**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure appropriate care and treatment related to weight monitoring was provided for 1 resident (R) (R86) of 2 sampled residents.The facility did not complete additional assessments and ensure the physician was notified when R86 had a weight gain of more than 2 pounds in 1 day.Findings include:The facility's Heart Failure-Clinical Protocol policy, revised April 2007, indicates: .2.The nurse will assess and document/report the following: a. Vital signs; b. General physical assessment .1. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights .) to monitor, when to report findings to the physician, etc. 2. The physician will address related medical issues .whether to modify doses of diuretics .1. The physician will help monitor the progress of individuals with heart failure, including ongoing evaluation and documentation of signs, symptoms, and condition changes .From 8/4/25 to 8/6/25, Surveyor reviewed R86's medical record. R86 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, localized edema (swelling), and chronic diastolic (congestive) heart failure. R86's Minimum Data Set (MDS) assessment, dated 6/18/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R86 had moderate cognitive impairment. R86 had an activated Power of Attorney (POA).R86's medical record contained the following order: Standing - weights daily and notify provider if weight gain of more than 2 pounds in 1 day or 5 pounds in 1 week (ordered 6/30/25). R86's medical record contained the following information:~ On 7/8/25, R86 weighed133.4 pounds. On 7/9/25, R86 weighed 135.6 pounds. R86's medical record did not indicate the physician was notified of the 2.2 pound weight gain.~ On 7/11/25, R86 weighed 135.4 pounds. On 7/12/25, R86 weighed 137.6 pounds. R86's medical record did not indicate the physician was notified of the 2.2 pound weight gain.~ On 7/24/25, R86 weighed 140.2 pounds. On 7/25/25, R86 weighed 142.8 pounds. R86's medical record did not indicate the physician was notified of the 2.6 pound weight gain.On 8/4/25 at 9:38 AM, Surveyor interviewed R86 and noted R86's bilateral lower extremities were edematous. R86 indicated R86 did not like wearing compression stockings.On 8/6/25 at 11:25 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R86 had an order to update the physician with a weight gain of more than 2 pounds in 1 day or 5 pounds in 1 week. When Surveyor asked if the physician was notified when R86 gained more than 2 pounds between 7/8/25 and 7/9/25, 7/11/25 and 7/12/25, and 7/17/25 and 7/18/25, DON-B indicated DON-B would look for physician notification and follow up with Surveyor.On 8/6/25 at 11:27 AM, Surveyor interviewed Registered Nurse (RN)-C who verified R86 had an order to notify the physician for a weight gain of 2 pounds in 1 day or 5 pounds in 1 week. RN-C also indicated respiratory and edema assessments should have been completed for a gain of more than 2 pounds in 1 day and staff should have updated the physician in accordance with R86's order.On 8/6/25 at 12:22 PM and 12:54 PM, DON-B provided Surveyor with multiple physician upate notes. A note, dated 7/7/25, indicated the physician was notified of R86's weights from 6/24/25 to 7/7/25. A note, dated 7/30/25, indicated the physician was notified of R86's weights from 6/30/25 to 7/30/25. A note, dated 7/22/25, indicated the physician was notified of R86's weights from 7/10/25 to 7/22/25. The physician updates did not include next day updates for weight increases of more than 2 pounds in 1 day. DON-B verified the physician should have been notified of R86's weight gain in accordance with R86's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R2) of 5 sampled residents had a call light within reach. On 1/8/25, R2's call light was wedged between the mattress and side rail of R2's bed and not within R2's reach. Findings include: On 1/8/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including history of falling, diabetes, hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebrovascular accident (CVA) affecting the right dominant side, morbid obesity, and anxiety disorder. R2's Minimum Data Set (MDS) assessment, dated 11/21/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R2 was not cognitively impaired. R2's care plan, dated 9/21/23, contained an intervention to keep call light in reach. On 1/8/25 at 9:32 AM, Surveyor observed and interviewed R2 in bed. Surveyor noted R2's call light was wedged between the upper left-hand side of the mattress and a side rail on the bed. When Surveyor asked if R2 was able to reach the call light, R2 indicated R2 could not reach the call light and stated, Lots of times they put it (call light) on the back of the bed and I can't reach it. On 1/8/25 at 9:37 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who indicated R2 should have a call light. CNA-D entered R2's room and asked R2, Did they not give it (call light) to you again? CNA-D located the call light at the top left-hand side of the bed and clipped the call light on R2's blanket per R2's request. On 1/8/25 at 11:25 AM, Surveyor again interviewed R2 who indicated it is rough when R2 doesn't have a call light and needs to use the restroom. R2 indicated R2 had incontinent episodes when the call light was not within reach and has had to holler to staff in the hallway to use the restroom. R2 indicated staff eventually show up to assist R2 to the restroom. On 1/8/25 at 12:50 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed call lights should be within reach of residents. On 1/8/25 at 1:05 PM, Surveyor interviewed Registered Nurse (RN)-E who indicated a call light should be on the resident or within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and family interview, and record review, the facility did not ensure 1 resident (R) (R44) of 18 residents had a call light within reach or a means to call staff for assistance. During two observations, Surveyor noted R44's call light was not within reach. In addition, R44 did not have the correct call light to meet R44's needs according to R44's plan of care. Findings include: From 6/4/24 to 6/6/24, Surveyor reviewed R44's medical record. R44 was admitted to the