Every finding on record at Aftenro Home

Based on observation, interview and document review, the facility failed to ensure the narcotic emergency kit was tracked to prevent potential theft and diversion of medications. This had the potential to affect all residents residing on the nursing unit.Findings include:On 3/18/26 at 1:05 p.m., a tour of the locked medication room was conducted with registered nurse (RN)-D. The medication room had one emergency kit that contained controlled substances, was locked in a cupboard and had a plastic numbered lock on it. RN-D stated the emergency kit containing narcotics was swapped out weekly by pharmacy. If the emergency kit was used they would fill out a slip identifying what was used and for which resident. RN-D stated the emergency kit containing narcotics was not part of the shift change narcotic count.The emergency kit contained the following controlled substances:hydrocodone/APAP (acetaminophen) 5/325 milligrams (mg) quantity of sixhydromorphone 2 mg quantity of twooxycodone 5 mg quantity of sixtramadol 50 mg quantity of sixmorphine oral solution 20 mg per milliliter quantity of sixoxycodone/APAP 5-325 mg quantity of sixlorazepam 0.5 mg quantity of sixDuring an interview on 3/19/26 at 2:40 p.m., the assistant director of nursing (ADON) verified they had an emergency kit that contained controlled substances and that it was not part of the controlled substance count at each change of shift. The ADON stated there was potential for diversion by not accounting for the emergency kit at each shift change.Narcotic (Controlled Substance) Control Policy dated 10/25/25, identified all narcotics would be securely stored, accurately documented, and reconciled at each shift change.

Based on interview and document review, in the absence of a full-time registered dietician the facility failed to designate a qualified person to serve as the director of food and nutrition services. This deficient practice had the potential to affect any resident in the facility.Findings include:During an interview on 3/16/26 at 8:22 a.m., the dietary manager (DM) stated she didn't have a certified dietary manager (CDM) certificate, and didn't think anyone here did, but the dietician was here several times a month. During an interview on 3/18/26 at 2:27 p.m., the administrator stated the DM didn't have a CDM certificate and wasn't enrolled in the program yet but had been at a previous employment. The administrator offered the DM did have a food safety manager training certificate of completion from 2/26/24.During an interview on 3/19/26 at 11:24 a.m., the registered dietician (RD) stated she was aware the RD didn't have a CDM and that she handled the quarterly reviews for residents.A policy regarding dietary management qualifications was requested but not received.

Based on observation, interview, and document review the facility failed to ensure a reliable system for identifying ingredients containing food allergens, and to ensure residents were not served items they were allergic to. In addition, the facility failed to have pre-planned menus for therapeutic diet types for 2 of 2 residents (R5, R35) reviewed for nutrition and food concerns.Findings include:R5's quarterly minimum data set (MDS) dated [DATE], identified R5 had intact cognition, a diagnosis of diabetes mellitus (DM), unplanned weight loss and needed set-up assistance with eating.R5's care plan dated 1/8/25, identified a focus statement related to DM and included interventions to have a dietary consult for nutritional regimen and ongoing monitoring, to discuss mealtimes, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, and compliance with nutritional regimen. Offer substitutes for foods not eaten. The care plan was updated on 1/30/26, the registered dietician (RD) added interventions for monitoring for signs of dysphagia, to monitor and report signs of malnutrition including weight loss of three pounds (lbs.) in a week, more than five percent in a month, or more than 7.5 percent in three months, or more than 10% in 6 months.R35's quarterly MDS dated [DATE], identified intact cognition and diagnoses of hypertensive heart failure, chronic kidney disease with kidney failure, and congestive heart failure (CHF). R35 needed set-up assistance with eating.R35's provider order dated 9/9/25, identified a two-gram sodium restricted diet.R35's care plan was created and last revised on 9/18/25, identified the need for set-up assistance with eating. A focus statement for nutrition