**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a resident's primary medical provider was notified of changes in condition for 1 of 1 resident (R1) who exhibited increased pain and extremity swelling after a fall, which required x-ray services, along with failure to ensure a physician order was acted upon for R1 after she returned from the emergency department (ED).Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment. R1's diagnoses included, but not limited to, diabetes, stroke, malnutrition, depression, bipolar disorder, chronic pain syndrome, insomnia, and vascular dementia. Additionally, R1 continued with hospice care. She was administered scheduled pain medication during the five days of the assessment period; however, no PRN medications and/or non-medication interventions for pain. R1 was unable to participate in the pain questionnaire and staff interview(s) indicated R1 lacked indicators of pain, or possible pain, during the assessment period. R1's May 2025 progress notes lacked pain related entries related to any R1 pain verbalizations and/or physical s/s of pain. R1's comprehensive care plan, identified, on 5/31/24, a pain care plan indicated R1's chronic pain and fibromyalgia (long-term condition causing widespread body pain, fatigue, etc.). Interventions directed staff to observe for signs of unmet pain and to report any increase in pain to MD/NP (medical doctor/nurse practitioner). A progress note, dated 6/12/25 at 9:48 p.m., identified R1 was found on the floor. R1 responded to staff she fell after they attempted to question her on fall details. An assessment was free of signs and/or symptoms (s/s) of injury, but she endorsed arm and back pain. Daughter, hospice, and on-call [facility] nurse were contacted. The note lacked evidence the medical provider was updated that evening. A Found on Floor Risk Management report, dated 6/12/25 at 7:45 p.m., identified the 6/12/25 progress note information, along with information R1's pain level was assessed at a 3 based on R1's negative vocalization (occasional moan or groan, low level of speech with a negative quality), her facial expression (sad, frightened, frown) and her body language (tensed, distressed pacing). The report indicated R1 was Agitated, forgetful, confused, did not always realize her limitations, and had dementia. The report lacked additional details to R1's agitation and/or any possibly associated behaviors. Additionally, the report lacked evidence the medical provider was updated. A hospice note, dated 6/12/25, indicated R1 was assessed by registered nurse (RN)-B in response to the fall. The assessment was free of fracture s/s. R1 was unable to verbalize pain. She laid in bed comfortably but appeared anxious and pulled at her clothing. Staff were instructed to utilize PRN pain medications. A progress note, dated 6/13/25, indicated the interdisciplinary team (IDT) meet and reviewed the fall. No injuries were identified. The nurse practitioner (NP) and the daughter were updated [time and/or route of the provider update was not identified]. R1's MARs, 5/1/25 through July 7/7/25 identified the following information:-Gabapentin in the evening for neurogenic pain each month.-Methadone 2.5mg twice a day: May (nine doses not administered due to her sleeping); June (18 doses not administered due to sleeping - seven instances prior to a 6/12/25 fall and 11 after); July (two doses not administered due to her sleeping).-Methadone 5mg (milligrams) at bedtime (HS) for chronic pain syndrome: May (with one dose not administered due to her sleeping); June (four doses not administered due to sleeping - one instance prior to the fall and three after); July (no missed administrations).-Tylenol 1000mg three times a day for pain: May (12 doses not administered due to her sleeping. Pain level monitoring indicated six shifts with documented pain, identified either a 2 or a 3 in intensity); June (27 doses not administered due to her sleeping and/or refusal - seven instances prior to the fall and 19 after. Pain level monitoring indicated no signs of pain prior to the fall and pain on four days with pain documented once as a 1, once as a 4, and twice as 6, after the fall); July (five doses not administered due to her sleeping and/or refusal. Pain level monitoring indicated three days with pain ranging from 4 to 5). -Hydromorphone PRN: May (no administrations); June (6/12/25 after the fall with a pain score of 8, and then on 6/20/25, 6/21/25, 6/23/25, 6/24/25 three times, 6/26/25, and 6/27/25 with pain ranging from a 4 to a 10); July (administered three times with pain ranging from 4 to 5).-Morphine sulfate PRN: May (no administrations); June (administered on 6/23/25 - 6/28/25, once each day with pain ranging from 6 to 8); July (administered twice with pain at a 4). -R1's June MAR/TAR lacked evidence fall monitoring was implemented after the fall to monitor for fall related concerns. A hospice Physician Order, dated 6/16/25, identified R1's every four-hour lorazepam was discontinued and a new order for three times a day dosing was initiated. R1's medical record lacked evidence her medical provider was updated on the lorazepam order and/or was collaborated with prior to, or after this adjustment. On 6/20/25, a progress note indicated R1's left arm was painful to touch with facial grimacing that morning. The area was free of redness and swelling. Staff questioned on possible reasons for the pain with no reasons identified. R1 was assessed additionally by a hospice nurse and no s/s of injury were identified. The note lacked evidence the medical provider was updated. On 6/22/25, a progress note indicated R1's left arm was swollen. After hospice assessed, hospice initiated an x-ray order. The note lacked evidence the medical provider was updated. A left elbow x-ray Final Report, dated 6/23/25, identified the following: There is a transverse fracture of the distal humerus extending from the medial to the lateral epicondyle. There are no dislocations. There is considerable soft tissue swelling adjacent to the facture. Impression: Distal humeral intra-articular fracture. Emergency Department (ED) Orthopedic Surgery Consultation/H&P progress note, dated 6/23/25, identified repeat x-rays were obtained which identified left supracondylar humerus fracture with mild extension deformity. Additionally, other injuries were noted on post splinting x-rays which included a proximal radial shaft fracture. Due to this, and R1's endorsement of some degree of potential pain, a left forearm and left hip x-rays were ordered; however, despite recommendations to stay for continued assessment, the daughter wished R1 returned to the nursing home and R1 was discharged back to the nursing home against medical advice (AMA). The provider instructed R1 to keep the extremity elevated and apply ice PRN to help improve pain and swelling, along with a non-weight bearing status. An After Visit Summary, dated 6/23/25, instructed an orthopedic/sports medicine referral for symptom recheck with a referral/Follow-Up Appointment within one week, and designated this appointment urgent, for the distal humerus fracture. The summary lacked recommendations for elevation, ice, and/or weight bearing status. Additionally, the summary lacked evidence staff addressed the appointment or acknowledged the referral order. R1's June 2025 Treatment Administration Record (TAR) lacked evidence an orthopedic appointment was made. R1's medical record lacked evidence R1 was assessed by her medical provider(s) after her fall on 6/12/25, or after her return from the ED on 6/23/25. R1's progress note, dated 6/24/25, at 1:52 a.m., identified the nurse was aware R1 required an orthopedic referral; however, the progress note does not indicate what occurred with this information. Documentation was requested related to medical provider update(s) and visits since 6/12/25. No visit evidence was provided, and the only clinic updates were on 6/23/25 to triage to update on the x-ray results and one to nurse practitioner (NP)-A that indicated the following: Pt under hospice care and was sent to the ER per hospice instruction. No orders and/or recommendations were identified. When interviewed via telephone on 7/7/25, at 12:14 p.m., R1's family member (FM)-A expressed significant concerns related to R1's post-fall management and fracture identification. FM-A explained it should not have taken a family assessment of R1's expressed pain to determine there was an issue. FM-A endorsed continued concerns related to R1's status after the fall as R1 appeared heavily sedated and drooling, where she was unable to control her mouth muscles. Additionally, R1 slept more than normal and was not talking. FM-A stated there were conversations R1 was going to graduate from hospice due to her overall stability; however, now R1 needed continued hospice support because of the fall and her associated declines. FM-A explained, prior to the fall, R1 was able to use her left arm to assist herself with eating. Now, due to the fall and the fracture, she was dependent on staff for eating and R1 was barely eating. On 7/7/25, at 1:23 p.m., and on 7/8/25, at 10:11 a.m., interactions with R1 were attempted; however, there were no verbal responses elicited. When interviewed via telephone on 7/8/25, at 11:33 a.m., hospice RN-A stated that prior to R1's fall, R1 was able to eat independently with setup, was at baseline, and was free of any significant declines. After the fall, and in response to the fall, R1 displayed more pain and sounds like she is eating less. They are now having to help her eat. During a telephone interview on 7/8/25, at 12:08 p.m., RN-B stated that on 6/12/25, during her assessment, she identified contractures to R1's left arm but did not identify any fracture concerns, nor did R1 show any increased pain. However, R1 pulled on her clothing and appeared anxious. RN-B indicated she questioned staff on this, as she had not worked with R1 before, to which staff reported this was typical for R1. RN-B stated she encouraged staff to utilize PRN pain medications for R1. RN-B expressed she expected facility staff updated the medical provider related to falls and any associated pain to ensure continued collaboration between the medical provider, hospice, the facility, and family. When interviewed via telephone on 7/8/25, at 1:13 p.m., R1's nurse practitioner (NP)-A stated R1 was not one to complaint of pain and her status fluctuated based on the day and time where R1 was so difficult to read; however, prior to the fall, R1 was overall stable. Hospice contemplated discharging her, but due to the fall, this did not occur. NP-A stated R1 overall looks about the same. but maybe [she was] not eating as much. NP-A identified R1's anxiety was very stable. NP-A identified she had not assessed R1 after her fall and/or after she was alerted to the x-ray results. She was aware R1 presented to the ED, and she indicated pain management was the main goal for R1 which was primarily managed by hospice. Additionally, as hospice was involved, hospice determined processes going on. NP-A stated fracture associated swelling could show up basically any time after a fall which was dependent on each patient individually. She was unable to estimate when she would expect such swelling to show up with R1. Further, she indicated as R1 was medicated already with scheduled pain medication, it potentially was harder to tell if R1 experienced increased pain. During an interview on 7/8/25, at 2:28 p.m., LPN-B stated she was expected to update the medical provider on any fall, along with hospice if applicable, in which she was to call the provider shortly after the fall. LPN-B stated R1's only complaints during the post-fall assessment were arm and back pain, which were not new complaints for R1 due to generalized pain. LPN-B indicated R1 had episodes where R1 took off her gown and staff had to keep putting it back on: It was one of those nights. LPN-B further explained that evening, R1 also attempted to get her legs off the bed which prompted multiple encounters of repositioning R1 to her back. Due to R1 being provided her bedtime medication, she was unable to give R1 any additional medications for the gown removal and leg actions. It was approximately 10 to 15 minutes after staff repositioned R1 due to these actions that she was found on the floor: [the fall] happened quick. LPN-B indicated R1's intake after the fall had lessened due to no longer being able to use her left hand to help herself eat, and she was more quiet and sleeping more but overall, she did not feel R1 showed any additional declines. During this interview, LPN-B indicated she contacted the on-call medical provider after the fall and they instructed her to call hospice. When interviewed on 7/8/25, at 2:49 p.m., RN-C stated prior to R1's fall, R1 really never showed signs of pain. R1 was always sleepy with no expression. If R1 were to show signs of increased pain, she was expected to update the provider and the nurse manager. On 6/22/25, around 4:00 p.m. or so, RN-C examined R1's arm based on R1's daughter's concerns that R1 had a fracture due to the arm being swollen. Her assessment of R1 identified swelling on the left arm, just above the elbow to the wrist area. RN-C explained when R1's arm was looked at, she could see from R1's facial expression she was in pain. In response, she called the on-call facility nurse who instructed her to contact hospice. Hospice, after their assessment, ordered an x-ray and informed her he wished for the x-ray to be completed that evening; however, if the x-ray company was unable to come out, then the x-ray would get done the next night. She ended her shift prior to the x-ray being completed that evening. RN-C identified she did not call the medical provider related to R1's arm swelling and/or the need for the x-ray. During an interview on 7/8/25, at 3:09 p.m., the health information manager (HIM) stated she and a health information assistant (HIA) typically processed orders. She explained, when a resident went to the ED, once they returned, they reviewed the after-visit summary for any order changes and/or appointment referrals. Unscheduled appointment referrals required them to make the appointment. They then placed these appointments on the TAR for staff notification. If the resident returned at a time, they were no longer there to process orders, they expect the nurse to review the after-visit summary for changes and place the summary in a designated bin for review once she and/or the HIA returned to work. There was no official audit completed to ensure appointments were made; however, they had a process to ensure things were not missed prior to the orders/after visit summary being scanned into the system, but she commented that there were more than just her and the HIA that scanned things into the medical record. The HIM reviewed R1's after visit summary and indicated the ortho appointment required a call to hospice for approval. She was unaware of this appointment for R1, or if anyone had spoken to hospice. She confirmed there was no indication on the after-visit summary to identify it was processed per the expectations, nor was there an appointment on R1's TAR. She expected a progress note in R1's record to indicate the follow-up for this appointment and hospice's response. During an interview on 7/8/25, at 3:28 p.m., the HIA stated any after visit summaries provided after hours were expected to go into a bin for her and the HIM to review. During this process, she reviewed for any changes, which included appointments. The HIM explained once the appointment was made, it was entered into the TAR. The HIA explained when there was an appointment, she expected the after-visit summary to have the appointment information highlighted. This was either done by the nurse or by her. If the summary just had an appointment indication, she would not expect any signatures or acknowledge of processing on the summary, but the appointment would be highlighted. The HIA indicated there was overall no process to ensure all orders/appointments on the after-visit summaries were completed prior to being scanned into the medical record. She identified R1's ortho appointment should have been setup, but explained this only would have been processed after approval from hospice was provided. She denied any prior instances where hospice had declined such follow up. The HIM verified she scanned the summary into R1's medical record and stated she was busy and probably overlooked it. When interviewed on 7/8/25, at approximately 3:45 p.m., the director of nursing (DON) stated after-hours and on the weekends, orders were initially processed by the nurse, but not necessarily an appointment order. She expected some sort of note, or indication, that this needed to be scheduled to decrease the risk of it getting missed. Further, she expected some sort of acknowledgement on the order, or after visit summary, along with any appointments on the TAR, to indicate it was taken care of, either by the nurse, the HIM, or the HIA. For R1's ortho appointment, she expected the ortho appointment to initially be placed into R1's order set until the appointment was clarified with hospice. She was unaware of this appointment, and she was under the understanding no follow-up appointments were to be required. Hospice would manage her pain but nothing above and beyond this would be done. She expected R1's chart to reflect this such information. Additionally, when staff noted R1's arm swelling and increased pain, she expected staff to update the medical provider, in addition to hospice. She explained, most often R1's medical provider deferred to hospice; however, this did not negate the fact the medical provider was ultimately the primary provider and make the overall medical decisions. The DON further expected such provider conversations and recommendations to be placed into the medical record. When interviewed via telephone on 7/9/25, at 10:56 a.m., nursing assistant (NA)-A stated she was R1's primary NA on 6/12/25 and placed R1 into bed for the night after evening cares, about 30 minutes after R1 finished supper: Maybe around 6:30 p.m. NA-A explained, that evening, R1 was restless the whole shift, and she had not witnessed such restlessness from R1 before. Typically, R1 was restless in the evening, but typically only removed her gown; however, that shift, R1 kicked out the pillows they used for positioning which was abnormal for [R1]. Additionally, R1 took off her gown, the blankets, pillows, everything. Both herself and the nurse had to replace the gown, the pillows, and reposition R1 multiple times when they checked on her. NA-A was unsure as to why R1 was restless, as when she attempted communication with R1, R1 would just look at her. During a follow-up telephone call on 7/9/25, at 11:08 p.m., LPN-B clarified she did not call the on-call medical provider the evening of the fall [to update on the fall and/or increased restlessness]. She only updated family, the hospice nurse, and the on-call facility nurse. She explained once a resident signed up for hospice, it was her understanding they only had to call hospice. When interviewed via telephone on 7/9/25, at 11:24 a.m., LPN-C stated if a resident showed increased pain and/or facial grimacing, she was expected to update the nurse manager as they would know additional resident information. She would then follow their direction; however, she would update the medical provider for anything medical, or any changes in condition. When LPN-C assessed R1 for pain on 6/20/25, R1's left extremity was painful to touch and R1 displayed facial grimacing when her arm was touched. Additionally, made noises at this same time. LPN-C was unsure if R1 had pain in her left extremity prior to the fall; however, also indicated this is a normal response for [R1]. R1's arm was free of swelling, and it was not red, there was nothing to give clue that something was there. She thought maybe R1 pulled her hand or arm too strong during a transfer, or something like that. She indicated she did not update the medical provider, only the nurse manager and hospice. During an interview on 7/9/25, at 12:41 p.m., the assistant director of nursing (ADON) identified herself as R1's unit manager and stated that on 6/12/25, she expected, if R1 was restless, non-pharmacological interventions, and then PRN medications, were to be utilized. If those still did not decrease the restlessness, provider contact was to be completed. The ADON identified she was updated about R1's pain on 6/20/25. She explained she instructed the nurse to contact hospice and the medical provider. She confirmed with the nurse hospice was updated, who instructed to continue to monitor and utilize pain medications; however, she did not confirm with the nurse if the medical provider were updated. She explained even though NP-A most likely would have deferred to hospice, she still should have been updated regardless as R1 was still her patient. This also provided the opportunity for collaboration between hospice and the medical provider, We all work together. The ADON stated R1 at baseline took significant narcotic medication for pain management and thus, she typically did not show signs of pain. If R1 displayed facial grimacing, this was a warning to her there was something going on that required addressing. The ADON stated the HIM and the HIA manage appointment setup and R1's ortho appointment was expected to be setup, especially as the facility had ortho follow-up that could be done inhouse. During a follow-up via telephone interview on 7/9/25, at 4:30 p.m., NP-A stated staff usually contacted the clinic to provide updates, or they called her personally and left a voicemail, or they sent her an email. In relation to R1's 6/20/25 complaints of pain, NP-A stated that anything related to pain was expected to be managed by hospice and she expected staff to update hospice versus her. In such cases, the hospice nurse would then consult with the hospice provider. NP-A identified she had yet to talk to R1's daughter about R1's status as this was a hospice responsibility. NP-A stated for R1's ortho follow-up hospice was responsible to authorize this, and she felt this was not a required appointment for R1; however, if the order was provided, she expected it was at least followed up on. She indicated the facility had orthopedics that was able to come to the facility and this was something that could be setup for R1. A policy related to order processing was requested; however, the DON indicated the facility lacked a specific policy related to this. A Notification of Changes policy, dated 3/2024, indicated changes in a resident's condition, or treatment, or an accident that may require physician intervention, were to be reported timely to the attending physician, or delegated nurse practitioner, to assist in decisions related to care, treatment and preferences to address the changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a resident's right to determine their own healthcare decisions for 1 of 1 resident (R30), and failed to ensure R30 had a right to revoke a power of attorney. Findings include: According to Minnesota Statutes 145C.06, a health care directive is effective for a health care decision when it meets the requirements of section 145C.03, subdivision 1; and the principal in the determination of the attending physician, advanced practice registered nurse, or physician assistant of the principal, lacks decision making capacity to make the health care decision; or if other conditions for effectiveness otherwise specified by the principal have been met. A health care directive is not effective for a health care decision when the principal , in the determination of the attending physician, advanced practice registered nurse, or physician assistant of the principal, recovers decision -making capacity; or if other conditions for effectiveness otherwise specified by the principal have been met. R30's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have evidence of an acute change in mental status, did not have inattention, disorganized thinking, or an altered level of consciousness, did not have physical, verbal, or other behaviors, was not important at all to have a family or close friend involved in discussions about care and had the following diagnoses: anemia, hypertension (high blood pressure), dementia, anxiety, depression, borderline personality disorder, and personal history of other mental and behavioral disorders. R30's quarterly MDS dated [DATE], indicated intact cognition, did not have an acute change in mental status from baseline, did not have inattention, disorganized thinking, or altered level of consciousness, and did not have hallucinations or delusions. R30's quarterly MDS dated [DATE], indicated intact cognition, did not have an acute change in mental status from the baseline, did not have inattention, disorganized thinking, altered level of consciousness, and did not have hallucinations or delusions. R30's quarterly MDS dated [DATE], indicated intact cognition, did not have an acute change in mental status from the baseline, did not have inattention, disorganized thinking, or an altered level of consciousness, and did not have hallucinations or delusions. R30's significant change in status MDS dated [DATE], indicated severe cognitive impairment, did not have inattention, disorganized thinking, or an altered level of consciousness, and did not have hallucinations or delusions. R30's Profile form in the electronic medical record (EMR) indicated R30's FM-A was her financial power of attorney (POA) and next to the heading, Power of attorney-care indicated, Do Not Use. R30's medical record was reviewed and lacked information R30 had a guardian. Additionally, R30's attending physician was (P)-K. R30's care plan dated 11/16/22, indicated R30 was alert and oriented to person and sometimes place, but needed cues and reminders for time and had short-term memory loss and family assisted in decision making. Interventions indicated ACP (Associated Clinic of Psychology) provide brief instructions, repeat instructions as needed, explain all cares and procedures, if having trouble with word finding, take time to listen, observe for changes in cognitive status. R30's care plan dated 3/17/23, indicated R30 was able to ask questions and answer questions, was easily distracted, had difficulty with word finding and interventions indicated to allow R30 enough time to process and answer questions, ask yes or no questions, gain attention before talking, speak in simple and direct terms, and speak clearly and distinctly and adjust tone of voice. R30's care plan dated 11/28/23, indicated R30 required assistance in reading and understanding health documents and interventions included, family would read instructions, pamphlets, or other written materials, from doctors or pharmacies. R30's IDT (Interdisciplinary team) Care Conference form dated 2/12/24, 5/14/24, and 8/7/24, indicated FM-A attended the care conference. The form lacked documentation R30 attended or declined to go to the care conference. R30's medical record lacked evidence R30 refused to go to care conferences, and documentation lacked evidence R30's participation in care planning was not practicable. R30's Honoring Choices Minnesota Health Care Directive signed by R30 on 9/23/2019, indicated the document gave treatment choices and preferences, and or appointed a health care agent to speak on a person's behalf if a person cannot communicate or make their own health care decisions. R30 identified family member (FM)-A as her primary health care agent. The form indicated the health care agent had the following powers when R30 was not able to communicate for herself: agree to, refuse, or cancel decisions about her healthcare, interpret any instruction in the document based their understanding of R30's wishes, review and release medical records, arrange for healthcare and treatment, decide which health care providers and organizations provide healthcare, make decisions about organ and tissue donation. Further, the document indicated R30 made the document willingly and was thinking clearly and if R30's wishes changed, would complete a new health care directive. Additionally, the health care instructions directed the health care agent to communicate choices and the health care team to honor them, if R30 could not communicate or make her own choices. R30's Resident Vaccine Administration Consent Form dated 10/1/24, indicated vaccines consented for included a check mark in the box next to influenza. In the box next to COVID-19 Vaccine/Booster appeared to be scribbled out and under the heading, Vaccines Declined, included a check mark in the box next to COVID-19 Vaccine/Booster. Next to the heading, Resident/Resident Representative's Signature, indicated the form was reviewed over the phone with FM. on 10/1/24. R30's physician progress notes dated 10/11/22 at 12:41 p.m., provided by the director of nursing (DON) on 11/7/24 at 11:06 a.m., indicated R30 had a rectovaginal fistula (an abnormal connection between the vagina and rectum) and wall thickening of the colon compatible with colitis (a disease that causes inflammation of the colon) and colonic diverticulosis (a condition where small pouches form in the large intestine). R30 was admitted to the hospital with acute (an illness that has a rapid onset but usually clears up) metabolic encephalopathy (a problem in the brain) likely secondary to rectovaginal fistula and colitis which were managed with antibiotics. Further, the note indicated R30 did not currently have the ability to make medical decisions for herself possibly due to acute encephalopathy and FM-A expressed concern over the past year R30 did not have the capacity to make medical decisions with progression of her memory issues. The note further indicated the next of kin would need to be involved for decisions. R30's hospital department of psychiatry follow up consultation note dated 3/16/23, indicated psychiatry was consulted to evaluate new visual hallucinations and was seen by neurology who felt the presentation was consistent with delirium. R30's diagnoses included acute encephalopathy that was improving, dementia with Parkinson's, history of major depressive disorder, borderline personality disorder, and seizure disorder. R30 was not currently demonstrating capacity and the note further indicated to involve next of kin for all decision making. The note further indicated R30 did not have visual hallucinations at baseline and at baseline, was social and enjoyed talking to people. R30 was admitted to the hospital for an acute perforated diverticulitis with associated abscess (a condition where a pouch in the colon ruptured, causing a hole in the bowel wall and a pocket of pus formed) and status post drain placement. R30's Associated Clinic of Psychology (ACP) noted dated 2/15/24, indicated R30 was clear cognitively. R30's ACP note dated 10/17/24, indicated R30 had verbal aggression toward FM-A because R30 felt FM-A was preventing her from receiving a vaccine. Additionally, the note indicated R30 was alert and oriented to person, place, and month. The note further indicated R30 clarified she did not need help with decisions, and was agreeable to the idea if she had others helping with health and financial decisions as necessary and feasible and staff were aware and working with FM-A regarding an alternate for decisions. Further, R30 felt strongly about voting and was receptive to potentially changing her decision making helper to a professional if an option as staff and sister have been discussing. R30's nurse practitioner ACP note dated 10/30/24, indicated R30 was alert and oriented, long term recall was adequate, and R30's short term recall was fair and did not want FM-A to be her power of attorney any longer and was planning to look into a non-family member assist with making decisions and managing her finances. Further, R30 was upset staff had to notify FM-A for everything. R30's progress notes dated 10/10/22 at 3:16 p.m., indicated R30 was