated he did not want the facility to send R1 to the hospital for further evaluation until he got to the facility in a couple of minutes. When FM-B got to the facility, he said that he wanted the facility to call EMS and send her to the hospital. DON stated he got to the facility before R1 left the facility. DON stated R1 did not look like herself and there was definitely a change in condition. DON stated the EMS as well as the nurses were all in R1's room so he did not get to see R1's facial color. DON stated he would expect when a licensed nurse saw a change in condition in a resident, the nurse would notify the provider and family right away. If the resident did have a change in condition, the assessments should be done immediately. When a resident had a gray facial color that was outside her baseline, the licensed staff should have assessed right away, and it would not be appropriate to wait three to four hours to assess. During an interview on 3/12/25 at 9:10 a.m., the administrator stated at the IDT meeting on 3/4/25 the IDT had talked about R1 being discharged that day, but nothing about the condition she was in. The administrator stated if a licensed nurse noticed a resident had a change in condition, she would expect the nurse to notify the provider, update vitals, and contact the resident's representative. The administrator stated she spoke with LPN-A after the incident and asked what she had meant by saying R1 had been unresponsive for four hours prior to EMS being called, LPN-A stated she meant to say that she was sleeping, not unresponsive. The administrator stated she did immediate education with LPN-A. During an interview on 3/12/25 at 9:39 a.m., medical director (MD)-A stated when she saw R1, she was minimally responsive to pain. R1 was not talking but her vitals were stable. MD-A stated the family was going to put R1 on hospice to get R1 more resources and help but not transition to end of life care by discontinuing treatments. MD-A stated when she did labs on R1, R1's creatinine was nine. MD-A stated R1's creatinine indicated how well the kidneys were functioning. MD-A stated R1 was put on a ventilator because R1 was not responsive. MD-A was unsure if R1's outcome would have changed if she would have gone to the hospital four hours prior. During an interview on 3/12/25 at 10:56 a.m., DON stated the facility did education with LPN-A on 3/4/25 after the incident. DON stated the facility also did education with all the licensed nurses working at the time about assessing a resident after a change in condition. During an email correspondence on 3/12/25 at 11:26 a.m., the administrator stated when a license staff notices a change in condition for a resident, a head-to-toe assessment should be completed along with notifying the provider of changes. LPN-A's personnel file included a signed LPN Care Coordinator description indicating LPN-A would be responsible for monitoring residents for changes in their condition and to report those changes to the RN. LPN-A was hired at the facility on 1/29/25. Included in the personnel file was an educational moment dated 3/12/25 that stated on 3/4/25 LPN-A had told the paramedic that R1's color changed four hours prior to EMS arrival. The document stated this would be considered a change in condition that would have required an immediate intervention and notification to the provider for the change in R1's medical status. It would be required to immediately communicate any change of resident condition to the appropriate parties in real-time. LPN-A did not have any additional corrective actions during her employment. The facility's Notification of Changes policy dated 3/2024, indicated nurses and other care staff were educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's provider, to ensure best outcomes of care for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an order for oxygen for one of seven residents (R1) who was on continuous oxygen. Findings include: R1's face sheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of acute cystitis with hematuria. R1's additional diagnoses included chronic obstructive pulmonary disease, covid-19, chronic respiratory failure, dependence on supplemental oxygen, chronic obstructive pulmonary disease with exacerbation, and obstructive sleep apnea. R1 was discharged from the facility on 3/4/25. R1's admission hospital medical records indicated R1 was admitted to the hospital from [DATE] to 2/25/25 due to covid-19, urinary tract infection, and encephalopathy. R1 was to resume home regimen including oxygen as needed to keep oxygen saturation from eighty-eight percent to ninety-four percent. R1 was on two liters of oxygen via nasal cannula. R1's progress note dated 2/25/25, indicated R1 was admitted to the facility and used two liters of supplemental oxygen. R1's Brief Interview for Mental Status (BIMS) assessment dated [DATE], indicated R1 scored eight, which indicated R1 was moderately cognitively impaired. R1's care plan dated 2/25/25, indicated R1 had an alteration in oxygen, gas exchange, and respiratory status. Interventions included staff to monitor oxygen saturations as ordered and as needed, monitor and document on respiratory status, keep the provider informed of changes, and monitor for cyanosis, accessory muscle use, shortness of breath, increased respirations, and difficulty coughing up sputum. R1's admission Data Collection assessment dated [DATE], indicated R1 required supplemental oxygen. R1's Minimum Data Set (MDS) dated [DATE], indicated R1 used continuous oxygen therapy. R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated February and March 2025, indicated R1 did not have an order for supplemental oxygen use. During an interview on 3/12/25 at 10:56 a.m., the director of nursing (DON) stated R1 was on continuous supplemental oxygen. The oxygen orders were not in the discharge orders but were hidden in the history and physical from the provider. DON stated those orders did not translate to R1's MAR and TAR. During an interview on 3/12/25 at 11:39 a.m., registered nurse (RN)-A stated he knew if a resident was supposed to be on supplemental oxygen by looking at the resident's MAR and TAR. The MAR and TAR would indicate how many liters of oxygen a resident was supposed to be on. RN-A stated if the resident did not have an order for supplemental oxygen, he would look at the facility's standing orders, apply supplemental oxygen if the standing order parameters allowed, and then he would contact the provider. RN-A stated R1 was on continuous supplemental oxygen. An admission orders policy was requested, and none was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure allegation of a potential drug diversion was recognized and reported to the state agency (SA), reviewed for misappropriation of property. Finding s included: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitive and had a diagnosis of narcolepsy (a rare neurological condition that makes people very sleepy during the day and can cause them to fall asleep suddenly). R1's order summary dated 1/6/25, identified an order for methylphenidate long acting (LA) (a stimulant medication to help with narcolepsy) 20 mg capsule to be given every day in the morning for narcolepsy. R1's Medication Administration Record (MAR) dated 1/6/25, identified R1 did not receive methylphenidate extended release (ER) 20 mg capsule as indicated by the number, 5 documented that indicated to see progress note. It was documented from 1/6/25 to 1/20/25, that R1 received his methylphenidate daily as indicated by nurse initials. R1's progress note dated 1/9/25 at 1:45 p.m., identified physical therapy (PT) went in R1's room to find R1 unresponsive to verbal and tactile stimuli. Writer was called and found R1 unresponsive, nystagmus (eyes rolled back in head), and experiencing involuntary jerking of bilateral arms. R1 had change in mental status and was unable to say his name and where he was. Writer notified primary and got the green light to send him to the hospital. 911 called and R1 was taken to the hospital. All parties notified. R1's ED (emergency department) progress note dated 1/9/25, at 1:54 p.m., identified during physical therapy (PT) R1 had a syncopal episode witnessed by staff. R1 was diagnosed with syncope (a brief loss of consciousness, or fainting, that occurs when blood flow to the brain is reduced) and collapse (a sudden loss of consciousness). Discharge instructions identified to follow up with provider and return if symptoms worsen. R1's progress note dated 1/9/25 at 6:00 p.m., R1 was returned via ambulance at 6:00 p.m. and was transferred to bed. R1 came back alert and orientated x 3. No significant findings found. No new orders given. When asked if R1 remembered what caused him to go to the hospital R1 stated he didn't remember a thing. R1's progress note dated 1/10/25 at 1:54 p.m., identified R1 was sent to the ED for decreased level of responsiveness . R1's hospital lab results dated 1/10/25 at 4:59 p.m., identified R1's inhouse rapid urine drug screen collected at 6:46 p.m., did not detect methamphetamine or amphetamines. The threshold concentrations used for amphetamines and methamphetamines was 500 ng/ml respectively. R1's ED course summary dated 1/10/25, identified R1 presented to the ED with intermittent episodes of confusion. EMS (emergency medical services) was called because R1 had one of what sounds to be his typical narcolepsy episode. R1's MAR from his nursing facility was reviewed and it does appear that he had been receiving his methylphenidate. It is possible he needed a dose adjustment on this medication. I did also consider possible drug diversion, given family stated that R1 had been on this dose of medication for quite some time and had been stable. At 5:10 p.m., amphetamine not detected .which was somewhat unexpected for R1 who was supposed to be receiving methylphenidate, including this morning. At 5:29 p.m., discussed with pharmacist and agree, would anticipate positive test for amphetamines on UDS (urine drug screen) if R1 was being given his medications appropriately. This does raise the concern for diversion of medications. At 6:52 p.m., R1's family was notified about the urine drug screen results, as well as my concern that we are not seeing an anticipated false positive for amphetamines in the setting of methylphenidate which was reportedly administered per MAR provided by nursing home, including this morning. Family would like to send confirmatory blood test; aware this is a send out test and this will take several days. At 6:56 p.m., emergency department registered nurse (EMRN)-A called and spoke with nurse for R1 at the Emeralds. Informed her of concern due to negative amphetamine results in urine drug screen although R1 was prescribed methamphetamines. Facility nurse stated she will email this information to their DON. R1's Discharge summary dated [DATE], identified R1's urine drug screen was negative for amphetamines, which is unexpected if you are taking methylphenidate. A confirmatory test will be sent and takes several days to come back. Please ensure that your medications are being administered as prescribed. This would likely be causing your increased episodes related to narcolepsy and cataplexy (sudden muscle weakness that occurs while a person is awake). R1's progress note dated 1/10/25 at 10:34 p.m., identified R1 came from hospital at around 9:45 p.m., lab showed that R1's urine screen was negative for amphetamines which showed that R1 has not been taking methylphenidate. Further identified R1 was seen for the following diagnoses altered mental status, unspecified altered mental status, narcolepsy and cataplexy. During an interview on 1/16/25 at 2:37 p.m., R1 was lying in bed and stated he was not sure if he was getting his medication for his narcolepsy and indicated he had been on that medication for years. R1 stated he normally took a white capsule. R1 stated if he doesn't take it, he would be sleeping. R1 further stated he never knows when the narcolepsy would hit him, but when he does fall asleep, he had been told its very hard to wake him. R1 further indicated he has had several ED trips since being in the facility and was not sure what he was at the ED for. During an interview on 1/21/25 at 2:45 p.m., via phone EDRN-A stated on 1/10/25 R1 was in the ED and the ED staff were very concerned that R1 had not been receiving his narcolepsy medication while at the nursing home due to R1's symptoms he was exhibiting and the negative urine drug screen that was performed. EDRN-A stated there was no way R1 could have been getting the medication because the urine test would have showed it. EDRN-A indicated she had called the facility and spoke to a nurse on 1/10/25 around 6:30 p.m., to report the ED's suspicions of drug diversion and the facility nurse told me they had no one on call and would notify their DON by email and follow up with this. During an interview on 1/22/25 at 11:23 a.m., via phone licensed practical nurse (LPN)-A stated he was the nurse responsible for R1 on the evening of 1/10/25. LPN-A indicated when R1 came back from the hospital he read R1's hospital discharge summary that indicated R1 was potentially not receiving his narcolepsy medication and confirmed he put a progress note in R1's record indicating this. LPN-A stated he did not report this to anyone because the supervisor at the facility was aware of this already. During a return phone call interview on 1/26/25, at 9:31 a.m., LPN-A indicated she was the nurse manager for R1 and was made aware that R1 potentially was not receiving his narcolepsy medication on 1/11/25, when she read R1's 1/10/25 progress note that indicated a hospital urine drug screen test did not show that R1 was receiving his narcolepsy medication. LPN-A immediately called the administrator to report it and was told to call the DON and report it. LPN-A called the DON on 1/11/25 at 2:24 p.m. and informed him R1's hospital urine drug screen was negative for amphetamines which showed R1 was not getting his medications. DON had directed LPN-A ensure the narcolepsy medication was in the lock box of the medication cart and to check PCC to ensure it was signed out after verifying it was given all days except for 1/6/25 due to not having a prescription. LPN-A stated she was not given any further instruction to investigate a drug diversion. LPN-A further indicated R1's family members had concerns R1 was not getting his narcolepsy medication due to his syncope episodes requiring ED visits, the family indicated he had been stable on this medication for quite some time with no syncope episodes. LPN-A stated with any allegations of drug diversion she would immediately report to the DON and administrator which she stated she did. During an interview on 1/21/25 at 3:30 p.m., interim director of nursing (IDON) verified through R1's medical record that R1's urine drug screen test results from the hospital dated 1/10/25, were negative for methylphenidate and the ED notes identified potential drug diversion for R1. DON indicated he had not reported this potential drug diversion to the state. During an interview on 1/22/25 at 9:08 a.m., the administrator stated the nurse that took the call from the hospital on 1/10/25 about R1's narcolepsy medication not being in his system on 1/10/25 would be an allegation of potential drug diversion and should have been reported immediately to the DON or myself and was not. Administrator further stated this should have been reported to the state agency immediately and the investigation would have immediately followed and had not been done. The facility policy, Abuse Prohibition/Vulnerable Adult Policy reviewed 3/24, identified Policy interpretation and implementation, 1. All staff are responsible for reporting any situation that is considered abuse or neglect along with injuries of unknown origin (including suspicious bruises, skin tears, or other injuries), misappropriation of resident property, or involuntary seclusion. A completed incident report will be routed per facility procedure. 2. A Supervisor will be notified immediately and will assess the situation to determine if any emergency treatment or action is required. Immediately, upon learning of the incident, staff will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury while the matter is being investigated .Incidents that must be reported to MDH include .g. Misappropriation of resident property .How and when to report to the Minnesota Department of Health (MDH)/ Office of Health Facility Complaints (OHFC) .3. If the suspected Neglect, Exploitation, or Misappropriation of resident property did not result in serious bodily injury, the reports must be made within 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to put a protection plan in place and thoroughly investigate an allegation of drug diversion for 1 of 1 resident (R1), reviewed for misappropriation of property. Finding s included: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitive and had a diagnosis of narcolepsy (a rare neurological condition that makes people very sleepy during the day and can cause them to fall asleep suddenly). R1's order summary dated 1/6/25, identified an order for methylphenidate long acting (LA) (a stimulant medication to help with narcolepsy) 20 mg capsule to be given every day in the morning for narcolepsy. R1's Medication Administration Record (MAR) dated 1/6/25, identified R1 did not receive methylphenidate extended release (ER) 20 mg capsule as indicated by the number, 5 documented that indicated to see progress note. It was documented from 1/6/25 to 1/20/25, that R1 received his methylphenidate daily as indicated by nurse initials. R1's progress note dated 1/9/25 at 1:45 p.m., identified physical therapy (PT) went in R1's room to find R1 unresponsive to verbal and tactile stimuli. 911 called and R1 was taken to the hospital. All parties notified. R1's ED (emergency department) progress note dated 1/9/25, at 1:54 p.m., identified during physical therapy (PT) R1 had a syncopal episode witnessed by staff. R1 was diagnosed with syncope (a brief loss of consciousness, or fainting, that occurs when blood flow to the brain is reduced) and collapse (a sudden loss of consciousness). Discharge instructions identified to follow up with provider and return if symptoms worsen. R1's progress note dated 1/9/25 at 6:00 p.m., R1 was returned via ambulance at 6:00 p.m. and was transferred to bed. R1 came back alert and orientated x 3. No significant findings found. No new orders given. When asked if R1 remembered what caused him to go to the hospital R1 stated he didn't remember a thing. R1's progress note dated 1/10/25 at 1:54 p.m., identified R1 was sent to the ED for decreased level of responsiveness. R1's ED course summary dated 1/10/25, identified R1 presented to the ED with intermittent episodes of confusion. EMS (emergency medical services) was called because R1 had one of what sounds to be his typical narcolepsy episode. R1's MAR from his nursing facility was reviewed and it does appear that he had been receiving his methylphenidate. It is possible he needed a dose adjustment on this medication. I did also consider possible drug diversion, given family stated that R1 had been on this dose of medication for quite some time and had been stable. At 5:10 p.m., amphetamine not detected .which was somewhat unexpected for R1 who was supposed to be receiving methylphenidate, including this morning. At 5:29 p.m., discussed with pharmacist and agree, would anticipate positive test for amphetamines on UDS (urine drug screen) if R1 was being given his medications appropriately. This does raise the concern for diversion of medications. At 6:52 p.m., R1's family was notified about the urine drug screen results, as well as my concern that we are not seeing an anticipated false positive for amphetamines in the setting of methylphenidate which was reportedly administered per MAR provided by nursing home, including this morning. Family would like to send confirmatory blood test; aware this is a send out test and this will take several days. At 6:56 p.m., emergency department registered nurse (EMRN)-A called and spoke with nurse for R1 at the Emeralds. Informed her of concern due to negative amphetamine results in urine drug screen although R1 was prescribed methamphetamines. Facility nurse stated she will email this information to their DON. The facility documentation did not identify a protection plan for R1 and like residents from potential drug diversion and did not include investigation activities as to why R1's drug screen would not be positive for amphetamine as per the hospital notations. During an interview on 1/21/25 at 2:45 p.m., via phone EDRN-A stated on 1/10/25 R1 was in the ED and the ED staff were very concerned that R1 had not been receiving his narcolepsy medication while at the nursing home due to R1's symptoms he was exhibiting and the negative urine drug screen that was performed. EDRN-A stated there was no way R1 could have been getting the medication because the urine test would have showed it. EDRN-A indicated she had called the facility and spoke to a nurse on 1/10/25 around 6:30 p.m., to report the ED's suspicions of drug diversion and the facility nurse told me they had no one on call and would notify their DON by email and follow up with this. During an interview on 1/16/25 at 2:37 p.m., R1 was lying in bed and stated he was not sure if he was getting his medication for his narcolepsy and indicated he had been on that medication for years. R1 stated he normally took a white capsule. R1 stated if he doesn't take it, he would be sleeping. R1 further indicated he has had several ED trips since being in the facility and was not sure what he was at the ED for. During an interview on 1/22/25 at 11:23 a.m., via phone licensed practical nurse (LPN)-A stated he was the nurse responsible for R1 on the evening of 1/10/25. LPN-A stated he did not report the potential drug diversion as indicated by the hospital discharge summary to anyone because the supervisor at the facility was aware. During a return phone call interview on 1/26/25, at 9:31 a.m., LPN-A indicated she was the nurse manager for R1 and was made aware that R1 potentially was not receiving his narcolepsy medication on 1/11/25, when she read R1's 1/10/25, progress note that indicated a hospital urine drug screen test did not show that R1 was receiving his narcolepsy medication. LPN-A stated she immediately called the administrator to report it and was told to call the DON and report it. LPN-A stated she called the DON on 1/11/25 at 2:24 p.m., and informed him R1's hospital urine drug screen was negative for amphetamines which showed R1 was not getting his medications. DON directed LPN-A to ensure the narcolepsy medication was in the lock box of the medication cart and to check PCC to ensure it was signed out after verifying it was given all days except for 1/6/25 due to not having a prescription. LPN-A stated she was not given any further instruction to investigate a drug diversion. During an interview on 1/21/25 at 3:30 p.m., interim director of nursing (IDON) verified through R1's medical record that R1's urine drug screen test results from the hospital dated 1/10/25, were negative for methylphenidate and the ED notes identified potential drug diversion for R1. DON indicated he had not put a protection plan in place or thoroughly investigate the potential drug diversion. During an interview on 1/22/25 at 9:08 a.m., the administrator stated the nurse that took the call from the hospital on 1/10/25 about R1's narcolepsy medication not being in his system on 1/10/25 would be an allegation of potential drug diversion and should have been reported immediately to the DON or myself and was not. Administrator further stated this should have been reported to the state agency immediately and the investigation would have immediately followed and had not been done. The facility policy, Abuse Prohibition/Vulnerable Adult Policy reviewed 3/24, identified Policy interpretation and implementation, 1. All staff are responsible for reporting any situation that is considered abuse or neglect along with injuries of unknown origin (including suspicious bruises, skin tears, or other injuries), misappropriation of resident property, or involuntary seclusion. A completed incident report will be routed per facility procedure. 2. A Supervisor will be notified immediately and will assess the situation to determine if any emergency treatment or action is required. Immediately, upon learning of the incident, staff will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury while the matter is being investigated .Incidents that must be reported to MDH include .g. Misappropriation of resident property .How and when to report to the Minnesota Department of Health (MDH)/ Office of Health Facility Complaints (OHFC) .3. If the suspected Neglect, Exploitation, or Misappropriation of resident property did not result in serious bodily injury, the reports must be made within 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the necessary coordination of services between the facility and the hospice agency for 1 of 3 residents (R2) reviewed for hospice services. Findings include: R1's admission minimum data set (MDS) dated [DATE], indicated intact cognition with diagnoses of cancer, malnutrition, and depression. R1 required moderate assist with transfers and maximal assist with toileting, bathing, and dressing. R1 was at risk for pressure ulcers but had not pressure ulcers. R1 had pressure relieving device in bed and chair and received medication or ointment to skin. R1 was on hospice. On 10/17/24 at 4:00 p.m., R1's medical record lacked current medication list with a list of medication-specific hospice covered medications, a care plan, goals for care, hospice certification, the hospice election form, hospice aide visits and hospice orders. During an interview on 10/17/24, hospice RN (HRN-A), stated the hospice was handling R1's pressure issues and had not been giving R1's comprehensive assessments to the facility because she did not know she had to. HRN-A stated the facility was the main care giver for the resident and should have an integrated care plan for resident, so everyone knew what was going on with the resident. It was an important part of care for the resident. HRN-A stated she would check in with the floor nurse as she wrote her note in the resident's hard hospice chart. HRN-A did not have access to the facilities electronic medical record (EMR). During an interview on 10/17/24 and 10/18/24, director of nursing (DON) stated the facility has reached out to the hospice agency (HA-A) via email, phone, and fax for copies of R1's hospice care plan and visit notes. HA-B sends their notes weekly and their interdisciplinary group meetings every two weeks. DON stated this has been a problem for the facility and HA-A. On 10/18/24 during a clarification interview DON stated there needed to be an integrated care plan and open communication for the hospice resident so everyone knew what was going on with the resident. DON stated it was his expectation the HRNs would update the nurse managers, DON, social worker (SW) or Administrator before leaving the facility, not just check in with the floor nurses. During an interview on 10/18/24 at 10:00 a.m., Administrator stated it was her expectation for the HRNs to update the nurse managers, DON, SW, or herself before leaving the facility. Furthermore, Administrator stated all hospice agencies have access to their EMR and if needed assistance with this they should address situation with her. Review of the Hospice facility's policy dated 11/2023, indicted the following: -It was the responsibility of the hospice agency to coordinate the resident's care as it relates to the terminal illness and related conditions, including: A. Determining the appropriate hospice plan. B. Changing the level of services provided when it was deemed appropriate. C. Providing medical direction, nursing, and clinical management of the terminal illness. D. Providing spiritual, bereavement and/or psychosocial counseling as needed. E. Provide medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms. -It was the responsibility of the facility staff to notify the hospice provider and primary care provider about a significant change in the resident's condition or situations requiring a revision of the plan of care. -The hospice agency will provide the facility staff with a copy of the hospice plan of care and scheduled visits. Hospice staff will communicate and coordinate care with the interdisciplinary team. The facility Hospice contract dated 5/1/24, indicated coordination of care between the facility and Hospice included Hospice would maintain adequate records of each authorization of Hospice admission. The Hospice in consultation with the facility, will develop and agree upon a coordinated plan of care which was consistent with the unique needs of the resident. Hospice will assume responsibility for determining the appropriate course of hospice care, including level of services provided. -3.2 (b) Communication of initial plan of care. A plan of care will be promptly developed for each resident and a copy of plan of care will be provided to facility. -4.3 (a) Facility shall coordinate with hospice in developing a plan of care and shall designate an individual to serve on the IDG. (d) facility shall coordinate with hospice regarding management to ensure continuity of communication and easy access to ongoing information. -5.4 Hospice will provide facility with written documentation of communication between facility and hospice wither in hard copy or electronic format, depending on the structure of the facility's documentation system, to ensure the needs of the resident are addressed and met 24 hours per day and facility agrees it will at all times abide by this communication process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to report an allegation of sexual abuse immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's admission Record dated 6/17/24, indicated R1's diagnoses included pain in left shoulder, weakness, history of falling and chronic kidney disease. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 required extensive assistance with activities of daily living (ADLs) and had intact cognition. R1's care plan dated 6/17/24 indicated R1 was at risk for abuse with interventions including staff to follow facility vulnerable adult policies and procedures, and the State Agency will be notified of any suspected abuse. On 9/4/24 at 12:21 a.m. R1 stated he was sexually abused on 8/23/24 when a female nurse touched his penis inappropriately after putting a cream on his left hip. He was pissed off and not happy about the situation. He requested the nurse manager in his room and told him about the abuse. The following day, he went to the social worker's office to report the incident. On 9/4/24 at 1:13 p.m. registered nurse (RN-A) stated he became aware of the incident about two weeks ago when R1 told him nursing staff touched his penis inappropriately. He went straight to report it to social worker (SW)-A, but did not know if it was reported to the SA or not. The incident should have been reported immediately. On 9/4/24 at 1:43 p.m. SW-A stated R1 told her a nursing staff checked his junk on 8/23/24. When she asked R1 for more details, R1 pointed his fingers toward his penis and said he was inappropriately touched. She did not report the allegation of sexual abuse immediately to the SA. On 9/4/24 at 3:37 p.m. RN-B stated R1 fell on 8/23/24, and when law enforcement and the emergency medical services (EMS) arrived to take R1 to the hospital, he told law enforcement he had been sexually abused. Law enforcement told her about the sexual abuse allegation. She reported the sexual abuse allegation to the administrator right away over the phone. On 9/4/24 at 4:46 p.m. the administrator stated when RN-B told her of R1's sexual abuse allegations on 8/23/24, she directed RN-B to write her statement. The facility should report allegations of sexual abuse to the SA immediately. She acknowledged R1's sexual allegation was not reported within two hours. The facility Abuse Prohibition/Vulnerable Adult policy revised 3/24 directed facility staff, other residents, consultants, or volunteers' staff or other agencies serving the individual to promptly report, document and investigate all incidents of alleged or suspected abuse/neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure an allegation of sexual abuse was thoroughly investigated and adequate resident protection provided to ensure safety for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's admission Record dated 6/17/24, indicated R1's diagnoses included pain in left shoulder, weakness, history of falling and chronic kidney disease. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 required extensive assistance with activities of daily living (ADLs) and had intact cognition. R1's care plan dated 6/17/24 indicated R1 was at risk for abuse with instruction to staff to follow facility vulnerable adult policies and procedures. R1's medical record lacked evidence of the incident being investigated. On 9/4/24 at 12:21 a.m. R1 stated he was sexually abused on 8/23/24 when a female nurse touched his penis inappropriately after putting a cream on his left hip. He was pissed off and not happy about the situation. He requested the nurse manager in his room and told him about the abuse. The following day, he went to the social worker's office to report the incident. On 9/4/24 at 1:13 p.m. registered nurse (RN-A) stated he became aware of the incident about two weeks ago when R1 told him nursing staff touched his penis inappropriately. He went straight to report it to the social worker (SW)-A. The incident should have been investigated immediately. On 9/4/24 at 4:46 p.m. the administrator stated when RN-B told her of R1's sexual abuse allegations on 8/23/24, she directed RN-B to write her statement, and told the supervisor to initiate an investigation. She acknowledged R1's allegation of sexual abuse was not investigated. The facility Abuse Prohibition/Vulnerable Adult Abuse policy revised 3/24 directed facility staff, other residents, consultants, or volunteers' staff or other agencies serving the individual to promptly report, document and investigate all incidents of alleged or suspected abuse/neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R5) who was observed to have medications in his room, had been appropriately assessed and deemed safe to self-administer medications. Findings include: R5's admission record, indicated history of a heart disease, morbid obesity and type 2 diabetes. R5's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R5 was cognitively intact, had clear speech, could understand and be understood. R5 was dependent upon staff for most activities of daily living other than set up for eating and oral hygiene. R5's June medication administration record (MAR) and treatment administration record (TAR) indicated 9:00 a.m. oral medication orders: 1. Cardizem CD capsule extended release 24-hour 120 milligram (mg) Give 1 capsule by mouth one time a day, dated 9/25/23. 2. Digox oral tablet 125 microgram (mcg) give 0.125 mg by mouth one time a day. Dated 9/25/23. 3. Losartan Potassium oral tablet 50 mg. Give 1 tablet by mouth one time a day. Dated 7/4/23. 4. Montelukast sodium oral tablet 10 mg. Give 1 tablet by mouth one time a day. Dated 7/4/23. 5. Potassium chloride oral packet 20 milliequivalent (MEQ). Give 20 MEQ by mouth in the morning for hypokalemia. Dated 2/28/24. 6. Torsemide oral tablet 40 MG. Give 80 mg by mouth one time a day. Dated 9/25/23. 7. Apixaban oral tablet. Give 5 mg by mouth two times a day. Dated 7/3/23. 8. Doxycycline hyclate tablet 100 mg. Give 1 tablet by mouth two times a day. Dated 6/10/24. 9. Sertraline HCL oral tablet. Give 100 mg by mouth two times a day. 10. Pramipexole dihydrochloride oral tablet 1 mg. Give 1 mg by mouth three times a day. R5's care plan dated 7/27/23, indicated administer medications as ordered. R5's provider visit date of service 5/9/24, indicated resident was ok to keep inhalers at bedside. Documentation did not address any other self-administration orders. R5's medical record lacked documentation of assessments for safe self-administration of oral medications. During an observation on 6/17/24 at 11:50 a.m., in R5's room, observed one paper souffle cup with multiple oral medications inside it and a plastic medication inhaler on R5's bedside table over her bed. During an interview on 6/17/24 at 11:50 a.m., R5 stated the medications and inhaler on her bedside table she had been given around 8:30 a.m. or 9:00 a.m R5 stated the nurse had come in earlier and told me to take the medications. The nurse had come back later and peaked her head in the door and said quick take those pills and again had come back before she left and asked did you take those pills. I don't want to get anyone in trouble, I just forgot to take them. During an interview on 6/17/24 at 12:08 p.m., trained medication aide (TMA)-A stated after looking into the computer for R5's MAR it identified R5 did have a self-administration order for her inhalers but did not have a self-administration order for oral medications. TMA-A stated R5 would not be capable to self-administer medications without a proper order from her provider. TMA-A was informed of finding medications in R5's room. TMA-A stated medications can only be left in a resident's room if the resident had a self-administration of medication order. During an interview on 6/18/24 at 11:43 a.m., director of nursing (DON) stated she would expect the person on the floor passing medications to follow the facility policy and what they had learned in school. DON stated visual observation of the resident taking the medications is expected if they do not have a self-administration order. DON stated for a resident to have a self-administration order they would need to be assessed and deemed safe to administer by them self and a provider would need to put in the self-administration order. Facility Policy dated 5/2022, indicated: 14) residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 18) the resident is always observed after the administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is to be noted on the MAR, and action is taken as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the standards of practice for the: (1) administration of nebulizer treatment solution and do the necessary assessment during and after the administration of the nebulizer treatment solution; and (2) failure to follow physician order to apply compression stockings daily for one of one resident (R8) observed for medication administration. Findings Include: R8's admission record indicated R8 had a history of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and history of pulmonary embolism. R8's admission Minimum Data Set (MDS) dated [DATE], indicated R8 was cognitively intact, had clear speech and was able to understand and be understood. MDS also indicated R8 had not exhibited rejection of cares. Resident's care plan for activities of daily living (ADL's) dated 6/18/24, indicated intervention of resident is able to put compression stockings on with help of a sock aide. R8's medication administration record (MAR) and treatment administration record (TAR) dated 6/2024 included orders for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligrams per 3 milliliters (mg/3ml). Inhale orally three times a day. R8's record also included Teds (Thrombo Embolic Deterrent) Stockings (anti-embolism stockings for the legs that help prevent blood clots) on in the a.m. and off in the p.m. for edema order start date of 4/13/24. During an observation on 6/17/24 at 1:07 p.m., R8 was being administered Ipratropium-Albuterol Inhalation solution 0.5-2.5 mg.3ml with nebulizer (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) treatment (Ipratropium-Albuterol Sulfate Inhalation Solution - the Albuterol is a beta-adrenergic bronchodilator which have cardiac effects that should be monitored during treatment) in R8's room. The assigned trained medication assistant (TMA)-B was observed by the medication cart near the nurses' station and was looking at the computer monitor to set up the next residents' medications. Observation revealed TMA-B left R8 unsupervised during the administration of the nebulizer treatment. TMA did not listen to R8's lung sounds, heart rate, check oxygen saturation and or pulse after the nebulization treatment. R8 was also observed to have swollen lower extremities with areas of redness and shininess noted on both lower extremities. Resident did not have any kind of stocking, wrap or compression dressing on. During an interview on 6/17/24 at 2:21 p.m., R8 stated she was supposed to have compression stockings on daily as her legs get swollen and will break open with sores. R8 reported she had been told by staff she needed to put them on herself and she stated she had told the staff multiple times she was unable to get the stockings on. R8 stated she had told the nurse but nothing had been done related to her concerns. R8's MAR/TAR on 6/17/24 at 2:27 p.m., indicated R8 to have compression stockings on. R8's medical record reviewed and lacked documentation to indicate assessment of lung sound assessments, pulse, restlessness, and or nervousness related to nebulizer treatments. During an observation on 6/17/24, at 2:27 p.m. R8 did not have any [NAME] stockings or compression wraps of any kind on her legs and they were noted to be open to air. During an interview on 6/18/24, at 9:21 a.m. R8 reported her legs had not gotten [NAME] stockings on yesterday and no one had removed them the night before as she has not had them on for days. R8 again reported concern of her skin splitting open and noted a small open area on the back of her right ankle. During an interview with the Director of Nursing (DON) on 4/14/23 at 9:51am, the above observations were relayed to the DON and the surveyor asked the DON about her expectations when nursing staff administer nebulizer treatment to any resident. The DON stated, [I expect the nursing staff] to stay with them [residents during the administration of the nebulizer treatment]. The DON further stated, I do not know the current policy for nebulizer treatments without looking it up but I would expect staff to follow the facility policy on administering nebulizer treatments. DON also stated if the TAR indicated for resident to have [NAME] stockings on daily staff should be documenting them to be on only if they are on and if they are not on should be documenting why they are not on and informing the provider if resident is refusing and or not wearing them. If staff were to document the resident has [NAME] stockings on and they didn't this is an error and depending on the severity we would provide corrective action and or re-education. Review of the facility's Oral Inhalation Administration policy and procedure revised 1/2018, included the following instructions for administering medication through a small volume (handheld) nebulizer, with additional instructions not listed below. K. Instruct the resident to take a deep breath, and then exhale normally. Repeat pattern throughout treatment. L. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. M. Approximately five minutes after the treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. N. Monitor for medication side effects, including rapid pulse, restlessness, and nervousness throughout the treatment. O. Stop treatment and notify the physician if the pulse increases 20 percent above baseline or if the resident complains of nausea or vomits. P. Tap the nebulizer cup occasionally to ensure release of droplets from the sides of the cup. Q. Encourage resident to cough and expectorate as needed. R. Administer therapy until medication is gone (mist has stopped) or until the designated time of the treatment has been reached. S. When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece, and medication cup. T. Obtain post-treatment pulse, respiratory rate and lung sounds and document findings (on the MAR or in the resident's medical record.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to provide pharmacy services for 1 of 1 resident (R6), who did not receive her scheduled medication for pain resulting in uncontrolled pain and the use of narcotic pain medication. Furthermore, the facility failed to follow safeguards to ensure residents received the correct medications for 1 of 1 resident (R6). R6's admission record indicated R6 had a history of perforation of the intestine, encounter for surgery on the digestive system, gastrostomy status and colostomy status. R6's admission Minimum Data Set (MDS) dated [DATE], indicated she was unable to complete the cognitive assessment and was sometimes understood and sometimes able to understand. MDS also indicated R6 to have pain and used as needed pain medication (PRN) in the last 5 days. R6's medication administration record (MAR) dated June 2024, indicated she was supposed to receive acetaminophen 1000 milligrams (mg) every 6 hours via percutaneous endoscopic gastrostomy (PEG) tube, for pain. During an observation of medication pass on 6/17/24 at 12:58 p.m., trained medication assistant (TMA)-B was observed setting up medications for a resident who needed medications via tube. TMA-B dispensed the medications into a blue cup wrote the room number on the cup and placed them in the top of the medication cart and locked the cart and walked away. During an interview on 6/17/24 at 12:58 p.m. TMA-B stated she was setting up medications for the nurse to administer when they returned from their break. TMA-B stated she was able to set medications up to assist the nurse and had not been told that she was not supposed to set medications up that she was not giving. During an interview on 6/17/24 at 1:07 p.m., clinical manager (CM)-A stated nobody should set up medications for someone else to give. If a person was to give medications, they had not dispensed they would not be able to identify they were giving the correct medications. During an observation on 6/17/24 at 2:43 p.m., R6 heard yelling and crying for help stating her pain was unbearable. During an interview on 6/17/24 at 2:43 p.m., R6 stated she was needing something for pain. R6 reported she had been asking for medication for pain since around noon and had been told that someone would be back in a couple minutes but they had never returned. During an interview on 6/17/24 at 2:51 p.m. registered nurse (RN)-A stated he had just started his shift and had been told R6 had not gotten her noon medications because the physician assistant had been in her room meeting with her and R6 had reported to her she was not having pain. RN-A reported he had given R6 her PRN oxycodone for a pain level of 10 per R6's request and physician orders. During an interview on 6/18/24 at 11:43 a.m., director of nursing (DON) stated the expectation is for the person passing medications on the floor to follow facility policy and what they had learned in school. DON indicated TMAs in the facility are not able to give medications through PEG tubes but should not be pre-setting or setting medications for others to pass ever as it is against facility policy. The person who would set up the medications is the person who should give the medications. Facility policy titled, Pharmacy Services for Nursing Facilities revised 12/2019, Medication administration general guidelines. 4.) Five Rights-Right resident, right drug, right dose, right route, and right time are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration. 7.) The person who prepares the dose for administration is the person who administers the dose. Facility policy titled, General Guidelines for Administering Medication Via Enteral Tube revised 1/2018, indicated, The facility assures safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietitian, and consultant pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a provider order for a urine analysis with urine culture (UA/UC) and sensitivity had been obtained in a timely manner for 1 of 1 resident (R7) reviewed for change of condition. Findings include: R7's admission record indicated a history of hemiplegia and hemiparesis following cerebral infarction, and chronic kidney disease. R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact, had clear speech and was understood and able to understand others. R7's provider order dated 6/13/24, indicated R7 required a UA/UC with sensitivity related to diagnosis of dysuria. R7's medication administration record (MAR) and treatment administration record dated 6/2024 indicated an order for UA/UC had been put in on 6/14/24 and had check marks with initials noted for the evening and night shift for 6/14, 6/15, 6/16, and 6/17. No documentation noted for the day shift. Leaving open holes on the day shifts. R7 progress note date 6/13/24 at 8:40 p.m., indicated having acute visit with provider for dysuria and facial tingling. Resident reported dysuria multiple times per day with urination, and incontinence with coughing and whenever she stands in EZ stand (mechanical lift used to assist resident to stand from seated position) to transfer to and from wheelchair. R7 progress note dated 6/18/24 at 10:27 a.m. indicated resident urine sample collected and sent to lab via staff. During an interview on 6/18/24 R 8:25 a.m., R7 stated she was informed by her nurse practitioner (NP) that she could have an urinary tract infection (UTI) even if she was on preventative medication. Provider had ordered UA/UC awhile ago and staff had still not collected the sample and she still did not have results. R7 reported she still had burning at times when she urinated. During an interview on 6/18/24 at 9:12 a.m., licensed practical nurse (LPN)-A stated if a resident has an order for a UA/UC it would be on the treatment administration record (TAR)and it should be collected as soon as possible. LPN-A stated she could see R7 had an order for an UA/UC but could not identify if the order had been completed as the documentation in the TAR indicated it had been completed every shift for the last three days. LPN-A stated sometimes the nurse on the floor will collect a specimen and send it in and forget to discontinue the order. She stated they should write a progress note or document somewhere in the medical record when the order had been completed but was unable to locate documentation. LPN-A indicated she would need to check with the nurse manager to find out if the UA/UC had been completed. During an interview on 6/18/24 at 12:50 p.m., NP stated she had seen R7 on 6/13/24 and had educated her to the fact that even when a person is taking prophylactic medications for UTI's they could still get the infection. NP indicated she had ordered an UA/UC on that date and still had not received the results of that lab test. NP stated she would expect that the facility would be able to collect the specimen within 48 hours or they should contact her. NP indicated that getting UTI results late could cause infection to travel to the kidneys, increase the infection and or cause more distress. During an interview on 6/18/2 at 11:43 a.m., the director of nursing (DON) stated she would expect that if a resident has an order for an UA/UC the urine specimen should be collected as soon as possible. Documentation in the MAR or TAR every shift related to if the specimen was collected, if it was not completed during their shift, staff should document in the medical record why it wasn't completed. A facility procedure/process for lab collection was requested however was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 1 residents (R20) who utilized a urinary catheter. Findings include: R20 quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of malnutrition, coronary artery disease (narrowing of blood vessels supplying the heart), hypertension, obstructive uropathy (difficulity fully voiding), depression and chronic obstructive pulmonary disease. In addition, R20 was documented requiring an indwelling catheter. R20's care plan dated 8/11/23, indicated, Foley catheter care per policy. During observation and interview on 2/5/24 at 2:09 p.m., R20 was laying in bed with a large urinary catheter bag attached to bed frame facing the hallway. No privacy bag was noted on the bed or on the wheelchair. R20 stated the facility did not offer or provide a cover for his catheter drainage bag while in his bedroom or out in the facility's hallway. During interview with registered nurse (RN)-A, on 2/7/24 at 8:11 a.m., RN-A stated, we should be putting a cover on them at all times. RN-A stated the rationale for providing privacy bags is, dignity. During interview with nursing assistant (NA)-B on 2/7/24 at 8:42 a.m., NA-B stated, catheters should be covered because of privacy and dignity. During interview with licensed practical nurse (LPN)-B on 2/7/24 at 8:53 a.m., LPN-B stated, we should always cover them for dignity. Even if they are in their room. During interview with the facility administrator on 2/7/24 at 11:05 a.m., administrator stated the expectation is for staff to cover the urinary catheters, at all times. Facility policy titled, Indwelling Catheter Care Procedure, updated 7/21/23 failed to state expectation of providing a cover for indwelling catheters. Facility policy on dignity was requested and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure resident and/or resident representatives participated in the resident care planning process and subsequent development of interventions for 2 of 2 residents (R53, R74) reviewed for participation in care planning. Findings include: R53 R53's admission Minimum Data Set (MDS) dated [DATE], indicated that R53's Brief Interview for Mental Status was left blank. The MDS indicated that R53's short- and long-term memory were ok and R53 was independent with decision making. The MDS indicated that R53 was diagnosed with diabetes, a heart dysrhythmia (irregular heart rhythm), a stroke, and a seizure disorder. R53's Care Conference Form dated 1/9/24, indicated the form was completed for R53's admission care conference and included blank sections for medication assessment, physical restraints, fall risk, positioning, exams (dental and eye, bowel, bladder/bladder and bathing, immunizations, IDT (interdisciplinary team) care conference summary, nurse signature, activity participation/involvement, therapeutic recreation signature, dietary, dietary director signature, and other IDT team members/ family/resident in attendance. The form contained the social services assessment, social services signature, and resident weight. R53's progress note dated 1/8/24 at 2:29 p.m., indicated that the social services department had spoken with R53's daughter, who would like to have a care conference to discuss R53's status and discharge planning. The note indicated that the meeting was set up for 1/9/24 at 2 p.m During an interview on 2/5/24 at 5:24 p.m., family member (FM)-B, the responsible party, stated that she remembered having a meeting with the social worker, but she was never a part of a care conference involving the interdisciplinary team. FM-B confirmed with R53 who also stated that R53 had not been invited to a multidisciplinary care conference. R74 R74's admission MDS dated [DATE], indicated that R74 had moderate cognitive impairment and was diagnosed with kidney disease requiring dialysis and hypertension. The MDS indicated that R74 required no physical assistance with any self-care activities. R74's Care Conference Form dated 1/12/24, indicated the form was completed for R74's admission care conference. The form was blank except for a resident weight from 2/7/24. During an interview on 2/7/24 at 10:06 a.m., social services director (SS)-A stated that when a care conference was completed, she filled out a form and added it to the medical record. SS-A stated she had reviewed R53's medical record but was unable to find a form showing that a care conference had taken place. SS-A stated that she had a discussion with R74 in the past. SS-A stated that she had a care conference that solely included her and the resident's guardian. SS-A stated that she had completed the care conference without R74 because she wanted to get a better background on him from the guardian. SS-A stated that normally she would attempt to include more departments in the care conference but besides his dialysis, there isn't a whole lot to go over and it hadn't felt necessary at that point. During an interview on 2/5/24 at 1:48 p.m., R74 stated that he was not invited to a multidisciplinary care conference but would have liked to opportunity to ask questions to other departments and go over what his plan was. During an interview on 2/8/24 at 8:45 a.m., SS-A stated that she had opened a care conference form yesterday for R53 and R74 and this was not completed or in the medical record previously. During an interview on 2/8/24 at 9:26 a.m., the nurse manager (LPN)-C stated that the care conferences should have included activities staff, social services, activities, dietary, nursing, and hospice when applicable. LPN-C stated that it was important that the care conferences included these groups so collaboration between departments could take place. LPN-C stated that it was important that the residents were invited and included in these conferences to give them a voice, increase their awareness of what