**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain dignity for 1 of 1 resident (R62) reviewed for dignity. R62's discharge Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of quadriplegia, traumatic rupture of cervical intervertebral disc (C5-6), spinal stenosis, and neurogenic bladder. It further indicated R62 required substantial assistance with toileting, was always incontinent of urine, and received a diuretic on routine basis. R62's care plan dated 4/25/25, indicated the potential for alteration of bowel and bladder related to a diagnosis of a neurogenic bladder and included an intervention of R62 requiring 2 person assistance to use the toilet upon rising in the morning, before and after each meal, bedtime, on night rounds, and as needed. R62 also required assistance with all toileting tasks and used brief/pads for incontinence protection indicating he was not able to reliably notify staff of his need to be toileted. During interview on 5/12/25 at 5:25 p.m. R62 stated he had to wait 20-45 minutes (on average)almost every time he needed to use the urinal. Since his spinal cord injury, he doesn't have much notice when having to urinate and often ends up urinating in his brief. When that happens he then had to wait long periods of time sitting in his urine or feces. R62 also stated he had reported this to RN-E and the DON but nothing ever happened to fix the problem stating It's a culture here to not help each other out. I put my call light on and wait for staff to respond. When they don't respond, I go out into the hallway (in my wheelchair) to get help and I am often told by staff they're not my aide and then continue to play on their phone. During observation on 5/14/25 at 7:04 a.m., the following events occurred: -7:15 a.m. R62 put his call light on. -7:28 a.m. NA-E answered call light for another resident who's room was in close proximity to R62's room (exited the room at 7:34 a.m.) but failed to answer R62's call light when she was finished assisting the other resident. -7:35 a.m. NA-F was walking down the hall towards R62's room with the vital signs (VS) machine. NA-F entered the room and asked R62 what he needed because his call light was on. He stated he had to urinate but he already urinated in his brief because he couldn't hold it. NA-G stated that was okay, proceeded to take his blood pressure, then left the room stating I will come back later and get you up when she's (unknown) done. -7:45 a.m. NA-F assisted another resident with a shower. -8:01 a.m. registered nurse (RN)-D entered R62's room with medications, blood sugar monitor, and stethoscope. RN-D asked his name, date of birth , took his VS, tested his blood sugar, administered his medications, and gave him a nebulizer treatment. RN-D did not change R62's brief. -8:30 a.m. RN-D exited R62's room. -8:34 a.m. R62 stated RN-D did not change him while she was in his room and that he put his call light on at 7:15 a.m. when he first had to go to the bathroom. -8:40 a.m. R62 put on his call light again. -8:42 a.m. NA-F answered R62's call light and R62 stated he was still waiting for his brief to be changed. NA-F changed his brief (which was visibly full of urine) and removed the pad underneath him which was also visibly wet. During interview on 5/14/25 at 9:15 a.m. NA-F verified R62 told her he had urinated in his brief when she answered his call light at 7:35 a.m. NA-F stated was waiting for the nurse to go in and do what she needed to do but she should have changed him right away before the next call light went on. During interview on 5/14/25 at 9:30 a.m. RN-D stated anyone can answer call lights but it was usually the NA's who answer them. They try to answer call lights within 15 minutes and if a resident stated they need to be changed, staff should try to do that immediately or as soon as possible and changing a brief would take precedence over giving a resident a shower. RN-D further stated NA's are assigned to a group of residents but the other NA's are expected to answer the call lights and help each other out. If the nurse needs to administer medications or perform cares, etc. they can wait if a resident needed to be changed. RN-D verified she did not change R62 when she was in his room because she was unaware he needed to be changed. There was no reason he needed to wait to be changed until after she was done working with him. During interview on 5/14/25 at 2:00 p.m. NA-D stated NA's are assigned to a certain group of residents and we stick with our residents, unless someone is really busy, but everyone can help. NA-D further stated they try to answer call lights within 15 minutes and changing a residents brief should be done before giving a resident shower. An hour was too long for a resident to wait to have their brief changed and stated 10 minutes should be the longest they should have to wait unless they were really busy. During an follow up interview on 5/15/25 at 11:16 a.m., R62 stated if he hadn't fallen, he would still be able to do all all the things the staff do for him by himself and it took awhile for him to get used to staff having to help him and when he has to sit in his own urine or feces he feels useless and worthless. When it takes 45 minutes to an hour for staff to come, It makes him think staff don't want to help him and it's embarrassing and degrading. During interview on 5/15/24 at 10:56 a.m., the director of nursing (DON) stated he did not think an hour was too long for a resident to have to sit in a wet brief and there wouldn't be any negative outcomes as a result (specifically skin breakdown). The DON further stated changing a residents brief didn't necessarily take precedence over giving another resident a shower and would depend on the situation. He was unable to provide an approximate amount/range of time he would expect a residents call light to be answered or a residents brief to be changed (once they put their call light on.) A facility policy reagrding dignity was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure personal privacy during activities of daily living (ADLs) was provided for 1 of 2 residents (R9) reviewed for privacy. Findings include: R9's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, did not reject cares, used a wheelchair, and required substantial assist with toileting hygiene, and partial to moderate assist with dressing. R9's optional state assessment (OSA) dated 4/11/25, indicated R9 required assist with bed mobility, transfers, and toileting. R9's Facesheet undated, indicated the following diagnoses: rheumatoid arthritis, Myelodysplastic syndrome, weakness, history of falling, and Alzheimer's disease. R9's care plan dated 4/14/25, indicated R9 had an alteration in ADLs and required assist of one with dressing, and grooming. R9's care plan dated 4/14/25, indicated R9 had an alteration in mobility and required assist of one with transfers and ambulating. R9's care plan dated 4/14/25, indicated R9 had an alteration in toileting and interventions included to assist with toileting upon rising before and after meals, at bedtime, on night rounds and as needed. R9'S care sheet undated, indicated R9 required assist of one with toileting. During observation on 5/13/25 at 8:57 a.m., nursing assistant (NA)-H entered R9's room and asked if she was ready to get up. At 9:01 a.m., NA-H asked resident if she wanted to go into the bathroom and stated they bring R9 to the bathroom and complete cares in the bathroom. At 9:03 a.m., NA-H assisted R9 to the bathroom and R9 stood up in the bathroom using the sink and sat on the toilet. At 9:03 a.m., registered nurse (RN)-F entered R9's room. At 9:08 a.m., NA-H donned R9's hip protector and pants. R9's wheelchair was outside the bathroom door and R9's room mate was in bed sleeping across from the opened bathroom door. There was no privacy curtain located on the track on the ceiling to provide privacy between the bathroom and R9's roommate. At 9:17 a.m., R9 was assisted by NA-H to stand up and R9's pants were down, the bathroom door was opened, and R9's roommate was in bed. NA-H wiped R9's bottom with the door open and pulled up R9's incontinent brief, hip protector and pants as R9 held on to the sink. During interview on 5/13/25 at 9:24 a.m., NA-H verified there was no privacy curtain and stated there used to be a curtain because there were hooks on the track and further stated it would be important to have for privacy and stated the bathroom was crowded and R9 liked to sit on the toilet in the a.m. During interview on 5/13/25 at 10:02 a.m., RN-F verified there was no privacy curtain between the bathroom in R9's room and R9's roommate and stated she thought it was taken off to be washed and stated there could be a reason for why the curtain wasn't on the track and further stated it was important for privacy and added even though a resident had dementia, you still provide them with privacy. During interview on 5/13/25 at 3:42 p.m., the director of nursing (DON) viewed R9's room and stated one of the staff members informed the DON the curtains went down to the laundry and stated he expected staff provide privacy if a resident was in the bathroom with the door wide open with another resident in the room. A form, Combined Federal and State [NAME] of Rights, dated 6/18/19, indicated the resident has a right to personal privacy. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and document review, the facility failed to ensure resident specific target behavior monitoring for antipsychotic use and further failed to ensure a gradual dose reduction (GDR) of an antipsychotic for 1 of 4 residents reviewed (R9) for antipsychotic use. Findings include: R9's annual Minimum Data Set (MDS) dated [DATE], indicated R9 did not take an antipsychotic. R9's quarterly MDS dated [DATE], indicated R9 routinely took an antipsychotic and a GDR had not been attempted and the physician had not documented a GDR was clinically contraindicated. Further, did not have physical, verbal, or other behavioral symptoms, did not reject care, and did not wander. R9's quarterly MDS dated [DATE], indicated R9 routinely took an antipsychotic and a gradual dose reduction (GDR) had not been attempted. Further, the MDS indicated a GDR (gradual dose reduction) had not been documented by a physician as clinically contraindicated. Further, R9 did not have physical, verbal, or other behavioral symptoms, did not reject care, and did not wander. R9's quarterly MDS dated [DATE], indicated R9 routinely took an antipsychotic and a GDR had not been attempted and was documented by a physician as clinically contraindicated on 8/1/24. Further R9 did not have physical, verbal, or other behaviors, did not reject care, and did not wander. R9's annual MDS dated [DATE], indicated R9 routinely took an antipsychotic, and a GDR had not been attempted and was documented by a physician as clinically contraindicated on 8/1/24. Further, R9 did not have physical, verbal, or other behaviors, did not reject care, and did not wander and R9's behavior status, wandering and rejection of care status remained the same compared to prior assessments. R9's quarterly MDS dated [DATE], indicated R9 routinely took an antipsychotic, and a GDR had not been attempted and was documented by a physician as clinically contraindicated on 8/1/24. Further, R9 did not have physical, verbal, or other behavior symptoms, did not reject cares, and did not wander. R9's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, did not reject cares, did not hallucinate or have delusions, or physical, verbal, or other behavioral symptoms, did not wander and R9's behavior remained the same compared to prior assessment. Further, R9 routinely took an antipsychotic and a GDR had not been attempted and was documented by a physician as clinically contraindicated on 8/1/24. R9's Resident Census form dated 5/15/25, indicated R9 moved to the Villa (a locked unit) on 1/28/25, from another unit at the facility. Further, the form indicated R9's payer changed to hospice on 4/4/25. R9's care area assessment (CAA) dated 4/14/25, for psychotropic use indicated R9 received Seroquel (an antipsychotic) for psychosis with delusions and Zoloft for her diagnoses of depression and started on hospice care on 4/4/25. R9's care plan dated 4/14/25, indicated R9 was on the falling star program and was at risk for falling. Interventions included providing essential oils, ensure R9 wore her glasses, provide reminders not to ambulate or transfer without assist, keep the call light in reach. R9's care plan dated 4/14/25, indicated R9 wandered looking for her husband or car to go home and interventions indicated to approach from the front and walk in step before redirecting, will have a wander guard to ensure safety, when wandering provide comfort measures for basic needs. R9's care plan dated 4/14/25, indicated R9 was at risk for complications from psychotropic use related to receiving Zoloft for depression, Seroquel for a psychotic disorder with delusions and interventions indicated to monitor target behaviors, observe for changes in mood and behavior, observe for side effects, proper dosing and continued need, and pharmacy consultant review. The care plan lacked information what R9's target behaviors were. R9's care plan dated 5/12/25, indicated R9 was at high risk for falling due to dementia and an overall decline. Interventions included fall prevention and reduction precautions per facility protocol, monitor side effects of medication: cardiac medication as ordered, narcotic pain medication as ordered. R9's Orders form indicated the following orders: • Starting on 2/28/24, and discontinued on 5/15/25, target behavior interventions for Seroquel, code 1 for refusing to leave her room, code a 2 for self-isolation, special instructions indicated code 1 for redirection, 2 for 1:1, 3 for activity, 4 for offer food/fluid, 5 for toilet, 6 for reposition, 7 for adjusting room temperature, 8 for a back rub, 9 for a warm pack, 10 for music, and 11 for a quiet environment, 12 for lotion, 13 for aromatherapy, 14 for walking, 15 for reading, 16 for pet therapy, and 17 for rest. The target behaviors lacked information R9 looked for family including her husband, children, or sister. • 2/28/24, Monitor for potential side effects of antipsychotic medication such as an increase in sedation, drowsiness, dry mouth, blurred vision, constipation, urinary retention, tachycardia, muscle weakness, agitation, headaches, skin rash, excess weight gain, insomnia, dizziness, and nausea. Document (-) for no side effects and (+) for side effect present every shift. • 3/20/24, Seroquel (quetiapine) tablet, 25 milligrams (mg) daily at 4:00 p.m. • 1/29/25, Zoloft (an antidepressant) 125 mg orally every a.m. • 5/15/25, target behavior interventions for antipsychotic, code 1 for hallucinations, code a 2 for looking for car keys to go to work, code a 3 for wanting to go home, code a 4 for looking for family, husband, children, or sister. Special instructions indicated code a 1 for redirection, 2 for 1 to 1, 3 for activity, 4 for offering food and fluids, 5 for toileting, 6 for repositioning, 7 for adjusting the room temperature, 8 for a back rub, 9 for a warm or cold pack, 10 for music, 11 for quiet environment, 12 for lotion, 13 for aromatherapy, 14 for walking , 15 for reading, 16 for pet therapy, 17 for resting twice a day. R9's medication administration record (MAR) and treatment administration record (TAR) dated 1/1/25, to 1/31/25, indicated R9 received Seroquel 25 mg at 4:00 p.m., for a psychotic disorder with delusions due to a known physiological condition. R9's TAR indicated target behavior interventions for Seroquel included to code 1 for refusing to leave her room and code a 2 for self-isolation. The form indicated zeros and dashes from 1/1/25, to 1/31/25, for the 7:00 a.m., to 3:00 p.m. shift for the number of behaviors. The 3:00 p.m., to 11:00 p.m., shift indicated four documented behavior episodes coded as a 1 for refusing to leave her room on 1/3/25, 1/13/25, 1/17/25, and 1/27/25. The 11:00 p.m., to 7:00 a.m., shift indicated one documented behavior on 1/21/25, coded as a 1, refusing to leave the room. The form lacked target behaviors of looking for her husband, children, or sister, wanting to go home, or looking for car keys to go to work. R9's MAR and TAR dated 2/1/25, to 2/28/25, indicated R9 received Seroquel 25 mg at 4:00 p.m. R9's TAR indicated target behavior interventions for Seroquel included to code 1 for refusing to leave her room and code a 2 for self-isolation. R9 had three behaviors coded as a 2, on the day shift, one behavior coded as a 1 on the evening shift, and one behavior coded as a 1 on the night shift. The form lacked target behaviors of looking for her husband, children, or sister, wanting to go home, or looking for car keys to go to work. R9's MAR and TAR dated 3/1/25, to 3/31/25, indicated R9 received Seroquel 25 mg at 4:00 p.m. R9's TAR indicated target behavior interventions for Seroquel included to code 1 for refusing to leave her room and code a 2 for self-isolation. R9 had zeros and dashes documented on the day shift, evening shift, and had two behaviors coded as a 1 on the night shift. The form lacked target behaviors of looking for her husband, children, or sister, wanting to go home, or looking for car keys to go to work. R9's MAR and TAR dated 4/1/25, to 4/30/25, indicated R9 received 25 mg at 4:00 p.m. R9's TAR indicated target behavior interventions for Seroquel included to code 1 for refusing to leave her room and code a 2 for self-isolation. R9 had zeros and dashes for the day shift, evening shift, and had one behavior coded as a 1 on the night shift. The form lacked target behaviors of looking for her husband, children, or sister, wanting to go home, or looking for car keys to go to work. R9's MAR and TAR dated 5/1/25, to 5/15/25, indicated R9 received 25 mg at 4:00 p.m. R9's TAR indicated target behavior interventions for Seroquel included to code 1 for refusing to leave her room and code a 2 for self-isolation. R9 had zeros and dashes for the day shift, evening shift, and the night shift. R9's MAR and TAR dated 5/1/25, indicated new target behavior interventions for an antipsychotic, dated 5/15/25, that included code 1 for hallucinations, code 2 for looking for car keys to go to work, code a 3 for wanting to go home, code a four for looking for family (husband, children or sister). The day shift on 5/15/25, was coded as a zero for the number of behaviors. R9's consulting pharmacist recommendation to the physician dated 7/26/24, indicated R9 was discussed at IDT (interdisciplinary team) meeting and staff reported R9 had distress and agitation in the afternoon, mostly based on looking for her husband or other family and had some exit seeking and recommended increasing R9's Zoloft to 100 mg in the hope it would calm her and ease distress and then begin tapering off the Seroquel. The physician documented on 8/1/24, they disagreed with the pharmacist recommendation and indicated sundowning was a common behavior in R9's age group and recommended monitoring because R9 was in an environment she was not used to. R9's consulting pharmacist recommendation to the physician dated 1/25/25, indicated R9 continued to perseverate on her husband and was distressed at times and was on Seroquel 25 mg daily which was not likely effective at that dose but was difficult to discontinue considering her distress and further, R9's dose of Zoloft was not optimized at 100 mg daily. The pharmacist recommended increasing the Zoloft up to 125 mg daily in the hope of alleviating R9's anxiety and distress thus allowing them to discontinue the high-risk antipsychotic. The physician agreed on 1/29/25, with the recommendation. The record was reviewed and lacked evidence a GDR for the Seroquel was attempted following the recommendation. R9's consulting pharmacist recommendation reports were reviewed for November 2024, December 2024, February 2025, March 2025, and April 2025 and lacked information a GDR was attempted. R9's Associated Clinic of Psychology (ACP) note dated 4/24/24, indicated staff did not identify any behavior changes, thought processes were scattered, but denied any distress in her life, and was in good spirits, compliant with medications and cares, and was well adjusted to the facility. R9's physician's progress note dated 4/2/25, indicated R9 had Alzheimer's disease and R9's daughter reported R9 had increased confusion and anxiety in the evening, calling R9's daughter multiple times and having delusions such as having job interviews. Further, the note indicated, R9's Zoloft was increased, but was not effective. Additionally, R9 was on Zoloft 100 mg daily and the dose was increased on 8/21/24, due to ongoing evening anxiety behaviors, delusions, and wandering and was also on Seroquel 25 mg daily, and according to report, R9 was stable. R9's Behavior Management Follow Up form dated 12/9/24, indicated R9's targeted behavior was going to other residents [sic] room and up and down. Further, the document indicated behavioral symptoms were exhibited in the evening and occurred daily, was easily altered. Non-pharmacological interventions included calm her down and measures included redirection and aromatherapy. The form indicated these interventions were effective following use of aromatherapy. Further, pharmacological interventions of Seroquel 25 mg were usually effective, and dose reductions had been attempted. An evaluation of R9's behavior symptoms indicated there was no change as compared to 90 days ago or last assessment and further indicated to continue the current plan of care. R9's Behavior Management Follow Up form dated 3/7/25, indicated a targeted behavior of wandering, but the form was not further completed to indicate when symptoms were exhibited, how frequent, whether behaviors were able to be altered. No other targeted behaviors were identified on the form. Further, no pharmacological and non-pharmacological interventions were identified and the form lacked information an evaluation of whether behaviors improved, declined, or stayed the same. R9's Behavior Management Follow Up form dated 4/8/25, indicated N/A under a heading, Describe Resident's Specific Targeted Behavior. The form was not further completed to indicate when symptoms were exhibited, how frequent, and whether behaviors could be altered. Further, no pharmacological and non-pharmacological interventions were identified or outcomes of interventions. A heading, Evaluation lacked information R9's behavioral symptoms improved, declined, or stayed the same. A heading, Care Planning indicated the facility would continue with the current plan of care. R9's Point of Care History form, dated 11/1/24, to 11/30/24, indicated R9 had verbal expressions of distress two times out of 90 opportunities and the behavior was easily altered. R9's Point of Care History form, dated 12/1/24 to 12/31/24, indicated R9 had verbal expressions of distress 1 time out of 93 opportunities that included negative statements and was not easily altered. R9's Point of Care History form, dated 1/1/25, to 1/31/25, indicated R9 had verbal expressions of distress 5 times out of 95 opportunities and behaviors were easily altered. R9's Point of Care History form, dated 2/1/25, to 2/28/25, indicated R9 had verbal expressions of distress including repetitive questions, 16 times out of 93 opportunities and behaviors were easily altered. R9's Point of Care History form, dated 3/1/25, to 3/31/25, indicated R9 had verbal expressions of distress 6 times out of 95 opportunities. R9 had a behavior of stating something terrible was going to happen on 3/20/25, and 3/22/25, was not easily altered, and all other behaviors were easily altered. R9's Point of Care History form, dated 4/1/25, to 4/30/25, indicated R9 had verbal expressions of distress 16 times out of 98 opportunities and behaviors were easily altered. R9's Point of Care History form, dated 5/1/25, to 5/15/25, indicated R9 had verbal expressions of distress 9 times out of 49 opportunities and behaviors were easily altered. R9's progress note dated 3/22/24 at 6:03 p.m., indicated R9 went to other floors looking for her husband. R9's progress note dated 4/15/24 at 11:25 p.m., indicated R9 was confused and had hallucinations, was looking for her driver's license, needing to pick up her husband, looking for her mother and went down the elevator and tried to get out the main door. R9's progress note dated 6/8/24 at 7:23 p.m., indicated R9 was looking for her husband and wanted to go see him and headed towards the elevator multiple times trying to locate her husband and was redirected multiple times without effect. R9's progress note dated 12/19/24 at 2:12 p.m., indicated R9 was confused and was wandering in other rooms at the beginning of the shift. R9's progress note dated 1/28/25, indicated R9 moved to the Villa community (locked unit) of the facility from the Oakview unit. R9's progress note dated 4/11/25, indicated R9 asked about R9's sisters who are all deceased and was surprised at the information. R9's progress note dated 4/23/25, indicated R9 was in a secure memory care unit and hospice IDT met to discuss the need for wander guard placement and determined the wander guard would be removed with agreement with IDT because R9's wandering decreased significantly since signing onto hospice. R9's progress note dated 4/28/25, indicated R9 was combative during cares and did not want to get up. R9's social worker (SW) documented two progress notes from 1/1/24, through 5/13/25. The SW progress note on 2/4/25 at 10:03 a.m., indicated the IDT reviewed interventions from a fall on 1/1/25. Further, R9's SW progress note on 4/17/25, indicated R9's wandering decreased significantly since signing onto hospice and R9's wander guard would be removed. During observation on 5/12/25 at 1:58 p.m., R9 was in bed and a bruise was noted on the right side of R9's face. During observation on 5/13/25 at 8:11 a.m., R9 was in bed snoring softly. During interview on 5/13/25 at 9:24 a.m., nursing assistant (NA)-H stated she was the usual NA in the Villa. Further, NA-H stated R9 refused cares one time approximately two weeks ago, but otherwise did not refuse cares and asked the nurse to administer pain medications and added R9 did not fight or resist. During observation on 5/13/25 at 2:02 p.m., R9 was in the dining room talking with a staff person and appeared content socializing. During interview on 5/14/25 at 2:09 p.m., the pharmacist consultant (PC) stated gradual dose reductions (GDRs) were completed twice in the first year and then one time after that and wanted to taper R9's Seroquel and was on Zoloft 125 mg. R9 was perseverating on her husband and stated there had not been a GDR request on the Seroquel because he wanted to increase the Zoloft before decreasing the Seroquel and added a GDR was not done if a resident had distress. Further, PC stated the social worker would have notes regarding resident's behaviors and stated he had monthly meetings with the facility and speaks with nursing staff on how a patient is doing and receives his information through the meetings and not the medical record. Further, PC stated R9's behavior of perseverating on her husband should be a part of R9's targeted behaviors. During interview on 5/15/24 at 10:45 a.m., nursing assistant (NA)-H stated R9 did not have behaviors and stated every now and then R9 talks about her husband but stated it did not cause her any distress. Further NA-H stated R9 might state she is looking for her husband and NA-H will tell R9 her husband is at work and R9 was easily redirected. During interview on 5/15/25 at 10:48 a.m., registered nurse (RN)-F stated R9's behavior was moving up and down and wanting to go out but has not done that for a few months and stated R9's family visited frequently. R9 was focused on looking for her husband but behavior improved after moving to the Villa. RN-F stated R9 was easy to redirect and was not a combative person and did not ruminate since coming to the Villa. RN-F stated R9 moved to the locked unit on 1/28/25. When asked what R9's target behaviors were, RN-F stated R9's behaviors were asking for keys and looking for her husband. RN-F viewed R9's orders for target behaviors that were dated 5/15/25, and stated target behaviors for the antipsychotic were hallucinations, looking for car keys, wanting to go home, and looking for family and husband. During interview on 5/15/25 at 1:35 p.m., the director of nursing (DON) stated documentation for targeted behaviors was in the treatment administration record. The DON viewed R9's record for target behaviors that included refusal to leave the room and self-isolation from 2/28/24, and was discontinued on 5/15/25. The DON further stated targeted behaviors had been updated on 5/15/25, and stated they go over events every day and the targeted behaviors should have recent information and that was probably why the targeted behaviors were updated. The DON viewed the targeted behaviors from 5/15/25, that included looking for car keys, wanting to go home and looking for family and her husband and stated R9 was on hospice and was on the other unit prior to enrolling in hospice and was not aware R9 had a behavior of looking for her husband and further stated the pharmacist did not communicate that concern to anyone at the facility. The DON further stated the pharmacist communicates with the DON by going through resident's records and they also had behavior meetings where GDRs are discussed. A policy, Psychotropic Medication Use, dated 9/7/23, indicated psychotropic medications are used when ordered by medical providers after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral expressions have been identified and addressed. Psychotropic medications are given upon a medical provider order. The nursing associates collaborate with the medical provider to ensure the lowest possible dosage is given for the shortest period of time and are subject to gradual dose reductions and re-review. When resident exhibits expressions or indications of distress that interfere with daily living, the licensed nurse and or members of the IDT identify target behaviors, discuss and implement non-pharmacological interventions (i.e. aromatherapy, therapy doll, music, comforting touch, comforting foods, etc. When psychotropic medications are ordered, the IDT identifies target behaviors, medication side effects to be monitored and implements a resident centered care plan with both non-pharmacological and pharmacological interventions. GDRs begin within the first year in which a resident is admitted with or is newly prescribed a scheduled psychotropic medication. GDR is attempted in two separate quarters (with at least one month between the attempts), unless clinically contraindicated and documented by the medical provider. Contraindications may include the continued use is in accordance with relevant current standards of practice and the medical provider has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or the resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the medical provider has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. The IDT team monitors the resident condition and target behaviors for efficacy of the medications and any clinically significant adverse consequences. Documentation will reflect implementation of the above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to provide timely incontinence care for 1 of 1 resident (R62) reviewed for activities of daily living (ADL). Findings include: R62's discharge Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of quadriplegia, traumatic rupture of cervical intervertebral disc (C5-6), spinal stenosis, and neurogenic bladder. It further indicated R62 required substantial assistance with toileting, was always incontinent of urine, and received a diuretic on routine basis. R62's care plan dated 4/25/25, indicated the potential for alteration of bowel and bladder related to a diagnosis of a neurogenic bladder and included an intervention of R62 requiring 2-person assistance to use the toilet upon rising in the morning, before and after each meal, bedtime, on night rounds, and as needed. R62 also required assistance with all toileting tasks and used brief/pads for incontinence protection indicating he was not able to reliably notify staff of his need to be toileted. During interview on 5/12/25 at 5:25 p.m. R62 stated he had to wait 20-45 minutes (on average)almost every time he needed to use the urinal. Since his spinal cord injury, he doesn't have much notice when having to urinate and often ends up urinating in his brief. When that happens he then had to wait long periods of time sitting in his urine or feces. R62 also stated he had reported this to RN-E and the DON but nothing ever happened to fix the problem stating It's a culture here to not help each other out. I put my call light on and wait for staff to respond. When they don't respond, I go out into the hallway (in my wheelchair) to get help and I am often told by staff they're not my aide and then continue to play on their phone. During observation on 5/14/25 at 7:04 a.m., the following events occurred: -7:15 a.m. R62 put his call light on. -7:28 a.m. NA-E answered call light for another resident whose room was in close proximity to R62's room (exited the room at 7:34 a.m.) but failed to answer R62's call light when she was finished assisting the other resident. -7:35 a.m. NA-F was walking down the hall towards R62's room with the vital signs (VS) machine. NA-F entered the room and asked R62 what he needed because his call light was on. He stated he had to urinate but he already urinated in his brief because he couldn't hold it. NA-G stated that was okay, proceeded to take his blood pressure, then left the room stating I will come back later and get you up when she's (unknown) done. -7:45 a.m. NA-F assisted another resident with a shower. -8:01 a.m. registered nurse (RN)-D entered R62's room with medications, blood sugar monitor, and stethoscope. RN-D asked his name, date of birth , took his VS, tested his blood sugar, administered his medications, and gave him a nebulizer treatment. RN-D did not change R62's brief. -8:30 a.m. RN-D exited R62's room. -8:34 a.m. R62 stated RN-D did not change him while she was in his room and that he put his call light on at 7:15 a.m. when he first had to go to the bathroom. -8:40 a.m. R62 put on his call light again. -8:42 a.m. NA-F answered R62's call light and R62 stated he was still waiting for his brief to be changed. NA-F changed his brief (which was visibly full of urine) and removed the pad underneath him which was also visibly wet. During interview on 5/14/25 at 9:15 a.m. NA-F verified R62 told her he had urinated in his brief when she answered his call light at 7:35 a.m. NA-F stated was waiting for the nurse to go in and do what she needed to do but should have changed him right away before the next call light went on. During interview on 5/14/25 at 9:30 a.m. RN-D stated anyone can answer call lights but it was usually the NA's who answer them. They try to answer call lights within 15 minutes and if a resident stated they need to be changed, staff should try to do that immediately or as soon as possible and changing a brief would take precedence over giving a resident a shower. RN-D further stated NA's are assigned to a group of residents but the other NA's are expected to answer the call lights and help each other out. If the nurse needs to administer medications or perform cares, etc. they can wait if a resident needed to be changed. RN-D verified she did not change R62 when she was in his room because she was unaware he needed to be changed. There was no reason he needed to wait to be changed until after she was done working with him. During interview on 5/14/25 at 2:00 p.m. NA-D stated NA's are assigned to a certain group of residents and we stick with our residents, unless someone is really busy, but everyone can help. NA-D further stated they try to answer call lights within 15 minutes and changing a residents brief should be done before giving a resident shower. An hour was too long for a resident to wait to have their brief changed and stated 10 minutes should be the longest they should have to wait unless they were really busy. During interview on 5/15/24 at 10:56 a.m., the director of nursing (DON) stated he did not think an hour was too long for a resident to have to sit in a wet brief and there wouldn't be any negative outcomes as a result (specifically skin breakdown). The DON further stated changing a resident's brief didn't necessarily take precedence over giving another resident a shower and would depend on the situation. He was unable to provide an approximate amount/range of time he would expect a resident's call light to be answered or a resident's brief to be changed (once they put their call light on.) A facility policy reagrding ADL's was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Feeding Tube R37's quarterly Minimum Data Set (MDS) dated [DATE], indicated R37 was cognitively intact, was dependent on staff for all activities of daily living (ADLs), and required a FT for nutrition. R37's diagnoses included dysphagia (difficulty swallowing) and nutritional deficiency, R37's care plan dated 5/13/24, indicated R37 had swallowing difficulty related to severe esophageal dysphagia and required nutrition provided using a feeding tube through a G-tube. R37's care plan instructed staff to check residual every four hours, flush G-tube with water before and after medications, maintain FT materials, not allow formula to hang longer than eight hours at room temperature, and change set up daily. R37's provider orders included the following: -Diet: NPO (nothing by mouth) except small sips of water-4/17/25 -Diet: tube feeding 45cc per hour for 22 hours Novasource renal-5/13/25 -Ensure formula bag for enteral feed has time and date on bag. Discard formula and replace every 24 hours-10/29/22 -Hold tube feeding between 5:00 a.m. and 7:00 a.m.