sent to the hospital for altered mental status. R30's progress notes dated 10/20/22 at 3:57 p.m., indicated severe cognitive impairment. R30's progress notes dated 10/31/22 at 5:03 p.m., indicated R30 was not feeling well and was sent to the hospital. R30's progress note dated 11/15/22 at 9:05 a.m., indicated R30 returned to the facility from the hospital due to a diagnoses of a fistula of vagina to the large intestine and had a new colostomy. R30's progress note dated 2/13/23 at 4:00 p.m., indicated R30 had intact cognition. R30's progress note dated 3/1/23, at 1:05 p.m., indicated R30's was doing well cognitively and family has seen improvement at times logic was impaired and was able to make her needs known. R30's progress note dated 3/8/23, at 5:30 p.m., indicated R30 had increased confusion and difficulty with communication. R30's progress note dated 3/9/23 at 1:45 p.m., indicated R30 was lethargic. R30's progress note dated 3/9/23 at 6:59 p.m., indicated R30 was sent to the hospital for an evaluation. R30's progress note dated 3/17/23 at 10:12 p.m., indicated R30 returned, had a JP drain, and was on antibiotics for an abscess. R30's progress note dated 3/20/23 at 3:48 p.m., indicated R30 returned to the facility on 3/17/23 from the hospital with abdominal pain and diverticulitis. R30's progress note dated 4/4/23 at 1:47 p.m., indicated R30's cognition fluctuated a lot and was her judgement and reasoning. R30's progress note dated 6/16/23 at 4:59 p.m., indicated R30 was sent to the hospital for evaluation. R30's progress note dated 6/22/23 at 2:56 p.m., indicated R30 returned from the hospital with a diagnosis of severe sepsis with shock from an abdominal abscess. R30's progress note dated 7/31/23 at 10:19 a.m., indicated R30 was not oriented to place and asked if she could go back to the care center. R30 has been confused in the past about where she is after returning from a hospitalization or appointment. R30's progress note dated 9/13/23 at 11:16 a.m., indicated R30 was in the hospital for a planned surgery. R30's progress note dated 10/6/23 at 9:02 p.m., indicated R30 returned to the unit and was stable with no pain, ate 100% had a wound vac. R30's progress notes dated 10/9/23 at 2:25 p.m., indicated R30 was admitted to the facility and R30's emergency contact was FM-A. R30's progress note dated 10/9/23 at 4:16 p.m., indicated moderate cognitive impairment. R30's progress note dated 11/1/23 indicated severe cognitive impairment. R30's progress note dated 11/3/23 at 4:06 p.m., indicated R30 was recently diagnosed with pneumonia. R30's progress note dated 11/29/23 at 2:38 p.m., indicated R30's 48 hour care plan and summary was reviewed with FM-A. R30's progress note dated 12/28/23 at 4:55 p.m., indicated R30 tested positive for influenza A and the nurse received new orders for Tamiflu. R30's social services progress note dated 7/24/24 at 3:49 p.m., indicated R30 had intact cognition with no signs or symptoms of depression and R30 had a guardian. R30's nursing progress note dated 10/21/24 at 2:54 p.m., indicated R30 requested a COVID-19 vaccination and consent was obtained from the guardian via email and the vaccine was administered in the left arm. R30's social service progress note dated 10/23/24 at 4:16 p.m., indicated R30 was upset with FM-A and FM-A was looking into 3rd party guardian so FM-A was no longer the guardian. R30's progress note dated 10/29/24 at 3:17 p.m., indicated social services spoke to FM-A, resident's guardian who agreed to have R30 seen by in-house psychiatrist instead of going to the community. The progress notes lacked any re-evaluation following the acute illnesses whether R30 had the ability to make medical decisions. During interview on 11/4/24 between 2:19 p.m., and 2:39 p.m., R30 stated the facility contacted FM-A for a care conference, but nobody contacted R30. R30 stated she was upset the facility contacted FM-A and did not include R30 in decisions about her healthcare. R30 stated FM-A was her power of attorney (POA) and it was not working and R30 wanted to change that. R30 stated one of the nurses told R30 that FM-A did not want R30 to get the COVID shot and the next morning FM-A called and gave them her ok for R30 to receive the COVID shot which R30 stated should have been a given. R30 stated she informed social worker (SW)-A she was trying to change her POA and had also informed FM-A. During interview on 11/7/24 at 8:07 a.m., FM-A stated she was not R30's guardian, but was her POA and further stated R30 had gone to care conferences in the past, but has not gone recently and did not know why R30 had not gone to care conferences. During interview on 11/7/24 at 8:17 a.m., social worker (SW)-A stated care conferences were held per the MDS schedule and held on Tuesdays and on Wednesdays for memory care. SW-A stated they typically send invitations to therapy, activities, nursing, and dietary and discuss medications, code status, appointments, activities, and funeral home. SW-A stated she calls or emails the guardian or family and the resident is notified and can choose if they want to come. SW-A further stated she would document a note under social services in the care conference note if a resident did not want to attend. SW-A stated they looked on the profile form to know if a resident was capable of making their own decisions. SW-A stated if a resident had a guardianship, the guardianship paperwork was scanned into the miscellaneous file and would be identified on the Profile form in the electronic medical record (EMR). SW-A stated a resident would have to go through the court for a guardianship and stated it was up to the family to complete a POA and stated she did not assist residents in completing paperwork, but instructs the family to fill it out and she provided a contact card for the notary. SW-A further stated FM-A was R30's POA and guardian, then stated FM-A was not R30's guardian after viewing the Profile form, and thought FM-A was working on becoming R30's guardian and R30 made her own decisions and FM-A respected her decisions. SW-A stated FM-A lived in another state and started the process for guardianship and added R30 did not attend care conferences, but she could ask her if she wanted to attend her care conference 11/8/24, and stated they didn't want to confuse anyone or upset them and further stated R30 had intact cognition and should have been asked if she wanted to attend care conferences and further stated they would have the POA sign consents if a resident had a POA, even if the resident was their own decision maker, and added she could not speak for nurses for consents. SW-A stated FM-A wanted to look into a third party guardianship and thought she contacted somebody from Minnesota and would get in contact with FM-A for the care conference 11/8/24, and stated it would be up to FM-A to make a determination whether R30 needed a guardian because the facility does not have anything to do with it and stated she would enter a note about FM-A wanting a 3rd party guardian. During interview on 11/7/24 at 8:43 a.m., the director of nursing (DON) stated SW-A scheduled care conferences quarterly and asks residents if they want to participate and documents a note in the care conference summary if a resident does not want to be present and stated if R30 hasn't been deemed incapacitated or incompetent should be invited to care conferences and sign consents. A policy was requested on resident rights and the DON stated they had a bill of rights they review upon admission. During interview on 11/7/24 at 1:34 p.m., the administrator stated they had no other documentation for incapacitation and were going off a document the DON sent in an email on 11/7/24 at 11:06 a.m. A form, Resident [NAME] of Rights Minnesota Nursing Home and Boarding Care Home, dated 12/4/2015, indicated residents shall have the right to participate in the planning of their health care. This right includes the opportunity to discuss treatment and alternatives with individual caregivers, to request and participate in formal care conferences, and the right to include a family member or other chosen representative, or both. In the event that the resident cannot be present, a family member or other representative chosen by the resident may be included in such conferences. A policy, Care Planning-Interdisciplinary Team, dated 7/21/23, indicated the resident, the resident's family and or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan and every effort will be made to schedule interdisciplinary (IDT) care plan meetings at the best time of the day for the resident and family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the physician of a change in condition for 1 of 1 resident (R18) who was experiencing new vision loss. Findings include: R18's 5-day Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of type II diabetes mellitus, hypertension (HTN), and congestive heart failure (CHF). It further indicated R18 had adequate vision and didn't wear corrective lenses. R18's care plan dated 4/1/24, indicated adequate vision, able to read 12 point font, and does not wear glasses with an intervention to observe for signs and symptoms of changes in visual status and to notify the medical doctor (MD) if noted. R18's visit summary note from his last eye exam dated 7/30/24, indicated to schedule an appointment with a local retinal specialist/ophthalmology as soon as possible (ASAP) for evaluation and treatment. R18's physician's orders dated 11/6/24, indicated R18 had an appointment on 11/21/24 at 9:00 a.m. to see the retina specialist. R18's progress notes for the begining of November (11/1/24-11/6/24) lacked documentation the physician had been notified or an appotinment had been made. During observation and interview on 11/04/24 at 1:11 p.m. R18 had a band-aid taped over some gauze on his right eye, stating he lost his vision yesterday, it had been happening for 3 weeks, and nobody had done anything. R18 further stated it was like he was looking through a red fog. During interview on 11/06/24 at 10:11 a.m. the assistant director of nursing (ADON) stated R18 came back from Dialysis on Monday (11/4/24) with a patch over his right eye, stating he needed to make an eye appointment because his eye was irritated. The ADON further stated she had asked him what happened but since R18 had come back from Dialysis with new orders and they hadn't sent him to the hospital (right from Dialysis) that she didn't feel it was a cause for concern. The ADON stated she didn't know if anyone had assessed his eye and she would expect the nurses on each shift, (especially the nurse who worked on Monday, unkown) to have looked at his eye, assessed it, and documented on it. The surveyor asked the ADON how they would determine if R18's injury was severe or was an emergency situation and the ADON responded that's a good question. The provider was walking out of the building on Monday and the ADON stopped her and stated R18's eye was irritated and he had an eye appointment scheduled (did not tell her the date), and was wondering if he was still able to go out into the community. The ADON verified she did not document anything about the incident or that she had notified the provider stating It was my fault, I should have put in a note. The ADON also verified none of the nurses had documented they had assessed R18's eye or notified the provider. During a follow up interview on 11/6/24 at 12:46 p.m., R18 stated LPN-B put the eye patch/bandage on his eye on Monday (11/4/24) before he went to Dialysis and no one had looked at his eye or assessed it since then. It's bleeding inside and swirls of blood are coming into my sight, it's irritated, if I look into the light, it hurts. If I take the patch off my right eye, it screws up my vision in my left eye. The eye doctor had told him previously he had bleeders in both eyes but it wasn't that bad and his vision was still clear, but he should see a specialist to get a better scan. R18 stated his eye has been irritated for 3 weeks and felt like he had hair in his eyes. They (facility) was supposed to make another appointment in early September but they never did. During interview on 11/6/24 at 1:05 p.m., licensed practical nurse (LPN)-B stated R18 had the eye patch on before leaving for Dialysis on Monday (11/4/24). R18 told him he had the patch because the light was bothering his eye and the night nurse had put the eye patch/bandage on for him. LPN-B further stated he only applied more tape to the bandage because R18 stated the light was shining through it but didn't assess his eye or document on it. LPN also stated he looked in the physician's orders but he didn't see anything regarding R18's eye. During interview on 11/7/24 at 9:35 a.m. the doctor of Optometery (OD) stated R18 had bleeding in both eyes and it was getting very close to the macula. When the blood get's into the macula it can cause vision loss and at the time of the appointment his vision was 20/20 therefore it was very important to get him into the retina specialist to prevent that from happening. The OD stated that was why she indicated on the visit summary to make him an appointment ASAP stating she rarely puts ASAP for a follow up appointment but felt very strongly about it in this case. During interview on 11/7/24 at 9:50 a.m. registered nurse (RN)-A stated if a resident had a new injury/bandage, they would ask the resident what happened, remove the dressing/bandage to assess the area, notify the physician, and document it. During interview on 11/7/24 at 9:55 a.m. (RN)-C stated if a resident had a new injury or bandage/dressing, etc. they would ask the resident how it happened, remove the bandage, assess the area, document, and notify the nurse practioner (NP). During interview on 11/7/24 at 10:07 a.m., the Health Information Manager (HIM) stated she and one other staff HIM-B were responsible for scheduling appointments for residents. She further stated R18 came to her at the begining of the week (not sure what day, possibly Tuesday) and said he needed to see the eye doctor so she went to look for the documentation of last visit (with Healthdrive) and couldn't find it, so she called them to fax it to her. The HIM further stated she wasn't aware R18 was supposed to make a follow up appointment and the first time she heard about it was when R18 told her his eye was bothering him. Usually Healthdrive sends the documentation over after each appointment and there was no system in place to check and make sure the documentation was sent over. The surveyor asked the HIM why the appointment for the retina specialist was scheduled out a few weeks when the visit summary from the last eye appointment stated it should be made ASAP. The HIM verified she thought it indicated to schedule a follow up appointment in 1-2 months but verified she missed seeing that it actually said to schedule it ASAP. During interview on 11/7/24 at 12:15 p.m., the director of nursing (DON) stated if a resident had a change in condition or new injury/bandage the nurses were responbile for removing the bandage, assessing the area, try to find out how it happened, fill out a risk management, call the provider to receive further instruction, and doumen The facility's policy on notification of a change in condition dated 3/2024, indicated it is the policy of this facility that changes in a resident's condition or treatment be shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). Nurses and other care staff are 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 physician, to ensure best outcomes of care for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review, the facility failed to ensure residents were invited to care conferences for 1 of 1 resident (R30) reviewed for care planning. Findings include: R30's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have evidence of an acute change in mental status, did not have inattention, disorganized thinking, or an altered level of consciousness, did not have physical, verbal, or other behaviors, was not important at all to have a family or close friend involved in discussions about care and had the following diagnoses: anemia, hypertension (high blood pressure), dementia, anxiety, depression, borderline personality disorder, and personal history of other mental and behavioral disorders. R30's Profile form in the electronic medical record (EMR) indicated R30's FM-A was her financial power of attorney (POA) and next to the heading, Power of attorney-care indicated, Do Not Use. R30's medical record was reviewed and lacked information R30 had a guardian. R30's care plan dated 11/16/22, indicated R30 was alert and oriented to person and sometimes place, but needed cues and reminders for time and had short-term memory loss and family assisted in decision making. Interventions indicated ACP (Associated Clinic of Psychology) provide brief instructions, repeat instructions as needed, explain all cares and procedures, if having trouble with word finding, take time to listen, observe for changes in cognitive status. R30's care plan dated 3/17/23, indicated R30 was able to ask questions and answer questions, was easily distracted, had difficulty with word finding and interventions indicated to allow R30 enough time to process and answer questions, ask yes or no questions, gain attention before talking, speak in simple and direct terms, and speak clearly and distinctly and adjust tone of voice. R30's care plan dated 11/28/23, indicated R30 required assistance in reading and understanding health documents and interventions included, family would read instructions, pamphlets, or other written materials, from doctors or pharmacies. R30's IDT (Interdisciplinary team) Care Conference form dated 2/12/24, 5/14/24, and 8/7/24, indicated FM-A attended the care conferences. The form lacked documentation R30 attended or declined to go to the care conference. R30's medical record lacked evidence R30 refused to go to care conferences, and documentation lacked evidence R30's participation in care planning was not practicable. R30's Honoring Choices Minnesota Health Care Directive signed by R30 on 9/23/2019, indicated the document gave treatment choices and preferences, and or appointed a health care agent to speak on a person's behalf if a person cannot communicate or make their own health care decisions. R30 identified family member (FM)-A as her primary health care agent. The form indicated the health care agent had the following powers when R30 was not able to communicate for herself: agree to, refuse, or cancel decisions about her healthcare, interpret any instruction in the document based their understanding of R30's wishes, review and release medical records, arrange for healthcare and treatment, decide which health care providers and organizations provide healthcare, make decisions about organ and tissue donation. Further, the document indicated R30 made the document willingly and was thinking clearly and if R30's wishes changed, would complete a new health care directive. R30's ACP note dated 10/17/24, indicated R30 had verbal aggression toward FM-A because R30 felt FM-A was preventing her from receiving a vaccine. Additionally, the note indicated R30 was alert and oriented to person, place, and month. The note further indicated R30 clarified she did not need help with decisions, and was agreeable to the idea if she had others helping with health and financial decisions as necessary and feasible and staff were aware and working with FM-A regarding an alternate for decisions. Further, R30 felt strongly about voting and was receptive to potentially changing her decision making helper to a professional if an option as staff and sister have been discussing. R30's nurse practitioner ACP note dated 10/30/24, indicated R30 was alert and oriented, long term recall was adequate, and R30's short term recall was fair and did not want FM-A to be her power of attorney any longer and was planning to look into a non-family member assist with making decisions and managing her finances. Further, R30 was upset staff had to notify FM-A for everything. During interview on 11/4/24 at 2:39 p.m., R30 stated the facility contacted FM-A for a care conference, but nobody contacted R30. R30 stated she was upset the facility contacted FM-A and did not include R30 in decisions about her healthcare. During interview on 11/7/24 at 8:07 a.m., FM-A stated she was not R30's guardian, but was her POA and further stated R30 had gone to care conferences in the past, but has not gone recently and did not know why R30 had not gone to care conferences. During interview on 11/7/24 at 8:17 a.m., social worker (SW)-A stated care conferences were held per the MDS schedule and held on Tuesdays and on Wednesdays for memory care. SW-A stated they typically send invitations to therapy, activities, nursing, and dietary and discuss medications, code status, appointments, activities, and funeral home. SW-A stated she calls or emails the guardian or family and the resident is notified and can choose if they want to come. SW-A further stated she would document a note under social services in the care conference note if a resident did not want to attend. SW-A stated they looked on the profile form to know if a resident was capable of making their own decisions. SW-A stated if a resident had a guardianship, the guardianship paperwork was scanned into the miscellaneous file and would be identified on the Profile form in the EMR. SW-A stated a resident would have to go through the court for a guardianship and stated it was up to the family to complete a POA and stated she did not assist residents in completing paperwork, but instructs the family to fill it out and she provided a contact card for the notary. SW-A further stated FM-A was R30's POA and guardian, then stated FM-A was not R30's guardian after viewing the Profile form, and thought FM-A was working on becoming R30's guardian and R30 made her own decisions and FM-A respected her decisions. SW-A stated FM-A lived in another state and started the process for guardianship and added R30 did not attend care conferences, but she could ask her if she wanted to attend her care conference 11/8/24, and stated they didn't want to confuse anyone or upset them and further stated R30 had intact cognition and should have been asked if she wanted to attend care conferences and further stated they would have the POA sign consents if a resident had a POA, even if the resident was their own decision maker, and added she could not speak for nurses regarding the consents nurses obtained. SW-A stated FM-A wanted to look into a third party guardianship and thought she contacted somebody from Minnesota and would get in contact with FM-A for the care conference 11/8/24, and stated it would be up to FM-A to make a determination whether R30 needed a guardian because the facility does not have anything to do with assisting with guardianship and stated she would enter a note about FM-A wanting a 3rd party guardian. During interview on 11/7/24 at 8:43 a.m., the director of nursing (DON) stated SW-A scheduled care conferences quarterly and asks residents if they want to participate and documents a note in the care conference summary if a resident does not want to be present and stated if R30 hasn't been deemed incapacitated or incompetent should be invited to care conferences and sign consents. A policy was requested on resident rights and the DON stated they had a bill of rights they review upon admission. During interview on 11/7/24 at 1:34 p.m., the administrator stated they had no other documentation for incapacitation and were going off a document the DON sent in an email on 11/7/24 at 11:06 a.m. A form, Resident [NAME] of Rights Minnesota Nursing Home and Boarding Care Home, dated 12/4/2015, indicated residents shall have the right to participate in the planning of their health care. This right includes the opportunity to discuss treatment and alternatives with individual caregivers, to request and participate in formal care conferences, and the right to include a family member or other chosen representative, or both. In the event that the resident cannot be present, a family member or other representative chosen by the resident may be included in such conferences. A policy, Care Planning-Interdisciplinary Team, dated 7/21/23, indicated the resident, the resident's family and or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan and every effort will be made to schedule interdisciplinary (IDT) care plan meetings at the best time of the day for the resident and family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure swallow study referral discharge needs were identified in the post-discharge plan for 1 of 1 resident (R54) reviewed for discharge. Findings include: R54's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of type one diabetes mellitus (DM1), dysphagia (difficulty swallowing), heart failure, hypertension, kidney disease and depression. R54 was on a therapeutic diet and active discharge planning was place. R54's Care Area Assessment (CAA) dated 9/25/24, identified functional abilities (self-care and mobility) was triggered. R54 was admitted with poorly controlled DM1, end stage renal disease on dialysis, dysphagia, weakness, and muscle spasms. Physical, occupational and speech therapy were to evaluate. R54 had a history of noncompliance with medications and was at risk for decline related to medication noncompliance and diabetic complications. R54's care plan dated 9/13/24, identified the goal was to return to the community once rehab was completed and medically stable. Interventions included staff would make necessary referrals as needed to carry out discharge goals. The care plan lacked intervention of R54 making her own post discharge appointments for a swallow study. R54's speech language pathologist (SLP) Evaluation and Plan of Care dated 9/13/24 through 10/12/24, identified R54 reported a swallow study was previously recommended, which has yet to be scheduled. Additionally, dysphagia was present and without skilled therapeutic intervention the patient was at risk for aspiration. Additionally, R54 lacked capacity for chronic disease management. R54's SLP Discharge summary dated [DATE] through 9/25/24, identified she was referred for a swallow study and nursing would schedule the appointment. R54's SLP order dated 9/19/24, identified a swallow study was recommended for esophageal like symptoms. R54's progress notes dated 9/12/24 through 11/4/24, lacked documentation if the swallow study was scheduled, or if a discussion was held with R54 regarding any arrangements. R54's Care Conference Form dated 9/20/24, identified SLP worked on swallowing strategies, and a swallow study was recommended for follow up. The care conference had not addressed who would set up the swallow study. R54's progress note dated 9/26/24 at 1:56 p.m., identified she declined dialysis because while eating popcorn the night before, a hub got stuck in her throat, causing coughing to the point of vomiting. R54's Discharge Instructions and Summary form dated 11/1/24 identified the reason for discharge was OT/PT (occupational and physical) therapy were completed and R54 was ready to discharge home with home care. Follow up appointments were included to see the primary doctor seven to 10 days after discharge. R54's corresponding Order Summary Reort dated 11/1/24, identified on 9/19/24, a swallow study was recommended but lacked identification of R54's needs related to making the appointment. During an interview on 11/6/24 at 11:13 a.m., R54 stated she was discharged recently but was not made aware of arrangements for her recommended swallow study. R54 stated the appointment should have been set up before she was discharged because she feels food gets stuck in her throat. R54 stated instructions or appointments for swallow study were not on her discharge paperwork. During an interview on 11/6/24 at 11:35 a.m., the therapy program manager (TPM) stated SLP evaluated and treated R54 while she was a resident of the facility, and a recommendation was made for a swallow up study. The TPM stated the order was given to nursing and would have expected the appointment to be scheduled. The order was placed on 9/19/24 and R54 discharged on 11/4/24, which was 45 days after the order was placed. During an interview on 11/6/24 at 11:46 a.m., licensed practical nurse (LPN)-A stated typically social services (SW)-A would coordinate the discharge planning and was not aware of any SLP referrals for swallow study. If there was one, it would be present on the discharge summary in the electronic health record (EHR). During an interview on 11/6/24 at 11:48 a.m., SW-A stated updates from therapy should be included in the discharge summary given to the patient along with any referrals. SW-A stated SW-B had managed R54's discharge and was not aware of the status of a swallow study. During an interview on 11/6/24 at 11:54 a.m., R54's home health care intake provider (HHC) stated they were not made aware of any referrals for a swallow study but could pursue one if needed. During an interview on 11/6/24 at 12:04 p.m., SW-B stated referrals would be documented on care conferences and discharge summary. SW-B stated she made home health referrals for physical and occupational therapy but not for swallow study. During an interview on 11/6/24 at 1:15 p.m., the SLP stated she made R54's recommendation on 9/19/24, for a swallow study because of esophageal dysphagia. The SLP reviewed R54's medical record and could not find documentation on the follow up arrangements for a swallow study. The SLP stated she would have expected nursing to set up the appointment while a resident to ensure safe swallowing. During a follow up interview on 11/6/24 at 2:00 p.m., LPN-A reviewed R54's medical record and stated the swallow study arrangements should have done while R54 was a resident. LPN-A added nursing would not schedule it, but the health unit coordinator would (HUC). During an interview on 11/6/24 at 2:41 p.m., the HUC stated when she gets an order for a referral, she puts it in the computer and nursing verifies the order. The HUC stated she would schedule appointments as needed. The HUC stated she thinks she remembers when the order was written and R54 was also scheduled to discharge, but she thought R54 would make the appointment independently. However, R54's medical record and discharge summary lacked instructions for R54 to do so. During a follow up interview on 11/7/24 at 8:08 a.m., R54 stated she wanted the facility to help her schedule it as she was not aware how to do that. R54 denied stating she would make the appointment independently. During an interview on 11/7/24 at 12:00 p.m., the director of nursing (DON) stated outside referrals such as swallow studies should have instructions included on the discharge summary. The facility's Discharge Planning Policy dated 11/2016, identified a discharge planning would be coordinated is coordinated by the interdisciplinary team in cooperation with community resources. The discharge plan would provide the resident with needed care and services, and to work out an acceptable solution for all concerned. Discharge planning was done to assure continuity of care to meet the needs of a resident returning to independent living in the community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observation, interview, and record review the facility failed to ensure that residents received proper treatment to maintain vision for 1 of 1 resident (R18) reviewed for vision services. Findings include: R18's 5-day Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of type II diabetes mellitus, hypertension (HTN), and congestive heart failure (CHF). It further indicated R18 had adequate vision and didn't wear corrective lenses. R18's care plan dated 4/1/24, indicated adequate vision, able to read 12 point font, and does not wear glasses with an intervention to observe for signs and symptoms of changes in visual status and to notify the medical doctor (MD) if noted. R18's visit summary note from his last eye exam