**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for 2 of 3 residents (R3, R4) reviewed for dignity. Findings include: Resident council meeting minutes dated January 2025 identified call light times were long, March 2025 meeting notes identified call light times were still long. R3's admission MDS dated [DATE], identified intact cognition and no behaviors. He required substantial/maximal assistant with personal hygiene and upper body dressing, dependent upon staff to provide toileting hygiene, lower body dressing, and chair/bed to chair transfers. He had an indwelling urinary catheter and frequently incontinent of bowel. Medical diagnoses included neurogenic bladder (bladder dysfunction caused by neurologic damage due to brain, spinal cord, or nerve problems), urinary tract infection (UTI), paraplegia (paralysis that affects the lower half of the body on both sides), and seizure disorder. R3's care plan dated 4/22/25, identified self-care deficit with ADLs and directed staff to aid with all personal cares, toileting, and transfers. R4's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and no behaviors. He had impairment of functional range of motion (ROM) on one side and required substantial/maximal assistance with toileting hygiene, upper body dressing, personal hygiene, roll left and right, dependent for lower body dressing, all transfers, and used a manual wheelchair for mobility. He was frequently incontinent of bowel and bladder. Medical diagnoses include stroke, hemiplegia/hemiparalysis (paralysis or severe weakness on one side of the body), and depression. R4's care plan dated 6/9/25, identified self-care deficit with activities of daily living (ADLS) and directed staff to provide extensive assistance of one to two staff with all ADLS, bed mobility toileting, dressing, grooming, and wheelchair mobility, transfer with assistance of two staff and Hoyer lift, and care always provided in pairs of two caregivers. During an observation and interview on 7/2/25 at 11:50 a.m., R3 laid on his back, on his bed fully dressed, call light located outside, above his room door was on and activated before entry to room. R3 stated it had taken a long time for them to answer his call light, placed it on 10 minutes ago. R3 stated, they help him get up into his wheelchair, he wears a brief and was able to make staff aware when he required assistance, adding he was in an accident when his legs became paralyzed so he was unable to walk or self -transfer and wished he could do more for himself. He also indicated call light wait times were up to 15 to 20 minutes or longer and he was not ok with that. He was told by staff they do not want him to self-transfer and fall because they would get into trouble, then do not answer his call light for a long time. The long call light wait times happened all the time, not a certain time of the day/night. He stated it bothered him to have to wait a long time for assistance, made him mad, and felt like staff do not care. At 12:05 p.m. R3's call light remained on (over 15 observed minutes). He wanted to get up for lunch and use the telephone. At 12:12 p.m. nursing assistance NA-A carried two plates of food into his room (not acknowledging the call light) She asked him which one he wanted for lunch, R3 chose, she then turned around to exit the room and he stated can I get up in my chair please? NA-A stopped, turned around an stated, oh yea, and continued to walk down the hallway while she carried the plates of food. He stated the call light was turned on at least 10 minutes prior to the surveyor entering my room and would really like to get up for lunch, and off his back as he had been laying down for quite a while now. At 12:15 p.m. no staff were seen in the hallway. R3's call light remained on and continued to beep approximately every 9 seconds. At 12:18 p.m. (over 28 observed minutes) NA-A was seen walking in hallway towards his room, opened the door and entered a room located right before R3's room. In less than one minute NA-A exited the room and walked towards his room, and stated, this man needs to get up and entered R3's room. She informed him he was not forgotten and she had planned on helping him get out of bed. She left the call light on at 12:20 p.m., exited his room, and walked down the hallway. At 12:25 p.m. (over 40 observed minutes and 50 minutes per resident interview) NA-A and NA-B entered his room with a EZ lift machine, closed the door, and turned call light off. During an interview on 7/2/25 at 2:44 p.m., NA-B stated staff were expected to answer a resident's call light within 15 minutes, adding it would be important to respond to call lights right away in case the resident may have fallen, required assistance to be cleaned up or get up, and their needs/expectations are expected to be met. During an interview on 7/2/25 at 4:23 p.m., NA-A stated staff were expected to answer call lights within 15 minutes. We do not know what they are calling for and may be in need of medications, water, or are on the floor. We should not assume why they requested help. We are expected to respond to the call lights in a timely manner to meet the resident's needs. During an interview on 7/3/25 at 2:00 p.m., family member (FM) stated R4 had an episode in June 2025, when staff did not answer his call light for over almost an hour and he was sick and needed assistance. He continued to have concerns about long call light wait times after meals when he was in his wheelchair and requested to go back to bed so that he could use his urinal. Call light response time was anywhere from twenty minutes up to over one hour. There were times when staff came into his room, turned off call light off, indicated they would have to find another staff to assist and had taken up to one hour to return to his room. FM had received phone calls from R4 and he was incontinent of urine and unable to get assistance. He used a urinal to prevent incontinence but required staff to place the urinal for him while in bed. Prior to his stroke he was a very clean and well-groomed person, it really bothered him, and felt embarrassed to have had urine accidents. During an interview on 7/3/25 at 1:44 p.m. director of nursing (DON) stated staff were expected to respond to call lights in less than 15 minutes. The residents relied on staff for care and it could have been an emergent thing they need assistance with. Facility policy Answering the Call light dated 9/2022, identified staff were expected to response to resident call lights in a timely manner to meet their requests and needs. Calls lights were expected to be answered immediately. If resident required assistance indicate the approximate time it will take for you to respond. If the resident request was something you can fulfill, complete the task within five minutes if possible. Facility policy Combined Federal and Minnesota State [NAME] of Rights dated 6/8/19, identified resident rights was defined as a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident had the right to be treated with respect and dignity including the right to reside and receive services in the facility with reasonable accommodations of resident needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure 1 of 3 resident (R2) was free of significant medication errors when physician's orders for Darbepoetin (causes the bone marrow to produce red blood cells and used to treat anemia in people with chronic kidney failure) was not administered as prescribed, resulting in seven missed doses of Darbepoetin.Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and no behaviors. R2's quarterly MDS date 5/30/25, identified medical diagnoses of anemia (low red blood cell count), coronary disease (CAD), high blood pressure (HTN), renal failure, neurogenic bladder, diabetes mellitus (DM), anxiety, and depression. Currently taking a diuretic (reduces fluid buildup in body) and daily insulin. R2's emergency department (ED) record dated 8/23/24, identified . labs notable for hemoglobin of 6.8 which is baseline between 8 and 9. Creatinine is 3.2 with prior values between 2.5 and 3.3. Emails exchanged with provider and facility assistant director of nursing (ADON) prior to R2's admission to facility on 3/4/25, revealed the following: -on 2/27/25, from ADON to provider - received all correct documentation, diagnoses, length of time it will be prescribed and a note from a specialty it should be covered, would also need to get from a specialty clinic through our pharmacy so that if you guys are able to do a hemoglobin (hgb) this weekend and administer as needed so that we have time to get the medication, we can do Monday at 10:30 a.m. -on 2/28/25, from provider to ADON: the provider will continue monitoring the injections. We can arrange for continued transportation to and from renal clinic. -on 3/4/25, from ADON to provider: just need the layout of his rides and appointment times . main thing is the injections and make sure labs and rides are set-up, our lab days are Mondays. R2's hospital Discharge summary dated [DATE], identified acute kidney injury/chronic kidney disease (commonly caused by HTN and diabetes) vs end stage chronic kidney disease (CKD), stage four (very poor kidney function, kidneys were severely damaged and close to not working), right lower below the knee amputation. Has had progressively worsening renal function, admitted with encephalopathy (brain damage due to lack of oxygen), anemia likely due to CKD stage four and iron deficiency. No indications for dialysis . patient did not want dialysis . Hemoglobin (hgb) (a protein in the red blood cells that carries oxygen and carbon dioxide) dropped less than 7.0 to 6.7, on 2/2/25, transfused with one unit, 2/3/25 hgb 8.2 , and 2/10/25 hgb 8.4. Plan: will continue monitoring hgb intermittently and transfuse for hgb below 7, iron sucrose 200 milligrams (mg) intravenously (IV) times three days (1/28/25 through 1/30/25), started Darbepoetin 1/30/25, currently at 80 micrograms (mcg) every two weeks, next dose 3/13/25, complete blood count (CBC) should be drawn on 3/12/25 prior to dose and a four week follow up appointment. R2's hospital discharge medication orders dated 3/4/25, identified: -Darbepoetin Alfa, Recombinant injection solution 80 mcg/0.8 millimeters (ml) subcutaneously (SQ) every two weeks. Increase dose for next dose 3/13/25 (last dose 2/27/25), renal following indication: anemia. -Needs renal clinic follow up in one month with CBC and comprehensive metabolic panel (CMP) at Veteran's clinic, provider was arranging. Review of R2's electronic medication record (EMAR) for March 2025, April 2025, May 2025, June 2025, and July 2025, lacked evidence the order written on 3/4/25, for Darbepoetin Alfa, Recombinant injection solution 80 mcg/0.8 millimeters (ml) subcutaneously (SQ) every two weeks. Increase dose for next dose 3/13/25 (last dose 2/27/25), renal following, was not located or signed off as administered while R2 resided at the facility from 3/4/35, through 6/19/25, seven missed doses. R2's labs from 3/4/25 through 6/16/25, identified: - on 3/12/25 the R2's record lacked evidence a lab draw was completed as ordered.-on 3/24/25, Albumin (a protein in the blood plasma, keeps fluid from leaking out of the blood stream) 3.3 grams/deciliter (g/dL) low, carbon dioxide (CO2) (helps maintain acid/base balance in your body) 18 millimoles per liter (mmol/L) low, urea nitrogen (waste product the body removes from the blood) 50.6 mg/dl high, creatinine (waste product from muscle metabolism and excreted in urine) 3.6 mg/dL high, glomerular filtration rate (GFR) (checks to see how well the kidneys can filter the blood) estimate 21 mL/min low, hgb 9.1 g/dL low, and hematocrit (HCT) 28.8 %. -on 4/14/25, CO2 21 mmol/L low, urea nitrogen 49.1 mg/dl high, creatinine 3.90 mg/dL high, GFR estimate 17 mL/min low, hgb 9.2 g/dL low, HCT 29% low. -on 6/16/25, hgb 7.6 g/dL low. Handwritten note: results called to provider office and triage will update nurse practitioner (NP) on 6/16/25. Nurse practitioner (NP) visits dated 3/20/25, 4/10/25, 4/29/25, 5/14/25, and 6/10/25, identified list of current medications included Darbepoetin alfa recombinant injection solution 80 mcg/O ml SQ every two weeks. Increased dose for next dose 3/13/25 (last dose 2/7/25), renal following. Indication: for anemia. R2's provider order's dated 4/1/25 through 4/30/35, 5/1/25 through 5/31/25, 6/1/25 through 6/30/25, signed by provider each month, identified: Start dated 3/4/35 end date: open ended: Darbepoetin alfa recombinant injection solution mcg/0.8 ml solution; 0.8 ml; amt: 0.8 ml; subcutaneous. Special instructions: renal following, anemia. R2's renal consult dated 4/3/25, identified kidney function improved today creatinine 3.1, GFR 22 (best in months). Still would not want dialysis. Hgb at 10, continue same dose of Darbepoetin. Next renal appointment 7/2/25, 2:00 p.m. and labs at 1:00 p.m. R2's progress notes from 6/19/25, through 6/23/25, identified: -on 6/19/25 at 11:20 a.m., writer called NP regarding hgb 7.9 resident complained of extreme fatigue and he was not feeling well. Per provider okay to send to emergency room (ER) for evaluation. Resident was agreeable to go to hospital. -on 6/19/25 at 1:25 p.m., resident sent to hospital for low hgb 7.9 with extreme fatigue. Writer contacted power of attorney (POA), spoke with her and notified her of resident status. -on 6/19/15 at 8:19 p.m., writer called hospital . admitted . and unsure when he would be discharged . -on 6/21/25 at 1:04 a.m., writer called hospital . resident was being followed by renal related to high potassium and creatinine and low hgb . no discharge date at this time. During an interview on 7/2/25 at 1:40 p.m., pharmacist (P) stated the facility sent discharge orders dated 3/4/25, from the hospital and included an order for Darbepoetin. The pharmacy would have been able to fill the order and they could have administered it. This