care they were receiving and give them a chance to change things or ask questions to the different departments regarding their care. A policy regarding care conferences was requested and not received from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to assess a resident for the ability to self-administer medications with an albuterol inhaler bedside for one of one residents (R43) reviewed for self-administration of medications. Finding include: R43's quarterly Minimum Data Set, dated [DATE], indicated R43 was admitted to the facility on [DATE] and was cognitively intact. R43's Physician Orders, dated 7/3/23, indicated an order for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) - two puffs every four hours as needed for shortness of breath. R43's electronic medical record (EMR) lacked evidence of a self-administration of medication assessment and order for R43 to self-administer the albuterol inhaler. During observation and interview on 2/5/24 at 2:59 p.m., an albuterol inhaler, dated 9/22/23, was sitting on R43's bedside table. R43 stated a staff member had brought it in for her to take awhile ago and never took it back out. During observation on 2/6/24 at 1:14 p.m., the albuterol inhaler remained on R43's bedside table. During observation on 2/7/24 at 8:18 a.m., the albuterol inhaler remained on R43's bedside table. During observation and interview on 2/7/24 at 9:28 a.m., R43 handed the albuterol inhaler to nursing assistant (NA)-C, again stating a staff member had brought it in for her to use and never took it back out. NA-C stated R43 should not have the inhaler in her room and she would give it to the nurse. During an interview on 2/7/24 at 11:00 a.m., registered nurse (RN)-B stated either the floor nurses or the nurse manager should complete a self-administration of medication (SAM) assessment, confirming R43 should have had a SAM in place prior to the inhaler being left in R43's room. During an interview on 2/8/24 at 8:34 a.m., nurse manager and licensed practical nurse (LPN)-C stated the expectation would be for a resident to have a SAM in place prior to self-administering any medication. LPN-C stated the inhaler should have been removed and not left in R43's room as she did not have a SAM. A facility policy titled Self-Administration of Medications, dated 2/2024, indicated residents have the right to self-administer medications after the interdisciplinary team (IDT) has deemed it safe and clinically appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to develop and implement a system to help facilitate resident' choice and preference with regards to provided therapy services scheduling for 2 of 2 residents (R34, R58) reviewed who expressed concerns with how such services were provided. Findings include: R34's significant change in status Minimum Data Set (MDS), dated [DATE], identified R34 had intact cognition and demonstrated no delusional thinking. On 2/5/24 at 3:32 p.m., R34 was interviewed and stated she admitted to the care center from the hospital following a stroke several months prior. R34 voiced frustration and stated she felt she did not get a very good chance at therapy before she had been discharged from the service and attributed that to, in part, the lack of a set schedule or routine when therapy would be provided adding therapists would often just come in whenever. R34 stated she liked having a routine with her cares and having a therapy schedule would have helped her participate more adding, So [then] I could prepare myself. R34 stated she had asked therapy, while under their services, about arranging a schedule but was told such option was not possible. R34 reiterated a more set routine or schedule was never discussed or offered, despite even asking for it, and expressed frustration, again, with the situation adding, I don't feel I finished [therapy]. R34's progress note(s), dated 9/11/23 to 2/5/24, were reviewed and identified R34 admitted to the care center on 9/11/23. These included multiple notes labeled, Daily Skilled Note, which outlined R34 had a skilled need of therapy services (i.e., physical therapy, occupational therapy) and wound care. The last note which outlined this information was recorded on 11/12/23. When interviewed on 2/6/24 at 12:59 p.m., nursing assistant (NA)-D explained they had worked at the campus for multiple years and described R34 as needing help with most cares outside of being able to feed herself. NA-D stated R34 was very routine-dependent and liked having her care structured as best able. NA-D explained they had heard R34 make comments about not getting therapy any longer and still feeling she would benefit from it, but they had not heard any comments from R34 about the lack of a therapy schedule being upsetting. However, NA-D stated they had heard such comments from other residents within the care center. NA-D stated they were unsure if the care center' had employed or contracted therapy services but expressed the lack of a schedule with residents' needed to be addressed as therapy staff would take residents at random times, including from meals with them actively eating, which was an issue. NA-D stated the nurses and management were aware of this concern to their knowledge. During interview on 2/6/24 at 1:16 p.m., NA-C explained they had worked at the care center for several months and had worked with R34 multiple times prior. NA-C stated they had heard a few people make various comments about a lack of therapy services over the past months and these included once when a resident voiced frustration with a lack of therapy schedule. NA-C stated they had asked about getting therapy scheduled on a more consistent basis but was told therapy had multiple people on caseload and scheduling was not possible. R34's care plan, last reviewed 1/31/24, identified R34 had an alteration in mobility due to obesity and various medical conditions. The care plan outlined several interventions which included transfers via mechanical lift and three person assist, grab bars afixed to the bed to aide with mobility, and, PT per MD order. However, the care plan lacked evidence R34 ever had a therapy schedule provided or offered. In addition, R34's entire medical record was reviewed and lacked evidence R34 had ever been offered or asked (i.e., faciliated) about setting up a therapy schedule despite being identified as a routine-oriented person and direct care staff hearing comments or complaints about the lack of schedule from multiple residents. R58's quarterly MDS, dated [DATE], indicated R58 was cognitively intact. During interview on 2/6/24 at 1:17 p.m., R58 stated she wanted to get more physical therapy but would only get a therapy session once or twice and then be discharged . R58 stated the therapist would come to get her during Bingo and would not accommodate her schedule and do therapy after Bingo. R58 stated he felt she was discharged because she did not want to do physical therapy during Bingo. R58 stated she was frustrated therapy would not schedule a time with her around Bingo. On 2/6/24 at 2:32 p.m., the therapy director (TD) was interviewed. TD explained they were a contracted position at the care center from an outside therapy service and expressed the care center had no full-time therapy staff but only PRN [as needed] ones. TD verified R34 had been on caseload prior and did not recall R34 ever asking about a therapy schedule, but expressed setting such schedule would be difficult for us to do even for a range of time period (i.e., therapy will be between these times). TD stated there was no process in place to query or offer for a therapy schedule with residents' and such would only be done if it was specificially requested by them adding such would likely not even be documented in the medical record. TD stated the care center had never raised or voiced concerns to them about the lack of a process for offering or providing a therapy schedule (despite the direct care staff hearing concerns) and expressed any comments or concerns should definitely be brought forward. Immediately following, on 2/6/24 at 2:38 p.m., TD reviewed R58 and stated they were aware R58 had a lot of preferences and preferred mornings for service. The TD stated R58 was currently not on caseload because of scheduling issues. On 2/7/24 at 12:02 p.m., the administrator was interviewed and explained the contracted therapy service had been in place for less than a year now. The administrator stated they were unaware the direct care staff had been hearing comments from residents about the lack of a therapy schedule and expressed those comments should be reported to themself or TD so they could be addressed and the facility' process reviewed. The administrator stated it was important to ensure resident' choice options, such as the want or need for a therapy schedule, were addressed to provide a resident centered, homelike environment, adding residents have the right to be involved in their plan of care. A facility' policy on therapy service scheduling was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R43's quarterly Minimum Data Set, dated [DATE], indicated R43 was cognitively intact and had upper body and lower body impairment. R43's care plan, dated 7/27/23, indicated an intervention for the nursing assistants to assist with PT [physical therapy] recommended exercise program. The care plan indicated R43 had an exercise packet in her room to complete twice daily three times per week. The unit Care Sheet, dated 1/31/24, which gives direction to the nursing assistants on how to care for the residents, indicated exercise program to be done three times a week-see hand out in room. R43's nursing rehab task documentation indicated R43 had her exercise program (range of motion) done five times in the past 30 days. Once a day on 1/21/24, 1/24/24, 1/25/24, 1/27/24, and 2/7/24. During interview and observation on 2/7/24 at 9:04 a.m., R43 stated she was not doing any exercises since she had stopped therapy quite awhile ago. A packet with range of motion (ROM) exercises was hanging on a bulletin board on the wall behind her bed. During observation on 02/07/24 at 9:28 a.m., nursing assistant (NA)-C and NA-D provided morning cares to R43 to include washing R43's face and under arms, peri-care and providing clean clothes. NA-C and NA-D did not offer to assist R43 with her exercises or range of motion. R58's quarterly Minimum Data Set, dated [DATE], indicated R58 was cognitively intact and required supervision with transfers and partial to moderate assistance with walking 10 to 50 feet. R58's Care Plan, dated 8/12/22, indicated R58 had a self-care deficit related to weakness secondary to neuropathy. Interventions, dated 7/12/23, included PT Functional Maintenance Program: Walk 100+ feet or as tolerated with stand by assistance and two wheeled walker three times per week. The unit Care Sheet, dated 1/31/24, indicated walking program daily. R58's nursing rehab task documentation indicated staff had walked with R58 zeros times in the past 30 days. During interview on 2/7/24 at 9:14 a.m., R58 stated staff had not been walking with her, stating she could not remember the last time they did. R58 stated she had asked the night staff but would get the standard answer of that rule doesn't apply to us. During an interview on 2/7/24 at 9:47 a.m., NA-D stated the NAs used the unit Care Sheets to know how to care for a resident. NA-D stated she was not aware of any range of motion exercises for R43 and had not seen staff do any exercises with her. NA-D stated she believed R58 walked with therapy, but it had been awhile since she had seen therapy work with R58. NA-D stated the staff do not walk with her. During an interview on 2/7/24 at 11:00 a.m., registered nurse (RN)-B stated the functional maintenance programs were not consistently getting done, often because they were short staffed or had NAs from the pool agency who did not always know what to do with the residents. During an interview on 2/7/24 at 1:00 p.m., the therapy director (TD) confirmed R43 and R58 did have functional maintenance programs. The TD was unaware if the programs were getting done, stating she was evaluating R43's program for appropriateness and that R58's program remained appropriate. The TD stated if she was aware a functional maintenance program was not being done she would have the resident reevaluated for therapy as the residents could lose functional abilities if the functional maintenance programs were not being done properly. During an interview on 2/8/24 at 8:34 a.m., nurse manager and licensed practical nurse (LPN)-C stated the functional maintenance programs would be in the Tasks section of the electronic medical record for the NAs to complete. LPN-A confirmed R43's functional maintenance program was not being completed and stated R58 often refused to walk during the day and wanted to walk in the evening. LPN-C stated she would be concerned about R43 not getting her ROM exercises done as it is a comfort measure and a way to prevent contractures, which would make it difficult for R43 to continue to do the cares for herself she can currently can. LPN-C further stated she would also be concerned about R58 not walking with staff as she has a history of falls and the functional maintenance programs are a huge part of residents maintaining their independence. During an interview on 2/8/24 at 10:34 a.m., the director of nursing (DON) and administrator stated the functional maintenance programs should be complete and each program was individualized to promote the highest level of independence for residents. The administrator stated she would expect refusals to be addressed and education documented on why the program is important and appropriate follow up. Based on observation, interview and document review, the facility failed to provide ambulation services to maintain and prevent decline of function for 2 of 2 residents (R58 and R69) reviewed who required assistance with ambulation. Additonally, the facility failed to provided an exercise range of motion (ROM) program for 1 of 1 resident (R43) reviewed for ROM. Findings include: R69's quarterly Minimum Data Set (MDS) dated [DATE], indicated R69 had intact cognition and diagnoses of dementia, diabetes, and stroke. In addition, R69 had impairment to one side of both his upper and lower extremities and utilized a walker or wheelchair for mobility. R69's hospital Discharge summary dated [DATE], indicated R69 was involved in car accident on 7/10/23 with two left rib fractures, a thoracic (neck) vertebral fracture, and chronic compression fractures to lower thoracic vertebra (lower back bone). In addition, R69 experienced a fall at the hospital on [DATE] which resulted in a left femoral neck (hip) fracture. R69's physician orders dated 10/19/23 indicated, Activity and Weight bearing as tolerated to L LE [left lower extremity]. Nursing staff to re-evaluate and modify as appropriate. R69's Therapy Recommendations for Nursing Staff dated 11/15/23 indicated on the MOBILITY section of the form for Ambulation and assist of one staff using 2WW [2 wheeled walker] for assistive device and use wc [wheelchair] follow if outside pts room and 75 ft [feet] max. R69's care plan printed, indicated R69's intervention with a start date of 11/16/23, for nursing staff to perform, Ambulation program-A1 w/2WW x 75 feet, use w/c follow if outside patient's room. R69's treatment activity record (TAR) for January and February 2024 failed to indicate documentation of the ambulation program. During interview with therapy director (TD) on 2/6/24 at 2:49 p.m., TD stated, staff are supposed to walk him not on his own. During interview with trained medication aide (TMA)-A on 2/6/24 at 3:17 p.m., TMA-A stated facility staff were expected to document in R69's electronic medical record (EMR), if we walked him [it] should be documented pointing to R69's TAR. TMA-A looked in R69 EMR and stated, no history of staff documenting ambulation program. TMA-A stated the task for walking R69, does not pop up to cue the staff to walk or ambulate R69 and how often. During interview with registered nurse (RN)-A on 2/7/24 at 8:11 a.m., RN-A stated, he should be offered at least twice a day and as he requests. Also, RN-A stated facility staff, should [document in] progress note to indicate whether he walked. RN-A stated, I could see atrophy of his leg if not done. During interview with licensed practical nurse (LPN)-B on 2/7/24 at 8:53 a.m., LPN-B looked in R69 EMR and stated Looks like the walking program might have dropped off. I don't see it in there. This is where [documentation] would show up on the TAR. LPN-B stated R69 was at, risk for not being walked. Maybe his joints will get weaker and muscles get weak. During interview with facility administrator on 2/7/24 at 11:05 a.m., administrator stated the restorative program for R69 was important and R69 not getting walked per orders could result in a loss of function and mobility. Facility undated policy titled Emeralds of Faribault Functional Maintenance Program Process state, Documentation in the PCC notes will be completed with findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to comprehensively assess a resident for safe smoking practices for 1 of 1 resident (R44) reviewed for smoking. Findings include: R44's quarterly Minimum Data Set, dated [DATE], indicated R44 was admitted to the facility on [DATE], had moderate cognitive impairment and was independent with activities of daily living. R44's care plan, dated 10/2/22, indicated R44 currently smoked in the facility, would follow the smoking policy, and have a smoking evaluation per facility policy and as needed. R44's smoking assessment, dated 7/18/23, indicated R44 was currently identified as a smoker but did not have any smoking materials so was not assessed for safe smoking practices. During an interview on 2/5/24 at 2:41 p.m., R44 stated she smoked daily, either outside the front or back entrance, and would often get cigarettes from her roommate. During an interview on 2/7/24 at 9:47 a.m., nursing assistant (NA)-D stated she first noticed R44 smoking when she moved in with her current roommate (on 11/27/23). During an interview on 2/7/24 at 11:00 a.m., registered nurse (RN)-B stated R44 was smoking when she first admitted to the facility, did smoking cessation, and was aware R44 was smoking again since moving in with her current roommate. During an interview on 2/8/24 at 8:34 a.m., nurse manager and licensed practical nurse (LPN)-C stated any staff member can do a safe smoking assessment. The assessment included ensuring the resident could get outside and back inside independently, watching the resident light and extinguish the cigarette and watching the resident smoke to ensure there were no dexterity problems. LPN-C stated this was important to ensure the resident's safety. During an interview on 2/8/24 at 10:34 a.m., the administrator and director of nursing (DON) stated the expectation for smoking assessments were they to be done quarterly. A facility policy titled Resident Smoking Policy, dated 1/26/24, indicated a smoking evaluation would be completed with all residents regardless of smoking history. If a resident was determined to be a current smoker they would be evaluated for the need of adaptive equipment and evaluated for safe smoking practices upon admission, quarterly, annually and in case of a change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess to determine what, if any, interventions were needed or available to help reduce the risk of recurrent urinary tract infections (UTI) for 1 of 2 residents (R34) reviewed who had multiple, repeated infections. Findings include: A Mayo Clinic 5 Tips to Prevent a Urinary Tract Infection article, dated 6/2022, identified the most common symptoms of a UTI were painful urination, tenderness above the bladder area, and frequent or urgent urination. The article outlined, Women are at greater risk for a UTI . UTIs also are more common in postmenopausal women because low estrogen levels change vaginal and urethral tissue to increase the risk of infection . It's always better to prevent an infection rather than simply treat it. The article included tips which were identified as having, . with little or no potential negative side effects. These included drinking plenty of fluids (i.e., at least 50 ounces daily), taking cranberry supplements, and wiping front to back (i.e., proper peri-care). R34's significant change in status Minimum Data Set (MDS), dated [DATE], identified R34 had intact cognition, demonstrated no hallucinations or delusions during the review period, and required substantial assistance with personal hygiene and mobility (i.e., rolling left to right). Further, the MDS outlined R34 had chronic renal disease but had no UTI(s) within the past 30 days of the evaluation. R34's corresponding Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/20/23, identified R34 was evaluated as having a potential problem with urinary incontinence with text reading, Resident is triggered for alteration in elimination. The CAA identified such problem would be addressed in the care plan with overall objectives of maintaining current function and, Minimize risks. The CAA included, Staff offer toileting routinely and provide assist upon request . wears inc[ontinent] pads to aid [sic] in keeping skin clean and dry . will encourage fluids and monitor for constipation. S/s [signs and symptoms] of UTI, intervene accordingly . update provider with new or ongoing concerns with elimination. On 2/5/24 at 3:26 p.m., R34 was observed lying in bed while in her room. R34 had oxygen in place and was interviewed. R34 explained she had admitted to the care center from the hospital several months prior after suffering a stroke and, as a result, severely impaired mobility. R34 reported having several episodes of see things that aren't there sometimes since admitting to the care center adding, It's a big, big problem! R34 stated, to their recall, nobody had ever discussed the causes or, if needed, interventions to these with her. On 2/6/24 at 10:33 a.m., a subsequent interview with R34 was held. R34 reiterated her concerns with reported hallucinations over the past months and recalled she had several UTIs which, she felt, could be possibly causing the symptoms. R34 stated she recalled being treated with multiple, different antibiotics for these infections, however, had never been asked or talked to about what, if any, other potential interventions to reduce the risk of recurrent infection were available or appropriate for her (i.e., cranberry juice, peri-care audits, formal hydration program). R34 stated she usually had fluids available to her, however, nobody was monitoring them to her knowledge and explained the staff typically just seemed to argue with me when the symptoms started and then finally prescribe another antibiotic adding, That's really [the] only discussion [on it]. R34 stated she was open to trying other, non-pharmacological interventions to reduce the risk of another UTI. R34's progress notes, dated 9/11/23 to 2/2/24, were reviewed and identified R34 admitted to the care center on 9/11/23, post-stroke and with residual aphasia (a language disorder that affects the ability to communicate). These notes included: On 9/24/23, R34 developed confusion and was hallucinating so, as a result, the provider was updated and R34 was sent to the emergency department (ED) then admitted to the hospital. R34 returned to the care center on 9/28/23, with dictation reading, . post severe sepsis secondary to UTI. On 12/3/23, R34 again developed confusion and hallucinations with dictation, . seeing things that she knew wasn't real . reported that she was seeing people without a face. The provider was updated with more dictation present, . keep an eye on her. The following day, on 12/4/23, another note outlined R34 was again diagnosed with a UTI and an antibiotic was ordered. On 1/13/24, R34 was recorded as, again, having increased confusion. The provider was updated and dictation outlined, . increase fluids and update in 12 hours. The following day, on 1/14/24, R34 remained confused and, again, the provider was updated and a urinary analysis (UA) was obtained. R34 was started on another antibiotic on 1/17/24 for a UTI. R34's Treatment Administration Record (TAR), dated 2/2024, identified R34's current treatment-based interventions and corresponding staff initials to demonstrate what, if any, of them were completed. The TAR outlined an intervention which read, Continue to encourage fluids every shift, with a start date listed, 01/14/2024. This was recorded as completed every shift, so far, in the month; however, lacked any recorded amounts or goal of intake for R34 (i.e., 50 ounces/day). On 2/6/24 at 12:59 p.m., nursing assistant (NA)-D was interviewed and verified they had worked with R34 multiple times over the past months. NA-D described R34 as someone who spent a majority of time in bed, slept often, and needed total help with cares often using a bed pan for voiding but rarely being continent. NA-D stated they were aware R34 had a couple of them [UTI] over the past months and nurses had asked them to push fluids for R34; however, there was no formal hydration program or charting of the fluid intakes rather the nurses just expected the NA(s) to do so. NA-D stated they were unaware if all staff were doing it or not when asked, nor where they aware if R34 had ever been provided cranberry juice or supplements to help reduce the risk of recurrent infection. When interviewed on 2/6/24 at 1:16 p.m., NA-C stated they had worked with R34 prior and explained her as being pretty easy to care for as R34 rarely gets up from bed. NA-C stated R34 was sometimes incontinent of bladder but once in awhile would ask for the bed pan and have a continent void. When asked on what, if any, interventions were being done to reduce R34's risk for UTIs, NA-C stated they weren't sure adding, We don't usually get that information. However, NA-C stated they, to their recall, had never been asked or directed to push fluids or provide cranberry juice to R34 at meals. R34's care plan, last reviewed 1/31/24, identified R34 had an alteration in elimination due to weakness and diabetes mellitus, and it directed to offer toileting or bed pan use every two to three hours and as needed. However, the care plan lacked evidence R34's recurrent UTIs had been identified or developed with any problem statements, goals, or interventions despite having multiple UTIs since admission which, at times, included needing hospitalization. In addition, R34's medical record was reviewed and lacked evidence R34's recurrent UTIs had been comprehensively assessed to determine what, if any, proactive interventions (i.e., cranberry juice/supplement, formal hydration program) were available or needed to help reduce the risk of recurrent infection. When interviewed on 2/6/24 at 2:45 p.m., registered nurse (RN)-B explained they had worked with R34 multiple times prior and staff have to do everything for her cares nearly. RN-B stated R34 had repeated UTIs and would sometimes ask for the bed pan to void, however, outside of those times was primarily incontinent of bladder. RN-B reviewed R34's TAR and acknowledged the intervention which directed to push fluids. RN-B stated the intervention was an open order and they interpreted it to mean just ensuring R34 had fluids available to her, as it had no specific instructions for amount or times to provide any fluids. RN-B stated R34 was not on any formal hydration programs, to their knowledge, and expressed the nurses' could provide more structured fluid amounts to R34 but, again, reiterated, Like I said, there's no specific order. RN-B stated they were unsure if R34 consumed cranberry juice or supplements but added, I have not seen it. Further, RN-B stated they had never been asked or directed to audit or monitor R34's peri-cares to ensure the NA(s) were completing it appropriately and in a manner which would not encourage another infection. On 2/7/24 at 8:37 a.m., licensed practical nurse clinical coordinator (LPN)-C was interviewed. LPN-C verified they had reviewed R34's medical record, and they described R34 as having mixed continence and needing moderate to extensive assist with most cares. LPN-C explained the facility, as a whole, had identified a need to respond with better prevention measures and techniques to UTIs and had slowly started adding to our plan as a result with items like care audits and staff education. LPN-C added they had just the day prior (2/6/24) faxed R34's provider and gotten an order for cranberry supplement to help be more proactive with UTI prevention. LPN-C stated resident' level issues, including infections, should be assessed and evaluated using the SBAR [situation, background, assessment, response] process and note; however, there was none identified for R34's repeated UTIs. LPN-C stated it was important to ensure developed problems, including repeated UTIs, were assessed and evaluated as the facility was responsible for the care of the resident and as residents weren't always able to report their own symptoms so staff was responsible to monitor that and follow up with it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure scheduled medication administration times reflected the actual, current physician orders to reduce the risk of administration error or complication (i.e. GI upset) for 1 of 5 residents (R34) reviewed for unnecessary medication use. Findings include: A Mayo Clinic Metformin (Oral Route) Proper Use article, updated 2/1/24, identified the medication was used to treat high blood sugar levels caused by diabetes mellitus. The article listed a section labeled, Proper Use, which directed to take the medication with meals to reduce the risk of stomach or bowel side effects which were most common during the first few weeks of treatment. R34's significant change in status Minimum Data Set (MDS), dated [DATE], identified R34 had intact cognition along with several medical conditions including gastroesophageal reflux disease (GERD; a digestive disease in which stomach acid or bile irritates the food pipe lining) and diabetes mellitus. R34's most recent Order Summary Report, signed 1/21/24, identified R34's current physician-ordered medications and treatments. This included, metFORMIN HCL [medication used to stabilize blood glucose levels] . 