-4/4/25 -Change bag, tubing, and syringe daily-1/12/23 -Flush G-tube with 30cc water before and after each medication-2/3/22 During observation on 5/12/25 at 12:29 p.m., R37 in bed with TF running with a pump. There was one bag of formula and one bag of water flush. A graduated cylinder containing a syringe sat on the dresser with other supplies. The cylinder was dated 5/4 at 0430 (4:30 a.m.). During observation on 5/13/25 at 8:14 a.m., R37 was lying in bed. Cylinder with syringe on dresser dated 5/12/25. No TF or water bag hanging on pole and pump turned off. During observation on 5/13/25 at 9:46 a.m., R37 was sleeping in bed. Still no TF being administered. During observation and interview on 5/13/25 at 10:13 a.m., registered nurse (RN)-A into R37's room to administer medications. R37 stated, It's time to hook me up to my food, isn't it? meds. RN-A administered medications using the syringe and cylinder date 5/12/25 and then hung a new bag of tube feeding formula, tubing and water flush. RN-A labeled both bags with date and time. RN-A stated the date on the cylinder reflected when the cylinder and the syringe were last changed, in this case 5/12/25. RN-A could not state how often they needed to be changed and stated, I will have to check on that and left the room. R37 stated her TF had been turned off and disconnected at about 5:00 a.m. and should have been restarted by now. During interview on 5/13/25 at 10:36 a.m., RN-A stated the cylinder and syringe were supposed to be changed daily and proceeded to date a new cylinder and placed in R37's room. During observation of 5/14/25 at 7:18 a.m., a full bag of TF hanging with water flush bag but pump not on and tubing not attached to R37. Neither TF bag nor water bag dated. Cylinder with syringe sitting on dresser dated 5/13. During observation on 5/15/25 at 8:10 a.m., cylinder with syringe labeled 5/13, water bag now labeled 5/14/25- 8:00 a.m. TF bag not dated. During observation and interview on 5/15/25 at 8:25 a.m., licensed practical nurse (LPN)- A stated the TF bag and tubing should be changed out every 24 hours and was on the treatment administration record (TAR) for the evening shift to complete. LPN-A stated evening shift will leave the bag up since there was still TF formula left in it, in which case nights or days would change it. LPN-A stated if the formal runs out and the bag had not reached 24 hours, they will just add more TF formula to the hanging bag. LPN-A stated she added the label to the water bag yesterday at 8:00 a.m., but could not confirm when the bags or tubing had been changed prior to that time since they were not dated. LPN-A stated the entire set up including the bags, tubing, cylinder and syringe should be changed every 24 hours and should be labeled with the date and time of change. LPN-A confirmed the cylinder with syringe was dated 5/13 and should have been changed yesterday (5/14/25). LPN-A stated she would change out the whole set up this morning and label everything appropriately. During interview on 5/15/25 at 10:09 a.m., RN-B stated staff should change TF materials including bag, tubing and syringe every 24 hours and all should be labeled to indicate the date and time of change. RN-B stated the TF materials change was scheduled for evening shift, but not always done on that shift, which made it very important to indicate the date and time of change. RN-B stated TF materials should not be used for longer than 24 hours due to the increased risk of bacterial growth and possible infection. During interview on 5/15/25 at 10:40 a.m., director of nursing (DON) stated expectation for staff to administer and maintain TF per provider orders. DON referred to facility policy and stated TF materials should be changed out every 24 hours and labeled with date and time when changed. DON stated TF materials used greater than recommended time could lead to bacterial growth and could cause infection. Facility policy Gastrostomy G Tube Use, undated, indicated syringe and administration set should be changed every 24 hours. The policy further indicated, On the formula label document initials, date and time the formula was hung/administered. Based on observation, interview and document review, the facility failed to ensure appropriate monitoring was in place for 1 of 1 residents (R60) who sustained an injury during a transfer reviewed for safe resident handling. In addition, the facility failed to ensure tube feeding (TF) was administered and maintained per provider orders. Findings include: R60's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and required partial-to-moderate assistance for bed mobility but was dependent on staff for transfers. The MDS identified diagnoses of a cerebrovascular accident or CVA (a stroke, or an episode of insufficient blood supply to the brain caused by either a blood clot or abnormal bleeding), and hemiplegia (one-sided weakness) or hemiparesis (one-sided paralysis) and aphasia (a language disorder caused by injury to the brain). R60's Care Area Assessment (CAA) dated 6/16/24, for Activities of Daily Living (ADLs) triggered related to her needing assistance with cares and mobility related to her CVA with left-sided hemiparesis. The CAA indicated she required 2 staff assist with bed mobility and transfers and directed staff to proceed to the plan of care. R60's treatment administration record (TAR) dated 4/2025 reflected the following orders: - NWB L arm every shift, dated 4/25/25 (where NWB denoted non-weight bearing). - Ok for ice pack on L shoulder Q1 hr as needed, dated 4/25/25 (where L denoted left and Q1 hr denoted every 1 hour). - Sling L arm - on day off in bed x 2 weeks for left humerus fracture, dated 4/25/25 - 5/9/25. Her TAR dated 4/25 was reviewed 5/14/25 and lacked documentation of neurovascular assessments of her left upper extremity. Neurovascular assessments would include an evaluation of the color, temperature, capillary refill or circulation, palpable pulse, edema or swelling, sensation, motor function or strength, and pain to her left upper extremity compared to both her baseline and her right upper extremity. R60's TAR dated 5/25 reflected the following orders: - ensure L) arm in sling at all times every shift, dated 5/12/25. - NWB L arm every shift, dated 4/25/25. - Ok for ice pack on L shoulder Q1 hr as needed, dated 4/25/25. - Sling L arm - on day off in bed x 2 weeks for left humerus fracture, dated 4/25/25 - 5/9/25. The TAR dated 5/25 was reviewed 5/15/25 and lacked documentation of neurovascular monitoring. A provider progress note dated 4/29/25 indicated she was seen for follow-up sustaining an injury from a transfer via hoyer. The progress note referenced the x-ray dated 4/24/25, which showed the proximal humerus fracture, and indicated R60 was having unrelieved pain and did not appear comfortable. The progress note identified under the Assessment/Plan: header the plan was to consult orthopedics, OK to ice, non-weight bearing status to left upper extremity, wear a sling 24/7 and have a follow-up x-ray in 4 weeks. R60's electronic health record (EHR) was reviewed 5/14/25 and lacked documentation of neurovascular monitoring of her left upper extremity. During observation and interview on 5/12/25 at 4:54 p.m., R60 was lying in her bed without a sling on her left arm. She stated while she was getting into bed, I heard a big crack, it hurt. R60 stated she was okay to have the sling off while in bed but needed to have staff assist her with putting it on when out of bed. She stated not a lot of staff knew how to put the sling on. She stated she broke her left shoulder, which was the side affected by her stroke. She stated she felt staff were doing a pretty good job at managing her pain, however, were not offering her ice packs anymore, which was something she would like to have for pain management. During observation on 5/13/25 at 9:24 a.m., R60 was up in her wheelchair and requested to lay down. She pushed her call light at 9:25 a.m. and at 9:29 a.m., registered nurse (RN)-E and nursing assistant (NA)-Q entered her room to answer her call light. After performing hand hygiene, donning gloves and providing for privacy, NA-Q retrieved the lift sling from the back of the door and asked her to lean forward and began tucking the sling behind and down her back. NA-Q pulled the sling straps under her legs, first under her right hip and through the front of her right leg and then NA-Q repeated the steps on the left side. NA-Q walked across the room and pulled the ceiling mechanical lift from one side of the room over to above R60 and used the remote to lower the lift. RN-E asked her to hold onto her left hand and guided her to her affected left hand in the sling. NA-Q crisscrossed the sling straps in the front and hooked the sling straps up to the mechanical lift before using the remote to lift her up from the wheelchair. The bottom hem of the sling was above her sacral level; however, her head was above the top hem and there was no slipping observed during the transfer. Together, RN-E and NA-Q pushed her over top of her bed and NA-Q used the remote to lower her onto the bed. R60 made an ouch noise during the transfer and NA-Q asked her if she was okay, and she answered, yeah. RN-E and NA-Q assisted her to turn to the side to tuck the sling, and then to sit forward. Together, they removed the sling out from behind her. RN-E stated she had a stroke and only had one working arm and hand and had always transferred with a mechanical body lift. NA-Q provided the call light within her reach, lowered the bed and gave her a stuffed animal. There was no offer to elevate her left arm on a pillow and no assessment of her pain prior to staff exiting the room, however, R60 did not report her pain to staff. During observation and interview on 5/14/25 at 11:49, R60 was wearing her sling and stated she had not been offered ice for her shoulder. R60 stated she had numbness and tingling in her left hand and fingers that was not her baseline. The color in her left fingers was normal per her race and she indicated the strength in her moveable index finger felt the same as before the fracture. R60 stated staff had not asked her about the sensation or strength in her left hand or arm, and family member (FM)-J endorsed this. FM-J stated they visited R60 often and had not heard staff asking about sensation, movement, temperature or strength to her affected arm. During interview on 5/14/25 at 12:08 p.m., nurse practitioner (NP)-H reviewed previous documentation and stated she had a proximal left humerus fracture and recent follow-up imaging showed the fracture was more prominent, which NP-H explained meant there was no evidence of healing on the x-ray. NP-H stated the x-ray results probably means the matrix hasn't formed yet and it's still a fracture. NP-H further explained the matrix formed after a fracture began to heal and formed a callus, and the follow-up x-ray did not show such a callus. NP-H indicated she was non-compliant with her sling and stated when she was wearing the sling, she's moving it around a lot, referring to her left upper extremity. NP-H indicated her follow-up x-ray was sent to geriatric orthopedics and physical therapy (PT) and occupation therapy (OT) for further evaluation. NP-H hoped PT/OT could evaluate her for a better fitting wheelchair that would promote better positioning for her arm to help elevate it and maintained ice and elevation remained appropriate interventions for her fracture. During interview on 5/14/25 at 2:26 p.m., registered nurse (RN)-E expected staff to monitor for pain and swelling and stated initially, R60 was using ice for pain management but now when we ask she says no, she does not want ice. RN-E expected staff to elevate her affected arm on a pillow and to perform a neurovascular assessment (circulation, movement, sensation or CMS) and indicated the assessment should be documented in progress notes. RN-E reviewed her progress notes and was unable to locate such documentation. RN-E reviewed her treatment orders and indicated there was an order to assess previously but stated, it fell off, it looks like. It was on there from before, so they were documenting that from before, but it fell of. RN-E confirmed there was no current documentation or order in place and stated there should be. During interview on 5/15/25 at 11:54 a.m., the director of nursing (DON) stated assessing for neurovascular changes (CMS changes) after a fracture was a standard of practice and expected staff to perform the assessment when applying R60's sling per orders. The DON reviewed her orders and identified the order to ensure her sling was on at all times or 24/7. When asked what part of the order directed staff to assess her neurovascular status or for CMS changes, the DON stated the order did not state specifically to monitor, however, identified progress notes in which staff documented swelling in her shoulder and discomfort. When asked about documentation of sensation, temperature, pulses, color, and strength, the DON indicated staff should be charting by exception. A request was made for documentation of staff's assessment of her neurovascular status or CMS after the fracture, however this information was not received. During interview on 5/15/25 at 12:45 p.m., licensed practical nurse (LPN)-B stated NAs put R60's sling on in the morning, but I can put it on, too. LPN-B stated, there's an order in there I mark off every day if its on or not. LPN-B stated for a resident who sustained a fracture, I look for signs of swelling at the site of fracture, signs of infection, like redness and warmth, and I assess for pain. LPN-B stated they could compare it to the other side to see how it looked and would document that if noted. During interview on 5/15/25 at 12:50 p.m., NA-M stated NAs normally applied her sling in the morning and confirmed applying that morning stating, I heard they were having trouble with her sling this morning, so I helped with it. A policy pertaining to monitoring and/or assessing post-accident or fracture was requested but not available and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R9's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, did not reject cares, used a wheelchair, and required substantial assist with toileting hygiene, and partial to moderate assist with dressing. Further, R9's vision was adequate with glasses. R9's care area assessment (CAA) dated 4/14/25, indicated R9 triggered for falls due to needing assist with cares, mobility, toileting due to multiple diagnoses and received Seroquel for psychotic disorder with delusions, and Zoloft for depression. R9's optional state assessment (OSA) dated 4/11/25, indicated R9 required assist with bed mobility, transfers, and toileting. R9's Facesheet undated, indicated the following diagnoses: rheumatoid arthritis, Myelodysplastic syndrome, weakness, history of falling, and Alzheimer's disease. R9's Active Orders form indicated the following orders: • 3/20/24, Seroquel (an antipsychotic) 25 milligram (MG) tablet orally daily at 4:00 p.m. • 1/2/25, hip protector on at all times every shift. • 1/29/25, Zoloft (an antidepressant) 125 mg orally every a.m. • 4/4/25, Admit to Allina Hospice with a primary diagnosis of vascular dementia. R9's medication administration record (MAR) and treatment administration record (TAR) dated April 2025, indicated starting 2/5/25, and ending 4/22/25, R9 required night staff to check on the resident, prepare her, and bring her to the dining room for monitoring before the end of their shift to prevent falls. R9's care plan dated 4/14/25, indicated R9 had good vision and required assistance with her glasses as needed, additionally R9 had an intervention to assist with vision exams as needed. R9's care plan dated 4/14/25, indicated R9 had an alteration in activities of daily living (ADLs) due to needing assist with cares and required assist of one with bathing, dressing grooming. Additionally, R9 required her call light be within reach. R9's care plan dated 4/14/25, indicated R9 had an alteration in mobility and required one assist with transfers, her wheelchair, and ambulation. R9's care plan dated 4/14/25, indicated R9 was on the Falling Star program, and was at risk for falls due to needing assist with cares, mobility, toileting, and had a history of frequent falls due to multiple diagnoses. R9's goal was to remain free from falls with injury and had the following interventions: essential oils as needed, night staff check on the resident, prepare her, and bring her to the dining room for monitoring before the end of the shift, anti-roll backs on wheelchair, ensure R9 wore her glasses and that they were clean and in good repair, keep call light in reach at all times, keep the bed in the lowest position to allow feet to be flat on the floor with the brakes locked, give verbal reminders not to ambulate or transfer without assist, wears hip protector at all times to minimize injury, provide proper, well maintained footwear, provide an environment free of clutter, keep personal items and frequently used items within reach, and toilet per plan of care. R9's care plan dated 4/14/25, indicated R9 required assist with toileting upon rising, before and after meals, at bedtime, on night rounds, and as needed. R9's care plan dated 5/12/25, indicated R9 was at high risk for falling due to dementia and overall decline and interventions included fall prevention reduction precautions per facility protocol, monitor side effects of medication: cardiac medication as ordered. Narcotic pain medication as ordered. Monitor for side effects such as dizziness, lethargy, increased confusion, decreased respirations and report to the provider, and toilet per the urinary bowel section of the care plan. R9's Villa Team Report sheet dated 4/22/25, and provided by registered nurse (RN)-F on 5/12/25 at 12:08 p.m., indicated R9 was a falling star, ensure resident is in bed in the early hours, hip protector at all times, and night staff to check on the resident, prepare her, and bring her to the dining room for monitoring before the end of their shift. R9's Team 1 Villa Assignments sheet, undated, indicated R9 was at high risk for falling, was a falling star, required assist of one for dressing, grooming, toileting, and staff were to offer to toilet every three hours and as needed and the night staff were to check and toilet patient before their shift ended and bring R9 to the dining room for monitoring. Further, the form indicated R9 always needed her call light and personal items in reach with the bed in the low position, gripper socks on when in bed, hip protector at all times, and could not be left unattended on the toilet or in the room unless sleeping. Further, the form indicated R9 required anti-roll backs on the wheelchair, and staff needed to monitor the bruise on R9's right forehead. R9's Event Report dated 2/4/25 at 9:37 a.m., indicated R9 was in her room when she fell trying to go to the bathroom. Further, R9 took 9 or more medications including antidepressants, antihypertensives, and antipsychotics and had fallen previously on 1/1/25. Additionally, R9 was on the floor behind the door and was last seen at 7:10 a.m. R9's interdisciplinary team (IDT) reviewed the fall on 2/5/25, and determined the night staff would check on the resident, prepare her, and bring her to the dining room for monitoring before the end of their shift, as she was an early riser and preventative measures to avoid fall injuries would continue, such as utilizing hip protectors. R9's Event Report dated 2/18/25, indicated R9 fell in her room. R9 was in her wheelchair in the hallway prior to the fall and R9 stated the entrance of the door slipped her and she fell. Under a heading, Possible Contributing Factors indicated R9 had confusion. Under a heading, Drug Review-Does resident use any of the following types of medications? indicated check boxes for various medications including antidepressants, analgesics, and antipsychotics. Additionally, there was a check box for None of above. The information was undocumented. Under a heading, Notes, indicated R9 was in the hall and wheeling her wheelchair around her room prior to the fall. R9 was on the floor and the wheelchair was far away from the resident. R9 was transferred to her wheelchair and brought to the dining room to prevent another fall and on 2/19/25 at 12:29 a.m., was escorted to the hospital. Further, the IDT reviewed R9's fall and determined to prevent injuries from frequent falls, R9 wore a hip protector additionally, plans were in place to install an anti-roll back device on R9's wheelchair. Further, the Event Report indicated IDT met on 3/4/25, and evaluated the effectiveness of interventions related to R9's fall on 2/18/25 and determined therapy was not appropriate and would implement hip protectors and install an anti-rollback device on R9's wheelchair. R9's Event Report dated 5/11/25, indicated R9 fell from her wheelchair in the dining room at 7:04 p.m., and sustained a bump on her right forehead. IDT reviewed R9's fall on 5/12/25, and indicated R9 was in the dining room using her wheelchair when another resident came up from behind and pushed R9's wheelchair causing R9 to fall and interventions implemented included providing the other resident with a stroller and a doll when showing a tendency to push other residents. R9's Post Fall report dated 3/10/24, indicated R9 fell going to the bathroom to brush her teeth and was re-educated on using her call button for help. R9's Post Fall report dated 1/2/25, indicated R9 fell backward in her room and under a heading, EVALUATION indicated, Call light not use. Further, measures taken to prevent further falls included frequent checks and assist R9 with toileting per the care plan. R9's Post Fall report dated 2/5/25, indicated R9 was in bed prior to falling, took antidepressants and antihypertensives, and last fell on [DATE]. Further, R9 was at risk for falls due to dementia, and not getting resident up early when she is up, and staff would get resident up when she is up and toilet R9 to prevent falling. R9's Post Fall report dated 2/19/25, indicated R9 was sitting on the floor when staff members entered the room and was previously in her wheelchair, complained of chest pain and was sent to the ED for further evaluation. R9's Post Fall report dated 5/12/25, indicated R9 had a witnessed fall in the dining room from her wheelchair, did not take 9 or more medications, took antidepressants, and narcotics. Under a heading, EVALUATION was left undocumented and under a subheading, Describe measures to be taken to prevent further falls was left undocumented. During observation on 5/12/25 at 1:58 p.m., R9 was in bed and her call light was on the floor under the bed on the side closest to the door. R9's wheelchair was unlocked and approximately two to three feet from the foot of the bed next to the room divider curtain and parallel to the foot of the bed. R9 had a bruise on the right side of her face. During interview on 5/12/25 at 3:13 p.m., family member (FM)-K stated there was another resident on the floor and did not know if the resident was pushing R9 or went to push R9 and scared her, but R9 fell out of her wheelchair and hit her head on the table. FM-K stated the facility updated her and further, did not indicate if there were any new interventions to prevent falls. FM-K stated when R9 lays down, staff provide a call light and clip it so R9 can see it, but didn't know if R9 understood what it was. Further, FM-K stated FM-K stated R9 lost her glasses three weeks ago and has been without glasses since. FM-K further stated she told SW-A on 5/9/25, he had to do something because R9's glasses still had not been found. During observation on 5/13/25 at 8:11 a.m., R9's door was closed. During observation on 5/13/25 at 8:12 a.m., R9 was in bed and her wheelchair was located by her closet and next to a garbage can and unlocked. R9's call light was on the floor under her bed and on the side closest to the door and there was a clip on the call light cord. R9's glasses were not located on the nightstand. During interview and observation on 5/13/25 at 8:35 a.m., nursing assistant (NA)-H entered R9's room and checked on both residents and was going to leave the room and stated she got the residents up when they were awake and further stated they were both not early persons. NA-H stated R9 sometimes woke up early and stated R9 used her call light. NA-H verified R9's call light was on the floor and picked the call light up and clipped it to R9's sheet. During interview and observation on 5/13/25 between 8:57 a.m., and 9:17 a.m., NA-H went into R9's room and asked if she was ready to get up and offered clothing. At 8:59 a.m., NA-H left the room and stated she would be right back. R9 did not have glasses on. At 9:01 a.m., NA-H asked R9 to go to the bathroom and donned R9's shoes, but did not tie the laces. At 9:01 a.m., NA-H applied a gait belt and at 9:02 a.m., NA-H assisted to stand R9 and pivot transfer her to the wheelchair. R9's shoelaces were dragging on the floor. NA-H did not apply any glasses. At 9:03 a.m., NA-H assisted R9 to stand in the bathroom using the sink and registered nurse (RN)-F entered the room. R9 sat down on the toilet and her shoes were still untied. At 9:06 a.m., NA-H verified R9's shoes were untied and stated she would tie the shoes. At 9:08 a.m., NA-H donned R9's pants and hip protector and at 9:19 a.m., assisted resident to sit down again in her wheelchair. R9 did not have glasses on. During interview and observation on 5/13/25 at 9:24 a.m., R9 did not have anti tips or rollbacks on her wheelchair. NA-H stated R9 refused cares one time a couple of weeks ago because she did not want to get up. NA-H stated she looked to the care sheet to know what cares a resident required and pulled out a care sheet that indicated the night shift was to check and toilet patient before the shift ended and bring R9 to the dining room for monitoring and stated the night shift ended at 7:00 a.m. Further, NA-H stated if a resident refused, they documented and let the nurse know and verified R9's care sheet indicated nights were supposed to get R9 up. NA-H stated R9 was a falling star and staff had to keep an eye on the falling star person and added there was a time when R9 would wake up early and then they brought her to the dining room to keep an eye on her for safety and stated she guessed R9 was sleeping and that was why they didn't get R9 up. NA-H stated they don't close the door 100% for safety. NA-H stated she could not provide a copy of her care sheet. During interview on 5/13/25 at 9:35 a.m., RN-F stated the aides used care sheets and further, care plans were updated and then they printed new care sheets. RN-F stated a blue star indicated a patient fell a few times and call it a falling star. During interview on 5/13/25 at 9:47 a.m., RN-F stated the care plan should be followed and if care deviated from the care plan they would have to document the deviation. RN-F stated R9's glasses have been missing and stated they looked in the laundry and couldn't find them and the social worker (SW)-A was aware. RN-F stated R9 should have her call light in bed and stated once in a while she used it and R9 probably shook the bed. RN-F verified R9's care plan indicated night staff were to check on R9, prepare her and bring her to the dining room for monitoring before the end of their shift and stated if R9 was awake then nights would get R9 up. RN-F verified R9 did not have antiroll backs on her wheelchair and verified R9's care plan indicated R9 required antiroll backs. Further, RN-F stated they normally kept doors ajar to check on residents. During interview on 5/13/25 at approximately 1:50 p.m., social worker (SW)-A stated he was aware R9 was missing her glasses and had been missing a couple of weeks and would check to see if R9 was signed up for HealthDrive and verified R9 had signed up for HealthDrive on 3/3/23. During observation on 5/13/25 at 2:02 p.m., R9 was in the dining room and did not have glasses on and did not have the antiroll backs on the wheelchair. During interview on 5/13/25 at 2:45 p.m., NA-P stated he worked on 5/11/25, and witnessed R9 was sitting in her wheelchair and used her feet to move the chair and was trying to get past the threshold when another resident came from behind to push R9 forward in her chair and stated R9 fell out of her chair. NA-P stated they had strollers for the other resident so the other resident wouldn't push residents. During interview on 5:13/25 at 3:30 p.m., the director of nursing (DON) stated he expected staff follow the care plan and if interventions were no longer relevant expected interventions be discontinued. Further the DON stated interventions implemented should reflect on the care plan and nursing assistant assignment sheet and stated R9 had anti roll backs on her wheelchair in February because R9 tried to stand and the chair moved backward and stated the intervention for R9's chair was in place unless they washed the chair, or if hospice changed R9's chair. The DON stated the SW-A was working on the concern of R9's missing glasses. At 3:42 p.m., the DON checked R9's wheelchair and verified she did not have anti roll backs. A policy, Integrated Fall Management, undated, indicated fall risk assessment, identification and implementation of appropriate interventions as necessary to maintain resident safety, prevent falls, and reduce further injury from falls. Residents at risk for falls have an individualized resident centered care plan developed. Care plan interventions are based on the finding of the fall risk assessment. The IDT reviews the fall and care plan changes and may, if needed, implement additional interventions. Documentation of the above items is completed. Based on observation, interview and document review, the facility failed to ensure safe resident handling for 2 of 2 residents reviewed for accidents (R47, R60). Furthermore, the facility failed to reassess and, if needed, develop new interventions to reduce the risk of injury during resident handling for 1 of 1 residents (R60) who sustained an injury during a transfer at the facility. In addition, the facility failed to ensure fall interventions were implemented for 1 of 1 resident (R9) reviewed for falls. Findings include: R47 R47's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition, required partial-to-moderate staff physical assistance for bed mobility and was dependent on staff for transfers. The MDS reported diagnoses of a cerebrovascular accident or CVA (a stroke, or an episode of insufficient blood supply to the brain caused by either a blood clot or abnormal bleeding), and hemiplegia (one-sided weakness) or hemiparesis (one-sided paralysis) and aphasia (a language disorder caused by injury to the brain). R47's Care Area Assessment (CAA) dated 1/13/25 for Activities of Daily Living (ADLs) was triggered related to needing assistance with cares and mobility due to CVA and left-sided hemiplegia, in addition to other co-morbidities. The CAA indicated he required extensive assist of 2 with bed mobility, transfers (EZstand), and toileting and directed staff to proceed to the care plan for risk. A safe lifting and movement assessment dated [DATE], indicated R47 was able to bear weight as tolerated to is upper and lower extremities but was unable to stand safely for 8 seconds without any assistive devices. The assessment identified his hemiplegia and pain as physical limitations to a safe transfer and recommended two person transfer with Stand Assist Lift. The assessment indicated the lift manufacturer recommendations for correct harness size and his care plan was reviewed. R47's care plan last revised 2/26/25 identified his alteration in mobility related to his need for assistance with mobility due to CVA and left-sided hemiplegia, among his other co-morbidities. The care plan directed staff assist 2 with transfers (EZs Stand). The care plan also identified he was susceptible for abuse related to residing in a skilled nursing facility (SNF) and directed staff to provide a safe environment for him and follow his plan of care to ensure for safety. An undated nursing assistant (NA) care sheet identified R47 required assist of 2 with an EZ Lift. During a continuous observation on 5/13/25 between 11:19 a.m. and 11:41 a.m., R47 was in his wheelchair and was in a laid-back position. NA-B pulled R47's wheelchair from a table and NA-D locked the brakes on the wheelchair. NA-D used their foot to push the pedal on his wheelchair that said TILT and the wheelchair reclined backwards. NA-B and NA-I stood in front of R47 facing him and each of the NAs put one of their arms under one of his arms until they were under his shoulder joint on either side. The NAs counted to three and together they lifted him in an upwards and backwards motion so his buttocks was off of the wheelchair seat and he was boosted up in his wheelchair. NA-B asked, are you alright? and NA-D unlocked the brakes on the wheelchair, used their foot to press the TILT pedal and the wheelchair was moved forward in an upright position. NA-D pushed his wheelchair back to the table. At 11:40 a.m., R47's was in his wheelchair in a semi-reclined/laid-back position. At 11:41 a.m., he was in his wheelchair outside of the elevator doors and waiting for the elevator. The NAs reclined his wheelchair using the TILT pedal and locked the brakes on the wheelchair. NA-B and NA-I stood facing him and each of the NAs put one of their arms under one of his arms until they were under his shoulder joint. Next, the NAs each put their other arm under one of his legs, each positioning their hand above his knee joint in the middle of his upper leg on his thigh. The NAs together lifted him in an upwards and backwards motion in the wheelchair and R47 groaned out as the NAs performed the maneuver. When the NAs finished, he was sitting upright in his wheelchair. During interview on 5/13/25 at 11:45 a.m., NA-D confirmed the observation stated he always sides down in his chair and indicated staff used the observed positioning maneuver or sometimes we pull the waist of his pants to pull him up. NA-D stated he had weakness on his left side and said staff grab very gently and then we pull him. NA-D stated staff used the TILT pedal on his wheelchair to recline him because it allowed staff to pull him back easier in his chair as well as helped keep pressure off his backside. NA-D stated he required 2 staff assistance for his transfers and had to be repositioned like, every 10-15 minutes because he would slide down that way in his wheelchair. NA-D explained to position him, staff would lay the chair all way back, support his head with pillows if he was in his room, use their arms to support his weak side because his weak side does not go up, so we have to support that side and we position him that way. NA-D stated it was important to be mindful of his weak side during positioning because his weak side was painful and if staff were not cautious, he will scream. NA-D demonstrated his weak side's restricted range of motion (ROM) and stated he would scream if staff were not careful. Per interview on 5/13/25 at 3:18 p.m. with the director of physical therapy (PT)-I, the recommended approach to reposition a resident in a wheelchair would be to use a gait belt and pull their hips back against the edge of the chair. PT-I stated if the resident had a tilt and space wheelchair, staff could tilt the wheelchair back and let gravity take effect to assist with the repositioning. When asked if it would be appropriate to reposition a resident as observed by pulling a resident upwards and backwards by their underarms, PT-I stated depending on the resident's body physical characteristics, like body shape, height and weight; if staff had good support from the legs, you could boost someone like that, but it shouldn't be the primary method. I would recommend trying to get a gait belt under and behind the resident so they can get support from the trunk area instead of under the arms. PT-I indicated the observed method of positioning R47 should be reserved a last resort for boosting/positioning. PT-I stated there are a lot of nerves under a person's shoulder and indicated there could be potential for injury. Per interview on 5/14/25 at 7:25 a.m., registered nurse (RN)-E stated staff should not position or boost a resident by their arms as observed because of the risk of bodily harm to the resident or themselves. RN-E stated all staff underwent safe lifting education and if management observed such positioning or boosting, were expected to provided education on the spot and provide re-education to the involved staff, which would go in their file. RN-E expected staff to position a resident with their hips or the appropriate lift as identified on their care plan as opposed to under their arms. RN-E indicated NA-B and NA-D would be educated regarding appropriate positioning techniques. Per interview on 5/15/25 at 12:34 p.m., the director of nursing (DON) stated staff were trained on more appropriate ways to position a resident. R60 Findings include: R60's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and required partial-to-moderate assistance for bed mobility but was dependent on staff for transfers. The MDS identified diagnoses of a cerebrovascular accident or CVA (a stroke, or an episode of insufficient blood supply to the brain caused by either a blood clot or abnormal bleeding), and hemiplegia (one-sided weakness) or hemiparesis (one-sided paralysis) and aphasia (a language disorder caused by injury to the brain). R60's Care Area Assessment (CAA) dated 6/16/24, for Activities of Daily Living (ADLs) triggered related to her needing assistance with cares and mobility related to her CVA with left-sided hemiparesis. The CAA indicated she required 2 staff assist with bed mobility and transfers and directed staff to proceed to the plan of care. A safe lifting and movement assessment dated [DATE], indicated R60 was unable to bear weight in her upper and lower extremities and was not able to stand safely for 8 seconds without holding onto an assistive device. The assessment identified her hemiparesis as a physical limitation to safe transfers and recommended two person transfer with full lift. The assessment also indicated lift manufacturer recommendation were reviewed to ensure for correct sling size and her care plan was reviewed. R60's care plan last revised 3/11/25, identified her alteration in mobility related to her needing assistance with mobility due to her CVA and left-sided hemiparesis, among her other co-morbidities. The care plan direct staff to transfer her using the ceiling lift and 2-person assistance. The care plan also identified she had a fracture to her left humerus (the long bone going from the shoulder to the elbow in the upper arm) due to and not limited to pathological bone changes, which was identified by a provider on an x-ray, dated 5/12/25. A North Star mobile X-ray patient report dated 4/24/25, indicated the x-ray results or findings were a proximal humeral fracture is identified just beneath the humeral head. Inferior medial displacement of the distal fracture fragment is noted. A proximal humeral fracture is a fracture or break in the upper arm bone near the shoulder joint. A progress note dated 4/22/25 indicated it was recorded as Late Entry on 4/24/25 5:29 p.m. and reported resident complain of pain writer assess resident note resident was lying on her side, writer reposition resident vitals are stable, administer two Tylenol 500mg as staff continue to monitor. A progress note dated 4/23/25 at 10:59 a.m., indicated the writer was updated on R60's painful shoulder and during an assessment, the left shoulder was swollen, warm and tender to touch and had limited mobility due to pain. The progress note indicated she denied falling and utilized assistance of 2 with a mechanical lift for transfers. The progress note identified she received Tylenol for pain which was effective. The progress note reported her NP was updated. An additional progress note dated 4/23/25 at 1:45 p.m., indicated R60 complained of pain when staff were assisting her with dressing and she was unable to move her left arm. The progress note indicated Tylenol was administered and an ice pack was applied to her left shoulder, her NP and family were updated. A progress note dated 4/26/25 indicated the interdisciplinary team (IDT) reviewed an incident that occurred on 4/22/25 around [sic] while staff assisted with cares. The progress note indicated staff were interviewed on 4/22/25 and while two staff members assisted the resident from her wheelchair into bed using a ceiling lift R60 heard a crack sound she stated came from her left shoulder. The progress note indicated a nursing assistant (NA) notified the nurse promptly of her complaint and a nurse assessed her and found that the resident experienced pain associated with the popping sound during the transfer. The progress note indicated the nurse administered 1000 mg of Tylenol. The progress note continued, on April 23, 2025, the resident continued to report pain in her left shoulder during morning care assistance provided by nursing assistants. R60's nurse practitioner (NP) was updated regarding her reports of pain and limited range of motion (ROM) to her left upper extremity and ordered an x-ray and pain management plan including acetaminophen 1000 mg three times daily, tramadol 25 mg as needed every four hours, and the application of ice packs. The progress note indicated she took omeprazole, a proton pump inhibitor that increases the risk of bone fractures. The progress note stated staff would continue to monitor her condition and update the provider as needed but lacked documentation of further assessment of R60's safe lifting and movement to determine if new interventions were necessary to reduce the risk of future injury during transfers. R60's electronic health record (EHR) was reviewed on 5/15/25 and lacked documentation of post-incident safe lifting and movement assessment. During observation and interview on 5/12/25 at 4:54 p.m., R60 was lying in her bed without a sling on her left arm. She stated while she was getting into bed, I heard a big crack, it hurt. R60 stated she was okay to have the sling off while in bed but needed to have staff assist her with putting it on when out of bed. She stated not a lot of staff knew how to put the sling on. She stated she broke her left shoulder, which was the side affected by her stroke. She stated she felt staff were doing a pretty good job at managing her pain, however, were not offering her ice packs anymore, which was something she would like to have for pain management. During observation on 5/13/25 at 9:24 a.m., R60 was up in her wheelchair and requested to lay down. She pushed her call light at 9:25 a.m. and at 9:29 a.m., registered nurse (RN)-E and nursing assistant (NA)-Q entered her room to answer her call light. After performing hand hygiene, donning gloves and providing for privacy, NA-Q retrieved the lift sling from the back of the door and asked her to lean forward and began tucking the sling behind and down her back. NA-Q pulled the sling straps under her legs, first under her right hip and through the front of her right leg and then NA-Q repeated the steps on the left side. NA-Q walked across the room and pulled the ceiling mechanical lift from one side of the room over to above R60 and used the remote to lower the lift. RN-E asked her to hold onto her left hand and guided her to her affected left hand in the sling. NA-Q crisscrossed the sling straps in the front and hooked the sling straps up to the mechanical lift before using the remote to lift her up from the wheelchair. The bottom hem of the sling was above her sacral level; however, her head was above the top hem and there was no slipping observed during the transfer. Together, RN-E and NA-Q pushed her over top of her bed and NA-Q used the remote to lower her onto the bed. NA-Q asked her if she was okay and she answered, yeah. RN-E and NA-Q assisted her to turn to the side to tuck the sling, and then to sit forward. Together, they removed the sling out from behind her. RN-E stated she had a stroke and only had one working arm and hand and had always transferred with a mechanical body lift. NA-Q provided the call light within her reach, lowered the bed and gave her a stuffed animal. During observation and interview on 5/14/25 at 11:49, R60 was wearing her sling and family member (FM)-J stated being told she had a fracture that wouldn't require surgery but could not recall if the facility had reported how the fracture occurred. FM-J stated, I was not told how this happened, only that the injury occurred. FM-J stated preference for wanting to know what happened to have caused to injury. FM-J stated, the day it happened, I wasn't here when it happened, I was here beforehand, and after she told me about the pain. FM-J indicated the nursing supervisors was notified the following day and decided R60 needed a doctor to look her over and he decided she need an x-ray and ice [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to follow up on reported grievances in a timely manner for 1 of 2 residents (R9) reviewed for grievances. Findings include: See also F689 related to falls. R9's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, did not reject cares, used a wheelchair, and required substantial assist with toileting hygiene, and partial to moderate assist with dressing. Further, R9's vision was adequate with glasses. R9's optional state assessment (OSA) dated 4/11/25, indicated R9 required assist with bed mobility, transfers, and toileting. R9's Facesheet undated, indicated the following diagnoses: rheumatoid arthritis, Myelodysplastic syndrome, weakness, history of falling, and Alzheimer's disease. R9's care plan dated 4/14/25, indicated R9 had an alteration in ADLs and required assist of one with dressing, and grooming. R9's care plan dated 4/14/25, indicated R9 had an alteration in mobility and required assist of one with transfers and ambulating. R9's care plan dated 4/14/25, indicated R9 had vision, and interventions indicated to assist with glasses as needed, and provide vision exams as needed. R9's care plan dated 4/14/25, indicated R9 was on the facility Falling Star program and was at risk for falling due to multiple diagnoses. R9's goal was to be free from falls with injury and interventions included ensuring R9 wore her glasses and that they were clean and in good repair. R9's care sheet undated, lacked information R9 wore glasses. R9's HealthDrive Eye Care Group note dated 2/28/25, indicated R9's daughter reported R9 had a bad fall the week prior and was in the hospital. Further, R9 required full time use of glasses for distance and reading. R9's progress notes were reviewed from 3/10/25, to 5/15/25, and lacked documentation on any efforts the facility made to locate R9's glasses or that R9 was missing her glasses. A form, Customer Concerns Database, dated 2/13/25, through 5/13/25, was provided by the facility that included a list of residents in various units with various concern types including missing items. The form was reviewed and lacked information R9 was missing any items. A form, Lost Items Log dated 2025, was provided by the facility on 5/13/25 at 10:54 a.m., that indicated a list of residents with missing clothing items and the dates reported along with various notes whether items were found or if staff searched for the missing items. The form was reviewed and lacked information R9 was missing any items. A form, Combined Federal and State [NAME] of Rights, dated 6/18/19, indicated the resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, and other concerns regarding their LTC (long-term care) facility stay. The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. The facility must make information on how to file a grievance or complaint available to the resident. The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights. The grievance policy must include, notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally or in writing, the contact information of the grievance official with whom a grievance can be filed, a reasonable expected time frame for completing the review of the grievance, the right to obtain a written decision regarding his or her grievance, and the contact information of independent entities with whom grievances may be filed including the state agency, quality improvement organization, State survey agency, and the State Long Term Care Ombudsman program. Further, the policy must identify the grievance official, as necessary take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated, ensure all written grievance decisions including the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued, and maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision. A form, Grievance Notice, dated 11/2022, indicated residents had a right to file grievances orally or in writing, and the right to file grievances anonymously. Further, the form indicated