identified interventions of serving a two-gram sodium diet as ordered.During an interview on 3/16/26 at 12:01 p.m., R35 stated there were no options if you didn't like the main course, and added she was sensitive to salt. R35 stated frustration at not being able to choose anything, and when you get an alternative, they give you want they want.During an interview on 3/16/26 at 12:26 p.m., R5 stated he was allergic to fish and they kept sending it to him, he demonstrated date and time-stamped pictures on his phone of a lettuce salad with dressing on it. R5 stated that was Cesear salad and he can't have it because of the dressing, and once last fall he was served tuna fish. R5 stated he normally called the kitchen on a day fish will be served to ask for a burger. R5 stated the facility didn't have an alternate menu.During an observation on 3/17/26 at 11:49 a.m., the current week's menu was posted on the dietary door on the first floor. At the bottom of the sign, it indicated alternative meal options were available and to call the kitchen two hours before the meal to allow staff to prepare your request.During an interview on 3/17/26 at 12:45 p.m., R35 stated she sent back her tray because it was sausage and peppers, which she stated she couldn't eat because of the sodium. R35 wasn't sure what she would eat, she didn't feel like going to her refrigerator, and staff didn't offer an alternative this time. R35 stated she had talked to the dietician right after she moved here, and they told her she could cross off the menu items she didn't want, and she made a list of everything she couldn't have. During an interview on 3/18/26 at 2:27 p.m., the administrator stated they had a huge action plan for resident satisfaction in dining, including a new ticket system. Their new food distributor will come to the facility and provide training, they have talked with dining consultants to come in and work with the DM on getting kitchen operations down, but first they were working on getting some consistency with staffing. The administrator stated the always-available menu hadn't been published yet, so there currently wasn't one. During an interview on 3/19/26 at 9:10 a.m., the DM stated they didn't have specific menus for things like diabetic and low sodium menus. They used a diet spreadsheet, so if there was a replacement needed they could make the adjustment, for example it could be a portion size change for them so they weren't completely devoid of a meal they would enjoy. The DM demonstrated a list written by R35 of food items she didn't want, including no salt or seasoning added. For R35, if she had asked for something different, they would have brought it up for her. For residents with food allergies typically the resident assistant (RA) will come down and let them know what the resident would like in place of the item. For R5, it was just common knowledge he couldn't have fish products, and he would call down for a burger. Their current ticket system didn't recognize ingredients in the recipe as potential allergens. The DA stated she depended on staff to look at the allergy and make an informed decision, and she wasn't aware if the Caesar dressing they used had anchovy paste in it and they didn't have any right now to check. It was noted Caesar salad was on the current four-week menu rotation.During an interview on 3/19/26 at 11:24 a.m., the registered dietician (RD) stated the menus were written and approved by a dietician at the food distributor, the current 4-week rotation was for a general diet. They didn't have separate menus for therapeutic diets, they had a spreadsheet with the diet types and what the substation for a particular item would be, and the cook must check the tray ticket to see the resident's diet type and what the substituted item would be when they are dishing up the plate. The RD stated she would expect preplanning to be sure you had what you needed. For R35, with a sodium-restricted diet, she wouldn't want her to receive sausage and peppers for dinner on a day she had sausage for breakfast. And for R5, he would say ahead of time what he wanted instead of fish.During an interview on 3/19/26 at 12:53 p.m., the director of nursing (DON) stated it was important to follow a provider-ordered diet, but the resident could dictate their own diet, they could refuse an item or get something else they wanted. The DON would expect the kitchen to send the therapeutic diet, and for products containing fish not to be served to a resident with a fish allergy.