500 mg [milligrams] by mouth two times a day . TAKE WITH MEALS. The order listed a start date, 09/11/2023. However, R34's Medication Administration Record (MAR), dated 2/2024, identified R34's current orders along with staff' initials recorded to demonstrate the time scheduled and their subsequent administration of the medication. This outlined the order for Metformin along with the same dictation, TAKE WITH MEALS, however, the times scheduled in the MAR for staff to provide the medications, and subsequently recorded as such, were 8:00 a.m. and 8:00 p.m., respectively. On 2/6/24 at 12:34 p.m., R34 was interviewed and her medication regimen was discussed. R34 stated she had diabetes and was on Metformin twice a day to her knowledge but was not exactly sure what time(s) of day it was being given although added, I think it's at supper time? R34 denied issues with GI upset when asked, and she was unable to recall what, if any, medications were typically given to her at bedtime (i.e., 8:00 p.m.). R34's medical record was reviewed and lacked evidence the discrepancy between the physician order and the scheduled time of administration had been identified or acted upon to ensure the physician order was implemented as written (i.e., taken with meals) and R34 was provided the medication at meal time(s) as directed. When interviewed on 2/6/24 at 2:53 p.m., registered nurse (RN)-B verified they were the nurse currently assigned to care for R34. RN-B explained they work for an outside agency (i.e., POOL) but had been working at the facility care center for several months now adding they worked all over on multiple units where assigned. RN-B stated R34 had all of her medications prepared and given by the nurses, and RN-B recalled R34 consumed Metformin. RN-B reviewed R34's MAR at the request of the surveyor, and verified it remained scheduled for 8:00 a.m. and 8:00 p.m. hours which was a couple hours after the supper meal was typically served. RN-B acknowledged the corresponding physician order directed to give the medication with meals then paused and said aloud, Interesting, before further adding, This [8:00 p.m. scheduled dose] is an oversight. RN-B stated they had worked both morning and evening shifts with R34 prior and never noticed this scheduled administration time prior adding the scheduled administration time needed to be adjusted to reflect meal times. RN-B stated it was important to follow physician orders, as written, and expressed R34's medication should be given with meals as it was diabetic medication and could impact R34's blood sugar levels adding they had noticed R34's blood sugars seemed a little bit low at times. On 2/7/24 at 8:37 a.m., licensed practical nurse care coordinator (LPN)-C was interviewed and verified they had reviewed R34's medical record. LPN-C stated they had entered the order into the MAR themselves and didn't catch the scheduled timing error adding, It has since been changed. LPN-C stated other nurses' could have identified and corrected the error, too, but regardless verified the medication given without meals or food could cause abdominal discomfort and should be given as ordered. LPN-C added, The meds work best with food. A facility' policy on order scheduling and/or clarification was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure acute, potentially distressing psychoactive symptoms were recorded and non-pharmacological interventions were attempted or recorded prior to the administration of as-needed (i.e., PRN) psychotropic medication for 1 of 5 residents (R34) reviewed for unnecessary medication use. Findings include: R34's significant change Minimum Data Set (MDS), dated [DATE], identified R34 had intact cognition and demonstrated no hallucinations or delusional thinking during the review period. Further, the MDS outlined R34 received antidepressant medication and anticoagulant medication (to thin the blood) but did not receive anti-anxiety medication during the review period. R34's most recent Order Summary Report, signed 1/21/24, identified R34's current physician-ordered medications and treatments. This included orders for gabapentin (an anti-convulsant medication) daily, paroxetine (an antidepressant medication) daily at bedtime, along with an order which read, Ativan [a psychotropic used for anxiety] . Give 1 mg [milligram] by mouth every 6 hours as needed for Anxiety . for 6 months. The order had a listed start date, 11/20/2023. In addition, the report listed interventions which included, Behavior: Non-Pharmacological Intervention Codes . [multiple options listed such as music, bring to activity] . every shift, with a listed start date, 12/28/2023; and, Behavior: Non-Pharmacological Interventions . [multiple options listed such as redirection, ambulate, offer activity] . every shift to Offer prior to PRN Pyschotropic [sic] Medication, with a listed start date, 11/20/2023. R34's care plan, dated 1/31/24, identified R34 had an alteration in mood and behavior with a diagnosis of generalized anxiety disorder. The care plan outlined a goal which read, Resident's mood/behavioral state will remain stable, and listed several interventions including monitoring and documenting mood state and behaviors upon occurrence, providing medications as ordered and, Monitor Target Behaviors per protocol. The care plan continued and identified R34 was at risk for psychotropic medication adverse reactions due to daily use of them, and directed staff to monitor for reactions and update the physician as needed. On 2/6/24 at 12:34 p.m., R34 was interviewed and expressed she recalled being put on Ativan a few years prior but added the physician limited how much she could have as he doesn't like me taking it. R34 stated the medication was given only upon her request, and expressed she took it for what she felt was that anxiety feeling. R34 stated she was unable to get up from bed without staff' help, so she was limited on non-pharmacological ways to reduce her anxiety and liked the medication. However, R34 explained she had noticed that, at times, trying to focus on other things (i.e., distraction) or doing some slower breathing seemed to help. When asked about what, if any, ideas or non-pharmacological interventions the staff helped her attempt or do before giving the medication, R34 responded the staff do, at times, offer an approach but not always adding they pretty much just get the medication and provide it to her. R34 attributed the lack of non-pharmacological interventions being consistently offered with the PRN medication to the fact she had resided at the care center for awhile adding, We already talked about it so they don't offer it every time. R34's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 2/2024, were reviewed and outlined the same orders, including the behavior interventions, listed on the signed Order Summary Report (dated 1/21/24). This identified the following administrations of the PRN psychotropic medication: On 2/1/24, a dose of PRN Ativan was recorded at 12:43 a.m., with the results listed as, E [effective]. A corresponding progress note, dated 2/1/24, identified the medication was given but lacked any recorded symptoms or behaviors which supported use of the medication, nor any non-pharmacological interventions being attempted or done prior to the medication. In addition, the corresponding TAR intervention used to list what, if any, non-pharmacological interventions were done on each shift were each recorded as, 0. On 2/2/24, a dose of the PRN Ativan was recorded at 9:47 p.m. with the results listed as, E. A corresponding progress note, dated 2/2/24, identified the medication was given but lacked any recorded symptoms or behaviors which supported use of the medication, nor any non-pharmacological interventions being attempted or done prior to the medication. In addition, the corresponding TAR intervention used to list what, if any, non-pharmacological interventions were done on each shift were each recorded as, 0. On 2/6/24, a dose of the PRN Ativan was recorded at 2:35 a.m. with the results listed as, E. A corresponding progress note, dated 2/2/24, identified the medication was given with dictation reading, . given for anxiety, but lacked what, if any, specific symptoms or behaviors were demonstrated or reported to support the use of the medication, nor any non-pharmacological interventions being attempted or done prior to the medication. In addition, the corresponding TAR intervention used to list what, if any, non-pharmacological interventions were done on each shift were each recorded as, 0. In total, six doses of the PRN psychotropic medication were given. However, none of the recorded doses had any recorded symptoms or behaviors recorded to demonstrate what R34 reported or demonstrated to justify the medication being given. In addition, only three of the six doses had any evidence non-pharmacological interventions had been offered, provided or attempted with R34 prior to medication being provided despite R34 reporting success with several non-pharmacological approaches (i.e., slow breathing, distraction). When interviewed on 2/6/24 at 2:53 p.m., registered nurse (RN)-B explained they worked for an outside agency (i.e., POOL) but had been contracted at the care center for several months now working on both morning and evening shifts. RN-B stated they had worked with R34 multiple times prior, and verified the staff administered all of R34's medications to her. RN-B stated R34 seemed to take the PRN Ativan more in the evening with general reports to staff of, I think I am anxious. R34 would, at times, also have physical symptoms like frequent leg movements. RN-B explained nurses should be trying to do non-pharmacological interventions, such as talking with R34 when feeling anxious, and pointed out the interventions listed on R34's TAR which could be done. RN-B stated the TAR intervention, with the listed non-pharmacological interventions, was typically recorded by nurses more at the end of the shift and not in-the-moment when happening. RN-B verified all PRN medications, including psychotropic medications, should have symptoms and non-pharmacological interventions attempted and recorded. This was important so the provider can reassess [need of medication]. On 2/7/24 at 8:37 a.m., licensed practical nurse care coordinator (LPN)-C was interviewed and verified they had reviewed R34's medical record. LPN-C explained the nurses should be attempting non-pharmacological interventions and recording them using the TAR intervention. This was important to do as it could reduce the medication that is given. LPN-C verified R34's medical record lacked consistent documentation on what, if any, symptoms R34 demonstrated when the PRN Ativan was provided, nor was there evidence for multiple administrations of what, if any, non-pharmacological interventions were done prior adding, There's not a lot of charting. LPN-C reiterated it was important to do to help staff determine intervention ideas and track what worked last time. A provided facility' Psychotropic Medication Use policy, undated, identified psychotropic medications could be considered for residents with symptoms which have been identified and the interdisciplinary team (IDT) has deemed medication would benefit such. The policy outlined, Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented. Further, Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided to reduce the risk of severe disease for 3 of 5 residents (R43, R44, R47) reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults chart dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained for adults 65 years and older as outlined: -The chart indicated when a resident had received no prior pneumococcal vaccines, they should receive the pneumococcal 20-valent Conjugate Vaccine (PCV20) or the pneumococcal 15-valent Conjugate Vaccine (PCV15). -The chart indicated that when a resident with an immunocompromising condition had received the Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age, the pneumococcal polysaccharide vaccine 23 (PPSV23) at less than 65 years, and it had been eight weeks or more since the previous PCV13 dose and five years or more since the previous PPSV23 dose, they should receive the PPSV23 or the PCV20. -The chart indicated that when a resident had received the PCV13 at any age and the PPSV23 at greater than 65 years, then the resident and provider may choose to administer the PCV20. R43 R43's quarterly Minimum Data Set (MDS) dated [DATE], indicated that R43 was [AGE] years old at time of assessment, had intact cognition, and was diagnosed with heart failure, kidney disease, and asthma. R43's Resident Vaccine Administration Consent Form dated 9/20/23, indicated that R43 was to receive the influenza and COVID-19 vaccination but the check box for the pneumococcal vaccination was left blank. The section titled Vaccine(s) not indicated: I do not wish to have the following vaccination(s) at this time, contained a check box for the pneumococcal vaccination that was left unchecked. The form was signed by R43. R43's immunization record dated 11/6/23, indicated R43 had not received any form of pneumococcal vaccination. R43's medical record was reviewed and did not indicate an updated pneumococcal vaccination had been offered or administered before 2/5/24. R43's progress note dated 2/8/24 at 10:02, indicated that R43 gave verbal consent for the pneumococcal vaccination. R44 R44's quarterly MDS dated [DATE], indicated R44 was [AGE] years old at time of assessment, had moderately impaired cognition, and was diagnosed with diabetes, a hip fracture, and chronic obstructive lung disease (COPD- incurable lung disease causing breathlessness, frequent coughing, and chest tightness). R44's Resident Vaccine Administration Consent Form dated 9/19/23, indicated that R44 was to receive the influenza and COVID-19 vaccination but the check box for the pneumococcal vaccination was left blank. The section titled Vaccine(s) not indicated: I do not wish to have the following vaccination(s) at this time, contained an unchecked box for the pneumococcal vaccination. The form was signed by the resident representative. R44's immunization record dated 12/14/23, indicated that R44 had received the PCV13 on 11/30/17 and 8/25/20 and the PPSV23 on 8/2/04 (less than [AGE] years old at this time). The record did not indicate that R44 had received or been offered the PCV20 or an additional PPSV23 dose. R44's progress note dated 2/7/24 at 3:47 p.m., indicated that R44 gave verbal consent for the pneumococcal vaccination. R44's medical record was reviewed and did not indicate an updated pneumococcal vaccination had been offered or administered before 2/5/24. During an interview on 2/7/24 at 1:35 p.m., R44 stated that facility staff had not given her information on or offered an updated pneumococcal vaccination, but she would have liked to receive one if it was available. R47 R47's quarterly MDS dated [DATE], indicated that R47 was [AGE] years old at time of assessment, had intact cognition, and was diagnosed with kidney disease, diabetes, and heart disease. R47's undated Resident Vaccine Administration Consent Form, indicated that R47 was to receive the influenza and COVID-19 vaccination but the check box for the pneumococcal vaccination was left blank. The section titled Vaccine(s) not indicated: I do not wish to have the following vaccination(s) at this time, contained a check box for the pneumococcal vaccination that was left unchecked. The form was signed by R47. R47's immunization record dated 10/2/23, indicated R47 had received the PPSV23 on 8/12/2010 ([AGE] years old at that time) and PCV-13 on 4/30/15. R47's medical record was reviewed and did not indicate an updated pneumococcal vaccination had been offered or administered before 2/5/24. During an interview on 2/7/24 at 1:29 p.m., R47 stated she thought facility staff had not offered or given education regarding receiving an updated pneumococcal vaccine but would have liked to discuss it with them and have the option to receive it. During an interview on 2/7/24 at 3:24 p.m., the infection preventionist (IP) stated he was in the process of completing a rehaul of the infection prevention program at the facility and addressing the pneumococcal vaccinations was on his list but had not yet been completed. The infection preventionist (IP) stated that R43, R44, and R47 had not been assessed for the desire to receive an updated dose of the pneumococcal vaccination. The IP stated that he had reviewed R43's medical record and did not find evidence that R47 had recieved any pneumococcal vaccinations. The IP stated that R44 should have received the PCV20 but after reviewing her medical record, it appeared she had not. The IP stated that the pneumococcal vaccinations were a seatbelt and an important safety measure for disease prevention. The facility's Pneumococcal Policy dated 2/8/24, indicated that all resident's pneumococcal vaccination statuses should have been assessed within five days of admittance to the facility. The policy indicated that the residents should have been offered applicable pneumococcal vaccinations per CDC guidance within 30 days of admission. The policy indicated that the resident/resident's representative had the right to refuse the vaccination and that refusal would have been documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R31's annual MDS, dated [DATE], indicated R31 was cognitively intact and required maximum assistance with bathing and personal hygiene. R31's Weekly Skin Inspections for 11/30/23 through January 2024 indicated R31 had received a bed bath on 1/18/24, 1/11/24, 1/4/24, 12/21/23, 12/13/23 and 11/30/23 during the past two months. R31's care plan did not address how to bath or wash R31's hair. R31's electronic medical record (EMR), including progress notes, lacked evidence R31 had refused baths or hair care. During observation and interview on 2/5/24 at 5:56 p.m., R31 was observed with extremely matted, disheveled hair forming a tightly packed mass of hair. R31 stated she would like it washed and brushed but it had been a long time as there is not enough help. R31 stated when she asked, she was told they did not have enough time to help her with her hair. During observation and interview on 2/8/24 R31's hair remained extremely matted and disheveled. R31 stated she received a bed bath last night, but her hair had not been brushed or washed. During an interview on 2/8/24 at 8:29 a.m., nursing assistant (NA)-C stated they should be offering to use a shampoo cap with R31 during her bed baths. NA-C confirmed R31's hair was really matted, stating it had been weeks since R31 had her hair brushed or washed as she often refused cares. During an interview on 2/8/24 at 8:34 a.m., nurse manager and licensed practical nurse (LPN)-C stated she had noticed how matted R31's hair was. LPN-C stated it was care planned that R31 would refuse care and staff were expected to reapproach R31 when she refused. LPN-C stated R31's hair could be washed in the beauty salon, but the care planned lacked an intervention to wash R31's hair at the salon. During an interview on 2/8/24 at 10:34 a.m., the administrator and director of nursing (DON) stated R31 had previously let a specific staff member brush her hair. The administrator further stated she would have expected staff to reapproach, try different things, and exhaust all measures before staff stopped washing or brushing R31's hair. Facility policy titled Activities of Daily Living (ADLs)/Maintain Abilities Policy dated 3/31/23 state, The facility will provide care and services for the following activities of daily living: a. Hygiene-bathing, dressin, grooming, and oral care,. R69's quarterly MDS, dated [DATE], indicated admission to facility on 10/19/23, with intact cognition and diagnoses of dementia, diabetes, and stroke. In addition, R69 required assistance with setting up and cleaning up of personal hygiene (combing hair, shaving, etc) and did not reject care. R69's care plan, dated 10/21/23, documented, Assist x1 with personal hygiene. During observation on 2/5/24 at 1:22 p.m., and 2/6/24 at 3:23 p.m., R69 was observed with dark matter caked under all fingernails of the left hand. During interview with trained medication aide (TMA)-A on 2/6/24 at 3:23 p.m., and R69, TMA-A stated R69, should be getting nail care on bath days and as needed. R69 stated he had received a shower on Saturday [2/3/24] and they did not do my nails. During interview with registered nurse (RN)-A on 2/7/24 at 8:11 a.m., RN-A stated the expectation was for nail care to be done on scheduled bath days and per request. RN-A stated the nurse is expected to document attempts for nail care when performing the weekly skin assessments that are done on scheduled bath days. During interview with nursing assistant (NA)-B on 2/7/24 at 8:42 a.m., NA-B stated nail care should be done on bath days or, when we see dirt under their nails. During interview with licensed practical nurse (LPN)-B on 2/7/24 at 8:53 a.m., LPN-B looked in R69's electronic medical record (EMR) for his weekly skin assessment dated [DATE] and stated, it was charted as not necessary for nail care. During interview with facility administrator on 2/7/24 at 11:05 a.m., administrator stated the expectation was for nail care to be completed on scheduled bath days that nursing assistants, are looking at nails daily. Based on observation, interview, and document review, the facility failed to ensure routine bathing and personal hygiene needs were addressed and completed for 3 of 5 residents (R47, R69, R31) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R47's quarterly Minimum Data Set (MDS), dated [DATE], identified R47 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS outlined R47's care plan, dated 11/21/23, identified R47 had a self-care deficit due to a mobility decline and listed a goal for R47 to accept assistance with all self cares. The care plan including several interventions to help meet this goal including, Bathing Preferences: Tub bath or shower, day or evening, once weekly. Further, the care plan outlined R47 needed assistance with dressing and personal hygiene needs. On 2/5/24 at 2:08 p.m., R47 was interviewed about their care at the facility and she expressed frustration as they hadn't received a shower or bath in well over a week. R47 stated she had repeatedly asked for one but added, It's not happening. R47 stated the care center had staffing issues and a bath aide was often not scheduled so baths weren't getting done adding it seemed to be happening more and more. R47 reiterated she wanted help to get a bath, at least weekly, and was upset about not getting one adding, I'm sad about it. R47's medical record was reviewed and a series of MHM (Monarch Healthcare Management) Weekly Skin Inspection - V4, dated 12/2023 to 2/2024, were identified. These contained various sections to be completed by the nurse which included a review of the resident' skin status along with a section labeled, Bath and Nail Care, with a corresponding response of what, if any, type of bath as provided or if it was refused. These outlined R47 had a shower and/or tub bath completed on 12/23/23 and 1/13/24; however, R47 had refused bathing on 2/2/24 but remained with, No skin issues observed. However, there were no other completed inspections documented in the medical record to demonstrate bathing had occurred or, at least, been offered between 12/23/23 to 1/13/24 and 1/13/24 to 2/2/24. R47's Follow Up Question Report, dated 1/8/24 to 2/7/24, identified the nursing assistant (NA) completed charting for the time period. This outlined a subsection labeled, Bathing, which outlined staff response on how much support R47 needed to complete bathing. This outlined R47 needed physical assistance multiple times in the period, including on days when bathing was not charted as completed on the corresponding skin inspection forms. R47's medical record was reviewed and lacked evidence an actual shower and/or tub bath was offered, provided or refused to R47 between 12/24/24 and 1/12/24 (over two weeks) or between 1/14/24 to 2/1/24 (nearly three weeks). When interviewed on 2/6/24 at 1:05 p.m., NA-D explained they had worked at the campus for several years and were supposed to have a bath aide who helped with baths and shower; however, if census was reduced then each NA working on the floor was responsible to do their own. NA-D stated bathing was recorded in their computer charting (i.e., support given), however, stated they recorded the assistance in the charting for all their worked shifts and not just when a bath or shower was actually given. NA-D stated any refusals should be reported to the nurses and they would document such on their end and in their respective charting (i.e., skin inspections). NA-D stated when the campus was challenged staffed, then baths and showers were not always completed adding, We try to do it but don't really have time. NA-D stated the residents, including R47, would often voice frustration or comments about the baths not getting done and management was aware of it. NA-D stated the issue had been present for awhile. When interviewed on 2/6/24 at 1:20 p.m., NA-C stated they had worked at the campus for several months and had worked with R47 prior. NA-C stated R47 was cognitively intact and had voiced multiple comments about her baths or showers not getting completed. NA-C explained the bath aide had been taken away months prior and, as a result, the direct care NA was responsible to do their own bathing, respectively. NA-C stated if there was a call-in or someone who didn't show up for work, then baths would often not get done adding even that day (on 2/6/24), None of our baths were done. NA-C stated such happened, often, very often, and management was aware but just repeatedly told staff to get them done. NA-C expressed baths or showers not getting done was just one of many items not routinely being completed due to the shortage of staff members adding, It's pretty hard working short staffed and still having to keep up. On 2/6/24 at 3:07 p.m., registered nurse (RN)-B was interviewed and explained they worked with an outside agency but had been contracted to the campus for a few months now. RN-B stated a bath or shower, when completed or refused, was supposed to be recorded in the medical record using the weekly skin check form. RN-B reviewed R47's medical record, including the completed skin inspections, and verified many weeks did not have one documented to demonstrate a bath or shower had been offered or done. RN-B stated the lack of them was a tricky part as staff would often forget or not have time to always chart care done. However, RN-B verified baths or showers were supposed to be documented using the weekly skin evaluations to their knowledge. When interviewed on 2/7/24 at 8:29 a.m., licensed practical nurse care coordinator (LPN)-C explained R47 had a preference to have female caregivers with bathing so, at times, staff would have to adjust the plan for her. LPN-C stated R47 was scheduled for weekly bathing until just yesterday, when they followed up with her due to the surveyor investigation, and updated her (R47) to twice weekly bathing going forward. LPN-C stated when a bath or shower was completed, the NA should report to the nurse any refusals of care or the nurse should complete the corresponding weekly skin check in the medical record. LPN-C stated the NA will also chart in their system but the charting was pretty generic and the amount of pool staff (i.e., agency) used made it so charting was not always being completed timely or accurately. LPN-C stated they had in the past been told baths and showers were not getting completed due to staffing levels, however, had not heard such in awhile. LPN-C stated if baths were not getting completed, then the floor nurses need to be told so the issue can be brought forward adding the lack of such was a break in communication and education was needed. LPN-C stated it was important to ensure weekly bathing or showers were completed as it was a cleanliness thing, it's comfort.