social worker (SW)-A was the community's grievance officer responsible for receiving grievances. Additionally, the form indicated the grievance officer generally acknowledges receipt of grievances within one business day and generally completes review of the grievance within five business days. The form provided a list of independent agencies with whom grievances may be filed including the Minnesota Department of Health (MDH), Livanta LLC (Medicare Beneficiary and Family Centered Care Quality Improvement Organization), and the Minnesota office of Ombudsman for Long-Term Care. An undocumented Customer Concern form provided by SW-A on 5/13/25 at approximately 1:50 p.m., indicated a facility feedback investigation form that included an area for documenting the resident's name, the person voicing the concern and their phone number, a description of the concern with a request to include all details, including dates, times and description, the date and time of the event, the expected outcome, and the staff person who received the concern. During interview on 5/12/25 at 3:13 p.m., family member (FM)-K stated R9 used to go into other resident's rooms and lie down and would take off her glasses. FM-K stated R9 lost her glasses three weeks ago and has been without glasses since. FM-K further stated she told SW-A on 5/9/25, he had to do something because R9's glasses still had not been found. During observation on 5/13/25 at 8:12 a.m., R9 was in bed snoring softly and did not have glasses on her nightstand. During interview and observation on 5/13/25 between 8:57 a.m., and 9:19 a.m., nursing assistant (NA)-H entered R9's room and asked if she was ready to get up. R9 did not have her glasses on. At 9:01 a.m., NA-H donned R9's shoes, but did not tie the laces and at 9:02 a.m., NA-H assisted to stand R9 to pivot transfer into her wheelchair. R9's shoelaces were dragging on the floor during the transfer. NA-H did not apply any glasses. At 9:19 a.m., NA-H completed assisting R9 in the bathroom and R9 did not have her glasses on. During interview on 5/13/25 at 9:35 a.m., registered nurse (RN)-F stated they updated care plans and printed care sheets for the aides to know what cares a resident required and stated R9 required assist with all cares and further stated R9 had a blue star that indicated she fell a few times and was called a falling star. During interview on 5/13/25 at 9:47 a.m., RN-F stated staff were supposed to report missing items to SW-A and they look for the items by checking rooms and looking in the laundry and document the missing item. RN-F stated R9 was missing her glasses, and they could not locate them and stated R9's daughter was aware R9's glasses were missing and further stated SW-A was also aware of the missing glasses. RN-F viewed R9's care plan and stated it would be important for R9 to have her glasses because she was a falling star and was important to prevent falls. During interview on 5/13/25, at approximately 1:50 p.m., SW-A stated if nursing or the front desk was aware of a missing item, they provide a missing item form to the resident or family, and SW-A will put the forms in a customer concerns data base and stated he did not have any concerns in the data base at this time. SW-A viewed the data base and verified nothing was documented in the database and mentioned another two residents with glasses missing and a resident with missing hearing aides and stated the residents he mentioned already had plans in place and stated staff notify him of missing items and will go through the resident's room, the med cart and common spaces and then would get entered in the data base once identified as missing and they conducted a walk through a few days later. SW-A stated he was aware R9 was missing her glasses and stated he could add it in the data base and was working with the family to try to locate her glasses. SW-A further stated it had been a while and would confirm R9 was on the list for HealthDrive and stated HealthDrive sends the facility a list of residents to see and stated he would check to see if R9 was signed up for the actual service. SW-A viewed R9's chart and verified R9 signed up for the HealthDrive service as of 3/3/23, but not because her glasses were missing, and further stated R9's glasses had been missing for a couple of weeks and stated it was his fault for not putting the information in there. SW-A stated R9 needed her glasses and verified the Concern log, was their grievance log and the purpose for completing the form was to ensure concerns were followed up on and to let residents know they are addressing concerns and added it was like a physical reminder. SW-A stated Concern forms were located by the elevators and the front desk and provided a concern form and verified he had not completed a form for R9. During interview on 5/13/25 at 3:42 p.m., the director of nursing (DON) stated grievances should be documented immediately and expected staff follow up immediately. During interview on 5/15/25 at 12:34 p.m., the administrator, (A)-C stated she had been at the facility about four weeks and stated if something could not be resolved in the moment, it was considered a grievance and further stated lost glasses didn't consist of a concern, but stated she expected a reasonable timeframe would be within a week to let someone know the status of a missing item and further stated SW-A was working on R9's missing glasses. During interview on 5/15/25 at 2:10 p.m., A-C stated she revisited with SW-A and confirmed the family was aware of the missing eye glasses for a while and when asked about the expectation for following up with the family on the status A-C stated SW-A chatted with family on 5/14/25, and let them know they were going to have the optometrist come in and provide R9 an eye exam. A policy, Concerns, Grievances, dated 6/29/22, indicated the purpose was to create an environment where resident and customer concerns were solicited and readily resolved. Further, a resident/customer/resident representative has the right to voice grievances and concerns without discrimination or reprisal and without fear of discrimination or reprisal. The term voice concerns is not limited to a formal, written grievance process, but may include a resident's verbalized concerns to staff. The community view customer concerns as a primary method to learn of and meet customer expectations. In keeping with this belief, staff is trained to obtain and respond to resident/resident representative customer concerns. The community assures that after receiving a concern, there is a prompt response by the associates to acknowledge the receipt of the concern, investigate, seek a resolution, and keep the resident appropriately apprised of progress toward resolution. When a resident, resident representative, visitor or family member voices a concern to a staff member, the staff member completes a concern form and forwards the form to the social services department/Grievance Officer/designee. Completed forms are processed in a timely manner. The SW checks the confidential container daily, removes the completed forms, logs the concern, and routes the copy to the staff responsible to acknowledge, investigate, and resolve the concern. The SW assigns the concern to an associate accountable for the work area and the staff person responsible acknowledges receipt of the concern with the resident/resident representative/customer within 24 hours or the next working day, in the event of a holiday or weekend and documents acknowledgement. The staff person responsible investigates, resolves the issue, and responds back to the customer within five business days and documents action. If more time is needed for a resolution, the customer is updated on the status until resolution. Documentation in the medical record, when applicable, reflects the concern, plan for addressing, and follow-up of the resolution. All written grievance decisions will include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.

Based on observation, interview, and document review the facility failed to ensure the daily cleaning schedule was followed in the kitchen. During observation on 5/12/25 at 12:05 p.m., the kitchen floor was visibly soiled with dirt, there were multiple footprints, food spills, it was sticky, and there were copious amounts of food particles pushed down into the grout of the floor. During observation and interview on 5/14/25 at 10:37 a.m., the kitchen floor was visibly soiled with dirt, there were multiple footprints, food spills, it was sticky, and there were copious amounts of food particles pushed down into the grout of the floor. The director of dining services (DDS) verified the floor was dirty and stated kitchen staff were responsible for mopping the floor daily. During interview on 5/14/25 at 11:04 a.m., dietary aide (DA)-A stated the dishwasher was responsible for mopping the kitchen floor every day and verified the floor was dirty stating It had been a while since it had been cleaned. During interview on 5/15/25 at 10:47 a.m., the administrator stated the kitchen staff were contracted employees, it was their responsibility to clean the kitchen, and she expected them to be following their cleaning schedule and their policies. The cleaning schedule for the kitchen titled Back of the House Cleaning Log for the month of May 2025, indicated the kitchen floor should be swept and mopped daily. It further indicated the last time the floor had been swept and/or mopped was on 5/10/25. A facility policy regarding the cleaning schedule for the kitchen was requested and received, however did not address cleaning of the floor or frequency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure proper hand hygiene practices for 2 of 2 residents (R62, R59) observed during personal cares. In addition, the facility failed to ensure appropriate room assignment for 6 of 10 residents (R26,R23,R136,R74,R12,R11) reviewed for transmission based precautions (TBP). Also, the facility failed to ensure consistent and appropriate personal protective equipment (PPE) use for 5 of 10 residents (R11,R12,R73,R76, R59) reviewed for TBP and staff handling soiled laundry. Findings include: Room Assignment From CDC website: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes | LTCFs | CDC Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. The resident is given dedicated equipment (e.g., stethoscope and blood pressure cuff) and is placed in a private room. When private rooms are not available, some residents (e.g., residents with the same pathogen) may be roomed together. Residents on Contact Precautions are recommended to be restricted to their rooms except for medically necessary care, including restriction from participation in group activities. Contact Precautions are generally intended to be time limited and, when implemented, should include a plan for discontinuation or de-escalation. Facility provided infection precautions for Transmission Based Precaution (TBP) list printed 5/14/25, indicated R12, R26, and R136 were on contact precautions due to Methicillin-resistant Staphylococcus aureus (MRSA). The list did not indicate R11, R23, and R74 were on contact precautions. Facility provided infection precautions for Enhanced Barrier Precautions (EBP) list printed 5/14/25, indicated R23 was on EBP due to a urinary catheter. Resident census dated 5/12/25, indicated R26 and R23, R136 and R74, and R11 and R12 shared double occupancy rooms. During interview on 5/14/25 at 12:50 p.m., infection preventionist (IP) and director of nursing (DON) stated ideally residents not requiring TBP should not be sharing a room with residents who do require TBP. In the example where a resident on contact precautions for MRSA shared a room with a resident not on contact precautions, the whole room should be treated with contact precautions and staff would need to gown and glove prior to entrance into the room. During interview on 5/15/25 at 11:03 a.m., IP stated R23 was on EBP due to a urinary catheter and was considered high risk for contracting a facility acquired organism, R23 should not be sharing a room with R26 who was on contact precautions due to MRSA. Facility policy Contact Precautions dated 9/2023, indicated resident placement would be made on a case by case basis, and consideration would be given to risk of transmission to a roommate. Considerations included, Cohort residents who are infected or colonized with the same pathogen. Additional considerations included, Avoid placing residents on Contact Precautions in the same room with residents who have conditions that place them at risk of adverse outcomes, should they become infected - or that may facilitate transmission. This includes, but is not limited to: .Those with any form of tube - foley catheter, G/J tube for feeding. TBP R11 and R12 R11's admission Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively intact, was dependent on staff for many activities of daily living (ADLs), and had a fracture of the right shoulder. R11's care plan dated 4/17/25, lacked evidence of need for any transmission based precautions (TBP). R11's provider orders lacked evidence of need for any TBP. R12's quarterly MDS dated [DATE], indicated R12 was cognitively intact, required substantial/maximal assistance with most ADLs, occasionally incontinent of bowel and bladder, and had a recent hip replacement. R12's diagnoses included MRSA infection, infection and inflammatory reaction due to internal right hip prosthesis, and bacteremia. R12's care plan dated 5/14/25, indicated R12 was on isolation contact precautions due to MRSA of the urine. R12's care plan indicated R12 would be isolated to the room to prevent spread of the infection. The care plan further instructed staff to wash hands, wear gown, mask, gloves and goggle as needed to prevent spread of infection. R12's provider order dated 1/10/25, indicated, Contact Isolation ESBL [extended-spectrum beta-lactamase-an enzyme produced by a bacteria that causes resistance to several antibiotics], MRSA [methicillin-resistant staphylococcus aureus-a staph bacteria resistant to many antibiotics]. Facility resident census indicated R11 and R12 shared a double occupancy room. During observation on 5/13/25 at 8:53 a.m., signage indicating Contact Precautions was posted outside R11/R12's room. An unidentified housekeeper was cleaning the room and was not wearing a gown. Director of spiritual care also in the room speaking to R11 and was not wearing any PPE. During observation on 5/13/25 at 8:54 a.m., nurse practitioner (NP) entered R11/R12's room and did not don any PPE. During observation on 5/13/25 at 9:21 a.m., activities personnel (A)-A entered R11/R12's room without donning PPE. A-A asked both invited both residents to attend morning exercise group upstairs. Both declined. During observation on 5/13/25 at 9:53 a.m., A-A entered R12's room and did not perform hand hygiene and did not don any PPE. A-A invited R12 to a different activity and R12 accepted. A-A pushed R12 out of the room to the elevator. During interview on 5/14/25 at 7:45 a.m., nursing assistant (NA)-D stated R12 was on contact precautions and R11 was not on precautions, therefore if she needs to just drop something off to R11, PPE was not necessary, but would use PPE if providing any cares for either R11 or R12. NA-D was not sure if someone on contact precautions should be leaving the room and joining activities. During observation on 5/15/25 at 8:07 a.m., licensed practical nurse (LPN)-A entered R11's room to administer medications. LPN-A did not don any PPE. R73 and R76 During observation on 5/14/25 at 11:36 a.m., nurse practitioner (NP) entered R73 and R76's room without donning a gown or gloves. The room had signage indicating Contact Precautions. NP stopped to talk R76 into seeing podiatry today. NP touched R76's bedside table to move it out of the way, pulled off R76's socks and touched and assessed his feet and toenails. NP was not wearing gloves or gown. NP went over to R73's side of the room and moved R73's bedside table out of the way touching it without gloves. During observation at 5/14/25 at 11:37 a.m., NA-B donned gown and gloves to enter and deliver R76's meal to his bedside table. During observation on 5/14/25 at 11:41 a.m., R76 wheeled self out of room to go to visit podiatry. During observation on 5/14/25 at 11:43 a.m., NA-C entered room to deliver R73's meal and did not don gown or gloves prior to entrance. During interview on 5/14/25 at 11:49 a.m., NP stated R73 had diagnoses history of right lower extremity wound and MRSA. NP stated R76 had a history of MRSA with location not classified. NP stated neither R73 nor R76 had active infections and did not think they were on contact precautions; therefore he did not gown and glove prior to entrance. NP did not agree the two residents required contact precautions, but stated if signage directed staff to use contact precautions the sign should be followed, and precautions should be utilized. NP stated thinking the signage was in place due to facility policy and that they just follow policy when the state comes in. NP stated, we are just spreading it. Laundry During observation on 5/15/25 at 10:15 a.m., laundry aide (LA)-A was sorting dirty clothes and linen in the soiled laundry room. LA-A had gloves on but did not have a gown on. Director of environmental services (DES) stated the expectation was for staff to be wearing gown and gloves whenever handling and sorting soiled linen. During interview 5/15/25 at 10:16 a.m., LA-A stated she usually wore a gown and gloves when sorting soiled linen and could not explain why she was not wearing a gown now. During interview on 5/15/25 at 10:57 a.m., infection preventionist (IP) stated expectation for staff to wear correct PPE to include gown and glove anytime they were handling soiled linen. Laundry workers should wear a gown and gloves when sorting soiled laundry. During interview on 5/15/25 at 11:29 a.m., Administrator stated expectation that staff follow the policy and wear gown and glove when handling and sorting soiled clothing and linen. Facility policy Linen and Laundry, undated, indicated, Soiled health care textiles must be assumed to be contaminated; personnel who handle soiled textiles must follow Standard Precautions including gloves and a gown. R62 R62's discharge MDS dated [DATE], indicated intact cognition and diagnoses of quadriplegia, traumatic rupture of cervical intervertebral disc (C5-6), spinal stenosis, and neurogenic bladder. It further indicated R62 required substantial assistance with toileting and was always incontinent of urine. During observation on 5/14/25 at 8:42 a.m., NA-F entered R62's room to answer his call light and asked him if someone had changed his brief yet. R62 responded no. NA-F washed her hands and put on gloves, handed R62 a wet washcloth to wash his face, and then removed his bilateral heel protectors. NA-F removed R62's gown and brief (which was visibly full of urine) and assisted him to turn on his right side, and wiped his bottom with wipes. Then NA-F removed the pad from underneath him (which was also visibly wet), put it in a plastic bag, assisted him to turn onto his back, and wiped his peri area. NA-F then fastened his brief, pulled up his pants, touched the back of his shoulder, put on his shoes, grabbed a pack of wipes and put them on his dresser, and touched the door handle. NA-F then removed her gown and gloves but did not perform hand hygiene. NA-F then grabbed the EZ stand lift from the hallway, got new gloves from R62's bathroom, touched the bed remote, applied the sling, and NA-E assisted her to transfer R62 to his wheelchair. Once he was in his chair NA-F made the bed and then removed her gown and gloves, brought the EZ stand lift out into the hallway, brought a bag of dirty laundry to the soiled utility room, and did not perform hand hygiene. NA-F then applied new gloves and went into another resident's room and shut the door. During interview on 5/14/25 at 9:15 a.m. NA-F stated when entering a resident's room to perform cares, she washes her hands and puts on gloves and then when the cares have been completed, she will remove her gloves and wash her hands. NA-F verified she had not removed her gloves or performed hand hygiene after removing R62's wet brief and did not perform hand hygiene in between glove changes and should have. During interview on 5/14/25 at 9:30 a.m., registered nurse (RN)-D stated when going from a dirty area to clean area while performing personal cares for a resident, staff should change gloves and then perform hand hygiene. This was important in order to prevent spreading germs. During interview on 5/14/25 at 2:00 p.m., (NA)-G stated when you are performing cares and you go from a dirty area (changing a wet/soiled brief) to a clean area (assisting a resident to get dressed), staff should change gloves, wash their hands/use hand sanitizer, and apply new gloves. During interview on 5/15/24 at 10:56 a.m., the DON stated when staff are performing personal cares and going from a dirty area to a clean area, they should change gloves and perform hand hygiene. Staff should also be performing hand hygiene in between glove changes. This was important because there was the potential of spreading germs to other residents or the staff. R59 (hand hygine/TBP) R59's admission Minimum Data Set (MDS) dated [DATE], indicated R59 was cognitively intact and had diagnoses of bilateral humerus (upper arm) fractures. Furthermore, R59 had occasional incontinence and required staff assistance with toileting. R59 did not require isolation due to active infectious disease. R59's provider order dated 4/22/25, indicated R59 required contact precautions due to Methicillin-resistant Staphylococcus aureus (a resistant bacteria MRSA) of the nare. R59's care plan dated 4/22/25, indicated R59 was on contact precautions due to MRSA of the nares and R59 would be isolated to their room to prevent the spread of infection. Interventions directed staff to wash hands, wear gown, mask, gloves and goggles as needed to prevent spread of infection. Staff were also required to perform hand hygiene upon entrance and exit of R59's room. An observation on 5/12/25 at 1:42 p.m., R59's room had a sign that read contact isolation on their door. The sign further instructed staff to gown and glove when entering the room. An observation on 5/12/25 at 5:18 p.m., NA-I was picking up dinner trays. NA-I had gloved hands on and pushed a cart near R59's room. Without gowning, hand hygiene or glove exchange, NA-I entered R59's room came out with the dinner tray and placed it on the cart. With the same gloves, NA-I entered room [ROOM NUMBER] and exited with the dinner tray and placed it on the cart. With the same gloves, NA-I entered room [ROOM NUMBER]-I and exited with the dinner tray and placed it on the cart. With same gloves, NA-I pushed the cart down to the kitchen area. When interviewed on 5/12/25 at 5:18 p.m., NA-I verified they had not donned a gown as instructed when entering R59's room and had worn the same gloves in all three resident rooms. NA-I stated hand hygiene should have been done and new gloves placed for each room. NA-I stated other staff were waiting for the dirty dishes and they were in a hurry. An observation on 5/13/25 at 9:37 a.m., after donning gown and gloves, NA-J entered R59's room to assist with morning cares. After helping R59 choose clothing, NA-J assisted R123 with putting on gripper socks, placed a transfer belt on and assisted walking R59 to the bathroom. R123 walked by the toilet and NA-J then assisted R59 with pulling down the brief. NA-J removed the soiled brief and placed in the garbage. R59 sat on the toilet. NA-J then removed gloves and without hand hygiene, placed donned new gloves. NA-J then assisted with washing face, arms, back and legs. R59's gown was removed and NA-J assisted R59 with putting on a shirt. NA-J then assisted putting a clean brief and pants around R59's ankles before assisting R59 to stand. Once standing, NA-J used wipes to provide peri cares for front and back. NA-J removed gloves and without hand hygiene donned new gloves. R59's clean brief and pants were pulled up and R59 was assisted out of the bathroom to their wheelchair. NA-J assisted R59 to be positioned in the wheelchair in the room and provided R59 the call light. NA-Jthen removed gown and gloves before exiting room and performed hand hygiene upon exit. When interviewed on 5/13/25 at 10:12 a.m., NA-J verified they had not performed hand hygiene after glove removals and was supposed to. NA-J stated R59 was on contact precautions but was not sure why. NA-J stated they follow the signs on the doors. When interviewed on 5/13/25 at 10:16 a.m., registered nurse (RN)-I stated R59 was on contact precautions for MRSA. RN-I further stated the MRSA was not active and many times contact precautions were placed as more of a precautionary basis. R73 R73's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and diagnoses of high blood pressure and diabetes. The MDS also reported she received application of ointment(s) to areas other than her feet during the lookback period. R73's physician order report dated 4/1/25 - 4/30/25 included the following orders: - Unna Boots - every Friday. Remove, cleanse with warm water, re-wrap Unna and Coban cover once daily every Friday, dated 9/27/24 (Unna Boots are a type of compression bandage and Coban is a brand of self-adherent wrap). The physician order report further indicated R73's diagnoses included non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity, and methicillin-resistant Staphylococcus aureus (MRSA) infection as the cause of diseases classified elsewhere-RLE (right lower extremity). R73's care plan dated 12/7/24, identified she was on contact precautions related to MRSA and directed all staff to wash hands; wear gown, mask, gloves and googles as needed to prevent spread of infection. An undated nursing assistant (NA) care sheet identified R73 was on contact precautions for MRSA. R76 R76's quarterly MDS date 4/1/25, indicated he had intact cognition with diagnoses of high blood pressure and high cholesterol. The MDS also reported he received application of ointment(s) and dressings to areas other than his feet. R76's Care Area Assessment (CAA) dated 10/5/24 for Activities of Daily Living (ADLs) triggered related to needing assist with cares and mobility due to his cellulitis-MRSA/pseudomonas in his lower extremities. The CAA indicated he required assist of 1 with cares and mobility and directed staff to the plan of care to support his care mobility needs. R76's CAA dated 10/5/24 for Pressure Ulcer/Injury indicated he had recurring open aeras on both legs and the CAA triggered related to cellulitis - MRSA/pseudomonas. R76's physician order reported dated 4/1/25 - 4/30/25 included the following orders: - Bilateral leg dressing; Change twice weekly; cleanse, apply 2 grams ammonium lactate lotion to each leg, apply Vaseline gauze to open areas wrap Unna boots. Do not leave leg unwrapped for > [sic, greater than] 30 min. [sic, minutes]. Once Click or tap here to enter text. day and once a day as needed, dated 4/17/25. The order report also identified diagnoses including cellulitis of right lower limb (a bacterial skin infection), non-pressure chronic ulcer of unspecified lower leg with unspecified severity - bilateral (meaning both sides), MRSA infection, and pseudomonas (aeruginosa) (mallei) (psedomallei). R76's care plan last reviewed/revised 4/8/25, identified under diagnosis his MRSA and pseudomonas (aeruginosa) (mallei) (pseduomalleli), however, lacked documentation of measurable objectives and timeframes to meet his medical and nursing needs related to his MRSA and pseudmonas infection and lacked documentation of interventions related to transmission-based precautions (TBP). An undated NA care sheet identified R76 was on contact precautions. Per observation on 5/12/25 at 5:39 p.m., R73 and R76 were on contact precautions evidenced by the signage posted outside their shared room next to the door frame at approximate standing eye-level. The sign read, Contact Precautions: Everyone Must: clean hands when entering and leaving room. Doctors and Staff Must: gown and gloves at door. During observation on 5/13/25 at 8:52 a.m., nursing assistant (NA)-N pushed a four-wheeled meal cart down the unit hallway. NA-N stopped the cart outside of R73 and R76's room and walked past the contact precautions signage into the room without performing hand hygiene or donning personal protective equipment (PPE) of gown and gloves. NA-N walked back out of the room, did not perform hand hygiene, returned to the cart and poured liquid from a carafe into a cup and re-entered the room without performing hand hygiene and without donning PPE. NA-N exited the room again and returned to the cart, without performing hand hygiene, picked up utensils from the cart, and walked past contact precautions signage and into the room without performing hand hygiene or donning PPE. NA-N walked out of the room and back to the cart, did not perform hand hygiene, and picked up the carafe and poured liquid into a cup and picked up condiments from the cart and walked past the contact precautions signage and into the room without performing hand hygiene or donning PPE. NA-N exited the room, did not perform hand hygiene, and used bare hands to push the meal cart down the hallway to the next room. NA-N did not perform hand hygiene before entering the next room and told the unidentified resident, I have your breakfast. NA-N exited the room, did not perform hand hygiene, and used bare hands to pick up a white plate with food on it and walked it into the unidentified resident's room. NA-N exited the room, did not perform hand hygiene and stated, lord tell me I didn't forget a fork, and used bare hands to grab the handle of a fork. NA-N re-entered the unidentified resident's room without performing hand hygiene. NA-N exited the room without performing hand hygiene, walked across the hallway to a covered linen cart, used bare hands to pick up towels. At 8:55 a.m., NA-N re-enters the resident's room and sets up the bedside table with the meal before exiting the room without performing hand hygiene. Per follow-up interview at 8:55 a.m. with NA-N, staff should wear PPE for contact precautions when doing the cares. NA-N and the surveyor walked to R73 and R76's shared room to review the contact precautions signage. When asked when to wear gown and gloves in their shared room, NA-N stated, I can ask my manager, and then asked the surveyor if they could return to delivering the breakfast so it doesn't get cold. Surveyor asked NA-N to review the contact precautions signage and asked when staff should wear PPE and NA-N stated, when doing cares, before walking away. During observation and interview on 5/13/25 at 8:58 a.m., NA-M was at R73 and R76's shared door and performed hand hygiene before donning a gown and gloves. NA-M entered the shared room and delivered two mugs with lids. NA-M remarked how warm the room temperature was and offered to submit a work order for them. With the room door open, NA-M was observed doffing the gown and gloves at the doorway, then performing hand hygiene before exiting the room. At 9:01 a.m., NA-M stated staff should wear PPE whenever going in or out of the room just in case you come in contact with them or something. When asked if NA-N should have donned gown and gloves as the signage indicated outside R73 and R76's shared room, NA-M confirmed, the general rule is you should do what you read but said everybody kinda just does their own thing. Per interview on 5/13/25 at 9:03 a.m., licensed practical nurse (LPN)-B confirmed both R73 and R76 were on contact precautions and verified staff were expected to follow TBP signage instructions if they were posted on the resident's door. Per interview on 5/14/25 at 9:27 a.m., registered nurse (RN)-E would expect staff to follow [transmission-based] precaution signs posted on the resident's doorway. When asked if staff would be expected to don full PPE of gown and gloves for a resident room identified as having contact precautions to deliver meal trays, RN-E stated if staff were not expecting to come into contact with a resident for cares, they would not need to don full PPE. During the interview, RN-E and surveyor reviewed the Center for Disease Control (CDC)'s recommendations for Transmission-Based Precautions dated 4/3/24, which indicated, Wear gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Additionally, RN-E and the surveyor reviewed the CDC's Contact Precautions signage, which indicated, providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. RN-E acknowledged there was confusion among staff with TBP and requested to speak with the facility's infection preventionist (IP) to clarify. RN-E stated the expectation was staff follow the CDC's recommendations for precautions. Per interview on 5/15/25 at 12:38 p.m. with the director of nursing (DON), staff were expected to follow the signage on a resident's door as it related to TBP. The DON stated if staff were unsure what PPE to wear or had questions about in what situations they needed to wear PPE, they knew they could ask either the DON or the IP. Per facility policy titled Contact Precautions last revised 9/23, contact precautions were used to prevent nosocomial spread of organisms that could be transmitted by direct resident contact or indirect contact of environmental surfaces or contaminated resident care equipment. The policy directed staff to perform the following steps for appropriate contact precaution procedure: 1. Hand Hygiene is done prior to donning PPE. 2. PPE is donned prior to entering room. A gown and gloves are needed upon entering room. 3. Change gown and gloves between residents even if only one resident is on Contact Precautions. 4. Use of masks, eye protection and face shields is not routinely part of contact precautions, however, just as with Standard Precautions, these items are own during resident care activities that are likely to create splashes or sprays of blood, bodily fluid, secretions, and excretions. 5. Hand hygiene is performed between glove changes and when removing gloves. Furthermore, the policy directed associates to practice hand hygiene and don gown and gloves before entering and remove gown and gloves prior to exiting room per CDC guidelines. Hand Hygiene must occur once PPE is removed.

Based on observation, interview, and document review, the facility failed to ensure the dining room floor for 1 of 3 dining rooms was clean and sanitary. Findings include: During observation on 8/12/24 at 12:17 p.m., the dining room floor of the Villa unit had copious amounts of dried food and spilled liquids and was very sticky upon walking on it. During observation on 8/12/24 at 1:30 p.m., all the residents in the Villa unit were in the dining room waiting to go to McDonalds for lunch and the floor was observed to be visibly soiled and sticky. During interview on 8/13/24 at 7:49 a.m., licensed practical nurse (LPN)-A verified the dining room floor (Villa unit) was visibly soiled, had many areas of dried food/liquid spills, and was sticky. LPN-A stated housekeeping came every morning at 8:00 a.m. and mopped the floor. -At 9:37 a.m. environmental services (ES)-A finished mopping the dining room floor, put out wet floor signs, and left the unit. Surveyor observed numerous sticky spots and spills of juice that still remained on the floor. During observation and interview on 8/13/24 at 10:03 a.m., the director of environmental services verifed the dining room floor was visibly dirty, sticky and there was more then one day of built up dirt/food spills stating I don't know what happened to this floor. During interview on 8/14/24 at 8:49 a.m. environmental services (ES)-B stated they cleaned the dining room floors on each unit daily. They come in the morning and clean the tables, then after lunch they sweep and mop the dining room floors. During interview on 8/14/24 at 12:21 p.m. nursing assistant NA-C stated the dining room floor (Villa unit) was usually pretty sticky and dirty. The floor cleaning schedule (undated) indicated dining rooms/kitchen serving areas were mopped 2 times per day, in the morning and after lunch. The sign off sheets for documenting whether the floor had been cleaned or not were requested but not received. A facility policy regarding cleaning was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a comprehensive and individualized care plan was developed for 1 of 3 residents (R88) reviewed for psychotropic medication use. Findings include: R88's admission MDS dated [DATE], indicated R88 had moderate cognitive impairment and diagnoses of sepsis, metabolic encephalopathy (change in how the brain works due to an underlying condition), delirium related to known physiological condition (a temporary mental state characterized by confusion, incoherent speech, and hallucinations), and age-related cognitive decline. Furthermore, R88's MDS indicated R88 had received an antipsychotic medication. R88's care plan revised on 8/12/24 at 3:45 p.m., (after the start of survey) indicated R88 used quetiapine for delirium. Interventions included to administer medication as ordered, ask for a possible dose reduction every three months, and monitor for side effects. Interventions further included monitoring behaviors every shift and document. R88's care plan lacked non-pharmacological or personalized interventions were in place to support any signs of delirium or delusions. R88's nursing task sheet no date, lacked indication R88 had behaviors or confusion. When interviewed on 8/14/24 at 12:33 p.m., nursing assistant (NA)-B stated R88 was confused at times but did not really have any behaviors or outbursts. NA-B further acknowledged there were no alerts on the task sheet identifying any behavioral concerns for R88 and wasn't aware of any interventions. When interviewed on 8/14/24 at 1:00 p.m., registered nurse (RN)-A stated if a resident was experiencing some anxiety or getting agitated, we use distraction by going for a walk or their mind on something else and it would depend on the situation. RN-A further stated they were not aware of any behaviors for R88 or personalized interventions that were in place. When interviewed on 8/15/24 at 10:06 a.m., the Director of Nursing (DON) stated the care plan was developed from the MDS nurse and the unit's nurse manager. DON verified R88's care plan lacked individualized interventions and furthermore expected care plans to be individualized to each resident. A facility policy titled Comprehensive Assessment and Care Planning revised 9/2023, directed an all-person-centered care plan interventions will by implemented by qualified personal and may be communicated through the electronic health record, profile, assignment sheets or verbal communications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide routine showers for 1 of 1 residents (R90) reviewed for activities of daily living (ADLs). Findings include: R90's admission Minimum Data Set (MDS) dated [DATE], indicated R90 was cognitively intact and had diagnoses of cellulites (skin infection) of right lower limb, lymphedema (swelling from due to lymphatic system problem), and fracture of right foot 5th toe. R90's admission MDS further indicated R90 did not reject cares, required substantial assistance for lower body dressing, supervision or touching assistance for personal hygiene, and had not been assess for bathing showering assistance due to medical/safety concerns. R90's care plan dated 7/28/24, indicated R90 had difficulty with bathing related to decline in mobility, lymphedema, and leg wounds. Interventions included staff assist with bathing weekly. R90's nursing care sheet no date, provided at survey exit indicated R90's bath day was on Monday. R90's nursing order dated 7/25/24, indicated R90's bath day was once a day on Monday morning. R90's treatment administration record (TAR) for 8/1/24-8/13/24, indicated R90 had not received a bath on 8/5/24 or 8/12/24. The TAR indicated the reason the bath was not administered was shower day was Tuesday. R90's point of care documentation dated 7/25/24- 8/13/24, lacked indication R90 had a shower or bath. When interviewed on 8/12/24 at 12:35 p.m., R90 was seated in the recliner chair in their room. R90 stated when admitted , she hadn't had a shower in almost 2 weeks and had to complain a lot to get one. R90 stated she was supposed to be on a schedule now, but not sure as she had not had one since. R90 did not know what day it was supposed to be or when the next one was. When interviewed on 8/14/24 at 6:41 a.m., nursing assistant (NA)-A stated resident bath days were found on the care sheets. NA-A verified R90's bath day on the care sheet was on Tuesday mornings. A follow up interview on 8/14/24 at 11:35 p.m., R90 stated a shower was not offered on Monday 8/12/24 or Tuesday 8/13/24. R90 further stated she found out the shower was supposed to happen on Monday but had not. When R90 asked about it on Tuesday, staff told her it was not her bath day and had not received one. When interviewed on 8/14/24 at 12:33 p.m., NA-B stated resident shower days were listed on the care sheet. NA-B stated if a resident refused a bath or shower, it would be documented in the POC documentation, and the nurse would be notified. NA-B pulled out the care sheet and verified R90's shower day was Tuesday. NA-B reviewed R90's POC documentation and verified there had been no bathing/shower documentation the past few weeks. When interviewed on 8/14/24 at 1:00 p.m., registered nurse (RN)-A stated resident bath days were located on the care sheets as well as a nursing order. RN-A further stated sometimes the days were changed per resident request. RN-A verified the nursing documentation indicating R90 had not had a shower or bath the past 2 Mondays as the bath day was on Tuesday. RN-A also verified the care sheet indicated the bath day was on Tuesday. RN-A was not sure if R90 had been given a bath or shower and wasn't sure why the order and care sheet were different. RN-A stated the care sheet, or the order needed to be updated and match up, so showers were not missed. When interviewed on 8/15/24 at 10:06 a.m., the Director of Nursing (DON) stated upon admission residents were assigned a specific bath day by the unit managers. DON further verified the NAs would document in POC when the shower or bath was completed, and the nurse would document it as a treatment. DON acknowledged there was some miscommunication around R90's shower days and verified the shower day should be on Mondays and coordinated with occupational therapy as they were managing R90's edema wraps. A facility policy titled Activities of Daily Living dated 2021, directed staff to provide care appropriate to maintain their ability to maintain or improve their ability to carry out ADLs. Furthermore, the policy directed staff to assist residents who are unable to carry out ADL's independently including bathing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and document review, the facility failed to implement a walking program as written to prevent potential decrease in mobility for 1 of 1 resident (R73) reviewed for walking programs. Findings include: R73's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified she had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15/15, and no behaviors or rejection of care. R73 had no hearing difficulty in normal conversation, had clear speech, responded adequately to simple, direct communication