Based on observation, interview and record review, the facility failed to ensure no more than 14 hours between the dinner and breakfast meals without offering a substantial snack.Findings include:A document, Dining Room Meal Service, listed breakfast as 7:30 a.m. to 8:15 a.m., lunch at 11:30 a.m. to 12:15 a.m., and dinner at 5 p.m. to 5:45 p.m. To ensure you receive your meal, please be in the dining room during the scheduled service time. Otherwise, a tray will be sent to your room.Food committee minutes dated 10/23/25, identified the administrator and dietary manager were in attendance. Concerns included the transition to more nutritious snack options with plans to phase out less healthy snack items. Residents mentioned staff members were witnessed helping themselves to resident snacks. Additionally, residents raised concerns about diabetic snacks and snack requests being unmet, after witnessing staff eating snacks.Food committee minutes dated November 2025, identified the dietary manager was in attendance. Residents requested snacks, egg salad to have for midnight snacks. A decision was identified, the nutrition director will coordinate with dietary cooks to prepare egg salad to be stored in a container on each floor along with a loaf of bread, residents can request assistance from on-duty staff to ensure optimal freshness.Resident council minutes dated 11/24/25, identified new business included a statement about snacks and soda, Aftenro is not going to supply everyone with soda and unhealthy snacks on a regular basis, only at special events such as bingo or happy hour. To do so would be outside the budget and mission. The facility will look at putting soda for sale in the country store for those residents who didn't leave the building. Residents requested [NAME] cookies and [NAME] Krispie treats and were informed these suggestions could go to the dietary manager. Sandwiches, fruit, vegetables are snacks that Aftenro can provide to residents. Items listed under the topic of kitchen included too many carbs at meals, 4-week menu cycle very repetitive, meat is too stringy, not many homemade meals, many things come out of a package, green beans and carrots are often undercooked and difficult to eat, diabetics need a more substantial snack between dinner and breakfast, snack situation still needs to be remedied, residents requested the administrators presence at the next food committee citing nothing gets done otherwise. There were noted discrepancies to the time, temperature and order correctness of items delivered to the floors.Food committee meeting minutes dated December 2025, identified the administrator and dietary manager were in attendance. Noted was a follow up on snacks, including a decision by the nutrition director to make the following snacks available at the nurse's station on each floor: microwave popcorn, crackers with peanut butter, granola bars, fig newtons, fresh fruit, pudding, Jello, popsicles, cheesy crackers, crackers with cheese. Noted for the next meeting was a discussion with residents about potential scheduled snack pass.During an interview on 3/16/26 at 8:22 a.m., the dietary manager (DM) stated the meals were delivered to the second and third floors prior to starting service in the dining room.During an interview on 3/16/26 at 12:26 p.m., R5 stated he was diabetic and needed a bedtime snack and there weren't snacks out anymore. During an interview on 3/17/26 at 7:23 p.m., trained medication aid (TMA)-A stated they didn't specifically offer snacks, but the residents all knew they could ask for them. At dinnertime a couple of the diabetics will get an extra sandwich.During an interview on 3/18/26 2:13 p.m., R35 stated never once had anyone gone around offering snacks. Even when you were to ask, it would take them a long time to go check and see if there was a snack. During an interview on 3/18/26 at 2:27 p.m., the administrator stated he had removed the big bowl of candy, snacks and pop because they were here to provide healthy snacks for the residents. The administrator stated they were not currently doing a snack pass where they go resident to resident and offer something, but they were in the process of changing the mealtimes so they could be within the 14 hours.During an interview on 3/19/26 at 11 a.m., registered nurse (RN)-A stated snacks were offered as needed; they used to have a snack cart out in the dining room for residents to help themselves, but they had issues with residents taking more than they should or not the right diet type. RN-A stated they did recently stop having soda, which was a cost savings. Almost every single resident had complained about this. During an interview on 3/19/26 at 11:24 a.m., the RD stated she was just recently made aware of the dissatisfaction of snacks here, when they used to have a very nice snack situation, she didn't know what changed and when this change had occurred. The RD stated there needed to be snacks residents wanted, and she would suggest something with protein and some milk would be helpful snacks in the event of low blood sugars, and as far as juice from concentrate being any healthier than soda, the RD felt it was a perception and the juice may be fortified with vitamins. A policy regarding timing of meals and snacks was requested but not received.Food Committee meeting minutes from January 2026 to present were requested but not received.An undated policy, Aftenro Home Snack and Beverage Availability Policy, described the purpose of the policy was to promote resident autonomy and access to snacks between meals. The policy defined the snack availability process as a designated area where residents may obtain food or beverages from staff or by requesting them from the nursing station. General requirements identified snacks, including whole fresh fruit such as bananas and oranges, may be provided by staff or available upon request at the nursing station. Only appropriate foods shall be provided by staff or made available upon request. Snack items must be stored in clean, designated areas and provided to residents by staff or upon request. For resident safety, staff must monitor and redirect residents who attempt to obtain food inconsistent with their care plan. For supervision and monitoring, staff are responsible for controlling access to snacks and ensuring safe distribution.