medication was ordered due to the diagnoses of severe anemia. The medication helps make red blood cells in order to keep the hgb up and prevent anemia. This medication was a specialty drug and required clarification/preauthorized of the LTC facility. We contacted the facility for clarification, no response back, and Darbepoetin was not ordered, requested, or provided from our pharmacy. This medication was ordered to be administered every two weeks. During an interview on 7/2/25 at 2:20 p.m., PharmD (PD) stated there was an order for Darbepoetin. On 3/4/25, the medication was entered by health unit coordinator (HUC), verified by licensed practical nurse (LPN)-A, and discontinued on 7/2/25. The Darbepoetin was usually administered for anemia and if received would have helped keep up R2's hgb. He ran and reviewed the resident medications every month, searched order history, Darbepoetin did not show up on his reports (EMAR/TAR/notes), and most likely was missed. He was unable to identify when or if the medication was administered while he was a resident at the facility. During an interview on 7/2/25 at 4:15 p.m., HUC stated she was responsible to enter the orders for a new admission into the EMAR from the orders received. The floor nurse or ADON would be the second staff to verify all ordered entered. On 3/4/25, she entered R2's orders into the EMAR and LPN-A came down from 2nd floor and verified them. She recalled the order for the Darbepoetin and was unsure what happened when it was not located on the EMAR. HUC stated she was unaware of this error until it was brought to her attention today. When an order was placed in the general orders, staff were unable to view it on the EMAR to administer the medication and would have only been seen on the order sheets in the electronic medical records. She did not recall a fax or call from pharmacy for clarification regarding that specific medication. During an interview on 7/3/25 at 9:47 a.m., LPN-A stated the HUC uploads the medication orders into the EMAR and then notifies the nurse to verify them. Two staff were required to verify the orders entered and one of them must be a nurse. LPN-A stated he systematically reviewed each medication with the printed discharge orders from the hospital with the EMAR and had not remembered verification of R2's medications on 3/4/25. He was unaware of a medication error (Darbepoetin) and how that could have happened. During an interview on 7/3/25 at 10:15 a.m., ADON stated the HUC was responsible to enter orders into the EMAR and a staff nurse should have verified them. The Darbepoetin was placed in the general order which meant we were not intending to administer it in house. R2 received a dose of Darbepoetin SQ prior to his discharge from the hospital on 3/4/25 and admitted to our facility. He was to continue to receive the injections at the renal clinic. Labs (CBC) were ordered to be completed on 3/12/25 prior to the next injection on 3/13/25 and were not completed until 3/24/25. The HUC would have been responsible to schedule the follow- up appointment with renal provider, who would then administer the injection. R2 was seen by renal on 3/21/25, order was to continue Darbepoetin injections and was signed off by the facility staff nurse. R2 resided in our facility, he was our responsibility, and we failed to follow through and he had not received the Darbepoetin as ordered. The medication should have been given for his chronic kidney disease. This was considered a medication error and the provider should have been notified. Call placed on 7/3/25 at 1:22 p.m., renal provider, voicemail left, but no return call received. During an interview on 7/2/25 at 4:05 p.m., director of nursing (DON) stated the order for the Darbepoetin was entered correctly by the HUC but it may have defaulted and went into the general flow sheet section instead of the medication flow sheet and therefore did not show up on the EMAR. The nurse verified R2's admission orders were entered into the computer system but was unaware this medication was placed in the general section and not on the EMAR, and so it got missed. R2 had not received the Darbepoetin as ordered. Facility policy Administering Medications dated 4/2019, identified medications are to be administered in a safe and timely manner, and as prescribed. Facility policy Adverse Consequences and Medication Errors dated 2/2023, identified the definition of a medication error as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. An example of medication error include omission of a drug ordered but not administered. A significant medication-related error was defined as requiring hospitalization, or extending a hospitalization, requiring medication discontinuation or dose modification, and requiring treatment with a prescription medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure appropriate hand hygiene was performed during personal cares for 1 of 1 resident (R4) reviewed for infection prevention and control.Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, impairment of functional range of motion (ROM) on one side and required substantial/maximal assistance with toileting hygiene, upper body dressing, personal hygiene, roll left and right, dependent for lower body dressing, all transfers, and used a manual wheelchair for mobility. He was frequently incontinent of bowel and bladder. Medical diagnoses include stroke, hemiplegia/hemiparalysis (paralysis or severe weakness on one side of the body), and depression. R4's care plan dated 9/26/25, identified self-care deficit with activities of daily living (ADL) and directed staff to provide extensive assistance of one to two staff with all ADL, bed mobility toileting, dressing, grooming, and wheelchair mobility, transfer with assistance of two staff and Hoyer lift, and care always provided in pairs of two. During an observation on 7/2/25 at 12:27 p.m., R4's room call light was noted to be on. He laid in bed on his back covered up with a sheet, and head of bed up approximately 20 degrees. At 12:37 p.m. two nursing assistants (NA)-A and NA-B entered the room with an EZ way smart lift machine. NA-B opened drawers and was unable to find wipes. NA-B exited the room without sanitizing hands and returned shortly thereafter with wipes. NA-A and NA-B applied gloves, and together pulled down his pants and the front of his brief. NA-A wiped the front peri area from front to back. He was turned onto his left side, brief was pulled away from his buttocks, NA-A wiped his rectal area from front to back and stool was visible on the wipe and brief. NA-A was not observed removing her gloves, sanitizing her hands and donning new gloves before she placed a clean brief and the lift sling underneath him. R4 was turned onto his right side, while NA-A placed her gloved hands on his left shoulder and right leg, pulled him over, pulled up brief and pants. NA-A and NA-B each placed a shoe on one foot. NA-A grabbed the EZ lift machine by the handles and pushed it over to the resident while he laid in bed. NA-A hooked up the lift sling loops to the EZ lift machine, raised him off the bed, lowered him down into his wheelchair and removed the lift sheet loops from the EZ lift machine. NA-A straightened the bed sheets, placed dirty linen in two clear bags, removed her gloves, and did not sanitize her hands. She held the dirty gloves in her hand along with the two bags of dirty linen, exited the room, walked down the hallway, entered a dirty utility room, disposed of the two bags and the dirty gloves, all without observation of sanitizing her hands. She then walked back down the hallway, opened the door, entered the nurse's station, and washed her hands at the sink with soap and water, and dried them with a paper towel. During an interview on 7/2/25 at 2:44 p.m., NA-B stated staff were expected to complete hand hygiene prior to the start of and after cares with a resident, prior to when the resident goes to dining room, before they eat, and when gloves were changed. Hand hygiene was important to help prevent the spread of germs from one area to another. During an interview on 7/2/225 at 4:23 p.m., NA-A stated staff were expected to complete hand hygiene before and after resident cares and after removal of gloves. She preferred to use soap and water to make sure hands were thoroughly clean. Hand hygiene was important for resident and staff safety to help prevent the spread of sickness, disease, and infection around by touching something dirty then touching clothing or the resident. NA-A stated she had changed her gloves after she completed R4's peri cares (though this was not in the observation)but did not sanitize her hands prior to the application of a new pair of gloves or exiting the resident's room and should have. She usually had hand sanitizer in her pocket but had forgot it. During an interview on 7/3/25 at 10:15 a.m., assistant director of nursing (ADON) stated staff were expected to complete hand hygiene prior to taking care of a resident, prior to entering their room, exiting their room, in between cares, before and after glove use. Hand hygiene was important to prevent infection. During an interview on 7/3/25 at 1:44 p.m., director of nursing (DON) stated staff were expected to complete hand hygiene prior to resident cares, after cares as they leave the room, after removal of gloves, before clean gloves were applied to prevent infection. The staff should have completed hand hygiene multiple times during the observation with R4's cares and transfer. Facility policy Handwashing/Hand Hygiene dated 10/2023, identified hand hygiene is the primary means to prevent the spread of healthcare associated infections. Hand hygiene was indicated: immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces, after touching the resident's environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal. Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea. Single-use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids, and when in contact with resident, equipment or environment of a resident who is on contact precautions. The use of gloves does not replace hand washing/hygiene. Perform hand hygiene before and after application of gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure call lights were within reach and accessible for 1 of 3 residents (R2) who was dependent on staff for care. Findings include: R2's admission Minimal Data Set (MDS) dated [DATE], indicated R2 had diagnoses which included hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (or stroke, a condition where a part of the brain is damaged or dies due to a lack of blood supply) affecting left non-dominant side, chronic pain syndrome, depression and anxiety disorder. R2's cognition was intact and R2 required substantial assistance by staff for toileting, dressing, and bed mobility. On 4/9/25 at 12:16 p.m., R2 was observed in his room sitting in his standard manual wheelchair. R2's call light was wrapped around the grab bar of his bed on the left side along the window and wall side of his room. R2 was in front of the television and call light was not within reach. R2 stated he would utilize the call light to get staff's attention however its on the side of the bed stating, I tell them not to put it there but that is where it's at. R2 added sometimes he had to call his sister using his personal cell phone to have her call the facility to let the staff know he needed assistance because his call light was not accessible. Further, R2 stated he also had to self-propel himself in his wheelchair to the nurses' station to get staff to assist him, we have had problems with that. In addition, R2 stated he was not able to stand up from his wheelchair without assistance and reach across his bed to get to his call light especially since the left side of his body was immobile following a stroke. On 4/9/25 at 12:24 p.m., registered nurse (RN)-A enters R2's room to offer R2 his lunch options. When asked about the call light, RN-A unwrapped R2's call light from the grab bar and clipped the call light to edge of the bed. RN-A stated staff were expected to ensure R2's call light was within reach if he was not in bed. On 4/9/25 at 12:33 p.m., RN-A approached surveyor and stated she spoke with RN-B and R2's call light was supposed to be tied to the handrail so he can reach over and press it I guess. On 4/9/25 at 3:01 p.m., RN-B stated R2 required staff assistance with all activities of daily living (ADLs) and stated staff would be expected to remove R2's call light from the grab bar and drape it across his bed so R2 could easily grab it. RN-B stated R2 would not be able to stand up from his wheelchair independently as he required assist of two staff with a mechanical lift for transfers. On 4/10/25 at 9:30 a.m., director of nursing (DON) stated staff were expected to ensure call lights were within reach and accessible to all residents. Review of facility policy titled Resident Care-Call Light dated 11/24, indicated residents were provided with a means to call staff for assistance through a communication system that directly calls a staff member or centralized workstation. Further, each resident would be provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure adaptive equipment was provided for 1 of 2 residents (R3) reviewed for safety while smoking. Findings include: R3's significant change Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnoses which included chronic obstructive pulmonary disease, schizophrenia, and R3 was cognitively intact. R3's Smoking assessment dated [DATE], indicated R3 used 6-10 cigarettes a day and did not have a preference on time of day he liked to smoke. R3 was assessed to need a smoking apron for adaptive equipment while smoking. Further, interdisciplinary team reviewed and determined R3 had a modified smoking plan, wears an apron for safety and had not been observed falling asleep with current assessment. Review of