only, and may miss some part of a message but comprehended most conversation. Functional physical impairments of upper and lower extremities were present, a wheelchair was normally used, and a cane was not identified as having been used. R73's walking ability was left blank, however she required partial to moderate assistance for chair to bed transfers, sit to stand and sit to laying down and was independent with wheelchair mobility. Diagnoses included stroke and aphasia (impaired communication after a stroke). R73's Activities of Daily Living Care Area Assessment (ADL CAA) dated 11/9/23, was triggered due to assist needed with cares and mobility due to stroke, right sided weakness, and aphasia. R73's undated nursing assistant care sheet identified a walking program was in place to and from meals, using contact guard assist with right AFO, gait belt and quad cane. Family not able to ambulate with resident. Ask yes/no questions or use communication board. R73's care plan interventions with a start date of 4/1/24, also identified a walking program with meals at 10:30 a.m., 4:30 p.m., and 7:00 p.m., was in place. Use contact guard assist (CGA) which is hands on assist to steady the resident's balance; a gait belt, right AFO (ankle foot orthotic) and quad cane in the hallway. The care required sign off in Point of Care (POC) system which is the nursing assistant documentation software. R73's care plan interventions with a start date of 3/8/24, identified to ask yes/no questions or use communication board. R73's POC documentation from 4/1/24 through 8/15/24, identified walking in the corridor (hallway) in accordance with the walking program, occurred at the following frequency: 4/1/24 through 4/30/24: once out of 30 days. 5/1/24 through 5/31/24: none. 6/1/24 through 6/30/24: three times in 30 days. 7/1/24 through 7/31/24: none. 8/1/24 through 8/15/24: once out of 15 days. R73's POC documentation had not supported the ambulation program was carried out as ordered. R73's outpatient physical therapy note dated 7/30/24, identified to please walk using her quad cane every day, needs assistance. R73's active orders dated 7/30/24, identified please walk using her quad cane every day (needs assistance). During an interview on 8/12/24 at 12:41 p.m., R73 stated no when asked if staff walk with her every day and stated yes when asked if she'd like to walk more often. During an observation on 8/12/24 at 5:00 p.m., R74 was not offered an opportunity to walk at the evening meal. During an observation on 8/13/24 at 11:00 a.m., R74 was not offered an opportunity to walk at the brunch meal. During an interview on 8/13/24 at 1:11 p.m., nursing assistant (NA)-D stated if a resident was on an ambulation program it would be on the care sheets and in POC charting to sign off. NA-D stated R73 was in her care today and she had not walked her to brunch meal as ordered on the care sheet and care plan, because she had not noticed it on the assignment sheet. NA-D stated the nursing assistants would document walking programs and not the registered nurses (RN) or licensed practical nurses (LPN). During an interview on 8/13/24 at 2:04 p.m., NA-E stated R73 could walk, but she had not seen her walking with nursing assistants lately. NA-E stated the nursing assistants document walking programs they carried out, and not the RNs or LPNs. During observations on 8/14/24, at 8:36 a.m. through 9:31 a.m., NA-F completed R73's morning cares, and stated R73 would self-propel in her wheelchair to brunch. At 10:35 a.m., R73 started to self-propel in her wheelchair to the brunch meal. An unidentified staff pushed her in the wheelchair the rest of the way. At 11:57 a.m., R73 self-propelled in her wheelchair back to her room. An opportunity to walk to and from her meal was not offered as identified in the care plan and care sheet. After surveyor asked if R73 wanted to walk and if it was ok to observe the walking program, on 8/14/24 at 12:00 p.m., R73 went up to NA-F and indicated she wanted to walk. NA-F assisted R73 with a gait belt and her quad cane, walked down the hallway and partway back for a total of about 10 minutes with 125 feet. NA-F stated there was not always the opportunity to walk with R73 due to being busy. During an interview on 8/14/24 at 12:00 p.m., licensed practical nurse (LPN)-B stated the nursing order dated 7/30/24, for the walking program was an acknowledgement of the order, and not an order for nursing to complete the walking program. The nursing assistants were responsible to complete walking programs and document in POC. LPN-B stated she had seen R73 do her walking program in the hallway before but was not sure how recently she last saw it completed. During an interview on 8/14/24 at 12:30 p.m., the facility's physical therapy assistant (PTA) stated R73 they had worked with R73 in house, she had a walking program in place with nursing staff, and it was important to complete as ordered so the resident could achieve their highest level of functioning. R73 was now discharged to an outpatient physical therapy department. During an interview on 8/14/24 at 12:41 p.m., the outpatient physical therapist (PT)-B, stated she was told a walking program was already in place with the facility prior to transferring to outpatient. PT-B stated the ambulation program should be carried out daily as written, as they were trying to get R73 to tolerate up to 30 minutes of exercise. The PT-B stated R73 walked a distance ranging from 100 feet to around 200 feet at the outpatient facility. During an interview together with the director of nursing (DON) and regional registered nurse (RRN) on 8/15/24 at 11:00 a.m., the DON stated walking programs were usually established when a resident was done with physical therapy. The DON stated he expected walking programs to be completed as ordered. The RRN stated the TAR documentation from 7/30/24 through 8/15/24 identified the ambulation program had been completed by the nurses, even though the nursing assistant documentation was not in place. (However, that did not explain the lack of documentation from 4/1/24 through 7/29/24, on the care planned walking program.) The DON reviewed the POC documentation report and acknowledged the lack of documentation on the walking program. The DON also verified the nursing assistant care sheet identified the ambulation program was currently in place. During an interview on 8/15/24 at 11:33 a.m., LPN-C stated the nursing assistants documented on the walking programs and activities of daily living (ADLs) they carried out, and the RNs or LPNs did not document on the NA's behalf. During an interview on 8/15/24 at 11:40 a.m., RN-G also stated the nursing assistants documented in POC on the walking programs and activities of daily living (ADLs) they were assigned to complete, and the RNs or LPNs did not document on the NA's behalf. During an interview on 8/15/24 at 11:46 a.m., the MDS RN-H stated if ambulation occurred during the lookback period, it would be documented on the MDS, she used the nursing assistant charting in POC, the nursing assessments for the MDS section GG, and interviews to guide the MDS information. The facility's ADL policy dated 6/2021, identified care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking). Additionally, the resident's response to interventions would be documented, monitored, evaluated, and revised as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to comprehensively assess past trauma and implement individualized care plan interventions utilizing a trauma-informed approach for 1 of 1 (R47) resident reviewed who had post-traumatic stress disorder (PTSD) symptoms. Findings include: R47's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and was dependent on staff for eating, lower body dressing, and toileting assistance. Required substantial to maximal assistance with shower, bathing, and upper body dressing. Diagnoses included depression and bipolar disorder. R47's Activities of Daily Living (ADL) Care Area Assessment (CAA) worksheet dated 1/16/24, identified psychosocial well-being triggered due to six or more activities flagged as not important at all. R47 was admitted to skilled nursing facility with bipolar disorder and had a diagnosis of depression so changes in mood was expected. R47's trauma screening dated 1/20/22, identified she had been through life threatening or traumatic events and wanted to be left alone if angry or upset. The sections for triggers that make this worse or things to help manage difficult times was left blank. R47's medical record lacked additional follow up trauma screenings. R47's care plan dated 8/12/24, lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization. R47's nursing orders dated 8/1/24, identified: per patient request, no male nursing assistants were allowed to provide care. R47's Associated Clinic of Psychology (ACP) note dated 8/6/24, identified the patient requested a visit due to PTSD symptoms. There was an incident where a male provided personal cares and she began having flashbacks of childhood abuse. R47 discussed circumstances from foster care and childhood trauma, she also reported nightmares one to three times per week and day-time flashbacks. R47 felt safe at the facility if cares were not provided by male nursing assistants. R47 responded well to trauma informed CBT (cognitive behavioral therapy) during the session. During an interview on 8/13/24 at 1:11 p.m., nursing assistant (NA)-D was not aware of R47's PTSD or if she could have male caregivers. NA-D reviewed R47's nursing assistant care sheet, which had not identified any triggers or approaches related to PTSD. During an interview on 8/13/24 at 1:22 p.m., R47 stated she deals with PTSD and had not talked about it until recently, when she was re-traumatized after having a male caregiver. She stated she had no male caregivers before by chance, however, after she had one, she asked to not have male caregivers going forward. R47 stated if she had no males and staff approached her with kindness and understanding, she would continue to feel safe. R47 stated she deals with PTSD and talked to her counselor about it, and she would be comfortable speaking with the facility's social services director about trauma informed care. During an interview on 8/13/24 at 2:04 p.m., NA-F stated she knew R47 could not have male caregivers, because R47 had told her about it when she had the male caregiver. After, R47 would ask NA-F if any males were working that day, and NA-F would ensure they would not work with R47. NA-F reviewed the care sheet and agreed it lacked triggers or approaches related to PTSD, and it might be helpful so all caregivers could be made aware. During an interview on 8/14/24 at 1:31 p.m., the ACP SW-A stated R47 had not brought up PTSD before in their sessions, but after she had a male caregiver and requested an ACP visit, she was clearly exhibiting PTSD during their visit. SW-A stated R47 had some underlying PTSD, and she would expect the facility to follow up with trauma informed care based off the facility protocol. During an interview on 8/14/24 at 1:49 p.m., licensed practical nurse (LPN)-B stated she never knew about R47's PTSD until she spoke up about it after a male nursing assistant was assigned. LPN-B stated she then had the order added to the nursing administration records. LPN-B agreed the trauma triggers or preferred trauma informed care approaches were not listed on the care plan or nursing assistant care sheets, and it would be helpful to have the information easily accessible to reference. LPN-B stated social services completed trauma assessments. During an interview on 8/14/24 at 2:00 p.m., the facility's social services director (SSD) stated he was aware of R47's PTSD which she discussed with her counselor and other facility staff. The SSD was unsure how often trauma screenings needed to be completed at the facility. The SSD stated if PTSD symptoms were new, a new trauma screening should be completed to reassess trauma triggers, approaches, and add interventions to the care plan to help minimize re-traumatization. The facility policy titled Trauma Informed Care, revised on 5/28/24, identified residents that have a history of trauma would be assessed, and have goals and interventions added to their care plan to address potential triggers and approaches to minimize or eliminate the effect of the trigger on the resident. If the trauma survivor was reluctant to share history, the facility was still responsible to try to identify triggers which may cause re-traumatization and develop care plan interventions which minimized or eliminated the effect of the trigger.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review the facility failed to ensure assistance to a family member with determining mental capacity for 1 of 1 resident (R15) reviewed for social services. Findings include: R15's admission Minimum Data Set, dated [DATE], indicated R15's preferred language was Hmong, did not need an interpreter, had difficulty hearing in some environments such as when speaking softly or a noisy setting and required a hearing device, a brief interview for mental status (BIMS) should have been conducted, however was not conducted, did not have hallucinations or delusions, did not exhibit wandering behavior, and did not reject care. Additionally, R15 used a cane, required partial to moderate assistance with toileting, showering, upper and lower body dressing, hygiene, and donning/doffing footwear. R15 required partial to moderate assist with sitting to standing safely and required supervision or touching assistance to ambulate 10 feet. R15 was incontinent of bowel and bladder, had an anxiety disorder, cardiogenic shock (the heart cannot pump enough blood to the brain and other organs), acute respiratory failure with hypoxia (the body doesn't have enough oxygen at the tissue level), acute pulmonary edema (a condition where too much fluid builds up in the lungs), acute on chronic combined systolic and diastolic heart failure, had a defibrillator, had a life expectancy of less than 6 months, took an antipsychotic and antianxiety medication, was on hospice and did not use restraints. R15's face sheet indicated R15 was not responsible for himself, and family member (FM)-B was R15's primary emergency contact. Additionally, R15 had the following diagnoses: restlessness and agitation, generalized edema, and other encephalopathy (a disease in which the functioning of the brain is affected by an agent or condition). R15's care plan dated 7/3/24, indicated R15 was on hospice with an expected decline in condition and the following hospice staff visited: nursing and nursing assistants weekly, social services and chaplain monthly, and volunteers. R15's care plan dated 7/3/24, indicated R15 did not want resuscitation and interventions included healthcare directives signed by appropriate individuals (physician, resident, family, legal representative). R15's care plan lacked information whether R15 could make his own decisions. R15's care sheet dated 8/9/24, indicated R15 was impulsive, spoke English and staff needed to anticipate needs. R15's Provider Orders for Life-Sustaining Treatment (POLST) form indicated R15 did not want to be resuscitated and under documentation of discussion indicated 6 check boxes that included the following: Patient (Patient has capacity), court-appointed guardian, other surrogate, parent of minor, health care agent, and health care directive. The only check box marked was, health care agent and was signed by FM-B. Additionally, the POLST included instructions that a person with capacity, or the valid surrogate of a person without capacity, could void the form and request alternative treatment. R15's medication administration record (MAR) and treatment administration record (TAR) dated 8/4/24, through 8/12/24, indicated to monitor the placement of the wander guard every shift. Under comments on the MAR and TAR, indicated on 8/6/24 at 5:36 p.m., no wander guard, on 8/7/24 at 3:30 a.m., resident removed wander guard, on 8/7/24 at 8:40 p.m., not on, 8/8/24 at 1:55 a.m., resident removed, on 8/9/24 at 3:11 a.m., resident removed, 8/9/24 at 2:37 p.m., does not have a wander guard on, on 8/10/24 at 2:50 a.m., indicated no on and on 8/12/24 at 1:47 p.m., indicated discontinued. R15's cardiology note dated 6/17/24, indicated R15 was unable to participate in decision-making process. R15's nurse practitioner (NP) note dated 6/18/24, indicated FM-B asked for help in determining R15's capacity to make complex decisions if R15 improved enough to engage in discussions regarding goals and plan of care and gave an example of potential vulnerability to financial exploitation by unknown people in R15's home country where R15 intermittently sent significant amounts of money. Further, R15 demonstrated limited understanding. Last, under a heading, Decision Making Capacity indicated R15 required surrogate decision making due to critical illness and was unclear if R15 had decision-making capacity at baseline per daughter. R15's physician discharge to facility note dated 7/2/24, indicated R15 was unable to verbalize understanding of his condition and treatment plan due to being disoriented and the diagnosis and treatment plan was discussed with FM-B. R15's NP-D progress note dated 7/16/24, indicated R15 was independent with activities of daily living (ADLs), was ambulatory and R15's review of systems was limited due to cognitive impairment. R15's Application of a Health Officer or Peace Officer for Emergency admission form dated 8/4/24 at 1:15 p.m., indicated R15 was trying to walk 11 miles in 71-degree heat in a winter jacket. R15 was on hospice and tried to assault staff and refused to return and staff wanted R15 to go to the hospital. R15's emergency department note dated 8/4/24, indicated R15 eloped to go to the Hmong market and the police were contacted and intercepted R15 2 blocks away. Further, staff indicated R15 had to come to the hospital but did not elaborate and per EMS, family resided out of state except a daughter who was the power of attorney but R15 did not have contact with, and had organized thought content and processes, additionally FM-B was contacted and wanted R15 admitted for a psychiatric evaluation for capacity. It was explained to FM-B capacity could be completed outside the hospital and better in a legal setting versus a medical setting. R15's NP-D progress note dated 8/13/24, indicated R15 had dementia without behavioral disturbances, had cognitive limitations, and eloped on 8/4/24, attempting to ambulate to the store to purchase Hmong medications. Additionally, review of systems was limited secondary to cognitive impairment. OBSERVATION FORMS: R15's Clinical Documentation admission form dated 7/3/24 at 12:14 p.m., indicated staff could not identify whether R15 had an advanced directive due to a level of cognitive impairment. R15's Self-Administration of Medication form dated 7/7/24, indicated R15 was not appropriate to self-administer medications and R15's cognitive status was identified as moderately impaired-decisions poor; cues/supervision was required. R15's Long Term Care Social Service form dated 7/10/24 at 5:18 p.m., indicated R15 had minor forgetfulness, a vision or hearing problem that impaired communication, distorted and misrepresented events, did not fully understand physical limitations. R15's Notice of Resident/Patient Transfer or Discharge form dated 8/4/24 at 2:38 p.m., indicated R15 was involuntarily transferred to the hospital on 8/4/24, because R15's welfare and needs could not be met in the facility. R15's Resident Transfer Form dated 8/4/24 at 2:57 p.m., indicated FM-B was R15's health care proxy (someone designated to make medical decisions if a person is unable to themselves) was notified. Under the heading, Reason for Transfer What Happened indicated R15 eloped and attempted to hit staff. Further, Primary Clinical Reason for Transfer indicated a check box for other and identified acute chronic combined systolic and diastolic failure. Additionally, the form indicated R15 was alert and oriented and followed instructions, ambulated with a cane but did not indicate the distance R15 could ambulate, and was identified as not applicable under impairments including hearing and cognitive and a behavior started 8/4/24, when R15 went outside the building and tried to hit staff. R15's Social Services Elopement Risk form in progress dated 8/14/24 at 1:32 p.m., R15 exhibited combativeness, resisting redirection from staff, had a recent move to the facility, terminal illness, and preventative action taken included wanderguard, photograph posted and a check box indicating social services were marked in the check boxes. CARE CONFERENCE: R15's care conference notes last updated by the director of social services dated 7/16/24, indicated R15 scored a 6 out of 15 on the brief interview for mental status (BIMS) which indicated R15 had severe cognitive impairment. PROGRESS NOTES: R15's progress notes dated 7/3/24 at 2:16 p.m., indicated R15 was alert to self, unable to communicate needs and was alert and oriented times 2. R15's progress notes dated 8/4/24 at 1:20 p.m., indicated R15 went to the nurse's station around 11:40 a.m. to ask for the phone and did not understand what they were communicating due to a language barrier and after about 10 minutes, the supervisor received a call that R15 was outside on the right side of the building. The supervisor went outside to check immediately but did not locate the resident and followed protocol of searching for the resident. R15 was seen walking faster towards the intersection by McDonalds and therapy staff reached R15 first before the supervisor arrived. R15 stated he was going to go and get his Hmong medication for his legs. The note further indicated R15 was resistive and unable to be redirected after multiple attempts and kept following the way to board the bus and later became agitated and tried to hit staff multiple times. The police were contacted and were unable to redirect R15 and stood firm he was not going back to the facility. A family member was contacted who did not want to talk with R15 and the facility decided to send R15 to the hospital. R15's progress notes dated 8/4/24 at 7:19 p.m., indicated R15 returned from the hospital around 6:00 p.m. after an incident when the resident left the facility unaccompanied. To make sure the incident was not repeated, the nurse spoke with FM-B regarding wearing a wanderguard and planned to discuss issues of wearing a wanderguard by a resident with no diagnosis of a cognitive impairment on 8/5/24, with the director of social services and a wanderguard was placed on R15's right wrist and was on 15-minute checks. R15's hospice progress note dated 8/4/24 at 9:00 p.m., indicated the hospice nurse contacted the interpreter and R15 stated he wanted an herbal supplement for his kidneys because the medications were not working. R15's daughter was updated and stated 1 pill was $300.00 and could not get the medication. R15's progress notes dated 8/7/24 at 1:51 p.m., indicated on 8/4/24, R15 walked on foot to the bus station near McDonalds, about 10 minutes away from the facility and the supervisor and team of nurses and therapists located R15 at the bus station near McDonalds. FM-B agreed to a wanderguard placement to alert staff when R15 attempted to leave the facility. Further, the note indicated R15 did not elope was alert and oriented x 3 and knew the route to the bus station. R15's progress notes dated 8/7/24 at 4:39 p.m., and recorded as a late entry on 8/12/24 at 8:44 a.m., by the social services director indicated the following: Writer called and spoke with daughter regarding medication that resident has been asking for. Family reports that resident has taken the medication previously, but it is not easily sourced and not readily available through traditional means of purchasing medication. Resident is requesting this medication to help them to feel comfortable as the medication aligns with medicine in their culture. To align with resident's cultural beliefs and to respond to person centered care, writer and family will continue to discuss ways that this medication can be provided to the resident. According to the matrix care chart review and weekend supervisor, at 11:40 a.m., the patient requested a telephone at the nurses' station and made a call to a family member. The patient then left the building through the main entrance, despite attempts by the receptionist to redirect them back inside. The patient walked on foot to the bus station near McDonalds, about 10 minutes away from the facility, expressing an intention to obtain traditional medicine from a Hmong store. The receptionist promptly informed the building supervisor of the event. The supervisor and a team of nurses and therapists quickly located the patient at the bus station near McDonalds. Despite multiple attempts by staff members to redirect [R15] back, he became agitated and threatened physical violence. As efforts continued unsuccessfully, emergency services were called for assistance. R15's progress note dated 8/12/24 at 8:59 a.m., indicated the wanderguard was discontinued and was not appropriate to wear a wanderguard at this time. Further the note indicated R15 was alert and oriented times three. During interview on 8/13/24 at 11:37 a.m., FM-B stated she spoke with the social services director (SSD)-B about 3 days after incident who did not have much to say about the incident other than they put a wanderguard on R15. FM-B stated she was not sure if R15 still had the wanderguard, SSD-B mentioned R15 cut off the wanderguard. FM-B stated she understood R15 wanted to purchase a supplement that could only be purchased in the Hmong village and was walking with a cane and had a winter jacket on. FM-B stated she told the SSD-B R15 had the intention of doing this and SSD-B reassured FM-B someone was by the door all the time. FM-B stated the nurse contacted her and told her R15 left the facility and wanted her to tell R15 to go back and when FM-B tried to talk with R15, he would not listen, and the police were called. FM-B stated the police were unable to get R15 to come back and the nurse stated they were going to take R15 to the hospital because R15 tried to assault a staff member. FM-B further stated the physician contacted her and stated R15 was breathing ok and was confused because she thought R15 would be having a psychological evaluation. FM-B stated she did not think R15 could make sound reasonable decisions for himself, but was told due to no impairment, R15 could make decisions for himself. During interview and observation on 8/13/24 at 2:30 p.m., the interpreter was contacted and R15 stated he had been at the facility a long time and wanted to move out of the hospital and was unable to identify what facility R15 was at. R15 further stated the wanderguard did not help his illness and stated he would just take off the wanderguard. R15 stated he wanted to move to a Hmong facility where R15 could get medication to help his legs and stated he did not know the name of the medication but stated it was a Chinese medication. R15's feet were swollen and was wearing a pair of thong sandals. During interview on 8/14/24 at 8:38 a.m., registered nurse (RN)-E stated she looked at the care plan to know what kind of cares a resident required and stated they complete a clinical assessment and ask a few questions that they are safe and a resident's memory is ok to determine whether they can do something or not and stated she thought the social worker completed a cognitive assessment. During interview on 8/14/24 at 10:05 a.m., licensed practical nurse (LPN)-D stated the care plan sometimes had information on decision making capacity and stated it was also on the Facesheet. During interview on 8/14/24 at 10:19 a.m., when asked how she knows a resident was safe to leave the facility alone, registered nurse (RN)-F stated most of their residents could not leave the facility, some could go for appointments and stated she did not know if there was any kind of an assessment to make that determination and would have to go and check. RN-F stated they assess if someone can go in the community in the transitional care unit and further stated she would have to check into that. RN-F further stated therapy completed cognition screens to determine if a resident could make their own decisions, but stated R15 was on hospice and stated social services might determine if R15 could make his own decisions. During interview on 8/14/24 at 10:42 a.m., the social services director (SSD)-B stated they had care conferences and completed a BIMS interview to help determine whether a resident was able to make their own decisions and ultimately it was up to the court system and was done through a guardianship and stated it was documented under resident notes. Additionally, it was a court decision along with the physician's opinion. If a resident was admitted to the facility and they did not know whether a resident could make their own decisions they ask for health care directives and if that is not provided, would speak with the resident. SSD-B stated R15 could make decisions with the help of his family and further added if R15 put his safety at risk they follow what they need to follow to ensure R15 is safe and stated R15 had an elopement attempt. R15 went to the bus stop to go to the Hmong village to get a medication. SSD-B further stated R15's BIMS was a 6 out of 15 which indicated severe cognitive impairment. SSD-B further stated he did not have information whether R15 could make his own decisions and later stated they would approach that R15 was able to make his own decisions with support of family. When asked why a wanderguard was placed if R15 was able to make his own decisions, SSD-B stated it was applied for his safety because the decision R15 made put him in an unsafe position and was since taken off and stated it would be important to have an elopement risk on any patient to see what their potential for elopement was. During interview on 8/14/24 at 11:04 a.m., occupational therapists (OT)-H and OT-I stated they completed a cognitive assessment on every resident to determine their general baseline. The cognitive screens completed were Short Blessed Test and based on that score may do a SLUMS assessment that looked more at memory and sequencing, and they also had a cognitive performance test for medication management, choosing the appropriate clothing based on the weather outside and added they were more in depth than the BIMS. OT-H and OT-I verified R15 was not seen by therapy and verified there were no therapy notes in R15's medical record and stated R15 was on hospice so did not have any therapy orders and verified there was no cognitive assessment completed through therapy. During interview on 8/14/24 at 12:23 p.m., hospice social worker (HSW)-C stated he visited monthly and was looking for different placement for R15 and stated R15 enrolled in hospice on 7/3/24. HSW thought R15 could make his own decisions and stated he didn't have firsthand knowledge of R15's elopement and stated the note indicated R15 returned from the hospital after leaving the facility. During interview on 8/14/24 at 12:07 p.m., nurse practitioner (NP)-D stated R15 was a newer resident who spoke English ok, was on hospice, had edema to his legs but refused medications and eloped a few weeks ago. NP-D further stated R15 could make needs known, can make a choice such as applying lotion, but could not make medical or financial decisions and they would look to R15's family and added R15 had dementia and did not want his patient eloping. During interview on 8/15/24 at 9:26 a.m., the director of nursing (DON) stated the process to determine whether a resident was capable of making their own decisions was an ethical question and they had to assess mental capacity and stated it went through social services to see if a resident was capable and added it was an IDT approach and medical doctors and stated it depended if they came to the facility and had power of attorney documentation and if they didn't have documentation on file they question if it warrants getting the ombudsman or an attorney for a person or family member to be the decision maker and they would go through a process. DON further stated if they were assisting family members it was documented in a care conference and progress note or the social worker would enter a progress note. The DON stated they reviewed orders when a resident comes from the hospital and discharge summaries and stated either the DON or managers went through the resident's medical record to be on the safe side to know what was needed for a person just in case it was not in the orders and stated therapy staff also go through the history and physical. The DON further stated R15 was alert and oriented to the situation and can dial numbers and will tell you what he is going to do and stated R15 could go on an unsupervised leave. The DON stated R15 went out the front door and staff were called, saw R15 walking and stopped at the bus stop and other staff followed R15 and tried to redirect him. The DON further stated he instructed staff to contact the police because R15 was aggressive and the best thing they could do was send R15 to the emergency room. The DON stated this was not the first time R15 asked for medication, and they were working on a process to help get the supplement and stated R15 had not attempted to leave since. A job description, Social Services Designee dated February 2019, indicated the social services designee coordinates the overall interdisciplinary plan of care for a resident, from admission to discharge. Acts as a liaison between resident/family and healthcare personnel to ensure necessary care is provided promptly and effectively. Under a heading, Key Result Areas, and Essential Functions of the Job, indicated assist residents/patients with financial and legal matters i.e. POA (power of attorney), applying for medical assistance, referrals to lawyers, referrals to funeral homes for preplanning arrangements, guardian/conservator. A job description, Social Worker, dated February 2019, indicated the job summary which included, identify the need for medically related social services and pursue the provision of these services. This position is responsible for identifying the psychological, social and emotional needs of residents and devising and implementing services/interventions to meet those needs including collaboration with outside community resources. Under the heading, Key Result Areas/Essential Functions of the Job, indicated provide support and advocate for resident/patient and/or family, assist residents/patients with financial and legal matters i.e. POA, applying for Medical Assistance, referrals to lawyers, referrals to funeral homes for preplanning arrangements, guardian/conservator. A policy, Provision of Social Services, dated 11/28/17, indicated the purpose of the policy was to provide medically-related social services to residents and assures that the needs are met by appropriate disciplines. Further, Medically-related Social Services means services provided by the facility's staff to assist residents in attaining, maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. These services might include: Assisting residents with financial and legal matters (e.g., applying for pensions, referrals to lawyers, and referrals to funeral homes for preplanning arrangements). Assisting residents with advance care planning, including but not limited to completion of advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure the provider's response to the initial medication review was followed and failed to ensure monitoring was in place for 1 of 3 residents (R88) reviewed for antipsychotic medication use. Findings include: R88's admission MDS dated [DATE], indicated R88 had moderate cognitive impairment and diagnoses of sepsis, metabolic encephalopathy (change in how the brain works due to an underlying condition), delirium related to known physiological condition (a temporary mental state characterized by confusion, incoherent speech, and hallucinations), and age-related cognitive decline. Furthermore, R88's MDS indicated R88 had received an antipsychotic medication. R88's interim medication regimen review dated 7/20/24, indicated a pharmacist recommendation to the physician was sent. The recommendation stated R88 was taking the antipsychotic medication quetiapine for delirium however lacked an allowable diagnosis to support use. The recommendation included a list of allowable diagnoses for the provider to choose from. Nurse practitioner (NP)-A circled the diagnoses of delusional disorder (a type of psychiatric disorder involving one or more delusions or beliefs that something that is not true) and signed off on the recommendation on 8/6/24. R88's nursing and provider orders were reviewed on 8/13/24, indicated: -An order dated 7/18/24, indicated R88 required quetiapine 12.5 milligrams (mg) at bedtime for delirium due to known physiological condition. The order had not been updated to reflect the indication was for delusional disorder. -R88's orders lacked indication R88 was monitored for target behaviors or side effects related to quetiapine use. R88's face sheet printed 8/14/24, indicated R88's diagnoses list was not updated to delusional disorder. R88's care plan revised on 8/12/24 at 3:45 p.m., (after the start of survey) indicated R88 used quetiapine for delirium. Interventions included to administer medication as ordered, ask for a possible dose reduction every three months, and monitor behavior every shift and document. R88's care plan did not indicate what behaviors to monitor. When interviewed on 8/14/24 at 2:19 p.m., the consulting pharmacist (CP) stated for newly admitted residents, an initial pharmacy review was a day or two after admission. The initial review was about ensuring proper diagnoses for medications and looking to see if there were any major interactions. With transitional care residents they may not be at the facility long, so it was important to see them to ensure things were in place. CP acknowledged there wasn't monitoring in place for any target behaviors, and stated there wouldn't need to be as the dose of quetiapine was low and administered at night. Likely it would only be helping R88 sleep. When interviewed on 8/15/24 at 10:06 a.m., the Director of Nursing (DON) stated upon admission there were order sets that were used to ensure residents recieved the moitoring needed for high risk medications. DON verified there was not monitoring in place for R88's quetiapine. The CP, or another pharmacist do an initial review. If recommendations were made, they were placed in the chart. If it was an order the nurse or unit coordinator would change. For the diagnoses, that was up to health information management should have changed the diagnoses and order. DON further stated there was likely someone covering for them when on vacation and missed that step. DON expected the provider's response to the pharmacy recommendation to be reflected in the medical record when it was received. A facility policy titled Medication Monitoring Medication Regimen Review dated 12/2017, directed the CP identifies irregularities through a variety of sources including behavior monitoring information. The policy also directed the staff to ensure there was a written diagnosis, indication or documented objective findings to support each order and the duration of therapy was indicated and appropriate for the resident. Furthermore, the policy directed recommendations were acted upon and documented by facility staff and or the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure 1 of 3 residents (R88) who received antipsychotic medications had an appropriate indication and diagnoses for the medication. Furthermore, the facility failed to ensure staff were monitoring resident behaviors related to the antipsychotic medication and utilizing non-pharmacological approaches to ensure the antipsychotic medication was necessary. Findings include: R88's admission MDS dated [DATE], indicated R88 had moderate cognitive impairment and diagnoses of sepsis, metabolic encephalopathy (change in how the brain works due to an underlying condition), delirium related to known physiological condition (a temporary mental state characterized by confusion, incoherent speech, and hallucinations), and age-related cognitive decline. Furthermore, R88's MDS indicated R88 had received an antipsychotic medication. R88's hospital Discharge summary dated [DATE], indicated recommendations for the outpatient provider. The recommendation was to consider stopping quetiapine (antipsychotic medication). R88 required Seroquel due to delirium related to metabolic encephalopathy and R88's mental status was improving. An order dated 7/18/24, indicated R88 required quetiapine 12.5 milligrams (mg) at bedtime for delirium due to known physiological condition. R88's orders lacked indication R88 was monitored for target behaviors, had non-pharmacological interventions in place for target behaviors, or monitoring side effects related to quetiapine use. R88's care plan revised on 8/12/24 at 3:45 p.m., (after the start of survey) indicated R88 used quetiapine for delirium. Interventions included to administer medication as ordered, ask for a possible dose reduction every three months, and monitor behavior every shift and document. R88's care plan did not indicate what behaviors to monitor. R88's provider note dated 7/19/24, indicated R88 was seen for follow up from the hospital, was pleasant, confused, and oriented. R88 had some anxiety and difficulty word finding but appeared healthy. R88's provider notes further indicated to continue quetiapine. with a possible psychiatry consult and/or discontinuation of quetiapine. R88's interim medication regimen review dated 7/20/24, indicated a pharmacist recommendation to the physician was sent. The recommendation stated R88 was taking the antipsychotic medication quetiapine for delirium however lacked an allowable diagnosis to support use. The recommendation included a list of allowable diagnoses for the provider to choose from. Nurse practitioner (NP)-D circled the diagnoses of delusional disorder (a type of psychiatric disorder involving one or more delusions or beliefs that something that is not true) and signed off on the recommendation on 8/6/24. R88's provider note dated 8/7/24, indicated R88 appeared healthy, was pleasant and had some cognitive limitations and trouble sleeping. R88's note indicated the plan was to continue quetiapine and refer to ACP for cognitive therapy. R88's provider note had not identified behaviors associated with delusional disorder. R88's medical record lacked indication R88 had monitoring for behaviors related to delirium or delusional behaviors, lacked indication non-pharmacological interventions were placed for delirium or delusional behaviors, and lacked evidence R88 had experienced behaviors related to delirium or delusions. When interviewed on 08/12/24 at 12:14 p.m., R88 stated they were recently admitted for infection in the liver. R88 stated they didn't remember much about the hospital stay as they were pretty out of it from the infection. R88 was going to be going to an assisted living soon and was feeling much better. When interviewed on 8/14/24 at 12:33 p.m., nursing assistant (NA)-B stated R88 was confused at times but did not really have any behaviors. NA-B further stated R88 did not have any outbursts or