Based on observation and interview the facility failed to ensure 1 of 5 medication carts were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications. The deficient practice had the potential to affect all 13 residents that resided on the second floor of the facility. Findings include: Electronic communication (email) from the assigned Ombudsman (official/advocate appointed by the Minnesota Board on Aging) for the facility on 2/2/24 stated, Of note, I did observed a RN station that was unattended; unlocked med drawers and confidential information displayed on a pc [personal computer] screen. During observation and interview on 2/5/24 at 5:25 p.m., licensed practical nurse (LPN)-A walked away from second floor medication cart with pills in a medication cup and entered a resident room at the end of the hall. The medication cart was unlocked and laptop left open with patient identifying information visible to the 5 residents seated in the dining room eating their dinner. During interview, LPN-A stated the open laptop, shouldn't be visible to anyone. I wasn't near the cart and should have locked the cart when I walked away and went down the hallway. During interview with registered nurse (RN)-A on 2/7/24 at 8:11 a.m., RN-A stated the expectation of staff was to lock [medication cart] when you walk away from it because up here [second floor] the residents are very mobile, and they will have access to get into it and get at some meds. During interview with LPN-B on 2/7/24 at 8:53 a.m., LPN-B stated the expectation of nursing staff was to Always lock [cart] when we walk away and to turn off the computer screen when leaving cart. LPN-B stated, patient identifying information is privileged information and some of the residents here [on second floor] will pull on the drawers and get into it [if unlocked]. During interview with facility Administrator on 2/7/24 at 11:05 a.m., the administrator stated the expectation was for medication carts to be locked and patient identifying information not visible when unattended. The administrator stated the second floor unit has a resident who wanders around the unit up there and he opens doors, drawers, and rummages. Facility policy titled MEDICATION STORAGE IN THE FACILITY dated May 2022, documented, Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide meaningful activities for 1 of 1 resident (R8) reviewed for activities when the facility did not accommodate the resident's choice activity to watch television (TV). Findings include: R8's admission minimum data set (MDS), dated [DATE], indicated R8 had moderate difficulty hearing-speaker has to increase volume and speak distinctly, with no hearing devices. Section F indicated preferences for customary routine and activities. The following activities were identified as very important: to take care of your personal belongings or things, choosing your own bedtime, listen to the music that you like, keep up with the news, being able to use the phone in private, and being able to do your favorite activities. R8's quarterly MDS, dated [DATE], indicated R8 to have intact cognition and required supervision with transfers, walking, and toileting, used walker for mobility. R8' s' diagnoses included depression, adult failure to thrive and diabetes. R8's care plan, dated 3/1/23, indicated R8 had an alteration in communication with an intervention to use sound amplifier or hearing aide. Another care plan approach revised 6/30/23, indicated R8 enjoyed the following independent leisure activities: watching TV/movies, listening to music, and praying. Assist R8 with independent leisure needs upon request. R8's provider visit, dated 7/18/23, indicated R8 has chronic depression, reported decreasing mood related to situational stress. R8 appeared stable and was very open with his emotions during our conversations about his inability to hear and requested a single room to avoid bothering his roommate when he has the volume of his TV up. R8's progress note, dated 7/22/23, indicated FM-A brought R8 a television to his room. Advised FM-A to speak with business office and writer will leave message for follow-up. FM-A was adamant about connecting the cable to the television. FM-A stated, well he has no money, I will pay for it. I guess I will come Monday to figure it out. R8's collection note, dated 7/24/23, indicated business office manager (BOM)-A spoke with FM-A telling him the facility was going to have to disconnect R8's cable to the TV because no cable payments have been made to his past due balance. Message sent to maintenance (M)-A to go disconnect the cable from R8's TV. During an interview on 7/26/23, at 1:35 pm. FM-A stated that R8 called him last week because the facility took their TV out of his room because he did not pay his bill. FM-A brought R8 a TV to the to the facility, to replace the one removed by the facility and so he can hook up his wireless speakers. R8 cannot hear at all without them, he would have to have the TV on the highest volume. A nurse told FM-A R8 was not supposed to have a TV because he did not pay his bill. FM-A stated R8 has nothing else to do in the facility, he really enjoys watching TV. FM-A was told by the facility he needed to pay R8's cable bill or they would shut it off. During an observation and interview on 7/26/23, at 1:47 p.m. R8 was lying in bed with his eyes closed. R8 did not respond when his name was called, R8's shoulder was gently touched, and R8 opened his eyes. R8 stood up and grabbed his hearing amplifier off the tray table. R8 stated, he was very hard of hearing and could not hear without the use of the amplifier. R8 stated about a week ago the facility staff took their TV out of his room when he was sleeping, and no one told him why. R8 called FM-A to see if he could bring him a TV, which he did on or about 7/22/23; however, when R8 was sleeping, the facility disconnected the cable from the TV, R8 was not able to watch television. R8 stated FM-A gave him $25.00 to pay the cable bill. R8 took the money to the office. R8 stated the facility did not talk to him about the past due balance for cable television, they just disconnected it and was without access to the TV for about one week. R8 stated the new TV has Bluetooth to use wireless headphones when watching TV as to not disturb his roommate. R8 stated he did not have the television for about one week and when he tried to watch TV in the lounge area using his hearing amplifier, he still could not hear the TV, and others would yell at me to turn down the TV because it was too loud. R8 stated he is board at the facility, and it is difficult to participate in activities when you cannot hear. R8 stated he likes to watch TV until 1:00 a.m. to 2:00 a.m. identifying many TV programs. R8 stated when he does not have access to watch TV, he lays in his bed, feels like he is in a jail cell with no rights. R8 stated he feel humiliated by having the ability to watch TV taken away and is worried the facility will shut it off again. During an interview on 7/26/23, at 1:57 p.m. licensed practical nurse (LPN)-A stated she heard R8 did not have a TV for a day and stated he can always come to the dining area or lobby and watch TV. LPN-A state she believed R8 could hear the TV in these areas. During an interview on 7/26/23, at 2:33 p.m. director of social services (DOSS)-A stated cable TV is provided to the transitional care unit (TCU) residents for free, if they transition to our long-term care unit then they have to pay $25.00 a month. R8 had a facility TV for two months on the TCU, which was free. DOSS stated the administrator sent out a 30-day notice to all residents that they would have to start paying $25.00 for cable TV. DOSS did not know if R8 received a letter but stated R8's family did. DOSS stated if residents do not pay the cable TV bill, they no longer have access. R8 told the DOSS he likes to watch TV and she advised R8 to watch TV in the lobby and he was to use his amplifier to hear the TV. During an interview on 7/26/23, at 3:14 p.m. maintenance (M)-A, stated the facility has about 64 TVs in the building, the bed capacity was 90, and the current census was 60. The BOM-A told M-A he had to take R8's facility TV out of his room because he did not pay his cable bill. M-A stated R8 liked to watch TV and he felt bad about it. M-A waited until R8 went to lunch then took the TV out of his room. When FM-A brought R8 a new TV, the BOM-A told M-A to unhook R8's cable, which he did when R8 was at lunch. During an interview on 7/26/23, at 3:39 p.m. the BOM-A stated R8 told her he did not have any money to pay the bill and was told if could not pay the cable bill the facility would have to take the TV. BOM-A was not sure if there was a policy about cable TV access and cost and that she was directed by the facilities corporate off to charge residents for cable TV access. During an interview on 7/26/23, at 4:31 p.m. the activity director stated that TV was very important to R8, and his care plan indicated this. R8 is hard of hearing, he uses a pocket talker. The activity director stated she was not aware that the facility took R8's facility TV and then removed the cable from his personal TV. During an interview on 7/26/23, at 5:08 p.m. the administrator stated she was not aware that the facility staff removed the facility TV from R8's room and disconnected the cable to his TV that FM-A brought in because R8's cable bill was not paid. The administrator stated she would immediately notify maintenance to restore R8's cable TV, residents should be able to access to activities that are important to them. The administer state it was under a week that R8 did not have access to cable TV in his room. Activity policy was requested and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to arrange for safe transfers out of bed for 1 of 1 resident (R52) reviewed for accommodation of needs. Findings include: R52's Face Sheet dated 12/1/22, indicated she was admitted on [DATE]. R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact. The MDS indicated transfers did not occur for R52 in the look back period of seven days. R52's admission Data Collection assessment dated [DATE], indicated R52 weighed 374 pounds, and was weighed by a Hoyer lift (a mobility tool used to help with people with mobility challenges to get out of bed, or move from surface to surface safely) scale. The assessment further indicated R52 transferred with the assistance of two or more people and used a wheelchair for mobility. R52's noted bathing preference was a tub bath. R52's baseline care plan dated 5/11/22, indicated assist with mobility in and out of bed and assist with transfers with a Hoyer lift. R52's care plan dated 5/13/22, indicated assist with transfers by use of Hoyer lift with the assistance of three staff. R52's interdisciplinary team (IDT) note dated 10/11/22, indicated R52 needed to go to several appointments, but until the facility could get R52 out of bed, she could not attend the required appointments. The Hoyer lift manual indicated to use caution in using the correct sling for each resident, and further indicated the slings vary in weight limitations from 350 - 600 pounds. When interviewed on 11/28/22, at 3:54 p.m. R52 stated she needed to get to the dentist, the eye doctor and to Mayo Clinic for several appointments, but she was not able to get out of bed until the facility obtained a new Hoyer lift. R52 stated she had to cancel appointments because she was unable to get out of bed. R52 stated she had not been out of bed for a couple of months but was unsure of the exact time frame, and stated one of the staff had said the Hoyer lift was not working and needed to be replaced. R52 stated her current weight is around 390 pounds and the lift could accommodate 400 pounds. R52's recorded weight on 11/11/22, per Hoyer scale, was 380 pounds. When interviewed on 11/30/22, at 10:39 a.m. registered nurse (RN)-F stated R52 required a Hoyer lift to get out of bed, and further stated R52 had not been getting out of bed due to the weight limitations of the lift. When interviewed on 11/30/22, at 10:41 a.m. nursing assistant (NA)-B stated R52 required two to three people to help with her Hoyer lift, and further stated she had never transferred R52 out of bed, but also indicated R52 sometimes refused some cares. When interviewed on 12/01/22, at 9:05 a.m. RN-B stated R52 required a Hoyer lift to get out of bed, but the facility didn't have one that would meet R52's need as none were able to lift her due to her weight exceeding the lift limits. RN-B stated she stated she had never transferred R52 out of bed since she started work at the facility in the summer. RN-B further stated her understanding was the facility needed a new Hoyer lift for R52, but the facility declined to purchase one. RN-B stated she had raised the issue a number of times but was told the facility did not have the equipment to properly transfer R52, and was told it was the lift, and the sling. RN-B stated she was notified just that morning the facility Hoyer was adequate, but R52 required a new sling. RN-B stated R52 does sometimes refuse cares, but also stated R2 did want to get to her appointments. When interviewed on 11/30/22, at 10:57 a.m. the social worker (SW) stated there was discussion that day that R52 just needed a new bariatric sling for the Hoyer lift. When interviewed on 11/30/22, at 11:15 a.m. the health information director (HID) stated staff had tried to get R52 out of bed for a dental appointment, but the Hoyer lift would not safely hold R52's weight. The HID stated, It wasn't too long ago they said they didn't have a Hoyer for her. When interviewed on 11/30/22, at 2:51 p.m. the physical therapist (PT) stated the Hoyer lift limit was 400 pounds and should accommodate R52. When interviewed on 11/30/22, concurrently with the PT, the occupational therapist (OT) stated she was told the facility did not have a Hoyer lift to accommodate R52. When interviewed on 12/1/22, NA-E stated she and several other staff attempted to get R52 up for an appointment one day and the sling didn't work for R52 due to her weight and stated that it used to take up to six people to get R52 out of bed when they were able to get her out of bed. When interviewed on 12/01/22, at 1:06 p.m. the director of nursing (DON) stated the lift capacity was 450 pounds. The DON stated she was in the room when staff tried to get R52 out of bed for a dental appointment, and for safety, staff could not transfer R52. The DON stated she is not sure she has the right sling for the Hoyer lift in the building to support R52's weight but would order one. The DON further indicated R52 had been sent to other appointments on a stretcher and could transfer out that way again to other appointments. The DON stated the facility planned to obtain an appropriate sling for R52. The policy for accommodation of needs or mechanical lifts was requested and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R13's quarterly Minimum Data Set (MDS), dated [DATE], identified R13 had severe cognitive impairment and required extensive to total assistance with her activities of daily living (ADLs). R13's care plan, dated 9/19/22, identified R13 received hospice care while residing in the nursing home due to end-stage disease process. R13 was enrolled with Intrepid Hospice and a care plan goal was listed which read, Resident and family will receive comfort cares as desired and will verbalize satisfaction with cares received. The care plan listed interventions which included Intrepid Hospice contact information for the registered nurse (RN) and licensed social worker (SW), maintaining communication with hospice, and, See Hospice plan of care and visit schedule. A separate white-colored binder was present at the nursing station which contained R13's hospice progress notes and recertification information. However, there was no hospice care plan contained inside. Further, R13's medical record was reviewed and lacked evidence of a hospice care plan despite this being identified on R13's facility' developed care plan. There was no visit schedule or care plan information on when or what, if any, services hospice would provide. When interviewed on 11/30/22 at 10:40 a.m., nursing assistant (NA)-A stated she was unaware when hospice was coming or even if they provided care for R13. NA-A had never seen hospice work with R13. On 11/30/22 at 1:49 p.m., registered nurse (RN)-B was interviewed and stated R13 was on hospice care and they visited the nursing home once or twice a week. RN-B reviewed R13's medical record, and corresponding hospice information, and verified there was no hospice care plan available to demonstrate what, if any, services hospice would provide. RN-B stated there had been some communication concerns with R13's hospice provider and added she was unaware a hospice plan of care even existed. However, RN-B stated a plan of care would be beneficial to have so cares get provided. When interviewed on 12/1/22 at 10:08 a.m., hospice registered nurse (RN)-E stated R13 had been on hospice a long time and repeatedly qualified for continued services due to weight loss. RN-E stated she was unaware a hospice plan of care was not present at the nursing home and expressed there normally would be one adding, I think it got misplaced. RN-E stated it was important to have a hospice care plan so staff would be aware when hospice was coming and what services they were providing. A provided Hospice policy, dated 10/2018, identified the hospice agency would provide the facility staff with a copy of the hospice care plan and schedule of visits. Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate care was provided for 1 of 1 residents (R18) reviewed for dialysis; and 1 of 1 residents (R13) reviewed for hospice care coordination. Findings include: R18's significant change Minimum Data Set (MDS), dated [DATE], indicated R18 had intact cognition and required limited assistance of one staff for dressing, supervision with one-person physical assistance for personal hygiene and was independent for all other activities of daily living (ADLs). Section O Special Treatments and Programs indicated R18 was on dialysis while a resident in the facility. R18's diagnoses included chronic heart failure (CHF), end stage chronic kidney disease (CKD), diabetes, and chronic embolism and thrombosis (blood clots). R18's Care Area Assessment (CAA) dated 11/11/22, indicated R18 triggered for ADL function. R18's care plan dated 10/3/22, indicated R18 was on a therapeutic diet related to a history of CHF, CKD, and diabetes. R18 was at risk for weight changes due to dialysis treatment. Interventions included communication with R18's dialysis interdisciplinary team (IDT). The care plan lacked indication R18 received dialysis three days a week or was at risk for complications due to dialysis. The care plan also lacked interventions for monitoring R18 for complications related to dialysis treatment or the care of R18's dialysis access port. R18's physician orders revised on 11/15/22, indicated R18 received dialysis every Tuesday, Thursday, and Saturday from 5:45 a.m. to 9:15 a.m. at Northfield Davita Dialysis. During an interview on 12/1/22, at 1:41 p.m. RN-B stated nursing should assess R18's dialysis access site to ensure it was not bleeding or showing signs of infection. RN-F also verified R18's care plan lacked indication R18 was on dialysis or interventions related to possible complications due to dialysis treatment. During an interview on 12/1/22, at 3:08 p.m. the director of nursing (DON) stated R18's care plan should have indicated she was at risk for complications due to dialysis and R18's access port should have been assessed every shift for signs of infection or bleeding. The facility Hemodialysis policy dated 11/22/19, indicated the facility will ensure residents who require dialysis, receive such services consistent with professional standards of practice, and the comprehensive person-centered care plan. Staff will provide ongoing assessment of the resident's condition and monitored for complications before and after dialysis treatment. Information regarding the resident's dialysis treatment including the type and location of the resident's dialysis access site will be used to develop a care plan to minimize the risks and promote the resident's highest level of function. The resident's plan of care should include an individualized plan to address potential emergency situations that can include, but is not limited to, bleeding from the dialysis side.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure activities of daily living (ADLs) including weekly baths were provided for 3 of 3 residents (R40, R43, R44) who needed assistance with bathing. In addition, the facility failed to implement a communication system to ensure resident needs were met for 1 of 1 residents (R44) who's primary language was not English. Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], indicated R40 had intact cognition and required limited assistance of one staff for bed mobility, transfers, and personal hygiene, and extensive assistance of one staff for dressing and toileting. The MDS indicated R40 required physical help in part of bathing and used a walker and/or wheelchair for mobility. The MDS also indicated R40 did not have a history of refusing cares during the assessment period. R40's diagnoses included major depressive disorder high blood pressure, diabetes, chronic heart failure (CHF), candidiasis (fungal growth), obesity, and chronic kidney disease (CKD). R40's Care Area Assessment (CAAs) dated 6/28/22, indicated R40 triggered for activities of daily living (ADL) function, urinary incontinence, falls, pain, pressure ulcers, and psychotropic drug use. R40's care plan dated 11/28/20 indicated R40 had diabetes. Interventions included monitoring R40's feet for open areas, sores, pressure areas, blisters, edema, or redness. Staff were to monitor R40 for any signs of infection to any open areas, redness, pain, heat, swelling, or pus formation. R40 also had an alteration in elimination related to impaired mobility. Interventions included two staff assistance with toileting, providing assistance with peri-cares in the morning, evening and as needed, and assisting R40 to change incontinence products as needed. R40 also used psychotropic drugs daily. Interventions included R40 having a history of seeing/feeling black bugs crawling on and living in her skin. R40 was also at risk of skin breakdown related to impaired mobility, diabetes, CHF, and incontinence. Interventions included monitoring skin during daily cares, and a weekly skin audit on bath days. R40 was at risk for a self-care deficit related to immobility. Interventions included a weekly scheduled bath day and skin check and one staff assisting R40 with bathing, dressing, and personal hygiene. R40's physician orders dated 2/22/21, indicated R40 was to have weekly weights, vital signs, bath and skin assessments completed every evening on Saturdays. R40's November 2022, bath log indicated the following: 11/5/22, bath 11/12/22, refused bath 11/19/22, no bath 11/26/22, no bath R43's quarterly MDS dated [DATE], indicated R43 had intact cognition, was independent for all ADLs and required supervision with oversight for bathing. The MDS also indicated R43 used a walker and/or wheelchair for mobility. R43's diagnoses included spinal stenosis (a narrowing of the spinal column which compresses the spinal cord), diabetes, major depressive disorder, anxiety, and asthma. R43's CAAs dated 9/9/22, indicated R43 triggered for ADL function, falls, pain, and psychotropic drug use. R43's care plan dated 5/19/22, indicated R43 was at risk for falls related to weakness and decreased mobility. Interventions included adjusting medications that could contribute to falls. R43 was at risk for alteration in cognition and reported unwitnessed falls to staff. R43 was at risk for an alteration in mobility related to neuropathy (decreased feeling in nerve endings). Interventions included weekly skin audits with bath or shower. R43 was also as risk for alteration in psychosocial well-being. Interventions included monitoring and responding to R43's unmet needs. R43's November 2022, bath log indicated the following: 11/5/22, R43 took a bath on her own (no supervision or oversight was documented). 