facility document titled Mission Nursing Home Resident Leveling and Smoke Program, undated, identified R3 as a smoker, on a modified smoking program, and required a smoking apron. On 4/8/25 at approximately 10:00 a.m., R3 was observed to self-propel in his wheelchair to the smoking-room door, where door monitor (DM)-A removed R3's oxygen concentrator and assisted R3 inside the smoking room. R3 was then observed to independently smoke a cigarette. DM-A did not assist R3 with a smoking apron. On 4/8/25 at 11:24 a.m., DM-A stated he was responsible for unlocking the smoking room for the residents and assist with any adaptive equipment that the resident required for smoking safety such as apron. DM-A stated he had a list of residents who smoked and what adaptive equipment they required and referred to the facility document titled Mission Nursing Home Resident Leveling and Smoke Program. Further, DM-A confirmed he did not assist R3 with a smoking apron and stated R3 required an apron for smoking outside but did not require an apron if R3 was smoking in the smoking room. DM-A stated he did not have any safety concerns related to R3 smoking and there had been no incidents he was aware of that resulted in R3 sustaining any burns from smoking. On 4/9/25 at 12:28 p.m., R3 confirmed he did not wear an apron while smoking yesterday and stated some staff put an apron on him and some don't. R3 stated he had not sustained any burns or injuries while smoking. On 4/9/25 at 2:37 p.m., assistant director of nursing (ADON) stated upon admission and as needed staff complete a smoking assessment with a resident who was wanting to smoke, after the assessment was completed the interdisciplinary team (IDT) would then review the assessment and discuss if the adaptive equipment identified in the assessment was appropriate. ADON stated each DM had a list of all residents who smoke and what adaptive equipment was required, and the DM would be responsible to implement those interventions and assist with the adaptive equipment to ensure the resident was safe while smoking. On 4/9/25 at 3:01 p.m., registered nurse (RN)-B stated R3 was alert and orientated and required staff assistance with activities of daily living (ADLs). RN-B stated R3 was identified as a smoker and required an apron while smoking inside or outside to prevent any burns. RN-B stated there had been no incidents or burns for R3 that she was aware of. Further RN-B stated a smoking assessment would be completed with the resident and brought to the IDT meeting to review and determine interventions and adaptive equipment needs. RN-B stated the DMs would then be given a list that would identify interventions and adaptive equipment each resident required, and the DMs would be responsible to implement. On 4/10/25 at 9:30 a.m., director of nursing (DON) stated upon admission a smoking assessment would be completed to determine any adaptive equipment needs and the assessment would then be reviewed at the IDT meeting. DON stated a list, which DON identified as the facility document titled Mission Nursing Home Resident Leveling and Smoke Program, would be provided to the DMs and on the list adaptive equipment required would be identified and DMs would be expected to implement and assist the resident. Review of facility policy titled Mission Nursing Home (MNH) Smoking Policy implemented 2024, indicated any resident with adaptive equipment to safely smoke would be set up by staff, monitoring shall occur by a staff or family member, visitor or volunteer as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a level II pre-admission screen and resident review (PASSAR) was completed prior to admission for 1 of 1 residents (R54) reviewed who required a level II PASSAR screening for mental illness. Findings include: R54 quarterly minimum data set (MDS) dated [DATE], indicated R54 was cognitively intact, and had experienced feeling down, hopeless or depressed, had trouble falling asleep or staying asleep, felt tired or had little energy, and had difficulty concentrating on things at least half or more days in the two weeks prior to the assessment. R54's face sheet printed 3/12/25, indicated an admission date of 11/26/25, identified R54 as a veteran and listed diagnoses to include major depressive disorder, anxiety disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder and opioid dependency. R54's Minnesota Senior linkage Line preadmission screening results dated 11/25/24, indicated R54 met the requirements for a mental illness OBRA Level II assessment. The screening identified a lead agency and provided contact information. R54's medical record was reviewed on 3/10/25 and lacked documentation of results of a Level II assessment. During interview on 3/11/25 at 1:46 p.m., social services designee (SS)-A confirmed R54's chart lacked any documentation of a Level II assessment being completed. SS-A stated R54's admission PASSAR identified suicidal ideations in the six months prior to his admission PASSAR assessment and a Level II PASSAR was required to offer additional resources to R54. SS-A stated it was important to have the Level II PASSAR completed to ensure residents received all available mental health services. Facility policy was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure a thorough smoking assessment was completed on residents who wished to smoke for 5 of 5 residents (R54, R16, R34, R52 and R19) reviewed for smoking. Findings include: An undated facility document titled Mission Nursing Home Resident leveling and Smoking program identified R54, R16, R34, R52 and R19 as current smokers. R54's admission minimum data set (MDS) dated [DATE], indicated R54 admitted to the facility on [DATE] and had the following diagnoses: Stroke, Non-traumatic brain dysfunction, traumatic brain dysfunction, progressive neurological conditions, and traumatic spinal cord dysfunction. The MDS further indicated R54 was cognitively intact and identified R54 as a current tobacco user. R54's face sheet printed 3/12/25, identified R54 as a current daily smoker. R54's care plan with a last review/revision date of 3/10/25, indicated R54 was an independent smoker, had a goal of remaining safe while smoking and would be reassessed for smoking safety annually, with significant change and reviewed quarterly. R54's comprehensive smoking assessment, dated 11/27/24, indicated an in progress status and revealed entire sections of the assessment blank and unfinished. No further smoking assessments were completed or provided. R54's medical record contained a document titled MNH Smoking Policy which reviewed facility policies for smokers. R54's signature was on the bottom of the form next to the date of 12/27/24. A facility representative signature identified as social services (SS)-A was below R54's signature. R16's admission MDS dated [DATE], indicated R16 admitted to the facility on [DATE] and had the following diagnoses: stroke, high blood pressure, hemiplegia (paralyzed on one side of the body) anxiety and depression. The MDS further indicated R16 was cognitively intact and identified R16 as a current tobacco user. R16's face sheet printed 3/12/25, identified R16 as a current daily smoker. R16's care plan with a last review/revision date of 1/21/25, indicated R16 was an independent smoker, had a goal of remaining safe while smoking and would be reassessed for smoking safety annually, with significant change and reviewed quarterly. R16 had a completed comprehensive smoking assessment completed on 6/27/23, four months after his admission. No further smoking assessments were completed or provided. R16's medical record contained a document titled MNH Smoking Policy which reviewed facility policies for smokers. R16's signature was on the bottom of the form next to the date of 12/27/24. A facility representative signature identified as SS-A was below R16's signature. R34's admission MDS dated [DATE], indicated R34 admitted to the facility on [DATE], and had the following diagnoses: progressive neurological disorders, dementia, vascular dementia and personal history of trans ischemic attack (temporary blockage of blood flow to the brain). The MDS further indicated R34 was not cognitively intact. R34's face sheet printed 3/12/25, identified R34 as a former smoker. R34's care plan with a last review/revision date of 3/3/25, indicated R34 was an independent smoker, who had previously quit but had restarted smoking, had a goal of remaining safe while smoking and would be reassessed for smoking safety annually, with significant change and reviewed quarterly. R34's comprehensive smoking assessment dated [DATE], indicated an in progress status and revealed entire sections of the assessment blank and unfinished. No further smoking assessments were completed or provided. R34's medical record contained a document titled MNH Smoking Policy which reviewed facility policies for smokers. R34's signature was on the bottom of the form next to the date of 9/3/24. A facility representative signature identified as SS-A was below R34's signature R52's admission MDS dated [DATE], indicated R52 admitted to the facility on [DATE], and had the following diagnoses: anemia, high blood pressure, traumatic subdural hemorrhage, anxiety and depression. The MDS further indicated R52 was cognitively intact and identified R52 as a current tobacco user. R52's care plan with a last review/revision date of 2/4/25, indicated R52 was a dependent smoker and would need assistance to smoke as he was unable to hold a cigarette, had a goal of remaining safe while smoking and would be reassessed for smoking safety annually, with significant change and reviewed quarterly. R52's comprehensive smoking assessment, dated 12/26/24, (two months after admission) indicated an in progress status and revealed entire sections of the assessment blank and unfinished. No further smoking assessments were completed or provided. R52's medial record contained a document titled MNH Smoking Policy which reviewed facility policies for smokers. R52's signature was absent on the bottom of the. A facility representative signature identified as SS-A was below R52's printed name and was dated 1/15/25. R19's admission minimum data set (MDS) dated [DATE], included an admission date of 12/27/24. R19's diagnoses included hemiplegia (weakness on one side of the body), diabetes, and chronic obstructive pulmonary disease (COPD). R19's care plan reviewed 2/6/25, included R19 was an independent smoker. Care plan included resident would be reassessed for smoking annually and with significant change. Progress note dated 1/16/25, included R19 went downstairs for smoking as scheduled. R19's comprehensive smoking assessment dated [DATE], was incomplete with no data entered. During an interview on 3/11/25 at 1:48 p.m., SS-A stated no one person was solely responsible for completing the smoking assessment but it was the responsibility of multiple staff including nursing, social service and therapy services. SS-A stated nursing staff completed the first portion of the assessment which included watching the resident smoke to determine safety. SS-A went on to say a smoking assessment must be completed upon admission before a resident was allowed to smoke independently and then annually and with any significant change of condition. SS-A stated certain behaviors such as smoking outside of the designated smoking areas like in a resident room, or a resident who was noted to have burn marks on their clothing would indicate a necessity to be reassessed for safe smoking. During an interview on 3/12/25 at 10:01 a.m., director of nursing (DON) stated if an assessment was listed as in progress it indicated the assessment was still open and had not been completed. DON stated the initial smoking assessment should be done as part of the admission process and needed to be completed before a resident was allowed to smoke independently. DON went on to say after nursing completed the initial assessment, social services and if necessary, therapy would complete their portion of the smoking assessment and make recommendations for independent smoking, dependent or supervised smoking or needed adaptive equipment for smoking. Further, the DON stated in addition to being assessed as part of the admission process, a smoking assessment would also be completed annually and with any change of condition. DON stated a resident who had not been assessed for smoking, or whose assessment was not completed should not be allowed to smoke either independently or supervised until the smoking assessment was completed in its entirety by all required staff. Additionally, DON stated he expected staff to complete all necessary assessments on time and to communicate the findings of those assessments with the interdisciplinary team to ensure all team members were made aware of individual needs. DON stated completing, documenting, and communicating the results of the smoking assessment was important for resident safety, and to ensure any necessary precautions were being followed to prevent potential injuries to residents. Furthermore, DON confirmed R54's smoking assessment had not been completed, R16 had been assessed four months after admission in 2023 but had not received an annual assessment in 2024 or 2025, R34's smoking assessment had not been completed, R52's smoking assessment had not been started until two months after admission, but had never been completed, and R19 had never been assessed for smoking. Facility Policy title MNH Smoking Policy with a last revised date of 12/2024 indicated all residents who wished to smoke would be assessed for function, cognition, and financial ability to participate in the smoking program. The policy also indicated residents would be assessed upon admission to determine ability to smoke safely with or without supervision and would be reassessed annually, upon significant change (cognitive or physical) and as determined by staff.