hallucinations that she was aware of. When interviewed on 8/14/24 at 1:00 p.m., registered nurse (RN)-A stated when residents were admitted from the hospital, there was a lot of information that comes with them. If the information or in a verbal report, we are made aware of any behaviors we would review the medications and talk to the provider if needed. If a resident was experiencing some anxiety or getting agitated, we use distraction by going for a walk or their mind on something else and it would depend on the situation. RN-A stated R88 had some forgetfulness and tends to be repetitive in what they tell you, and for the most part was alert and oriented to person, place, and time. RN-A verified R88 had no delusions or hallucinations. RN-A verified R88 was on quetiapine for delirium. RN-A wasn't sure and thought maybe in the hospital R88 experienced that, but there was no delirium at the facility. RN-A verified there were no monitoring for behaviors related to quetiapine and stated there should be some behavior monitoring in place. When interviewed on 8/14/24 at 2:19 p.m., the consulting pharmacist (CP) stated for newly admitted residents, an initial pharmacy review was a day or two after admission. The initial review was about ensuring proper diagnoses for medications and looking to see if there were any major interactions. With transitional care residents they may not be at the facility long, so it was important to see them to ensure things were in place as often antipsychotic medications may be started in the hospital and were no longer needed. After reviewing the recommendation from pharmacist-A, CP stated it was likely R88 had delirium in the hospital and would have pushed the signed recommendation back to the nurse practitioner for discussion as R88 did not have a diagnosis which the delusional disorder stemmed from. CP acknowledged there wasn't monitoring in place for any target behaviors, and stated there wouldn't need to be as the dose of quetiapine was low and administered at night. Likely it would only be helping R88 sleep. CP stated it was difficult as the provider and staff just don't know the patient well enough at the time of the recommendation to determine if the quetiapine was no longer needed. CP further stated interdisciplinary behavior rounds were coming up next week and likely it would be discontinued. On 8/15/24 at 8:25 a.m., NP-D's office was contacted to interview NP-D. NP-D had not returned the call. When interviewed on 8/15/24 at 10:06 a.m., the Director of Nursing (DON) stated upon admission the if a resident was taking an anti-psychotic medication an order set was entered to ensure there was behavior and side effect monitoring in place. DON further stated the interdisciplinary team meets to discuss all resident on anti-psychotics monthly. This was where behaviors were reviewed to determine if the medication was required or effective. DON verified R88 was taking quetiapine for delusional disorder as indicated by the provider's pharmacy recommendation. DON stated delusional monitoring would include hallucinations and increased confusion and should be documented in the treatment record. DON confirmed an order to monitor R88's behaviors related to quetiapine use was not ordered and was not implemented into the care plan. R88's orders and care plan also lacked non-pharmacological interventions for staff to attempt if R88 had any delusional behaviors. as an order the nurse or unit coordinator would change. For the diagnoses, that was up to health information management should have changed the diagnoses and order. DON further stated there was likely someone covering for them when on vacation and missed that step. DON expected the provider's response to the pharmacy recommendation to be reflected in the medical record when it was received. DON expected staff to be monitoring R88 for any behaviors related to delusions and ensure documentation was completed. This was important to ensure the medication was appropriate and needed. A facility policy titled Psychotropic Medication Use revised 9/2023, directed nursing to collaborate with the medical provider to ensure the lowest possible dose of an a psychotropic medication was given for the shortest period of time. Furthermore, when psychotropic medications were ordered, the interdisciplinary team identifies target behaviors and implements a care plan with both non-pharmacological and pharmacological interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Skin assessments R90 R90's admission Minimum Data Set (MDS) dated [DATE], indicated R90 was cognitively intact and had diagnoses of sepsis (whole body response to an infection) R90's admission MDS further indicated R90 was not at risk for pressure injury and had no pressure injuries, venous ulcers, or other skin concerns. However, R90 required application of nonsurgical dressings other than the feet. R90's face sheet printed 8/13/24, indicated R90 had diagnoses of cellulitis (skin infection) to the right lower extremity, open wounds to right lower leg, lymphedema, and a right 5th toe fracture. R90's hospital Discharge summary dated [DATE], indicated R90 had chronic right leg wounds, and had stubbed the right toe in the shower and the right hallux was open and bleeding was noted. A review of R90's provider and nursing orders indicated: -on 7/25/24, R90 required a surgical shoe to the right foot when out of bed and with activity. -on7/25/24, R90 required wound care to the right hallux nail bed once daily. This order was discontinued on 8/12/24. -on 7/29/24, R90 required wound care for the right lower extremity anterior and posterior wounds on Monday, Wednesday, and Fridays. R90's wound observation notes dated 7/30/24, indicated on 7/26/24, three venous wounds were identified on R90's right shin and right calf. All three were identified as present on admission. R90's skin observation assessment dated [DATE], indicated R90 had edema that required lymphedema wraps. Furthermore, the assessment indicated R90 had a diabetic foot ulcer and other open areas on the foot. R90's assessment lacked indication R90 had venous ulcers that required nonsurgical dressings applied or required an operative shoe when out of bed. R90's skin observation assessment dated [DATE], indicated R90 had surgical wounds and surgical wound care. 90's assessment lacked indication R90 had edema that required lymphedema wraps, venous wounds that required dressings applied, an open area of the foot that required a dressing applied or required an operative shoe when out of bed. R90's skin observation assessment dated [DATE], indicated R90 had edema and an infection of the foot that required dressings, and had no pressure injury but required pressure injury wound care. R90's assessment lacked indication R90 had venous ulcers that required dressings applied, required lymphedema wraps, or required an operative shoe when out of bed. R90's care plan dated 7/28/24, indicated R90 had venous stasis wounds in the right lower extremity. Interventions directed staff to monitor R90's pressure ulcer in the right lower extremity and provide treatments as ordered. An observation on 8/14/24 at 11:58 p.m., registered nurse (RN)-A and occupational therapist (OT)-A entered R90's room to remove and replace R90's lymphedema wraps and provide wound care. R90 was sitting in the recliner chair and had on operative shoe on the right foot and had lymphedema wraps on both legs with the right one extending over the knee. The operative shoe and lymphedema wrap to the right leg was removed. R90 had two wounds on the right shin and one on the right calf. Wound care was provided per orders. RN-A stated the right hallux wound was now closed and no longer required wound care. When interviewed on 8/12/24 at 12:31 p.m., R90 was seated in their recliner with legs elevated and positioned with pillows. An operative shoe was on R90's right foot. R90 stated they had the wounds before admission to the facility and they had become infected. R90 stated she thought they started as bruises and then opened. R90 further stated their toe was better after the dressing change earlier in the day. R36 R36's admission MDS dated [DATE], indicated R36 was cognitively intact and had diagnoses of a spleen laceration and perforation of the intestine with surgical treatments, stroke with hemiparesis (weakness, loss of movement) of the left side and frail skin. Furthermore, R36's MDS indicated R36 had surgical wounds and skin tears that required treatment. R36's hospital Discharge summary dated [DATE], indicated R36 had a closed surgical incision that could be covered with gauze and changed daily or left open to air. R36 also had a right arm skin tear and right knee abrasion that was covered with a foam dressing to be changed weekly and as needed. A skin integrity event dated 7/22/24, indicated R36 had obtained a skin tear on 7/18/24 to the left lateral leg during a transfer and on 7/22/24, two skin tears were identified from an unknown cause on the left knee and left thigh. A review of R36's provider and nursing orders indicated: -on 7/23/24, R36's required monitoring of the abdominal surgical incision that was open to air. -on 7/23/24, R36 required dressing changes every 5 days with a foam dressing to the right knee, right lateral shin, and left thigh. A dressing change was also required to left shin for brace protection only. -on 8/1/24, R36 required monitoring of skin tear site that was secured with steri-strips and open to air to right medial calf and left knee. R36's skin observation assessment dated [DATE], indicated R36 utilized a brace or splint, had skin tears, and surgical wounds. R36's assessment lacked indication R36 required application of nonsurgical dressings for the skin tears. R36's skin observation assessment dated [DATE], indicated R36 had skin tears and surgical wounds. R36's assessment lacked indication R36 required application of dressings to the skin cares or utilized a brace or splint. R36's skin observation assessment dated [DATE], indicated R36 utilized a brace or splint and had surgical wounds. R36's assessment lacked indication R36 had skin tears that required application of dressings. R36's care plan dated 7/25/24, indicated R36 had skin tears on both lower extremities. Interventions included to monitor for healing, follow treatments of steri-strips and mepelix dressings. R36's careplan lacked indication R36 utilized braces for the left upper and lower extremity. An observation on 8/12/24 at 1:31 p.m., R36 was seated in the recliner chair. R36 had a brace on the left shoulder and one on the left foot. A foam dressing was observed on the left thigh. R36 had sleeves placed on both arms. R36 stated he had several skin tears, and his skin was very frail. R88 R88's admission MDS dated [DATE], indicated R88 had moderate cognitive impairment and diagnoses of sepsis, liver abscess, and presence of a hepatic drain (device used to drain liver abscess). Furthermore, R88's MDS indicated R88 had surgical incisions that required wound care. R88's hospital Discharge summary dated [DATE], indicated R88 had a hepatic drain but lacked indication R88 had surgical incisions. A review of R88's provider and nursing orders indicated: -on 7/18/24, R88 hepatic drain care directed staff to change the dressing around the drainage tube as needed. This order was discontinued on 8/12/24. -on 8/6/24, R88's hepatic drain site (now removed) required a gauze and tape dressing to be in place for 7 days and to be changed daily and as needed. This order was discontinued on 7/12/24. R88's skin observation assessment dated [DATE], indicated R88 had no surgical wounds, and did not require dressings or treatments. R88's assessment lacked evidence a drain was in place that required treatment. R88's skin observation assessment dated [DATE], indicated R88 had no open areas or surgical wounds and did not require dressings or treatments. R88's assessment lacked evidence a drain was in place that required treatment. R88's skin observation assessment dated [DATE], indicated R88 had no pressure ulcers, open areas, or surgical wounds and did not require dressings or treatments. R88's assessment lacked evidence a drain was in place that required treatment. R88's skin observation assessment dated [DATE], indicated R88 had no pressure ulcers, open areas, or surgical wounds. R88 did require surgical wound care. R88's assessment further indicated R88 had an infection of the foot. R88's care plan dated 7/22/24, indicated R88 had an actual infection. Interventions included to assess all wounds for signs of infection. R88's care plan lacked indication R88 had a drain that required treatment. When interviewed on 8/12/24 at 12:14 p.m., R88 was seated at the edge of the bed. R88 stated they had no skin issues, other than a site where she had a drain placed. R88 further stated the drain was placed to drain fluid from an infection and had been removed sometime last week. R88 lifted their shirt some to reveal gauze and tape on the right side of the abdomen. When interviewed on 8/13/24 at 12:54 a.m., RN- D stated a skin assessment was completed upon admission and any wounds or open areas, including skin tears, were measured, and documented in the wound observation note. A skin observation was also completed weekly for the first few weeks after admission. The skin observation assessment was a visual observation of the skin to identify any skin issues. The assessment also indicated risks for skin breakdown and interventions in place. RN-D reviewed R90's wound observation assessments and skin observation assessments and verified the inconsistent documentation. RN-D stated R90 did not have any surgical wounds, diabetic ulcers, or foot infection. RN-D reviewed R88's skin observation assessments and verified the drain was not documented. RN-D wasn't sure if drains were documented or not, but acknowledged a dressing was used. RN-D further stated R88 did have an infection, but it was not in their feet. RN-D stated R36 had very fragile skin and had skin tears and a surgical incision. RN-D reviewed R36's skin observations and verified they were not accurate and missing information. RN-D nurses likely complete the skin observations with what they know or what they think is going on by looking at the resident and wasn't sure if other areas of the chart were reviewed. When interviewed on 8/15/24, the Director of Nursing (DON) stated when residents were admitted , a skin assessment was completed during the first 72 hours. Then a skin assessment was completed weekly for an additional 4 weeks. DON expected the skin assessments to accurately reflect what skin altercations the resident had. Furthermore, this was important to help determine further interventions and provide an accurate plan of care. A facility policy titled Prevention and Treatment of Skin Breakdown dated 9/2018, directed staff to complete a skin risk assessment upon admission and weekly for 4 weeks after. The residents care plan was then implemented and updated based on the resident's skin assessment, areas of risk, Braden evaluation, provider assessment and preferences. Skin monitoring R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, disorganized thinking, and wandering. It further indicated diagnoses of dementia, falls, restlessness, and agitation. R4 requred partial to moderate assistance with transfers and had no falls since admission. R4's care plan dated 8/2/24, indicated an alteration in skin integrity as evidenced by abrasions and bruises on face, forehead, nose, and around the eyes. It further indicated an intervention to monitor the site until healed/resolved. During observation on 8/12/24 at 2:30 p.m., R4 was sitting in the dining room in her wheelchair. The left side of her forehead had yellowish/green bruising and under her right eye was a dark purple bruise. There were two red marks on the bridge of her nose and several small scratches on the right side of her forehead with dried blood. R4's progress note dated 8/6/24, indicated the interdisciplinary team (IDT) met to review resident's fall. According to staff, resident was in the wheelchair in dining room area prior to fall. Fall happened in the family room, resident either propelled herself to the family room or was assisted/wheeled towards the family room by one of the MR# 8105-01 (D.N.) came and informed the writer that resident is on the floor in the family room. When the staff went to the family room where resident, observed MR# 1039-01 (J.B.) pushing [R4's] wheelchair from the family room towards to the dining room.[ R4] was on the floor on her face, and her forehead & nose has abrasions. The staff helped the resident to sit and assessed the resident. Assessment done the resident's [range of motion] ROM x 3 done without pain/limitations or shortening. Resident was complaining of pain in her left hand middle finger. The finger was bruised had no rotation/deformity or shortening observed. The resident is alert and orient to her name & pain per baseline. Vital signs [VS] checked and noted in matrix care.The resident does not usually ambulate but can stand and pivot, with transfers and utilizes wheelchair (w/c) for mobility. The resident may have slid or fell out of the w/c, whilst propelling herself or being wheeled by the other resident ( J.B) who likes to assist other resident's on the unit, resulting in a fall. Resident has cognition impairment, contributing to poor safety awareness and limitation. Immediate intervention staff applied ice pack on forehead and right hand middle finger and did not swell. Call was placed to Fairview and talked to medical doctor (MD), on-call provider, updated on fall with injuries. The doctor gave the following orders: 3 view x-ray on left hand tomorrow and ok to send the patient to hospital for CT scan for bleeding or monitor per the facility's protocol per the family decision. The writer also talked to the resident's daughter before received doctor's order. Staff also called the resident's family after getting the orders from the doctor and left the message. X-ray result did not show any fractures, staff continues to monitor resident due to unwitnessed, the VS and neuro check are on going per facility's protocol. Resident's condition remains stable and at baseline, bruising resolving without any complications. R4's progress notes lacked indication of monitoring skin alterations/bruising after 8/6/24. Medication not administered R65's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and diagnoses of dementia, unspecified convulsions, and pain. It further indicated R65 required substantial assistance with activities of daily living (ADL), mobility, and no rejection of care behaviors were exhibited. R65's physician's orders indicated: -2/13/24 Methadone 2.5 milligrams (mg), give 2.5 mg at bedtime for pain. -8/3/23 Levetiracetam (Keppra) 100 mg/milliliters (ml) by mouth, give 7.5 ml twice a day for unspecified convulsions. R65's medication administration record (MAR) for the months of July and August (2024) indicated the following: Keppra -7/17/24 and 7/31/24 documented as not administered because the resident was sleeping, Methadone -8/7/24 documented as not administered because the resident was sleeping. R65's progress notes lacked any indication R65 had not received his medications. During interview on 8/14/24 at 7:30 a.m., licensed practical nurse LPN-A stated if a resident was sleeping when it was time to administer their medication(s), they would wait awhile and re-approach. If they were sleeping the whole shift, they would wake them up to take their medication(s). If the medications were not administered for some reason, LPN-A would call the doctor, the family and the supervisor to let them know. During interview on 8/14/24 at 8:10 a.m., registered nurse (RN)-E stated if a resident was sleeping when it was time to administer their medications, they would keep trying to give the medications and if the resident slept through the entire shift they would wake them up. If the resident refused to take their medications or didn't take them for any reason, RN-E would contact the provider. During interview on 8/14/24 1:51 p.m., clinical manager registered nurse (RN)-F stated if a resident was sleeping when it was time to administer their medications, staff should reapproach later and wake them up to take their medications if they sleep the entire shift stating sleeping was not considered a good reason to not give medications. Also, nurses were responsible for monitoring and documenting skin alterations (such as bruising) until they have resolved. During interview on 8/15/24 at 8:41 a.m., the director of nursing (DON) stated if a resident was sleeping when it was time to take their medications, the nurse should re-approach the resident. If they don't administer the patients medication during the shift they should pass it on to the on coming nurse during report. The DON declined to answer if a sleeping was an appropriate reason for not administering a residents medications. The DON further stated nurses were responsible for documenting and monitoring skin alterations, and it should be monitored until it's resolved. It only needs to be documented on if there are any changes. A policy regarding medication administration was requested and received, however did not address the process for what to do if a resident didn't receive their medications for reasons other then a refusal. Based on observation, interview, and document review, the facility failed to ensure vitals signs were taken as ordered for 1 of 3 residents (R77) reviewed for antipsychotic medication use and the facility failed to ensure resident's weights were monitored as ordered for 1 of 1 residents (R82) reviewed for nutrition. In addition, the facility failed to monitor skin alterations for 1 of 1 resident (R4) with facial bruising and failed to administer medications per doctor's order for 1 of 1 resident (R65) who repeatedly did not receive scheduled medications due to sleeping. Furthermore, the facility failed to ensure skin assessments were accurately documented for 3 of 3 residents (R90, R36, R88) reviewed for non-pressure skin altercations. Findings include: R77 R77's quarterly Minimum Data Set (MDS) dated [DATE], indicated R77 had severe cognitive impairment and received antipsychotic medications. R77's diagnoses included dementia, Alzheimer's disease, edema, vertigo, and asthma. R77 required substantial to full assistance with most activities of daily living (ADLs). R77's MDS further indicated no rejection of care behaviors exhibited by R77. R77's care plan (CP) indicated R77 was at risk for complications from psychotropic drug use and instructed staff to monitor vital signs weekly and as necessary. The CP further indicated R7 was at risk for falls related to needing assistance with most cares and instructed staff to monitor vital signs per protocol. R77's provide order included: -olanzapine tablet; 5mg; amt: 5mg; oral at bedtime HS med pass dated 4/16/24 -BHCI Standing Orders dated 12/6/23 -Monitor for side effects r/t use of antipsychotic medication to include but not limited to .tachycardia [fast heart rate] dated 12/8/23. R77's vital signs report dated 12/6/23 through 8/14/24, indicated prior to 8/14/24, the most recent vital signs taken on 3/5/24 included temperature 97.6, Pulse 69, reparations 18, blood pressure 127/79 and O2 saturation 95%. R77's progress note (PN) dated 5/7/24 at 8:33 a.m., indicated, patient has one episode of emesis, which was resolved after drinking ginger ale, the patient's vital signs bp 134/67, resp 16, temp 98, O2 97% at RA [room air], pulse 76, Staff will continue to monitor patent [sic]. R77's PN lacked evidence of any further vitals signs between 3/5/24 and 8/14/24. R77's medical doctor (MD) note dated 6/24/24, indicated, Vitals: BP 127/79 | Pulse 69| Temp 97.6 F | Resp 18| .SpO2 95%. R77's nurse practitioner (NP) note dated 8/9/24, indicated, Vitals: BP 127/79 | Pulse 69| Temp 97.6 F | Resp 18| .SpO2 95%. The NP note further indicated, Bilateral leg edema .no plan for diuretic with SBP's [systolic blood pressure] 120 and fall risk. During interview on 8/14/24 at 10:23 a.m., licensed practical nurse (LPN)-A stated any resident receiving antipsychotic medications would have behavior and side effect monitoring completed regularly. LPN-A stated orthostatic blood pressure changes could be a side effect of these medications and should be monitored. LPN-A stated vital signs should be taken weekly on all residents unless they had orders for more frequent monitoring. LPN-A stated facility protocol indicated vital signs were taken weekly on shower days and that even if a resident refused a shower, vital signs should still be taken. LPN-A confirmed R77 did not have any vital signs documented since 3/5/24 and stated R77 should have had vital signs taken weekly within that time. During interview on 8/14/24 at 10:40 a.m., registered nurse (RN)-F stated would expect blood pressures along with all other vital signs to be completed weekly on shower days unless ordered more frequently. RN-F looked at R77's medical record and confirmed no vital signs documented in the vital sign tab since 3/5/24 and only one other set of vital signs documented in progress notes on 5/7/24. RN-F further stated any refusals by the resident should be documented in the medical record. During interview on 8/14/24 at 11:52 a.m., director of nursing (DON) stated the expectation was for all residents to have a full set of vital signs completed and documented weekly on shower days unless a medical condition required more frequent monitoring. DON further stated R77 should have had vital signs completed weekly and confirmed they had only been checked and documented once in a progress note since 3/5/24. DON stated vital signs should be documented in the vital signs tab, so providers and other staff reference that location for the most recent vitals to assist in completing resident assessments and writing progress notes. Facility standing orders dated 7/23, indicated vital signs should be taken weekly for all residents residing in the long-term care community. R82 R82's admission MDS dated [DATE], indicated R82 was cognitively intact, had not had a weight change in the last six months prior to admission, and did not reject cares. The MDS indicated R82's diagnoses included high blood pressure, thyroid disease, and depression. R82's face sheet printed 8/13/24, indicated R82 was admitted to the facility on [DATE]. R82's CP dated 7/22/24, indicated R82 was at risk for nutritional status due to multiple diagnoses and instructed staff to monitor weight weekly. R82's provider order dated 7/20/24, indicated, Weight [sic] patient: per facility protocol. R82's initial nutritional assessment dated [DATE], indicated R82's admission weight was lower than usual body weight and listed goals included monitoring weights per orders. R82's progress notes dated 7/20/24 through 8?13/24, indicated, Weight Gain or Loss: No 19 times. R82's weight report for 7/19/24 through 8/13/24, indicated only one weight documented for R82 of 142.8 on 7/20/24. R82's medical record lacked evidence of any other weights taken or documented during that time. During interview on 8/12/24 at 2:33 p.m., R82 stated felt like she was losing weight but was not sure since she had only been weighed once just after admission to the facility. During interview on 8/13/24 at 1:10 p.m., nursing assistant (NA)-G stated nursing assistants weighed residents weekly on shower days unless they had orders for daily weights. NA-G stated NAs had access to enter the weight into the medical record. During interview on 8/13/24 at 2:04 p.m., RN-C stated the facility protocol was to complete weekly weights on shower days unless more frequent weights were ordered. RN-G stated weights would be done even if the resident refused a shower. RN-G confirmed R82 had only been one time since admission. During interview on 8/14/24 at 8:44 a.m., registered dietician (RD) stated expectation that residents without medical conditions like congestive heart failure (CHF) which would require daily weight monitoring, would be weighed at least weekly. RD stated R82 should have been weighed weekly per protocol and confirmed that had not been done. During interview on 8/14/24 at 11:46 a.m., DON stated expectation was for residents would be weighed according to the provider orders or per protocol. Facility protocol was for weekly weights on bath days. DON stated weights should still be completed even if the resident refused a bath. Facility standing orders dated 7/23, indicated residents admitted for a short stay (transition care unit) without CHF, obtain weekly weight unless directed otherwise.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure behaviors of potential wandering were comprehensively assessed for 3 of 3 residents (R15, R4, R21) and failed to assess for resident safety in the community for 1 of 1 resident (R15). The facility further failed to implement care planned interventions for 1 of 1 resident (R77) who wanders. Findings include: R15's admission Minimum Data Set, dated [DATE], indicated R15's preferred language was Hmong, did not need an interpreter, had difficulty hearing in some environments such as when speaking softly or a noisy setting and required a hearing device, a brief interview for mental status (BIMS) should have been conducted, however was not conducted, did not have hallucinations or delusions, did not exhibit wandering behavior, and did not reject care. Additionally, R15 used a cane, required partial to moderate assistance with toileting, showering, upper and lower body dressing, hygiene, and donning/doffing footwear. R15 required partial to moderate assist with sitting to standing safely and required supervision or touching assistance to ambulate 10 feet. R15 was incontinent of bowel and bladder, had an anxiety disorder, cardiogenic shock (the heart cannot pump enough blood to the brain and other organs), acute respiratory failure with hypoxia (the body doesn't have enough oxygen at the tissue level), acute pulmonary edema (a condition where too much fluid builds up in the lungs), acute on chronic combined systolic and diastolic heart failure, had a defibrillator, had a life expectancy of less than 6 months, took an antipsychotic and antianxiety medication, was on hospice and did not use restraints. R15's face sheet indicated R15 was not responsible for himself, and family member (FM)-B was R15's primary emergency contact. Additionally, R15 had the following diagnoses: restlessness and agitation, generalized edema, and other encephalopathy (a disease in which the functioning of the brain is affected by an agent or condition). R15's care area assessment (CAA) dated 7/9/24, indicated R15 triggered for falls due to needing assist with cares, mobility, transferring, toileting, incontinence, and diagnoses that included cardiogenic shock, congestive heart failure, and toxic metabolic encephalopathy (can lead to altered consciousness, going from delirium to coma). R15's CAA dated 7/10/24, indicated R15 took antipsychotic medications as needed for restlessness and agitation, and lorazepam for anxiety. R15's care plan dated 7/3/24, indicated R15 was on hospice with an expected decline in condition and the following hospice staff visited: nursing and nursing assistants weekly, social services and chaplain monthly, and volunteers. R15's care plan dated 7/3/24, indicated R15 did not want resuscitation and interventions included healthcare directives signed by appropriate individuals (physician, resident, family, legal representative). R15's care plan dated 7/6/24, indicated R15 had a self-care deficit and was at risk for falls. Interventions indicated R15 required assist of 1 staff for transfers using a gait belt and walker, and preferred staff to assist him in wheeling long distances. R15's care plan lacked information whether R15 was safe to go out in the community. R15's care sheet dated 8/9/24, indicated R15 was impulsive, spoke English and staff needed to anticipate needs. The care sheet lacked information R15 was safe to go out in the community. R15's Provider Orders for Life-Sustaining Treatment (POLST) form indicated R15 did not want to be resuscitated and under documentation of discussion indicated 6 check boxes that included the following: Patient (Patient has capacity), court-appointed guardian, other surrogate, parent of minor, health care agent, and health care directive. The only check box marked was, health care agent and was signed by FM-B. Additionally, the POLST included instructions that a person with capacity, or the valid surrogate of a person without capacity, could void the form and request alternative treatment. R15's physician orders indicated the following order: • 8/4/24, monitor the placement of wander guard and was discontinued on 8/12/24. R15's medication administration record (MAR) and treatment administration record (TAR) dated 8/4/24, through 8/12/24, indicated to monitor the placement of the wander guard every shift. Under comments on the MAR and TAR, indicated on 8/6/24 at 5:36 p.m., no wander guard, on 8/7/24 at 3:30 a.m., resident removed wander guard, on 8/7/24 at 8:40 p.m., not on, 8/8/24 at 1:55 a.m., resident removed, on 8/9/24 at 3:11 a.m., resident removed, 8/9/24 at 2:37 p.m., does not have a wander guard on, on 8/10/24 at 2:50 a.m., indicated no on and on 8/12/24 at 1:47 p.m., indicated discontinued. R15's cardiology note dated 6/17/24, indicated R15 was unable to participate in decision-making process. R15's nurse practitioner (NP) note dated 6/18/24, indicated FM-B asked for help in determining R15's capacity to make complex decisions if R15 improved enough to engage in discussions regarding goals and plan of care and gave an example of potential vulnerability to financial exploitation by unknown people in R15's home country where R15 intermittently sent significant amounts of money. Further, R15 demonstrated limited understanding. Last, under a heading, Decision Making Capacity indicated R15 required surrogate decision making due to critical illness and was unclear if R15 had decision-making capacity at baseline per daughter. R15's physician discharge to facility note dated 7/2/24, indicated R15 was unable to verbalize understanding of his condition and treatment plan due to being disoriented and the diagnosis and treatment plan was discussed with FM-B. R15's NP-D progress note dated 7/16/24, indicated R15 was independent with activities of daily living (ADLs), was ambulatory and R15's review of systems was limited due to cognitive impairment. R15's Application of a Health Officer or Peace Officer for Emergency admission form dated 8/4/24 at 1:15 p.m., indicated R15 was trying to walk 11 miles in 71-degree heat in a winter jacket. R15 was on hospice and tried to assault staff and refused to return and staff wanted R15 to go to the hospital. R15's emergency department note dated 8/4/24, indicated R15 eloped to go to the Hmong market and the police were contacted and intercepted R15 two blocks away. Further, staff indicated R15 had to come to the hospital but did not elaborate and per EMS, family resided out of state except a daughter who was the power of attorney but R15 did not have contact with, and had organized thought content and processes, additionally FM-B was contacted and wanted R15 admitted for a psychiatric evaluation for capacity. It was explained to FM-B capacity could be completed outside the hospital and better in a legal setting versus a medical setting. R15's NP-D progress note dated 8/13/24, indicated R15 had dementia without behavioral disturbances, had cognitive limitations, and eloped on 8/4/24, attempting to ambulate to the store to purchase Hmong medications. Additionally, review of systems was limited secondary to cognitive impairment. OBSERVATION FORMS: R15's Clinical Documentation admission form dated 7/3/24 at 12:14 p.m., indicated staff could not identify whether R15 had an advanced directive due to a level of cognitive impairment. R15's Clinical Documentation Functional Abilities form dated 7/3/24 at 12:21 p.m., indicated ambulating 10 feet was not attempted due to a medical condition or safety concern. Additionally, ambulating 50 feet and 150 feet was not attempted because R15 did not perform this activity prior to the current illness, exacerbation, or injury further, the ability to ambulate 10 feet on uneven surfaces, or go up and down a curb and or up and down one step was not attempted due to environmental limitations. R15's Self-Administration of Medication form dated 7/7/24, indicated R15 was not appropriate to self-administer medications and R15's cognitive status was identified as moderately impaired-decisions poor; cues/supervision was required. R15's Long Term Care Social Service form dated 7/10/24 at 5:18 p.m., indicated R15 had minor forgetfulness, a vision or hearing problem that impaired communication, distorted and misrepresented events, did not fully understand physical limitations. R15's Notice of Resident/Patient Transfer or Discharge form dated 8/4/24 at 2:38 p.m., indicated R15 was involuntarily transferred to the hospital on 8/4/24, because R15's welfare and needs could not be met in the facility. R15's Resident Transfer Form dated 8/4/24 at 2:57 p.m., indicated FM-B was R15's health care proxy (someone designated to make medical decisions if a person is unable to themselves) was notified. Under the heading, Reason for Transfer What Happened indicated R15 eloped and attempted to hit staff. Further, Primary Clinical Reason for Transfer indicated a check box for other and identified acute chronic combined systolic and diastolic failure. Additionally, the form indicated R15 was alert and oriented and followed instructions, ambulated with a cane but did not indicate the distance R15 could ambulate, and was identified as not applicable under impairments including hearing and cognitive and a behavior started 8/4/24, when R15 went outside the building and tried to hit staff. R15's Social Services Elopement Risk form in progress dated 8/14/24 at 1:32 p.m., R14 exhibited combativeness, resisting redirection from staff, had a recent move to the facility, terminal illness, and preventative action taken included wanderguard, photograph posted and a check box indicating social services were marked in the check boxes. EVENTS: R15's Safety Events Elopement form dated 8/4/24 at 7:57 p.m., indicated R15 eloped and was found near McDonald's in Silverlake and had not exhibited any of the following: anger regarding facility placement, combativeness, elopement attempts in the past, failure to return from outings and appointments, packing belongings, removing devices such as wanderguards, and tabs alarm, repeatedly opening doors, resisting redirection from staff, verbalizing statements about leaving, verbally abusive, wandering with no rational purpose and attempting to open doors. Further, the form indicated R15 was going to get Hmong medications and did not have any changes in mental status of a new onset which included agitation, anxiety, confusion, lethargy, resistiveness, restlessness, sleepiness, slurred speech. The form indicated None of above under the heading, Possible Contributing Factors that included anxiety and terminal illness. The form indicated there were no recent changes in medications, or new medications and under interventions to indicate measures taken which included door alarm bands such as a wanderguard, indicated none of above. Further, the police were contacted and R15 was transferred to the hospital. Under a heading, Notes indicated on 8/5/24 at 6:55 a.m., R15 was in bed sleeping and staff continued to observe R15 every 15 minutes. CARE CONFERENCE: R15's care conference notes last updated by the director of social services dated 7/16/24, indicated R15 scored a 6 out of 15 on the brief interview for mental status (BIMS) which indicated R15 had severe cognitive impairment. Further, R15 ambulated independently with the use of a single end cane and was assisted with ADLs and was not compliant with taking diuretic medications. R15's family reported R15 was uncomfortable with the swelling in his legs. PROGRESS NOTES: R15's progress notes dated 7/3/24 at 2:16 p.m., indicated R15 was alert to self, unable to communicate needs and was alert and oriented times 2. R15's progress notes dated 7/6/24 at 9:27 p.m., indicated R15 required assist of 1 with transfers, toileting, and ADLs. R15's progress notes dated 7/23/24 at 3:44 p.m., indicated hospice would have a discussion to locate a place that could accommodate R15 and R15 insisted on taking a Hmong medication from the market. R15's progress notes dated 8/4/24 at 1:20 p.m., indicated R15 went to the nurse's station around 11:40 a.m. to ask for the phone and did not understand what they were communicating due to a language barrier and after about 10 minutes, the supervisor received a call that R15 was outside on the right side of the building. The supervisor went outside to check immediately but did not locate the resident and followed protocol of searching for the resident. R15 was seen walking faster towards the intersection by McDonalds and therapy staff reached R15 first before the supervisor arrived. R15 stated he was going to go and get his Hmong medication for his legs. The note further indicated R15 was resistive and unable to be redirected after multiple attempts and kept following the way to board the bus and later became agitated and tried to hit staff multiple times. The police were contacted and were unable to redirect R15 and stood firm he was not going back to the facility. A family member was contacted who did not want to talk with R15 and the facility decided to send R15 to the hospital. R15's progress notes dated 8/4/24 at 7:19 p.m., indicated R15 returned from the hospital around 6:00 p.m. after an incident when the resident left the facility unaccompanied. To make sure the incident was not repeated, the nurse spoke with FM-B regarding wearing a wanderguard and planned to discuss issues of wearing a wanderguard by a resident with no diagnosis of a cognitive impairment on 8/5/24, with the director of social services and a wanderguard was placed on R15's right wrist and was on 15-minute checks. R15's hospice progress note dated 8/4/24 at 9:00 p.m., indicated the hospice nurse contacted the interpreter and R15 stated he wanted an herbal supplement for his kidneys because the medications were not working. R15's daughter was updated and stated 1 pill was $300.00 and could not get the medication. R15's progress notes dated 8/5/24 at 6:55 a.m., indicated staff observed R15 every 15 minutes. R15's progress notes dated 8/7/24 at 1:51 p.m., indicated on 8/4/24, R15 walked on foot to the bus station near McDonalds, about 10 minutes away from the facility and the supervisor and team of nurses and therapists located R15 at the bus station near McDonalds. FM-B agreed to a wanderguard placement to alert staff when R15 attempted to leave the facility. Further, the note indicated R15 did not elope was alert and oriented x 3 and knew the route to the bus station. R15's progress notes dated 8/7/24 at 4:39 p.m., and recorded as a late entry on 8/12/24 at 8:44 a.m., by the social services director indicated the following: Writer called and spoke with daughter regarding medication that resident has been asking for. Family reports that resident has taken the medication previously, but it is not easily sourced and not readily available through traditional means of purchasing medication. Resident is requesting this