Based on observation, interview and record review, the facility failed to ensure potentially hazardous food (PHF) was dated when opened and held at safe temperatures when served to residents. In addition, the facility failed to ensure expired PHF was removed from circulation, that temperature logs were complete, and that medical equipment wasn't stored with resident food. These deficient practices had the potential to affect anyone consuming food and beverages at the facility.Findings include:During an observation and interview on 3/16/26 at 8:22 a.m., the walk-in cooler in the main kitchen contained an open and undated, partially full container of Prairie Farms heavy cream. The dietary manager (DM) stated she would expect milk to be dated when it was opened.During an observation on 3/17/26 at 11:57 a.m., the beverage station near the second-floor nursing station had a small refrigerator and freezer. There was an ice pack in the freezer with individual cups of ice cream. A sign on the refrigerator door indicated it was for labeled food only, no ice packs. Ice packs were in the freezer in the conference room.During an observation on 3/17/26 at 4:28 p.m., an unidentified dietary aid (DA) brought a cart of milk and juice cartons, not on ice, to the area where plated food was going into the hot carts for delivery to the floors. The DA proceeded to place milk cartons on the trays inside of the hot cart as plated food is being loaded. The tables already had place settings and milk containers at several of them. At 4:40 p.m., the DA brought the whole cart with juice and milk back into the walk-in cooler. At 5:07 p.m., the hot cart for third floor left the dining room. At 5:12 p.m., the DM temped a container of milk which had been on a table at a place setting, the temperature was 50.7 degrees Fahrenheit (F). At 5:18 p.m., the DA temped a carton of milk from the hot cart for the second floor. The temperature was 53.6 degrees F. The DM stated she wasn't sure what an unsafe temperature for milk was, but she thought it had to be sustained at a certain temperature for it to be un-servable. At 5:21 p.m., the DA temped a carton of milk from the hot cart on the third floor, the temperature was 55 degrees F. The DA stated milk had to be out for two to four hours above 40 degrees to be dangerous.During an observation and interview on 3/18/26 at 1:31 p.m., the second-floor beverage station refrigerator had resident food dated and labeled, individual containers of juice, and a multiple-serving container of open and undated, partially full orange juice. The temperature log was taped to the wall nearby and had no entries for 3/7, 3/8 and 3/14, 3/15/26.During an interview on 3/18/26 at 1:36 p.m., the assistant director of nursing (ADON) stated either nursing or housekeeping documented the refrigerator temperature, and dietary would be in charge of making sure things were labeled and dated. During an observation and interview on 3/19/26 at 9:27 a.m., a refrigerator behind the third-floor nurse's station contained food for residents and a temperature recording log was taped to front of it. The log had no entries for 3/7, 3/8 and 3/14, 3/15/26. The DA stated housekeeping was responsible for recording the temperatures and they were not there on the weekends, so that would be the empty spots. The DA added she had hoped nursing would do those.During an observation and interview on 3/19/26 at 9:32 a.m., on the second floor behind the locked nurse's station, there was a room with a refrigerator with resident food and beverages. The temperature log was missing the same dates as the other two. There was one-percent chocolate milk expired on 3/15/26, and four open, undated partially full containers of juice. The DA stated she would expect expired items to be removed.An undated policy, Aftenro Home Snack and Beverage Availability Policy, identified all food must be stored and handled in accordance with Minnesota Food Code requirements, perishable or temperature-controlled foods shall not be left out for self-service. Dietary staff are responsible for ensuring proper rotation and freshness of items.