facility on [DATE] and had diagnoses including senile degeneration of brain, vascular dementia, and encounter for palliative care. R44's Minimum Data Set (MDS) assessment, dated 3/21/24, contained a Brief Interview for Mental Status (BIMS) assessment that indicated R44 was rarely or never understood. R44 was admitted to Hospice services on 3/15/24. R44's spouse was R44's activated Power of Attorney (POA). R44's plan of care contained interventions for a soft-touch call light (dated 8/24/23) and to keep R44's call light within reach (dated 7/12/23). On 6/4/24 at 10:51 AM, Surveyor interviewed R44's spouse and noted R44's call light was clipped to a blanket on top of R44's right shoulder. Surveyor noted the call light contained a push button instead of a soft-touch pad. R44's spouse indicated R44 was not able to reach the call light in that position because R44 could not raise R44's arms that high and would probably not be able to push the button. On 6/5/24 at 1:01 PM, Surveyor observed R44 in R44's room in Broda chair with the back of the chair against R44's bed. Surveyor noted R44's push button call light was laying on R44's bed and not within R44's reach. On 6/5/24 at 1:19 PM, Surveyor and Director of Nursing (DON)-B entered R44's room and observed R44's call light. DON-B confirmed R44's care plan indicated R44 should have a soft-touch call light within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not develop a comprehensive care plan for 1 resident (R) (R44) of 3 sampled residents. The facility's Matrix and R44's Significant Change Minimum Data Set (MDS) assessment indicated R44 received Hospice services. R44 did not have a care plan for Hospice services. Findings include: The facility's Hospice Program policy, revised 11/2016, indicates: The care plan shall be revised and updated as necessary to reflect the resident's current status. On 6/5/24, Surveyor reviewed R44's medical record. R44's was admitted to the facility on [DATE] and was admitted to Hospice services on 3/15/24. R44 had diagnoses including senile degeneration of the brain, vascular dementia, and encounter for palliative care. R44's Significant Change Minimum Data Set (MDS) assessment, dated 3/12/24, contained a Brief Interview for Mental Status (BIMS) assessment that indicated R44 was rarely or never understood and received Hospice services. R44's spouse was R44's activated power of attorney (POA). On 6/4/24 at 11:50 AM, Surveyor interviewed R44's spouse who confirmed R44 received Hospice services. On 6/6/24 at 2:24 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R44 did not have a care plan for Hospice services. DON-B indicated a care plan should be completed the day a resident signs on to Hospice services and should be updated with a Significant Change MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, and record review, the facility did not review and revise the plan of care for 1 Resident (R) (R1) of 7 residents. R1 received a new order for a restorative ambulation program. The facility did not update R1's care plan to incorporate the ambulation program. Findings include: The facility's Review of Care Plans policy, dated 12/2016, indicates: The Interdisciplinary Team must review and update the care plan. On 4/8/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including myelodysplastic syndrome, hypertension, atrial fibrillation, and diabetes. R1's Minimum Data Set (MDS) assessment, dated 1/24/24, contained a Brief Interview for Mental Status Score (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. The MDS also indicated R1 was independent with ambulation. A care plan, initiated on 1/17/24, indicated R1 required assistance with ambulation. R1's medical record contained a therapy order for R1 to ambulate in the hallway with a 2 wheeled walker with assistance once daily as tolerated. Nursing documentation indicated R1 walked in R1's room and walked once in the hallway between 2/28/24 and R1's discharge on [DATE]. Surveyor noted the ambulation program was not added to R1's care plan. On 4/8/24 at 12:16 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who stated R1 chose not to walk in the hallway but would often walk in R1's room. CNA-C stated CNA-C offered R1 the option to walk or use a wheelchair and R1 chose the wheelchair. CNA-C stated ambulation programs are listed on CNA care cards and showed Surveyor R1's care card. On 4/8/24 at 2:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R1's ambulation program was listed on R1's CNA care card but was not added to R1's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident representative and staff interview, and record review, the facility did not ensure written notice of a room change was provided for 1 Resident (R) (R1) of 2 residents reviewed. R1 was moved to a different room on 9/20/23. R1's medical record did not contain written notice to R1's representative notifying them of the room change. Findings include: The facility's Room Change/Roommate Assignment policy, revised May 2017, indicates: Prior to changing a room .all parties involved in the change/assignment (e.g., residents and their representatives) will be given notice of such change. R1 was admitted to the facility on [DATE] with diagnoses including urinary sepsis, chronic kidney disease, Alzheimer's disease, and depression. R1's most recent Minimum Data Set (MDS) assessment, dated 8/16/23, indicated R1's cognition was moderately impaired and R1 required extensive assistance of one to two staff for most activities of daily living (ADLs). R1 had an activated Power of Attorney for Healthcare (POAHC). On 11/21/23 at 10:34 AM, Surveyor interviewed R1's representative who stated when they went to visit R1 on 9/20/23, they were told R1 was moving to a different room. R1's representative indicated they were not provided written notice of the room change, including the reason for the room change. On 11/21/23 at 1:14 PM, Surveyor interviewed the Nursing Home Administrator (NHA)-A who stated a voicemail was left for R1's representative and secondary contact regarding the room change. NHA-A verified R1's representative was not given a written notice of the room change, including the reason for the room change.