dated 7/30/24, indicated to schedule an appointment with a local retinal specialist/ophthalmology as soon as possible (ASAP) for evaluation and treatment. R18's physician's orders dated 11/6/24, indicated R18 had an appointment on 11/21/24 at 9:00 a.m. to see the retina specialist. R18's progress notes for the begining of November (11/1/24-11/6/24) lacked documentation the physician had been notified or an appotinment had been made. During observation and interview on 11/04/24 at 1:11 p.m. R18 had a band-aid taped over some gauze on his right eye, stating he lost his vision yesterday, it had been happening for 3 weeks, and nobody had done anything. R18 further stated it was like he was looking through a red fog. During interview on 11/06/24 at 10:11 a.m. the assistant director of nursing (ADON) stated R18 came back from Dialysis on Monday (11/4/24) with a patch over his right eye, stating he needed to make an eye appointment because his eye was irritated. The ADON further stated she had asked him what happened but since R18 had come back from Dialysis with new orders and they hadn't sent him to the hospital (right from Dialysis) that she didn't feel it was a cause for concern. The ADON stated she didn't know if anyone had assessed his eye and she would expect the nurses on each shift, (especially the nurse who worked on Monday, unkown) to have looked at his eye, assessed it, and documented on it. The surveyor asked the ADON how they would determine if R18's injury was severe or was an emergency situation and the ADON responded that's a good question. The provider was walking out of the building on Monday and the ADON stopped her and stated R18's eye was irritated and he had an eye appointment scheduled (did not tell her the date), and was wondering if he was still able to go out into the community. The ADON verified she did not document anything about the incident or that she had notified the provider stating It was my fault, I should have put in a note. The ADON also verified none of the nurses had documented they had assessed R18's eye or notified the provider. During a follow up interview on 11/6/24 at 12:46 p.m., R18 stated LPN-B put the eye patch/bandage on his eye on Monday (11/4/24) before he went to Dialysis and no one had looked at his eye or assessed it since then. It's bleeding inside and swirls of blood are coming into my sight, it's irritated, if I look into the light, it hurts. If I take the patch off my right eye, it screws up my vision in my left eye. The eye doctor had told him previously he had bleeders in both eyes but it wasn't that bad and his vision was still clear, but he should see a specialist to get a better scan. R18 stated his eye has been irritated for 3 weeks and felt like he had hair in his eyes. They (facility) was supposed to make another appointment in early September but they never did. During interview on 11/6/24 at 1:05 p.m., licensed practical nurse (LPN)-B stated R18 had the eye patch on before leaving for Dialysis on Monday (11/4/24). R18 told him he had the patch because the light was bothering his eye and the night nurse had put the eye patch/bandage on for him. LPN-B further stated he only applied more tape to the bandage because R18 stated the light was shining through it but didn't assess his eye or document on it. LPN also stated he looked in the physician's orders but he didn't see anything regarding R18's eye. During interview on 11/7/24 at 9:35 a.m. the doctor of Optometery (OD) stated R18 had bleeding in both eyes and it was getting very close to the macula. When the blood get's into the macula it can cause vision loss and at the time of the appointment his vision was 20/20 therefore it was very important to get him into the retina specialist to prevent that from happening. The OD stated that was why she indicated on the visit summary to make him an appointment ASAP stating she rarely puts ASAP for a follow up appointment but felt very strongly about it in this case. During interview on 11/7/24 at 9:50 a.m. registered nurse (RN)-A stated if a resident had a new injury/bandage, they would ask the resident what happened, remove the dressing/bandage to assess the area, notify the physician, and document it. During interview on 11/7/24 at 9:55 a.m. (RN)-C stated if a resident had a new injury or bandage/dressing, etc. they would ask the resident how it happened, remove the bandage, assess the area, document, and notify the nurse practioner (NP). During interview on 11/7/24 at 10:07 a.m., the Health Information Manager (HIM) stated she and one other staff HIM-B were responsible for scheduling appointments for residents. She further stated R18 came to her at the begining of the week (not sure what day, possibly Tuesday) and said he needed to see the eye doctor so she went to look for the documentation of last visit (with Healthdrive) and couldn't find it, so she called them to fax it to her. The HIM further stated she wasn't aware R18 was supposed to make a follow up appointment and the first time she heard about it was when R18 told her his eye was bothering him. Usually Healthdrive sends the documentation over after each appointment and there was no system in place to check and make sure the documentation was sent over. The surveyor asked the HIM why the appointment for the retina specialist was scheduled out a few weeks when the visit summary from the last eye appointment stated it should be made ASAP. The HIM verified she thought it indicated to schedule a follow up appointment in 1-2 months but verified she missed seeing that it actually said to schedule it ASAP. During interview on 11/7/24 at 12:15 p.m., the director of nursing (DON) stated if a resident had a change in condition or new injury/bandage the nurses were responbile for removing the bandage, assessing the area, try to find out how it happened, fill out a risk management, call the provider to receive further instruction, and doument. A facility policy regarding ancilliary appointments was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R50's annual Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, and prior Brief Interview for Mental Status (BIMS) indicated intact cognition, did not have hallucinations or delusions, physical, verbal, or other behaviors directed towards others, did not reject care, had a motorized wheelchair, and had depression, alcohol use with intoxication, nicotine dependence, and took antipsychotics, antianxiety, and antidepressant medications. R50's Medical Diagnosis form undated, indicated the following diagnoses: major depressive disorder, recurrent, severe with psychotic symptoms, nicotine dependence, alcohol use with intoxication, and depression unspecified. R50's care plan dated [DATE], indicated R50 became frustrated and overwhelmed at times on the smoking patio with others and knew to call the nurse on-call in this situation. R50's care plan dated [DATE], indicated R50's safety would be protected through staff interventions that included R50 to report to staff if feeling threatened or bothered by other residents and or staff, remove R50 from potentially abusive situations, provide a safe environment for individual and others and ensure the safety of others, and if R50 displayed persistent or inappropriate behaviors, remove R50 to an area away from others. R50's care plan dated [DATE], indicated R50 had a behavior problem due to a diagnoses of depression, dementia and had a judgment or reasoning deficit and could be irritable at times and make comments about others especially when R50 felt disrespected and will tell others they are rude and inconsiderate and will attempt to defend others when R50 feels they are being disrespected especially female staff and residents and was in a resident to resident altercation 9/2024. Interventions included not to argue with resident and encourage R50 to come to staff when upset. R50's care plan dated [DATE], indicated R50 could easily become agitated by noise and environment and required redirection as able. An intervention included to redirect resident as needed from environment that can upset him. R50's care plan dated [DATE], indicated R50 had psychosocial issues and impaired coping mechanisms due to depression, judgement or reasoning deficit and became upset when other residents do not keep the smoking area clean and interventions dated [DATE], indicated to remind resident he does not need to clean the smoking area, and R50 has the on-call nurse number to call when he is upset with what other residents are doing or saying on the patio and agreed to call the number when upset. R50's care plan dated [DATE], indicated R50 was at risk for alterations in behavior related to trauma including resident to resident altercation and triggers included when people say dumb stuff and are rude. R50's care plan dated [DATE], indicated R50 had a history and diagnosis of substance use and interventions indicated monitoring R50 for intoxication or impairment. R50's nursing progress note dated [DATE] at 9:58 a.m., indicated a nurse reported when attempting to change R50's catheter, R50 stated, If you mess it up, I will kill you. R50 then refused catheter change and wanted a male nurse to complete. The director of nursing (DON) followed up with R50 who stated he did not mean what he said and was just kidding. R50's interdisciplinary team (IDT) progress note dated [DATE] at 12:08 p.m., indicated R50 had a resident to resident incident on [DATE]. R50 was outside smoking and heard another resident (R71) who was intoxicated make sexually inappropriate comments to other female residents and staff. R50 asked multiple times for R71 to stop and R50 rammed his wheelchair into R71. The two residents were separated by a visitor. The note further indicated R50 had been easily agitated. R50's social services progress note dated [DATE] at 4:46 p.m., indicated R50 was instructed he could not tell people to leave the smoking area and felt he needed to clean the area all the time and the assistant director of nursing (ADON) came in and explained to R50 he had to allow others to use the smoking area and to ignore the residents. R50 became upset and was not able to be redirected. R50's social services late entry progress note created on [DATE] at 7:24 p.m., for [DATE], indicated social worker (SW)-A followed up with R50 regarding smoking on the patio and provided R50 a nurse on call phone number and directed R50 to call the nurse on call if he had concerns with other residents and R50 stated he would do this moving forward rather than approaching other residents himself. R50's Incident Review and Analysis form dated [DATE], indicated on [DATE] at 8:40 p.m., R50 had a resident to resident altercation. R50 was outside smoking and overheard R71 being vulgar and inappropriate towards another resident and R50 became frustrated and asked R71 to stop. When R71 did not stop, R50 used his wheelchair to sit in front of R71. R50 continued to tell R71 to stop and R71 began threatening R50. R50 then wheeled his chair into R71's chair causing R71 to move backwards. Under a heading, Contributing Factors that Impacted Incident, included, Easily irritable. R50 reported feeling safe and did not want to file a police report. R50's Trauma Questionnaire form dated [DATE], at 9:24 a.m., indicated R50 had trauma that occurred after another resident made inappropriate comments and reported his triggers included when people said dumb stuff and were rude. R50 was not comfortable disclosing any coping strategies and allowing the strategies to be included with his plan of care. R50's nurse practitioner (NP) progress note dated [DATE], indicated when R50 was first admitted to the facility had frequent complaints, issues with compliance, and impulsivity and has less behavioral issues. Further R50's seroquel (antipsychotic) was decreased slightly in September and R50 was drinking heavily for a couple of weeks in September and had an altercation with another resident. The note indicated R50's cognitive impairment seemed more mild and had no significant mood disturbance and planned to continue tapering Seroquel very slowly, and R50's brief excessive drinking appeared to be resolved. During interview on [DATE] at 5:53 p.m., R50 stated R71 made the most profane remarks. R50 further stated R71 hasn't tried to do anything after the incident, except yell at him and give him the finger and stated he noticed R71 was back to smoking in the smoking area again. R50 stated R71 was not going to change and stated he tried to stay away from R71, but if R71 started again, R50 stated he would either call the nurse on call or if it becomes like last time will call 911. R50 stated he told SW-A he had a flashlight in case anybody tried to hit him and he could not get away, otherwise planned to call the nurse and 911. During interview on [DATE] at 6:35 p.m., R15 stated R71 was showing up outside after he was banned and nobody liked it. During interview on [DATE] at 6:59 p.m., SW-A stated there was an interaction in the smoking area where R50 pushed R71 and was determined R71 would smoke in the front to avoid altercations from happening and there had been no further incidents, and R71 could smoke in the back again and R50 was aware. SW-A stated R50 showed her the flashlight the other day and they tried to take it away, but R50 wanted it as protection and SW-A stated they reminded R50 there were nurses that could come down and instructed R50 to remove himself from the situation. SW-A stated R50 would not allow her or the assistant director of nursing (ADON) to take the flashlight. SW-A verified there was no mention of the flashlight in the care plan and stated R50 told them about the flashlight on [DATE], and they asked R50 to please not use it and keep it in his room and stated it should be on the care plan. SW-A stated she would have to talk with the ADON whether she changed the nurse aide sheets because SW-A did not touch those forms. SW-A stated R71 started going on the smoking patio again on [DATE]. Further, SW-A stated they wanted to take the flashlight out of the room for safe keeping so R50 wouldn't hurt anyone, but R50 refused and R71 was on a leave of absence. During interview on [DATE] between 2:45 p.m., and 2:52 p.m., with the administrator, SW-A, and the director of nursing (DON), the DON stated R50 had the flashlight in case the lights went out or if out on a leave of absence. At 2:52 p.m., the DON stated she did not know why the facility would want to take a flash light and kept emphasizing it was a flashlight and stated they didn't take it and R50 did not make any threat of violence. SW-A verified notes from interview [DATE], they wanted to take the flashlight away. When asked why take the flashlight away if there were no concerns, they did not provide a response and the DON stated she thought R50 wanted the flashlight in case of an emergency. During interview on [DATE] at 3:04 p.m., the DON stated she clarified with R50 and R50 stated he would rather she take the flashlight than think he had bad intentions and stated residents could smoke in the back or the front and stated both residents had no restrictions on smoking and stated they gave guidance on where to smoke and those had been lifted and further stated R50 and R71 avoid each other and did not hang out. During interview on [DATE] at 10:30 a.m., the certified occupational therapy assistant (COTA)-J stated he had been working in this building since [DATE], and had worked in previous facilities prior. COTA-J stated he did not know the process for when residents were evaluated for safety with power wheelchairs and was not familiar with R50 and stated occupational therapy (OT) completed the power chair screens. COTA-J stated for power wheel chair screens they look at whether a patient was the right size for the chair and not falling out and for safety wise, looked at whether a resident could control the wheelchair and get in safely and a resident's mental capacity and whether a resident was going to race through hallways or adjust the wheelchair so they weren't going too fast, and was not sure if they would conduct an assessment if a resident used a power chair purposefully to run into somebody and would have to ask their director of rehab. COTA-J viewed therapy notes and stated R50 had no OT notes. During interview on [DATE] at 10:44 a.m., nursing assistant (NA)-G stated she worked at the facility 5.5 years and stated the hearsay was R71 was drinking and rude to the women and R50 told him to stop and rammed into R71's chair. NA-G stated R50 sometimes states R71 is rude to ladies but does not associate with R71. During interview on [DATE] at 10:50 a.m., nursing assistant (NA)-F stated she worked at the facility for two years and was not aware R50 had a flashlight. During interview on [DATE] at 10:56 a.m., the assistant director of nursing (ADON)-F stated prior to the incident, everyone smoked on the back patio and after the incident with R50 and R71, the plan was R71 would smoke in the front and R50 still smoked in the back and when things died down they approached R50 and R71 to see if both were ok with going to the smoking patio and both seemed ok with no concerns so they went back to smoking in the same area and have not heard any issues, but was aware R71's alcohol use bothered R50. ADON-F further stated she and SW-A spoke with R50 on [DATE], because R50 was telling people they could not smoke and R50 was very upset and they didn't want R50 to get into another resident to resident incident. R50 was upset so she left and went back and R50 was calm and stated he would let the nurse know if he was bothered. ADON-F stated she was directed by the DON to provide the on-call phone number for the nurse and R50 agreed to use if he was feeling mad or overwhelmed. ADON-F stated they had a live camera outside, but other than that did not know it was safe for R50 and R71 to smoke together again and stated R50 was only bothered by R71 when R71 was drunk. ADON-F stated she did not think OT assessed R50 after the incident and reviewed the Power Operated Vehicle policy that indicated the resident will be expected to complete an assessment with OT upon presentation of a power operated vehicle (POV) at the facility. Updated assessments may be required annually or more often as determined by a change of condition, or incident related to operating POV. ADON-F stated R50 should have had an assessment completed according to the policy. During interview on [DATE] at 8:52 a.m., the director of nursing (DON) stated every conversation they had was for lighting and R50 never mentioned physically using the flashlight on anyone. Further, was told ADON-F and SW-A went in to talk to R50 about a smoking plan and did not know where the conversation led and stated R50 was upset and had a flashlight in his hand and was told they asked if they could hang on to the flashlight, and R50 did not say he was going to use it to harm anyone and did not know why they were trying to take it because he was using it for light purposes. Further, the DON stated the wheelchair policy indicated if an incident occurred additional evaluations may be required and stated it wouldn't be appropriate because R50 had the dexterity and could drive the POV and further stated they discussed it as a team and decided no additional assessment was needed and stated she would have to check where that information was documented and stated it might be in the OHFC file and stated IDT discussions were documented in the chart of OFHC file and no where else. An email from the DON sent on [DATE] at 11:06 a.m., indicated there was documentation R50 was not appropriate for an OT assessment on a daily follow up check list and the facility did not have a policy pertaining to resident safety. During interview on [DATE] at 1:34 p.m., the administrator provided a form, [DATE] Follow Up, that indicated to complete the POV form and that no OT was needed as per discussion in stand up. Based on observation, interview, and document review, the facility failed to ensure resident was adequately assessed for safe smoking for 1 of 1 resident (R15) reviewed for smoking. In addition, the facility failed to ensure an identified safety hazard was acted upon for 1 of 2 residents (R50) reviewed for resident to resident abuse. Findings include: R15's PPS (prospective payment system) Part A-Minimum Data Set (MDS) dated [DATE], indicated R15 was cognitively intact, was independent or required supervision with most activities of daily living (ADLs), used intermittent oxygen therapy, and required a wheelchair for mobility. R15's diagnoses included hereditary motor and sensory neuropathy (nerve condition causing tingling, swelling or muscle weakness), and chronic respiratory failure. R15's care plan last updated prior to survey start on [DATE], indicated R15 smoked independently, agreed to wear a smoking apron, and required smoking material to be stored in the treatment cart. The care plan further indicated a smoking incident occurred on [DATE] and instructed staff to complete a smoking evaluation per facility policy and as needed. R15's smoking assessment dated [DATE], indicated R15 was safe to smoke independently, could keep cigarettes and lighter in room, did not require adaptive equipment (smoking apron), and did not use oxygen. R15's smoking assessment dated [DATE], indicated R15 was safe to smoke independently, could keep cigarettes and lighter in room, and used oxygen. The assessment further indicated, Resident had old clothes with holes. Resident has agreed to throw away any clothes with holes .and remove items with burn holes .Resident understands that if new burn holes are seen cigarettes/lighter will be locked and will need to wear a smoking apron. R15's smoking assessment dated [DATE], indicated R15 was not deemed safe to store/handle cigarette and lighter and used oxygen. The assessment further indicated, Resident had lit a cigarette in her room .While observing resident on [DATE] at one time and ash dropped from her cigarette onto her sweater. Writer had to tell her it was there .Cigarettes/lighter will be locked in the nurse cart. She needs to wear a smoking apron, has to ask the nurse for her cigarettes and lighter each time she goes out and return them to the nurse when she comes in. R15's electronic health record (EHR) lacked evidence of any additional smoking assessments. During observation and interview on [DATE] at 9:12 a.m., R15 was lying in bed and was not wearing oxygen. The oxygen tank was not turned on. R15 stated having an incident a couple weeks ago when she lit up a cigarette in her room upon waking but put it out right away. R15 stated she was confused upon waking and did not have her oxygen on at that time and was independent with her oxygen use, which was primarily overnight. R15 stated staff evaluated her ability to smoke safely when she admitted in February and could not recall another evaluation until October when they found burn holes in her clothing. During interview on [DATE] at 9:58 a.m., R15 stated staff just recently watched her smoke and saw that she dropped some ash on her sweater. R15 stated she also had several burn holes in her clothing but could not say when the burn holes happened. R15 stated, they want to make sure I don't burn the place down or burn myself so now they hold onto my cigarettes and lighters, and I put this apron on before I can get them from the nurse cart. During interview on [DATE] at 10:11 a.m., registered nurse (RN)-A stated R15's cigarettes were stored in the cart and that R15 had to have the apron on prior to retrieving. RN-A stated social services performed the smoking assessments to determine if the residents were safe to smoke, but did not know how often those assessments occurred. During interview on [DATE] at 10:22 a.m., social work (SW)-A stated all residents were assessed on admission for smoking status and if they identified as a smoker then social services would complete a smoking assessment. SW-A further stated additional smoking assessments were completed by social services quarterly, with significant change and as needed. SW-A stated R15 had an assessment on admission and was identified as a safe smoker and did not have another assessment until [DATE] when they identified burn holes in her clothing. SW-A stated another assessment was completed after a smoking incident on [DATE] when R15 lit a cigarette in her room. SW-A stated during that assessment, R15 was observed dropping ash on her sweater and therefore, an apron was then required. SW-A further stated R15 should have had two additional quarterly smoking assessments between admission and [DATE], and that they could not determine when the burn holes had occurred. During interview on [DATE] at 10:43 a.m., assistant director of nursing (ADON) stated smoking assessments were completed upon admission, quarterly and as needed. ADON stated R15 recently had a smoking incident and had burn holes identified and observed with shaky hands and dropping ash on her clothing. ADON stated they took her smoking materials away to be stored in the cart and provided a smoking apron. ADON confirmed R15 lacked two quarterly smoking assessments and could not identify when the burn holes had occurred. During interview on [DATE] at 10:56 a.m., director of nursing (DON) stated residents were assessed upon admission by the admission nurse and that the smoking assessment included observation to determine if the resident was safe to smoke independently and hold their own material. DON stated social services would follow up with additional assessments and ensure appropriate interventions were in place and care plan up to date. DON stated the expectation was that smoking assessments were completed on admission, quarterly and with significant changes. Facility policy Resident Smoking Policy dated 10/2024, indicated, Residents who choose to smoke will be evaluated upon admission, quarterly, annually and if significant change in condition/cognition exists or resident exhibits inability to follow safe smoking practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure supplemental oxygen was properly maintained and accurately documented per professional standards for 1 of 1 resident (R20). Findings include: R20's significant change Minimum Data Set (MDS) dated [DATE], indicated R20 had intact cognition and the following diagnoses: pulmonary embolism (a blockage in the lung artery) without acute cor pulmonale (enlarged right ventricle due to a lung condition), enterocolitis due to clostridium difficile, and unspecified dyspnea. R20's Physician Orders form indicated the following orders: • 8/26/24, monitor for skin breakdown around the nose and behind the ears caused by oxygen tubing every shift. • 8/27/24, and discontinued on 10/29/24, staff to follow enteric contact precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) due to C. Difficile (a bacteria that causes infection of the colon) every shift. • 8/30/24, and discontinued on 10/2/24, oxygen sats 2 liters every shift for maintaining oxygen saturations at 88% or above and wean oxygen as able. • 9/1/24, change oxygen tubing weekly every night shift every Monday. • 10/2/24, oxygen sats 2 liters every shift for hypoxia wean oxygen as able, maintain oxygen saturations at 88% or above. R20's medication administration record (MAR) and treatment administration record (TAR) dated September 2024, indicated the following: • 8/27/24, to 10/29/24, Staff documented they were following contact precautions due to C. Difficile (a bacteria that causes infection of the colon) every shift. • R20 was on 1 to 2 liters of oxygen 28 out of 30 days. • R20's oxygen tubing was documented as changed on the night shift on 9/2/24, 9/9/24, 9/16/24, 9/23/24, and 9/30/24. R20's MAR and TAR dated October 2024, indicated the following: • Staff documented they followed contact precautions due to C. Difficile from 10/1/24, to 10/29/24. • R20 was on 2 liters of oxygen 31 of 31 days. • R20's oxygen tubing was documented as changed on the night shift on 10/7/24, 10/14, 24, 10/21/24, and 10/28/24. R20's MAR and TAR dated November 2024, saved on 11/4/24 at 4:40 p.m., indicated the following: • R20 was on 2 liters of oxygen for 4 of 4 days. R20's care plan dated 11/13/22, indicated R20 had frequent bladder incontinence and was occasionally incontinent of the bowel and required brief changes. R20's care plan dated 9/9/24, indicated R20 had an altered respiratory status and difficulty breathing due to pulmonary edema. During observation on 11/4/24 at 1:33 p.m., R20 was on 2 liters of oxygen in her room and the sticker on the tubing was dated 9/3. The tubing had not been signed off as changed in the MAR/TAR as of 4:42 p.m. During observation on 11/5/24 at 9:23 a.m., R2's oxygen tubing still contained the tape that indicated a date 9/3. During interview and observation on 11/5/24 at 9:34 a.m., registered nurse (RN)-A stated oxygen tubing was changed weekly when a resident used oxygen and further stated they sometimes dated the tubing and the order was also in the computer to change weekly. At 9:38 a.m., RN-A verified the oxygen tubing plugged into the oxygen unit contained a piece of tape and stated the tape was dated 9/3/24, and thought the extension and nasal cannula tubing was supposed to be changed weekly. During interview on 11/5/24 at 1:53 p.m., the assistant director of nursing (ADON) stated oxygen tubing should be changed weekly and dated with the date the tubing was changed and the old tubing discarded and further stated it was on the TAR and expected the nasal cannula and extension tubing to be changed and stated staff should document in the TAR once they changed the tubing. ADON stated staff should not have signed off they completed the task in the TAR because it was false documentation and was also important to change for infection control. A policy on respiratory care was requested. An email from the director of nursing (DON) dated 11/6/24 at 9:22 a.m., indicated they did not have a policy on oxygen tubing, but followed batch orders that instructed staff to change the tubing weekly. Additionally, they did not have a policy on accurate documentation and expected nurses follow orders and document accurately and if not completed, would follow the corrective action procedure. During interview on 11/7/24 at 8:50 a.m., the DON stated she expected staff to follow orders and not document if something was not completed and further stated she completed corrective action with their nurse and added the other nurse was an agency nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure 2 of 5 residents (R5 and R20) were offered and/or provided updated vaccinations for pneumococcal disease in accordance with the Centers for Disease Control (CDC) vaccination recommendations. Findings include: R5's Resident Information form dated 11/7/24, identified she was admitted on [DATE], and was currently [AGE] years old with diagnoses which increased the risk of pneumococcal disease including chronic obstructive pulmonary disease, heart failure and history of acute respiratory failure. R5's undated Immunizations form identified the PCV-13 and PPSV23 were given on 2/23/15. R5's vaccine consent form dated 9/7/24, identified she consented to receive the pneumococcal vaccines per primary care provider order and CDC guidelines. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 9/12/24, identified based on R5's age and vaccine history: though the vaccines were considered complete, based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. R5's medical record lacked a discussion of shared clinical decision making regarding additional pneumoccocal vaccines. R20's Resident Information form dated 11/7/24, identified she was admitted [DATE], and was currently [AGE] years old with diagnoses increasing the risk of pneumococcal disease including pulmonary embolism, dyspnea (difficulty breathing), chronic heart failure and obstructive sleep apnea. R20's vaccine consent form dated 11/12/22, identified she already had the PPSV23 and PCV-13 but there was a question mark by the date. R20's undated Immunizations form identified no history of the pneumococcal vaccinations. R20's medical record lacked follow up regarding declination or administration of the pneumococcal vaccines. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 9/12/24, identified based on R20's age and vaccine history: give one dose of PCV15, PCV20, or PCV21. If PCV20 or PCV21 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV23 to complete their pneumococcal vaccinations. During an interview on 11/7/24 at 12:00 p.m. the director of nursing (DON) who was also the infection preventionist, stated shared clinical decision making for additional pneumococcal vaccines was not completed with R5 because her vaccines were considered complete according to the Minnesota Immunization Information Connection (MIIC). The DON had not reviewed the vaccines in accordance with updated CDC recommendations. The DON stated no one had followed up to verify R20's vaccine history and should have. The facility's Pneumococcal Policy dated 2/2024, identified the current practice was to offer all residents the vaccines to aid in the prevention of pneumococcal/pneumonia infections. Within 30 days of admission, the resident will be offered the vaccine, when indicated, unless the resident has already been vaccinated or the vaccine is medically contraindicated. If the immunization status was unknown, staff would contact the physician to determine record of immunization status or verify using MIIC. The facility would refer to the current CDC Recommended Adult Immunization Schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Ice packs During observation on 11/5/24 at 9:45 a.m., the resident freezer in the third-floor kitchenette contained a reusable blue ice pack. It was touching residents' labeled containers of food. A sign posted on the refrigerator indicated for resident food only. During observation on 11/5/24 at 9:50 a.m., the resident freezer in the second-floor kitchenette contained a blue reusable ice pack, touching residents' labeled items. A sign posted on the refrigerator indicated for resident food only. When interviewed 11/5/24 at 10:00 a.m., registered nurse (RN)-B stated ice packs were not supposed to be in freezer in kitchenettes, and stated there was a freezer for residents' ice packs in the nursing office. Reusable ice packs were not supposed to be with food for infection control reasons. (RN)-B removed the ice pack from the freezer. During observation on 11/5/24 at 10:13 a.m., the resident freezer in the first-floor kitchenette contained multiple blue reusable ice packs. The ice packs were touching residents' frozen labeled items including ice cream and containers of food. A sign posted on the refrigerator indicated for residents' food only. When interviewed on 11/5/24 at 10:15 a.m., nursing assistant (NA)-D stated ice packs should not be stored in the freezer. At 10:17 a.m., the culinary director (CD)-G entered the kitchenette, removed the reuseable blue ice packs swiftly out of the freezer, and stated they didn't belong there, and stated there was medication freezer for the ice packs. When interviewed on 11/6/24 at 10:29 a.m., director of nursing (DON) stated the reusable ice packs should be stored separately in the medication room freezers and not freezers in the kitchenettes due to infection control concerns, and they expected all staff to know and follow this procedure. During an interview on 11/7/24 at 12:00 p.m., the director of nursing (DON) stated EBP should always be utilized for high-contact resident care activities for residents that meet the requirements, for infecton control purposes, and to help prevent the spread of multi-drug resistent organisms, and signage with directions including the needed supplies should be in place to assist with staff compliance. The DON stated hand hygiene should be completed between glove changes during major cares such as incontinence care. Shared resident equipment such as transfer lifts should be cleaned between uses, and have the disinfectant wipes in a bag on the lifts. The facility's EBP policy dated 4/1/24, defined EBP as the implementation of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (for example residents with wounds or indwelling medical devices). Indwelling medical devices included central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, and wounds including chronic owund ssuch as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers. Review of Monarch Healthcare Management Handwashing Policy dated 2/2024 directed staff: When conducting a procedure requiring the use of gloves, proper hand washing shall be completed before donning gloves and after removing gloves. R35's annual MDS dated [DATE], indicated intact cognition and diagnoses of chronic kidney disease (CKD) and type II diabetes. It further included R35 required staff assistance with activities of daily living, mobility, had a catheter and was frequently incontinent of bowel. R35's care plan dated 4/1/24, indicated R35 was currently on EBP related to a wound and foley catheter. It further included the following interventions: -staff to follow EBP -explain reason for and use of EBP -staff to don (put on)/doff (take off) personal protective equipement (PPE) when providing high contact cares. During observation on 11/04/24 at 3:02 p.m., R35 put on his call light and the assistant director of nursing (ADON)- entered the room. R35 stated he wanted to be boosted up in bed. The ADON applied gloves and assisted him to roll onto his left side, adjusted his brief, assisted him to roll onto his back, and pulled the trapeze bar down and handed it to him. R35 then used the bar to boost himself up in bed. The ADON then removed her gloves and left the room. The ADON was not wearing a gown while assisting R35. During interview on 11/4/24 at 3:13 p.m., the ADON verified she was not wearing a gown when assisting R35 with cares and was only required to wear a gown for catheter and wound care stating R35's order indicated he only need to be on enhanced barrier precations (EBP) for catheter and wound care. The ADON also stated EBP was specific to what each resident had for instance if a resident had a wound staff only needed to follow EBP when caring for the wound. During interview on 11/7/24 at 9:38 a.m., nursing assistant (NA)-C stated if a resident was put on EBP, staff were required to wear a gown and gloves when performing any personal cares. During interview on 11/7/24 at 9:45 a.m., NA-E stated staff were supposed to wear a gown, gloves, and a mask when performing cares on a resident who is on EBP. During interview on 11/7/24 at 9:50 a.m., RN-A stated when a resident was on EBP, staff were required to wear gloves and a gown for all personal cares. During interview on 11/7/24 at 10:00 a.m. RN-C stated staff are supposed to wear gown and gloves when performing any type of cares for a resident on EBP. R11 R11's quarterly MDS dated [DATE], indicated R11 had severe cognitive impairment, was frequently incontinent of bowel and bladder, and was dependent on staff for personal cares. R11's diagnoses included dementia, cerebral atherosclerosis (a condition causing plaque buildup in the arteries and decrease blood flow to the brain), and reduced mobility. R11's care plan updated 11/1/24, indicated R11 had a stage II pressure ulcer on sacrum and required enhanced barrier precautions (EBP) related to the wound. The care plan instructed staff to don/doff [put on/take off] PPE per [EBP] when providing high contact cares. R11's provider orders dated 11/1/24, indicated, Follow EBP while providing wound cares and other high contact care activities. During observation on 11/5/24 at 12:55 p.m., nursing assistant (NA)-B and NA-C wheeled R11 into her room to transfer back to bed and complete a brief change. Signage for EBP and all appropriate PPE observed on R11's door. Both NA-B and NA-C donned gloves, but neither donned a gown. R11's sling was attached to the Hoyer lift and R11 was lifted up and transferred to bed. R11's pants removed, and brief checked and found to have bowel movement (BM). Brief removed and dressing noted over the sacral wound. NA-B completed peri care wiping R11's bottom up to and including the bottom edge of the dressing. A new brief placed. R11 positioned and tucked in bed for a nap. During interview on 11/5/24 at 1:16 p.m., NA-B stated was not sure what the signage meant or if it was for R11 or her roommate. NA-B stated did not think he needed to wear a gown for peri care on R11. During interview on 11/5/24 at 1:23 p.m., NA-C stated EBP was for residents with a catheter or wound and that staff need to gown and glove when caring for those residents. NA-C stated R11's precautions must be new this week and did not notice the signage or PPE on her door. NA-C further stated he and NA-B should have donned gowns while performing cares on R11 since she had a wound. Based on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP) were implemented with the use of personal protective equipment (PPE) during high-contact resident care activities for 1 of 1 residents (R39) who had a central line, 1 of 1 residents (R38) who had wound dressings changed, and 1 of 3 residents (R11) observed during personal cares. The facility also failed to ensure appropriate hand hygiene was utilized for 1 of 2 residents (R38) observed during personal cares, and failed to ensure shared resident equipment was disinfected between uses for 1 of 1 residents (R3) observed for shared equipment. Lastly, the facility failed to ensure re-usable ice packs for clinical use were stored separately from food storage in 3 of 3 kitchen refrigerators. Findings include: R39's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, no rejection of care or behaviors, partial/moderate assistance needed for upper body dressing and supervision for personal hygiene. Diagnoses included extradural and subdural abscesses and type two diabetes mellitus. Injections and antibiotics were received 7/7 days. R39's functional abilities Care Area Assessment (CAA) worksheet dated 10/20/24, identified a history of infection following lumbar spine surgery which required intravenous (IV) antibiotics. The surgical site became reinfected and required additional surgery. Then, he was admitted to the facility on IV antibiotics, wound care and peripherally inserted central catheter (PICC) line (long, thin tube that's inserted through a vein in the arm and passes through to the larger veins near the heart, requires careful care and monitoring for complications, including infection) care. R39's care plan dated 10/17/24, identified contact precautions were in place due to VRE (vancomycin-resistant enterococci which is resistent to antibiotics, in lumbar area due to abscess. The care plan was marked as resolved on 10/25/24. There was no care plan in place for EBP until 11/4/24. R39's orders identified: 10/16/24, flush line (PICC) with 10 milliliters (mL) of normal saline prior to IV drug administration daily. 10/15/24, PICC/midline monitor site, location left arm every shift for s/s of infection and infiltration every shift. 10/21/24, PICC/midline change dressing location left arm using sterile technique weekly and as needed. 10/15/24, complete infection nurses note and document what antibiotics, how long, why, symptoms, side effects, effectiveness every day shift until 11/20/24. There were no orders for EBP until 11/4/24 at 11:00 p.m. During an observation and interview on 11/4/24 at 12:50 p.m., R39's door lacked EBP signage or nearby PPE. R39 was in bed and awake. A PICC line with dressing was observed on his left upper arm. He stated he got IV antibiotics through the PICC line, and he had not noticed staff wearing a gown while providing this care. During an observation on 11/4/24 at 1:50 p.m., registered nurse (RN)-D prepared to give R39 his IV antibiotic. RN-D performed hand hygiene, entered the room, put gloves on, used an alcohol wipe to clean the port of the PICC line and flushed the line with 10 mL of normal saline. He attached the antibiotic to the PICC line and opened (unclamped) the line to start the infusion. RN-D also assisted R39 to put on his back brace. RN-D had not worn a gown in accordance with EBP. During a follow up interview on 11/4/24 at 2:04 p.m., RN-D was not immediately sure if a gown was required for R39 high-contact cares since there was no signage or PPE bin outside. However, he added, he should have due to the PICC line. During an observation and interview on 11/5/24 at 1:52 p.m., R39's door had EBP signage and PPE organizer on the door. EBP signage directed staff to wear gloves and a gown for high-contact resident care activities including dressing, bathing, transfers, hygiene, incontinence care, and device care including lines, catheters, tubes tracheostomy and wound care. The PPE organizer contained gloves and gowns. RN-E prepared to give R39 his IV antibiotic. RN-E performed hand hygiene, entered the room, put gloves on, opened an alcohol wipe to clean the port of the PICC line, said he was going to start the IV antibiotics, and was stopped by surveyor and asked if EBP were required. RN-E initially had not known what EBP stood for and exited the room to check the orders. RN-E re-entered the room and came back with a gown, put it on and then put on gloves. R39 asked RN-E what the gown was for, and it was explained it was for IV site care and flushed the line with 10 mL of normal saline. RN-E attached the antibiotic to the PICC line and opened the line to start the infusion. After RN-E exited the room he stated for PICC line care staff needed EBP PPE on, he explained he had not thought of it today. R38 EBP R38's significant change MDS dated [DATE], indicated R38 had moderate cognitive impairment, was dependent on staff for personal cares, and received hospice services. R38's diagnoses included dementia, mood disturbance, anxiety, and adult failure to thrive. R38's care plan updated 4/8/24 indicated R38 required enhanced barrier precautions (EBP) related to a foley catheter and history of ESBL/MRSA [extended-spectrum beta-lactamase (an enzyme that make bacteria resistant to many antibiotic)]/methicillin-resistant Staphylococcus aureus ( a type of staph bacteria that is resistant to many antibiotics)]. R38's provider orders dated 6/5/24, indicated, Follow EBP while providing wound cares and other high contact care activities. During observation on 11/7/24 at 8:15 a.m., R38's door had EBP signage on door and PPE organizer outside the door. EBP signage directed staff to wear gloves and a gown for high-contact resident care activities including dressing, bathing, transfers, hygiene, incontinence care, and device care including lines, catheters, tubes tracheostomy and wound care. The PPE organizer contained gloves, masks and gowns. Doctor of Medicine (MD)-A (rounding wound doctor) entered R38's room. MD-A was wearing a mask, and applied gloves, but did not don a gown. MD-A observed R38's coccyx wound , and bilateral heels. MD completed an ultra sound mist treatment to R38's heel, removed her gloves, washed her hands and left the room. Interview on 11/7/24 at 8:30 a.m., MD-A indicated she missed the sign on the door that indicated R38 was on Enhanced Barrier Precautions., and indicated if she would have seen the sign, she would have put a gown on. R38 Hand Hygiene R38's significant change MDS dated [DATE], indicated R38 had moderate cognitive impairment, was dependent on staff for personal cares, and received hospice services. R38's diagnoses included dementia, mood disturbance and anxiety, and adult failure to thrive. R38's care plan updated 4/8/24 indicated R38 required enhanced barrier precautions (EBP) related to a foley catheter and history of ESBL/MRSA [extended-spectrum beta-lactamase (an enzyme that make bacteria resistant to many antibiotic)]/methicillin-resistant Staphylococcus aureus ( a type of staph bacteria that is resistant to many antibiotics)]. During observation on 11/6/24 at 7:43 a.m., Trained medication assistant (TMA)-A washed R38's rectal area, changed her gloves, but did not perform hand hygiene. TMA -A repositioned R38 in bed and removed her gloves and left the room. Interview on 11/06/24 at 07:58 a.m., TMA-A indicated that she should have used hand sanitizer or washed her hands after removing her gloves. Shared Equipment During observation on 11/6/24 at 9:10 a.m. TMA -A and nursing assistant (NA) - A transferred R3 into bed with a Hoyer lift (a lift that helps caregivers safely transfer patients from chair to bed). TMA-A removed the lift from R3's room into the spa room, and walked away. Interview on 11/6/24 at 9:21 a.m., TMA-A stated the lift should be cleaned when brought out of a resident's room, and left the spa room. TMA-A returned to the spa room at 9:30 a.m. and proceeded to clean the lift with wipes that were in the bag on the back of the lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a multi-resident shower room ceiling exhaust fan was cleaned. This had the potential to affect all residents on the third floor who used the shower room. Findings include: R71's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition. A Monthly Deep Clean Schedule form undated, indicated the 3rd floor long-term care north and south unit spa/bathrooms were deep cleaned on day 6 of the month. A Deep Clean Calendar dated October 2024, indicated spas were scheduled to be cleaned on 10/6/24. A November 2024 Deep Clean Calendar form was not provided. A procedure, undated, Deep Clean Procedures, indicated to check the posted deep clean schedule and clean the scheduled deep clean room. Further, the procedure directed staff to wipe the top and all sides of heating units and check top vents for accumulation of dust or other debris for resident rooms and to use a high duster to clean vents in restrooms. During interview and observation on 11/4/24 at 12:09 p.m., R71 stated he previously worked as a janitor and staff should dust the vents in the room by the window. R71's vent in the room contained dark colored debris and gray particles hanging off the grates and vent and R71 stated the common shower room vent was worse. During observation on 11/4/24 at 12:54 p.m., the shower room located across from room [ROOM NUMBER] had a vent on the ceiling that was coated with gray debris and some of the debris was hanging off of the vent. During interview and observation on 11/7/24 at 9:02 a.m., social worker (SW)-A stated it was maintenance's responsibility to clean the vents and viewed the vent on the ceiling in the community shower room on the third floor and stated it looked like it contained lint or dust and stated there was a lot of it and thought it was possible it had been there more than a couple of months and further stated they used to have another maintenance person who covered the building and would check with M-A or M-B to see when it was last cleaned. During interview and observation on 11/7/24 at 9:13 a.m., maintenance (M)-A stated he worked for the facility for 14 years and stated vents were cleaned monthly when they changed the filters and vents on the ceiling were cleaned by housekeeping. M-A stated this was a new company and further if they deep cleaned, cleaning was done when people were moved and housekeeping completed the shower room deep cleaning. M-A viewed the vent in the 3rd floor shower room and stated it was an exhaust fan and when residents showered, the room became a rain forest and stated the vent had been wetter than wet and it looked like there was fuzzy fuzz on the vent and did not know how long it had been there and then checked the light fixture for dust, which did not contain any and stated that was housekeeping's responsibility and added they would get that cleaned up. During interview on 11/7/24 at 9:32 a.m., housekeeping (H)-A stated she had been at the facility since 7/2024 and stated the shower room was cleaned daily from top to bottom and included dusting, cleaning mirrors, the sink, toilet, and stated the vents, grab bars, and shower head were all cleaned daily. During interview on 11/7/24 at 9:37 a.m., H-B stated shower rooms were cleaned daily as part of a routine as well as if needed and entailed the showers, tubs, toilets, sink, stocking, sweeping, mopping and dirty linen. H-B stated they did a deep cleanings monthly. At 9:42 a.m., H-B stated staff should have looked at the vent as part of a daily cleaning and expected the vent to be cleaned. A policy for cleaning schedules for deep cleaning and daily cleaning was requested. During interview on 11/7/24 at approximately 10:57 a.m. M-A stated he cleaned the bathroom exhaust fan in the 3rd floor shower room and had not spoken to the administrator. During interview on 11/7/24 at 11:03 a.m., with the administrator, a policy or check list for daily cleaning was requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to report an allegation of resident sexual abuse to the State Agency (SA) immediately, but not later than two hours after the allegation is made, for 1 of 1 resident (R1) reviewed who reported an allegation of sexual abuse in the facility. Findings include: R1's Minimum Data Set (MDS) assessment dated [DATE], indicated R1 admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia, traumatic brain injury, seizure disorder, depression, post-traumatic stress disorder, and encounter for palliative care. R1 had moderate cognitive impairment and was dependent on staff for all hygiene cares, mobility, and transfers. R1's care plan focus dated 5/24/24, identified R1 as a vulnerable adult. It included an intervention dated 5/24/24, the 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 #357954 submitted to the SA by the facility identified the date and time of submission as 10:35 a.m. on 9/16/24 and the submitter as the facility's administrator. The report noted at about 8:30 a.m. on 9/16/24, the administrator was notified by the assistant director of nursing (ADON) [R1] reported that she was raped at the facility to a family member who reported to R1's guardian who then reported to the facility. The date and time of the incident was identified as 5:24 p.m. on 9/14/24. The five day follow-up report submitted to the SA by the facility dated 9/20/24, noted on the night of 9/14/24 R1 made the statement that she was raped at the facility while on the phone with her [family member], with two staff members present. A document attached to the report, undated and unnamed, included an internal investigation was launched which led to the discovery of [nursing assistant (NA)-A] and agency [licensed practical nurse (LPN)-A] being present during the time of allegation on 9/14/24. During an interview on 9/24/24 at 7:33 a.m., NA-A stated she helped provide care for R1 on the evening shift on Saturday 9/14/24, but was not R1's assigned NA. She stated she was helping R1 make a phone call to a family member because R1 was upset and phone calls had helped calm her in the past. NA-A stated while R1 was talking on the phone to a family member she stated, can you please call the police for me . then she said I have been raped, can you please call the police for me. NA-A noted R1's nurse LPN-A was present in the room as she had come to give R1 some pills and was standing there. NA-A stated she asked LPN-A if she heard what R1 said, and LPN-A said yes and asked R1 why she was making these allegations and then left the room. NA-A stated after exiting R1's room she asked LPN-A again if LPN-A heard what R1 said and LPN-A stated yes, she had heard everything. NA-A stated she then concentrated on providing cares for her assigned residents and I didn't do anything else because the nurse was right there . so I was thinking she is supposed to take measures after that, so I focused on my own residents. The nurse is the one that is supposed to make the report, since she was there it was her responsibility and not me as an aide. During an interview on 9/24/24 at 9:52 a.m., the director of nursing (DON) noted the facility's investigation identified NA-A and LPN-A as present at the time R1 made the allegation of sexual abuse on the phone and overheard it. The DON stated NA-A said she did not report the event because the nurse was present at the time and NA-A assumed the nurse was going to report it. The DON stated she spoke to LPN-A who confirmed she heard the allegation but didn't think it was real and didn't report it. The DON identified the SA requires such allegations be reported immediately, but not more than two hours after the allegation is made. The DON stated, staff became aware of the sexual abuse allegation on Saturday when it happened, it was heard by the nurse and the aide . it should have been reported immediately . the policy is that it has to be reported immediately . this was not reported timely. During an interview on 9/24/24 at 10:55 a.m., LPN-A stated she provided care for R1 on the evening of 9/14/24. LPN-A stated she entered R1's room to give her medications and NA-A was there helping R1 make a phone call. After giving R1 the medications, LPN-A noted she walked out and left NA-A and R1 in the room and went to prepare medications for other residents. LPN-A stated she was then passing by R1's room and when she [R1] was on the phone with [the family member] she said they raped me . I heard [R1] say something like they raped me as I was walking by. LPN-A stated after that I continued passing med[ication]s because I was already late passing med[ications]s . after that I did not actually do anything. Of course, I was supposed to report it. I know there was no excuse, but I got caught up with so many things . I did not talk to the aide about it or tell anyone . I did not report it on Saturday. During an interview on 9/24/24 at 12:58 p.m., the administrator confirmed he reported an allegation of sexual abuse to the SA on 9/16/24 because R1 reported a rape at the facility. The administrator confirmed staff initially became aware of the allegation around 7:20 p.m. on 9/14/24 though he was not aware of it until the morning of 9/16/24 around 8:45 a.m. The administrator stated It was not reported timely. My expectation and the policy is that it would be reported immediately . we have to report sexual abuse to the state [SA] within two hours. Facility policy titled Sexual Abuse Allegations Procedure dated 6/18/19, included: The Administrator, Director of Nursing, or Social Worker will notify Minnesota Department of Health immediately. This notification MUST be made as soon as possible after learning of the allegation. Facility policy titled Abuse Prohibition/Vulnerable Adult Policy dated 3/2024, included: All staff are responsible for reporting any situation that is considered abuse or neglect along with injuries of unknown origin . Suspected abuse shall be reported to OHFC [Office of Health Facility Complaints] online reporting process not later than 2 hours after forming the suspicion of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to monitor edema and comprehensively assess non-pressure related wounds for 1 of 1 resident (R2) reviewed. Findings Include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 was admitted on [DATE] with diagnoses including malignant neoplasm of brain (brain cancer), hypertension, and chronic ischemic heart disease (weakening of the heart caused by reduced blood flow) and was receiving hospice care. R2's active physician order dated 2/19/24, directed nurses to chart R2's condition in nurse's notes every shift for edema (fluid retention in body tissues that can result in swelling and/or weight gain) checks noting edema as present or not present and lung checks noting lungs as clear or not clear. R2's treatment administration records (TAR) were reviewed in conjunction with progress notes and skin evaluations, it was not evident edema was consistently comprehensively evaluated. Although the TAR's which identified the physician orders for edema checks and lung sounds were completed, the extent of edema was not included. Instead the TAR for edema monitoring documentation had plus signs (+) indicating edema was present or minus signs (-) indicating no edema. In the boxes for lung sounds the boxes identified (cl) for clear and (+) for not clear. R2's active physician order dated 2/19/24, directed staff to complete weekly weights for R2 every Thursday. R2's weight record was reviewed in conjunction with progress notes and skin evaluations, R2's weight record identified between 2/19/24 to 4/25/24, R2 had a weight gain of 16.2 pounds (lbs). It was not evident R2's weight gains were comprehensively assessed to ascertain if the gains were nutritional and/or fluid related in order to evaluate for a change in R2's overall health status and possible disease progression and further treatment needs. Weights documented in R2's electronic health record (EHR) included: 181.4 pounds (lbs.) on 4/25/24 at 2:34 p.m. 181.4 lbs. on 4/25/24 at 12:48 p.m. 177.2 lbs. on 4/18/24 at 1:58 p.m. 177.2 lbs. on 4/18/24 at 1:55 p.m. 177.2 lbs. on 4/18/24 at 1:52 p.m. 180.8 lbs. on 4/11/24 at 2:47 p.m. 180.8 lbs. on 4/11/24 at 1:59 p.m. 181.0 lbs. on 4/4/24 at 2:56 p.m. 181.0 lbs. on 4/4/24 at 12:28 p.m. 182.4 lbs. on 3/28/24 at 12:18 p.m. 182.4 lbs. on 3/28/24 at 10:13 p.m. 177.4 lbs. on 3/21/24 at 1:44 p.m. 177.4 lbs. on 3/21/24 at 12:40 p.m. 176.6 lbs. on 3/14/24 at 8:59 p.m. 176.6 lbs. on 3/14/24 at 2:00 p.m. 176.6 lbs. 3/14/24 at 9:33 a.m. 175.4 lbs. on 3/7/24 at 1:59 p.m. 175.4 lbs. on 3/7/24 at 1:36 p.m. 171.4 lbs. on 2/29/24 at 2:49 p.m. 171.4 lbs. on 2/29/24 at 1:30 p.m. 169.6 lbs. on 2/22/24 at 10:42 a.m. 169.6 lbs. on 2/22/24 at 10:21 a.m. 165.2 lbs. on 2/19/24 at 2:20 p.m. 165.2 lbs. on 2/19/24 at 12:49 p.m. 165.2 lbs. on 2/19/24 at 12:32 p.m. A provider note dated 2/21/24, from R2's initial encounter indicated due to progressive functional and cognitive decline, oncology recommended transition to hospice. He is admitted here for LTC [long term care] on [agency name] hospice. It also noted R2 reported he quite smoking 39 years ago and his smoking use included cigarettes. R2's Weekly Skin Inspection dated 2/22/24, noted R2 had large bruises on his left inner and outer elbow and a scar, bruising on bilateral lower extremities (BLE, both legs), a scar on the left shin, and scratches on knees and shin. It did not note any other skin concerns or edema. R2's Skin Evaluation and Skin Risk Factors assessment dated [DATE], noted R2 had a left antecubital (inner elbow) skin tear, bruising on the left elbow, scar on the left elbow, and identified a skin issue on the left forearm but did not specify what type of issue. The description and summary sections noted R2 had a large superficial skin tear on his left forearm and an unspecified wound bed looked red. Drainage was listed as N/A, the periwound description and measurements were not completed. Risk factors selected from a pre-populated list of options were psychotropic drug use. R2's hypertension, cancer, history of smoking, left side hemiparesis, and cognitive impairment were not identified. The summary indicated R2 had no feeling on the left side as he said his left side upper and lower extremities are numb. No interventions were listed in the interventions section. R2's Wound Evaluation Form dated 2/23/24, noted a left forearm skin tear that was superficial with a red wound bed. A dressing was applied to the wound bed and covered with a gauze, no pain was associated with wound care. The measurements section was not completed. No additional Wound Evaluation Forms were identified during review of R2's EHR. A hospice communication note date 2/26/24, indicated wound care was completed for the left arm and included the following measurements of unspecified wounds: 4 x 2.5 centimeters (cm), 2.5 x 2 cm, 1 x 1 cm, 1 x 0.5 cm, and 1 x 0.5 cm. Information about the specific wound locations, types, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. R2's Weekly Skin Inspection dated 2/29/24, bruising on the left elbow, arm, and back of left hand, some scars and skin tears, bruising and scars on the back of the right hand, bruising on BLE, and signs of edema on both feet. Information about the specific wound locations, wound measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. Assessment of the edema was also not documented. A hospice communication note dated 3/1/24, indicated wound cares were completed on the left arm and included measurements of 4.5 x 1.5 cm outer left forearm wound, 2 x 1.5 cm inner left forearm wound, 1 x 1 cm elbow wound, and 1 x 1 and 0.5 x 0.5 cm wounds on the bottom of the left arm. Information about the wound types, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. A hospice communication note dated 3/5/24, indicated wound care was performed and included wound measurements of 3 x 2 cm, 0.5 x 1 cm, and 1 x 1 cm on the left top arm and 2 x 2 cm, 0.5 x 0.5 cm, and 1 x 1 cm on the left bottom arm. Information about the specific wound locations, wound types, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. R2's active physician order dated 3/7/24, directed staff to apply Velcro wraps (compression wraps) to BLE. R2's Weekly Skin Inspection dated 3/7/24, noted R3 had bruising on BLU (possible mis-type of BUE, bilateral upper extremities) and BLE with scars. It did not identify any edema or further skin issues. A hospice communication note dated 3/8/24, indicated wound care was performed. No information about the wounds was documented. A hospice communication note dated 3/11/24, indicated wound cares were completed on the left arm, four of five wounds were resolved, and included a measurement of 0.8 x 1 cm of a wound on [illegible] left forearm. Information about the wound bed, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. A progress note dated 3/12/24, noted a 30-day nutritional review was completed by dietary and identified a weight of 175.4 lbs. on 3/7/24, weight gain noted since admission, family and hospice updated, registered dietician will continue to observe per facility protocol. A progress note dated 3/12/24, noted R2 said he was going through a door and squeezed his left arm against the door, sustaining a skin tear on the left elbow. Information about the wound measurements, wound bed, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. R2's care plan identified a risk for alteration in skin integrity related to frail skin, left-sided hemiparesis (one-sided muscle weakness), and weakness dated 3/13/24. Interventions included application of a geri-sleeve (sleeve to protect fragile skin) to left and right arms covering R2's hands, forearms, and elbows to prevent skin tears/abrasions, inspection of skin daily with nursing aides to report any concerns to nurse, and weekly skin assessment by licensed staff. R2's skin care plan did not identify his edema or included related interventions. R2's Skin Evaluation and Skin Risk Factors assessment dated [DATE], identified a left elbow skin tear. The wound bed was described as approximated edges with steri-strips (adhesive bandages) applied. It noted the periwound area (skin surrounding the wound) was intact and the wound bled a small amount at first with no further drainage. The presence of a new wound prompting assessment was marked yes. Risk factors selected from a pre-populated list of options were cognitive impairment and other: left side hemiparesis. R2's psychotropic drug use, hypertension, cancer, and history of smoking were not identified. Interventions included R2 wearing a geri-sleeve on the left arm. The summary described the incident causing the skin tear. R2's Weekly Skin Inspection dated 3/14/24, noted bruising on bilateral upper extremities (BUE) with wounds in healing on the left arm and scars as well as bruising on BLE. Information about the number and location of the wounds on the left arm, the wound measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. It did not identify edema. A progress note dated 3/15/24, noted a new small skin tear with a scab forming on the left forearm was identified while resident's geri-sleeve was removed for a shower. Information about the wound measurements, wound bed, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. A hospice communication note dated 3/15/24, indicated wound care was completed for the left arm. Information about the number and location of the wound(s) on the left arm, the wound measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. R2's Skin Evaluation and Skin Risk Factors assessment dated [DATE], noted skin tears on the left elbow and left forearm. The wound bed noted steri-strips on the left elbow skin tear and a small skin tear on the left forearm with a scab forming and Band-Aid applied. Drainage description noted scant blood but did not identify the associated wound(s). The periwound area was described as intact with no open areas. The presence of a new wound prompting assessment was marked yes. Risk factors selected from a pre-populated list of options were cognitive impairment, psychotropic drug use, and other: left side hemiparesis. R2's hypertension, cancer, and history of smoking were not identified. Interventions included geri-sleeve on left arm, wheelchair cushion, and an extended wheelchair arm rest for the left side requested from hospice. Information about the wound measurements and pain was not documented. A hospice communication note dated 3/19/24, indicated wound care was completed for the left leg and left arm. It noted left leg is new, unsure cause but appears vascular due to edema. Information about the extent of the edema was not identified. Furhter the number and location of the wounds, the wound measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. R2's Weekly Skin Inspection dated 3/21/24, noted bruising on BUE with scars on the back of both hands and open wounds on the left elbow, bruising on BLE, scars and a wound on the left shin, and bruising on the left side of the neck. Information about the number and location of the wound(s) on the left elbow, the wound measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. It did not identify edema. A hospice communication note dated 3/21/24, indicated wound care was completed, there was no complaint of pain, no signs or symptoms of infection, and included the following measurements: 1.5 x 1 cm left lateral arm wound, 3 x 2 cm left arm wound, and 1 x 0.5 cm left leg wound. Information about the wound beds, drainage, odor, periwound area and wound edges, and risk factors was not documented. A progress note dated 3/22/24, noted assessment was done of the right leg due to the weekly skin check indicating the presence of a wound. No wound or open area was noted, a small intact scab was identified. A hospice communication note dated 3/25/24, indicated wound care was completed on the left leg and arm. It noted several new wound[s] to left arm, will reassess on next visit for measurements. Information about the specific location of the wounds, measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. R2's active physician order dated 3/25/24, directed that R2 take 4 milligrams (mg) of dexamethasone (a steroid medication) by mouth once daily. R2's Weekly Skin Inspection dated 3/28/24, noted bruising on BUE with scars, an open area on the left forearm, bruising on the right lower extremity, and small scab on the right lower shin. Information about the wound measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. It did not identify edema. R2's Fall from Chair report dated 3/28/24, noted R2 fell and sustained injuries including bleeding from the left elbow at the site of a previous injury, and a skin tear in the inner upper arm. The left elbow injury was identified as a skin tear. Information about the measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. A progress note dated 3/31/24, noted R2 was found on the floor and sustained skin tears on the right arm and left hand. Information about the specific of the right arm wound, wound measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. A progress note dated 3/31/24, noted the on-call provider ordered monitoring of R2's skin tears. R2's Weekly Skin Inspection dated 4/4/24, noted bruising and scars on BUE, right lower extremity bruising, and a scab on the right shin. It did not identify edema. R2's Weekly Skin Inspection dated 4/11/24, noted bruising and scars on BUE, multiple bruises on the left arm, bruising on the right lower extremity, and a superficial scratch on the right thigh. It did not identify edema. A progress note dated 4/12/24, noted R2 bumped his hand on the toilet grab bar when sitting down and sustained a skin tear on the right hand. Information about the wound measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. R2's Skin Evaluation and Skin Risk Factors assessment dated [DATE], noted a skin tear on the back of the right hand. The description noted it was superficial with a wound bed of 100% epithelial tissue, drainage was a small amount of bleeding, and the periwound area had peeled skin around the edges of the wound. A new wound prompting assessment was marked yes. Risk factors identified included other: hemiplegia and frail skin. R's psychotropic drug use, steroid medication, hypertension, cancer, history of smoking, and cognitive impairment were not identified. No interventions were identified. R2's Weekly Skin Inspection dated 4/18/24, noted bruising and scars on BUE, a scar on the right thigh, and some small bruising on the right lower extremity. It did not identify edema and noted there were no other skin issues at the time. A Fall Review Evaluation dated 4/20/24, noted R2 fell in the bathroom and no injury was found. A progress note dated 4/22/24, noted the inter-disciplinary team reviewed R2's fall on 4/20/24 and R2 had a small, scabbed area on his right posterior arm related to the fall. It did not include further assessment of the newly identified scabbed area. A progress noted dated 4/22/24, noted R2 had a skin tear on his right arm close to the elbow and the nurse manager was notified. Information about the wound measurements, wound bed, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. A progress note dated 4/24/24, noted R2 obtained a skin tear on 4/24/24 and had fragile skin and was at high risk for skin tears. Information about the specific wound location, wound measurements, wound bed, drainage, odor, periwound area and wound edges, specific risk factors, and pain was not documented. R2's Skin Evaluation and Skin Risk Factors assessment dated [DATE], listed left elbow skin tear injury. The wound beds were described as superficial with a red periwound area. The summary noted R2 had two open area on his left elbow that looked superficial. The drainage section was not complete. A new wound prompting assessment was marked yes. Risk factors selected from a pre-populated list of options were psychotropic drug use. R2's steroid medication, cognitive impairment, hemiparesis, hypertension, cancer, and history of smoking were not identified. No interventions were identified. Information about wound drainage, odor, pain, and measurements was not documented. R2's Weekly Skin Inspection dated 4/25/24, noted wounds on the left elbow and bruising, bruising and a wound on the right forearm, and bruising on the left lower extremity. Information about the specific number and location of the left elbow wounds, measurements, wound beds, drainage, odor, periwound area and wound edges, risk factors, and pain was not documented. No edema was identified. A hospice communication note dated 4/25/24, indicated wound care was completed on the Lt. FA [left forearm?], there was stinging afterwards, and R2 took a dose of as needed Tylenol. Information about the number of wounds, wound measurements, wound beds, drainage, odor, periwound area and wound edges, and risk factors was not documented. R2's Treatment Administration Record (TAR) included the active physician order for edema checks. Charting from the day shift on 4/29/24 noted no edema was present. During an observation on 4/29/24 at 10:22 a.m., R2's feet were examined with registered nurse (RN)-A. RN-A stated R2's right foot was swollen with pitting edema measuring 2+ to 3+ (edema that leaves a dimple after being pressed is pitting and is measured by depth of indention from 1+ most shallow to 4+ deepest) that extended up to his ankle. RN-A stated R2's left foot had pitting edema of 1+ on the inner side and 2+ on the left side extending up to his ankle. RN-A stated R2 had a history of edema and staff put socks and Velcro wraps on him every day and checked his feet and edema at this time. RN-A indicated that she would complete a progress note if edema was noted or, on shower days, a skin check was completed and she would include the edema in that documentation. RN-A stated if a nurse saw edema they would document it and include if it was trace edema, pitting edema, and the grade. During an interview on 4/29/24 at 10:26 a.m., R2 stated he wore the Velcro sleeves on his legs to help with the swelling and before he wore them his skin was swelling up so much it was breaking open. R2 stated the swelling was present for at least the last six months in both of his feet and he wore the Velcro sleeves every day. In an interview on 4/29/24 at 11:08 a.m., the director of nursing (DON) stated edema is monitored through daily observation from the aides who would notify the nurse of any concerns. The DON stated nurses also observe residents when they give medications and complete weekly skin checks. The DON noted the weekly skin checks should say if edema was noted and if it was pitting and the grade. The DON stated that if it was not the day of the week for the weekly skin check then edema would be documented in a progress note. The DON stated R2 had Velcro wraps applied daily, on in the mornings and off at bedtime. The DON confirmed that R2's TAR indicated no edema was present the prior day or that morning and stated she guessed it was not being specifically monitored other than when the Velcro wraps were applied. The DON noted staff were not monitoring R2's edema every shift or at least were not doing good documentation of doing so and R2's physician order directed staff to monitor the edema every shift. The DON stated she would expect edema to be on a resident's care plan, it should be captured in the skin section, and R2 had a skin care plan but it did not include edema. In the same interview on 4/29/24 at 11:08 a.m., the DON noted the facility had a dietician who monitored and audited resident weights weekly. The DON stated a significant weight change would probably be about a five lb. increase in one week. The DON identified that dietary updated hospice about R2's weight gain on 3/12/24 regarding his weight of 175.4 lbs. on 3/7/24. The DON confirmed that R2's weight on 4/25/24 was 181.4 lbs., which was an increase of 16 pounds since admission and 6 lbs. since 3/7/24. The DON stated she would expect hospice to be notified of the continued weight gain and there was no charting indicating hospice had been updated since 3/12/24. In the same interview on 4/29/24 at 11:08 a.m., the DON stated comprehensive assessments of wounds included the skin evaluation and would identify the site of the wound, if there was drainage, the type of wound, if someone had medications or diagnoses with the potential to delay healing or increase risk of compromised skin integrity, and what follow-up or treatments were. The DON stated she would want a description of the wound and what it is and the size of the wound and the facility always captured the size of a wound for the purpose of tracking healing. The DON confirmed that documentation of skin tears in R2's EHR included descriptions such as them being superficial and some included a description of small or large but they did not include length or width measurements and specifics of the exact sizes of the wounds were missing. Facility policy titled Resident Weight Evaluation dated 9/2012, included: Policy Statement: . To ensure that resident weight gains and losses are assessed regularly based on a comprehensive resident assessment and that follow-up interventions are implemented to ensure the resident reaches their highest potential . Policy Interpretation and Implementation: . 3.) When a weight is completed, it is documented on the Electronic Record by the nurse. The record will have a history of at least two months of past weights on it. Should the nurse note a five pound weight increase or decrease, he/she must weigh that individual again; 4.) If there is a weight change that meets the above criteria, the charge nurse and Hospitality Services Director determine the appropriate intervention and make a referral to the Dietitian. The Dietitian initiates a preliminary assessment to determine the cause and charts this in the nurses' notes. (Appropriate interventions might be requesting a diet change, encouraging low or high calorie snacks, [NAME] Plus, milkshakes, lab work, weekly weights, double desserts, etc.); 5.) At the discretion of the charge nurse and dietician, the Physician is notified. Facility policy titled Skin Assessment & Wound Management dated 3/2024, included: When a significant alteration in skin integrity is noted (i.e. large, or multiple bruising, large skin tear, or other non-pressure related wounds such as diabetic, venous, or arterial ulcers), the following actions will be taken . 10.) Initiate Skin and Wound Evaluation; 11.) Notify Nurse Manager/Wound Nurse; 12.) Referral to dietary, if appropriate; 13.) Referral to therapies, if appropriate; 14.) Review and update care plan including interventions; 15.) Update resident care lists; 16.) Updated care plan to identify risks for skin breakdown. A facility policy regarding management of edema was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the dignity of three of ten residents (R3, R6, R8) reviewed when residents were left soiled in their incontinent brief for extended periods of time. Findings include: R3's admission record printed on 2/1/24 states R3 was admitted to the facility on [DATE] with a primary diagnosis of heart failure. An additional pertinent diagnosis includes the absence of left foot. R3's Patient Activities of Daily Living (ADL) Recommendations assessment dated [DATE] indicated R3 was dependent upon staff for lower body dressing and toileting. The assessment does not indicate how many staff R3 is dependent upon for lower body dressing and toileting. The assessment indicated R3 was dependent upon two staff members for bed mobility and transfers using a EZ Lift (Hoyer). R3's Bowel and Bladder Data Collection assessment dated [DATE] indicated R3 is always incontinent of his bowels. The assessment indicated his bowel incontinence is managed using disposable briefs. The assessment does not indicate if R3 is continent or incontinent of his bladder but does state that he has an indwelling urinary catheter that staff need to change every month. The assessment does not indicate how many staff R3 is dependent upon for disposable brief changes or indwelling urinary catheter changes. R3's care plan dated 12/27/23 indicated R3 was dependent upon staff with toileting including clothing management. The care plan does not indicate how many staff R3 is dependent upon for toileting or clothing management. R3 requires extensive assistance from staff with grooming/hygiene. R3 was always incontinent of bowel. The care plan stated that R3 has a bed pan and a urinal at his bedside. R3's Minimum Data Set (MDS) dated [DATE] indicated R3 was dependent upon staff for all toileting needs, bathing, lower body dressing, sitting to lying transfers, and bed to chair transfers. The MDS does not indicate how many staff R3 is dependent upon for toileting needs, bathing, lower body dressing, sitting to lying transfers, and bed to chair transfers. The MDS indicated that R3 was always incontinent of his bowels. The MDS indicated R3 has an indwelling urinary catheter. During an interview with R3 on 1/30/24 at 12:45 p.m., R3 stated that he will wait 1-2 hours for help when he activated his call light when he has had a bowel movement in his brief. R3 stated that when he was sitting there waiting for staff for 1-2 hours it makes me feel like less of a human because they aren't helping you. R6's admission record printed on 2/1/24 stated R6 was admitted to the facility 8/21/23 with a primary diagnosis of hemiplegia (muscle weakness) on right side and repeated falls. R6's Bowel and Bladder Data Collection Assessment was dated on 11/21/23 indicated R6 was occasionally incontinent of her bowel and bladder. The assessment does not indicate how staff manages R6's incontinence. The assessment does not indicate how staff manage R6's bowel or bladder occasional incontinence. R6's Functional Abilities and Goals assessment dated on 11/23/23 indicated that R6 needs substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. R6 was dependent upon staff for toilet transfer to get on and off a toilet or commode. The assessment does not indicate how many staff R6 is dependent upon for toileting needs, bathing, lower body dressing, toilet transfers, and getting on and off a toilet or commode. R6's MDS dated on 11/23/23 indicated R6 needs substantial/maximal assistance from staff for toileting hygiene, bathing, and lower body dressing. R6 was frequently incontinent of her bowels and bladder. R6's care plan dated on 12/6/23 indicated R6 needs extensive assistance of two staff with an EZ stand for toileting and toileting-clothing management. R6 needs extensive assistance from staff for grooming and hygiene needs. The MDS does not indicate how many staff R6 is dependent upon for bathing, lower body dressing, grooming, and hygiene needs. During an interview with R6 on 1/30/24 at 2:22 p.m., R6 stated that when she puts her call light on it was usually because she needs to go to the bathroom. R6 stated that she can usually wait to go to the bathroom until staff come to help her but if she has to wait an hour and a half like she normally does she has to go to the bathroom in her brief. R6 stated that when that happens it affects dignity and it's like do you even consider me to even be a human? and It just steals your dignity. R8's admission record printed on 2/1/24 indicated R8 was admitted to the facility on [DATE] with a primary diagnosis of fracture of the thoracic vertebra (back). Additional pertinent diagnoses include injury of the spinal cord, neuromuscular dysfunction of the bladder, urinary tract infection, paraplegia (inability to move legs and lower body), and neurogenic bowel (loss of normal bowel function). R8's Functional Abilities and Goals assessment dated on 11/27/23 indicated R8 needs substantial/maximal assistance for toileting hygiene, bathing, lower body dressing, and all transfers. The assessment does not indicate how many staff R8 is dependent upon for toileting, bathing, lower body dressing, and transfer needs. R8's MDS dated on 11/28/23 indicated R8 has impairment on both sides of his body. R8 needs substantial/maximal assistance from staff for toileting hygiene, bathing, lower body dressing, and personal hygiene. The MDS indicated that R8 was frequently incontinent of his bowels and was intermittently catheterized. The MDS does not indicate how many staff R8 is dependent upon for toileting, bathing, lower body dressing and personal hygiene needs. R8's care plan dated on 12/20/23 indicated R8 needs extensive assistance of two staff with an EZ stand for transfers, toileting, and toileting-clothing management. R8 needs extensive assistance of one person for mobility. R8 needs extensive assistance with grooming and hygiene and needs physical help for bathing. The care plan does not indicate how many staff R8 is dependent upon for grooming or bathing needs. The care plan indicated that R8 was occasionally incontinent of bowels and has an order to be straight catheterized every 4-6 hours and as needed. The MDS does not indicate how staff manages R8's occasional bowel incontinence. R8's treatment authorization request (TAR) from January 2024 indicates R8 has an order to be straight catheterized every 4-6 hours and as needed four times a day. R8 does not have a Bowel and Bladder Assessment completed. During an interview with R8 on 1/30/24 at 2:38 p.m., R8 stated he was usually continent of his bowel and bladder, but he has occasionally sat in his urine and bowels in his brief due to waiting on staff for long periods of time to answer his call light. R8 stated staff will tell him it was okay if he goes to the bathroom in his brief because that was what it was there for. R8 stated I find that very disturbing because I don't want to lay in my own urine or bowel. It was awful when I have been waiting and I have to eliminate in my brief. During an interview with R10 on 1/31/24 at 8:55 a.m., R10 stated that her roommate, R6, was left on the commode for a longer period in the middle of the night and her roommate was yelling for help to get off the commode. None of the staff was around to help her off the commode. R10 stated that she got out of bed and wheeled past her roommate who was sitting on the commode and found a nursing assistant to help her roommate off the commode. R10 stated I felt bad for her because I wouldn't want my roommate going past me and watching me sit on the commode. That was embarrassing. Request for the facility's toileting policy but none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide nursing cares in a sufficient amount of time for ten of ten residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10) reviewed for call light times. R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10 depend on staff for assistance in their activities of daily living and there are delays in cares during to these call light times. Findings include: R1's admission record printed on 2/1/24 indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder bipolar type and obesity. Additional pertinent diagnoses include morbid obesity, urge incontinence, limitation of activities due to disability, dependence on wheelchair, and muscle weakness. R1's care plan completed on 7/11/23 indicated R1 needs an assistance of one staff with dressing, grooming, and toileting, extensive assistance with bathing, and wears disposable briefs. R1's care plan indicated the prompt response by staff to all requests for assistance when R1's call light is activated. R1's Bowel and Bladder Assessment completed on 10/24/23 indicated R1 was always incontinent of his bowel and bladder, and he wears disposable briefs. The assessment indicated that R1 is able to use his call light and able to ask to use the toilet. The assessment indicates R1 needs extensive assistance with toilet use. The assessment does not indicate how many staff R1 is dependent upon for toileting needs. R1's Nursing Functional Abilities Assessment completed on 10/27/23 indicated R1 needs substantial/maximal assistance with toileting, bathing, and personal hygiene. R1 needs partial/moderate assistance with dressing. The assessment does not indicate how many staff R1 is dependent upon for toileting, bathing, personal hygiene, or dressing needs. R1's Minimum Data Set (MDS) completed on 10/27/23 indicated R1 has a Brief Interview for Mental Status (BIMS) of 15 which indicated R1 is cognitively intact. The MDS indicated R1 needs substantial/maximal assistance with toileting hygiene, bathing, lower body dressing, and personal hygiene, and needs partial/moderate assistance for upper body dressing. The MDS indicates R1 is frequently incontinent of his bowel and bladder. The MDS does not indicate how many staff R1 is dependent upon for toileting, bathing, lower body dressing, personal hygiene, or upper body dressing needs. The MDS does not indicate how staff manages R1's incontinence of his bowel or bladder. R1's BIMS assessment completed on 1/26/24 indicated R1's score is 15 which indicates cognitively intact. On the undated nursing care sheets given to the nursing assistant-registered (NAR) during their shift, it indicated R1 is independent for transfers and requires assistance of one for all activities of daily living (ADL). During an interview with R1's legal guardian on 1/30/24 at 11:39 a.m., R1's legal guardian stated R1 will activate his call light, he will then fall asleep, and then staff will come in and then turn the call light off which makes R1 think that he will wait for assistance longer than he should. R2's admission record printed on 2/1/24 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of atherosclerotic heart disease of native coronary artery. Additional pertinent diagnoses include morbid obesity, heart failure, lymphedema (build-up of fluid in the legs), macular degeneration (eye disease that affect one's central vision), muscle spasms, muscle weakness, gastritis, and micturition. R2's progress note dated 4/12/23 stated that R2 denies being incontinent of her bladder or bowel and states that it all depends on how long it takes for the NAR to answer her call light. R2's Bowel and Bladder Assessment completed on 12/23/23 indicated R2 is occasionally incontinent of bladder and always continent of bowels. The assessment indicated R2 uses disposable incontinence products at night and staff to change every 4 hours at night. The assessment indicated staff to offer to toilet R2 every 4 hours and as needed while awake. The assessment indicated R2's need for assistance to transfer. The assessment indicated R2 is able to use her call light and ask to use the toilet. R2's Functional Abilities Assessment completed on 12/26/23 indicated R2 has bilateral lower extremity impairment. R2 needs substantial/maximal assistance with toileting, bathing, dressing, personal hygiene, and transfers. The assessment does not indicate how many staff R2 is dependent upon for toileting, bathing, dressing, personal hygiene, and transfer needs. R2's MDS completed on 12/27/23 indicated R2 has a BIMS of 14 which indicated R2 is cognitively intact. The MDS indicated R2 required substantial/maximal assistance with toileting, bathing, dressing, personal hygiene, and transfers. R2 is occasionally incontinent of her bladder and always continent of her bowels. The MDS does not indicate how many staff R2 is dependent upon for toileting, bathing, dressing, personal hygiene, or transfer needs. The MDS does not indicate how staff manages R2's bowel or bladder incontinence. R2's care plan completed on 1/10/24 indicated staff to perform restorative range of motion for R2. The care plan indicated R2's need for extensive assist of two staff for bed mobility, EZ stand transfers, and toileting. R2 requires extensive to total staff assistance with personal hygiene and grooming. The care plan does not indicate how many staff R2 is dependent upon for personal hygiene and grooming needs. The care plan indicated that R2 needs assistance with perineal hygiene after toileting. The care plan does not indicate how many staff R2 is dependent upon for perineal hygiene after toileting needs. R2 needed staff to ask her to assist her to use the commode every evening at 6:30 p.m. The care plan indicated the prompt response by staff to all requests for assistance when using the call light. On the undated nursing care sheets given to the NAR during their shift, R2 required assistance of two with EZ stand for transfers and an assist of one for ADLs. During an interview with R2 on 1/30/24 at 10:15 a.m., R2 stated she will put her call light on and if staff does not assist her within a timeframe that she thinks that they should come, she will wheel herself in her wheelchair to her doorway and yell out of her doorway for help until someone comes and helps her. R2 stated that this morning was a busy morning and she had to go to her doorway this morning and yell for help to get assistance because I must have been waiting for 45 minutes. R3's admission record printed 2/1/24 indicated R3 was admitted to the facility on [DATE] with a primary diagnosis of heart failure. Additional pertinent diagnoses include chronic obstructive pulmonary disease with exacerbation, and the absence of his left foot. R3's ADL Recommendations Assessment completed on 11/22/23 indicated R3 is dependent upon two staff for dressing, toileting, mobility, and transfers using an EZ lift. R3's Bowel and Bladder