medication to help them to feel comfortable as the medication aligns with medicine in their culture. To align with resident's cultural beliefs and to respond to person centered care, writer and family will continue to discuss ways that this medication can be provided to the resident. According to the matrix care chart review and weekend supervisor, at 11:40 a.m., the patient requested a telephone at the nurses' station and made a call to a family member. The patient then left the building through the main entrance, despite attempts by the receptionist to redirect them back inside. The patient walked on foot to the bus station near McDonalds, about 10 minutes away from the facility, expressing an intention to obtain traditional medicine from a Hmong store. The receptionist promptly informed the building supervisor of the event. The supervisor and a team of nurses and therapists quickly located the patient at the bus station near McDonalds. Despite multiple attempts by staff members to redirect [R15] back, he became agitated and threatened physical violence. As efforts continued unsuccessfully, emergency services were called for assistance. R15's progress note dated 8/12/24 at 8:59 a.m., indicated the wanderguard was discontinued and was not appropriate to wear a wanderguard at this time. Further the note indicated R15 was alert and oriented times three. During interview on 8/12/24 at 5:40 p.m., registered nurse (RN)-I stated she thought R15 tried to run away last week. During interview on 8/13/24 at 11:37 a.m., FM-B stated she spoke with the social services director (SSD)-B about 3 days after incident who did not have much to say about the incident other than they put a wanderguard on R15. FM-B stated she was not sure if R15 still had the wanderguard, SSD-B mentioned R15 cut off the wanderguard. FM-B stated she understood R15 wanted to purchase a supplement that could only be purchased in the Hmong village and was walking with a cane and had a winter jacket on. FM-B stated she told the SSD-B R15 had the intention of doing this and SSD-B reassured FM-B someone was by the door all the time. FM-B stated the nurse contacted her and told her R15 left the facility and wanted her to tell R15 to go back and when FM-B tried to talk with R15, he would not listen, and the police were called. FM-B stated the police were unable to get R15 to come back and the nurse stated they were going to take R15 to the hospital because R15 tried to assault a staff member. FM-B further stated the physician contacted her and stated R15 was breathing ok and was confused because she thought R15 would be having a psychological evaluation. FM-B stated she did not think R15 could make sound reasonable decisions for himself, but was told due to no impairment, R15 could make decisions for himself. During interview on 8/13/24 at 2:05 p.m., nursing assistant (NA)-H stated she looked at the care sheet and stated she was not working and when she came back to work heard R15 tried to escape and stated she needed to check to see if R15 had a wanderguard on and stated she would ask the nurse. NA-H further stated R15 asked her where he was, and NA-H wrote the name and address down and gave it to R15. During interview on 8/13/24 at 2:16 p.m., nursing assistant (NA)-I stated she thought R15 tried to escape and added he couldn't go anywhere because people were out there and further stated R15 only left once and stated everybody went to locate R15. During interview and observation on 8/13/24 at 2:30 p.m., the interpreter was contacted and R15 stated he had been at the facility a long time and wanted to move out of the hospital and was unable to identify what facility R15 was at. R15 further stated the wanderguard did not help his illness and stated he would just take off the wanderguard. R15 stated he wanted to move to a Hmong facility where R15 could get medication to help his legs and stated he did not know the name of the medication but stated it was a Chinese medication. R15's feet were swollen and was wearing a pair of thong sandals. During observation on 8/14/24 at 8:33 a.m., R15 was searching through his phone and did not acknowledge presence. R15 had a thick green winter jacket located on the top of the dresser and was trying to make a phone call. During interview on 8/14/24 at 8:38 a.m., registered nurse (RN)-E stated she looked at the care plan to know what kind of cares a resident required and stated they complete a clinical assessment and ask a few questions that they are safe and a resident's memory is ok to determine whether they can do something or not and stated she thought the social worker completed a cognitive assessment. RN-E further stated if a resident wandered, they placed a wanderguard and added she did not work in the locked unit. RN-E stated if a resident tried to leave, they call 911 and if they refuse to come back, they call 911 for help and then put an assessment in the computer and added it had not happened to her before. RN-E stated if a resident went out, they completed a safety check, and it would be on the resident's care plan on when to check on the resident and expected care plan interventions to know if a resident wandered. RN-E stated management added the form in the electronic medical record, and then the staff nurse completed the assessment. RN-E further stated she knew R15 was not going to make another attempt because R15 was not talking about leaving and would be a concern if R15 talked about wanting the Hmong medication. When asked why the facility placed a wanderguard if R15 was alert and oriented, RN-E stated R15 was trying to leave and wanted to get Hmong medication. During interview on 8/14/24 at 10:05 a.m., licensed practical nurse (LPN)-D stated she looked to the care plans to know what kind of cares a resident required and stated she would have to ask if there was any kind of assessment because she didn't complete assessments. LPN-D stated the care plan sometimes had information on decision making capacity and stated it was also on the Facesheet. LPN-D stated she would have to ask her supervisor what the process was if a resident eloped because she had never come in contact with a resident who eloped and added in the memory care unit they used wanderguards and the unit was locked and stated one resident on this unit tried to elope about two or three weeks ago, but could not recall the resident's name or room number and stated she thought they went out to look for the resident and informed the supervisor the resident refused to come in and they contacted the police. LPN-D stated they had to monitor the resident every 15 minutes and thought they applied a wanderguard. During interview on 8/14/24 at 10:19 a.m., when asked how she knows a resident was safe to leave the facility alone, registered nurse (RN)-F stated most of their residents could not leave the facility, some could go for appointments and stated she did not know if there was any kind of an assessment to make that determination and would have to go and check. RN-F stated they assess if someone can go in the community in the transitional care unit and further stated she would have to check into that. RN-F stated when a resident eloped, staff look for the resident and they are alerted to an elopement by an overhead, additionally they check all rooms, med rooms, bathrooms, and contact 911. RN-F stated when the resident is found, they complete an elopement event, update the family, and physician, and apply a wanderguard to make sure they don't do it again. RN-F further stated they completed an Elopement Risk assessment under the Observations tab. The form identifies if the resident experienced changes, a description of the resident's elopement risk and any preventative action. RN-F further stated they took a picture of residents at risk and placed the pictures in a book downstairs and was not sure if R15 had a picture downstairs and stated she would have to check on that. When asked if R15 should have an assessment to determine whether R15 was at risk for elopement, RN-F stated yes and no and added to be on the safe side it would be better to have an assessment. RN-F further stated therapy completed cognition screens to determine if a resident could make their own decisions, but stated R15 was on hospice and stated social services might determine if R15 could make his own decisions. RN-F verified R15 did not have an elopement risk assessment completed in the Observations form and stated they placed a wanderguard and was discontinued per R15's progress notes. RN-F stated she would check with the director of social services because she did not see anything in R15's chart for an elopement assessment. RN-F further stated if a resident left the facility, they usually completed a care plan with interventions. During interview on 8/14/24 at 10:42 a.m., the social services director (SSD)-B stated they had care conferences and completed a BIMS interview to help determine whether a resident was able to make their own decisions and ultimately it was up to the court system and was done through a guardianship and stated it was documented under resident notes. Additionally, it was a court decision along with the physician's opinion. If a resident was admitted to the facility and they did not know whether a resident could make their own decisions they ask for health care directives and if that is not provided, would speak with the resident. SSD stated they have therapy complete an evaluation to determine if someone was safe to leave and if a resident eloped, they call a Mr. Lost code and notify the police, administrator, and director of nursing. SSD-B stated an elopement risk assessment is completed within the first 48 hours after admission by the social worker and then after that the interdisciplinary team completed the assessment. SSD-B viewed R15's chart and verified R15 did not have an initial assessment completed and stated R15 should have had an assessment completed. SSD-B stated he did not know whether an assessment should be completed after a resident eloped. SSD-B stated R15 could make decisions with the help of his family and further added if R15 puts his safety at risk they follow what they need to follow to ensure R15 is safe and stated R15 had an elopement attempt. R15 went to the bus stop to go to the Hmong village to get a medication. SSD-B further stated the purpose of the elopement risk was to provide information to staff for residents at high risk and they provide information to the front desk. SSD-B stated he would have to check whether there should be a care plan for elopement and added R15 hadn't made other attempts and R15's BIMS was a 6 out of 15 which indicated severe cognitive impairment and added R15 had not expressed wanting to leave and did not know he would have a concern of R15 leaving again. SSD-B further stated he did not have information whether R15 could make his own decisions and later stated they would approach that R15 was able to make his own decisions with support of family. When asked why a wanderguard was placed if R15 was able to make his own decisions, SSD-B stated it was applied for his safety because the decision R15 made put him in an unsafe position and was since taken off and stated it would be important to have an elopement risk on any patient to see what their potential for elopement was. During interview on 8/14/24 at 11:04 a.m., occupational therapists (OT)-H and OT-I stated they completed a cognitive assessment on every resident to determine their general baseline. The cognitive screens completed were Short Blessed Test and based on that score may do a SLUMS assessment that looked more at memory and sequencing, and they also had a cognitive performance test for medication management, choosing the appropriate clothing based on the weather outside and added they were more in depth that the BIMS. OT-H and OT-I verified R15 was not seen by therapy and verified there were no therapy notes in R15's medical record and stated R15 was on hospice so did not have any therapy orders and verified there was no cognitive assessment completed through therapy. During interview and observation on 8/14/24 at 11:09 a.m., R15 was not located in the elopement book and front desk staff (FDS)-J verified R15 did not have a photograph in the elopement book. During interview on 8/14/24 at 12:23 p.m., hospice social worker (HSW)-C stated he visited monthly and was looking for different placement for R15 and stated R15 enrolled in hospice on 7/3/24. HSW thought R15 could make his own decisions and stated he didn't have firsthand knowledge of R15's elopement and stated the note indicated R15 returned from the hospital after leaving the facility. During interview on 8/14/24 at 12:07 p.m., nurse practitioner (NP)-D stated R15 was a newer resident who spoke English ok, was on hospice, had edema to his legs but refused medications and eloped a few weeks ago. NP-D further stated R15 could make needs known, can make a choice such as applying lotion, but could not make medical or financial decisions and they would look to R15's family and added R15 had dementia and did not want his patient eloping and expected the facility complete a risk assessment and stated he thought R15 cut off his wanderguard and stated he expected staff should have completed an assessment to determine R15 was safe and stated he was surprised they didn't get a plan put into place and stated it was an issue for the safety of the person if he doesn't have a wanderguard in place and is not in a secure unit and assumed the facility did something to ensure R15 was safe. During interview on 8/14/24 at 1:10 p.m., a policy on wandering and elopement was requested from the administrator. During interview on 8/15/24 at 9:26 a.m., the director of nursing (DON) stated the process to determine whether a resident was capable of making their own decisions was an ethical question and they had to assess mental capacity and stated it went through social services to see if a resident was capable and added it was an IDT approach and medical doctors and stated it depended if they came to the facility and had power of attorney documentation and if they didn't have documentation on file they question if it warrants getting the ombudsman or an attorney for a person or family member to be the decision maker and they would go through a process. DON further stated if they were assisting family members it was documented in a care conference and progress note or the social worker would enter a progress note. The DON stated they reviewed orders when a resident comes from the hospital and discharge summaries and stated either the DON or managers went through the resident's medical record to be on the safe side to know what was needed for a person just in case it was not in the orders and stated therapy staff also go through the history and physical. DON stated the elopement assessment was completed upon admission and was reassessed periodically quarterly. DON stated the purpose of the elopement assessment was to establish whether a resident was at risk for leaving the facility with out staff knowledge or going out unsafely depending on their cognitive status. The DON further stated R15 was alert and oriented to the situation and can dial numbers and will tell you what he is going to do and stated R15 could go on an unsupervised leave. The DON stated R15 went out the front door and staff were called, saw R15 walking and stopped at the bus stop and other staff followed R15 and tried to redirect him. The DON further stated he instructed staff to contact the police because R15 was aggressive and the best thing they could do was send R15 to the emergency room. The DON stated this was not the first time R15 asked for medication, and they were working on a process to help get the supplement and stated R15 had not attempted to leave since. The DON stated they tried to stop R15 because everyone went by orders and information that was relayed to him. Contrary to documentation, the DON stated staff went with R15 and R15 did not walk alone and further stated they planned to monitor R15 and make sure he was checked on every shift. R4 R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, disorganized thinking, and wandering with a diagnoses of dementia, restlessness, and agitation. It further indicated R4 required partial to moderate assistance with transfers. R4's last elopment risk assessment was dated 7/13/21, and was at moderate risk for elopement. R4's care plan dated 5/8/24, indicated R4 was having a tough time adjusting to a secure memory care unit, and may exhibit behaviors including crying, making angry statements about wanting to hurt herself or others, hitting/kicking caregivers, and refusing cares. It was taking awhile to adjust to many recent changes: environm[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (measures intended to prevent the spread of multidrug-resistant organisms ) were implemented for 2 of 3 residents (R83 and R24) observed for enhanced barrier precautions, and failed to ensure appropriate hand hygiene during assist with activities of daily living (ADLs) for 1 of 2 resident (R24). Last, the facility failed to ensure ice packs were stored separately from food storage in two unit refrigerators. This had the potential to impact the residents who resided on those units. Findings include: R83's admission Minimum Data Set (MDS) dated [DATE] indicated the use of an indwelling catheter (a thin, hollow tube that is inserted into the bladder through the urethra to collect and drain urine. R83's medical diagnosis form in the electronic medical record dated 7/16/2024 indicated the following diagnosis: Encounter for palliative care (comfort cares), acute cystitis with hematuria (a medical condition that causes bleeding in the bladder and blood to appear in the urine), Urinary tract infection (an illness in any part of the urinary tract), site not specified , other acute kidney failure, and encounter for fitting and adjustment of urinary device. R83's physician orders dated 7/11/24 indicated the following: urinary drain care The reason for the drain is : urinary incontinence and end of life care. The type of drain is: Foley 14 Fr., Placement date: 7/11/2024. Care instructions: per facility protocol. Change Foley cath leg bag , drainage bag, extension tubing Q 2 weeks. Empty Foley bag q shift and document output. Change Foley cath Q month. R83's plan of care reviewed on 8/14/24 at 8:00 a.m. did not include interventions regarding the Foley catheter or Enhanced Barrier Precautions. Random observations on 8/12/24 and 8/13/24, no enhanced barrier precaution signage was noted outside of R83's room. Observation on 8/14/24 at 7:25 a.m., R83's room door was closed, and no sign was noted outside of the door. Staff was noted to knock on the door and go into the room. Interview on 8/14/24 at 7:27 a.m., nursing assistant (NA) - H indicated any resident with a catheter is on precautions, and the staff are made aware by the signage on the door and in morning report. NA-H verified R83 had a catheter and no signs were on the door. Interview on 8/14/24 at 7:30 a.m., Registered nurse (RN) - E verified R83 did not have a sign on the door, and that is how the staff know who is on precautions. Observation on 8/14/24 at 7:49 a.m., RN-L was observed to put up an Enhanced Barrier Precaution sign outside of R83's door. When interviewed she indicated she was working with RN-K who is the new infection preventionist and was told to put the signage up. Interview on 8/14/24 at 7:55 a.m., RN-K indicated she was the new infection preventionist and did not know why there was no sign previously and indicated she would investigate it. Interview on 8/14/24 at 10:53 a.m., RN-J indicated she is the current infection preventionist and RN-K was learning the job. RN-J indicated any nurse on the floor can put up the signage for precautions, no matter what kind of precautions, and she would look into why there was no signage by R83's room. As of 08/15/24 at 10:11 AM no information received regarding why R83 did not have a signage up and was not on Enhanced Barrier Precautions since admission to the facility R24 R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, had a wheelchair, was dependent for toileting hygiene, lower body dressing, and transferring, and required substantial assistance with showering and bathing, and upper body dressing. Further R24 had an indwelling catheter. R24's Facesheet indicated R24 had the following diagnoses: spastic quadriplegic cerebral palsy, muscle weakness, urinary tract infection, bladder disorder, and encounter for attention to other artificial openings of urinary tract supra pubic, and a neuromuscular dysfunction of bladder. R24's physician's orders indicated the following orders: • 3/3/22, catheter change once a month on the 27th of the month [NAME] 16 FR and 15 cubic centimeters (CC) sterile water. • 5/28/24, patient is on enhanced barrier precautions (EBP) due to urinary catheter. R24's care plan dated 6/28/24, indicated R24 required EBP due to diagnoses of spastic quadriplegic cerebral palsy, presence of indwelling urinary catheter device and had the following interventions: assess resident for EBP need and implement precautions according to facility protocol, assure residents are not restricted to their rooms or limited to participation in group activities, monitor for signs and symptoms of infection, post clear signage on the door or wall outside the resident room indicating the type of precautions and required personal protective equipment (PPE), provide education to staff, residents, and visitors as needed, staff to apply gloves and gowns prior to facility-identified high-contact care activities, discard PPE in designated location following activities, and sanitize hands after PPE removal. R24's care plan dated 6/28/24, indicated R24 had an alteration in ADLs and interventions included: assist of one for grooming, dressing, and bathing. R24's care plan dated 6/28/24, indicated R24 had an alteration in mobility and required an assist of two with transfers using the ceiling lift. During observation and interview on 8/14/24 between 8:59 a.m., and 9:29 a.m., nursing assistant (NA)-J washed hands and donned gloves to assist R24 with cares. At 9:03 a.m., NA-J assisted in untying R24's gown and gave the wash rag to R24 to wash her face. At 9:08 a.m., NA-J turned R24 to pull R24's shirt down. NA-J cleaned the catheter tip with an alcohol wipe and removed gloves and sanitized hands and donned new gloves. At 9:11 a.m., NA-J moved R24's gown to take off the catheter bag. At 9:13 a.m., NA-J put vinegar in the catheter bag and took a cup and water from the faucet to pour into the catheter bag to clean the bag and put the catheter bag in a garbage bag and hung it up in the bathroom. NA-J doffed gloves and rinsed hands in the sink, however did not use soap and then took out gloves and tried to don the gloves. Moisture was observed through the gloves and NA-J took off the gloves and threw them away and grabbed new gloves and donned the new gloves without properly cleansing hands. At 9:16 a.m., NA-J removed her gloves and got a basin and placed it on the table and rinsed hands and again did not use soap or sanitizer and dried her hands and grabbed gloves. At 9:18 a.m. NA-J assisted in donning R24's pants and turned R24 to pull up R24's pants. At 9:22 a.m., NA-J doffed her gloves and used hand sanitizer and did not apply gloves and assisted R24 with a transfer into R24's wheelchair with the help of another staff person. At 9:24 a.m., NA-J donned gloves and put the lift up in the air and to the corner of the room. During interview at 9:29 a.m., NA-J verified she did not always use soap when she cleansed hands at the sink and further stated she did not need to use gloves to transfer R24 and stated R24 was on EBP because of the catheter. Additionally, NA-J verified hands were not completely dry when cleansing hands. Signage for EBP was located outside R24's door. During interview on 8/14/24 at 9:33 a.m., registered nurse (RN)-F stated if a resident was on EBP, staff donned gloves and gowns when completing cares and further stated PPE was required during transfers and stated if staff were sanitizing their hands at the sink, she expected soap to be used and stated hands should be dry before donning gloves. RN-F stated they didn't want to transmit drug resistant organisms because it could take a long time to heal and take a toll on residents. RN-F verified R24 was on EBP and expected PPE to be donned and hands washed with soap. During observation on 8/12/24 at 12:32 p.m., the Villa kitchenette an ice pack was located in the freezer that indicated, thermal soft gel and indicated it was the property of facility therapy. The ice pack was located in the freezer next to popsicles and vanilla ice cream, and ice cream sandwiches. The dietician stated she would pull the ice pack out of the freezer. During observation on 8/12/24 at 12:38 p.m., the freezer in the transitional care unit (TCU) contained a thermalsoft Gel hot and cold therapy pack that indicated it was the property of facility therapy. The ice pack was located next to ice cream and ice cream sandwiches, a package of lasagna, and cinnamon french toast bites. The dietician stated she planned to leave it on top of the freezer and stated she probably would not have put the ice pack in the freezer and was not sure why it was in there. During interview on 8/12/24 at 12:43 p.m., registered nurse (RN)-J stated they had separate freezers for ice packs and stated the ice packs should not be in these freezers because it was not sanitary to have mixed with the food. At 12:45 p.m., RN-J brought the ice pack from the TCU down to a room and placed it in the freezer that only contained ice packs. During interview on 8/15/24 at 9:05 a.m., the director of nursing (DON) stated staff could use hand sanitizer, or could go to the sink and use soap and water and if they went to the sink, should wash for about 30 seconds and stated hands should be dry or it would be difficult to apply gloves. Further, the DON stated staff should wear the gown and gloves during transfers or repositioning and when working directly with a resident and expected staff to use soap and water. The DON also stated he thought the ice packs were an isolated incident and was informed the ice packs were located in two different kitchenettes and requested a policy on ice pack storage, however was not received. Review of the Benedictine Health System Policy titled Enhanced Barrier Precautions revised 3/28/24 indicated the following: Purpose: Enhanced Barrier Precautions (EBP) is a strategy in nursing homes to decrease transmission of CDC-targeted and other epidemiologically important multidrug-resistant organisms (MDROs). EBP will be used for residents actively infected or colonized with CDC-targeted and other epidemiologically important MDROs. Additionally, residents at risk for MDROs, specifically those with an indwelling medical device and/or chronic wounds requiring a dressing will be required to use EBP. Policy: It is the policy of the community to protect residents and associates from the transmission of infectious diseases through use of appropriate precautions during resident care. Procedure: Enhanced Barrier Precautions (EBP) expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated. It also refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The policy further stated: When to use: Enhanced Barrier Precautions: All residents with any of the following: · Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply · Infection with an additional epidemiologically important MDRO when Contact Precautions do not otherwise apply · Chronic wounds (e.g. pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers), regardless of MDRO colonization status · Indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes tracheostomy/ventilator), regardless of MDRO colonization status. PPE used for the following situations: During high-contact resident care activities: · Dressing · Bathing/showering · Transferring · Providing hygiene · Changing linens · Changing briefs or assisting with toileting · Indwelling medical device care or use: central line, urinary catheter, feeding tube tracheostomy/ventilator · Chronic wound care: any skin opening requiring a dressing (excludes shorter lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage) Required PPE included: Gloves and gown prior to the high contact care activity (Change PPE before caring for another resident) (Face protection may also be needed if performing activity with risk of splash or spray) A policy, Hand Hygiene, dated 9/2023, indicated infection prevention begins with basic hand hygiene. Hand hygiene means cleaning hands using either handwashing (washing hands with soap and water), or antiseptic hand rub (alcohol-based hand sanitizer, including foam or gel). Times to perform hand hygiene are, but not limited to when arriving for work, before and after direct resident contact, before and after assisting a resident with personal cares, before and after handling peripheral vascular catheters and other invasive devices, upon an dafter coming in contact with a resident's intact skin, such as when taking vitals or after assisting with lifting, before and after assisting a resident with toileting wash hands with soap and water, after handling soiled or used linens, dressing, bedpans, catheters and urinals, after removing gloves or aprons. Further, the technique for washing hands with soap and water indicated to wet hands with water, holding hands downward in the sink, apply the soap, rub hands together vigorously for 20 seconds, covering all surfaces of hands, including palms, backs, fingers, between fingers, and under nails.

Based on observation, interview, and document review, the facility failed to ensure refrigerated food items were properly stored, labeled, and dated and disposed after expiration date. Furthermore, the facility failed to ensure the use of hair restraints. This deficient practice had the potential to affect all residents who receive food from the kitchen. Findings include: Food Storage: During the initial kitchen observation on 8/12/24 at 12:06 p.m., the refrigerator contained the following: • a gallon of 1% milk with a best by date of 8/11/24 and the dietician stated needed to be thrown out. Hair Restraints: During interview and observation on 8/12/24 at 12:23 p.m., cook (C)-A had uncovered facial hair and was preparing food in the Robot Coupe food processor and was observed not wearing a beard guard/restraint or net. At 12:25 p.m., the dietician verified C-A was not wearing a beard net and stated he should have one on and stated she would have to look at the policy. Kitchenettes: During the observation of the Villa kitchenette on 8/12/24 at 12:29 p.m., contained the following: • 1 nutrition supplement that was opened and undated. The dietician verified there was no date and the supplement indicated to consume within four days and stated it should be tossed because there was no open date to know when the supplement should be tossed. • two containers, one undated and the other dated 8/2/24. One was a container of bread and strawberries and the other a container with strawberries. The dietician stated they were a resident's food items and stated food items should only be in the refrigerator a total of 5 days. During the observation of the transitional care unit (TCU) kitchenette on 8/12/24 at 12:38 p.m., contained the following: • 1 nutritional shake that was almost empty and undated the dietician verified indicated on the container to toss after four days and verified there was no date identified of when the container was opened. During interview on 8/15/24 at 8:58 a.m., the dietary manager (DM) stated they provided beard nets and expected food to be labeled and dated and resident food items to be labeled and dated and stored in resident refrigerators. Further DM stated the kitchen provided supplements, but it was nursing's responsibility to label and date items as they open them and toss items when they are expired or by the directions on the container. A policy, Food Storage, dated 1/2024, indicated all products are labeled and dated with the receiving date. Once opened, products are covered to prevent contamination and dated with an open date. A policy, Personal Hygiene, undated, indicated team members must consistently demonstrate appropriate personal hygiene practices. Wear a hairnet or cap to restrain all hair, for anyone with facial hair, wear a beard and mustache restraint. A policy, Food Brought into Resident's/Patient's Room From Outside Sources dated 1/2024, indicated any food or beverage brought into the facility for resident/patient consumption will be checked by a staff member before being accepted for storage. Foods or beverages brought in from the outside will be labeled with the resident's/patient's name and room number. Nursing will date the food with the date the item was brought to the facility for storage. All cooked or prepared food brought in for a resident/patient and stored in the unit's pantry refrigerator or personal room refrigerator will be dated when accepted for storage and discarded after 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to implement care planned interventions to prevent worsening of existing pressure ulcers for 1 of 3 residents (R4) reviewed with a pressure ulcer. Findings include: R4's Resident Face Sheet indicated admission to facility on 8/3/23. The face sheet indicated diagnosis that included dementia, anxiety, muscle weakness and a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister) pressure ulcer. R4's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated he displayed no behaviors. The MDS indicated R4 was dependent on staff for putting on and taking off footwear and identified an unstageable (a full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar [dead tissue] in the wound bed) pressure ulcer. R4's care plan dated 8/4/23, identified a deep tissue injury on his right heel with potential for further pressure injuries related to need for assistance with cares, mobility and toileting. Care planned interventions included an air mattress and bilateral Prevalon heel protectors in bed and when up in chair. The care plan identified a self care deficit and indicated R4 required assistance for transfers and grooming. R4's nursing assistant (NA) care guide undated, directed staff to apply bilateral heel protectors in bed and wheel chair and identified the use of an air mattress for right heel wound. R4's Resident Progress Note dated 5/21/24, indicated impaired skin integrity on right heel and identified a 2.0 centimeter (cm) by 2.0 cm unstageable ulcer. Prevalon heel protectors to bilateral heels while in bed and wheelchair. During observation on 5/29/24 at 11:43 a.m., R4 was seated in a wheel chair in the dining room. R4 was wearing red gripper socks on both feet, no Prevalon boots. During interview on 5/29/24 at 11:58 a.m., licensed practical nurse (LPN)-A stated R4 was supposed to be wearing Prevalon boots. At 12:13 p.m. NA-A was asked about the Prevalon boots and said R4 should be wearing them. At 12:14 p.m. a Prevalon boot was observed in a box at the end of R4's bed. During observation on 5/30/24 at 9:03 a.m., R4 was seated at the table in the dining room wearing gripper socks but no Prevalon boots. During observation of R4's room at approximately 9:45 a.m., R4's bed did not have an air mattress and the Prevalon boot was in a box at the end of his bed. During interview on 5/30/24 at 9:48 a.m., NA-B stated R4 had a wound on his heel. NA-B said R4 would say no to the boots in the morning but would allow them in the afternoon. NA-B said if he refused staff would tell the nurse and the nurse would document at the end of the shift. R4's medical record lacked documentation that R4 refused the Prevalon boots. During interview on 5/30/24 at 11:20 a.m., registered nurse (RN)-A and the director of nursing (DON) were interviewed. RN-A stated R4 had Prevalon boots he was supposed to wear due to his heel ulcer. RN-A said R4 used them in bed but would try to take them off when he was in the chair but she still expected staff to offer them. RN-A stated the air mattress had been removed when R4 had been discontinued from hospice cares and had not been replaced. RN-A and the DON acknowledged R4's medical record lacked evidence he refused the Prevalon boots. Facility Policy Prevention and Treatment of Skin Breakdown dated 2018, indicated if a resident is admitted with impaired skin integrity or a new pressure ulcer wound develops the licensed nurse implements the following items: Evaluate current pressure reduction interventions and revise resident centered care plan. Re-evaluate plan of care as appropriate. Documentation reflects areas addressed above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed demonstrate root cause analysis, failed to perform ongoing analysis and failed to implement individualized interventions to reduce the risk for falls for 1 of 3 resident (R5) who sustained multiple falls since admission to the facility. Findings include: R5's Resident Face Sheet indicated she admitted to the facility on [DATE], with diagnosis that included failure to thrive, weakness, cognitive deficits and a history of falls. R5's Observation Detail List Report dated 3/13/24, indicated she was alert and oriented, had adequate vision and required the use of assistive devices, impaired mobility and/or assist with toileting. Medication use included antihypertensives. History of falls in the last three months indicated none. Fall risk score was seven which indicated R5 was not at risk for falls. Observation Detail List Report dated 3/30/24, indicated R5 sustained one to two falls in the past three months and indicated a score of 9 which indicated R5 was not at risk for falls. R5's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition, did not refuse cares and indicated she required substantial/maximal assistance for toileting and partial/moderate assistance for transfers. The MDS indicated R4 had sustained two or more falls since the prior assessment. R5's care area assessment dated [DATE], identified falls. Conclusions about the root cause, contributing factors related to previous falls was left blank. Clinical performance limitations: balance, gait, strength, muscle endurance; was left blank. Medications; left blank. Internal risk factors, circulatory; left blank. Internal risk factors, neuromuscular/functions; left blank. All other internal risk factors left blank. Environmental factors left blank. Analysis indicated R5 triggered for falls related to needing assistance with cares, mobility, toileting, incontinence due to urinary tract infection, anemia, obesity, cognitive decline. Call light in reach and remind to use it. History of frequent falls at home. R5's care plan dated 4/10/24, identified a risk for falls. The care included the following interventions implemented on 3/18/24: call light and personal items in reach, ambulation to promote strengthening, room free from clutter, adequate lighting, bed low/appropriate height to res feet on floor, toilet upon rising, before and after meals, in the evening and overnight as needed, grab bars, gripper socks on when in bed. 3/20/24, the care plan was updated to include offer toileting if awake at 5:00 a.m. R5's Event Reports and correlating Resident Progress Notes identified the following falls: 3/18/24 at 5:05 a.m., R5 was found on the floor in her bathroom. R5 reported she was trying to get to the bathroom. Progress note dated 3/20/24, indicated the interdisciplinary [NAME] (IDT) met to review the fall and intervention to toilet R5 in early morning hours was implemented. 3/28/24 at 7:56 a.m., R5 was found on the floor in her room. R5 reported she went to get clothes from her closet and her legs gave out causing her to slide to the floor. Progress note dated 4/1/24, indicated IDT met to review the fall. On assessment R5 was lying on her back on the floor with her feet stretched toward the nightstand and her head on a pillow. Actual time of the fall was unknown. R5 was able to verbalize her needs but did not use the call light consistently. R5 was re-educated on call light use and waiting for assistance. Writer offered resident to be assisted to wake early and she refused. 4/14/24 at 12:58 p.m., R5 fell in her room. R5 reported she was trying to get her shoes from under her bed. Progress note dated 4/16/24, indicated IDT met to review the fall. R5 reported she was trying to reach her shoes using the reacher. Call light was within reach but R5 had not used it, R5 was reminded to use call light and request assistance. 4/16/24 at 8:32 a.m. R5 fell in her bathroom. R5 reported she was changing her clothes. Progress note indicated on 4/23/24, IDT met to review the fall. Staff reported R5 had her bathroom light on and was calling for help. R5 reported she slipped from the toilet. R5 was educated on using the call light and waiting for assistance. Signage was placed in the room to remind R5 to ask for assistance. 4/27/24 at 6:06 a.m. R5 fell in her room. R5 reported she was trying to get to the bathroom. 4/29/24 at 5:50 a.m. R5 fell in her room and was unable to report what she was trying to do. R5 had a laceration below her right eyebrow. R5's Resident Progress Note dated 5/2/24, indicated IDT met to review falls on 4/27/24 and 4/29/24. The first fall R5 was observed sliding down the bed and fell before staff could intervene. The second fall R5 was observed lying on the floor next to her bed and was unable to state what she was trying to do. R5's gown was saturated with urine. R5 sustained a 2.5 centimeter laceration to her right eye that was actively bleeding. R5 was alert with intermittent confusion as evidence by R5 sating she could take herself in the bathroom and dress herself. R5 agreed to to allow staff assist but would forget to ask. Continue to remind R5 to ask for help and wait. 5/4/24 at 3:13 p.m. fell in her room. R5 reported she came from the bathroom and was about to sit in the wheelchair and lost her balance. Progress note dated 5/13/24, indicated IDT met to review the fall. R5's call light had not been used. Staff will continue to educate on call light. 