11/12/22, bath 11/19/22, no bath 11/26/22, bath R44's admission MDS dated [DATE], indicated R44 had mild cognitive deficits and required extensive assistance of two staff for bed mobility, transfers, and toileting, extensive assistance of one staff for personal hygiene and was independent with eating. R44 was not steady moving from a seated to standing position or from surface to surface and required staff assistance for stability. The MDS also indicated R44 used a walker and/or wheelchair for mobility. R44's diagnoses included disorders involving R44's immune system, anxiety, bilateral hearing loss, major depressive disorder, diabetes, dementia, psychotic and mood disturbances, fatigue, heart failure, chronic obstructive pulmonary disease (COPD), and a fracture of the lumbar vertebra (lower back). R44's CAAs dated 9/14/22, indicated R44 triggered for cognitive loss/dementia, ADL function, urinary incontinence, psychosocial well-being, activities, falls, and pressure ulcers. R44's care plan dated 9/14/22, indicated R44 had potential for alteration in cognition due to dementia. Interventions included maintaining a consistent environment and providing cues and supervision as needed. R44 also had alteration in elimination with a history of urinary tract infections (UTIs). Interventions included two staff assisting R44 with toileting and monitoring R44's skin integrity. R44 also had an alteration in mobility due to a history of falls. Interventions included weekly skin audits with bath or shower. R44 had a potential for alteration in psychosocial well-being. Interventions included monitoring and responding to R44's unmet needs. R44 also had a self-care deficit related to a history of falls, weakness, and dementia. Interventions included extensive one staff assistance with bathing. R44's November 2022, bathing log indicated the following: 11/6/22, bath 11/13/22, no bath 11/20/22, bath 11/27/22, no bath During an interview on 11/28/22, at 2:29 p.m. R44 stated she did not know when she was supposed to get a bah but stated it had been two weeks since she had one. R44's family member (FM)-A stated R44 needed to have a bath every week because she was often incontinent and couldn't wash herself properly. During an interview and observation on 11/28/22, at 5:23 p.m. R43 stated she was supposed to get a bath every week, but she didn't always get it. R43's roommate, R40 was observed to be washing her hair in the shared room sink while seated in her wheelchair. During an interview on 11/30/22, at 11:35 a.m. nursing assistant (NA)-F stated, I'm not gonna lie, sometimes staff did not have time to give the residents their baths. During an interview on 12/1/22, at 1:58 p.m. registered nurse (RN)-B stated she didn't think R40 had received a bath for the last two weeks. During an interview on 12/1/22, at 2:56 p.m. the director of nursing (DON) stated baths can be a struggle. The DON stated trying to give residents baths every week was a challenge because of staffing and many residents and family members had complained that residents were not getting their weekly bath. A facility policy on resident bathing or ADL care was requested but not received. Communication (R40) R40's quarterly Minimum Data Set (MDS) dated [DATE], indicated R40 had intact cognition and required limited assistance of one staff for bed mobility, transfers, and personal hygiene, and extensive assistance of one staff for dressing and toileting. The MDS indicated R40 required physical help in part of bathing and used a walker and/or wheelchair for mobility. R40's diagnoses included major depressive disorder high blood pressure, diabetes, chronic heart failure (CHF), candidiasis (fungal growth), obesity, and chronic kidney disease (CKD). R40's Care Area Assessment (CAAs) dated 6/28/22, indicated R40 triggered for activities of daily living (ADL) function, urinary incontinence, falls, pain, pressure ulcers, and psychotropic drug use. R40's care plan dated 6/21/21, indicated R40 was confused at times, possibly due to a language barrier because R40 spoke Spanish and some English. R40 enjoyed using her tablet, reading, and watching the Spanish channel. Interventions indicated R40 enjoyed participating in exercise program, socials, and music, and to invite R40 to related activities. Interventions also included providing R40 with reading material, and topics R40 may be interested in talking about were family, shopping, and Mexico. R40 also had an alteration in communication due to English being her second language. Interventions included speaking clearly and distinctly to R40 or use R40's preferred communication method; however, no preferred method was indicated. R40 also was at risk for an alteration in mood. Interventions included offering to play Spanish music. R40 was at risk for psychosocial well-being related to a language barrier. Interventions included contacting R40's niece for translation and offering translation services when her niece was not available or as needed. During an interview on 11/28/22, at 3:23 p.m. R43, R40's roommate stated the staff didn't talk to R40 much and did not use a phone or any other device to try to communicate with R40. During an interview on 11/28/22, at 5:46 p.m. using an interpreter line, R40 stated things were not going well and suggested maybe because I'm Mexican. R40 stated no one in the facility spoke Spanish and it was difficult to communicate her concerns to the staff or ask them questions. R40 stated she could participate in some activities, but not all, and she tried her best. R40 stated she had word-find activities in Spanish, but there was not TV or music in Spanish. R40 stated staff had never asked to assist her to find or listen to Spanish programs although R40 had been a resident at the facility for three years. R40 stated it was upsetting because staff didn't ask R40 what she needed or wanted. During an interview on 11/28/22, at 5:35 p.m. licensed practical nurse (LPN)-D stated R40 spoke some limited English. LPN-D stated there was no translator line or anything else the staff used to communicate with R40, it was just what little she can understand. During an interview on 11/30/22, at 11:27 a.m. nursing assistant (NA)-F stated she just used yes or no questions to communicate with R40. NA-F stated some days were better than others when trying to communicate with R40, but NA-F didn't know of any other way to communicate with R40. NA-F stated R40 had a tablet she used to call her family and that R40 would have the TV on, however, NA-F could not recall if it was ever in Spanish or if there were Spanish channels available for R40. During an interview on 11/30/22, at 11:00 a.m. activities director (AD) stated there was a period of time that R40 wanted to learn English and requested staff to only speak in English; however, the AD did not know if R40 was offered english classes. During an interview on 12/1/22, at 1:37 p.m. RN-B stated for day to day cares the staff spoke English to R40. RN-B stated staff could call R40's family to help with translation if needed also. RN-B also stated she did not think the facility had Spanish channels but thought R40 may have been able to access Spanish TV on her electronic tablet. RN-B was unaware if the facility had facility documents in Spanish for R40 or if R40 had requested them. RN-B further stated there was an interpreter tablet the management team could use for new admissions; however, they did not use it often. During an interview on 12/1/22, the DON stated she thought staff relied on habits and routine to provide cares for R40 and was unaware of any techniques or devises staff had tried to use to communicate with R40. A facility policy on providing care for residents who did not speak English was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R13's quarterly Minimum Date Set (MDS), dated [DATE], indicated R13 had severe cognitive impairment and required total assistance from staff to meet her toileting needs. R13's care plan, dated 10/2021, identified R13 was incontinent of bowel and bladder and listed a goal which read, Resident's dignity will be preserved by being clean and odor free. The care plan listed interventions to help R13 meet this goal which included two assist with toileting, and, Staff to complete peri cares [every] AM, HS [bedtime], and after each incontinent episode. On 11/30/22 at 9:48 a.m., R13 was assisted to her room while seated in her wheelchair. R13 was non-verbal and attached to a mechanical lift by registered nurse unit manager (RN)-B and nursing assistant (NA)-B. R13 was lifted up from her wheelchair which resulted in an immediate, obvious odor of BM which lingered in the room. R13 was placed into her bed and positioned on her side before RN-B and NA-B turned to leave the room. There was no attempt to check R13 for incontinence despite the odor of BM present. NA-B and RN-B were then stopped by the surveyor and questioned on when R13 had last been checked for incontinence. RN-B stated R13 should be checked every two hours and they should have checked R13 then but did not. RN-B then asked NA-A to assist NA-B with R13's personal cares. R13's pants were removed exposing incontinent stool which was soiled through R13's pants and running down her leg. When interviewed immediately following personal care,, on 11/30/22 at 10:40 a.m. NA-A stated residents should be checked for incontinence, and needed cares provided, when residents are assisted to bed. NA-B acknowledged the odor of BM was present when they assisted R13 using the mechanical lift, and verified they did not plan to help R13 with incontinence care until the surveyor intervened. On 11/30/22 at 1:47 p.m., RN-B was interviewed and verified they did not assist R13 with incontinence care despite the BM odor adding she had completely forget to check R13. RN-B attributed this to nerves adding, I think we we're both just so nervous. Further, RN-B stated incontinence care should be provided to prevent skin breakdown adding, That was my bad. A provided Activities of Daily Living (ADLs), Supporting policy, dated 3/2018, identified residents would be provided with care, treatment and services appropriate to maintain or improve their ability to carry out ADLs. The policy continued, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. This included assistance with hygiene and elimination. Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., shaving) and meal set-up was offered or provided to 1 of 4 residents (R5) reviewed for activities of daily living (ADLs) and who was dependent on staff for care. In addition, the facility failed to ensure personal hygiene and incontinence care was provided to 1 of 1 resident (R13) who had bowel incontinence and required staff assistance for care. Findings include: R5's Face Sheet dated 12/1/22, indicated a diagnosis of dementia. R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was moderately cognitively impaired, and required supervision, oversight, or cueing for ADLs and set-up for meals. R5's care plan printed dated 3/30/21, indicated R5 had a self-care deficit related to weakness and memory issues and indicated staff assist with personal hygiene. The care plan did not mention R5 required meal set-up. R5's nursing assistant (NA) care sheets lacked instruction for shaving or meal set-up. During observation on 11/28/22, at 5:32 p.m. R5 was observed to have many chin hairs, several inches long. When interviewed on 11/28/22, at 5:33 p.m. R5 stated she would like to have her chin hairs shaved. When interviewed on 11/28/22, at 6:56 p.m. NA-C stated shaving needs were not on the resident care sheets and indicated shaving only occurred for residents with their own shavers and acknowledged R5's chin hairs were several inches long. During observation on 11/30/22, at 1:36 p.m. R5's chin hairs were still present and R5 again stated she still would like to have them shaved. Also, R5's lunch tray was on her tray table, with the plate cover over the plate, the plastic lid on the glass of milk, and the rice krispie bar was still covered in plastic. R5 was lying flat in bed. When interviewed on 11/30/22, at 1:46 p.m NA-D stated R5 did not have her own shaver. NA-D stated staff were required to notify the family if a razor was needed. NA-D stated she had not notified anyone R5 needed a razor. Additionally, RN-D stated the lunch meal was delivered at approximately noon and should have been set up for R5, including elevating R5 in bed, moving the tray table with the lunch tray in front of R5, and all the covers should have been removed from the food. NA-D stated R5 could feed herself only after a meal was set up. When interviewed on 12/01/22, at 9:05 a.m. registered nurse (RN)-B stated staff should have asked R5 if she owned a razor and should have either called the family to request a razor, or let the social worker know R5 needed a razor. RN-B stated R5's chin hairs should not have been as long as they were. RN-B further stated staff were expected to assist R5 with meal set-up which included opening containers and removing lids. RN-B acknowledged meal set-up and shaving were not on R5's NA care sheet. When interviewed on 12/1/22, at 1:09 p.m. the director of nursing (DON) stated meal set-up and shaving should be on the NA care sheets, and ADL care should be provided according to resident needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively reassess and develop or implement meaningful and engaging activities for 1 of 3 residents (R13) reviewed who had an expected decline in condition and could no longer participate in activities as once prior. Findings include: R13's quarterly Minimum Data Set (MDS), dated [DATE], identified R13 had severe cognitive impairment and was almost totally dependent on staff for her activities of daily living (ADLs). R13's most recent MHM (Monarch Healthcare Management) Activity Participation Review, dated 9/19/22, identified R13 passively participated in group gatherings and independent leisure activities. R13 was recorded as tiring easily, being non-verbal, and needing assistance to attend activities. The assessment outlined R13 had attended religious gatherings, being read to, rest and relaxation, listening to television/music within the past 30 days. Further, a section labeled, Activity Plan Review, identified R13's activity-related focuses on her care plan remained appropriate and her established goals had been met. However, R13's Order Summary Report, signed 10/5/22, identified R13's current physician-ordered medications and interventions. This included, RESIDENT CAN ONLY BE UP FOR ONE HOUR AT MEAL TIME . related to PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE. In addition, R13's Integrated Wound Care (IWC) Follow-Up Progress Note, dated 11/17/22, identified R13 was seen for wound care of an unstageable pressure ulcer on her medial sacral area and listed a section labeled, Treatment Recommendations, which directed, . Area must be offloaded. Limit time in chair [wheelchair] to meals only . R13's care plan, dated 9/19/22, identified R13 had dementia and needed to be invited and/or assisted to all group activities. R13 was recorded as enjoying dogs, horses, snacking, and sensory activities with a care planned goal, By next review [R13] will maintain their current status as well as participate in group gatherings/sensory groups of interest. The care plan listed several interventions to help R13 meet this goal including invite/remind/assisting R13 to activities of interest, providing a monthly activity calendar, and talking about topics she enjoyed like traveling to Japan, Australia and England. The care plan lacked what, if any, new approaches or activities-related interventions would be completed for R13 since the wound-derived orders limited her time in the wheelchair to meals only and reduced her ability to participate, even passively, with group based activities as her listed care plan goal directed. During observations on 11/28/22 from 1:30 p.m. to 3:41 p.m., R13 was observed lying in bed in a dim-lit room with no music or TV on in the room. No staff engagement was observed during this time. On 11/28/22, from 1:30 p.m. to 3:41 p.m. multiple observations were made of R13 where she was observed laying in her bed each time, and the room had no audible music playing or television noise. Further, no staff approaches, engagements, or personal one-to-one activities were provided or observed during this period. On 11/29/22 at 8:55 a.m., R13's family member (FM)-D stated R13 enjoyed music, but they could not recall ever having heard music in R13's room when they visited. FM-D stated they felt the nursing home staff often forgot about R13. Further, FM-D stated they had never been asked or questioned about R13's activity preferences. When interviewed on 11/30/22 at 11:01 a.m., nursing assistant (NA)-B stated she was unaware of what, if any, activities R13 attended or was being provided. NA-B stated the therapeutic recreation director (TRD)-E would know and directed the surveyor to them. R13's Activity/Leisure Time, dated 11/1/22 to 11/30/22, identified R13's attend activities for the month. This outlined R13 attended television watching three (3) times, reading group and/or book club one (1) time, current events one (1) time, wheelchair rides one (1) time, and an intervention which read, Looking out the window/Music/Time spent in room, a total of 10 times in the month period. There were no recorded activities, including one-to-one(s), provided with or for R13 on 11/2/22, 11/4/22, 11/5/22, 11/6/22, 11/7/22, 11/19/22, 11/20/22, 11/24/22, 11/25/22, 11/26/22, 11/27/22, 11/28/22, or 11/29/22. R13's medical record was reviewed and lacked evidence R13 had been comprehensively reassessed for her activities participation and preferences despite having sustained a decline, being mostly non-verbal, and being limited to up in her wheelchair for meals only due to physical wounds (i.e., reducing her ability to participate in group activities). Further, there was no evidence the care plan had been adjusted with new interventions (i.e., music in her room) to reflect this change of condition and reduced ability to participate in group activities which her care plan directed remained her goal. On 11/30/22 at 12:30 p.m., TRD-E was interviewed and explained residents, including R13, were assessed for activities using a therapeutic recreation (TR) social history form upon admission to the nursing home. Family would be consulted if the resident was unable to communicate their preferences. TRD-E explained activities were tracked using the provided flow sheets (i.e., Activity/Leisure Time) and stated if a resident sustained a change of condition, it would be communicated to TR through the clinical meetings. This would usually cause the care plan to be adjusted; however, there was no formal process to formally comprehensively reassess the resident for their activities preference or abilities with a change of condition. TRD-E stated she was normally a part of the clinical meetings, however, lately had missed several of them due to working on the floor as the department was short staffed. When questioned on R13 being comprehensively reassessed after the physician orders limiting her time in the wheelchair (i.e., her decline), TRD-E stated there had been no reassessment since the previous quarterly Activity Participation Review (dated 9/19/22). TRD-E stated R13 rested in her room much of the time and added she was unaware what, if any, activities R13's involved hospice provider was doing for her, nor had she considered placing a radio or audio book in R13's room. When interviewed on 11/30/22 at 1:49 p.m., registered nurse (RN)-B stated R13 was mostly non-verbal with just a few words being spoken at times. RN-B could not recall a radio or audio books ever being played or tried with R13 and expressed she did not know if activities was doing any one-to-ones with her despite being largely confined to her bed (due to pressure injuries). RN-B stated TRD-E was responsible to assess for changes in activities participation and added herself, RN-B, should have also maybe identified those things and helped to get more activities involvement started. RN-B added it was maybe a miss on my part. A facility policy on resident activities assessment and care planning was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** HOSPICE CARE COORDINATION: R13's quarterly Minimum Data Set (MDS), dated [DATE], identified R13 had severe cognitive impairment, required extensive to total dependence on staff for their activities of daily living (ADLs), and received hospice care while a resident. On 11/28/22, from 1:30 p.m. to 3:41 p.m. multiple observations were made of R13 where she was observed laying in her bed each time with her eyes closed. The room had no audible music playing or television noise. R13 appeared comfortable with no obvious physical signs or symptoms of pain present. Further, no staff approaches, engagements, or personal activities were provided or observed during this period. R13's care plan, dated 9/19/22, identified R13 received hospice care while residing in the nursing home due to end-stage disease process. R13 was enrolled with Intrepid Hospice and a care plan goal was listed which read, Resident and family will receive comfort cares as desired and will verbalize satisfaction with cares received. The care plan listed interventions which included Intrepid Hospice contact information for the registered nurse (RN) and licensed social worker (LSW), maintaining communication with hospice, and, See Hospice plan of care and visit schedule. R13's most recent Hospice Patient Service Agreement, dated 10/2022, identified and explanation of the hospice program and benefit. The agreement was signed by R13's family member (FM) and the hospice provider representative. A separate white-colored binder was present at the nursing station which contained R13's hospice progress notes and recertification information. However, there was no hospice care plan contained inside. R13's medical record was reviewed and lacked evidence of a hospice care plan (SEE F656 FOR ADDITIONAL INFORMATION). The white-colored binder was reviewed which identified several tabbed sections for various aspects of R13's hospice care including progress notes, certifications, and one for a visit calendar. However, the section dedicated for a hospice visit schedule/calendar was empty with no evidence schedule of upcoming visits located. The most recent certification review being dated over a year prior (3/11/21), and there was no evidence of what, if any, additional services the hospice provider was scheduled to provide and/or implement for R13 aside from her routine nursing care. A series of hand-written progress notes were contained inside the same white-colored binder. These were completed by the registered nurses (RN) visiting R13 from the hospice agency and identified the following: On 10/31/22, R13 was sleeping during the visit. The hospice RN visited with the nursing home staff about R13's developed pressure injury, and hospice explained they would send saline to the nursing home instead of wound cleanser. The note concluded, No new concerns [and] continue w/ [with] POC [plan of care]. The note listed a section for, Next Visit, which was recorded as, 11/15/22. On 11/15/22, the hospice agency spoke with the nursing home staff who reported no new concerns. R13 displayed no signs of pain, and the note concluded, Cont[inue] w/ POC. However, the section provided to record the next visit was left blank and not completed. On 11/21/22, the hospice agency nurse spoke with a nursing home nurse who had no new concerns. R13 would be re-certified again. However, again, the section provided to record the next visit date was left blank and not completed. There were no recorded progress notes or entries demonstrating a hospice NA had ever visited or provided care for R13 in the binder. When interviewed on 11/30/22 at 10:40 a.m., nursing assistant (NA)-A stated she was unaware when, if ever, hospice came and assisted R13. NA-A stated she was unaware what services they were providing R13 adding she had never seen them (hospice) work with R13 before. On 11/30/22 at 12:30 p.m., therapeutic recreational director (TRD)-E was interviewed. TRD-E explained she was unsure what, if any, activities hospice was providing with R13. TRD-E stated she did not collaborate with the hospice provider regarding R13's activities (SEE F679 FOR ADDITIONAL INFORMATION). During interview on 11/30/22 at 1:06 p.m., registered nurse (RN)-D stated she had worked at the nursing home for a few days, however, was unsure what, if any, services hospice provided for R13. RN-D stated she had never seen or heard anyone from the hospice agency and expressed she was unsure where to locate what, if any, services were being provided to R13 through the outside hospice agency. On 11/30/22 at 1:49 p.m., registered nurse unit manager (RN)-B explained R13 was mostly non-verbal and would only say yes or no responses at times. RN-B stated R13 had been on hospice for several years no and the hospice agency staff visited her once or twice a week. RN-B stated she was not going to lie and expressed there was poor communication between the nursing home and the hospice agency at times demonstrated, in part, by the nursing home not always knowing when, or if, the hospice agency was going to show up or provide care. RN-B expressed several weeks ago she had not even seen the hospice agency at the nursing home in weeks so she contacted them and expressed the communication had to be better. RN-B reiterated, Their communication isn't great, and expressed they never left a calendar or visit schedule so staff were, again, not always sure when they planned to be at the nursing home. RN-B stated R13 had never run out of hospice-supplied items (i.e., medications, wound supplies) but added she had never seen hospice provide any bathing or activities with R13 in the past several months. RN-B reviewed R13's medical record and the white-colored binder and verified it lacked a visit schedule or care plan. RN-B stated the nursing home should have those items for the benefit for the patient and so cares get provided to help R13. When interviewed on 12/1/22 at 10:08 a.m. hospice registered nurse (RN)-E stated R13 received both nursing and nursing aide services through the hospice agency. RN-E was unsure how often the hospice aide visited, but expressed it was likely on a weekly basis. RN-E stated the nursing home would typically have a visit schedule or calendar, and hospice plan of care, in place for collaboration; however, added they may have been misplaced. RN-E acknowledged these items were important for the nursing home to have so the direct care staff could look and see when we are coming and what we are doing [with R13]. RN-E expressed no concerns with the communication between the nursing home and hospice agency. A provided MHM (Monarch Healthcare Management) Hospice policy, dated 10/2018, identified the nursing home' parent corporation had agreements with various hospice agencies to provide services. Hospice providers who contracted with the nursing home would have a written agreement in place, and were held to . the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. The policy directed it was the responsibility of the hospice agency to coordinate the resident's care related to the terminal condition including determine the plan of care, change the level(s) of services provided, and providing medical supplies. Further, the policy directed a hospice plan of care would be provided to the nursing home and, Hospice staff will communicate and coordinate care with the IDT [interdisciplinary team]. HYDRATION: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated R19 had severe cognitive impairment and required supervision with meal set up. R19's diagnoses included ankylosing spondylitis (inflammatory arthritis affecting the spine and large joints), morbid obesity, diabetes, and chronic kidney disease. R19's nurse practitioner note dated 11/18/22, indicated R19 had additional diagnoses of moderate dementia, a history of stroke in 2013, and limited mobility due to weakness. R19's physician order dated 9/20/22, stated, Push oral fluids three times a day for Dry Mouth. R19's registered dietician (RD) note to physician dated 11/8/22, indicated R19 was hospitalized [DATE] to 9/17/22 and 10/5/22 to 10/7/22 for sepsis from urinary source. During observation on 11/28/22, a sign posted above R19's bed stated, PLEASE HELP RESIDENT PUSH FLUIDS: AM-1000ML, PM-1000ML, NOC-300ML. R19's treatment administration record (TAR) from September 20, 2022 to November 30, 2022 indicate documentation from staff for oral intake as a check mark and initials of staff. No indication of amounts of intake for R19 was documented during this period. Interview with nursing assistant (NA)-A on 11/30/22 at 10:33a.m., stated the care sheet for R19 failed to state how much water or fluid to offer R19 and did not notice the sign over R19 bed stating how much fluid to offer. NA-A stated the nursing assistants look at the water pitcher at the end of their shift to know how much water or fluid the resident consumes. NA-A stated the nursing assistants did not document in the electronic medical record (EMR) and were expected to give a verbal report to the assigned nurse at end of shift, then it is up to the nurse to chart, I guess. Interview with registered nurse (RN)-F on 11/30/22 at 10:35 a.m., stated the order was confusing and, I don't know how to read that order. I just document that it was offered. I don't put in the amount that she drank. RN-F stated she was unaware of the sign posted over R19 ' s bed also to push fluids. Interview with unit nurse manager and registered nurse RN-B on 11/30/22 at 10:38 a.m., stated the order for R19, is very vague. I don't know how to interpret it. Looks like the way we have it set up is that resident was offered fluids but no amount is indicated. RN-B stated she was the staff member that posted the sign over R19's bed after seeing an order put in by MD on 9/20/22. RN-B stated she did not know how she determined the amounts of fluid to push since there was no evidence in the electronic medical record or physician order to support it. Interview with director of nursing (DON) on 11/30/22 at 11:50 a.m., stated R19 with history of 3 urinary tract infections (UTI's), that I am aware of. DON stated R19 required assistance and reminders to drink. DON stated R19 is vulnerable for UTI's due to her recent history of UTI's. The DON stated, it's a miss that the facility failed to clarify the physician order. Interview with registered dietician (RD) on 12/1/22 at 9:56 a.m., stated R19, must be offered hydration due to dementia and vulnerability to UTI's. RD stated she was not aware of the sign over R19's bed to push fluids. RD stated the order did not clarify amount of fluids that R19 was offered or if it indicated fluids were offered or refused. RD stated R19's September 20, 2022 to November 30, 2022 TAR demonstrates inability to determine R19 hydration intake accurately since it did not show, exact amount she ingested. Based on observation, interview, and document review, the facility failed to comprehensively assess and provide interventions for developed skin irritations for 1 of 1 resident (R37) reviewed for non-pressure skin concerns. In addition, the facility failed to approrpiately monitor hydration-related interventions for efficacy to reduce the risk of urinary tract infection (UTI) for 1 of 1 resident (R19); and failed to ensure adequate and appropriate coordination of care with an outside hospice agency for 1 of 1 resident (R13) reviewed for hospice care. Findings include: SKIN IRRITATION: R37's annual Minimum Data Set (MDS) dated [DATE], indicated no skin issues, but indicated ointment was applied to skin other than to the feet. R37's face sheet dated 12/1/22, listed R37's current medical diagnoses, which did not include any mention of skin issues. R37's provider active orders dated 7/25/22, indicated Nystatin powder [anti-fungal medication] under folds three times daily for yeast dermatitis [skin inflammation]. Additionally, R37 had an active order for weekly skin inspections. R 37's provider note dated 9/23/22, indicated no rashes or lesions, but the provider continued the order for Nystatin three