Assessment completed on 12/6/23 indicated R3 is always incontinent of his bowels and his incontinence is managed by disposable incontinent brief's. The assessment indicated R3's urinary incontinence is managed by an indwelling foley catheter that is to be changed once a month. The assessment indicated R3 required assistance to transfer, and he is on bed rest. The assessment indicated R3 is able to use his call light and ask to use the toilet. R3's care plan completed on 12/27/23 indicated R3 required a mechanical lift and assist of two for transfers and mobility. R3's care plan stated R3 is dependent upon staff with toileting and bathing. The care plan does not indicate how many staff R3 is dependent upon for toileting and bathing needs. The care plan indicated R3 is frequently incontinent of his bowels and required staff to assist with perineal cares with pad changes. The care plan does not indicate how many staff R3 is dependent upon for perineal cares. The care plan indicated prompt response by staff to all requests for assistance when R3's call light is activated. R3's MDS completed on 12/29/23 indicated R3 has a BIMS of 15 which indicated R3 is cognitively intact. The MDS indicated R3 is dependent upon staff for toileting, bathing, lower body dressing, and transfers from bed to chair and sitting to lying. The MDS does not indicate how many staff R3 is dependent upon for toileting, bathing, lower body dressing, and transfers from bed to chair and sitting to lying. The MDS indicated R3 is always incontinent of his bowels. The MDS does not indicate how staff manages R3's bowel incontinence. R3's filed a grievance report on 1/15/24 which stated that he activated his call light on 1/14/24 at 6:30 p.m. and he did not receive assistance until 8:30 p.m. The staff investigated this concern by watching cameras and concluded that staff was not in R3's room from 5:45 p.m. to 8:14 p.m. and that the main hallway call light was on but was not able to indicate which individual call light was activated. The follow up actions by management included staff education in huddles on 1/18/24 and 1/19/24. On the undated nursing care sheets given to the NAR during their shift, R3 required assistance of two with a Hoyer lift for transfers and an assist of two for ADLs. During an interview with R3 on 1/30/24 at 12:45 p.m., R3 stated there are long call light wait times here. R3 stated that it happens most of the time on 2nd shift. R3 stated that it takes about 1-2 hours for staff to assist him on the 2nd shift. R3 stated that he depends on staff for everything. R3 stated that if he had a heart attack I would be dead by the time they got to me. R3 stated that he will go 1-2 hours for assistance when he has a BM in his brief and it makes me feel like less of a human because they aren't helping you. R3 stated that he does not activate his call light frequently but when he does, he really does need something. R4's admission record printed 2/1/24 indicated R4 was admitted to the facility on [DATE] with a primary diagnosis of gout. Additional pertinent diagnoses include heart failure and obesity. R4's ADL Recommendations Assessment completed on 5/17/23 indicated R4 required extensive assistance with toileting, extensive assistance of two staff with transfers using an EZ stand, limited assistance with lower body dressing, and supervised assistance with upper body dressing. The assessment does not indicate how many staff R4 is dependent upon for toileting, lower body dressing, or upper body dressing. R4's Bowel and Bladder Assessment completed on 12/29/23 indicated R4 is always continent of his bowel and bladder. The assessment indicated R4 is able to use his call light and is able to ask to use the toilet. R4's Nursing Functional Abilities Assessment completed on 1/1/24 indicated R4 needs partial/moderate assistance with oral hygiene, toileting, dressing, and transfers. The assessment indicated R4 needs substantial/maximal assistance with bathing and personal hygiene. The assessment does not indicate how many staff R4 is dependent upon for oral hygiene, toileting, dressing, transfers, bathing, or personal hygiene. R4's MDS completed on 1/2/24 indicated R4 has a BIMS of 12 which indicated R4 has moderately impaired cognition. The MDS indicated R4 requires substantial/maximal assistance with bathing and personal hygiene, partial/moderate assistance with oral hygiene, toileting, dressing, and transfers. The MDS does not indicate how many staff R4 is dependent upon for bathing, personal hygiene, oral hygiene, toileting, dressing, and transfer needs. The MDS indicated R4 is always continent of his bowel and bladder. R4's care plan completed on 1/18/24 indicated R4 required assistance of two staff with EZ stand for transfers, toileting, and clothing management and extensive assist for bathing. The care plan indicated prompt response by staff to all requests for assistance when R4's call light is activated. On the undated nursing care sheets given to the NAR during their shift, R4 required assistance of two with an EZ stand for transfers and an assist of one for ADLs. During an interview with R4 on 1/30/24 at 1:56 p.m., R4 stated it varies how long it takes staff to get to him. R4 stated that in general it takes anywhere from 2-5 minutes to 45 minutes for staff to answer my call light. R5's admission record printed 2/1/24 indicated R5 was admitted to the facility on [DATE] with a primary diagnosis of cerebrovascular disease. Additional pertinent diagnoses include heart failure, dementia, multiple sclerosis, and hypoxemia. R5's Functional Abilities and Goals Assessment completed on 10/13/23 indicated R5 required partial/moderate assistance with toileting and dressing. The assessment indicated R5 requires substantial/maximal assistance with bathing. The assessment did not indicate how many staff R5 is dependent upon for toileting, dressing, or bathing needs. R5 received an occupational therapy (OT) evaluation on 10/25/23 that indicated R5 required partial/moderate assistance for toileting and dressing, and substantial/maximal assistance for bathing. The evaluation does not indicate how many staff R5 is dependent upon for toileting, dressing, or bathing needs. R5's Bowel and Bladder Assessment completed on 10/27/23 indicated R5 is always continent of his bowel and bladder. The assessment indicated that R5 can use the toilet alone. The assessment indicated R5 is able to use his call light and is able to ask to use the toilet. R5's MDS completed on 1/7/24 indicated R5 has a BIMS score of 15 which indicated R5 is cognitively intact. The MDS indicated R5 needed supervision assistance with oral hygiene, toileting, lower body dressing and transfers to toilet and bed-to-chair. R5 needs partial/moderate assistance with bathing. The MDS indicates R5 is always continent of his bowel and bladder. The MDS does not indicate how many staff R5 is dependent upon for bathing needs. R5's care plan completed on 1/23/24 indicated R5 required limited assistance with toileting, dressing, and grooming. The care plan does not indicate how many staff R5 is dependent upon for toileting, dressing, and grooming needs. The care plan indicated R5 required one person assistance for bathing. The care plan indicated R5 is occasionally incontinent of his bladder. The care plan indicated R5 required assistance with perineal hygiene after toileting and pad change. The care plan indicated R5 needed staff to change his incontinent brief every 2-3 hours and as needed. The care plan indicated a prompt response by staff to all requests for assistance when R5's call light is activated. On the undated nursing care sheets given to the NAR during their shift, R5 required supervised stand pivot for transfers and an assist of one for ADLs. During an interview with R5 and R5's power of attorney (POA) on 1/30/24 at 2:11 p.m., R5 stated the call light times are slow. R5 stated that it will be 45 minutes to 1 hour to wait for someone. R5 stated that it is usually 1 hour he is waiting at night for assistance. During my interview with R5, R5's POA stated that there was an instance when R5 had diarrhea and he put on his call light, and he was waiting on the staff for a little while and she was there with him. R5's POA stated that staff did not come for about 45 minutes to 1 hour and R5 asked her if he could take him to the bathroom and R5's POA was hesitant on bringing him to the bathroom because she did not want to be responsible for hurting herself or R5. R5 stated that when he has diarrhea, he will self-transfer instead of waiting on staff and he will change his disposable brief himself. R6's admission record printed 2/1/24 indicated R6 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia (muscle weakness) on right side. Additional pertinent diagnoses include repeated falls and cellulitis of right lower leg. R6's Bowel and Bladder Assessment completed on 11/21/23 indicated R6 is occasionally incontinent of her bowel and bladder. The assessment does not indicate how staff manages R6's occasional bowel or bladder incontinence. The assessment indicated that R6 is able to use her call light and is able to ask to use the toilet. The assessment indicated R6 requires extensive assistance with toileting. The assessment does not indicate how many staff R6 is dependent upon for toileting needs. R6's Functional Abilities and Goals Assessment completed on 11/23/23 indicated R6 required substantial/maximal assistance with toileting, bathing, lower body dressing, and transfers from sitting to lying and lying to sitting on the side of the bed. R6 required partial/moderate assistance with upper body dressing, personal hygiene, and rolling from side to side in bed. R6 is dependent upon staff for transfers from bed to chair and to get on and off a toilet or commode. The assessment does not indicate how many staff R6 is dependent upon for toileting, bathing, lower body dressing, transfers from sitting to lying, transfers from lying to sitting on the side of the bed, upper body dressing, personal hygiene, tolling from side to side in bed, transfers from bed to chair, and to get on and off the toilet or commode needs. R6's MDs completed on 11/23/23 indicated R6's BIMS score is 15 which indicated R6 is cognitively intact. The MDS indicated R6 needs substantial/maximal assistance with toileting, bathing, lower body dressing, and transfers from sitting to lying and lying to sitting on the side of the bed. The MDS indicated R6 required partial/moderate assistance with upper body dressing, personal hygiene, and rolling from side to side in bed. The MDS indicated R6 is dependent upon staff for bed to chair transfers and toilet and bath transfers. The MDS does not indicate how many staff R6 is dependent upon for toileting, bathing, lower body dressing, transfers from sitting to lying, transfers from lying to sitting on the side of the bed, upper body dressing, personal hygiene, rolling from side to side in bed, bed to chair transfers, and transfers to and from the toilet or bath needs. The MDS indicated R6 is frequently incontinent of her bowel and bladder. The MDS does not indicate how staff manages R6's bowel or bladder incontinence. R6's care plan completed on 12/6/23 indicated R6 required extensive assistance with mobility, grooming, hygiene, and dressing. The care plan indicated R6 required extensive assistance of two with an EZ stand for toileting and transfers. The care plan does not indicate how many staff R6 is dependent upon for mobility, grooming, hygiene, dressing, toileting, or transfer needs. The care plan indicated a prompt response by staff to all requests for assistance when R6 activates her call light. On the undated nursing care sheets given to the NAR during their shift, R6 required assistance of two with an EZ stand for transfers and assistance of one for ADLs. During an interview with R6 on 1/30/24 at 2:22 p.m., R6 stated it will usually take 30 minutes to an hour and a half for staff to answer her call light. R6 stated that when she puts her call light on it is because she needs to go to the bathroom. When she is waiting for staff, she can retain her bowel and bladder, but cannot hold it for 30 minutes to an hour and a half and is forced to use the bathroom in her disposable brief. R6 stated that this affects your dignity and it's like do you even consider me to even be a human? and This just steals your dignity. R6 stated that the call light times are worse on the evening and overnight shifts. R6 stated that a few nights ago, one of the NARS put her on the commode and when she was ready, she activated her call light and waited for 45 minutes for assistance. R6 stated that the only reason she received assistance is because her roommate had to get out of bed and wheel around in her wheelchair trying to find assistance for her. R7's admission record printed 2/1/24 indicated R7 was admitted to the facility on [DATE] with a primary diagnosis of bilateral osteoarthritis of the knees. Additional pertinent diagnoses include muscle spasms, radiculopathy (nerve damage in the back that creates radiating pain) in the back, muscle weakness, and obesity. R7's care plan completed on 11/22/23 indicated R7 required supervision for stand-pivot transfers, and limited assistance for toileting, personal hygiene, grooming, and bathing. The care plan does not indicate how many staff R7 is dependent upon for toileting, personal hygiene, or grooming needs. The care plan indicated R7 required physical help needed to transfer into bath. The care plan does not indicate how many staff R7 is dependent upon for transfers into the bath. The care plan indicated one person to assist R7 with bathing. The care plan indicated a prompt response by staff to all requests for assistance when R7 activates his call light. R7's MDS completed on 11/23/23 indicated R7 has a BIMS score of 15 which indicated R7 is cognitively intact. The MDS indicated R7 is independent with eating, oral hygiene, dressing, personal hygiene, and transfers. The MDS indicated R7 required clean-up assistance with toileting and bathing. The MDS indicated R7 is always continent of his bowels and bladder. R7's Bowel and Bladder Assessment completed on 12/3/23 indicated he is always continent of his bowel and bladder. The assessment indicated that he is not able to use his call light and not able to ask to use the toilet. R7's progress note dated 1/24/24 indicated that R7 complained no one was answering his call light for a long time. The writer of the progress note stated that the aide was new to the floor and the writer talked to his aide to give R7 attention to the call light, the aide provided care to R7, and R7 was satisfied. On the undated nursing care sheets given to the NAR during their shift, R7 required supervised assistance for transfers and assistance of two for ADLs. During an interview with R7 on 1/30/24 at 2:30 p.m., R7 stated he has concerns about the call light times. R7 stated that staff does not answer the call lights. R7 stated that he has waited on staff for 30-40 minutes while he was ready to get off the toilet. R8's admission record printed 2/1/24 indicated R8 was admitted to the facility on [DATE] with a primary diagnosis of fracture of thoracic vertebra (back). Additional pertinent diagnoses include morbid obesity, injury of the spinal cord, neuromuscular dysfunction of the bladder (lack of bladder control), paraplegia (inability to move legs and lower body), neurogenic bowel (loss of normal bowel function), and muscle spasms. R8's Bladder and Bowel Assessment completed on 11/25/23 indicated R8 is always continent of his bowel. The assessment indicated R8 has intermittent catheterization for his neurogenic bladder. The assessment indicated the R8 is able to use his call light and is able to ask to use the toilet. The assessment indicated R8 required total dependence for toilet use. The assessment does not indicate how many staff R8 is dependent upon for toileting needs. The assessment indicated R8 wears disposable briefs for his bowel and bladder incontinence. R8's Functional Abilities and Goals Assessment completed on 11/27/23 indicated R8 required substantial/maximal assistance with toileting, bathing, lower body dressing, and transfers including rolling from side to side in bed, sitting to lying, lying to sitting on the side of the bed, getting on and off a toilet or commode, and tub/shower transfer. The assessment indicated R8 requires partial/moderate assistance with upper body dressing and personal hygiene. The assessment indicated R8 is dependent upon staff for transfers from chair/bed-to-chair. The assessment does not indicate how many staff R8 is dependent upon for toileting, bathing, lower body dressing, transfers, upper body transfers, and personal hygiene. R8's MDS completed on 11/28/23 indicated R8's BIMs score is 15 which indicated R8 is cognitively intact. The MDS indicated R8 requires substantial/maximal assistance with toileting, bathing, lower body dressing, personal hygiene, rolling from side to side in bed, sitting to lying, lying to sitting on side of the bed, and transfers into the tub/shower. The MDS indicated R8 required partial/moderate assistance with upper body dressing. The MDS does not indicate how many staff R8 is dependent upon for toileting, bathing, lower body dressing personal hygiene, rolling from side to side in bed, sitting to lying position, from lying to sitting on the side of the bed, transfers into the tub/shower, chair/bed-to-chair transfers, toilet transfers, and upper body dressing needs. The MDS indicated R8 is dependent upon staff for chair/bed-to-chair and toilet transfers. The MDS indicated R8 is intermittently catheterized and is frequently incontinent of his bowel. The MDS does not indicate how staff manages how bowel incontinence. R8's care plan completed on 12/20/23 indicated R8 required extensive assistance of two staff with an EZ stand with transfers and toileting, needs extensive assistance with bed mobility, lower body dressing, grooming and hygiene, and needs physical help with bathing. The care plan indicated R8 is able to ask to use the toilet for bowel movements (BMs) and is occasionally incontinent of his bowels. The care plan does not indicate how staff manages R8's occasional bowel incontinence. The care plan indicated a prompt response by staff to all requests for assistance when R8 activates his call light. R8's medication administration record (MAR) from January 2024 indicated an order for staff to reposition R8 every 2 hours on all shifts. R8's TAR from January 2024 indicated an order for R8 to be straight catheterized every 4-6 hours and as needed. On the undated nursing care sheets given to the NAR during their shift, R8 required assistance of two with an EZ stand for transfers and assistance of two for ADLs. During an interview with R8 on 1/30/24 at 2:38 p.m., R8 stated he has concerns about the call light times. R8 stated the long call light times happen on every shift but is worse from 10 p.m. to 6 a.m. R8 stated staff say that the long call light times are due to being short staffed. R8 stated he has waited anywhere from 20 minutes to 1 hour for assistance. R9's admission record printed 2/1/24 indicated R9 was admitted to the facility on [DATE] with a primary diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy. Additional pertinent diagnoses include neuromuscular dysfunction of the bladder, morbid obesity, lumbago with sciatic (low back pain that radiates down legs), and muscle spasms. R9's Bowel and Bladder Assessment completed on 12/22/23 indicated R9 is always continent of his bowel and has an indwelling foley catheter. The assessment indicated R9 wears disposable briefs. The assessment indicates R9 is able to use his call light and is able to ask to use the toilet. R9's Functional Abilities and Goals Assessment completed on 12/26/23 indicated R9 requires substantial/maximal assistance with toileting, bathing, lower body dressing, transfers from lying to sitting on the side of the bed, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. The assessment indicated R9 requires partial/moderate assistance with upper body dressing, personal hygiene, rolling from side to side in bed, and from a sitting to lying position. The assessment does not indicate how many staff R9 is dependent upon for toileting, bathing, lower body dressing, transfers from lying to sitting on the side of the bed, chair/bed-to-chair transfers, toilet transfers, tub/shower transfers, upper body dressing, hygiene, rolling from side to side in bed, and from a sitting to lying position needs. R9's MDS completed on 12/26/23 indicated R9's BIMS score is 15 which indicated R9 is cognitively intact. The MDS indicated R9 required substantial/maximal assistance with toileting, bathing, lower body dressing, chair/bed-to-chair transfers, and toilet and tub/shower transfers. The MDS indicated R9 requires partial/moderate assistance with upper body dressing, personal hygiene, rolling from side to side in bed, and from a sitting to a lying position. The MDS does not indicate how many staff R9 is dependent upon for toileting, bathing, lower body dressing, chair/bed-to-chair transfers, toilet and tub/shower transfers, upper body dressing, personal hygiene, rolling from side to side in bed, and from a sitting to lying position needs. The MDS indicated that R9 is always continent of his bowels and has an indwelling urinary catheter. R9's care plan completed on 1/8/24 indicated R9 required an assist of one for stand pivot transfers, bathing, and catheter cares. The care plan indicated R9 needs occasional limited assistance for toileting. The care plan does not indicate how many staff R9 is dependent upon for toileting needs. The care plan indicated R9 required occasional limited to extensive assistance of one staff with dressing/grooming and hygiene. The care plan indicated R9 is occasionally incontinent of his bowels and to offer toileting in the morning, at night, after meals, with cares, and during rounds, and directs staff to assist R9 to and from the toilet. The care plan directs staff to empty R9's catheter every shift. The care plan directs staff to answer R9's call light as soon as possible. On the undated nursing care sheets given to the NAR during their shift, R9 required supervision for transfers with walker and assistance of one with ADLs. During an interview with R9 on 1/30/24 at 3:54 p.m., R9 stated that he does not use his call light because he knows staff will not answer it. R9 stated it takes a long time for the staff to get to me. R9 stated it could be anywhere from 15 minutes to 45 minutes for staff to assist him. R9 states that he will try to a lot of the cares by himself because he does not want to rely on the staff. R10's admission record printed 2/1/24 indicated R10 was admitted to the facility on [DATE] with a primary diagnosis of a fracture in her left lower leg. Additional pertinent diagnoses include morbid obesity, spinal stenosis (narrowing of the spinal canal causing pain, numbness, muscle weakness, and impaired bladder or bowel control), and an overactive bladder. R10's Bowel and Bladder Assessment completed on 10/14/23 indicated R10 is always continent of her bowel and bladder. The assessment indicated that R10 is able to use her call light and is able to ask to use the toilet. R10's MDS completed on 11/3/23 indicated R10's BIMs score is 15 which indicated R10 is cognitively intact. The MDS did not indicate R10's need for assistance. R10's care plan completed on 1/18/24 indicated R10 requires assistance from staff with all transfer needs. The care plan indicated a prompt response by staff for all requests for assistance when R10 activates her call light. The care plan indicated R10 requires extensive assistance from one staff with transfers with toileting, transfers, bed mobility, and bathing. The care plan indicated R10 required assistance from staff with perineal hygiene after toileting. The care plan does not indicate how many staff R10 is dependent upon for perineal hygiene after toileting. The care plan directs staff to assist R10 with transfers to the toilet. On the undated nursing care sheets given to the NAR during their shift, R10 required assistance of one with stand pivot transfers and assistance of one for ADLs. During an interview with R10 on 1/31/24 at 8:55 a.m., R10 stated she has concerns with the call lights and how long it takes staff to answer them. R10 stated that the long call light waits usually happen between 10:30 p.m. and 4 a.m. R10 states that she is usually independent with her cares but when she does need help with her cares, she will activate her call light and it will take staff about 20 minutes to an hour and a half for staff to assist her. R10 stated there was a time recently when her roommate was on the commode in the middle of the night, and she was yelling for help and her call light was on. R10 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a baseline care plan was reviewed and provided timely to ensure knowledge of care and promote person-centered care planning for 1 of 2 residents (R24) reviewed for care planning. Findings include: R24's face sheet undated, indicated R24 admitted to the facility 9/11/23, was readmitted to the hospital on [DATE], and readmitted to the facility on [DATE] R24's admission cognition assessment dated [DATE], indicated R24 was cognitively intact. R24's diagnoses list dated 9/11/23, indicated R24's diagnoses included spinal stenosis cervical region, diabetes mellitus, occlusion and stenosis of left carotid artery, and cerebral infarction (disrupted blood flow to the brain) R24's baseline care plan initiated 9/12/23, included pain, psychotropic medications, respiratory diagnosis, and skin with no interventions listed. During interview on 10/26/23 at 12:20 p.m., R24's significant other (SO) indicated he had not received any information regarding R24's plan of care or what the expectations for R24 were. SO denied R24 having a care conference or being invited to a care conference, or being provided anything verbally or in writing regarding R24's cares. During interview on 10/26/23 at 1:36 p.m., social service director stated an initial care conference should be held by day 21. She verified a 48 hour care plan was not given to R24 and the process needs improvement. The facility policy: 48 Hour Care Plan Summary & Baseline Care Plan dated 5/18/2023, indicated, The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- be developed within 48 hours of a resident' s admission. Once the 48 hour summary and care plan is complete both must be printed out, reviewed with and a signed copy given to the resident or resident representative prior to completion of the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to revise the care plan for 1 of 1 resident (R54) reviewed for ongoing medication refusals. Findings include: R54's quarterly Minimum Data Set (MDS) dated [DATE], indicated R54 had cognitive impairment and rejection of care which occurred one to three days in a seven day period. R54's face sheet printed 10/23/23, indicated diagnosis of major depressive disorder recurrent (a mood disorder that causes a persistent feeling of sadness and loss of interest) generalized anxiety disorder (GAD; the feeling of being extremely worried or nervous more frequently about things, even when there is little or no reason to worry about them), dissociative and conversion disorder (mental health conditions that can occur together. Dissociative disorders cause a person to become disconnected from important aspects of their lives. Conversion disorder causes physical symptoms that mimic neurological conditions), and personal history of transient ischemic attack ( a stroke that lasts only a few minutes. It occurs when the blood supply to part of the brain is briefly interrupted). R54's care plan undated, lacked documentation of ongoing medication refusals with goals and intervention to address R54's daily refusals of medications since transferred to the second floor in 7/2023. R54's physician orders as of 10/25/23, included the following medications: -Fluoxetine Hydrochloride (hcl) capsule 30 milligram (mg) by mouth (PO) one time a day related to major depressive disorder. -Lisinopril 20 mg tablet PO one time a day related to essential hypertension. -Remeron tablet give 15 mg PO at bedtime related to major depressive disorder. -Carvedilol tablet give 25 mg po two times a day related to essential hypertension. R54's medication administration record (MAR) for 10/2023, indicated R54 refused all her medications daily for at least 25 days up to the time of review on 10/26/23, and was coded a 3 on the MAR, which indicated refusals. R54's progress notes included the following: -8/10/23 at 9:05 a.m., shook head no when morning meds offerred. Refused breakfast to her room. -8/14/23 at 11:05 a.m., resident refused all morning medication; she stated she will take them when the doctor says she can leave second floor. -10/2/23 at 7:17 p.m., resident is resistive to taking her meds -10/6/23 at 9:28 a.m., resident refused to take her scheduled medication. After review of R54's numerous progress notes, lacked documentation of R54's ongoing daily refusals of medications with no interventions. During an interview on 10/25/23 at 11:26 a.m., nurse manager registered nurse (RN)-C verified R54 did not have a care plan with goals and interventions regarding R54's ongoing daily refusals of medications and verified R54's ongoing daily refusals of medications should have been care planned. During an interview on 10/26/23 at 1:00 p.m., MDS coordinator (MDSC) stated there should be a careplan if R54 had ongoing medication refusals since R54 was coded for rejection of care. MDSC verified R54 did not have a care plan in place to verify the ongoing medication refusals. During an interview on 10/26/23 at 1:30 p.m., director of nursing (DON) stated R54 should have a care plan in place for her ongoing refusals of medications with goals and interventions, and verified R54 did not currently have one. DON further clarified the care plan could be done as a target behaviour with approaches and would be beneficial if R54 had one. The facility policy updated 10/2022, indicated it is the policy of Volunteers of America to provide a temporary care plan within 48 hours of admission (admission Individual Care Plan) and a complete person centered and comprehensive care plan by the resident's 21st day of admission. The care plan will ensure the resident the appropriate care required to maintain or attain the resident's highest level of practicable function possible consistent with resident rights. This comprehensive care plan will have problem/strength statements, measureable goal statements, treatment preferences and interventions. The care plan will be written in a culturally competent manner recognizing the patient's diverse values, beliefs, and behaviors, including tailoring delivery to meet patient's social, cultural, and linguistic needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R13's quarterly Minimum Data Set (MDS) dated [DATE], included diagnoses of Acute Kidney Failure, Anemia, and lacked a dermatology diagnosis. R13's Provider orders (Surgery Aftercare date 10/11/23), included surgery aftercare orders. R13's treatment administration record (TAR) (printed 10/26/23) for dates 10/11/23 - 10/25/23, indicates wound care treatment twice daily. The TAR was updated 10/26/23 to record pressure dressing removal on 10/12/23. R13's care plan (last updated 8/24/23), lacked a surgical skin after-care procedure related to skin excisions. During an observation and interview on 10/23/23 at 1:50 p.m., R13 had a large, tan soiled Band-Aid on upper forehead with dried blood under the front edge. No date noted on Band-Aid. R13 stated surgery was performed on [R13]'s head, but did not elaborate further. During an observation on 10/24/23 at 1:21 p.m., R13 had the same large, tan, soiled Band-Aid with dried blood on front edge of adhesive area on the upper forehead. During an observation on 10/25/23 at 9:33 a.m., a different style Band-Aid was on R13's