Based on observation, interview, and record review the facility failed to ensure proper measures were in place for the handling of resident and facility laundry. In addition, the facility failed to ensure residents were offered an opportunity to clean their hands prior to meals and that staff properly sanitized hands during dining services. These deficient practices had the potential to impact all residents who resided at the facility.Findings include: During an interview on 3/18/26 at 2:13 p.m., housekeeper HK-A gave a tour of the laundry area. HK-A explained dirty resident and facility laundry entered the laundry area via the laundry chute and then got sorted by color and type. They had been trained to wear eye protection if they had to rinse laundry, to wear gloves when they sorted laundry, and proper times that required hand sanitizing. HK-A stated they had not been told to wear a personal protective gown when sorting laundry, but they thought staff could if they wanted to, but it wasn't required. During an interview on 3/19/26 at 9:30 a.m., HK-B stated when they sorted laundry, they always wore gloves. HK-B opened the cabinet door next to the laundry scute and pointed to a single rolled up PPE gown and stated sometimes they wore the PPE gown in addition to gloves to protect themselves from things like urine-soaked linen. During an interview on 3/19/26 at 11:52 a.m., the director of nursing (DON) stated staff should always wear a PPE gown and gloves when they sorted laundry. This was important for personal safety and infection prevention reasons. During an interview on 3/19/26 at 1:17 p.m., the house keeping supervisor HKS stated for infection prevention reasons, staff were required to wear gloves when they sorted laundry. Staff were also required to wear a PPE gown when they sorted laundry bags marked with a biohazard sticker because those bags contained items that were soiled with substances like urine/BM (bowel movement), or blood. They believed once staff were done sorting the biohazardous laundry, they should then remove the gown and put it in the wash. It should not be reused. It would be optional for staff to wear a gown to sort general dirty laundry, but they were not required to do so. HKS did not identify any concerns with staff not wearing a gown to sort general laundry. The Facility policy In-House Laundry Services Policy & Procedure dated 10/25/25, directed all resident linen and personal laundry was to be handled and processed in adherence with infection prevention standards. The policy referenced F880, F584, and F550. The policy did not clearly state stand precautions including PPE gown should be utilized for soiled linen handling. During an observation and interview on 3/17/26 at 12:28 p.m., NA-A was pushing a cart with meal trays, there was no hand sanitizer or hand cleaning wipes on the cart or the resident meal trays. NA-A delivered meal trays to R23 and R36's rooms, entering their rooms setting the trays down. NA-A stated she didn't offer to clean their hands, and she didn't sanitize her own hands in between resident rooms. NA-A explained she hadn't really seen anyone else do that either. At 12:35 p.m., NA-B delivered room trays to R2, R24, R37 without providing cleaning wipes or other opportunities for residents to clean their hands before eating. NA-B stated they could offer wipes, but she hadn't seen any around here.

Based on interview and record review, the facility failed to provide timely follow up to resident suggestions from the resident council. This deficient practice had the potential to affect any resident whose requests were brought forth at resident council.Findings include:Resident council minutes 10/27/25: ongoing challenges were noted regarding wheelchair cleanliness. Aftenro will explore implementing a suggestion box to encourage resident feedback and ideas.11/24/25: kitchen issues brought up by resident council included too many carbohydrates at meals, a 4-week menu cycle was too repetitive, not many homemade meals as many things are pre-packaged, diabetics needed a more substantial snack between dinner and breakfast, residents requested administrators presence at the next meeting, discrepancies in timing of meals delivered to the floors, food not kept warm, and wrong orders.12/29/25: resident council suggested cleaning wheelchairs and walkers, the administrator and dietary manager will follow up, residents suggested they could make a list of residents and cross one off a day. The dietary manager will follow up on a suggestion box and find a great location for it.1/28/26: old minutes reviewed including administrator following up with wheelchair cleaning and a suggestion box. Request for an agenda and minutes of past meetings to be present at all resident council meetings.2/25/26: Follow up on old topics, wheelchair cleaning and suggestion box, the administrator will continue to follow up.During an interview on 3/18/26 at 10 a.m., the resident council stated there were certain things that were brought up every month, but they keep getting put off, like the suggestion box, wheelchair washing, and food issues. The resident council explained the suggestion box wasn't for complaints but for people who want to have input into resident council but didn't come to the meetings. They also explained they asked about wheelchair washing because they appeared dirty, and they thought the facility could make a schedule and do them routinely. The resident council stated food has been an issue they talk about, for example too many carbs, too much chicken and processed food, but not all the residents were willing to say anything about it. The resident council stated they didn't feel like they got answers and weren't sure what the holdup was.During an interview on 3/19/26 at 3:40 p.m., social worker (SW)-A stated she thought progress had been made with the suggestion box as one has been ordered. For the wheelchair washing, she knew maintenance and housekeeping had been working on clearing the area for washing wheelchairs. SW-A stated they have offered to wash wheelchairs when requested.