times daily for affected area for the diagnosis of yeast dermatitis. The affected area was not identified. R37's care plan did not include skin issues, despite the order for Nystatin power for yeast dermatitis. During observation on 11/28/22, at 3:10 p.m. R37 had multiple open pin-point sores on her nose, forehead, and right arm. R37 stated no one else had said anything about them. During observation on 11/30/22, 1:19 p.m. R37 still had open areas on her face. R37 stated they were eczema (inflammation to the skin also known as dermatitis) and she had it many times before. R37 stated her previous eczema outbreaks were treated with minocycline (an antibiotic used to treat bacterial infections, often to skin) on previous occasions. R37 stated she had no current treatment for this episode. When interviewed on 11/30/22, at 1:23 p.m. registered nurse (RN)-F. stated she had seen the sores on R37's face but had not had time to report it. RN-F further stated she knew R37 had a Nystatin order for her groin area but acknowledged no skin issues were noted on R37's care plan. When interviewed on 12/01/22, at 8:52 a.m. nursing assistant (NA)-E stated R37 always had the sores on her face and stated she had told several nurses but was unsure who she had told. When interviewed on 12/01/22, at 9:05 a.m. RN-B stated staff should have contacted a provider about the rash on R37's face. When interviewed on 12/01/22, at 1:19 p.m. the director of nursing (DON) stated she would expect a nurse to notify a physician to seek assessment of a new rash. The Skin Assessment and Wound Management Policy dated 5/27/22, indicated when a new alteration in skin integrity was noted staff would notify a provider and resident representative, provide education to the resident and resident representative about the skin issue, and update the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide services to maintain vision for 1 of 1 resident (R52) reviewed for visual impairment. Findings include: R52's Face Sheet dated 12/1/22, indicated she was admitted to the facility on [DATE]. R52's Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact, and further, indicated R52 wore corrective lenses. R52's admission Data Collection assessment dated [DATE], indicated R52 wore corrective lenses and her last eye appointment was, About a year ago. R52's Interdisciplinary Team (IDT) progress note dated 10/11/22, indicated R52 voiced concerns in need to follow up with her eye doctor. R52's progress note dated 5/18/22, indicated R52 complained of double vision and would like to be seen for some eye care. The note further indicated staff would arrange an eye care visit with either the in-house eye care provider or would talk to R52 about other options. R52's clinical record lacked evidence of a signed consent form for eye care and lacked evidence an appointment was scheduled. When interviewed on 11/28/22, at 3:54 p.m. R52 stated she needed to get to the optometrist for new glasses as she was experiencing double vision at times. When interviewed on 11/30/22, at 11:15 a.m. the health information director (HID) stated she had been scheduling eye appointments for residents at a local eye clinic but had not for R52. The HID stated she was new in the position and was trying to catch up on needed appointments for residents and did not have a consent on file for R52. When interviewed on 12/01/22, at 1:06 p.m. the director of nursing stated the eye appointment for R52 had not been arranged as it should have been. The vision services policy was requested and not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide timely repositioning and complete weekly skin monitoring, in accordance with the care plan and assessed needs, to reduce the risk or pressure injury development and/or worsening for 1 of 2 residents (R13) reviewed for pressure injuries. Findings include: R13's quarterly Minimum Data Set (MDS), dated [DATE], indicated R13 had severe cognitive impairment, required extensive assistance with bed mobility, and was dependent on two staff members for all transfers. Further, the MDS indicated R13 was at risk for pressure injury development and had one unhealed stage IV pressure ulcer (defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling). R13's most recent MHM (Monarch Healthcare Management) Braden Scale, dated 9/15/22, identified R13 was at high risk for pressure injuries and skin breakdown and listed a section labeled, Summary and Interventions, which directed, . is at risk for skin break down [related to] decrease in mobility, age, poor intake . is non ambulatory and is non weight bearing . unable to vocalize needs . is A2 [assist of two] with transfers via hoyer lift [mechanical lift] . is dependent on staff for all cares. Current preventative skin cares include . is to be up for meals only . and weekly skin inspection. [R13] has hx [history] of pressure related area to sacral area. Resident also has a hx of open areas between her toes. R13's Order Summary Report, signed 10/5/22, identified R13's current physician-ordered medications and interventions. This included, RESIDENT CAN ONLY BE UP FOR ONE HOUR AT MEAL TIME. DO NOT POSITION ON HER BACK, REPOSITION EVERY TWO HOURS . related to PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE. However, R13's Integrated Wound Care (IWC) Follow-Up Progress Note, dated 11/17/22, identified R13 was seen for wound care of an unstageable pressure ulcer on her medial sacral area. The wound measured 4.2 centimeters (cm) by 4.3 cm by 0.1 cm and had 100% (percent) slough tissue present. A section was present labeled, Treatment Recommendations, which directed, . Area must be offloaded. Limit time in chair [wheelchair] to meals only . In addition, a subsequent IWS Follow-Up Progress Note, dated 11/25/22, identified R13 continued with an unstageable pressure ulcer on her sacral area. The note, again, directed, . Area must be offloaded. Limit time in chair to meals only. These notes were signed by the IWS nurse practitioner (NP). R13's care plan, dated 8/16/22, identified R13 had an alteration in skin integrity , was currently enrolled in hospice care, and had a history of pressure ulcers in addition to a current stage IV pressure ulcer on her sacral area. The care plan listed several goals for R13 including skin breakdown resolving and remaining free of additional skin breakdown; along with several interventions for staff to implement to help R13 meet these goals including, Monitor skin integrity during daily cares. Weekly skin inspection by nurse, and, Turn and reposition or reminders to offload [every] 2-3 hours and PRN [as needed]. The care plan lacked direction or interventions to have up in her wheelchair for one hour or for meals only despite the signed physician orders and the repeated IWS progress notes directing such interventions. On 11/30/22, from 7:45 a.m. to 9:45 a.m., a continuous observation was completed of R13. At 7:45 a.m., R13 was seated in her wheelchair in front of the television in the commons area. R13's eyes were closed. At 8:00 a.m., R13 was pushed into the main dining room and remained at the table until 9:11 a.m. when R13 was pushed back out of the dining room after being assisted with eating. R13 was then placed back in the commons area in front of the television with no offer or attempt to reposition her being made. R13 remained in the commons area until 9:41 a.m. (nearly two hours later) when she was pushed into her room. R13 was then transferred to her bed using a mechanical lift and incontinence care was completed by registered nurse unit manager (RN)-B and nursing assistant (NA)-B. R13's incontinence product was removed and a visible Optifoam dressing (undated) was present on her sacrum. The dressing was not removed and the wound bed was not visible. At 9:48 a.m. NA-A entered the room and assisted NA-B to finish the incontinence cares for R13. R13 was positioned on her left side and heel protector boots were placed prior to the staff leaving the room. Following the observation, on 11/30/22 at 10:40 a.m., NA-B and NA-A were interviewed. NA-A stated she was aware R13 was supposed to be up in her wheelchair for one hour only (i.e., meals); however, added, We don't have time [to do that]. NA-B stated she was unaware R13 had physician orders to be up for only one hour intervals and added she had only been told to get her up for meals and then help her back to bed. NA-B and NA-A both verified R13 had breached a one hour interval between repositioning assistance; nor had R13 been assisted back to bed immediately following her finished breakfast meal. R13's medical record and completed MHM Weekly Skin Inspection(s) were reviewed. However, the last completed MHM Weekly Skin Inspection was completed on 11/12/22 (nearly three weeks prior), and prior to 11/12/22, the most recently completed inspection was dated 10/29/22 (two weeks prior). The medical record lacked evidence a weekly skin inspection had been completed and recorded despite the care planned intervention directing to do so, and R13 having a history of pressure injuries and breakdown on her sacrum, heel, and toes. On 11/30/22 at 1:29 p.m., RN-B and licensed practical nurse (LPN)-C were interviewed. RN-B verified R13 was to be up in her wheelchair for meals only, in accordance with her ISW notes, as they had determined R13's pressure injury had started to look worse in the past weeks. RN-B reviewed R13's care plan and the NA 'care sheets' and verified they lacked this intervention despite the repeated IWS notes and physician orders. RN-B stated the intervention should be listed adding, I think the aides don't realize the time frame for her [R13]. I think we need to do more education. RN-B further stated the importance of timely repositioning was so the wound doesn't worsen or cause other breakdown. RN-B reviewed R13's medical record and stated the weekly skin inspections should have been completed as care planned, however, the last one in the medical record was on 11/12/22 (nearly three weeks prior). These should have been completed to ensure R13 didn't have new skin breakdown and to help ensure staff weren't missing any new skin issues. A facility provided Skin Assessment & Wound Management policy, dated 5/27/22, identified a weekly skin inspection would be completed by licensed staff and listed steps to implement if a new skin issues, including pressure injury, was identified. A section labeled, Ongoing skin issues, directed to update the medical provider and resident/representative as needed, and update the care plan as needed, however, lacked directions or information on ensuring timely repositioning or implementing the care plans already established for identified skin issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure 3 of 3 residents (R32, R40, R44) received restorative therapy and range of motion (ROM) exercises to prevent potential decline in ROM and/or mobility. Finding include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 had a Brief Interview for Mental Status (BIMS) score of 99 indicating R32 was unable to complete the test. R32's diagnoses included a stroke affecting R32's right dominant side, congestive heart failure (CHF), atrial fibrillation (an irregular heartbeat increasing the formation of clots in the heart), diabetes, dysphagia (difficulty swallowing), chronic kidney disease (CKD), high blood pressure, skin cancer, and lymphoma (lymph node cancer). R32's Care Area Assessment (CAA) dated 6/26/22, indicated R32 triggered for communication, activities of daily living (ADLs), cognitive loss/dementia, and pressure ulcers. R32's care plan dated 6/2/22, indicated R32 had an alteration in mobility related to a stroke. Interventions included encouraging R32 to complete the home excercise program (HEP) in his room per physical therapy (PT) recommendations, to follow PT per physician orders, and to follow PT instructions. R32's care plan indicated he was at risk for falls. Interventions included to encourage/assist resident with lower extremity program in resident's room and follow PT and occupational therapy (OT) instructions for mobility function. R32 also had potential for an alteration in psychosocial well-being related to right-sided paralysis. Interventions included encouraging R32 to attend/participate in wellness/exercise activities per therapy recommendations. R32 was also at risk for skin breakdown due to immobility and had a self-care deficit. Interventions included OT per physician order and following OT instructions. R32's physician orders dated 11/30/22, indicated a nursing order beginning 6/11/22, for R32 to be on an OT functional maintenance program which included: Slow, gentle stretching to right arm. 10-12 reps [repetitions] per exercise. Exercises posted in room. R32 was also to complete a HEP in his room one time a day for 3-5 days per week. R32's nursing assistant (NA) care sheet dated 11/28/22, indicated to encourage R32 to participate in wellness activities. The care sheet lacked indication of physician ordered ROM exercises. During an interview on 11/28/22, at 3:34 a.m. R32 stated the stated the staff put him in his recliner after lunch and don't take him out of it until dinner, approximately five hours later. R32 stated he used to be able to walk but he doesn't get PT anymore and the staff don't help him with exercises. R40's quarterly Minimum Data Set (MDS) dated [DATE], indicated R40 had intact cognition and required limited assistance of one staff for bed mobility, transfers, and personal hygiene, and extensive assistance of one staff for dressing and toileting. The MDS indicated R40 required physical help in part of bathing and used a walker and/or wheelchair for mobility. R40's diagnoses included major depressive disorder high blood pressure, diabetes, chronic heart failure (CHF), obesity, and chronic kidney disease (CKD). R40's Care Area Assessment (CAAs) dated 6/28/22, indicated R40 triggered for activities of daily living (ADL) function, urinary incontinence, falls, pain, pressure ulcers, and psychotropic drug use. R40's care plan dated 3/14/20 indicated R40 had impaired physical mobility related to pain. Interventions included physical therapy (PT) per physician order, following PT instructions, an assist of one staff using a four-wheeled walker and Sara Steady (mechanical transfer device requiring the resident to be able to stand while being transferred) as needed. R40 also had pain/discomfort related to immobility. Interventions included pain medications, repositioning, rest, and massage. R40 was also at risk for self-care deficit related to immobility. Interventions included OT per physician order and following OT instructions. R40's Therapy Recommendations for Nursing Staff dated 4/7/22, indicated to ambulate R40 with the assistance of one staff using a four-wheeled walker. R40's Therapy Recommendations dated 6/16/22, indicated staff were to walk with R40 when transferring from the bed, chair, wheelchair, or toilet with a four-wheeled walker. R40's Therapy Recommendations dated 11/9/22, indicated to have R40 propel herself in her wheelchair or walk with a four-wheeled walker to the scale to be weighed. R40's NA care sheet dated 11/28/22, indicated R40 ambulated using a four-wheeled walker with the assistance of one staff member. The care sheet also indicated to encourage walking and to have R40 ambulate in the hallway 100 feet twice a day, five days a week. During an interview on 11/28/22, at 5:46 p.m. R40 stated through a translator, she was unable to stand because she had pain in her legs. R40 stated she had had the pain for a long time and the staff were aware. R40 further stated she occasionally got therapy, but not often and wanted more. R44's admission MDS dated [DATE], indicated R44 had mild cognitive deficits and required extensive assistance of two staff for bed mobility, transfers, and toileting, extensive assistance of one staff for personal hygiene and was independent with eating. R44 was not steady moving from a seated to standing position or from surface to surface and required staff assistance for stability. The MDS also indicated R44 used a walker and/or wheelchair for mobility. R44's diagnoses included disorders involving R44's immune system, anxiety, bilateral hearing loss, major depressive disorder, diabetes, dementia, psychotic and mood disturbances, fatigue, heart failure, chronic obstructive pulmonary disease (COPD), and a fracture of the lumbar vertebra (lower back). R44's CAAs dated 9/14/22, indicated R44 triggered for cognitive loss/dementia, ADL function, urinary incontinence, psychosocial well-being, activities, falls, and pressure ulcers. R44's care plan dated 9/14/22, indicated R44 was at risk for falls related to weakness. Interventions included PT per physician orders, following PT and OT instructions for mobility function, walking with R44 to and from meals to the dining room and two staff assisting R44 with ambulation using a four-wheeled walker. R44 also had a self-care deficit related to a history of falls, weakness, and dementia. Interventions included following OT instructions. R44's physician orders dated 9/21/22, indicated to walk with R44 to the dining room and back following meals. Use a four-wheeled walker and wheelchair to follow, during ambulation every shift. R44's physician orders dated 11/15/22, indicated for PT to evaluate and treat R44 for gait, strengthening due to diagnoses of lumbar fracture and a history of polio affecting R44's left leg. R44's Therapy Recommendations for Staff dated 9/9/22, indicated R44 was an assist of two staff using a two-wheeled walker in her room only. R44's NA care sheet dated 11/28/22, indicated R44 ambulated with a four-wheeled walker and an assist of two staff members in her room only. R44's treatment administration record (TAR) dated 11/29/22, to 11/30/22, indicated R44's was not assisted to walk to and from the dining room for meals using a four-wheeled walker and followed by a wheelchair for three out of six meals. During an interview on 11/30/22, at 1:26 p.m. R44 stated although she would like staff to assist her to ambulate, it had been months since they helped her walk down the hallway. R44 further stated the staff didn't do any kind of exercises with her. R44 stated she used to walk down the hallway using her walker, and the staff would follow with her wheelchair. R44 further stated she had to propel herself in her wheelchair to the dining room because staff didn't come to help her. R44 stated she would get out of breath and often decided to just eat in her room instead. During an interview on 11/30/22, at 1:56 p.m. nursing assistant (NA)-A stated there was a binder on the unit with therapy recommendations for the residents. NA-A stated she was unaware if R32 or R40 were supposed to do ROM exercises. NA-A further stated she had not done ROM exercises with R32 or R40 that day. During an interview on 11/30/22, at 1:58 p.m. NA-B stated R44 was independent and would call if she needed any assistance. NA-B stated R44 was pretty steady on her feet. NA-B further stated she had only seen R44 in her wheelchair and had only seen R44 eating meals in her room. During an interview on 11/30/22, at 11:35 a.m. nursing assistant (NA)-F stated charting was just something we don't have time to do and therefore, you would not know if a resident was performing their ROM exercises if it wasn't listed as an order in the resident TAR for the nurses to chart on. During an interview on 12/1/22, at 1:13 p.m. registered nurse (RN)-B stated after a resident discharged from therapy services and was placed on a maintenance program, therapy would educate staff on their recommendations for the resident and place the recommendations with the staff education signatures in a binder on the resident's unit. The exercises should also have been put on the nursing assistant (NA) care sheet and the resident's care plan. The exercises would only be listed in a resident's treatment administration record (TAR) if they were also written as a physician's order, or a nurse created an order. Otherwise, RN-B stated, since NAs didn't chart on any resident cares, there was no documentation to indicate if the exercises were being completed or if the resident refused to do them. RN-B stated she did not know why some resident therapy recommendations were entered as an order and others were not. RN-B verified R40 did not have an order for therapy recommendations and therefore, she could not verify if they were being completed or if R40 was refusing to do the exercises. RN-B stated she had not seen R44 being assisted to walk with a four-wheeled walker to and from the dining room and was unaware if R44 had been using her walker ambulate at all. During an interview on 12/1/22, at 3:02 p.m. the director of nursing (DON) stated when a new therapy recommendation was written for a resident, therapy would train the staff that was working that day on the exercises and the staff would sign off on the recommendation. The recommendation was then placed into a binder on the resident's unit. The nurse manager for the unit should then update the NA care sheets and resident care plan with the recommendations; however, the nurse manager may not have time and the recommendations may get missed. The DON further stated there was no way to know if the exercises were being done because the NAs don't chart any cares. A facility policy on resident ROM exercises and/or therapy recommendations was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to identify, comprehensively assess, and implement interventions for 1 of 1 residents (R32) who had an unplanned weight loss of greater than 10% in three months. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], identified, severe cognitive impairment with diagnoses including a stroke, heart failure, diabetes and dysphagia (difficulty swallowing). R32 required supervision and set up for eating. The MDS also identified R32 had a loss of liquids/solids from mouth while eating and had an unplanned weight loss of 5% or more in the previous 6 months. R32's Care Area Assessment (CAA) dated 6/26/22, indicated R32 triggered for nutrition and referred to R32's care plan for interventions. R32 also triggered for communication, activities of daily living (ADLs), cognitive loss/dementia, and pressure ulcers. R32's care plan dated 9/22/22, indicated R32 was on a mechanically altered diet with honey thickened liquids. The care plan also indicated R32 had lost 11.4 pounds (6.1%) since 8/17/22. An intervention for two snacks daily (increased from one) was added on 9/7/22. No other interventions were added to address R32's unplanned weight loss. R32's physician orders dated 11/30/22, indicated R32 was on a diuretic (to control water retention in the lungs due to CHF). Staff were to monitor for decreased oral intake and generalized weakness. Beginning 9/7/22, R32 was also to receive two snacks daily, making sure R32 received a nightly snack for blood sugar control. R18's weight log indicated the following: 6/15/22, 186.2 pounds 6/22/22, 188.6 pounds 6/28/22, 185.4 pounds 7/5/22, 189.0 pounds 7/13/22, 188.0 pounds 7/20/22, 189.0 pounds 7/27/22, 189.4 pounds 8/3/22, 188.2 pounds 8/10/22, 188.0 pounds 8/17/22 188.4 pounds 8/19/22, 172.8 pounds (a weight loss of 8.28% in two days) Although R32 had a weight loss of 8.28% in two days, the staff did not re-weigh him for 18 days. 9/7/22, 177.6 pounds 9/21/22 177.0 pounds 9/28/22, 176.4 pounds 10/3/22, 176.4 pounds 10/5/22, 176.9 pounds 10/12/22, 176.6 pounds 10/19/22, 176.0 pounds 10/28/22, 175.0 pounds 11/4/22, 175.0 pounds 11/11/22, 176.2 pounds 11/18/22, at 11:39 a.m. 176.5 pounds 11/18/22, at 8:59 p.m. 168.2 pounds (a weight loss of 4.70% in 9.5 hours and a weight loss of 10.72 % in three months) Although R32 had a weight loss of 4.70% in 9.5 hours, the staff did not re-weigh him for 12 days. 11/30/22, 169.8 pounds During an interview on 11/28/22, at 3:34 p.m. R32 stated he got pureed crap that wasn't very good. R32 stated he had lost weight and said it was because he didn't like the food. R32 stated his family used to bring him food but he was no longer allowed to eat it since he had three strokes. During an interview on 12/1/22, at 11:31 a.m. registered dietician (RD) stated she was in the facility once a week and ran a weekly report to assess resident weights but expected staff to notify her the same day they noticed a resident with a significant weight change. The RD stated she was unaware of R32's weight loss on 8/19/22, until she saw her report on 8/24/22. The RD stated although R32 had a weight loss of 8.28% in two days, the RD did not assess R32 to determine why he had lost weight, ask staff to re-weigh R32, or notify the provider of R32's significant weight loss. The RD stated she should have asked nursing staff if they were aware of any contributing factors to R32's significant weight loss and updated the care plan with interventions. The RD further stated after R32's next weight on 9/7/22, confirmed his weight loss, the RD ordered R32 to receive two daily snacks instead of one; no other interventions were added. The RD was also unaware of R32's weight loss on 11/18/22 until she ran her report 10 days later, on 11/28/22. The RD did not order a re-weight until 11/30/22, which confirmed R32's weight loss. The RD had not spoken to R32, the staff or the provider regarding R32's continued weight loss but stated it was a concern for R32's health and should be assessed for a root cause. During an interview on 12/1/22, at 2:40 p.m. the director of nursing (DON) stated nursing staff should have notified the nurse manager as soon as they were aware a resident had a significant weight change. The DON stated the nurse manager would notify the management team during the daily meeting and the management team would determine what the next steps would be, including re-weighing the resident, determining a root cause, and/or notifying the provider. The DON stated the RD would be notified through the daily meeting minutes. The DON further stated she was unaware of R32's significant weight loss but after a recent swallow study, speech therapy had recommended dysphagia exercises that should have been added to his care plan. A facility policy on resident weights and nutrition was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to monitor for complications related to dialysis and a dialysis access port for bleeding and/or infection for 1 of 1 residents (R43) reviewed for dialysis care. Findings include: R18's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition, was on dialysis and had diagnoses including, heart failure, kidney failure and diabetes. R18's care plan dated 10/3/22, included they were at risk for eight changes due to dialysis treatment and was on a therapeutic diet due to heart failure, kidney disease and diabetes and staff were to communicate with the dialysis interdisciplinary team. However, the care plan did not identify when they went to dialysis or any monitoring related to dialysis treatment or how to assess, monitor or care for R18's dialysis access port. During an interview on 11/28/22, at 6:52 p.m. R18 stated she had an access port on her upper chest for dialysis and that staff did not assess it or provide any care for it. R18's physician orders revised on 11/15/22, indicated R18 received dialysis every Tuesday, Thursday, and Saturday from 5:45 a.m. to 9:15 a.m. R18's orders lacked an order for the care and monitoring of R18's dialysis access port. During an interview on 11/30/22, at 1:17 p.m. registered nurse (RN)-F stated she did not know if R18's dialysis access was a port (a catheter placed in a large vein such as in the neck or chest) or a fistula (an access made by using a piece of soft tube to join an artery and a vein in the arm) and had never assessed the access site. RN-F also stated there was no order on R18's medication administration record (MAR) or treatment administration record (TAR) to monitor or assess R18's dialysis access site. During an interview on 12/1/22, at 1:41 p.m. RN-B stated nursing should assess R18's dialysis access site to ensure it was not bleeding or showing signs of infection. RN-F also stated there was no physician order to assess R18's access site every shift, or interventions in R18's care plan to monitor R18 for complications due to dialysis, although there should have been. During an interview on 12/1/22, at 3:08 p.m. the director of nursing (DON) verified there should have been a physician order for nursing staff to monitor R18's dialysis access port for bleeding and infection. The DON also stated R18's care plan should have indicated she was at risk for complications due to dialysis and staff should have been assessing R18 and her access port every shift. The facility Hemodialysis policy dated 11/22/19, indicated the facility will