5/15/24 at 2:19 p.m. R5 fell in her room and reported she had been transferring from the bed to the wheelchair and lost her balance. Progress note dated 5/28/24, indicated IDT met to review the fall. Staff reported R5 was observed on the floor at 12:10 p.m. by another staff who was passing by. Call light was not used and wheelchair was not locked. R5 had signage in room to ask for assistance which was not being utilized due to R5's impaired cognition. No additional intervention was identified. During observation on 5/30/24 at 8:48 a.m., R5 was lying in bed with her eyes closed. At 10:00 a.m. R5 was up in her wheelchair in the dining room. During interview on 5/30/24 at 10:00 a.m., R5 stated she had been at the facility for about a year and said it was going well. R5 stated she usually got up early, but not today. R5 denied having any concerns related to falling. During interview on 5/30/24 at approximately 10:10 a.m., NA-C said she was on-call and did not know R5 very well. NA-C said she did not know R5's fall interventions but could look on the care plan to find them. During interview on 5/30/24 at 10:14 a.m., NA-D stated she was not normally working when R5 fell. NA-D stated R5's fall interventions included a low bed, toilet her as much as possible and letting her know her call light was in reach. NA-D stated R5 could use her call light and did well waiting and being patient. NA-D said R5 was a late sleeper and if they got her up early she fell asleep in her chair. On 5/30/24 at 11:30 a.m. the director of nursing (DON) and registered nurse (RN)-A were interviewed. The DON stated the IDT met daily Monday through Friday to review falls. The DON stated they reviewed the cause of the falls, if an injury occurred and if the care plan had been followed at the time of the fall. The DON said they established the root cause of the fall then brainstormed possible interventions. RN-A stated R5 admitted on [DATE] and fell on 3/18/24. RN-A said at that time they were just getting to know her and her routine. The DON said they implemented toileting in the early morning and encourage call light use. The DON stated when R5 fell again they determined she did not use her call light consistently so they provided re-education. When asked about further intervention, RN-A stated the signage reminding R5 to use her call light was removed because it had not been effective. The DON stated he had been talking to the corporate office to tell them interventions were not working and ask what they thought was best. In regard to performing ongoing analysis of R5's falls, the DON stated they performed an assessment when the residents admitted and said they had planned to review R5 this week. Facility Policy Integrated Fall Management dated 20xx, indicated residents are assessed for their risk for falls upon admission, significant change and quarterly, Residents with risk for falling will have interventions implemented through the resident centered care plan. Residents at risk for falls have an individualized, resident centered care plan developed. Interventions are based on the finding of the fall risk assessment. The IDT reviews the falls and and may if needed implement additional interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 3 residents (R2) reviewed for activities of daily living. Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and R2 required moderate assistance with personal hygiene (helper does less than half the effort). R2's Diagnosis List printed 3/11/24, indicated diagnoses of dementia and muscle weakness. R2's Provider Order dated 1/26/24, directed staff to provide R2 with feeding assistance for meals three times daily. R2's care plan dated 10/10/23, indicated R2 required assistance with grooming and bathing. On 3/8/23 at 1:03 p.m., R2 was observed in his wheelchair in the dining room. R2's clothes were soiled with white substance splattered on his pajama pants, and food stains on his shirt. R2's fingernails were also observed to be dirty, with brown substance under them. On 3/8/24 at 2:19 p.m.,family member (FM)-A stated R2 would not have liked to be seen in dirty clothes. FM-A stated she trimmed R2's nails every two weeks because, they are always dirty and have blood in them. It makes him feel good. He is concerned about being well kept. When he gets taken care of, he gets so happy, and is so appreciative when I clean his nails or when he gets a haircut. He used to be in the military and liked to look good. FM-A further stated R2 did not use a clothing protector when he ate, and the meal from 3/7/24, was all over him hours after the meal. It was like four to five hours after the meal. He has his pride and wouldn't want to look like that. I just want to make sure he is kept clean and neat. On 3/8/24 at 3:18 p.m., R2 nails remained dirty with brown matter under the nails, and he was still wearing the soiled shirt. On 3/8/24 at 3:23 p.m., nursing assistant (NA)-A stated NAs provided nail care when they did baths. NA-A stated R2's bath was scheduled on Friday evening. NA-A stated R2's daughter cut R2's nails, but NAs cleaned them, and nails can be cleaned any day if they were dirty. NA-A acknowledged R2's shirt and nails were dirty and stated, It's not good. I wouldn't feel comfortable in dirty clothes. It doesn't look good. It affects how they feel. He still knows what he looks like. On 3/11/24 at 8:30 a.m., R2 was sitting in the dining room. R2's fingernails on both hands were dirty with brown substance under them. On 3/11/24 at 11:22 a.m., during an observation R2 ate tomato soup, spilled soup on his shirt, and tried to wipe it off with a napkin. On 3/11/24 at 11:54 a.m., NA-C stated R2's nails and shirt were dirty, and the NAs should change the shirt when it was dirty. NA-C stated nails should be cleaned when R2 had a bath. NA-C stated, [The fingernails] can get cleaned anytime. He scratches himself. It's not good to look like that. R2 looked at NA-C and stated, They are filthy. On 3/11/24 at 2:29 p.m., registered nurse (RN)-C stated cleaning nails was an expectation during bath time and as needed. RN-C stated if R2's clothing was soiled, the clothing should have been changed. On 3/11/24 at 3:49 p.m., the director of nursing (DON) stated, When the resident has dirty clothes on, the staff should offer clean clothes. Nail care is on shower days and as needed. If [R2] called the staff member's attention to it [dirty nails], they should have helped the resident to clean them. The person would not feel good to wear dirty clothes or have dirty nails. Well, that would make him feel uncomfortable. A policy on dignity was requested and not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to implement the comprehensive care plan that included interventions to assist with eating for 1 of 3 residents (R2) reviewed for activities of daily living. Findings include: R2's significant change Minimum Data Set, dated [DATE] indicated R2 had severe cognitive impairment. R2's Provider Order dated 1/26/24 directed R2 to receive feeding assistance for meals. R2's care plan dated 10/10/23 indicated R2 had inadequate oral intake related to a history of poor appetite and impaired cognition, and R2 required assistance for meal with supervision and encouragement. On 3/8/24 at 4:12 p.m., R2 was observed in the dining room. At the table there was milk, water, an empty jello bowl (which R2 had consumed) and a plate that contained corn, fish, and potatoes. A nursing assistant opened R2's tartar sauce and buttered the bun on his plate. R2 attempted to eat one bite of corn and it dropped down the front of himself. R2 ate his bun, drank his water and milk, and did not attempt to eat the corn, fish or potatoes. Dining staff brought R2 an ice cream cup, removed the lid and R2 proceeded to eat it. At 4:33 pm NA-D took R2's plate. No staff encouraged R2 to eat his meal. On 3/11/24 at 11:22 a.m., R2 ate tomato soup, spilled soup on his shirt, and tried to wipe it off with a napkin. No staff encouraged R2 to eat his meal. On 3/11/24 at 11:42 a.m., family member (FM)-A stated, No one offered to help him [R2] with his fruit [bowl of peaches]. They only help at the table with the people they sit by. On 3/11/124 at 11:50 a.m., NA-B stated, He doesn't need any assistance. We just give him his food. I did not know he needed encouragement with his meal. On 3/11/24 at 3:49 p.m., the director of nursing (DON) stated when a resident required assistance with eating, staff should assist the resident with eating. The facility policy Resident/Family Participation in Care Planning dated 11/28/17 directed care planning included decisions about care and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide quarterly interdisciplinary team (IDT) care conferences for 1 of 5 residents (R6) reviewed for care plan timing and revision. Findings include: R6's quarterly MDS dated [DATE], indicated R6 had severe cognitive impairment. R6's medical record indicated quarterly care conferences were held on 3/23/23 and 6/22/23. No care conferences had been held since that time. On 3/11/23 at 2:29 p.m., registered nurse (RN)-C stated the facility typically performed a care conference for each resident the first week after admission, quarterly, and as needs arose. RN-C acknowledged R6 missed several care conferences. On 3/11/24 at 3:24 p.m., the social worker (SW)-A stated, We have recently had some changes, and one employee didn't work out, partly because she wasn't having and documenting care conferences. SW-A further acknowledged there were no notes for R6's care conferences after 6/22/23, and no care conferences were scheduled for R6. SW-A stated care conferences should be scheduled quarterly. On 3/11/24 at 3:49 p.m., the director of nursing (DON) stated the care conferences should be held quarterly and as needed. The facility policy Resident/Family Participation in Care Planning dated 11/28/2017, directed the resident had the right to participate in planning care and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure nail care and feeding assistance was provided for 1 of 3 residents (R2) reviewed for activities of daily living (ADLs). Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], indicated R2 had severe cognitive impairment, required supervision for eating, and moderate assistance with personal hygiene. R2's Provider Order dated 1/26/24, directed staff to provide feeding assistance for meals three times daily. R2's Provider Order dated 1/19/24, directed R2's bath day was Friday, and Licensed nurse to complete body audit on resident bath day and document nail[s] in task. R2's care plan dated 10/10/23, indicated R2 required assistance for meal with supervision and encouragement. On 3/8/24 at 1:05 p.m., registered nurse (RN)-A stated R2 used to eat independently but now required assistance. RN-A stated, We encourage [R2] and sometimes have to just get [R2] get started [to eat.]. [R2] doesn't have the appetite he used to. Staff has to be next to [R2] when he is eating. On 3/8/24 at 2:19 p.m., family member (FM)-A stated R2 had dementia and required assistance in nail care. FM-A stated she cut R2's nails every couple of weeks, but staff should have been cleaning R4's nails in between cutting, during bath time. FM-A stated R2's nails were dirty and had brown matter under them. On 3/8/24 at 3:23 p.m. nursing assistant (NA)-A stated R2's daughter cut his nails, but staff cleaned them. NA-A acknowledged R2's nails were dirty and stated, It's not good. It doesn't look good. It affects how they feel. He still knows what he looks like. On 3/8/24 at 4:12 p.m., R2 was observed in the dining room. At the table there was milk, water, an empty jello bowl (which R2 had consumed) and a plate that contained corn, fish, and potatoes. A nursing assistant opened R2's tartar sauce and buttered the bun on his plate. R2 attempted to eat one bite of corn and it dropped down the front of himself. R2 ate his bun, drank his water and milk, and did not attempt to eat the corn, fish or potatoes. Dining staff brought R2 an ice cream cup, removed the lid and R2 proceeded to eat it. At 4:33 pm NA-D took R2's plate. No staff encouraged R2 to eat his meal. On 3/11/24 at 11:22 a.m., R2 was observed eating tomato soup. R2 spilled soup on his shirt. R2 tried to wipe the soup off his shirt with a napkin. No staff encouraged R2 to eat his meal. On 3/11/24 at 11:42 a.m., FM-A was present during the mid-day meal and stated, No one offered to help with fruit [bowl of peaches]. They only help at the table with the people they sit by. Three staff was observed sitting at one table helping other residents eat. On 3/11/24 at 11:50 a.m., NA-B asked R2 if he was done with his meal, R2 nodded yes. NA-B removed R2's peaches without offering encouragement or assistance to eat them. NA-B stated she did not know R2 required assistance or encouragement to eat. On 3/11/24 at 11:54 a.m., NA-C stated R2 required assistance to eat, but acknowledged staff had not helped R2 eat lunch. NA-C stated R2 ate better with encouragement. NA-C also acknowledged R2 had dirty fingernails. On 3/11/23 at 2:29 p.m., RN-C stated R2 required assistance eating and verified it was in R2's care plan. On 3/11/24 at 3:49 p.m., the director of nursing (DON) stated when a resident required assistance with their meals, if the assessment and care plan indicated they needed assistance, the resident should be assisted. The DON stated nail care was performed on shower days and as needed. The DON stated, The resident would not feel good to wear dirty clothes or have dirty nails. Well, that would make him feel uncomfortable. The facility policy Activities of Daily Living dated June 2021, directed residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed follow safeguards in place to ensure residents received the correct medications for 1 of 3 residents (R4) reviewed for medication error. Findings include: R4's Medicare 5-Day Minimum Data Sheet (MDS) dated [DATE] indicated R4 was cognitively intact. R4's Diagnoses List printed 3/11/24, indicated R4 had a diagnosis of glaucoma in both eyes. R4's Provider Orders dated 8/29/23, indicated brimonidine drops (used to lower pressure in the eyes related to glaucoma), 0.2%, administer one drop in each eye twice daily. R4's care plan printed dated 8/30/23, indicated administer medications per doctor's order. On 3/11/24 at 10:22 a.m., R4 stated on 9/7/23, she administered her own eye drops that were left on her tray table by licensed practical nurse (LPN)-A. R4 stated she then discovered they were for someone else. R4 stated the nurse notified the provider, and R4's own eye drops were held for one dose as a result. R4 denied any ill effects from using the wrong eye drops, and flushed her own eyes after she realized the drops were not her medication. On 3/11/24 at 1:05 p.m., registered nurse (RN)-B stated R4 administered her own eye drops on 9/7/3 at 8:10 p.m., but instead of the prescribed bromodine eye drops, R4 administered dorzalamide eye drops (used to lower pressure in the eyes related to glaucoma). RN-B acknowledged R4 had received another resident's eye drops. RN-B stated R4 had not been assessed to ensure R4 could safely administer her own eye drops. RN-B stated licensed practical nurse (LPN)-A should not have left the room prior to the eye drop administration, and should have checked to ensure R4 had been given the correct medication. RN-B stated LPN-A set up two residents' medications at the same time, and had delivered the wrong medication to R4. On 3/11/24 at 3:49 p.m., the director of nursing (DON) verified R4 received the wrong eye drops on 9/7/23. The facility Administering Medications Policy dated February 2019, direted medications were administered by licensed nurses or trained associates after ensuring the right resident had the right medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dignity was maintained for 1 of 2 residents (R241) who had incontinent episodes due to lack of timely staff response to assist with toileting. Findings include: R241's admission Minimum Data Set (MDS), dated [DATE], indicated R241 was cognitively intact, required extensive 2-person physical assistance with transfers and toileting and was always continent of bowel and bladder. R241's diagnoses included periprosthetic fracture around internal prosthetic right hip joint (complications following total hip replacement and revision), and left knee pain. R241's care plan (CP) dated 8/25/23, indicated R241 had impaired ability to transfer and required two-persons physical assist with EZ aide lift. The care plan further indicated R241 had potential for alteration in bowel and bladder related to her diagnoses and instructed staff to assist R241 to the toilet upon rising in the morning, before and after each meal, at bedtime and on night rounds and as needed. R241's progress note dated 8/24/23 at 10:39 p.m., indicated, R241 is continent of bowel and bladder. Mode of transfer is assist of 2 with walker+ gait belt + brace on. R241's progress note dated 8/25/23 at 11:40 p.m., indicated, R241 was alert and oriented times four and required assists with EZ-stand continent with bowel and bladder. R241's progress note dated 8/25/23 at 12:32 a.m., indicated R241 was continent of bowel and bladder. Needs extensive assistance with toileting. R241's progress noted dated 9/3/23 at 7:10 p.m., indicated R241 was two assist with transfer and incontinent with bowel and bladder. R241's progress noted dated 9/5/23 at 11:36 p.m., indicated R241 was occasionally incontinent of bowel and bladder due to functional status. During interview on 9/11/23 at 7:13 p.m., R241 stated had two episodes of incontinence since admission and felt awful, embarrassed and demoralizing after waiting for staff to assist with toileting. R241 stated staff would respond to the call light timely but turn it off and say they needed to go get help and would not return for 30 minutes or more. R241 stated she often kept hitting the call light, but they would just continue to turn it off without assisting her to the toilet. During interview on 9/13/23 at 8:10 a.m., R241 stated staff did not round regularly to offer toileting and relied on her to notify them by activating her call light. R241 further stated sometimes staff took forever to return and on those two instances, did not return in time forcing her to be incontinent. During interview at 9/13/23 at 9:11 a.m., nursing assistant (NA)-G stated R241 required two-person assistance with the EZ aide lift for transfers. NA-G further stated staff relied on R241 to use the call light to notify them of her need to toilet since she was fully cognitively intact. NA-G stated, There may have been a couple times I may have been serving [meals] and the other aide was busy, and we did not get there in time and she would be incontinent. NA-G further stated R241 had the ability to hold it and be continent, but a couple accidents happened. During interview on 9/13/23 at 11:22 a.m., registered nurse (RN)-A stated R241 required two-person assistance with the EZ aide lift for transfers and toileting and she was continent of bowel and bladder. RN-A stated R241 could use the call light to request assistance to toilet when needed. During interview on 9/13/23 at 11:28 a.m., RN-B stated R241 had occasionally been incontinent due to being in too much pain to hold it. RN-B further stated staff should be toileting R241 in the morning, before and after meals, at bedtime and rounded on throughout the night as requested. RN-B further stated expectation was for staff to respond to R241's requests to toilet timely. During interview on 9/13/23 at 11:53 a.m., director of nursing (DON) stated staff should be offering R241 to toilet before and after meal service, and if requested during the meal service, staff should make toileting a priority. DON further stated an incontinent episode involving a continent resident could cause the resident to feel undignified. Facility policy Activities of Daily Living (ADL) dated 6/21, indicated staff would assist residents with mobility and elimination when they were unable to carry out such activities independently. Facility policy Call Lights dated 5/17/16, indicated staff should answer call lights promptly and turn off the call light only after the resident's request was met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to assess 2 of 2 residents (R1, R70) for self-administration of medications, reviewed for medication found in rooms during survey. Findings Include: R1's significant change Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact, with diagnosis that included hyperlipidemia, thyroid disorder and arthritis. R1's fall care plan dated 9/1/23, indicated R1understood medications had the potential for side effects and drug interactions related to R1's pyelonephritis (a bacterial infection causing inflammation of the kidneys), with interventions that included: preferred for staff to monitor side effects or drug interactions for current medications and report abnormalities. R1's face sheet undated, diagnosis included, dry eye syndrome (condition that occurs when your tears aren't able to provide adequate lubrication for your eyes) of unspecified lacrimal gland of unspecified lacrimal; Vitamin deficiency, unspecified, gland; and other seasonal allergic rhinitis (disease characterized by symptoms of nasal congestion, clear rhinorrhea, sneezing, postnasal drip, and nasal pruritis). R1's physician orders dated 8/08/2023, included preserVision AREDS, 1 tablet by mouth for dry eye syndrome of unspecified lacrimal gland (tear-shaped gland with the primary function of secreting the aqueous portion of the tear film, thereby maintaining the ocular surface); give twice a day. R1's physician orders lacked an order for cetrizine hydrochloride10 milligrams (mg) and melatonin 5 mg until 9/14/23, after surveyor had asked about medications found in R1's room. R1's medical record lacked documentation of a self-administration of medication for R70. During observation and interview on 9/12/23 at 3:06 p.m., one bottle of melatonin 5 milligram (mg) and one bottle predserversion areds 2, 100 soft gels tabs was noted on R1's bed side table. R1 stated takes the melatonin at night a few times a week when roommate is loud, and takes the predserversion areds 2 about one to two times weekly. During observation on 9/13/23 at 7:42 a.m., one bottle of equate allergy relief tabs, cetrizine hydrochloride 10 mg antihistamine, expiration date of 10/23, was on top of R1's dresser in basin; on top of a tooth brush and tooth paste. During observation on 9/13/23 at 8:19 a.m., predserversion areds 2 100 soft gels tabs was found in a kleenex box on top of a wooden dresser in R1's room. During observation on 9/14/23 at 9:46 a.m., one bottle of melatonin 5 mg, with expiration date of 10/25, was on R1's bedside table which was placed over the bed. There were approximately over 30 pills in the 5 mg melatonin bottle. Approximately over 50 pills were noted in the predserversion areds 2 100 soft gels bottle. Also found one bottle equate allergy relief tabs/ cetrizine hydrocloride 10 mg tab expiration date of 10/23, with approximately 50 pillsR1's room. During interview on 9/13/23 at 8:25 a.m., nursing assistant (NA)-K stated did not observe medications in R1's room and had not seen any medications in room prior. During interview on 9/14/23 at 10:17 a.m., clinical manager, registered nurse (RN)-D stated R1 was a recent admit in the last month and the predserversion and melatonin could have come in with R1; R1did not give medications to the facility. RN-D verified medications were in the room and should not have been. R1 did not have an order for the allergy pill but had placed a call out for an order. RN-D also verified R1 did not have a SAM completed, to self administer her medications. R70's significant change Minimum Data Set (MDS), dated [DATE], indicated R70 had moderate cognitive impairment, with diagnosis that included diabetes mellitus and received insulin injections in the previous seven days of the assessment period. R70's care plan updated 4/28/23, indicated R70 received medications which placed her at a high risk for adverse reactions: Basaglar Kwik Pen Insulin, fluoxetine, insulin aspart, methylphenidate HCl and venlafaxine. R70's care plan lacked reference to resident self-administration of medications (SAM). R70's face sheet printed 9/15/23, had diagnosis that included Type 2 diabetes mellitus without macular edema, bilateral, with mild nonproliferative diabetic retinopathy (the early stage of the disease in which symptoms will be mild or nonexistent and the blood vessels in the retina are weakened. Tiny bulges in the blood vessels, called microaneurysms, may leak fluid into the retina.) R70's physician order dated 5/21/23, indicated Basaglar KwikPen U-100 Insulin (insulin glargine) insulin pen; 100 unit/ milliliter (ml) (3 ml); amount: 30 units subcutaneous; diagnosis: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy; without macular edema, bilateral; give once during am medication pass. R70's medical record lacked documentation of a self-administration of medication for R70. During observation on 9/12/23 at 9:00 a.m., Basaglar Kwik Insulin Pen was noted lying on R70's bedside table. Label on insulin pen was faded and unable to find a name on Basaglar insulin pen when reviewed. Insulin pen had approximately 10 to 20 mls of Insulin in the pen lying on R70's bedside table. There was no needle attached to the insulin pen. During observation on 9/12/23 at 9:25 a.m., Basaglar Kwik Insulin Pen was noted lying on R70's bedside table. Label on insulin pen was faded and unable to find a name on the pen label. Insulin pen had approximately 10 to 20 mls of Insulin in the pen lying on the bedside table. There was no needle attached to insulin pen. During observation on 9/12/23 at 10:09 a.m., the insulin pen was no longer on R70's bedside table. During interview on 9/12/23 at 3:21 p.m., registered nurse (RN)- E stated had found the insulin pen after entered into R70's room to administer morning medications. RN-E further explained, found Basagaglar Kwik Insulin pen on R70's bedside table, but was not the one who had left it on the bedside table. RN-E also stated when the insulin pen was found on R70's bed side table during R70's medication administration, the Basaglar Kwik insulin pen was removed out of R70's room and discarded. RN-E stated insulin pens and other medications should not be left in resident's room unless there is a self-administration of medication assessment completed. During interview on 9/14/23 at 10:17 a.m., clinical manager, RN-D verified had been informed of R70's insulin pen found in room on bed side table and had begun the investigation with the staff to determine who had left the insulin pen in the R70's room. RN-D verified R70 did not have a SAM assessment completed. During interview on 9/14/23 at 3:24 p.m., corporate nurse consultant (CNC) stated staff were expected not to leave any medications in resident's rooms and staff may have possibly not noticed the insulin pen had been left on R70's bed side table. CNC also stated all staff were aware to let the supervisor know if medications were found in resident's rooms. The facility Self-Administration of Medications policy updated 2020, indicated the nursing associates will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Assessment is documented in the electronic health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to assess and reassess for potential restraints for 1 of 1 resident (R43) reviewed for perimeter mattress use. Findings include: R43's annual Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and a diagnosis of vascular dementia. R43 had not rejected cares, required total assist with bed mobility and transfers, and had no restraints. R43 had no falls since the prior assessment. R43's care plan dated 6/21/23, identified a risk for falls but lacked the intervention of a perimeter mattress (a mattress with raised edges). R43's Physician Order Report dated 8/14/23 through 9/14/23, lacked an order for perimeter mattress or corresponding medical symptom for the device. R43's progress note dated 4/12/21 at 10:10 a.m., identified R43 had a fall out of bed on 4/9/21, and a perimeter mattress was placed. There was no corresponding assessment to determine if the perimeter mattress was a potential restraint. R43's Restraint/Adaptive Equipment Reduction assessment dated [DATE], lacked a description of any adaptive equipment or restraints in use. R43's Restraint/Adaptive Equipment Reduction assessment dated [DATE], identified with a check mark only grab bars were in place. Perimeter mattress was an option but was not checked. R43's Event History dated 4/1/21 through 9/14/23, identified the last recorded fall from bed occurred on 5/30/22. R43 had no falls during the past one year and three and a half months. During an observation on 9/11/23 at 12:55 p.m., R43 was in bed with a perimeter mattress in place. During an interview and observation on 9/11/23 at 4:08 p.m., nursing assistant (NA)-E and NA-F stated R43 was cooperative with cares, had not tried to get out of bed recently, and they were not sure what the perimeter mattress was for. NA-E and NA-F stated R43 was able to move her arms and legs and had not had a decline in her abilities. NA-E and NA-F assisted R43 out of bed using the ceiling lift. R43 had not participated in the process though instructions were provided by the NA's. During multiple observations on 9/12/23 at 8:28 a.m., 9/12/23 at 1:48 p.m., 9/13/23 at 7:28 a.m., and 9/13/23 at 2:28 p.m., R43 was in bed and had not made attempts to get out of bed. During an interview on 9/14/23 at 8:18 a.m., licensed practical nurse (LPN)-A stated R43 had tried to get out of bed in the last six months but had not attempted recently. During an interview on 9/14/23 at 8:18 a.m., the assistant director of nursing (ADON) stated R43's perimeter mattress was placed after a fall on 4/12/21. The ADON stated physical devices and potential restraints were supposed to be reviewed quarterly. The ADON reviewed R43's assessments and agreed the perimeter mattress had not been initially assessed or reassessed as a potential restraint or for ongoing appropriateness of use. During an interview on 9/14/23 at 2:00 p.m., the corporate nurse consultant (CNC) stated R43's assessments lacked the perimeter mattress evaluation. Additionally, potential restraints and physical devices should be assessed quarterly and with significant changes. The facility policy titled Adaptive Equipment dated 1/2015, identified concave mattresses as adaptive equipment which required assessments annually, quarterly, with a significant change and as needed to ensure the safe use of adaptive equipment to aid in resident's mobility, and to prohibit the use of adaptive equipment as restraints unless necessary to treat a resident's medical symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a significant change in status Minimum Data Set (MDS) was completed in a timely manner after hospice services were initiated for 1 of 1 resident (R24) reviewed for significant change. Findings include: The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2019, identified a comprehensive MDS assessment included completion of the MDS along with the corresponding Care Area Assessment (CAA) and subsequent care planning. The manual outlined such MDS(s) included admission, annual, significant change in status (SCSA), and significant correction to prior comprehensive MDS(s). A table was provided to demonstrate the time periods allowed for such assessments to be completed. This identified a SCSA should have a reference date established within 14 days of determining a significant change has occurred. Further, a section labeled, Significant Change in Status Assessment (SCSA), outlined such assessment must be completed when the interdisciplinary team (IDT) has determined a resident meets the criteria for a major improvement or decline adding, A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program . The ARD [assessment reference date] must be within 14 days from the effective date of the hospice election . A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. R24's admission MDS, dated [DATE], identified R24 admitted to the facility on [DATE]. The MDS section labeled, Section O - Special Treatments and Programs, outlined treatments and programs, including hospice care, to be selected and indicated on the MDS. This was marked, Z. None of the above. R24's physician's orders dated 6/29/23, indicated admit to hospice. R24's care plan dated 6/29/23, indicated R24 elected the hospice benefit on 6/29/23. R24's nursing progress note dated 6/23/23 at 10:43 a.m., indicated the assistant director of nursing discussed hospice with R24's family and R24's family were in agreement to pursue an order for a hospice evaluation and treatment. R24's nursing progress note dated 6/23/23 at 3:13 p.m., indicated an order for a hospice evaluation and treatment was received. R24's nursing progress note dated 6/29/23 at 6:33 p.m., indicated R24 was admitted to hospice. During interview on 9/12/23 at 2:08 p.m., licensed practical nurse (LPN)-B stated R24 was on hospice care. During interview on 9/13/23 at approximately 11:00 a.m., registered nurse (RN)-C stated a SCSA MDS was completed when a resident is at the facility and elects the hospice benefit. RN-C stated the significant change MDS has to be completed and submitted by day 14 and verified R24 was admitted to the facility on [DATE], and enrolled into hospice on 6/29/23. RN-C further stated a significant change MDS should have completed. During interview on 9/13/23 at 11:16 a.m., the director of nursing (DON) verified R24 enrolled into hospice on 6/29/23, and the significant change MDS was never completed. A policy, Comprehensive Assessments and Care Planning dated 2017, indicated a significant change assessment was appropriate if there was a consistent pattern of changes, with 2 or more areas of decline, 2 or more areas of improvement, or 1 area of improvement/decline that required extensive care plan revision which may include 2 areas within a particular domain such as activities of daily living (ADL) decline or improvement. Additionally, the facility had 14 days from the time a significant change was identified, to the time of the assessment reference date (ARD) (the last day of the observation or look back period the assessment covers for the resident). The policy lacked information identifying a significant change in status assessment was required when a resident enrolled in a hospice program and the ARD must be completed within 14 days from the effective date of the hospice election.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to offer and/or provide a written copy of the baseline care plan to the resident for 1 of 1 resident (R137) reviewed for baseline care plan. Findings include: R137's undated census report identified an admission date of 9/5/23. R137's admission Minimum Data Set (MDS) dated [DATE], identified a diagnosis of left thigh bone fracture. R137 made herself understood and had clear comprehension. R137 required extensive assist with transfers, dressing, hygiene, and toileting. R137 was independent with eating. R137 expected to be discharged to the community. R137's care plan dated 9/7/23, lacked discharge planning goals. During an interview on 9/11/23 at 12:21 p.m., R137 stated she was admitted to the facility on [DATE], (seven days ago) and her main goal was to discharge home as soon as possible. R137 stated she was not provided a copy of her baseline care plan and wanted one. R137 stated there had been no communication of her goals, care needs or discharge planning. R137 stated she received conflicting information from staff on how much assistance with activities of daily living she required. During an interview on 9/14/23 at 12:15 p.m., the director of social services (DSS) stated R137 should have had a care conference and had her baseline care plan provided within the first five days following admission and had not because the primary case manager was out of the office. The DSS said it was important to implement discharge planning timely in the transitional care unit (TCU) due to the short term stay expectation. During an interview on 9/14/23 at 2:00 p.m., the corporate nurse consultant (CNC) stated social services was responsible to provide the 48-hour care plan to the resident. The facility policy titled Care Planning dated 11/21/16, identified a temporary care plan should be developed within 48 hours of admission and provided to the resident or representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to update care plans for 1of 2 residents (R53) reviewed for falls. Findings Include: R53's quarterly Minimum Data Set (MDS) dated [DATE], had diagnosis that included progressive neurological conditions, hypertension and Non-Alzheimer's Dementia. R53 was cognitively impaired. R53 had two falls without injury since admission, took antidepressants and opioids seven days in the look back period. R53's face sheet printed 9/15/23, indicated diagnosis included unspecified fall, subsequent encounter, for other orthopedic aftercare status post hip fixation and pinning; and repeated falls. R53's falls events documentation: -2/26/23 at 3:50 p.m.; no injury: interventions: encourage to have staff assist her as much as possible - 3/5/23 at 5:57 a.m.; no injury: immediate intervention left blank; - 3/12/23 at 10:21 a.m; no injury; intervention: every two hours check and encouragement of using her call light at all times. - 4/1/23 at 5:56 p.m.; no injury; intervention: no care necessary - 4/5/23 at 2:16 a.m.; no injury noted: no care necessary - 4/15/23 at 10:51a.m.; no Injury; intervention: no care necessary - 4/25/23 at 9:28 p.m.; no injury; interventions: no care necessary; rest - 5/3/23 at 2:49 p.m.; no injury; interventions: analgesics - 5/5/23 at 9:50 a.m.; no injury; interventions: rest - 5/25/23 at 10:49 a.m.; no Injury;iInterventions: rest - 5/29/23 at 1:52 p.m.; no Injury; interventions: take resident to restroom and transfer her to her bed. - 6/12/23 at 10:43 a.m.; no Injury; interventions: rest - 7/11/23 at 10:21 a.m.; no Injury: no care necessary - 7/12/23 at 9:48 p.m.; no injury: no care necessary - 7/30/23 at 10:41 a.m.; no Injury noted: no care necessary - 8/11/23 at 9:43 p.m.; no Injury; no care necessary - 9/10/23 at 10:19 a.m.; no Injury noted; rest; direct pressure to wound R53 had a total of 17 falls since 2/23; many of the falls lacked interventions with care plan revisions to prevent additional falls. R53's falls care plan updated 7/13/23, indicated R53's goal was to reduce risk for injuries related to falls and had fall interventions which included, call light and personal items within residents reach at all times; keep residents room free from clutter; ensure adequate lighting in resident's room; keep bed low at appropriate height to allow resident's feet to rest flat on floor; toilet resident per care plan; two and a half upper side rails on resident bed to help with mobility and positioning when in bed; gripper socks on when in bed; hip protectors to be worn at all times; wellness director to recommend essential oils to decrease anxiety, restlessness, impulsivity, and pain. R53's falls care plan lacked intervention after each fall. During observation on 9/13/23 at 7:56 a.m., R53 was lying in bed with bed in low position. R53's call light was connected to bed but call button was on the floor and out of R53's reach. During interview on 9/14/23 at 10:28 a.m., nursing assistant (NA)-K stated had dressed R53 for the day during morning cares. NA-K was then asked by surveyor to observe R53's transfer to wheelchair. NA-K informed surveyor, another staff had already completed R53's transfer into wheelchair. NA-K further explained, R53 was dressed by NA-K for the day during morning cares, but explained after questioning by surveyor to verify R53's hip protectors were in place, that although had gotten R53 ready and dressed for the day, R53's hip protectors were not placed during assistance with dressing during morning cares, since the hip protectors were sent to the laundry to be washed and were not available. NA stated this was part of R53's fall intervention but was not placed during morning cares since it was not available. During interview on 9/14/23 at 1:08 p.m., clinical manager, registered nurse (RN)-D stated R53 can be impulsive and does not remember to use the call light. RN-D stated when R53 was taken to the bathroom she would immediately attempt to go to the bathroom by herself. RN-D further stated facility did not always update the care pan unless there was a new intervention put in place. During interview on 9/14/23 at 3:24 p.m., corporate nurse consultant stated most falls typically have a follow up note from the interdiciplinary team and there would be a determination if staff needed to update the care plan. We do not always update the care plan unless there was a new intervention. The facility Comprehensive Assessments and Care Planning policy updated 2017, to provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the RAI specified by the State.