Based on interview and record review, the facility failed to develop a plan that defined measurable goals and create a system to collect feedback from resident and resident representatives. This had the potential to affect all 56 residents in the facility. Findings Include: During entrance interview on 3/10/25 at 12:54 p.m., a request for a copy of the Quality Assurance and Performance Improvement (QAPI) plan was made to the director of nursing (DON). On 3/13/25 at 1:37 p.m., another request was made for a copy of the QAPI plan. On 3/13/25 at 2:25 p.m., the facility's QAPI program policy was provided. On 3/12/25 at 2:44 p.m., the director of nursing (DON) provided meeting minutes for the last four quarters, but failed to provide an overall plan. QAPI meeting minutes included attendees, agenda, and data related to focuses such as infections, wounds, medication errors, admission/discharges, and weight changes. The document lacked evidence of target goals for sustainability. The document failed to provided evidence that resident and resident representative feedback was obtained to assist in determining quality measures. During interview on 3/13/25 at 2:44 p.m., DON stated they do not have a document that specifically states goals and how the facility will evaluate if the focus was successful or not. The DON was unable to state how feedback was collected from residents and resident representatives. Facility QAPI policy dated March 2020, included it was the QAPI committee's duty to establish benchmarks and goals by which to measure performance improvement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure dignity was maintained for 1 of 1 resident (R19) reviewed for dignity. Findings include: R19's admission minimum data set (MDS) dated [DATE], indicated a brief interview for mental status (BIMS-cognitive test) score of 15/15 indicating cognitively intact, self-care deficit requiring substantial/maximal assistance for toileting hygiene, upper and lower dressing, positioning and transfers. R19's diagnoses included but were not limited to hemiplegia (weakness or paralysis of one side of the body), bipolar disease (a mental health condition that causes mood swings), and hypertension (high blood pressure). R19's care plan dated 2/14/24 indicated R19's ability to perform activities of daily living (ADL's) had deteriorated related to a diagnosis of hemiplegia and required extensive staff assistance of one to two staff for toileting, dressing, bathing, grooming and bed mobility. Total dependence with Hoyer lift (a device designed to assist caregivers in safely transferring patients or individuals with limited mobility) for all transfers. R19's occupational therapy assessment dated [DATE] indicated R19 had diagnoses of hemiplegia and muscle weakness which required the need for assistance with personal cares. The assessment further indicated R19's left upper extremity to include shoulder, forearm, elbow, wrist, and hand were impaired with decreased strength and movement. During observation on 5/29/24 at 03:04 p.m., R19 was driving an electric wheelchair in hallway outside his room and through doorway into his room. R19 was wearing a light brown T-shirt, black basketball shorts, white ankle socks and tennis shoes. R19's shorts were tucked under abdominal fold and t-shirt was pulled up over the abdomen, above the belly button exposing approximately six inches of R19's stomach. A tan Hoyer sling was noted under resident with straps hanging loose. During observation on 5/30/24, at 02:12 p.m., R19 was driving an electric wheelchair towards smoking room on first floor wearing black basketball shorts and green t-shirt. R19's shorts were tucked under abdominal fold, legs During interview on 5/30/24 at 10:26, a.m., certified nursing assistant CNA-B stated after transferring a resident into their wheelchair staff should make sure their clothing was pulled down and neat. were bunched together and the shorts were pushed in towards his groin, T-shirt pulled up over abdomen exposing approximately 4 inches of R19's stomach. [NAME] edges of adult incontinent product was exposed at side waist band of basketball shorts. A tan Hoyer sling was visible under R19. During interview on 5/30/24 at 10:51 a.m., CNA-C stated if a resident's clothes were pushed up or under after a transfer, we fix them. During interview on 5/30/24, at 10:59 a.m., DON stated she expected staff to fix the residents clothes after transfers and expected staff to make sure they were happy with how they looked. Additionally, any refusals needed to be documented. DON stated not doing so could be embarrassing to the resident and affect their dignity. DON went on to say it was important to assist residents and ensure they feel good about how they look and feel. During observation on 5/31/24, at 09:19 a.m., R19 was seated in wheelchair in front of nurse desk wearing gray t-shirt, black basketball shorts, white ankle socks and tennis shoes. T-shirt pulled up exposing approximately 3-5 inches of stomach. [NAME] edges of adult incontinent product observed over waist band of basketball shorts. A tan Hoyer sling was under R19 with sling straps behind and to the outside of knees. During interview on 5/31/24, at 11:50 a.m., R19 stated he did not like the sling left under him after transfers, and right now my diaper is showing. R19 went on to say when his shirt was not pulled down everyone can see my fat and stretch marks .it makes me feel bad and people make fun of me. At 12:56 p.m., after transfer from bed to wheelchair R19 asked staff if his pants were up and stated I feel like my diaper is hanging out. Its embarrassing. CNA-D adjusted R19's shirt and shorts to cover R19's exposed skin. A facility policy was requested but none provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident received unopened mail for 1 of 2 residents reviewed for their right to receive communication with privacy. Findings include: R55's admission minimum data set (MDS) dated [DATE] indicated a brief interview for mental status (BIMS) was 14 and R55 was cognitively intact. R55's MDS listed the following diagnoses: congestive heart failure (heart does not pump blood efficiently), Diabetes Mellitus, depression, and post traumatic stress disorder (PTSD). On 5/30/24 at 10:29 a.m., resident council met and R15 stated sometimes social services (SS)-A went through their mail for contraband. On 5/30/24 at 11:03 a.m., SS-A stated they were responsible for sorting and delivering the mail on the weekdays. SS-A stated they delivered the mail unopened but had performed searches of the mail for suspected illicit drugs or alcohol, with the consent of the resident. On 5/30/24 at 4:04 p.m., the administrator stated they were unaware SS-A had been going through the mail of some residents. The administrator expected staff to only search the residents mail with probable cause and not with random searches. On 5/31/24 at 11:00 a.m., SS-A stated the resident had opened the mail with them and go through it together. SS-A stated there were only two residents they would regularly check related to concerns in the past. Names were provided. However, R15, the resident who originally brought forth the concern, was not one of them. One resident had discharged and the other was R55. On 5/31/24 at 12:44 p.m., R55 stated approximately one month ago they had received two separate pieces of mail that had been opened prior to him receiving them. One was a medical bill, and the second was paperwork from their case manager. On 5/31/24 at 11:39 a.m., the director of nursing (DON) stated they were unaware of any policy regarding searching the mail, and their expectation was a search would have only been conducted if there was suspicion of drugs or alcohol, probable cause, and they needed to get the resident's consent. The facility's Resident Rights Policy last revised February 2021, indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to communicate in person, by mail, email, and telephone with privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure advanced directives were accurately documented in the resident's electronic medical record (EMR) under physician orders for 1 of 1 residents (R109) reviewed for accurate code status. Findings include: R109's hospital discharge orders dated [DATE], identified the need for postoperative care and an order for full code (the initiation of cardiopulmonary resuscitation (CPR) in the absence of a pulse). R109's facility signed physician order report dated [DATE], identified an order dated [DATE] for full code. R109's EMR banner identified a code status of do not resuscitate (DNR). R109's facility face sheet dated [DATE] identified an admission date of [DATE], diagnoses of cholecystectomy (a procedure to remove the gallbladder) aftercare, abscesses (confined pockets of pus caused by infection) of the liver and peritoneum (the tissue that lines the abdominal wall and pelvic cavity). The face sheet identified R109's code status as DNR. R109's facility signed limited treatment consent form dated [DATE] found in the resident's paper chart at the nurse's desk, identified resident wishes for no CPR and for CPR to be withheld in the event of a cardiac event. (DNR) R109's signed provider orders for life-sustaining treatment (POLST) dated [DATE] and found in the resident's paper chart kept at the nurse's desk, identified DNR if having no pulse and is not breathing. When interviewed on [DATE] at 5:35 p.m., R109 confirmed his wishes as DNR and stated he was full code in the hospital for his surgical procedures only. When interviewed on [DATE] at 5:48 p.m., nursing assistant (NA)-A stated when a resident was found unresponsive or not breathing, a licensed nurse was notified via walkie and someone remained with the resident. When interviewed on [DATE] at 5:51 p.m., registered nurse (RN)-A stated when notified a resident was found unresponsive or not breathing, he immediately checked the resident EMR banner for code status or the paper form in the resident paper chart at the nurse's desk to ensure implementing appropriate response according to their wishes. RN-A stated he would not look to the resident physician orders because it would take longer to scroll through them. RN-A identified R109's code status as DNR on the EMR banner. When interviewed on [DATE] at 6:01 p.m., RN-B stated when a resident was found unresponsive or not breathing she looked at the EMR banner or the paper chart because they were the most up to date and current. RN-B identified R109's code status was DNR on the resident's EMR banner. RN-B would not look to the physician orders. RN-B acknowledged the physician order was for full code but that was an error. RN-B stated she would check with the resident and notify the provider to clarify and correct. When interviewed on [DATE] at 2:06 p.m., health unit coordinator (HUC) stated the assistant director of nursing (ADON) reviewed the admission referral information including orders and background information before a resident arrived. The HUC stated after she entered the orders a second check was completed by the ADON or a floor nurse. The HUC stated R109's orders upon admit were for full code but may have changed after someone discussed and went through the admission forms with him. The HUC acknowledged R109's signed code status form did not get communicated to her and therefore the order was not updated or accurate. When interviewed on [DATE] at 12:30 p.m., the director of nursing (DON) stated the admission orders were entered by the HUC and then a paper form regarding code status wishes was reviewed and signed by the resident or representative. The DON stated when the admission orders and signed forms did not match, they were clarified right away. The DON stated resident's code status was in several different parts of the EMR and paper charts. They need to match. This was important to ensure the appropriate interventions per resident wishes were implemented in an emergency situation. The facility policy Advanced Directives dated [DATE], identified The resident has the right to formulate an advance directive, including the right to accept or refuse medical treatment and The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure resident rooms were kept clean and in good condition for 1 of 2 residents (R36) reviewed for environment. Findings include: R36's quarterly minimum data set (MDS) dated [DATE] indicated a brief interview for mental status (BIMS) of 9, moderately cognitively impaired, and diagnoses included: heart failure (heart not pumping blood efficiently), hypertension (HTN), and hemiparesis (inability to move part of the body). On 5/28/24 at 12:51 p.m., R36's room had large amount of what resembled brown ground meat across the floor starting from approximately 2 feet to the left of the bed across the main walkway of the room and under the table across from the resident's bed about 2 feet into the room's threshold, spanning approximately 3 feet across the floor. There were straw wrappers and other paper debris on the floor. The resident was in bed resting. On 5/28/24 at 4:52 p.m., the resident's family member (O)-G stated they had recently come to visit on multiple occasions and there had been wrappers, bottles and garbage on the floor and under the bed. O-G stated they had come visit on a recent weekend, and then came again the following week, and had seen the same piece of garbage under the bed that had been there the previous week's visit. On 5/29/24 at 8:42 a.m., the resident was in bed and the large amount of what resembled brown ground meat was still present on the floor and had not been cleaned up. On 5/29/24 at 8:47 a.m., the housekeeper (HK)-A stated they clean the resident's room daily if all three housekeepers were working, if not they cleaned their assigned wings, and the rooms not cleaned on that day would be done the next time that housekeeper worked. Daily in each room they cleaned the bathroom, [NAME], sweep, mop, and changed the linen. On 5/29/24 at 11:17 a.m., the resident was in his room in bed and the large amount of what resembled brown ground meat was still present on the floor and had not been cleaned up. The hallway directly outside the resident's room had been cleaned and a wet floor sign was placed near the door to R36's room. On 5/29/24 at 1:27 p.m., the resident was watching television in his room and the large amount of what resembled brown ground meat was still present on the floor and had not been cleaned up from the previous day. On 5/29/24 at 2:45 p.m., the director of environmental services (HK)-B stated they expected when any staff saw the large amount brown ground meat on the floor, they stoped and cleaned it up immediately. HK-B stated if all three housekeepers were working all rooms were cleaned daily. HK-B accompanied surveyor to the room. When we had arrived to the room at 2:48 p.m. it had been cleaned. The facility document titled Rooms dated 5/24/24 and 5/27/24 through 5/29/24 indicated R36's room had last been cleaned on Friday, 5/24/24, five days prior. On 5/30/24 at 8:49 a.m., the director of nursing (DON) stated their expectation was the rooms were