ensure residents who require dialysis, receive such services consistent with professional standards of practice, and the comprehensive person-centered care plan. Staff will provide ongoing assessment of the resident's condition and monitored for complications before and after dialysis treatment. Information regarding the resident's dialysis treatment including the type and location of the resident's dialysis access site will be used to develop a care plan to minimize the risks and promote the resident's highest level of function. The policy indicated ongoing assessment/evaluation of the resident's condition and monitoring for complications should occur before and after dialysis treatment including: -Infection-warm, pain, redness, swelling, discharge, temperature, tenderness -patency-feel the access for a thrill, listen with a stethoscope for a bruit Documentation requirements will be met to assure treatments are provided as ordered and should include pre and post assessment/documentation, daily check of the access site, evaluation for signs and symptoms of infection, fluid intake amounts for each shift with a 24 hour total if applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to arrange assessment and treatment for dental care for 2 of 4 residents (R52 and R3) reviewed for dental care. Findings include: R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact. R52's significant change MDS dated [DATE], indicated R52 had obvious or likely cavities or broken teeth. R52's admission Data Collection assessment dated [DATE], lacked assessment of R52's ability to chew. The assessment indicated R52 reported she had fillings coming out as well as broken teeth. R52's care plan dated 6/6/22, directed staff to provide dental visits as needed. R52's progress note dated 5/18/22, indicated R52 complained of mouth pain and showed interest in dental services. R52' facility Oral/Dental Evaluation dated 6/28/22, indicated fillings had fallen out and a tooth had crumbled over the previous few months, and R52 wanted to see a dentist. R52's Appletree Dental progress note dated 9/13/22, indicated only a brief exam could be performed at the facility and R52 needed X-rays to continue with dental care and a more comprehensive exam. R52's Interdisciplinary Team (IDT) progress note dated 10/11/22, indicated R52 would like to see a dentist. When interviewed on 11/28/22, at 3:54 p.m. R52 stated she needed to get to the dentist for several teeth that had broken. R52 stated she had seen a dentist in September, but the dentist had done only a brief examination at the facility, and she still needed dental work, including extractions of several broken teeth. Staff had not assisted her in getting an appointment. R3's quarterly MDS dated [DATE], indicated R3 was moderately cognitively impaired. R3's admission MDS dated [DATE], indicated no dental issues. R3's admission Data Collection assessment dated [DATE], indicated no upper teeth, one to three lower teeth, and difficulty chewing. R3's care plan dated 7/27/22, indicated chewing difficulties. R3's facility Oral/Dental Evaluation dated 11/22/22, indicated R3 had dentures, but did not wear them as they did not fit. R3's facility Oral/Dental Evaluation dated 8/26/22, indicated R3 had no teeth, and did not wear her dentures but lacked indications why. The note further indicated R3 could chew her food with dentures. R3's progress note dated 11/22/22, indicated R3 complained of mouth pain and showed interest in dental services. R3's electronic health record lacked evidence of a dental consent on file. When interviewed on 11/29/22, at 9:36 a.m. R3 stated she did not wear her dentures because they did not fit. R3 stated she had informed staff. When interviewed on 12/1/22, registered nurse (RN)-B stated R3 was a hospice patient, and that was perhaps why the ill-fitting dentures had not been addressed. When interviewed on 12/1/22, at 12:11 p.m. the culinary assistant director (CAD) stated R3 had recently chosen a regular diet, and the facility had performed a risk/benefit analysis with R3, as R3 cannot safely eat a regular diet without dentures. When interviewed on 11/30/22, at 11:15 a.m. the health information director (HID) stated she had been scheduling dental appointments for residents at a local dental clinic but had not for R3 and R52. The HID stated she was new in the position and was trying to catch up on needed appointments for residents, and further indicated she had no dental consent on file for R3. When interviewed on 12/01/22, at 1:06 p.m. the director of nursing stated the dental appointment for R52 had not been arranged as it should have been. The DON stated the X-rays could be done on site at the facility but have not been arranged. She further stated the appointment for R3 had also not been arranged and should have. The dental policy was requested and not provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide sufficient nursing staff to meet assessed needs and reduce the risk of adverse event (i.e., skin breakdown, range of motion decline, poor hygiene) for 1 of 2 residents (R13) reviewed for pressure ulcer care; 3 of 5 residents (R40, R43, R44) reviewed for activities of daily living (ADLs); 3 of 3 residents (R32, R40, R44) reviewed for range of motion (ROM); 3 of 4 residents (R43, R28, R44), and 8 of 8 staff members (NA-R, NA-S, NA-T, RN-O, NA-C, NA-Q, RN-F, RN-B) who expressed concerns about the lack of sufficient nursing staff at the nursing home. Findings include: ASSESSED NEEDS NOT MET: R13's quarterly Minimum Data Set (MDS), dated [DATE], indicated R13 had severe cognitive impairment, required extensive assistance with bed mobility, and was dependent on two staff members for all transfers. Further, the MDS indicated R13 was at risk for pressure injury development and had one unhealed stage IV pressure ulcer (defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling). R13's Order Summary Report, signed 10/5/22, identified R13's current physician-ordered medications and interventions. This included, RESIDENT CAN ONLY BE UP FOR ONE HOUR AT MEAL TIME. DO NOT POSITION ON HER BACK, REPOSITION EVERY TWO HOURS . related to PRESSURE ULCER OF SACRAL REGION, UNSTAGEABLE. Further, R13's Integrated Wound Care (IWC) Follow-Up Progress Note, dated 11/17/22, identified R13 was seen for wound care of an unstageable pressure ulcer on her medial sacral area. The wound measured 4.2 centimeters (cm) by 4.3 cm by 0.1 cm and had 100% (percent) slough tissue present. A section was present labeled, Treatment Recommendations, which directed, . Area must be offloaded. Limit time in chair [wheelchair] to meals only . On 11/30/22, from 7:45 a.m. to 9:45 a.m., a continuous observation was completed of R13. At 7:45 a.m., R13 was seated in her wheelchair in front of the television in the commons area. R13's eyes were closed. At 8:00 a.m., R13 was pushed into the main dining room and remained at the table until 9:11 a.m. when R13 was pushed back out of the dining room after being assisted with eating. R13 was then placed back in the commons area in front of the television with no offer or attempt to reposition her being made. R13 remained in the commons area until 9:41 a.m. (nearly two hours later) when she was pushed into her room. R13 was then transferred to her bed using a mechanical lift and incontinence care was completed by registered nurse unit manager (RN)-B and nursing assistant (NA)-B. At 9:48 a.m. NA-A entered the room and assisted NA-B to finish the incontinence cares for R13. Following the observation, on 11/30/22 at 10:40 a.m., NA-B and NA-A were interviewed. NA-A stated she was aware R13 was supposed to be up in her wheelchair for one hour only (i.e., meals); however, added, We don't have time [to do that]. NA-B stated she was unaware R13 had physician orders to be up for only one hour intervals and added she had only been told to get her up for meals and then help her back to bed. NA-B and NA-A both verified R13 had breached a one hour interval between repositioning assistance; nor had R13 been assisted back to bed immediately following her finished breakfast meal. On 11/30/22 at 1:29 p.m., RN-B and licensed practical nurse (LPN)-C were interviewed. RN-B verified R13 was to be up in her wheelchair for meals only, in accordance with her ISW notes, as they had determined R13's pressure injury had started to look worse in the past weeks. RN-B reviewed R13's care plan and the NA 'care sheets' and verified they lacked this intervention despite the repeated IWS notes and physician orders. RN-B stated the intervention should be listed adding, I think the aides don't realize the time frame for her [R13]. I think we need to do more education. RN-B further stated the importance of timely repositioning was so the wound doesn't worsen or cause other breakdown. SEE F686 FOR ADDITIONAL INFORMATION. R40's quarterly Minimum Data Set (MDS), dated [DATE], indicated R40 had intact cognition and required physical help in part of bathing. Further, the MDS indicated R40 did not have a history of refusing cares during the assessment period. R40's November 2022, bath log indicated the following: On 11/5/22, bath completed. On 11/12/22, refused bath On 11/19/22, no bath completed. On 11/26/22, no bath completed. R43's quarterly MDS, dated [DATE], indicated R43 had intact cognition and required supervision with oversight for bathing. During an interview on 11/28/22, at 5:23 p.m. R43 stated she was supposed to get a bath every week, but she didn't always get it. R43's November 2022, bath log indicated the following: On 11/5/22, R43 took a bath on her own (no supervision or oversight was documented). On 11/12/22, bath completed. On 11/19/22, no bath completed. On 11/26/22, bath completed. R44's admission MDS, dated [DATE], indicated R44 had mild cognitive impairment and required extensive assistance for bed mobility, transfers, and toileting, and personal hygiene. During an interview on 11/28/22, at 2:29 p.m. R44 stated she did not know when she was supposed to get a bath, but she added it had been two weeks since she last had one. R44's family member (FM)-A stated R44 needed to have a bath every week because she was often incontinent and couldn't wash herself properly. R44's November 2022, bath log indicated the following: On 11/6/22, bath completed. On 11/13/22, no bath completed. On 11/20/22, bath completed. On 11/27/22, no bath completed. During an interview on 11/30/22 at 11:35 a.m., nursing assistant (NA)-F stated, I'm not gonna lie, and expressed sometimes staff did not have time to give the residents their baths. During an interview on 12/1/22, at 2:56 p.m. the director of nursing (DON) stated baths can be a struggle. The DON stated trying to give residents baths every week was a challenge because of staffing and many residents and family members had complained that residents were not getting their weekly bath. SEE F676 AND F677 FOR ADDITIONAL INFORMATION. R32's physician orders, dated 11/30/22, indicated a nursing order beginning on 6/11/22, which directed R32 to be on an OT (occupational therapy) functional maintenance program which included, Slow, gentle stretching to right arm. 10-12 reps [repetitions] per exercise. Exercises posted in room. R32 was also to complete a HEP in his room one time a day for 3-5 days per week. During an interview on 11/28/22, at 3:34 p.m. R32 stated the staff put him in his recliner after lunch and don't take him out of it until dinner, approximately five hours later. R32 stated he used to be able to walk but he doesn't get PT anymore and the staff don't help him with the exercises. R40's Therapy Recommendations for Nursing Staff, dated 4/7/22, indicated to ambulate R40 with the assistance of one staff using a four-wheeled walker. A subsequent Therapy Recommendations, dated 6/16/22, indicated staff were to walk with R40 when transferring from the bed, chair, wheelchair, or toilet with a four-wheeled walker. Further, another Therapy Recommendations, dated 11/9/22, indicated to have R40 propel herself in her wheelchair or walk with a four-wheeled walker to the scale to be weighed. R40's NA care sheet, dated 11/28/22, indicated R40 ambulated using a four-wheeled walker with the assistance of one staff member. The care sheet also indicated to encourage walking and to have R40 ambulate in the hallway 100 feet twice a day, five days a week. On 11/28/22, at 5:46 p.m. R40 was interviewed via a translator. R40 stated she was unable to stand because she had pain in her legs. R40 stated she had the pain for a long time and the staff were aware. R40 further stated she occasionally got therapy, but not often and wanted more. R44's physician orders dated 9/21/22, indicated to walk with R44 to the dining room and back following meals. Use a four-wheeled walker and wheelchair to follow, during ambulation every shift. In addition, R44's physician orders, dated 11/15/22, indicated for PT to evaluate and treat R44 for gait, strengthening due to diagnoses of lumbar fracture and a history of polio affecting R44's left leg. R44's Therapy Recommendations for Staff dated 9/9/22, indicated R44 was an assist of two staff using a two-wheeled walker in her room only. R44's Treatment Administration Record (TAR), dated 11/29/22 to 11/30/22, indicated R44's was not assisted to walk to and from the dining room for meals using a four-wheeled walker and followed by a wheelchair for three out of six meals. During an interview on 11/30/22, at 1:26 p.m. R44 stated although she would like staff to assist her to ambulate, it had been months since they helped her walk down the hallway. R44 further stated the staff didn't do any kind of exercises with her. R44 stated she used to walk down the hallway using her walker, and the staff would follow with her wheelchair. R44 further stated she had to propel herself in her wheelchair to the dining room because staff didn't come to help her. R44 stated she would get out of breath and often decided to just eat in her room instead. During an interview on 11/30/22, at 11:35 a.m. nursing assistant (NA)-F stated charting was just something we don't have time to do and therefore, you would not know if a resident was performing their ROM exercises if it wasn't listed as an order in the resident TAR for the nurses to chart on. During an interview on 12/1/22, at 1:13 p.m. registered nurse (RN)-B stated after a resident discharged from therapy services and was placed on a maintenance program, therapy would educate staff on their recommendations for the resident and place the recommendations with the staff education signatures in a binder on the resident's unit. The exercises should also have been put on the nursing assistant (NA) care sheet and the resident's care plan. The exercises would only be listed in a resident's treatment administration record (TAR) if they were also written as a physician's order, or a nurse created an order. Otherwise, RN-B stated, since NA's didn't chart on any resident cares, there was no documentation to indicate if the exercises were being completed or if the resident refused to do them. RN-B stated she did not know why some resident therapy recommendations were entered as an order and others were not. RN-B verified R40 did not have an order for therapy recommendations and therefore, she could not verify if they were being completed or if R40 was refusing to do the exercises. RN-B stated she had not seen R44 being assisted to walk with a four-wheeled walker to and from the dining room and was unaware if R44 had been using her walker ambulate at all. SEE F688 FOR ADDITIONAL INFORMATION. ADDITIONAL RESIDENT CONCERNS: R43's quarterly MDS, dated [DATE], identified R43 had intact cognition and required supervision with bathing. When interviewed on 11/28/22 at 5:23 p.m., R43 expressed she was not getting her twice weekly baths consistently due to poor staffing in the facility. R43 stated the staff just don't have time to get them done so she goes without. R28's significant change MDS, dated [DATE], identified R28 had intact cognition and required limited assistance with most ADLs. When interviewed on 11/29/22 at 9:28 a.m., R28 stated the facility needed more staff to help resident as call lights could take up to two hours to get answered at times. The poor staffing made it take a long time to get water passed, medications were late at times, and meals were often served late. R28 stated the nursing home should not take new residents if they can't care for everyone already living there. R44's admission MDS, dated [DATE], identified R44 had mild cognitive impairment and required extensive assistance with most ADLs. During interview on 11/30/22 at 1:26 p.m. R44 stated the weekend baths, when her's was scheduled, weren't getting done due to a lack of sufficient staff. R44's roommate (R18), whom was present at the time of interview, voiced the same frustration. STAFF CONCERNS: When interviewed on 11/28/22 at 6:28 p.m., NA-R stated they worked on the 90's unit which was the transitional care unit (TCU). NA-R stated the unit was typically staff with three (3) NA(s); however, expressed a few times a week they worked short. This caused some tasks, like baths, to not be completed and shift to the following day, if able. During interview on 11/28/22 at 6:40 p.m., NA-S stated they had worked at the nursing home for a couple years and explained the West unit had 15-16 residents which required heavier cares. NA-S stated there was also nine residents who required mechanical lifts to transfer. NA-S explained baths were sometimes not completed as they were a 'last priority' when staffing was down. NA-S added weekend shifts were usually the poorest staffed it seemed. When interviewed on 11/28/22 at 6:48 p.m., NA-T expressed the West unit needed more staff due to the care needs. NA-T stated they often work short on each of the units and, as a result, baths are often missed and not completed if they cannot be re-scheduled. NA-T added weekend staffing levels were simply, Horrible. During interview on 11/28/22 at 6:55 p.m., registered nurse (RN)-O stated they had worked at the nursing home 'off and on' for over one year now coming from the Monarch Float Pool. RN-O explained their ability to get all assigned tasks done varied and depended on the census and available NA staffing for a given day. RN-O stated they were often not able to get all assigned cares or tasks done which caused them to routinely work double shifts (i.e., a.m. and p.m. shifts back-to-back) so the morning tasks could get bumped to the evenings and still completed. RN-O stated there was usually always short staffing on the weekends which caused the nurses to have to help with feeding in the dining room which they also did not have time to complete. When interviewed on 11/28/22 at 6:56 p.m., NA-C stated the direct care staff were, at times, mandated to stay past their shift due to poor staffing in the nursing home. This caused baths and routine grooming tasks (i.e., shaving) to not be completed at times; it also caused meals to often be served late which resulted in cold food. NA-C stated, at times, residents even get put to bed in their daytime clothes and repositioning was not always happening timely. When interviewed on 11/30/22 at 11:35 a.m., NA-Q stated the staff did work short at times and then, usually, were unable to get baths done. Further, NA-Q stated the nursing home used a lot of pool (agency) staff and there was often little or no time to chart, so it was also missed and often not completed. During interview on 11/30/22 at 1:23 p.m., RN-F stated the nursing home staff were often short which caused the nurses to be late with their medication passes. RN-F stated they were responsible for medications with 25 residents and there was not time to do all of them within one hour of them being due, and at times, didn't even have time to complete all the assigned treatments (i.e., skin creams) due to not enough staff being present. On 12/1/22 at 1:58 p.m., registered nurse unit manager (RN)-B explained 'fully staffed' on the long-term care wing(s) would be having four NA with another bath aide; however, when short staffed the bath aide was pulled to the floor to assist with cares. This resulted in baths not always being completed. RN-B expressed there had been numerous complaints, by residents and families, about scheduled baths not getting completed and long responses for call lights. RN-B stated the weekend shifts were often not filled, either, causing the manager staff to get called-in to help, at times. RN-B stated the lack of sufficient staff was affecting patient care. The provided Daily Attendance Report(s), dated 11/28/22 to 12/1/22, identified the current working schedules for nursing staff for the week period. These identified the following: On 11/28/22, one open NA shift was listed (via a blank space) on the TCU unit for AM shift. On 11/29/22, one open NA shift was listed on the LTC unit for the PM shift; and one RN and one NA shift was open on the TCU on the PM shift. On 11/30/22, one open NA shift was listed on the LTC unit for the PM shift. When interviewed on 12/1/22 at 12:30 p.m., the staff coordinator stated staffing levels were determined using the census and per-patient-day (PPD) system which was reviewed on a daily basis by herself, the director of nursing (DON) and administrator. The staffing coordinator provided several weeks of working schedules and verified the presence of many open shifts on them adding the nurses should be helping to answer call lights and passing meal trays when the NA(s) are working short-staffed. The coordinator expressed there were staff 'call-ins' on a almost daily basis and the facility used many outside pool agency NA(s) to help fill the empty schedule spots. The staffing coordinator acknowledged the staff had verbalized some 'hints' the staffing was not sufficient; however, they were unaware assigned tasks were not being completed. Further, the coordinator explained the staffing had been a struggle for the past few months and stated they needed to come together as a team and review what, if any, changes they could make to ensure the residents are cared for appropriately. The Emeralds at Faribault Facility Assessment, dated 9/6/22, identified the nursing home had 90 beds with an average daily census of 70 to 75 persons. The nursing home cared for numerous medical and cognitive disorders including depression, anxiety disorder, congestive heart failure, Parkinson's Disease, stroke, and skin ulcers. The assessment identified the acuity of the patient population was reviewed . and elevated regularly, with an average case mix index (CMI) of 1.07 (a relative value assigned to individual patients). The facility offered assistance with ADLs (i.e., bathing, toileting), mobility and fall prevention services, medication management, and management of medical conditions. A section of the assessment labeled, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, identified a sub-section labeled, Staff Type, which outlined several types of staff were used at the nursing home including administration, nursing personnel, and food and nutrition services staff. The included a section labeled, Staffing Plan, which identified the resident population, CMI and census would be taken into consideration daily to determine sufficient staffing needs. This included review of admissions and discharges, and using CDC guidance during potential COVID-19 outbreaks to meet minimum staffing requirements of the nursing home. The completed Facility assessment lacked any numeric formulas to determine staffing levels, nor any definition of what was considered 'fully staffed' versus 'minimum staffing' as described. On 12/1/22 at 2:25 p.m., the DON and administrator were interviewed. The facility was staffed using the PPD review which fluctuates along with the daily census. In addition, the acuity of the patient census and assistance with transfers (i.e., two assist/person) was considered. The administrator explained they tried to have five NA(s) and two nurses on the long-term care unit(s); with two nurses and two NA(s) on the TCU. The DON acknowledged staffing had been a struggle, at times, and expressed family members even approach her in the community to discuss their concerns with it. The administrator stated they continued to attempt to recruit staff using incentives, bonuses and prizes; however, expressed they also expected the management and leadership to help with cares and call lights, if needed and when able. The administrator stated it was not possible to print or provide call light system reports (i.e., time light was on) as the system was older and not capable of such reported. The DON stated she had, on occasion, heard concerns with bathing not getting completed; however, overall the staff had not expressed an inability to get their assigned cares completed to them. A provided Staffing policy, dated 2017, identified the facility would sufficent numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the Facility Assessment and resident' care plans. A licensed nurse would be available 24 hours per day, and staffing numbers would be determined . by the needs of the residents based on each resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to implement appropriate infection control protocols for 1 of 1 resident (R26) following diagnosis and confirmation of Influenza A. This had the potential to affect all 71 residents of the facility. Findings include: The current Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for Influenza, identified a resident who tests positive for Influenza should be immediately placed on standard and droplet precautions and if possible a private room. Standard precautions include performing hand hygiene before and after touching resident or environment, wearing gloves if hand contact with respiratory secretions or potentially contaminated surfaces is anticipated, and wearing a gown if soiling of clothes with a resident's respiratory secretions is anticipated. Droplet precautions include wearing facemask upon entering residents' room and if resident movement or transport is necessary, have the resident wear a facemask, if possible. Because residents with influenza may continue to shed influenza viruses while on antiviral treatment, infection control measures to reduce transmission, including following Standard and Droplet Precautions, should continue while the resident is taking antiviral therapy. R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 cognition was intact with diagnoses including, heart failure, chronic obstructive pulmonary disease, and dementia. R26's nursing progress note dated 11/27/22, at 8:37 a.m. identified R26 had fallen in room and had hit head. Nurse notified on-call leader of facility and provider and sent R26 to hospital for assessment. R26's after visit summary from the hospital dated 11/27/22, identified they were diagnosed with Influenza A and to start taking oseltamivir (TAMIFLU) by mouth two times daily for 5 days. R26's nursing progress note dated 11/27/22, at 3:03 p.m. included, resident returned from hospital after testing, positive for the FLU virus. Tamiflu prescribed. When interviewed on 11/29/22, at 8:37 a.m. the unit manager and licensed practical nurse (LPN)-A stated R26 had fallen on 11/27/22, was sent to the hospital and returned he same day. R26 was not placed on droplet precautions until 11/28/22, despite knowing they had Influenza A. LPN-A stated, I would expect him to be on precautions right away when he returned from the hospital. LPN-A stated R26 smokes and leaves his room several times per day to wheel down the hall to the designated smoking area putting other residents and staff at risk for infection. When interviewed on 11/29/22, at 10:09 a.m. the infection preventionist (IP) stated she was not aware R26 had tested positive for Influenza A until 11/28/22. The nurse who re-admitted R26 after going to the hospital failed to notify the on-call leader of the Influenza A diagnosis, and did not initiate precautions to prevent the spread to other residents. When interviewed on 11/29/22, at 10:29 a.m. the director of nursing (DON) stated, there was a breakdown in communication with staff receiving R26 from the hospital and notifying the on-call nurse of his return to the facility and Influenza A diagnosis. The DON stated R26 had left his room to smoke when he returned to the facility from the afternoon of 11/27/22 to the afternoon of 11/28/22 when he was placed in precautions. In addition, the DON stated when he left his room without wearing a mask to smoke, there is a risk to expose other residents who are vulnerable with the potential for a spread in the building. Facility policy titled MHM Disease-Specific Precautions, revised January 2008 identified droplet precautions were to be initiated for Influenza.