forehead. No date was marked on the Band-Aid, but there was still some dried blood on front and left edges of the Band-Aid. During an interview on 10/25/23 at 9:52 a.m., registered nurse (RN)-A stated surgical wounds are not considered like other wounds, therefore dressings are not initialed and dated when changed. Surgical wounds are assessed weekly on bath day by the wound care team and are not measured daily. RN-A stated R13 had a shower yesterday and the band aid was changed by RN-A because the wound needs to be kept dry. RN-A indicated R13's wound care was found in the physician order. However, the order was not yet scanned into the electronic medical record (EMR). RN-A stated the need for the surveyor to speak with the wound nurse, who was the assistant director of nursing (ADON) for further explanation. During an interview on 10/25/23 at 10:02 a.m., ADON stated the bandage was to be changed twice daily with Vaseline or Aquaphor ointment applied over the steri-strips. ADON directed RN-A to change the bandage at this time. ADON further stated attend weekly wound rounds with the wound provider, so ADON was known as the wound nurse. During an interview and observation on 10/25/23 at 10:13 a.m., RN-A again stated R13 had a shower yesterday (10/24/23) and the Band-Aid was replaced at that time. RN-A, using aseptic technique, removed the Band-Aid exposing adhered steri-strips, cleansed the wound with soap and water on 4X4 gauze, dried area with new 4X4 gauze, applied Aquaphor onto the steri-strips and covered the area with three smaller Band-Aids. During an interview on 10/25/23 at 10:32 a.m., R13 stated today was the first time wound care has been done for a while, however couldn't state when the last time the wound care was done but stated it was not done every day. During an interview on 10/25/23 at 10:41 a.m., the ADON found the to-be-scanned Surgery Aftercare instructions form from the dermatology clinic which indicated no wound care would be necessary while the steri-strips were still attached. ADON suggested there was confusion with the order because the order also indicated to gently wash area daily with soap and water, then apply ointment and cover with Band-Aid twice daily. ADON stated it appeared the second part of the order should have occurred after the steri-strips have fallen off. ADON acknowledged the order left room for interpretation, and verified the staff should have clarified the order. During an interview on 10/26/23 at 2:10 p.m., the director of nursing (DON) stated it was important to have clear orders to reduce errors. DON also stated when a resident comes back from an outside appointment with orders, the housing unit coordinator should enter the orders, then a RN should review the order. DON further stated if there were any questions with an order the RN was to contact a nurse manager, or contact the on-call clinic manager for further instruction. A policy for transcribing orders was not provided. Based on observation, interview, and document review, the facility failed to monitor skin conditions for 1 of 1 resident (R238) who had facial bruising upon admission. The facility also failed to ensure physician's orders were accurately transcribed for 1 of 1 resident (R13)reviewed who required follow-up care after skin excisions. Findings include: R238's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of displaced fracture of the second cervical vertebra, osteoporosis with current pathological fracture, chronic pain syndrome, and syncope (fainting) and collapse. It further indicated R238 required moderate assistance with activities of daily living (ADL), dependent on staff for transfers and mobility and had a fall with fracture prior to admission. R238's admission/readmission (day 1) assessment dated [DATE], indicated R238 had facial bruising under her right eye. R238's nursing weekly skin checks dated 10/15/23 and 10/22/23 lacked documentation of the bruise under her right eye. During observation/interview on 10/23/23 at 8:11 a.m., R238 was lying in bed wearing a cervical collar and had a bruise underneath her right eye. R238 stated she received the bruise as a result of a fall at home before she was admitted . During an observation on 10/25/23 at 9:21 a.m., R238 was sitting in her wheelchair in her room, watching television. She had her cervical collar on had a bruise underneath her right eye. During an interview on 10/26/23 at 9:21 a.m., registered nurse (RN)-B stated when a resident was admitted with a bruise or a new bruise was discovered, the nurses were responsible for filling out a risk management and documenting it. Then going forward, the nurse would be responsible for documenting the bruise on the weekly skin assessments and monitoring it until it was resolved. During an interview on 10/26/23 at 9:31 a.m., licensed practical nurse (LPN)-A verified R238 had a bruise under her right eye and R238 had been admitted with the bruise. LPN-A further stated when a resident was admitted with bruising/a bruise, the nurses were responsible for documenting it and including it in the admission assessment. Then going forward, the nurses would be responsible for documenting the bruise on the weekly skin assessments and following it through until the bruise was gone. During an interview on 10/26/23 at 10:04 a.m., the assistant director of nursing (ADON) verified R238's weekly skin checks dated 10/15/23 and 10/22/23 lacked documentation of the bruise under her right eye. ADON stated when a resident was admitted with a bruise(s) the nurses were expected to complete a thorough skin check and capture everything on the day one assessment. The ADON further stated she expected the nurses to be specific about the size of the bruise and where it was located. The bruise(s) should also be captured on every weekly skin check until they were resolved. During an interview on 10/26/23 at 1:00 p.m., the director of nursing (DON) stated when a resident was admitted with bruises or a bruise was discovered, the nurses were responsible for documenting the bruises and montioring them until they had resolved. A policy for monitoring bruising was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure interventions were in place for 1 of 2 residents (R12) at risk for pressure ulcers. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 was cognitively impaired, required two person total assistance for most activities of daily living (ADLs) and was at risk for developing pressure ulcers, and had two stage II ulcers (partial thickness lost of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. may also present as an intact or open/ruptured serum filled blister) and one stage III pressure ulcer (full thickness tissue loss. subcutaneous fat may be visible, but bone, tendon or muscle is not exposed). R12's diagnosis included end stage renal disease (ESRD), chronic obstructive pulmonary disease (COPD), dementia, obesity, diabetes mellitus with neuropathy, and anemia. R12's care plan printed 10/26/23, indicated R12 had alteration in skin integrity related to mobility deficit, incontinence, chronic pain, bipolar disorder, depression, opioid and psychotropic use. Has itchy skin that may be related to ESRD. Interventions included: will show no complications in wounds with ordered wound treatment , I require Prevalon boots to be on my bilateral feet at all times to protect my heels from pressure. I require repositioning every 2 hrs. Pressure reducing device for bed. Pressure reducing device for chair. Weekly skin assessment by Licensed Nurses R12's physician orders dated 9/21/23, indicated : Wound care: Right heel and right ankle- Remove and discard old dressing, clean wound with wound cleaner and dry with clean gauze, cut piece of calcium alginate to fit in wound bed and apply Cover with foam dressing, change daily and prn (as needed) if dirty or soiled or falling off. Prevalon boots ( a heel protector boot that has a cushioned bottom that floats the heel off the surface of a mattress, helping reduce pressure) to bilateral heels at all times. During observation on 10/24/23 at 5:27 p.m., R12 was sitting in a broda chair (a wheelchair that provides supportive positioning through a combination of tilt, recline, adjustable legrest angle, wings with shoulder bolsters and height adjustable arms). in the dining room. R12 had grippy socks on, no Prevalon boots. During observation on 10/24/23 an 6:28 p.m., R12 was in the same position in the dining room. During observation on 10/24/23 at 6:42p.m., the director of nursing (DON) and nursing assistant (NA)-B assisted R12 into bed. The DON indicated there was only one Prevalon boot and it was for R12's right foot. During observation on 10/25/23 at 10:55 a.m., R12 was sitting in Broda chair in the hallway with a Prevalon blue boot on the right foot only. During observation on 10/25/23 at 3:20 p.m., R12 was sitting in a broda chair by the nurses office, and did not have any Prevalon boots on. During interview on 10/25/23 at 3:24 p.m., registered nurse (RN) -B indicated R12 had two Prevalon boots, and had just removed them, and showed me both boots. RN-B indicated the dressing change was completed in the morning and both areas were healed . Interview on 10/26/23 at 9:21 a.m., the assistant director of nursing (ADON) indicated R12 has two boots and they are preventative, as R12 has a history of the areas on her ankles opening up, and R12 should wear the Prevalon boots all the time. During observation on 10/26/23 at 11:8 a.m., ADON and the hospice nurse completed the dressing change to R12's right foot. Only one open area was noted. ADON applied both Prevalon boots after the dressing change was complete. A policy was not provided. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review, the facility failed to ensure the medical record reflected accurate care and monitoring of the dialysis access site for 1 of 1 residents (R23) reviewed for dialysis. Findings include: R23's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition, no rejection of care and diagnoses of kidney failure and dialysis dependency. R23 required substantial/maximal assistance with upper body dressing. R23's Care Plan dated 4/21/22, identified a dialysis shunt location (central line) in the right upper chest. Interventions included no blood draws from central line, and in emergency situations if shunt started to bleed, apply ice and pressure, if bleeding does not cease after 15 minutes, call 911, doctor, dialysis and family. The care plan lacked interventions related to a dialysis fistula such as removing a pressure dressing after dialysis session, assessment of bruit and thrill (sounds and vibrations that indicated a fistula worked properly), and to ensure no blood pressures, blood draws or intravenous access occurred to the left upper arm fistula. R23's dialysis Treatment Details report dated 10/18/23, identified the left upper arm fistula was placed on 7/7/22. Additionally, R23 arrived to dialysis with pressure dressing on access from the previous dialysis session two days ago. R23 was advised to let care center staff know to remove the dressing since R23 lacked the strength to remove the dressing. R23's facility Dialysis Data Collection Pre and Post Appointment form dated 10/23/23, identified the bruit and thrill were assessed but lacked mention of care provided to the pressure dressing. R23's facility Dialysis Data Collection Pre and Post Appointment form dated 10/25/23, identified the bruit and thrill were assessed but lacked mention of care provided to the pressure dressing. R23's Order Summary Report dated 10/26/23, identified a shunt location (central line) in right upper chest. The orders lacked interventions related to a dialysis fistula such as location of fistula, removing a pressure dressing after dialysis session, assessment of bruit and thrill (sounds and vibrations that indicated a fistula worked properly), and to ensure no blood pressures, blood draws or intravenous access occurred to the left arm. During an interview on 10/23/23 at 8:57 a.m., R23 stated he had a dialysis fistula in his left upper arm and no longer had dialysis central line in his right upper chest. During an interview on 10/25/23 at 12:03 p.m., registered nurse (RN)-A stated she would check the resident orders and care plan for dialysis interventions. RN-A stated she worked with R23 routinely and R23 would update nursing on new dialysis orders. RN-A reviewed R23's dialysis orders and care plan and agreed they did not match the current cares provided. RN-A stated she knew to remove the pressure dressing to fistula after the session because R23 had told her in the past. RN-A stated she knew to assess bruit, thrill, and emergency care of a fistula from her past training. RN-A added it could be confusing to a nurse not familiar to the resident which cares were required if the orders and care plan were not up to date. During an interview on 10/26/23 at 10:54 a.m., the dialysis RN (DRN) stated R23 had a upper left arm fistula and not a central line. After the dialysis session a pressure dressing was placed and the facility would need to remove the pressure dressing a couple of hours after the dialysis session. The DRN stated there were a couple of times R23's pressure dressing remained in place until the next dialysis session two days later. The DRN stated if left in place for too long the pressure dressing may damage the resident's access site. The DRN stated additional cares to the upper left arm fistula included no blood pressures, intravenous access or blood draws to the affected arm due to the risk of disrupting the flow to the access site. During an interview on 10/26/23 at 12:35 p.m., RN-B stated she would look on resident orders and care plan for dialysis interventions, if there was a discrepancy the dialysis clinic would be contacted for clarification. During an interview on 10/26/23 at 12:49 p.m., the director of nursing (DON) verified R23's order and care plan had not been updated to reflect current care and monitoring of the left upper arm fistula. The DON agreed it was important to ensure orders were consistent and the dialysis access was cared for properly because it was R23's lifeline. The facility policy titled Hemodialysis dated 8/2021, identified cares and services for dialysis would be consistent with professional standards of practice and included the comprehensive person-centered care plan, and the residents' goals and preferences, and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to assess for and identify potential triggers for 1 of 1 resident (R28) who had a history of trauma. Findings include: R28's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition, no rejection of care and diagnoses of depression, bipolar disease and post-traumatic stress disorder (PTSD). R28 had several days in the lookback period where he felt little interest or pleasure in doing things or felt down, depressed, or hopeless. R28's Mood/Trauma care plan dated 7/25/18, identified a diagnosis of PTSD. Interventions included to call 911 in an urgent situation, complete a suicide self-harm interview as needed, remove items resident threatens to kill himself with, implement Threats to Self Harm policy and 1:1 checks, refer to psychologist as needed and encourage to express feelings and utilize family. The care plan lacked identification of triggers which had the potential to re-traumatize. R28's Social Services Resident History, Demographics and Goals assessment dated [DATE], 7/3/23, and 4/5/23 lacked notation of trauma history or potential triggers. R28's Behavior Monitoring form dated 9/26/23 through 10/25/23, identified no behaviors were observed. During an interview on 10/23/23 at 1:36 p.m., R28 stated had PTSD and was more withdrawn and had difficulty sleeping. R28 stated he talked to a counselor about it and changes were made to his medications. R28 stated no one had talked to him about potential triggers for his PTSD. R28 stated his triggers include loud noises, slamming doors and those occurred at the facility occasionally. During an interview on 10/25/23 at 11:38 a.m., nursing assistant (NA)-A stated he worked with R28 routinely. NA-A stated he had online training on trauma informed care. NA-A stated he was unaware of R28's diagnosis of PTSD or potential triggers. During an interview on 10/25/23 at 12:03 p.m., registered nurse (RN)-A stated she worked with R28 routinely and had online training on trauma informed care. RN-A stated R28's behavior was monitored but was not aware of a diagnosis of PTSD or any triggers R28 might have. During an interview on 10/25/23 12:04 p.m., social services (SS)-A stated trauma was assessed and reassessed upon admission, quarterly, annually and with any changes. SS-A reviewed R28's care plan and verified potential triggers for PTSD had not been assessed. R28 stated one trigger for R28 was his lack of family visits. SS-A stated assessment for potential triggers was important to avoid retraumatization. During an interview on 10/26/23 at 11:23 a.m., the director of social services (DSS) stated potential triggers for R28's PTSD had not been assessed and and implemented into the care plan and should have been. The facility policy titled Trauma Informed Care and PTSD dated 9/1/20, identified it was important for staff to be well-informed regarding the recognition of PTSD, appropriate interventions and the facility must identify triggers which could re-traumatize residents with a history of trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure antibiotic medications had appropriate monitoring, diagnosis, and indication for use for 1 of 1 resident (R15) reviewed for unnecessary medications. Findings include: R15's quarterly minimum data set (MDS) dated [DATE], indicates a brief interview for mental status (BIMS) score of 15, and R15 had an indwelling urinary catheter. R15's hospital progress plan note dated 8/9/23, had the order to continue Bacitracin three times daily to reduce catheter irritation. R15's provider orders (after visit summary) dated 8/11/23, included the medications Bacitracin (topical antibiotic ointment) and cefpodoxime (oral antibiotic). R15's order summary report printed 10/26/23, included provider orders since 8/1/23, which did not include an order for Bacitracin. However, the follow-up visit dated 9/5/23, included Bacitracin for catheter care. R15's treatment administration record (TAR) for October 2023, has Bacitracin for catheter care discontinued on 10/26/23, and restarted 10/26/23, with the indication of prophylaxis to prevent urinary tract infection (UTI). No end date noted. R15's care plan printed 10/26/23, has a self-administration of medication plan starting 8/30/23, and antibiotic use dated 8/31/23. R15's medical record lacked evidence of the physician's rationale for continued use of Bacitracin ointment. During an interview on 10/25/23 at 12:36 p.m., R15 stated the nurses provide catheter care and antibiotic administration. During an observation on 10/25/23 at 12:54 p.m., R15's room revealed a cup with packets of Bacitracin at R15's bedside. During an interview on 10/26/23 at 8:19 a.m., registered nurse (RN)-A stated that nurses provide all catheter care and medications associated with catheter care. RN-A also stated R1's Bacitracin was ordered prophylactically after urinary stent removal. RN-A stated R15 was prone to infection, explaining the reason why there was no end date for administration. RN-A removed the cup with Bacitracin packets from R15's room. During an interview on 10/26/23 at 10:28 a.m., the assistant director of nursing (ADON) stated a nursing assessment/infection note was ordered twice daily if a resident was on an antibiotic. ADON also stated the housing unit coordinator (HUC) enters the order for these assessments. ADON stated there should be a stop date on antibiotics, however, prophylactic use was an exception. During an interview on 10/26/23 at 1:34 p.m., the director of nursing (DON) stated antibiotics treating an acute infection need an infection note from a nurse assessment every shift. DON also stated infection notes and end dates are not required for prophylactic antibiotics. DON stated medication orders require a rationale. During an interview on 10/26/23 at 1:48 p.m., the consulting pharmacist (CP) stated there are instances when an antibiotic could be ordered without an end date, including prophylactically. CP also stated a rationale for the antibiotic should be included in the order. During an interview on 10/26/23 at 2:12 p.m., the ADON stated the provider will make the decision on the continued necessity of an antibiotic, and nurses also monitor effectiveness and adverse effects. The facility's antibiotic stewardship protocol dated September 2022 indicates all antibiotics ordered and placed in the electronic health (EHR) record will display on the antibiotic clinical dashboard. The IP will then start the infection control data collection tool in the EHR that analyzes for the required criteria to merit using an antibiotic. The nurse is to follow-up in the chart 48 hours after the antibiotic is completed or infection cleared. The infection is to be added to the care plan and resolved when the infection is cleared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to implement protocols to ensure appropriate antibiotic treatment was in place for 1 of 1 resident (R15) with an active infection. Furthermore, the facility failed to ensure monitoring and documentation of prophylactic antibiotic use for 1 of 1 resident (R15) reviewed for antibiotic stewardship. R15's quarterly minimum data set (MDS) dated [DATE], indicated a brief interview for mental status (BIMS) score of 15, and R15 has an indwelling urinary catheter. R15's provider orders (after visit summary) dated 8/11/23, included the medications Bacitracin and cefpodoxime (oral antibiotic), and follow-up visit dated 9/5/23, included Bactrim and Bacitracin. R15's medication administration record (MAR) for October 2023, revealed administration of Bactrim twice daily for 10 days, Diflucan (an antifungal), and continuation of Bacitracin three times daily with catheter care. R15's care plan printed 10/26/23, indicated a self-administration of medication plan started 8/30/23, and antibiotic use dated 8/31/23. R15's infection nurses note printed 10/26/23, revealed last assessment completed on 11/10/22, for urinary tract infection (UTI). However, R15 was listed on a spreadsheet for house acquired infections which indicated the antibiotic cefpodoxime with a resolution date of 8/25/23. The facility's clinical dashboard for antibiotic medications printed 10/26/23, revealed a start date of 10/26/23, for R15's Bacitracin. Nystatin, an antifungal was reported on the dashboard as well. However, R15's current administration of Diflucan was not reported. R15's hospital progress plan note dated 8/9/23, had the order to continue Bacitracin three times daily to reduce catheter irritation. During an interview on 10/26/23 at 8:19 a.m.,registered nurse (RN)-A stated R1's Bacitracin was ordered prophylactically after urinary stent removal. RN-A stated R15 was prone to infection, explaining why there was no end date for administration. During an interview on 10/26/23 at 10:28 a.m., the assistant director of nursing (ADON) and infection preventionist (IP) stated a nursing assessment/infection note was ordered twice daily if a resident was on an antibiotic. ADON also stated the housing unit coordinator (HUC) enters the order for these assessments when an antibiotic was ordered. ADON stated there should be a stop date on antibiotics, however, prophylactic use was an exception. During an interview on 10/26/23 at 1:34 p.m., the director of nursing (DON) stated antibiotics treating an acute infection need an infection note from a nurse assessment every shift. DON also stated infection notes and end dates are not required for prophylactic antibiotics. DON stated medication orders require a rationale. During an interview on 10/26/23 at 1:48 p.m., the consulting pharmacist (CP) stated there are instances when an antibiotic could be ordered without an end date, including prophylactically. CP also stated a rationale for the antibiotic should be included in the order. During an interview on 10/26/23 at 2:12 p.m., the ADON stated the provider will make the decision on the continued necessity of an antibiotic, and nurses also monitor effectiveness and adverse effects. The facility's antibiotic stewardship protocol dated September 2022 indicates all antibiotics ordered and placed in the electronic health (EHR) record will display on the antibiotic clinical dashboard. The IP will then start the infection control data collection tool in the EHR that analyzes for the required criteria to merit using an antibiotic. The nurse is to follow-up in the chart 48 hours after the antibiotic is completed or infection cleared. The infection is to be added to the care plan and resolved when the infection is cleared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure appropriate interventions were implemented to reduce the risk of falls for 1 of 1 resident (R37) who had repeated falls and was reviewed for accidents. Findings include: R37's significant change Minimum Data Set (MDS) dated [DATE] indicated mildly impaired cognition and diagnoses which included unspecified dementia with behavioral disturbance, repeated falls, reduced mobility, unsteadiness on feet, Alzheimer's disease and signs and symptoms involving cognitive functions and awareness. It further indicated a behavior of wandering 1-3 times per week, required supervision with locomotion on the unit, and extensive assistance with all other activities of daily living (ADL's). It also indicated R37 had 2 or more falls without injury and 2 or more falls with injury, since admission. R37's care plan dated 2/16/21, included R37 required assistance of two staff for stand pivot transfers. It further included R37 was at risk for falls related to having a history of falls, weakness, dyskinesia, poor balance, need for staff assistance with performance of most ADLs, frequent incontinence, use of antidepressant medications, and impaired mobility with the following interventions: resident near to staff and reminded resident to call for help before getting up, analyze previous falls to determine whether pattern/trend can be addressed, anticipate and meet needs, place in staff view when restless. R37's Fall Risk Summary dated 5/4/22, included R37 had a Morse Fall Scale completed with a score of 55.0, putting her at a high risk for falling. R37's post incident reviews included: -4/1/22 R37 fell while attempting to self transfer from her bed to her wheelchair with an intervention to put resident near staff and remind her to call for help before getting up. -4/9/22 R37 fell while trying to self transfer from her wheelchair to her bed, with an intervention to put resident near staff and remind her to call for help before getting up. No new interventions were added. -4/12/22 R37 fell out of her wheelchair, with an intervention to put resident near staff and remind her to call for help before getting up. No new interventions were added. -4/22/22 indicated R37 fell while self propelling in her wheelchair, with an intervention to put resident near staff and remind her to call for help before getting up. No new interventions were added. -4/25/22, indicated R37 fell while attempting to self transfer from wheelchair to bed, with an intervention to put resident near staff and remind her to call for help before getting up. No new interventions were added. During observation on 6/28/22, at 12:53 p.m. R37 was in the hallway in her wheelchair, attempting to enter another residents room. Nursing assistant (NA)-C reminded her which room was her's by pointing out the bluebird decals on the wall by her door. NA-C then pushed R37 in her wheelchair to her room, assisted her into bed and exited the room, leaving R37's wheelchair next to the bed. R37 sat up on the side of her bed and then stood up and took a few steps toward the door and hung onto it. The door was moving back and forth and R37 was unsteady. R37 looked at surveyor and stated Ma ' am, I can't push this chair. as she was trying to use one hand to push her wheelchair so she could sit down. Surveyor asked Are you supposed to be getting up by yourself? Memory Support Director (MDS) came around the corner and shook her head no to me. She went into R37's room and assisted her to sit down in her wheelchair, brought her into the common area, and walked away. R37 self propelled her wheelchair over to a row of chairs against the wall in the common area and transferred herself from the wheelchair to the chair in the dining area. Licensed practical nurse (LPN)-B was standing a few feet away at the medication cart but didn't appear to notice the resident. At 1:13 p.m., R37 transferred herself from the chair to her wheelchair. Recreational Therapist (RT)-A was in the common area but didn't notice because she was trying to turn on the television (TV). During observation on 6/29/22, at 8:05 a.m. R37 was self propelling her wheelchair in the hallway. RT-A walked up to R37 and stated let me push you as she brought her to her room and then went to get a nursing assistant (NA). NA-B stated when he went into R37's room she was in her bed, so he assisted her back into her wheelchair and left the room. R37 sat on her bed. She stood up and took a few steps around her room while hanging onto the door. The door swung back and forth and R37 was unsteady. Surveyor went to get help in order to prevent R37 from falling. The director of nursing (DON) and Administrator were standing by the nurses station and went to assist R37 to sit down in her wheelchair. The DON then brought R37 out into the common area. During observation on 6/29/22, at 1:13 p.m. R37 self-propelled her wheelchair into the common area and started talking to another resident. R37 stood up from her wheelchair and as she was standing, NA-B walked into the common area, looked at R37, and walked away. NA-B didn't assist R37 to sit down or transfer into the chair. R37 transferred herself into the chair next to the other resident. During an interview on 6/29/22, at 8:05 a.m. NA-B stated R37 always tries to stand and transfer on her own especially when she's alone, she's very quick but she's supposed to get help. During an interview on 6/30/22, 11:16 a.m. NA-C stated R37 frequently moves around the unit, going in others residents rooms. NA-C further stated R37 often self transfers but she requires the assistance of 2 staff when transferring. During an interview on 6/30/22, at 9:12 a.m. RN-G was asked what interventions they've tried to prevent R37 from falling. RN-G stated they monitor her and had Occupational Therapy (OT) evaluate her for a new wheelchair. She further stated the nursing assistant's shouldn't be leaving her in her room alone. That would be atypical for them to do that. During an interview on 6/30/22, at 10:05 a.m. the director of nursing (DON), stated R37 had just started self transferring again and they really hadn't had a chance to implement or educate staff on interventions. The DON further stated the facility has had OT evaluate R37 for a new wheelchair (which she received) and they've tried several things in order to figure out why R37 had a change in condition (pain assessment, blood sugar checks, medication review, etc.), however none of these things addressed interventions that were put in place to prevent R37 from self-transferring. The facility's policy titled Fall Data Collection Policy and Protocol last reviewed 2/16/19, included in step 10 under the heading Procedure once the cause and contributing factors are identified, identify a new intervention that will eliminate or minimize the cause and contributing factors. It further included in step 11 the interdisciplinary team will meet daily and as needed (PRN) to review accident/incidents and determine if investigation of incident is need and will assist with assessing for further interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, documentation, and interview, the facility failed to ensure the tube feeding bag was changed every 24 hours for 1 of 1 resident (R30) who utilized tube feedings to meet their nutritional needs. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], included R30 was rarely/never understood and diagnoses of dysphagia following cerebral infarction, diabetes, vascular dementia without behavioral disturbance, epilepsy, and respiratory failure with hypoxia. It further included R30 had a feeding tube and required total dependence on staff with eating. R30's doctor's order dated 3/10/22, included Enteral Feed Order every day shift change tube feeding tubing, bag, kit, syringe, and graduate daily and date and initial on change. During observation on 6/27/22, at 2:48 p.m. R30 was laying in bed and her tube feeding was connected. The bag containing her tube feeding was dated 6/26/22, 0800 (8:00 a.m.). The bag could hold 1200 milliliters (ml) of formula (Diabetisource) and there was approximately 350 ml left in the bag. The pump had stopped running and the monitor indicated dose done. Registered nurse (RN)-D verified she had not changed the bag and had added the formula to the bag from the day before. RN-D stated she was unaware how often R30's bag should be changed and she directed surveyor to licensed practical nurse (LPN)-B to answer any further questions. LPN-B verified R30's tube feeding bag should be changed every day. During an interview on 6/29/22, at 1:30 p.m. RN-G stated R30's tube feeding bag needed to be changed every 24 hours. During an interview on 6/30/22, at 10:05 a.m. the director of nursing (DON) stated R30's tube feeding bag should be changed every morning shift. A facility skills checklist titled Enteral tube feeding, continuous, gastrostomy and jejunosteomy dated 7/9/21 included label the enteral administration set with the date and time that it was first hung. Change an open-system administration set every 24 hours. Change a closed-system administration set according to the manufacturer's instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to adequately and comprehensively monitor the pre-and post-treatment condition or access site for 1 of 1 resident (R188) receiving hemodialysis. R188's admission Minimum Data Set (MDS) dated [DATE], indicated R188 was cognitively intact and was receiving dialysis. R188's medical diagnoses included hydronephrosis with renal and ureteral calculous obstruction (excess fluid in kidneys due to stones in the kidneys and ureters), end stage renal disease and dependence on renal dialysis. R188's dialysis care plan dated 6/16/22, indicated R188 required hemodialysis due to acute kidney failure, had a right chest catheter site and received dialysis three times a week. The care plan directed staff to observe for complications following dialysis: hypotension, febrile reaction [fever], bleeding, infection. R188's physician order dated 6/16/22, instructed staff to open and complete a pre- and post-dialysis data collection form every evening shift Monday, Wednesday and Friday. R188's physician order dated 6/20/22, instructed staff to check right chest for tunneled catheter placement and make sure it was intact without bleeding. R188's Dialysis Data Collection Pre and Post Appointment (DDCPPA) form dated 6/20/22, indicated an assessment (mental, skin, edema, lungs, GI, cardiac, access condition) and vital signs (VS), blood pressure (BP), temperature (T), pulse (P) and respirations (R) in the post dialysis section but lacked a pre dialysis assessment and VS. R188's DDCPPA assessment dated [DATE], indicated a pre dialysis assessment and VS but lacked a post dialysis assessment with VS for the post assessment documented as collected on 6/22/22, at 7:33 a.m. R188's DDCPPA dated 6/27/22, indicated a pre and post dialysis assessment with VS for the post assessment documented as collected on 6/26/22, at 8:56 a.m. (BP and P), 6/26/22, at 9:18 a.m. (T) and 6/25/22, at 21:41 p.m. (R). R188's DDCPPA for dialysis on 6/29/22, was completed by registered nurse (RN)-H on 6/30/22 after being questioned by state surveyor. During interview on 6/28/22, at 9:14 a.m. R188 stated staff never look at her access site after dialysis and sometimes check her oxygen level, BP, and T. R188 further stated staff have never used a stethoscope to listen to her heart, lungs, or chest. During interview on 6/30/22, at 8:30 a.m. RN-H stated an assessment should be done on all dialysis residents before and after dialysis. RN-H stated some of the things to assess were VS, medications due, and the access site for bleeding. RN-H further stated it was important to check the resident's BP and blood glucose after dialysis and observe for nausea. RN-H stated she did not complete the DDCPPA for R188 the day before (6/29/22) even though she did document in the treatment administration record (TAR) that it had been completed. RN-H stated she remembered at the end of her shift she had not completed the DDCPPA for R188 and had planned to complete it today (6/30/22) but stated it should be completed the same day as the dialysis appointment. During interview on 6/30/22, at 8:47 a.m. licensed practical nurse (LPN)-C stated the nurses were supposed to complete a pre and post dialysis assessment using the DDCPPA form in the electronic health record (EHR) and that it should be completed timely. LPN-C further stated it was not appropriate for DDCPPA to be completed a day later as the assessment must be done before and after each dialysis appointment. During interview on 6/30/22, at 9:49 a.m. director of nursing (DON) stated an assessment should be done pre and post each dialysis appointment by the nurse and they should complete the DDCPPA in the EHR. DON stated there was a reason those forms were in the EHR and that they should be completed accurately with up-to-date VS and assessments. The facility policy Dialysis (Program Guidelines), dated 2006, instructed staff to assess the resident for complications post dialysis therapy. The policy indicated hypotension (low BP) as the most common complication. The policy listed other possible complications such as fever, pulmonary edema, nausea and vomiting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R188's admission MDS dated [DATE], indicated R188 was cognitively intact and required extensive two plus person assist with bed mobility and transfers. R188's medical diagnoses included end stage renal disease and morbid obesity. R188's PDDCE dated 6/18/22, indicated R188 did not currently use any physical device. R188's PDDCE dated 6/29/22, indicated R188 used a left and right half side rail. R188's falls care plan dated 6/16/22, indicated R188 was at risk for falls. R188's falls care plan did not include side rails as an intervention. R188's physical device care plan dated 6/29/22, indicated R188 required the use of a physical device for positioning to prevent falls and increase independence. R188's Informed Choice Consent for Physical Devices (ICCPD) dated 6/18/22, indicated R188 was informed of the risks of using bed rails due to 100% risk of falling. R188's ICCPD dated 6/29/22, indicated R188 was informed of the risks of using bilateral side rails to aide in independence with repositioning due to muscle weakness and chronic pain. R188's physician order dated 6/18/22, indicated two half side rails in bed to aide in independence with reposition. During observation and interview on 6/28/22, at 8:46 a.m. R188's bed had bilateral half side rails. R188 stated the right bed rail was very loose and that the side rails had been installed shortly after she was admitted to the facility. R188 pulled on the right side rail and demonstrated the loose side rail which moved back and forth several inches. During interview on 6/29/22, at 9:16 a.m. M-A stated he installed new side rails on R188's bed the previous day (6/28/22) because she got a new bed and that her old bed had side rails that he had installed previously on 6/18/22. During interview on 6/29/22, at 9:56 a.m. health unit coordinator (HUC)-A stated she normally entered the order for side rails and initiated a work order for maintenance to install them. HUC-A further stated it was the nurse's responsibility to ensure the consent (ICCPD) and assessment (PDDCE) was completed. During interview on 6/29/22, at 10:11 a.m. licensed practical nurse (LPN)-C stated not being aware of R188's side rails until that day. LPN-C stated the process for side rails included an order, consent indicating risks and benefits, and an assessment to ensure the resident could safely use the side rails. During interview on 6/29/22, at 10:22 a.m. RN-B stated she worked with R188 on 6/18/22, and was aware R188 requested side rails be placed on her bed. RN-B stated she told LPN-C who then initiated the ICCPD form in which she (RN-B) had R188 review and sign on 6/18/22. During interview on 6/29/22, at 11:23 a.m. LPN-C stated RN-B completed the PDDCE on 6/18/22, prior to the side rail installation but should have waited until after they were installed since she (RN-B) was aware of the new order for side rail placement. LPN-C further stated she could see that there was a breakdown in that process. During interview on 6/29/22, at 12:54 p.m. LPN-C stated R188's second PDDCE was completed that day (6/29/22) since it was brought to her attention it had not been completed accurately previously. LPN-C further stated R188's ICCPD was updated with an appropriate reason for use and re-signed by R188 on 6/29/22. During interview on 6/30/22, at 9:42 a.m. DON stated due to the survey, the facility reviewed all residents and found some residents with side rails had not been assessed for the safe use of side rails. DON further stated the PDDCE should have been completed for R188 when they were first installed to ensure appropriateness and her ability to use them safely. During interview on 6/30/22, at 10:59 a.m. maintenance director (M)-B stated there was no formal schedule for checking or maintaining side rails. Facility policy Physical Device Data Collection and Evaluation dated 7/2018, indicated a physical device data collection tool would be completed on admission, quarterly, annually and with the initiation of any physical device by a licensed nurse and reviewed by the IDT (interdisciplinary team) to ensure the safety of the resident utilizing a physical device. All physical devices would have a medical symptom to warrant the use along with a physician's order. The device would then be listed on the resident's care plan. Based on observation, interview and document review, the facility failed to assess the use of bed rails prior to their initiation and failed to establish a process for ongoing monitoring of bed rails for 2 of 2 residents (R74 and R188) reviewed who utilized bed rails. Findings include: R74's significant change Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition. R74 required supervision and one staff to physically assist with bed mobility. R74 was independent with transfers after set-up. The MDS indicated R74 had a diagnosis of lymphoma (a type of cancer.) R74's Physical Device Data Collection Evaluations (PDDCE) dated 2/4/22, and 5/23/22, lacked notation of any physical devices such as grab bars or bed rails. R74's Activity of Daily Living (ADL) care plan dated 8/10/21, lacked mention of use of grab bars. R74's medical record lacked assessment for the use of bed rails (including grab bars), a review of risks including entrapment, that the bed was appropriate for the resident and lacked information that the bed rails were properly installed and maintained. During an observation and interview 6/27/22, at 12:20 p.m. R74 was in bed with a grab bar on the right and left side of the bed. R74 stated she had a concern with her grab bars being loose. R74 shook her left grab bar which was able to be moved back and forth about four inches. The right grab bar was loose also, and able to be moved back and forth about one inch. R74 had a folded napkin she had wedged into the left grab bar to try and make it more stable. R74 stated she did not remember if any of the staff knew, but the grab bars had been this way since she moved into the room. During an interview on 6/28/22, at 2:57 p.m. nursing assistant (NA)-A shook R74's grab bars after being prompted to, and verified they were loose. NA-A stated the grab bars were not safe and R74 could fall. NA-A stated they would check grab bars periodically during cares, however, R74 was independent with transfers so they had not been checked. During an interview on 6/28/22, at 3:05 p.m. maintenance staff (M)-A stated his department did not have a list of residents with bed rails to monitor routinely. M-A stated he thought scheduled inspections were done by nursing for the use of bed rails. M-A stated they had tried giving R74 other rails in the past. M-A entered R74's room, moved the grab bars and verified the grab bars were loose. During an interview on 6/29/22, at 9:45 a.m. registered nurse (RN)-F stated residents should be assessed for bed rails or grab bars before use and as scheduled. RN-F looked in R74's medical record and verified the physical device assessment had not been completed, did not include the evaluation of grab bars and should have. During an observation on 6/29/22, at 10:15 a.m. R74 no longer had any bed rails or grab bars on her bed. During a follow up interview on 6/29/22, at 1:30 p.m. M-A stated he took the grab bars off R74's bed. M-A stated when R74 moved to her current room, the bed in the room had existing grab bars that were left on the bed without an order and should not have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure medications were provided as ordered for 2 of 5 residents (R23 and R10); and failed to ensure staff were aware of appropriate disposal of fentanyl patches (a controlled narcotic medication) to prevent potential drug diversion for 1 of 1 residents (R10) reviewed for medication administration. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. R23 had a diagnosis of anxiety. R23's care plan dated 8/2/19, indicated R23 took psychotropic meds to include an antianxiety related to obsessive compulsive disorder and anxiety. R23 was followed by a outside psychiatrist and in house psychologist. R23's Medication Administration Record (MAR) for June 2022 included the following: 1. An order for Clonazepam tablet 0.5 milligrams (mg) by mouth one time daily at 1500 (3:00 p.m.) related to anxiety disorder. The MAR indicated R23 had missed two doses: one on 6/27/22 and one on 6/28/22 and to refer to progress notes. 2. An additional order for Clonazepam tablet 0.5 mg by mouth two time daily at 0600 (6:00 a.m. and 1900 (7:00 p.m.) related to anxiety disorder. The MAR indicated R23 had missed one dose on 6/27/22, at 7:00 p.m. and to refer to progress notes. R23's progress notes dated 6/27/22, at 16:19 (4:19 p.m.) indicated the Clonazepam was not available and pharmacy was notified. A new script (prescription) was needed from the doctor first. During an observation and interview on 6/27/22, at 6:08 p.m. registered nurse (RN)-A prepared R23's evening medications. RN-A looked through the narcotics drawer on the medication cart and stated the scheduled Clonazepam was empty and she had already notified the clinical manager. RN-A stated the facility had an emergency supply of medication in the Omnicell (an automated medication dispensing cabinet) but she did not think Clonazepam was included in the supply. RN-A went to find R23 to give her the other evening medications. R23 stated she had not slept well and stated she felt like going out of my mind and did not know why. The Omnicell stock list, provided on 6/28/22, included Clonazepam 0.5 mg. During an observation and interview on 6/28/22, at 3:10 p.m. licensed practical nurse (LPN)-A prepared R23's afternoon medications. LPN-A stated she was not able to give the Clonazepam as ordered because the prescription was out. LPN-A brought the other scheduled medications to R23, administered them, exited the room and started preparing the next resident's medications. When LPN-A was asked if she could obtain the Clonazepam from the Omnicell machine, LPN-A stated she did not have access but could go see if the nurse manager would obtain R23's medications from the Omnicell. R10's quarterly MDS dated [DATE], identified intact cognition. R10 had a diagnosis of chronic pain syndrome and gastro-esophageal reflux disease (GERD). R10's Pain Care Plan dated 3/29/22, indicated an alteration in comfort related to (r/t) chronic pain syndrome and GERD. Staff were directed to administer medications as ordered. R10's MAR for June 2022, included the following: 1. An order for Protonix (pantoprazole) tablet delayed release 40 mg one time daily by mouth related to GERD. From 6/25/22 through 6/30/22, the MAR indicated the medication was not administered which resulted in six doses of the medication not being administered 2. An order for fentanyl patch 75 micrograms/hour (mcg/hr) apply one patch transdermally (on the skin) every 48 hours for pain and remove per schedule with an order 3. An order to check for patch placement and removal every shift for fentanyl patch 4. An order for famotidine tablet 20 mg by mouth two times a day at 0600 (6:00 a.m.) and 1600 (4:00 p.m.) related to GERD. During an interview on 6/28/22, at 8:34 a.m. R10 stated his pantoprazole for GERD had not been administered for four days. R10 stated medications were sometimes not ordered until the last minute or when they ran out. During a follow up interview at 2:16 p.m. R10 stated he felt heartburn as a result of his missed pantoprazole. R10's progress notes from 6/25/22 through 6/28/22 lacked rationale why the pantoprazole was not provided or follow up attempts to obtain the medication. During an observation on 6/28/22, at 3:33 p.m. LPN-A removed R23's used fentanyl patch, folded it and set it to the side. LPN-A applied the new patch as ordered. LPN-A exited the room, placed the used patch in a small freestanding sharps container on the nurse's cart in the hallway. LPN-A stated fentanyl patches were placed in the sharps bins and verified the bin was not secure. During an interview on 6/28/22, at 3:43 p.m. RN-A also stated she would put used fentanyl patches in the small freestanding sharps disposal container located on her medication cart in the hallway. During an observation on 6/29/22, at 7:25 a.m. RN-B was preparing R10's morning medications. RN-B picked up one card of the famotidine 20 mg tablets and punched out one pill into a pill cup. RN-B picked up a second bubble pack of the famotidine 20 mg tablets and punched out another pill into the pill cup. This would give R10 double the amount of medication that he was prescribed. RN-B stated the pantoprazole was not available in the medication cart and she would need to check the Omnicell. RN-B went to the Omnicell and the machine displayed a message that the med was not stocked in this cabinet. RN-B was not able to provide the pantoprazole. As RN-B prepared to go into R10's room, she was advised to recheck her medications. RN-B located the extra tablet of famotidine and removed it from the pill cup. During an interview on 6/29/22, at 10:25 a.m. RN-C stated there was an issue with medications not being reordered timely and running out of the supply, and medications should be re-ordered when there is one week's worth remaining to ensure they don't run out. RN-C stated nurses were additionally expected to either get a back up medication from the Omnicell and/or call the pharmacy to ensure a prescription refill had been ordered. Lastly, Fentanyl patches should be disposed of in the facility Drug Buster containers and not in the sharps containers. RN-C showed the Drug Buster units which are available in the medication storage unit room. During an interview on 6/30/22, at 9:53 a.m. the director of nursing (DON) stated she expected medications to be administered as ordered and reordered when the supply ran low. The DON also stated fentanyl patches should be folded in half and disposed of in the Drug Buster. Facility policy General Dose Preparation and Medication Administration dated 1/1/22, indicated facility staff should verify each time a medication is administered that it was the correct dose. Facility policy Reordering, Changing and Discontinuing orders, dated 1/1/22, indicated facilities were encouraged to reorder medications electronically or by fax whenever possible. Additionally, facility staff should review the transmitted re-orders for status and potential issues and pharmacy response. Facility policy, Prescribing, Administration and Disposal of Fentanyl Transdermal Systems dated 1/1/22, indicated patches should be disposed of my folding in half and placed in commercially available disposal kit. The policy noted fentanyl patches are not biohazard waste and should not be placed in sharps containers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure provide appropriate side effect monitoring for signs of tardive dyskinesia (TD) [involuntary movements caused by antipsychotic use] with antipsychotic medication consumption for 1 of 4 (R16) residents reviewed for unnecessary medications and utilized antipsychotic medications. Further, the facility failed to ensure orders for as needed (PRN) antianxiety and antipsychotic medication were reassessed or ceased after 14 days, for 1 of 1 residents (R16) reviewed who had orders for as needed psychotropic medication. Findings include: R16's significant change Minimum Data Set (MDS), dated [DATE], identified R16 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADLs). Further the MDS outlined R16 experiences no hallucinations, delusions or other alteration in mood or behavior during the assessment period. R16's diagnoses included, schizoaffective disorder, major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. R16's Medication Administration Record (MAR) dated June 2022, included: Seroquel tablet [an antipsychotic medication] 75 mg (milligrams) by mouth two times a day and give 100 mg one time a day for hallucinations and delusions. Haldol [an antipsychotic medication] 2 mg/ml (milliliter) give 0.25 ml by mouth every 1 hours as needed for agitation related to schizoaffective disorder with a start date of 5/27/22 and no documented stop date. R16 received this medication 1 time during the month of June. Seroquel tablet give 50 mg by mouth as needed for hallucinations and delusions related to schizoaffective disorder with a start date of 4/21/22 and no documented stop date. R16 had not received this medication during the month of June. Lorazepam [an antianxiety medication] 2 mg/ml give 0.25 ml by mouth every 2 hours as needed for anxiety with a start date of 5/27/22 and no documented stop date. R16 has used this medication 2 times during the month of June. R16's care plan dated 7/1/21 included, I take psychotropic meds due to depression, anxiety and schizophrenia. A corresponding intervention dated 3/2/22, instructed, complete AIMS per order and monitor for adverse effects of medication. R16's Pharmacy Consult Report dated 3/23/22, recommended adding 14 day stop dates to PRN orders for antipsychotic and anxiolytic medications and reassess use. R16's Pharmacy Consultation Report dated 4/27/22, noted an Abnormal Involuntary Movement Scale (AIMS) [an assessment of the mental and physical effect of antipsychotic medications] or other appropriate assessment to identify symptoms of Tardive Dyskinesia (TD) was not documented in R16's medical record within the previous 6 months. Additionally, the Consultation Report included a recommendation to monitor for involuntary movements now and at least every 6 months or per facility protocol. An additional Pharmacy Consultation Report dated 4/27/22 recommended adding a 14 day stop as required by regulation. R16's Pharmacy Consultation Report dated 6/22/22, noted, REPEATED RECOMMENDATION from 4/27/22, and included a recommendation to discontinue the PRN orders, or assess and add a 14 day stop as required by regulation. R16's medical record showed the most recent AIMS was completed 9/21/21, and indicated a score of 5 out of 28 [the higher the score the great the impact of observed movements on resident]. R16's physician progress note dated 5/10/22, included, Rather severe movement disorder of tardive dyskinesia with tremor with intention of both upper extremities. On 6/27/22, at 3:10 p.m. surveyor observed R16 with a noticeable tremor in his hands. During an interview on 6/29/22, at 10:45 a.m. the director of nursing (DON) stated an AIMS should be completed every 6 months for any resident taking an antipsychotic medication to ensure that medication does not cause any irreversible negative effects such as TD. Additionally, the DON stated hospice providers don't want to provide stop dates for as needed medications. During a follow-up interview on 6/29/22, at 1:54 p.m. the DON stated R16's PRN psychotropic medications have not been appropriately reassessed or stopped after 14 days. The facility policy, Psychoactive Medication Use and Gradual Dose Reduction, dated 2010, instructed, Abnormal Involuntary Movement (AIMS) will be performed on residents receiving antipsychotic medications to screen for tardive dyskinesia every 6 months. Additionally, the policy included, For PRN psychotropic drugs the physician/prescribing practitioner must document their rationale in the resident medical record if he/she believes it is appropriate to extend the order beyond 14 days. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 16% with 4 errors out of 25 opportunities involving 2 of 4 residents (R23 and R10) who were observed during medication administration. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. R23 had a diagnosis of anxiety. R23's Medication Administration Record (MAR) for June 2022 included the following orders: 1. clonazepam tablet 0.5 milligrams (mg) by mouth one time daily at 1500 (3:00 p.m.) related to anxiety disorder. 2. clonazepam tablet 0.5 mg by mouth two times daily at 0600 (6:00 a.m. and 1900 (7:00 p.m) related to anxiety disorder. During an observation and interview on 6/27/22, at 6:08 p.m. registered nurse (RN)-A prepared R23's evening medications. RN-A looked through the narcotics drawer on the medication cart and stated the scheduled clonazepam was empty and she had notified the clinical manager. RN-A gave R23 other scheduled medications. RN-A had not administered the scheduled clonazepam. During an observation and interview on 6/28/22, at 3:10 p.m. licensed practical nurse (LPN)-A prepared R23's afternoon medications. LPN-A stated she was not able to give the clonazepam as ordered because the prescription was out. LPN-A gave R23 other scheduled medications. LPN-A had not administered the scheduled clonazepam. R10's quarterly MDS dated [DATE], identified intact cognition. R10 had a diagnosis of gastro-esophageal reflux disease (GERD) and chronic pain syndrome. R10's MAR for June 2022, included the following orders: 1. Protonix (pantoprazole) tablet delayed release 40 mg one time daily by mouth related to GERD 2. famotidine tablet 20 mg by mouth two times a day at 0600 (6:00 a.m. and 1600 (4:00 p.m.) related to GERD. During an observation on 6/29/22, at 7:25 a.m. RN-B was preparing R10's morning medications. RN-B picked up one card of the famotidine 20 mg tablets and punched out one pill into a pill cup. RN-B picked up a second bubble pack also of famotidine 20 mg tablets and punched out another pill into the same pill cup. This would give R10 double the amount of medication that he was prescribed. Next, RN-B stated the pantoprazole was not available in the medication cart because the medication ran out. As RN-B prepared to go into R10's room, she was advised to recheck her medications. RN-B located the extra tablet of famotidine and removed it from the pill cup. RN-B gave R10 other scheduled medications. RN-B had not administered the scheduled pantoprazole. During an interview on 6/30/22, at 9:53 a.m. the director of nursing (DON) stated she expected medications to be administered as ordered and reordered when the supply ran low. Facility policy General Dose Preparation and Medication Administration dated 1/1/22, indicated facility staff should verify each time a medication is administered that it was the correct dose. Facility policy Reordering, Changing and Discontinuing orders, dated 1/1/22, indicated facilities were encouraged to reorder medications electronically or by fax whenever possible. Additionally, facility staff should review the transmitted re-orders for status and potential issues and pharmacy response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to store and label food to prevent potentially degraded food from being served to residents. This had the potential to affect all 80 of the 81 residents who received food from the kitchen. Findings included: On 6/27/22 at 12:05 p.m. surveyor conducted a kitchen tour with the director of dietary services (DDS) and observed the following in the walking coolers: - A large partially used bag of cut lettuce tapped shut with masking tape - illegible writing on the tape. DDS stated she was unable to read the handwriting, could not identify the date the protect had been opened. - A serving bowl of prepared 3-bean salad - undated - A partially used bag of French toast - undated - 2 small serving bowls of ground beef - undated - 3 large partially used, plastic containers of Reliance salad dressing. Each container displayed a handwritten date which indicated when the product was opened - 5/30, 6/7, and 6/8 - A large partially used plastic container of thousand island salad dressing - dated 5/21/22 - A large partially used plastic container of coleslaw - date 5/1. There were multiple small spots of furry blue/gray matter on the outside of the container. DDS identified the matter as mold. - 1 large partially used plastic container of honey mustard salad dressing - dated 4/4. There were multiple small spots of furry blue/gray matter on the outside of the container. DDS stated the matter appeared to be mold. - 4 individually wrapped meat and cheese sandwiches - undated - A partially used container of beef base - undated - A partially used container of vegetable base - dated 5/13/22 - A large partially used jug of salsa - dated 6/16 - A large partially used container of pickle relish - dated 6/7 - A full tray of individually dished chocolate pudding with whipped cream - dated 6/13 - 2 serving bowls of prepared ham pasta salad - undated - A serving bowl of cubed turkey - undated - A partially used stick of butter - undated - A partially used block of pre-sliced American cheese - undated - A partial tray of individually dished apple crisp with whipped cream - undated - A partially used bag of shredded mozzarella cheese - undated - A Styrofoam to-go container containing grapes and sliced watermelon - undated - 2 small bowls of light brown pudding-like food. DDS identified the item as, something pureed but was unable to provide additional identification - undated - A serving bowl of crushed pineapple - dated 6/22 - A serving bowl of chocolate pudding dated - 6/16 - A partially used bag of flour tortillas - dated 3/8/22 and another partially used bag of flour tortillas - undated - 3 containers of partially used egg salad - undated - A large partially used container of Italian salad dressing - dated 6/15 - A partially used package of pancakes - undated - A partially used carton of liquid whole eggs - undated - A serving bowl of diced peaches - dated 6/21/22 When interviewed during the tour, DDS stated when a food item has been opened or prepared staff should clearly label with the date. All food items should be used or disposed of within 7 days of that date. DDS was unable to state when the observed undated food had been opened or prepared. DDS stated all open undated food or food prepared more than 7 days ago will need to be discarded. The facility policy, Food Storage, dated 2021, included, All stock must be rotated with each new order received. Rotating [NAME] is essential to assure the freshness and highest quality of all foods. The policy goes on to inform, Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code.