to be cleaned daily and confirmed any items on the floor should have been cleaned up immediately. On 5/30/24 at 4:04 p.m., the administrator stated they expected their staff to have cleaned up any mess or items found on the floor, and it was important to ensure the residents dignity and provide a clean living and working environment for residents and staff. A facility policy for room cleaning was requested and none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure a written notification of transfer was sent to the office of the Ombudsman for long term care for 1 of 2 residents (R44) reviewed for hospitalization. Findings include: R44's undated face sheet listed the following diagnoses: heart failure, arthritis, pain, cellulitis (infection of the cell), pleural effusions (collection of fluid, air, pus, or blood between the lining of the lung and the lung itself, causes difficulty breathing), atrial fibrillation (top chambers of the heart beat erratically), lymphedema (collection of fluid in the extremities), chronic obstructive pulmonary disease (COPD- lung disease that makes it difficult to breath), chronic kidney disease-stage 4 (CKD-end stage kidney disease), atherosclerotic heart disease, prosthetic heart valve, pacemaker, obstructive sleep apnea (spells of absent breathing when sleeping), transient ischemic attack (TIA-brief stroke like event), depression, shortness of breath, and dizziness. R44's Interagency transfer orders dated 3/29/24 indicted R44 was hospitalized from [DATE] until 3/29/24 for Acute chronic systolic congestive heart failure. R44's progress notes dated 4/25/24 through 4/26/24 indicated R44 was hospitalized after a fall. R44's medical record lacked evidence a written notification of transfer was sent to the Ombudsman for long term care for either hospital transfer. On 5/29/24 at 4:39p.m., an electronic mail (e-mail) was received from the Office of the Ombudsman indicating no notifications of transfer were received for R44. On 5/30/24 at 08:16 a.m., registered nurse (RN)-A, stated when a resident goes into the hospital, they normally update the provider, got an order to transfer, prepared resident information, filled out a bed hold and sent a copy of the transfer to the ombudsman at the time of transfer, however they were unsure if it had been completed for either stay in the hospital for R44. On 5/30/24 at 08:39 a.m., the director of nursing (DON) stated they expected the floor staff at the time of the transfer faxed a copy of the bed hold form to the office of the Ombudsman to inform them of the transfer. The facility policy Discharge/Transfer Notification of Ombudsman last reviewed 10/2022, indicated if a resident was transferred to the hospital for any reason, the nurse who was doing the transfer will complete the notification form and fax it to the State Ombudsman's office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately implement physician's orders for 1 of 1 resident (R44) reviewed for hospitalizations. Findings include: R44's admission minimum data set (MDS) dated [DATE] indicated the brief interview for mental status (BIMS) of 15/15, cognitively intact. R44's undated face sheet listed the following diagnoses: heart failure, arthritis, pain, cellulitis (infection of the cell), pleural effusions (collection of fluid, air, pus, or blood between the lining of the lung and the lung itself, causes difficulty breathing), atrial fibrillation (top chambers of the heart beat erratically), lymphedema (collection of fluid in the extremities), chronic obstructive pulmonary disease (COPD- lung disease that makes it difficult to breath), chronic kidney disease-stage 4 (CKD-end stage kidney disease), atherosclerotic heart disease, prosthetic heart valve, pacemaker, obstructive sleep apnea (spells of absent breathing when sleeping), transient ischemic attack (TIA-brief stroke like event), depression, shortness of breath, and dizziness. R44's orders dated 3/11/24, indicated a fluid restriction of 2000 ml's and was not changed per physician order upon R44's return to the facility. R44's Interagency Transfer Orders dated 3/29/24 indicted R44 was hospitalized from [DATE] through 3/29/24 for acute chronic systolic congestive heart failure and returned to the facility with an order for a 1500 ml fluid restriction dated to begin 3/29/24. On 5/30/24 at 8:16 a.m., registered nurse (RN)-A stated R44 was on a fluid restriction of 2000 ml' s' and confirmed it had been 2000 ml since RN-A could remember, and it had not been changed following the March hospitalization. ON 5/30/24 at 8:49 a.m., the director of nursing (DON) stated their expectation was upon a residents return from a hospitalization the discharge orders were entered by the health unit coordinator (HUC) and then verified by and RN or an RN would enter it and then it would be verified by a second nurse. DON stated they assumed they had missed the order and it was not entered appropriately. On 5/31/24 at 11:45 a.m., the DON confirmed the hospital discharge orders were not followed and stated it should have been completed and was important to prevent any further exacerbations (worsening of conditions). The facility admission Criteria policy last revised March 2019, indicated prior to time of admission the residents physician provides the facility with information needed for immediate care of the resident including orders covering at least: type of diet, medication orders, and routine care orders to maintain or improve the residents function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to prevent an avoidable pressure injury related to improper placement and use of a mechanical lift sling for 1 of 1 residents (R19) reviewed for pressure injuries. This deficient practice resulted in actual harm for R19 who developed pressure and shearing related injury to his groin, thighs, and buttocks. Findings include: R19's admission minimum data set (MDS) dated [DATE], showed R19 had a brief interview for mental status (BIMS) score of 15/15 indicating cognitively intact, self-care deficit requiring substantial/maximal assistance for toileting hygiene, upper and lower dressing, positioning and transfers. R19's diagnoses included but were not limited to hemiplegia (weakness or paralysis of one side of the body), bipolar disease (a mental health condition that causes mood swings), and hypertension (high blood pressure). R19's care plan dated 2/14/24 indicated performance of activities of daily living (ADL's) had deteriorated related to a diagnosis of hemiplegia and required extensive staff assistance of one to two staff for toileting, dressing, bathing, grooming and bed mobility. Total dependence with Hoyer lift (a device designed to assist caregivers in safely transferring patients with limited mobility) for all transfers. Risk for pressure ulcers related to need for assist with bed mobility, transfers, and incontinence. Interventions included avoid shearing residents' skin during positioning, transferring, and turning; conduct a systematic skin inspection weekly; keep clean and dry as possible; keep linens clean, dry and wrinkle free; provide incontinence care after each incontinent episode and avoid friction to skin. R19's care plan lacked evidence of the size or color of sling required. EZ Way Smart Lift manufacturer operator instructions indicate the following: -Log roll the patient on his/her side away from you. -Position the sling so the handles on the back of the sling are facing the mattress. -Tuck half of the sling underneath the patient. -Using the center handle as a guide, center the sling on the patient's spine with the base of the sling approximately two inches below the base of the tailbone. -Logroll patient in opposite direction and pull rest of sling out the other side. -Lay patient on their back. Make sure the sling is centered beneath the patient. -Lift patient's left thigh and pull the left sling leg of the sling under patient's thigh. Then place excess sling left over the top of the patient's left thigh. -Repeat steps for the right thigh. -Move the EZ Way Smart lift until the tip of the boom (green nose cone) is centered of the patient's torso. -Take the sling leg lying over the left leg, cross it over and attach it on the hook of the hanger bar located on the right side of the patient. Take the sling lying over the right leg, cross it over and attach it on the hook of the hangar bar on the left side of the patient using the same length and color of loop strap on both sides. -This procedure will ensure the sling is under the patient's tailbone and behind his/her back, with the patient's weight evenly distributed on the sling. -Gently lift the patient's left knee, pulling the sling legs our from underneath the patient's thigh. Continue to right knee. -Lean patient slightly forward and grasp the side handles or the center handle, pulling the sling of from behind the patient. During observation on 5/28/24 at 03:13 p.m., R19 requested nursing assistants (CNA)-G and CNA-H assist him to change incontinent product and clothing. R19 stated the shorts he was wearing were wet with urine. CNA-H crossed the lift sling straps between R19's legs approximately one inch from his groin, connected all four mechanical sling straps to Hoyer lift while CNA-G ran the controls. When CNA-G began to lift R19 the bottom edge of the tan lift sling was noted to be just below R19's coccyx. The lower half of the sling was darker in color from the area under R19's buttocks extending up towards mid back. A strong odor of urine was noted. CNA-G turned the lift and pushed it towards R19's bed. CNA-G lowered R19 to his bed. CNA-H disconnected the sling straps CNA-G moved the lift away and walked to the opposite side of the bed from CNA-H and assisted with product and clothing change. CNA-H stated the sling was wet, however, continued to apply the device. CNA-G crossed straps of tan sling between R19's legs, pulled the straps together to the right side of R19's groin, and instructed CNA-H to move the lift to R19's bed. Both lower sling straps were positioned nearest to R19's right leg. CNA-G connected the lower sling straps to the lift. CNA-H again stated the sling was wet, however, continued to connect the wet sling straps to the lift. R19 asked CNA-H to wipe off the wheelchair cushion stating it had urine on it. CNA-G lifted R19 off the bed while CNA-H kept her hands on R19's back. R19's abdomen was not fully supported. His weight was not evenly distributed during the transfer due to the lower straps positioning. R19 stated ouch and it's pinching me. Neither staff addressed R19's concerns of pain. On 5/31/24 during continuous observation from 11:58 a.m. through 01:00 p.m., R19 was seated in his wheelchair with a green sling beneath him and lower straps noted to be aligned with his hips. Approximately 8 inches of green sling was folded and bunched behind R19 where his wheelchair back met the seat. CNA-E, and CNA-D connected the lift sling straps and raised R19 from his wheelchair. CNA-E was on R19's left side and stated the sling was not under R19 very well and instructed CNA-D to lower R19. CNA-D lowered R19, forcefully pulled the sling under R19's buttocks by grabbing the loop of the sling strap and pulling hard towards the mechanical lift. -At 12:08 p.m., two additional staff entered the room. Registered nurse RN-D attempted to pull the sling under R19 by pulling the lower left strap towards the mechanical lift and instructed staff to do the same on the lower right side. RN-D instructed staff to raise the sling. She again pulled the sling towards the mechanical lift by yanking on the straps. -At 12:13 p.m., R19 stated I feel like I'm going to be pulled out of my chair Staff continued to raise, lower, and readjust sling under R19. At 12:16 p.m., CNA-F entered room, instructed staff, and stated the sling was not under R19 correctly. CNA-F instructed staff to connect the sling straps to the lift using the yellow loop on the lower portion of sling and green loop on the upper portion of the sling. As staff began raising the lift R19 stated Ouch. RN-D and CNA-F completed transfer and left the room. Assistant director of nursing (ADON) entered the room. -During skin inspection ADON stated R19 had two reddish purple lines approximately 8 centimeters on lower inner thigh extending into groin and going up R19's right buttock. There was an abrasion approximately 3 centimeters by 3 centimeters on right buttock and another 2 centimeters by 3 centimeter to the front lower scrotum with scant blood. Further, there were three small abrasions to the back of scrotum and a reddish purple line approximately 10 centimeters on front of left upper thigh extending into groin. -During interview on 05/30/24, at 10:51 a.m., CNA-C stated residents had slings in their room. Further, slings that had to be crossed at the legs must always be removed from under the resident after transfer. -During interview on 05/30/24, at 10:26 a.m., registered nurse (RN)-A stated the sling normally used for R19, who weighed 298 lbs, went up to 200 lbs., and he did not know who determined what sling to use. Additionally, he stated slings were routinely left under residents and the care plan would include this information. Review of R19's careplan lacked evidence of type or color of sling to be used. During interview on 5/31/24, at 03:04 p.m., with ADON and DON, ADON stated the abrasions and reddish-purple lines on R19's groin were from improper sling use and improper transfer techniques. ADON stated by leaving a wet sling under a resident and forcefully tugging on the sling straps would cause increased pressure to R19's skin and cause tearing of the skin. ADON stated the injuries to R19's groin were consistent with friction or shearing, and that she had notified R19's physician and requested orders for management. DON stated she expected all staff to immediately report any alterations in a resident's skin to the nursing staff. DON stated this was important so nursing staff can investigate the root cause of the skin alteration and monitor the resident's skin for signs of infection or worsening wounds. Facility procedure titled Lifting Machine, using a Mechanical with a revised date of July 2017 indicated lift design and operation varied across manufacturers and staff must be trained and demonstrate competency using the specific machines or devices utilized by the facility. Measure the resident for proper sling size and purpose, according to manufacturer's instructions. Double check the sling and machine's weight limits against the resident's weight. Visually check the size to ensure it is not too large or too small. Make sure the sling is attached to the clips and that it is properly balanced. Lift the resident 2 inches from the surface to check stability of the attachments, the fit of the sling and the weight distribution. Check the resident's comfort level by asking or observing for signs of pinching or pulling of the skin. Carefully remove the sling from under the resident. Document the reason for the transfer, the type of lift used, equipment size and condition, names, and titles of staff assisting, resident's physical