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure an ordered hand splint program and range of motion program were provided consistently for 1 of 2 residents (R45) reviewed for positioning and mobility. Findings include R45's quarterly Minimum Data Set (MDS) dated [DATE], identified mildly impaired cognition and diagnosis of a stroke with left sided weakness. R45 had not rejected cares and required extensive assist with bed mobility, transfers, eating and hygiene. R45 had zero days listed of restorative nursing splint/brace programs. R45's care plan dated 7/26/23, identified a left-hand splint was on in the morning and off at bedtime. R45's Physician Order report dated 8/14/23 through 9/14/23, identified a start date of 1/14/20, for left-hand splint on in the morning and off at bedtime. R45's nursing assistant (NA) assignment sheet dated 9/8/23, identified a left-hand splint should be placed on in the morning and off at bedtime. During an observation and interview on 9/11/23 at 2:44 p.m., R45 was seated in his wheelchair next to bed. R45's used his right hand to hold his left hand in place, the left hand was observed to be flaccid with the fingers curved inward. R45 shook his head no when asked if he wore a splint on his left hand. During an observation on 9/12/23 at 1:08 p.m., R45 was brought into his room by two unidentified staff. R45 had no left-hand splint on. During a follow up interview on 9/12/23 at 1:10 p.m., R45 stated yes he had worked with therapy and had not had a left-hand splint on today. During an interview on 9/12/23 at 1:26 p.m., NA-A stated would refer to the NA assignment sheets and care plan for adaptive equipment needs. NA-A stated R45 got a new customized wheelchair about six months ago and since then he was no longer required to wear his left-hand splint. During an interview on 9/13/23 at 11:16 a.m., NA-B stated completed the morning cares for R45 today. NA-B stated she had not put the left-hand splint on today either, and she removed it from the bedside dresser drawer to show the Velcro was not working well so the brace no longer fit well. During an interview 9/13/23 at 11:23 a.m., licensed practical nurse (LPN)-A stated was not sure the last time R45 had his left-hand splint on. LPN-A stated occupational therapy should be updated if the splint was no longer working. LPN-A stated R45 should have the splint on as ordered. During an interview on 9/13/23 at 11:38 a.m., occupational therapist (OT)-A stated had not assessed R45's left-hand splint as there was a nursing order in place. OT-A stated R45 should have it on as ordered and if the splint was not working properly, OT could assess and revise the order if needed. During an observation and interview on 9/13/23 at 1:02 p.m., physical therapy assistant (PTA)-A checked R45's left-hand splint for appropriate fit, which was now on R45's left hand. PTA-A stated the purpose of the splint was to prevent contractures. PTA-A demonstrated how R45's fingers were beginning to curve under and stated the splint would help keep R45's fingers straight and maintain ability to move his hand. R45 nodded yes when asked if the splint felt comfortable. During an interview on 9/13/23 1:32 p.m., the director of rehabilitation (DOR) stated the fit of R45's left-hand splint was okay and since the Velcro was worn, she would order him a new one. During an interview on 9/13/23 at 2:45 p.m., the director of nursing (DON) stated hand splints should be put on as ordered, or if assessed otherwise to notify the provider. The facility policy titled Rehabilitative and Restorative Care dated 2018, identified passive and active range of motion (ROM) and/or splint or brace assistance would be provided as assessed to promote the resident's highest level of independence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to implement fall prevention interventions for 2 of 4 residents (R4 and R53) reviewed for falls. Findings include: R4's Face Sheet form in the electronic medical record (EMR) indicated R4's diagnoses included: unspecified dementia, age related osteoporosis, and a fall on the same level. R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, continuously had disorganized thinking, wandered, required extensive assistance in most activities of daily living (ADLs) including dressing, hygiene, toileting, bed mobility and transfers and was frequently incontinent of urine and bowel. R4's care area assessment (CAA) dated 11/8/22, indicated R4 triggered for falls related to needing assist with cares, mobility, toileting, history of falls, dementia, osteoporosis and scored a 10 on the falls risk assessment. R4's care sheet identified R4 was at risk for falls and indicated R4's environment had to be clutter free, personal items and call light were within reach, the bed was in the low position so R4's feet rested on the floor, place R4's wheelchair by the bed when R4 was in bed to aid in safer transfers due to a history of self transferring. R4's care sheet lacked information regarding placement of shoes. R4's care plan dated 8/8/23, indicated R4 was at risk for falls due to needing assist with cares, mobility, toileting, history of falls, and scored an 11 on the falls risk assessment. Interventions indicated to place the wheelchair near the bed when R4 was in bed due to a history of self transfers to assist with safer transferring ability, keep the call light within reach at all times, keep personal items and frequently used items within reach, provide an environment free of clutter, provide proper well maintained footwear, toilet per POC. R4's nursing progress notes dated 6/12/23 at 11:23 a.m., indicated R4 had a bruise on her left hip. R4's nursing progress notes dated 6/12/23 at 4:26 p.m., indicated the bruise measured approximately 8 by 6.2 centimeters (cm) and an x-ray was obtained that revealed no evidence of an acute fracture or dislocation. R4's nursing progress note dated 6/15/23 at 3:59 p.m., indicated R4 was removed from the falling star program but remained a fall risk. Additionally, the note indicated R4 had been self transferring from her bed to the wheelchair and the wheelchair was placed at the bed side to prevent a fall. During observation on 9/11/23 at 1:45 p.m., R4 was in bed and her wheelchair was located at the foot of the bed with the seat of the wheelchair located at the middle of the end of the bed out of R4's reach and facing away from R4. The wheelchair was unlocked. During observation on 9/14/23 at 7:56 a.m., R4 was in bed and a pair of shoes was located on the floor between the bed and R4's table. R4's wheelchair was located along the wall opposite of the head of the bed, unlocked and out of R4's reach. During interview and observation on 9/14/23 at 7:57 a.m., nursing assistant (NA)-H stated everyone was at risk for falls and added R4 did not have a star and was not at risk for falling. NA-H reviewed R4's care sheet and further, NA-H stated R4 tries to self transfer and verified R4's wheelchair was not close enough for her to reach and stated the w/c should be locked by the bed because R4 could get up to transfer and the wheelchair would roll back and R4 would end up on the floor. NA-H stated she did not know whether R4's shoes should be located on the floor between R4's bed and table. NA-H left R4's room and did not move the w/c next to the bed. During interview and observation on 9/14/23 at 8:04 a.m., licensed practical nurse (LPN)-C verified the wheelchair was not next to R4's bed and stated R4's shoes should not be on the floor because R4 would trip. LPN-C stated the aide should have moved the wheelchair by the bed because R4 could wake up any time and transfer herself. During interview on 9/14/23 at 10:32 a.m., corporate nurse consultant (CNC) stated clutter was a matter of definition and we try to make their rooms homey. Further, CNC stated R4 needed an environment free from clutter so she did not fall and added the care plan indicated items used frequently were kept in reach and could not speak to the person who wrote the care plan regarding shoes. Further, expected R4's wheelchair be kept at the bedside and care plan followed. R53's quarterly Minimum Data Set (MDS) dated [DATE], had diagnosis that included progressive neurological conditions hypertension and Non-Alzheimer's Dementia. R53 had two falls without injury since admission, took antidepressants and opioids seven days in the look back period. R53's face sheet printed 9/15/23, indicated diagnosis included unspecified fall, subsequent encounter, for other orthopedic aftercare status post hip fixation and pinning; repeated falls. R53's falls events documentation: - 2/26/23 at 3:50 p.m.; no injury; interventions: encourage to have staff assist her as much as possible - 3/5/23 at 5:57 a.m.; no Injury: immediate intervention left blank; - 3/12/23 at 8:21 p.m.; no injury; intervention: every two hours check and encouragement of using her call light at all times. - 4/1/23 at 5:56 p.m.; no injury; intervention: no care necessary - 4/5/23 at 2:16 a.m.; no injury noted: no care necessary - 4/15/23 at 10:51 p.m.; no Injury; intervention: no care necessary - 4/25/23 at 9:28 a.m.; no injury; interventions: no care necessary; Rest - 5/3/23 at 2:49 p.m.; no injury; interventions: analgesics - 5/5/23 at 9:50 p.m.; no injury; interventions: rest - 5/25/23 at 10:49 a.m.; no Injury; interventions: rest - 5/29/23 at 1:52 p.m.; no Injury; Interventions: take resident to restroom and transfer her to her bed - 6/12/23 at 10:43 a.m.; no Injury; interventions: Rest - 7/11/23 at 10:21 p.m.; no Injury: no care necessary - 7/12/23 at 9:48 a.m.; no injury: no care necessary - 7/30/23 at 10:41 p.m.; no Injury noted: no care necessary - 8/11/23 at 9:43 p.m.; no Injury: no care necessary - 9/10/23 at 10:19 a.m.; no Injury noted; rest; direct pressure to wound R53 had a total of 17 falls since 2/23, with many of the falls lacking interventions to prevent additional falls. R53 had a fall with injury on 3/5/23, resulting in a left humerus fracture. R53's interdisciplinary team (IDT) progress notes: -3/7/23 at 1:09 p.m., IDT review unwitnessed fall on 3/5/23 at 5:57 a.m., R53 an [AGE] year old female admitted to secured memory unit on 2/13/23, with diagnosis not limited to: Left humerus fracture, dementia, fall, pain, anxiety. Medications reviewed scheduled and as needed oxycodone for pain, prn methocarbamol. Resident was very active in her room and attempts to independently transfer and ambulate to/from bathroom and within her room. Resident was noted on the floor near bed with knees drawn to chest stating fell onto buttock and was trying to go to the bathroom. R53 did use call light for assistance but in this case did not use the call light. Staff heard R53 calling out she had fallen. Immediate intervention included safe lifting protocol followed, assisted to toilet, no injuries noted, denies increased pain, range of motion and neuros intact per baseline. IDT intervention: was to continue with current plan of care and fall interventions at this time. -3/15/23 at 2:56 p.m., IDT review unwitnessed fall on 3/12/23 at 10:21 p.m.; R53 was encouraged to come in the dinning for activities and for meals but declined and vital signs stable. Left hip bruise 2.5 centimeters (cm) x 2.5cm noted 3/13/23, day shift, guarding left hip, requesting staff not to touch left hip area. Pain medication given. Provider ordered X-ray to left hip/pelvis/Left humerus, Tylenol 1000 mg three times a day. Nursing updated provider of frequently stating the need to void. Provider ordered urinalysis and urine culture and okay to straight catch for specimen. X-ray results acute left hip fracture; send to emergency department at Mercy Hospital. Family updated. IDT intervention: Nursing will re-asses plan of care upon re-admission. Need time of progress note. -3/17/23 at 2:44 p.m., diagnosis: pneumonia, Left hip fracture, dementia, hypertension, anxiety, and pain. Resident was returned to facility at 12:05 p.m., via wheelchair from Mercy Hospital. Patient was alert and oriented to person, place and time. Vital signs: blood pressure: 127/83, pulse: 65, temperature: 98.2, respiration: 18, oxygen saturation at 98% on room air. Resident complained of pain in arm and hip. Rated pain 6/10. Scheduled Tylenol 1000 mg administered and effective. Lung sound clear bilaterally. Resident was on antibiotic for pneumonia. No shortness of breath or respiratory distress noted. Heart rate was regular. No edema noted. Bowel sounds was active in all quadrants. Resident continent of bowel and incontinent of bladder. Abdomen soft and non-distended. Assist of 1 staff with transfer and care. Non weight bearing in left arm and leg. COVID rapid swab test was negative. Resident has glasses and hearing aids in both ears. R53's fall care plan updated 7/13/23, indicated R53's goal was to reduce risk for injuries related to falls and had fall interventions: approach to use call light and personal items within residents reach at all times Keep residents room free from clutter; ensure adequate lighting in resident's room; keep bed low/ appropriate height to allow resident's feet to rest flat on floor; toilet resident per care plan; two and a half upper side rails on resident bed to help; with mobility and positioning when in bed; gripper socks on when in bed; Hip protectors to be worn at all times; wellness director to recommend essential oils to decrease anxiety, restlessness, impulsivity, and pain. R53's fall care plan lacked intervention after each fall. During observation on 9/13/23 at 7:56 a.m., R53 was lying in bed with bed in low position. R53's call light was connected to bed but call button was on the floor and out of R53's reach. During interview on 9/14/23 at 10:28 a.m., nursing assistant (NA)-K stated had gotten R53 dressed for the day during morning cares. NA-K was then asked by surveyor to observe R53's transfer to wheelchair. NA-K informed surveyor, another staff had already completed R53's transfer into wheelchair. NA-K further explained, R53 was dressed by NA-K for the day during morning cares, but explained after questioning by surveyor to verify R53's hip protectors were in place, that although had gotten R53 ready and dressed for the day, R53's hip protectors were not placed during assistance with dressing during morning cares, since the hip protectors were sent to the laundry to be washed and were not available. NA stated this was part of R53's fall intervention but was not placed today since it was not available. During interview on 9/14/23 at 1:08 p.m., clinical manager registered nurse (RN)-D stated R53 can be impulsive and does not remember to use the call light. RN-D stated when R53 was taken to the bathroom she would immediately attempt to go to the bathroom by herself. RN-D further stated facility did not always update the care pan unless there was a new intervention put in place. During interview on 9/14/23 at 3:24 p.m., corporate nurse consultant stated most falls would have a follow up note from the IDT team and there would be a determination if staff needed to update the care plan. The facility did not always update the care plan unless there was a new intervention. The facility Integrated Fall Management policy updated 8/24/17, indicated residents are assessed for their risk of falls upon admission, significant change and quarterly thereafter. Residents with risk for falling will have interventions implemented through the resident centered care plan. When a resident experiences a fall, a licensed nurse assesses the resident's condition, provides care for, safety and comfort. Residents at risk for falls have an individualized resident centered care plan developed. Care plan interventions are based on the finding of the fall risk assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R70) reviewed for nutrition had received thickened liquid per physician orders. Findings include: R70's significant change Minimum Data Set (MDS) dated [DATE], indicated R70 had moderate cognitive impairment, with diagnosis that included cardiovascular accident (CVA), transient ischemic attack (TIA), or stroke and aphasia. R70 was independent with eating. R70's nutritional care plan updated 8/11/23, indicated swallowing difficulty related to cerebrovascular accident (an interruption in the flow of blood to cells in the brain) with history of dysphagia (difficulty swallowing) and aspiration. Diet puree mildly thick. R70 to be encouraged to eat and drink. R70's face sheet printed 9/16/23, indicated pneumonitis (general inflammation in the lungs that can affect how well you breathe and cause other bodily symptoms) due to inhalation of food and vomit, dysphagia following cerebral infarction. R70's nutritional assessment updated during survey on 9/14/23, indicated, diet: pureed and mildly thick water. R70's undated nursing assistant (NA) care sheets, indicated puree diet and mildly thickened fluids. R70's physician orders dated 8/4/23, indicated diet: puree with mildly thick liquids with diagnosis of dysphasia following cerebral infarction. During observations on 9/14/23 at 9:37 a.m. R70 had a cup of regular thin water with ice on bedside table with straw. During interview on 9/14/23 at 10:17 a.m., clinical manager, registered nurse (RN)-D stated resident was on thickened liquid and should not have a cup of water with ice in the room. RN-D also stated dietary used to have stickers next to residents' names near the door to alert staff a resident was on thickened liquid and would check in with dietary. RN-D verified water in pitcher was not thickened and there were no green stickers which indicated a resident was on thickened liquids next to R70's name near door. During interview on 9/14/23 at 10:28 a.m., NA-K stated had passed water to assigned residents that morning including R70. NA-K stated was new with working with R70 and was not aware R70 was on thickened liquids. NA-K also stated the groups were changed and was then reassigned to R70 during shift that morning. During interview on 9/14/23 at 12:29 p.m., registered dietician (RD) stated R70 was on mildly thickened liquids and pureed diet. RD further stated the facility previously had signage for residents on thickened liquids with use of stickers but did not currently. The old dietician had started the process of stickers. RD also stated was new at the facility and about 4 months earlier the team decided only to use red stickers which indicated resident was nothing by mouth (NPO), but would not use stickers for residents on thickened liquids. Thickened liquids was placed on plan of care documentation instead. During interview on 9/14/23 at 3:24 p.m., corporate nurse consultant stated was unsure if the thickened liquids stickers were still in use at the facility, but staff were notified in reports and should also have the resident's diet on the nursing assistant care sheets to know who was on thickened liquids. It was the expectation to verify orders when passing out fluids. A provided facility policy dated 2012, titled Thickened Liquids indicated, residents receive thickened liquids per a physician's order which specifically states the consistency of the thickened liquids. It is the responsibility of all staff to ensure that the resident receives all liquids in the appropriate consistency to prevent aspiration while promoting adequate hydration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to obtain a provider's order with indication for use of oxygen and failed to administer oxygen in accordance with the provider orders for 2 of 2 residents (R23 and R54) reviewed for respiratory care. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and a diagnosis of chronic obstructive pulmonary disease (COPD, an inflammatory lung disease which causes obstructed airflow). R23 used oxygen and required extensive assist with dressing, transfers, and hygiene and supervision after set-up for eating. R23's COPD care plan dated 9/5/23, identified monitor and record respiratory status every shift when using oxygen and administer oxygen per physician orders. R23's Medication Administration Record (MAR) and Treatment Administration Records (TAR) dated 7/1/23 through 9/12/23, lacked documentation of oxygen administration. R23's Physician Order Report dated 8/14/23 through 9/14/23, identified there was no order for oxygen until 9/12/23. The 9/12/23 order read O2 (oxygen) 3 L (liters flow per minute) NC (nasal cannula delivery device) at bedtime. R23's undated oxygen saturations report identified the following readings with oxygen use: 9/11/23 at 7:26 p.m., 94% on 2 L 9/9/23 at 5:01 p.m., 96% on 2 L 9/3/23 at 3:24 p.m., 94% on 2 L 8/29/23 at 4:51 p.m., 94% on 2 L. R23 was administered oxygen from 8/29/23 through 9/11/23 without a physician's order. During an observation on 9/11/23 at 2:39 p.m., R23 was in bed with oxygen via NC at 2 L. During an interview on 9/11/23 at 3:35 p.m., nursing assistant (NA)-F stated staff had to set up and put on R23's oxygen. NA-F stated R23 had been on oxygen for a while. During an observation on 9/11/23 at 3:44 p.m., NA-F brought R23 into the dining room. R23 had oxygen via NC at 2 L. During an interview on 9/12/23 at 2:13 p.m., NA-A stated R23 sometimes had oxygen on during the day but usually only wore it at night. During an interview on 9/12/23 at 2:12 p.m., licensed practical nurse (LPN)-A stated R23 only wore oxygen at night. During a follow up interview on 9/13/23 at 10:10 a.m., LPN-A stated after was asked about R23's oxygen administration the previous day, realized there was no physician's order, so obtained one on 9/12/23 for oxygen at 3 L at bedtime. During an observation and interview on 9/13/23 at 10:11 a.m., R23 was in bed and her oxygen was set at one L. R23's oxygen was not being administered in accordance with the physician's order. LPN-A stated was not sure why the oxygen was set at one instead of the prescribed 3 L. During an observation and interview on 9/14/23 at 8:38 a.m., R23 was in bed with O2 set at 2 L instead of the prescribed 3 L. LPN-A stated the O2 should have been set at 3 L per the order and was not sure why it had not been. LPN-A changed the oxygen back to 3 L as ordered. R54's quarterly MDS dated [DATE], identified intact cognition and a diagnosis of dependence on supplemental oxygen. Oxygen use was not identified and R54 required total assistance with eating and transfers, and extensive assistance with dressing and hygiene. R54's care plan dated 7/19/23, identified diagnosis of oxygen dependence but lacked approaches or interventions toward oxygen use or weaning. R54's Physician Order Report dated 8/14/23 through 9/14/23, identified a start date of 10/29/22, for oxygen one to three liters (L) continuous to keep saturations greater than 90%. Wean oxygen to off as able. R54's TAR dated 8/15/23 through 9/14/23, identified oxygen saturations were checked every shift, however a liter flow was not identified. R54's oxygen saturations were consistently above 95%. There was no documentation of attempts to wean off oxygen. R54's progress notes from 6/7/23 through 9/7/23, lacked documentation of attempts to wean oxygen. During an observation and interview on 9/11/23 at 2:57 p.m., R54 was in bed with oxygen on via nasal cannula set at 2 L (liter flow per minute). R54 stated she had oxygen on all the time and there had been no attempts to reduce the oxygen use. During an interview on 9/12/23 at 10:21 p.m., NA-D stated R54's oxygen was on all the time set at 2 L. During an observation on 9/12/23 at 1:06 p.m., R54 was in bed with oxygen on via NC set at 2 L. During an interview on 9/13/23 at 9:17 a.m., NA-B stated R54's oxygen was on all the time set at 2 L. During an interview on 9/13/23 at 9:47 a.m., LPN-A stated nursing had not attempted to wean R54 off oxygen. LPN-A reviewed R54's oxygen saturations in the medical record and agreed they were within normal limits. LPN-A stated it would be appropriate to attempt to wean based off the oxygen saturation levels and the physician's order. During an interview on 9/13/23 at 2:45 p.m., the director of nursing (DON) stated it was acceptable for a resident to have oxygen administered for 72 hours before notification to the provider for formal orders. The DON stated oxygen was a medication, so a physician's order was required. Additionally, physician's orders should be followed as written and attempts at weaning a resident from oxygen would be documented in progress notes. The purpose of weaning was to help prevent supplemental oxygen dependence. The facility policy titled Oxygen Therapy dated 2017, identified oxygen therapy would be provided to residents in a safe manner as identified by a prescribed provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure pharmacy recommendations were addressed timely for 1 of 5 residents (R53) reviewed for unnecessary medications. Findings include: R53's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and diagnoses of dementia and high blood pressure. R53 required supervision with eating, and extensive assist with hygiene. R53's care plan dated 8/16/23, identified a goal to show stable cardiac status with interventions listed to observe for abnormal vital signs and complete medications, labs and treatments per MD (medical doctor) orders. R53's Medication Administration Records (MAR) dated 4/1/23 through 7/31/23, identified the following cardiac medication orders: 1. amlodipine five milligrams (mg) by mouth once daily 2. atenolol 25 mg by mouth once daily 3. lisinopril 20 mg by mouth once daily R53's Consultant Pharmacist (CP) Recommendation to Physician reports dated 4/30/23, 5/29/23, and 6/23/23, identified a repeated recommendation: R53's blood pressure readings have been below goal ranging between 104/63 to 132/77 with most of the readings at the lower end of the range. A recommendation was suggested to reduce the amlodipine to 2.5 mg daily. The CP made the same recommendation for three months in a row without follow up by the facility. R53's CP Recommendation to Physician report dated 7/28/23, identified the above recommendation again with a prescriber/provider signed order at the bottom of the form dated 7/31/23, to decrease atenolol to 12.5 mg daily and decrease lisinopril to 10 mg daily. No order to reduce the amlodipine were given. R53's Medication Administration Records (MAR) dated 8/1/23 through 9/13/23, identified the corresponding reduced cardiac medication orders: 1. atenolol 12.5 mg by mouth once daily 2. lisinopril 10 mg by mouth once daily During an interview on 9/14/23 at 11:40 a.m., the CP stated he would have expected R53's initial recommendation to reduce the cardiac medications to be followed up within one month, instead of after the fourth monthly recommendation. The CP stated R53 had repeated falls and low blood pressures could have contributed to the falls. During an interview on 9/14/23 at 2:00 p.m., the corporate nurse consultant (CNC) stated he was unsure why the CP recommendations had gone unaddressed for three months. The CNC stated he would expect the recommendations to be followed up on but would not state an expected timeframe. The facility policy titled Pharmacy Recommendation dated 10/12/10, identified the director of nursing (DON) would delegate the recommendations to the appropriate staff. If there was no response from the physician after the second attempt, the DON would follow up with the medical director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure foods were labeled and dated in the main kitchen and kitchenettes, and failed to ensure the use of hair restraints during food preparation. This had the potential to affect all residents, family, and staff who received food from the kitchen. Findings include: During the initial kitchen tour with the director of dining services (DDS) on 9/11/23 at 12:11 p.m., observed the following: Kitchen Reach in Freezer: • 1 package of four chicken breasts with a used by date 8/14. DDS took the items out of the freezer and threw the items away. • 1 package of undated and unlabeled meat DDS stated looked like country fried steak. DDS threw the items away. • 1 package of four burger patties DDS stated should have been labeled and DDS threw items away. During interview and observation on 9/11/23 at 12:35 p.m., observed dietary aide (DA)-A with a beard working with food items with no facial hair restraint covering. DDS stated DA-A should have his facial hair covered while working with food. During follow up observation in the kitchenette areas on 9/14/23, observed the following: Second Floor Kitchenette: • On 9/14/23 at 7:40 a.m., nursing assistant (NA)-I stated it was the kitchen's responsibility to maintain the refrigerators. Observed an uncovered tray that NA-I stated contained two chicken tuna sandwiches undated. First Floor Kitchenette: • On 9/14/23 at 8:16 a.m., NA-J stated the kitchen was in charge of maintaining the kitchenette. Observed an unlabeled container NA-J stated was cucumbers. First Floor Transitional Care Unit (TCU) Kitchenette: • On 9/14/23 at 8:25 a.m., observed an opened package of corn dogs with two in the package. The package indicated instructions to keep frozen. NA-G stated the kitchen was in charge of maintaining the refrigerator and thought the corndogs were for a resident and verified there was no label to identify who the package was for or how long they were in the refrigerator. • On 9/14/23 at 8:28 a.m., wellness coordinator (WC) stated the corn dogs were not labeled and stated they should not be stored in the refrigerator and put the corndogs in the freezer. Later, at 8:44 a.m., WC stated the corndogs did not belong to anyone and stated she threw the corndogs out. • On 9/14/23 at 8:31 a.m., observed the cook supervisor (CS) with a beard who went through the refrigerator in the TCU with no hairnet on and stated when he was in the kitchen he wore a hat and stated he never used any kind of hair restraint for his beard. During observation and interview on 9/14/23 at 8:38 a.m., CS was observed wearing a hat in the kitchen, however the hat did not cover all the hair on CS's head and was talking to DDS. DDS stated he ordered hair restraints and facial hair could not be bushy or egregious when working with food or serving food. DDS further stated the maintenance of the kitchenette refrigerators were a team effort that culinary stocked the refrigerators and the nursing department got supplements and liquids and verified items were supposed to be labeled and dated. A policy, Use of Hair Restraints dated 9/2023, indicated hair nets, [NAME] caps, chef hats and or mustache beard restraints were to be worn when any employee was in the food production and kitchen area. Additionally, hair restraints and mustache and beard guards must be worn to cover all visible hair. [NAME] guards must cover mustache and sideburns. If facial hair cannot be covered by the guard, hair must be trimmed to comply. No policy for dating and labeling food received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 3 (R1) residents reviewed for accidents. Findings include: R1 ' s care plan initiated on 5/5/23, noted R1 required physical assistance of one staff using a gait belt and FWW [sik] to transfer but on the next page of the care plan, it noted R1 required the assistance of two staff and an EZ Stand (electronic mechanical lift) to transfer to the toilet, upon rising in the morning, before and after each meal at bedtime, on night rounds and as needed. An Occupational Therapy (OT) Discharge summary dated [DATE], noted therapy recommended R1 ' s transfer status to be assist of two with an EZ Aide (mechanical lift) machine. R1 ' s significant change Minimum Data Set (MDS) dated [DATE], noted R1 had intact cognition and required extensive assistance of two staff with bed mobility, transfers, and toileting. R1's diagnoses included sepsis, urinary tract infection, and weakness. A progress note dated 7/3/23, noted nursing assistant (NA)-A notified the nurse that R1 had a fall at 12:00 p.m. The noted stated R1 was found sitting on the base of the EZ Aide machine with her back resting against the recliner in her room. R1 did not obtain any injuries, denied hitting her head and was assisted off the floor with the EZ Lift (full body electronic mechanical lift) and NA-A was educated on the importance of having a second person present during mechanical lift transfers. During an interview on 7/17/23, at 10:24 a.m. R1 stated at the time of the fall NA-A was using the EZ Aide machine without the assistance of another staff member, R1 stated she recalled the seat of the recliner was elevated, she was positioned over her reclining chair when the EZ Aide machine stated to roll away from her and she landed on the floor on her buttocks. R1 stated she was not injured. During an interview on 7/17/23, at 12:13 p.m. NA-A stated they have care sheets that provide information on how residents are transferred but noted R1 ' s transfer status does not indicate the need for 2 staff, only that she transfers with an EZ Aide machine. NA-A stated she used the EZ Aide machine without the assistance of another person on 7/3/23, and had received education immediately that all mechanical lift machines require 2 staff to use for resident safety. NA-A stated she does not have access to view R1 ' s care plan only the care sheets to direct her on resident transfer status. During an interview on 7/17/23, at 1:55 p.m. the physical therapist (PT) stated the facility used 4 types of mechanical lifts and they were distinct; a total body ceiling lift, the EZ Lift machine (an electric full body mechanical lift), EZ Stand machine (an electric stand lift) and EZ Aide machine (stand lift) and that the names of the machines were not interchangeable. The PT stated he expected a care plan to note the correct device recommended. During an interview on 7/17/23, at 2:42 p.m. the director of nursing (DON) stated R1 ' s care plan was not updated to reflect the correct transfer status and the outdated information should have been deleted. The DON stated the care plan was not confusing to staff as when they need to know a residents transfer status, they should refer to the care sheets. The DON stated the care assignment sheets were where staff would see how a resident transfers though acknowledged R1 ' s care sheet should have noted R1 required the assistance of 2 staff and the EZ Aide machine for transfers as the facility policy required. A care plan policy was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure medications were administered in a timely manner according to orders and professional standards for 2 of 2 residents (R1, R3) reviewed for medication administration. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had mild cognitive deficits and a Patient Health Questionnaire (PHQ-9) score of 10, indicating moderate depression. R1 required total assistance for transfers and extensive assistance for all other activities of daily living (ADLs). The MDS indicated bed mobility did not occur during the assessment period. R1 had diagnoses that included a displaced fracture of the cervical spine (neck), Parkinson's disease, repeated falls, dementia without behavioral disturbance, psychotic and mood disturbance, anxiety, thoracic (low back) fractures, failure to thrive, acute pain due to trauma, high blood pressure, asthma, overactive bladder, depression, gastro-esophageal reflux disease (GERD), insomnia, muscle spasms, constipation, and chronic pain. R1's Care Area Assessment (CAA) dated 1/13/23, indicated R1 triggered for cognitive loss/dementia, communication, ADLs, psychosocial well-being, mood, urinary incontinence, falls, psychotropic drug use, and pain. R1's care plan dated 1/11/23, indicated R1 was at risk for complications due to psychotropic drug use. Interventions included observing for side effects, proper dosing and continued need of medication. R1 had potential for pain related to end stage Parkinson's, spinal fractures, dementia, depression, anxiety, and asthma. Interventions included administering pain medications and treatments per hospice orders, observing non-verbal cues of pain and reporting signs of pain or discomfort. Staff were also to offer pain medications as ordered, monitor their use and effectiveness, and provide a calm and quiet environment. R1 was also at risk for nutrition due to diagnoses and disease process and was on hospice. Interventions included administering medications as ordered. R1's physician orders indicated to Ask resident if having pain and offer pain medication. The orders indicated the morning (AM) medication administration (Med Pass) time was 7:00 a.m. to 10:00 a.m., the evening (PM) Med Pass time was 3:00 p.m. to 6:00 p.m. and the night Med Pass (HS) was 7:00 p.m. to 10:00 p.m. The orders also indicated R1 received the following medications: -albuterol sulfate solution for nebulizer three times a day (AM, PM, HS) for shortness of breath. -carbidopa-levidopa extended release 25-250 milligrams (mg) four times a day (8:00 a.m., 11:30 a.m., 2:00 p.m., 5:00 p.m.) for Parkinson's disease. -Cymbalta (duloxetine) delayed release 60 mg (AM) for depression and anxiety. -lidocaine patch 4% twice a day (8:00 a.m., 8:00 p.m.) a 24-hour application for pain. -methadone (a narcotic) 2.5 mg three times a day (8:00 a.m., 2:00 p.m., 10:00 p.m.) for pain. -methocarbamol 250 mg twice a day (AM, PM) for muscle spasms. -omeprazole delayed release 20 mg (AM) for GERD. -oxycodone 5 mg sublingual as needed every hour for pain. -rivastigmine patch twice a day (8:00 a.m., 8:00 p.m.) for dementia associated with Parkinson's. -acetaminophen (Tylenol Extra Strength) 1000 mg three times a day (AM, PM, HS) for pain. During an interview and observation on 1/31/23, at 9:58 a.m. R1 was lying flat on her back in bed. R1's arms were on her abdomen and her whole body was shaking. R1 was staring at the ceiling and was slow to respond to questions. R1 stated she had not received any medications that morning. R1 stated she was having pain in her shoulders, neck, and abdomen (pointing to her epigastrium). R1 stated her pain was a 10/10. During an interview on 1/31/23, at 10:06 a.m. trained medical assistant (TMA)-A stated she had not given R1 any medications yet and did not know if the nurse had given R1 any of her hourly PRN oxycodone medications that morning. TMA-A verified R1's electronic medical record (EMR) indicated R1 had not been offered or given any PRN oxycodone medication that morning for pain. During an interview on 1/31/23, at 10:09 a.m. registered nurse (RN)-A stated she asked R1 if she wanted pain medication at 8:30 a.m. but R1 refused. RN-A did not return to R1's room after 8:30 a.m. because she knew TMA-A would be giving R1 her scheduled pain medication during the AM Med Pass. RN-A stated she did not document assessing R1's pain or R1's refusal of the PRN oxycodone at 8:30 a.m. yet and would do that later. RN-A also confirmed because she had not documented R1's pain assessment or refusal of her PRN pain medication, TMA-A would not know if R1 had received her PRN oxycodone. During a continuous observation and interview on 1/31/23, from 10:19 a.m. to 10:50 a.m. hospice nursing assistant (HNA)-A was in R1's room giving her a bed bath when RN-A entered and gave R1 2.5 mg of methadone for her pain. RN-A did not ask R1 if she was having pain or ask R1 to rate her pain. RN-A then left R1's room. RN-A stated she did not ask R1 if she was having pain because R1 was unable to verbalize or rate her pain. At 10:27 a.m., RN-A administered the rest of R1's AM oral medications. At 10:43 a.m. RN-A entered R1's room to apply R1's medication patches. RN-A rolled R1 onto her right side and lifted the back of R1's shirt. RN-A applied the lidocaine patch, for pain, to the middle of R1's back and the rivastigmine patch, for dementia and depression, to R1's left shoulder blade. There were no previously applied medication patches observed on R1's back. RN-A lowered R1's shirt, rolled her onto her back and left the room. At the medication cart, RN-A stated R1's medication patches were removed before she went to bed and therefore there would not be previously applied patches on R1's skin. At 10:50 a.m. RN-A verified R1's medication patches were to be applied for 24 hours and returned to R1's room. After inspection of R1's skin a rivastigmine patch dated 1/30/23, was found on R1's left upper arm and a rivastigmine patch dated 1/29/23, was found on R1's upper right arm. RN-A removed the old patches and stated all previously applied medication patches should be removed prior to applying new patches to avoid over-medicating a resident. During an interview on 1/31/23, at 1:54 p.m. R1 was supine in bed with minimal shaking observed. R1 was organizing her bedside table and stated she was feeling better since she received her medications. R1 stated her pain was 5/10 and tolerable. R3's admission MDS dated [DATE], indicated R3 had intact cognition and required total assistance with transfers and extensive assistance with all other ADLs. R3 had diagnoses that included bacterial pneumonia, malignant neoplasm of the bronchus or lung resulting in a lobectomy (cancer of the airway/lung resulting in the removal of part of the lung), chronic heart failure, (CHF, causing fluid build-up in the lungs), shortness of breath, atherosclerotic heart disease (causing plaque build-up in the arteries of the heart resulting in decreased blood flow), atrial fibrillation (afib, an irregular heartbeat resulting in increased formation of clots), oxygen dependence, diabetes, anxiety, pain, myocardial infarction (heart attack), pneumonia, chronic obstructive pulmonary disease (COPD, causing difficulty breathing), depression, GERD, constipation, osteoporosis (decreased bone density), and malnutrition. R3's CAA dated 11/29/22, indicated R3 triggered for communication, ADLs, urinary incontinence, falls, nutrition, dehydration, and pain. R3's care plan dated 11/23/22, indicated R3 had the potential for pain related to cancer, CHF, high blood pressure, afib, an enlarged heart, pneumonia, anxiety, protein malnutrition, and hospice. Interventions included assessing R3 for signs of pain or discomfort. Staff were to reposition and align R3 for comfort and administer pain medications as ordered by the provider and monitor pain medication use and effectiveness. The care plan also indicated R3 was at risk for psychotropic drug use. Interventions included administering medications as ordered by hospice and offering non-pharmacological interventions. The care plan also indicated R3 was at risk for a nutritional deficit related to disease progress and hospice status. Interventions included administering medications as ordered. R3's physician orders indicated the morning (AM) medication administration (Med Pass) time was 7:00 a.m. to 10:00 a.m., the noon Med Pass was 11:30 a.m. to 2:00 p.m., the evening (PM) Med Pass time was 3:00 p.m. to 6:00 p.m. and the night Med Pass (HS) was 7:00 p.m. to 10:00 p.m. The orders indicated R3 received the following medications: -acetaminophen 1000 mg twice a day (AM, HS) for pain. -apixaban (Eliquis, an anticoagulant) 2.5 mg twice a day (7:30 a.m to 10:30 a.m. and 7:30 p.m. to 10:30 p.m. -ipratropium-albuterol solution for nebulizer/inhalation four times a day (AM, Noon, PM, HS) for shortness of breath. -metoprolol succinate extended release 24 hour; 25 mg (7:30 a.m. to 10:30 a.m.) for high blood pressure. -morphine (a narcotic pain medication) 10 mg four times a day (AM, Noon, PM, HS) for pain. -pantoprazole delayed release 40 mg (AM) for GERD. During an interview on 1/31/23, at 11:14 a.m. R3 was observed slid down in her bed in a reclined position with a nasal cannula applied and delivering oxygen through her nose. R3 was attempting to eat but stated she did not have an appetite and had been better. R3 was grimacing and only able to speak three words at a time. R3 stated she was having shortness of breath and chest pain that went to her back. R3 stated she told the staff a long time ago but that they were very busy and it came with the territory. R3 further stated she had received her AM medications around 11:00 a.m. although they were scheduled for 8:00 a.m. R3's multiple attempts to reposition herself to ease her discomfort were ineffective. A nebulizer machine was on but R3 did not have the nebulizer mask on her face. During an observation on 1/31/23, at 11:16 a.m. RN-A entered R3's room, turned off the nebulizer machine, and left. RN-A did not speak to R3 or assess her shortness of breath or pain. During an observation and interview on 1/31/23, at 11:44 a.m. R3 remained in a reclined position, low in her bed with a nasal cannula delivering oxygen. R3 stated she was still uncomfortable and only able to speak three words at a time. R3 further stated she received her medications late almost every day. R3 had eaten only a few bites of her food and stated she got too tired to eat. During an interview on 1/31/23, at 12:00 p.m. RN-A and TMA-A reviewed both R1 and R3's EMR's and verified both residents received their medications at the time they were documented despite the documentation indicating the medications were administered on time and only charted late. RN-A also verified she had charted under TMA-A's credentials for some of the medications. RN-A and TMA-A verified inaccurate documentation could result in residents receiving medications too close to their next dose causing them to be overmedicated. During an interview on 1/31/23, at 5:03 p.m. the interim director of nursing (DON) stated staff should be administering medications, including pain medications, as they are ordered. The DON also stated nurse managers were available to assist the nurses and TMAs if they were falling behind in administering medications to residents. The DON stated nursing staff should assess a resident's pain before and after giving the medication to determine its effectiveness. The DON further stated old medication patches should be removed prior to applying a new patch to avoid over-medicating a resident. During an interview on 2/1/23, at 10:57 a.m. the consulting pharmacist (PH) stated residents should be receiving their medications no more than one hour prior to or one hour after their scheduled time to maintain therapeutic effect and over or under-medicating a resident. The PH stated it was particularly important for residents to receive Parkinson's and pain medications at even intervals throughout the day to maintain their efficacy. The PH further stated medications should be documented as soon as they are given to avoid confusion and administering medications too close together. The facility Administering Medications policy dated 2020, indicated medications were to be administered in accordance with the provider orders and within their prescribed time. The policy also indicated medications were to be documented in the EMR at the time they were administered. The policy also indicated to document when a resident refused medications. The facility Pain Management policy dated 2022, indicated staff were to evaluate residents for verbal and nonverbal signs and symptoms of pain, and encourage the resident to tell the staff about their pain. Staff were also to reevaluate and document a resident's pain at regular intervals after pharmacological and nonpharmacological interventions.