and mental condition before and after the procedure and how the resident tolerated the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] M. Based on observation, interview, and document review, the facility failed to perform mechanical lift and lift sling assessments for 1 of 1 residents (R19) to ensure appropriate use and proper size. Further the facility failed to adequately train staff on manufacturers guidelines for use of mechanical lift. This deficient practice had the potential to effect all residents requiring assist with a mechanical lift. Findings include: R19's admission minimum data set (MDS) dated [DATE], showed R19 had a brief interview for mental status (BIMS) score of 15/15, cognitively intact, self-care deficit requiring substantial/maximal assistance for toileting hygiene, upper and lower dressing, positioning and transfers. R19's diagnoses included hemiplegia (weakness or paralysis of one side of the body) and muscle weakness. R19's care plan dated 2/14/24 indicated R19's ability to perform activities of daily living (ADL's) had deteriorated related to a diagnosis of hemiplegia and required extensive staff assistance of one to two staff for toileting, dressing, bathing, grooming and bed mobility. Total dependence with Hoyer lift (EZ Way Smart Lift- a device designed to assist caregivers in safely transferring patients with limited mobility) for all transfers. R19's care plan lacked evidence of the size or color of sling required. R19's record lacked evidence of a comprehensive safe transfer assessment to determine the appropriate sling to use with the mechanical lift. During observation on 5/29/24, at 03:04 p.m., R19 was driving an electric wheelchair in hallway outside his room and through doorway into his room. [NAME] mechanical lift sling noted under resident with sling straps hanging loose. During observation on 5/28/24 at 03:13 p.m., R19 requested certified nursing assistants (CNA)-G and CNA-H assist him to change his incontinent product and clothing. CNA-H crossed the lift sling straps between R19's legs approximately one inch from his groin, connected all four mechanical sling straps to EZ Way Smart lift while CNA-G ran the controls. CNA-H kept her hand on R19 while CNA-G turned the lift and pushed it towards R19's bed. When R19 was situated above his bed CNA-G began lowering R19 to his bed. CNA-H disconnected the sling straps when R19 was completely lowered to the bed. CNA-G then moved the lift machine away from the bed but walked around to the opposite side of the bed from (CNA)H to assist with the incontinent product and clothing change. Upon completion of changing of clothing and incontinent product, (CNA)H stated the sling was wet but did not retrieve a clean sling. CNA-G crossed straps of tan sling between R19s legs and pulled both straps to the right side of R19's groin. They instructed CNA-H to move the mechanical lift to R19's bed and began to connect the sling straps to the lift. CNA-H again stated the sling was wet while holding the upper sling strap but continued to connect the sling straps to the lift. R19 asked CNA-H to wipe off his wheelchair cushion stating it had urine on it. CNA-G began to lift R19 off the bed while CNA-H kept her hands on R19's back. R19's abdomen was not fully supported, and weight was unevenly distributed during the transfer due to the lower straps positioning. R19 stated ouch and it's pinching me throughout the transfer to his wheelchair. On 5/31/24 during continuous observation from 11:58 a.m. through 01:00 p.m., R19 was seated in his wheelchair with a green sling beneath him with lower straps/loops noted to be aligned with his hips. Approximately 8 inches of green sling was folded and bunched behind R19 where his wheelchair back met the seat. CNA-E, and CNA-D connected the mechanical lift sling straps and began to raise R19 from his wheelchair approximately one inch when CNA-E, who was on R19's left side, stated the sling was not under R19 very well and instructed CNA-D to lower R19 back to the wheelchair. CNA-D lowered R19 to the wheelchair and attempted to pull the sling under R19's buttocks by grabbing the loop of the sling strap and pulling hard towards the mechanical lift. At 12:08 p.m., two additional staff, registered nurse RN-D and RN-E entered the room. RN-D attempted to pull the sling under R19 by pulling the lower left strap towards the mechanical lift and instructed staff to do the same on the lower right side. RN-D instructed staff to raise the sling and then she again attempted to pull the sling towards the mechanical lift. At 12:13 p.m., R19 stated I feel like I'm going to be pulled out of my chair. CNA-E had his hands on R19 while CNA-D continued to raise, lower, and attempt to readjust sling under R19. At 12:16 p.m., CNA-F entered room and stated the sling was not under R19. CNA-F instructed staff to connect the sling straps to the mechanical lift using the yellow loop on the lower portion of sling and green loop on the upper portion of the sling. As staff began raising the lift R19 state Ow. Staff continued transfer to R19's bed. When R19 was lowered onto his bed RN-D, RN-E, and CNA-F left the room. ADON entered the room. Staff completed incontinent cares and began the process of placing sling under R19 to transfer back to his wheelchair. At 12:55 p.m., CNA-D and CNA-F attached sling straps to the lift. ADON stated R19 was positioned to far to one side and told staff he could not be lifted in that position. Staff readjusted R19 to the center of the sling and reattached the sling to the mechanical lift. Staff began raising the lift when ADON asked if R19 had used the current sling before. CNA-D stated it was the only one in the room and continued the transfer of R19. During interview on 5/30/24, at 10:37 a.m., CNA-B stated two staff were needed to transfer with a mechanical lift. Additionally, he stated the case managers, or the doctors decided what sling size to use and usually the slings were in the room and staff would use whatever was in the resident's room. He went on to say the slings were typically left under a resident unless the doctor said not to. During interview on 5/30/24, at 10:51 a.m., CNA-C stated slings were left in a resident's room or found downstairs. Additionally, he stated staff made sure slings were not bunched up under a resident and the sling that required the straps to be crossed always had to be removed from beneath a resident. During interview on 5/30/24, at 10:26 a.m., RN-A stated he did not know how the sling size was determined and staff regularly left the sling under a resident after transfer. Furthermore, this information was found on a resident care plan. During interview on 5/30/24, at 10:57 a.m., DON stated all lifts required two staff. DON stated all residents had the slings kept in their rooms and it should be on the CNA care sheets. OT assessed sling size and to determine the appropriate way to transfer. DON stated she expected staff to removed the slings from under a resident unless there was a doctor's order instructing otherwise, or in the case of resident preference. DON also stated her expectation of staff included removing a soiled or wet sling from a resident's room and replacing it with a clean one. During interview on 5/30/24, at 11:08 a.m., licensed practical nurse and staff development coordinator (LPN-SDC) stated staff training was completed with an online education program. Additionally, staff were provided instruction during orientation on the floor by thier peers. During interview on 5/31/24, at 01:01 p.m., assistant director of nursing (ADON) stated upon admission occupational therapy (OT) would do an assessment for the appropriate mechanical lift. ADON stated the sling type and size was also determined at that time by OT. Additionally, ADON stated all nursing staff were trained upon hire on how to safely and appropriately operate the facility used mechanical lifts. ADON went on to say, It's obvious they need more training to do safe transfers. During interview on 5/31/24, at 02:28 p.m., certified occupational therapy assistant (COTA) stated therapy performed therapy evaluation upon admission if the resident had a physician order. COTA went on to state therapy made recommendations on the type of device or lift depending on the level of assistance required but did not make recommendations on the appropriate sling sizes or styles to be used. Furthermore, COTA stated nursing had the education on lift transfers and should be able to make a judgement on sling selections. During interview on 5/31/24, at 03:04 p.m., DON and ADON both stated they did not participate in new staff orientation and could not describe the methods used to educate staff on facility used mechanical lifts. EZ Way Smart Lift manufacturer operator instructions indicate the following: Log roll the patient on his/her side away from you. Position the sling so the handles on the back of the sling are facing the mattress. Tuck half of the sling underneath the patient. Using the center handle as a guide, center the sling on the patient's spine with the base of the sling approximately two inches below the base of the tailbone. Logroll patient in opposite direction and pull rest of sling out the other side. Lay patient on their back. Make sure the sling is centered beneath the patient. Lift patient's left thigh and pull the left sling leg of the sling under patient's thigh. Then place excess sling left over the top of the patient's left thigh. Repeat steps for the right thigh. Move the EZ Way Smart lift until the tip of the boom (green nose cone) is centered of the patient's torso. Take the sling leg lying over the left leg, cross it over and attach it on the hook of the hanger bar located on the right side of the patient. Take the sling lying over the right leg, cross it over and attach it on the hook of the hangar bar on the left side of the patient using the same length and color of loop strap on both sides. This procedure will ensure the sling is under the patient's tailbone and behind his/her back, with the patient's weight evenly distributed on the sling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure ongoing monitoring of weight was completed as directed for 1 of 3 residents (R45) reviewed for nutrition. Findings include: R45's quarterly minimum data set (MDS) dated [DATE], indicated R45 was cognitively intact, had poor appetite or overeating, and was independent with eating. The MDS also included diagnoses of hypertension (high blood pressure), hyperlipidemia (too much fat in a patient's blood), and paraplegia (partial or complete paralysis of the lower half of the body. Additionally, the MDS indicated R45 was at risk for pressure ulcers and had at least one stage two, partial thickness pressure ulcer, at least one stage three, full thickness pressure ulcer, one stage four, full thickness pressure ulcer with exposed bone, tendon, or muscle, and at least one unstageable pressure ulcer. R45's care plan dated 1/24/24 indicated R45 had a nutritional risk due to diagnoses of paraplegia, hypertension and hyperlipidemia, weight fluctuations with unplanned weight loss then significant weight gain, skin status/wounds, variable oral intake patterns, and high body mass index (BMI). Interventions included obtain weight as ordered and per facility protocol. R45's full nutritional assessment dated [DATE] indicated R45 had a BMI of <19 or >27, skipped meals, and nutritional risk indicator score of 11 indicating high risk. R45's signed physician order report dated 5/1/24, indicated R45 received Arginaid (a nutritional supplement) twice daily, received a regular diet with regular texture and thin liquids, and was ordered to be weighed monthly on bath days with special instructions to include weight be completed even if bath/shower was declined. R45's electronic medical record (EMR) indicated the following recorded weights: 4/3/24- 268.2lbs, 11/27/23-265.6lbs, 11/16/23- 263.1lbs, 10/5/23-245.7lbs, 7/12/23-244.7lbs, 6/22/23-248.8lbs, 5/23/23-237.1lbs. Progress note dated 12/27/23 at 09:19 a.m., signed by registered dietician (RD)-I indicated R45 was followed monthly due to skin status and noted weight gain; RD to continue to monitor, make changes/recommendations prn and follow monthly due to skin status and weight changes. Progress note dated 01/29/24 at 09:52 a.m., RD-H indicated no new nutritional changes; most recent weight noted of 265.6# 11/27/23; BMI: 36.0. RD will recommend an updated weight; RD to continue to monitor weights. Progress note dated 02/05/24 at 04:13 p.m., RD-H indicated no updated weight since 11/27/23 of 265.6# BMI: 36.02; significant weight gain noted at 30 days (+19.9#, +8%) and 180 days (+28.5#, +12%); elevated BMI, noted weight gain based on most recent weight over past year; RD will continue to monitor weights. Progress note dated 3/19/24 at 10:40 a.m., signed by RD-H indicated most recent weight noted of 265.6# on 11/27/23; BMI: 36.0. RD will recommend an updated weight; Res has increased needs to promote wound healing. Resident continues to be provided Ariginad BID for extra nutritional support to aid in wound healing; RD will continue to monitor weights. Progress note dated 4/16/24 at 10:31 a.m., signed by RD-H indicated weight (4/3/24): 268.2#; no 30 days or 90 days weight; 180 days (10/5/23): 245.7; RD will continue to monitor weights. Progress note dated 4/30/24 at 10:55 a.m., signed by RD-H indicated weight (4/3/24): 268.2#; BMI: 36.3; elevated BMI, noted weight gain based on most recent weight over past year, use of supplements to aid in meeting nutritional needs. RD will continue to monitor weights. Progress note dated 5/15/24 at 08:34 a.m., signed by RD-H indicated weight (4/3/24): 268.2#; no 30 days or 90 days weight; 180 days (10/5/23): 245.7# (+22.5, +9.1%); BMI: 36.3; RD will continue to monitor weights. Review of R45's EMR did not reveal any notification to physician of lapse in recorded weights. During interview on 5/29/24, at 09:28 a.m., RD-H stated the dietary manager attended care conferences and RD reviewed at risk residents. RD-H stated weights were done monthly for RD to review, however, if they were not completed RD would sent a request to DON to address. During interview on 5/30/24 at 11:06 a.m., DON stated weights were routinely done monthly for most residents, however, could be scheduled at a greater frequency with physician orders. After reviewing R45's EMR, DON confirmed R45 had not been getting weights done as ordered. DON stated her expectation was all staff followed the care plans and weighed residents per physician's orders, and, if residents refused it should be clearly documented and physician updated. DON went on to say weight monitoring and weight documentation was essential to accurately monitor residents' nutritional status, skin integrity and wound healing. Facility policy, Weighting and measuring the resident, indicated the purpose was to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. Further, the policy indicated if the resident refused the procedure, the reason why, the intervention taken, and notification of the nursing supervisor was to be documented.

Based on observation, interview and document review, the facility failed to ensure post-dialysis assessment and monitoring was completed for 1 of 2 residents (R42) reviewed for dialysis. Findings include: R42's Resident Face Sheet dated 5/31/24, included diagnosis of end stage renal disease (ESDR), hypotension of hemodialysis (low blood pressure), anemia in chronic kidney disease (low red blood cells), and dependence on renal dialysis. R42's physician order report dated 5/31/24, included an order to prepare a PRN dose of midodrine 10 mg (a medication to treat low blood pressure) to send with resident to dialysis Tuesday, Thursday and Saturday. Physician order report failed to include orders to monitor AV fistula for a thrill (a specific feeling over the dialysis graft) and a bruit (a whooshing sound heard with a stethoscope over the dialysis graft site) daily. R42's treatments administration history for May 2024 printed 5/30/24, included an order to avoid taking blood pressure or lab draws on left arm and to remind/encourage R42 to keep the pressure dressing intact after dialysis and monitor for bleeding once the pressure dressing was removed. Treatment administration history failed to include post dialysis monitoring including blood pressure, assessment of resident's overall condition or monitoring of the fistula site. R42's Care Plan, revised 4/24/24, included R42 had an AV fistula on right forearm. This was inconsistent with documentation to avoid blood pressure and lab draws on left arm due to fistula on resident's left arm. R42's care plan included he attended dialysis at HCMC Dialysis in Minneapolis and included a phone numbers for the location. R42's treatment details report was from DaVita dialysis center, not HCMC, dated 5/11/24 listed an access site of left upper arm. During interview on 5/30/24 at 12:26 p.m., dialysis center registered nurse stated it was best practice to monitor blood pressure and make sure the resident is not lightheaded or dizzy. The resident should not leave the pressure dressing on overnight but should be on for at least 3 hours and dialysis site should have been monitored. During interview on 5/31/24 at 10:38 a.m., director of nursing (DON) stated the facility did not have a policy for dialysis care. DON confirmed the facility had not completed post dialysis assessments when a resident returned from dialysis and had not monitored the fistula daily. DON stated this would have been important to have a policy to have formal expectations and standard care provided to every dialysis resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a clinical rationale for the extended use of an as needed (PRN) antianxiety medication (Ativan) beyond 14 days was documented for 1 of 1 resident (R25) reviewed for hospice services. Findings include: R25's quarterly minimum data set (MDS) dated [DATE], indicated R25 had a brief interview for mental status (BIMS) of 11 and was a substantial to maximum assist for dressing and cares and dependent for bathing. R25's MDS indicated diagnoses of hypertension (high blood pressure), diabetes mellitus, dementia (loss of cognitive functioning), hemiparesis (loss of ability to move part of one's body) and anxiety disorder. R25's current physician orders signed 5/1/24, indicated an order for lorazepam (Ativan) 1mg by mouth (PO) every 2 hours as needed (PRN). The start date was 3/13/24 and end date of 9/13/24. R25's medical record lacked clinical rationale for the extended use beyond 14 days. R25's electronic medical record (EMAR) reviewed 5/31/24, indicated R25 had last received a dose of Ativan on 5/19/24. R25's consultant pharmacist's medication review dated 3/5/24, indicated the following recommendations from the pharmacist: This patient's PRN Ativan order was updated on 2/9/24, however there was no stop date/duration listed for this medication on the medication administration record (MAR). Per updated CMS (Center for Medicaid Services) regulations, all new prn psychotropic medications orders must be re-evaluated within 14 days of initiation, and then at routine intervals thereafter. Additionally, when renewing the PRN psychotropic orders, clinical rationale for continuing the medication must be provided. NOTE: CMS had specified that hospice was not an exception to the rule. The physician response dated 3/13/24 did not provide a clinical rationale for use beyond 14 days. On 5/30/24 at 08:49 a.m., the director of nursing (DON) stated their expectation for a PRN psychotropic medication was the order would last 14 days or have a clinical indication for why the order was extended. On 5/31/24 at 11:22 a.m., the pharmacist (O)-C stated a PRN psychotropic medication order such as Ativan needed to have rational for use, duration, and clinical reasoning as to why the physician was extending the order past the 14 days. O-C confirmed the facility failed to provide a clinical rational for extending the order. Furthermore, O-C stated they had addressed this issue in the monthly pharmacy review from December, March and planned to address again in June. The facility's Psychotropics Policy and Procedure last reviewed 2/2024, indicated PRN medication orders were to be for 14 days then set to be renewed or discontinued depending on use and need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure 1 of 5 residents (R35) received a pneumococcal vaccine offered by the facility. Findings include: R35's undated face sheet indicated R35 was [AGE] years of age, admitted to the facility on [DATE], and had diagnoses of current smoker, traumatic subdural hemorrhage without loss of consciousness (stroke related to bleeding in the brain), dysphagia (difficulty swallowing), diabetes mellitus, atrial fibrillation (top chambers of the heart beat erratically), congestive heart failure (heart does not beat efficiently), and depression. R35's current physician orders reviewed 5/31/24, indicated a physician's order on 2/29/24 which read may receive pneumococcal vaccinations if indicated. R35's progress note dated 3/15/24, indicated R35 had received education and given consent upon admission to receive a dose of the pneumococcal conjugate vaccine (PCV) 15 or PCV-20. R35's vaccination record dated 5/29/24, lacked evidence a pneumococcal vaccination was received. R35's chart lacked evidence a dose of PCV-15 or PCV-20 was given. On 5/30/24 at 9:31 a.m., the infection preventionist licensed practical nurse (LPN)-A confirmed R35 had not received either a PCV-15 or PCV-20 dose. On 5/30/24 at 10:39 a.m., an electronic mail (e-mail) sent from thrify white pharmacy to the facility, indicated on 3/30/24 the pharmacy faxed an approval form for the vaccine which was not responded to or followed up on by the facility. On 5/31/24 at 3:48 p.m., the director of nursing (DON) expected the staff would go over education, consents and administer vaccinations upon admission to the facility to help reduce the risk of pneumonia. A pneumococcal vaccination policy was requested, and it was not provided.

Based on interview and document review the facility failed to ensure the infection control program included symptom tracking and ongoing analysis of trending of resident infections to prevent the spread of infections. This deficient practice had the potential to affect all 58 residents in the facility. Findings include: The facility's infection control logs were reviewed for March and April 2024. The logs identified tracking records of residents with infections, cultures, and treatments. However, the facility lacked documentation of analysis and/or trending of patterns identified. The facility utilized a form titled infection control log which had sections for each of the following items: identifying location, date, the patient, admission date, room number, unit, type, site and date of onset of infection, cultures, organisms, antibiotic resistance. Additionally, whether an antibiotic was started, infection definition (type of), classification section to select community or healthcare acquired infections, date resolved and if the resident was isolated or not. Furthermore, the form included sections regarding tracking of infections such as total number of different types of infections, number of new cases with and with out antibiotic resistance organisms, total number of infections, and reporting time period. Four infection control logs were provided by the facility, of those four, two were labeled April of 2024 and two were labeled May of 2024. One of the May of 2024 logs designated 2nd floor as a location, the other three lacked a location. The two infection control logs dated April of 2024, were filled out inconsistently and lacked part or all of the following information for the residents listed there: location of log, symptoms, location of infection, type of infection, cultures or diagnostics and dates taken, classification of infection, date resolved, if isolation was necessary, start dates of antibiotics, and whether or not criteria was met for the infection. Additionally, the form lacked documentation of analysis or tracking of symptoms and infections within the facility. The two infection control logs dated May of 2024, were filled out inconsistently and lacked part or all of the following information for the residents listed there: location of log, symptoms, location of infection, type of infection, cultures or diagnostics and dates taken, classification of infection, date resolved, if isolation was necessary, start dates of antibiotics, and whether or not criteria was met for the infection. Additionally, the form lacked documentation of analysis or tracking of symptoms and infections within the facility. The Quality assurance (QA) meeting minutes dated 4/8/2024, listed infection control: Jan-7, Feb-4, March-10. No additional details were provided. On 5/30/24 at 9:31 a.m., the infection preventionist licensed practical nurse (LPN)-A stated since the previous director of nursing (DON) left the facility near the end of March 2024, the current DON was responsible for symptom tracking and antibiotic stewardship in the facility. On 5/30/24 at 11:45 a.m., the DON stated since the previous DON had left the facility the infection preventionist LPN-A had been completing symptom tracking and antibiotic stewardship. DON had not completed either task. On 5/31/24 at 1:22 p.m., the DON and LPN-A confirmed neither person had been analyzing the data and trends with symptom tracking and antibiotic stewardship in the facility since the exit of the previous DON in late March 2024. On 5/31/24 at 3:30 p.m., the administrator stated they believed the DON had been analyzing and trending symptom tracking and antibiotic stewardship. They were informed the DON had stated it had not been completed. Administrator stated they also discuss them at QA, however deferred to nursing to provide the information discussed. The Infection Control-Surveillance Policy last reviewed 7/2023, indicated the infection preventionist or designated personnel was responsible for gathering and interpreting surveillance data. Interpreting Surveillance data: Analyze the date to identify trends, compare previous timeframes. The infection preventionist and quality assurance committee will review data quarterly to identify predominant pathogens or sites of infection or in particular units by recording month to month and observing trends.

Based on interview and document review the facility failed to implement a process for antibiotic stewardship to determine appropriate indications, dosage, duration, symptoms, analysis of trends and efficacy of antibiotic use. This had the potential to affect any of the 58 residents in the facility. Findings include: The facility's infection control logs were reviewed for March and April of 2024. The logs identified tracking records of residents with infections, cultures, and antibiotic treatments. However, the facility lacked documentation of analysis, trending of patterns identified or efficacy of antibiotics used. The facility utilized a form titled infection control log which had sections for each of the following items: identifying location, date, the patient, admission date, room number, unit, type, site and date of onset of infection, cultures, organisms, antibiotic resistance. Additionally, whether an antibiotic was started, infection definition (type of), classification section to select community or healthcare acquired infections, date resolved and if the resident was isolated or not. Furthermore, the form included sections regarding tracking of infections such as total number of different types of infections, number of new cases with and with out antibiotic resistance organisms, total number of infections, and reporting time period. Four infection control logs were provided by the facility, of those four, two were labeled April of 2024 and two were labeled May of 2024. One of the May of 2024 logs designated 2nd floor as a location, the other three lacked a location. The two infection control logs dated April of 2024, were filled out inconsistently and lacked part or all of the following information for the residents listed there: location of log, symptoms, location of infection, type of infection, cultures or diagnostics and dates taken, classification of infection, date resolved, if isolation was necessary, start dates of antibiotics, and whether or not criteria was met for the infection. Additionally, the form lacked documentation of analysis of antibiotic usage and efficacy within the facility. The two infection control logs dated May of 2024, were filled out inconsistently and lacked part or all of the following information for the residents listed there: location of log, symptoms, location of infection, type of infection, cultures or diagnostics and dates taken, classification of infection, date resolved, if isolation was necessary, start dates of antibiotics, and whether or not criteria was met for the infection. Additionally, the form lacked documentation of analysis of antibiotic usage and efficacy within the facility. The Quality assurance (QA) meeting minutes dated 4/8/2024, listed infection control: Jan-7, Feb-4, March-10. No additional details were provided. On 5/30/24 at 9:31 a.m., the infection preventionist licensed practical nurse (LPN)-A stated since the previous director of nursing (DON) left the facility near the end of March 2024, the current DON was responsible for antibiotic stewardship in the facility. On 5/30/24 at 11:45 a.m., the DON stated since the previous DON had left the facility the infection preventionist LPN-A had been completing antibiotic stewardship. DON had not completed antibiotic stewardship. On 5/31/24 at 1:22 p.m., the DON O-B and LPN-A confirmed neither person had been analyzing the data, usage trends and efficacy of antibiotics in the facility since the exit of the previous DON in late March 2024. DON and LPN-A stated each day during their interdisciplinary team meeting they discuss all new orders and why the resident was placed on the antibiotics. Staff were expected to chart in progress notes if the antibiotics were working or any reactions occurred. However, there was no follow up unless completed by the floor nurses. On 5/31/24 at 3:30 p.m., the administrator stated the the DON had been analyzing and trending the antibiotic stewardship program. They were informed the DON had stated it had not been completed. Administrator stated they also discussed them at QA, however deferred to nursing to provide the information discussed. The Antibiotic Stewardship Policy last reviewed in 2024, indicated the purpose of the antibiotic stewardship program was to monitor the use of antibiotics in our residents. Orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure confidentiality of personal records for one of one resident (R1) reviewed. The facility gave R1's medical information to his probation officer and the electric health monitor case manager. Findings Include: R1's Face sheet printed on 4/24/24 indicated R1 was admitted to the facility on [DATE]. Diagnoses included alcoholic gastric without bleeding, alcohol induced acute pancreatitis, and alcohol dependence. R1's progress note dated 2/16/24 indicated R1 was admitted to the facility for alcohol induced gastritis, esophagitis, and metabolic acidosis. R1's brief interview for mental status (BIMS) assessment dated [DATE] indicated R1 had a score of 15 which meant R1 was cognitively intact. R1's progress note dated 3/14/24 indicated facility staff found empty bottles of alcohol in R1's room. The progress note indicated R1 admitted to drinking two pints of alcohol in the last eight days. R1's progress note dated 3/18/24 indicated R1 had anxiety, nausea, and easy agitation. R1's progress note dated 4/16/24 signed by the interim director of nursing (IDON) indicated R1 was upset with the nurse practitioner (NP) while saying she was worthless. R1's progress note dated 4/23/24 signed by IDON indicated the name of R1's probation officer (PO) as well as the phone number for the PO. An email correspondence between the admission director (AD) and the EHM (electronic health monitor) case manager on 4/19/24 at 10:32 a.m., AD stated to EHM that she needed R1's PO name and phone number because the facility had suspicion of abuse of R1's probation. An email correspondence between R1's PO and AD on 4/20/24 at 9:00 a.m., R1's PO stated she will be visiting with R1 that day and that she would go over the contract he signed regarding the conditions of his program. An email correspondence between the AD and R1's PO on 4/20/24 at 9:06 a.m., AD stated R1's behavior has been off recently. AD stated the facility's concern is that he may still be using alcohol. AD stated R1 had been previously discharged during another stay for his use of alcohol. AD stated R1 has been caught doing the same thing during the current stay. During an interview with R1 on 4/24/24 at 9:41 a.m., R1 stated he was on house arrest for driving under the influence (DUI). R1 stated his EHM case manager and his PO have been in contact with the facility. R1 stated there is a lot of conversations going on about his legal status and his medical status. R1 stated he did not give the facility authorization to speak with his PO or the EHM. During an interview with registered nurse (RN)-A on 4/24/24 at 1:02 p.m., RN-A stated the facility was in contact with R1's PO because his PO was inquiring about R1's compliance with not drinking alcohol. During an interview with IDON on 4/24/24 at 1:35 p.m., IDON stated R1 is his own legal guardian. IDON stated there is a monitor on R1's room floor and it was saying that R1 was out of compliance. IDON stated the message on the monitor stated he was out of compliance, R1 not having performed his breathalyzer examination, and that R1's phone number was not in service. IDON stated she contacted Hennepin County and spoke with R1's PO stating he had an outburst recently and the facility thought he was using drugs or alcohol. IDON stated she thought his PO needed to intervene. IDON stated she did not have documentation where R1 gave the facility permission to speak with R1's PO. During an interview with AD on 4/24/24 at 1:56 p.m., AD stated the facility had a concern with R1 using alcohol in the facility. AD stated she contacted R1's PO stating the facility had concerns over his behavior and being out of compliance with his monitor base that was in his room. AD stated she did not have a release of information (ROI) on file to speak with R1's EHM or his PO. A policy for medical records was requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide a timely influenza immunization as recommended by the Centers for Disease Control (CDC) for 1 of 5 residents (R2) residents reviewed for immunizations. Findings include: The CDC recommends before an outbreak occurs the influenza vaccination should be provided routinely to all residents and healthcare personnel of long-term care facilities. If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. For persons aged =65 years, the following quadrivalent influenza vaccines are recommended: high-dose IIV, adjuvanted IIV, or recombinant influenza vaccine. If not available, standard-dose IIV may be given. R2's admission Minimum Data Set (MDS) dated [DATE] indicated he had a medial diagnosis of Parkinson's Disease. The MDS assessment lacked documentation of influenza immunization. R2's Influenza Consent form signed by R2 on 10/18/23 indicated he wished to receive the influenza immunization. R2's medical record lacked documentation of the influenza immunization for the 2023 influenza season. R2's Minnesota Immunization Information Connection (MIIC) form dated 10/20/23 lacked influenza immunization administration for the 2023 influenza season. On 12/12/23, at 4:03 p.m., the director of nursing (DON) stated R2 was not given the influenza vaccine. On 12/13/23 at 8:52 a.m., the DON stated she and licensed practical nurse (LPN)-B shared the responsibility of tracking and administration of immunizations. On 12/13/23 at 4:08 p.m., licensed practical nurse (LPN)-B stated she was not aware R2 wanted an influenza immunization. On 12/13/23 at 4:10 p.m., the DON stated the facility had not been following their previous process of which residents wanted to get the vaccine. this doesn't really make sense without more info. The DON stated the regulations only stated the immunizations needed to be offered, but did not specify when they were supposed to be administered. The facility Influenza policy dated 1/23 directed between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. The policy also directed administration of the influenza vaccine will be made in accordance with current CDC recommendations at the time of the vaccination.

Based on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) for source control was worn by all staff, per the Centers for Disease Control (CDC) grid, directing everyone should mask in communal areas of the facility while in COVID-19 outbreak status. This had the opportunity to affect all residents and visitors. Findings include: The CDC PPE grid directs source control is recommended by those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 (COVID-19) or other outbreak of respiratory infection; universal use of source control could be discontinued as mitigation measure once the outbreak is over; no new cases of COVID-19 have been identified for 14 days. On 12/12/23 at 9:27 a.m., at the entrance of the facility, a sign indicated the facility had three cases of COVID in the building. On 12/12/23 at 9:27 a.m., a facility document posted on the wall in the entrance of the facility dated 4/17/23 directed masks were no longer required while in the building. On 12/12/23 at 9:27 a.m., the receptionist (R)-A was not wearing a mask while in a communal area on the first floor. On 12/12/23 at 9:28 a.m., social services (SS)-A was not wearing a mask as she walked through the communal area on first floor. On 12/12/23 at 9:28 a.m., the facility administrator walked through the communal areas of first and second floors without a mask. On 12/12/23 at 9:29 a.m., physical therapist (PT)-A was pushing a resident in a wheelchair in the communal area of second floor without a mask. On 12/12/23 at 9:30 a.m., nursing assistant (NA)-A was in the communal area of the second floor without a mask. NA-A stated there were two cases of COVID on the second floor. NA-A stated staff did not wear masks in the hall, but wore them when they entered COVID positive resident rooms. On 12/12/23 at 9:30 a.m., licensed practical nurse (LPN)-A was in the communal area of the second floor without a mask. LPN-A stated there were current cases of COVID in the facility. LPN-A stated staff were not wearing masks in the hall. On 12/12/23 at 9:32 a.m., the administrator stated there were three cases of COVID in the building. The administrator stated COVID had just started 12/11/23. The administrator stated there were also staff out with COVID. On 12/12/23 at 9:35 a.m., trained medication aide (TMA)-A was in the communal area of the second floor without a mask. On 12/12/23 at 10:55 a.m., the director of nursing (DON) stated staff should be wearing masks in communal areas due to the presence of positive COVID cases in the facility. On 12/12/23 at 11:58 a.m., the assistant director of nursing (ADON) stated the current COVID outbreak started on 12/9/23. On 12/12/23 at 3:00 p.m., the medical director (MD)-A stated staff should be wearing masks in the halls and resident areas on the unit where COVID is present. A facility document Employee Health dated 9/20/23 directed all staff to wear an N95 grade mask, and eye protection, goggles or face shield. If you are taking care of a COVID positive resident in their room, you should also wear an isolation gown.

Based on interview and document review the facility failed to honor residents right to refuse care for 1 of 1 resident (R10) reviewed for resident rights. Findings include: R10's Minimum Data Set (MDS) was in process. R10's medical diagnoses list dated 6/28/23, indicated R10 had diagnoses which included adjustment disorder, antisocial personality disorder, phobic anxiety disorder, generalized anxiety disorder and major depressive disorder. R10's care plan dated 6/28/23, indicated R10 was an independent smoker and was allowed to vape in his room due to his current wound issues and would be reminded of the smoking rules and would change him to a monitored smoking program per policy if he did not follow them. A general nursing order dated 7/8/23, indicated to take R10's vaping privileges away if he refused any cares such as repositioning, catheter care, getting up for lunch and wound care. During an interview on 7/10/23 at 1:58 p.m., R10 stated the staff would punish him if he refused cares by threatening to take away his vape. R10 stated he would not do anything he did not want to for anyone. R10 stated the reason he refused cares was because he was in pain related to the wounds on his feet and he did not like to be around other people. R10 stated he felt he was given an ultimatum to comply or else he would lose his vape which helped keep him calm and reduced his anxiety. R10 stated the thought of not being able to vape was distressing and caused him to have anxiety. During an interview on 7/11/23 at 8:33 a.m., registered nurse (RN)-A stated R10 had a history of being noncompliant with activities of daily living (ADLs). RN-A stated R10 had special privileges to use his vape in his room due to the wounds on his feet. RN-A stated the facility used R10's vape privilege as an incentive and would take it away if R10 was noncompliant. RN-A stated this worked the other day because after R10 was told he would not be able to keep or use his vape if he didn't get out of bed, R10 got out of bed and sat in his chair for approximately 30 minutes. During an interview on 7/11/23 at 5:10 p.m., director of nursing (DON) stated all residents were assessed for smoking/vaping upon admission, annually and with significant change to determine if the resident could be independent or required modified assistance with smoking/vaping. DON stated residents who smoke/vape signed the smoking policy and by signing the policy acknowledged that smoking was a privilege and not a resident right, therefore smoking privileges could be taken away for noncompliance of ADLs as indicated in said policy. DON stated the most common reason smoking privileges were taken away was for noncompliance with showers or incontinence. DON stated all staff could take away smoking/vaping privileges from a resident when necessary. DON stated the facility did not have a formal process that was followed when deciding to take away the smoking/vaping privileges. DON stated the facility did not often have to take away smoking/vaping privileges because as soon as the noncompliant resident was told their smoking/vaping privileges would be taken away if the desired task was not completed, most residents would then comply. DON reviewed smoking policy, confirmed it did not indicate smoking/vaping was a privilege, and further did not indicate a resident would not be able to smoke or vape for noncompliance with ADLs. DON stated the facility had a secondary policy that listed the ADL component but later stated no secondary policy could be located. During an interview on 7/11/23 at 5:27 p.m., the administrator stated he understood smoking and vaping was a privilege and not a resident right and could be taken away from a resident for noncompliance with ADLs. During an interview on 7/12/23 at 8:16 a.m., nursing assistant (NA)-A stated staff could take away a resident's smoking privilege if they felt it necessary to get the resident to complete a specific ADL. NA-A stated she had never taken away a resident's smoking/vaping privilege because she did not think it would be the right thing to do and felt it would be punishing the resident. They have the right to refuse care. NA-A stated it didn't do the facility any good to take smoking/vaping privileges away because then they had to deal with angry and aggressive behaviors. NA-A stated she was unaware of staff training on the process to follow if they removed smoking/vaping privileges. During an interview on 7/12/23 at 8:33 a.m., social services (SS)-A stated the facility did not have set rules or a formal process to follow when deciding if a residents' smoking/vaping privileges would be taken away. SS-A stated she would normally give the resident a warning instead of taking away smoking/vaping privileges because that caused the residents to become angry, verbally aggressive, and disruptive to others. A facility policy requesting, refusing and/or discontinuing care or treatment dated, February 2021 indicated residents had the right to request, refuse and/or discontinue treatment and would not under any circumstance be coerced, intimidated, manipulated, or threatened for refusing care or treatment.