Based on interview and record review, the facility failed to revise the care plan for skin and wound care interventions for a resident at risk for and having actual pressure ulcers for 1 of 6 (R8) reviewed for pressure ulcers. The facility also failed to include interventions related to high-risk medication use for 2 of 5 residents (R4, R12) reviewed for unnecessary medications. In addition, the facility to ensure care conferences were scheduled quarterly and/or for significant changes for 1 of 1 resident (R6) reviewed for care planning. Findings include: R8: R8's admission minimum data set (MDS) dated [DATE], identified impaired cognition and diagnoses of hypertension (HTN), hemiplegia, protein-calorie malnutrition, general weakness, and reduced mobility. R8 had limited range of motion upper and lower on both sides, was dependent for all activities of daily living (ADL)s, transfers, and locomotion. R8 was at risk for, and had an actual stage two, pressure ulcer. R8 needed hearing aids and glasses. A care area assessment (CAA) worksheet dated 4/1/25, identified R8 was at risk for impaired skin integrity due to urinary incontinence, impaired mobility, ambulatory dysfunction, impaired cognition, and chronic disease process. Braden score of 15 indicating at risk for pressure ulcer injuries. Proceed to plan of care. R8's significant change in condition (SCSA) MDS dated [DATE], identified R8 was at risk for and had an actual stage three pressure ulcer. A CAA worksheet dated 11/24/25, identified a stage three pressure on R8's left buttock area. R8 was resistive to turning and repositioning and declines to lie in his bed at any time, preferring to sit in his recliner most of the day and throughout the night. R8 was encouraged to allow staff to assist him with reposition, toileting, perineal hygiene and brief changes as necessary. He receives wound care from staff daily for existing pressure injury and monitored for any changes in skin integrity or development of new injury. Encourage and assist with repositioning or changing every two hours. Encourage and assist with repositioning or changing every two hours. Wound care and skin integrity was monitored and provided two times a day and as needed for R8. Staff will continue to follow his current plan of care. R8's care plan, created and last updated on 4/3/25, identified a focus statement for self-care deficit including the need for two staff to move his legs, turn, reposition or boost in bed. R8 also required the assist of two staff to transfer to the toilet, provide incontinent care and clothing adjustment. The care plan didn't indicate a frequency for incontinent care or repositioning. The care plan didn't include intervention for routine skin monitoring by a licensed nurse. Didn't include monitoring for the area under the glasses and hearing aid wires. Didn't include managing refusals of care or interventions, when to remove the hearing aid, or glasses. A progress note dated 10/14/25, identified the appearance of a sore on the top of R8's ear. A provider order dated 11/10/25, identified to encourage R8 to reposition every two hours. A progress note dated 11/21/25, identified an order to place Band-Aids on top of right ear before placing hearing aids. An order on 3/3/26, leave hearing aids out until directed by hospice RN. During an observation and interview on 3/16/26 at 10:52 a.m., R8 wasn't wearing hearing aids and was having difficulty hearing. R8's spouse stated she thought the nursing staff had the hearing aids because of the sore on his right ear from his glasses and hearing aid wire rubbing. During an interview on 3/19/26 at 10:30 a.m., registered nurse (RN)-A stated R8's hearing aids were not being placed due to a sore on his ear. RN-A stated R8 was someone who wouldn't remove them at night, and he had a sore on his ear from it. On scheduled bath day the NA has a skin assessment on their POC charting. The aids can then call the nurse and they come and do the assessment. During an interview on 3/19/26 at 1:28 p.m., the director of nursing (DON) explained hospice had made the decision to remove R8's hearing aids to help his ears heal. The DON added R8 had been wearing them for years without removing them, so his ear canals had been in bad shape too. The DON stated this was probably something they had missed with their care planning process. Care plans were reviewed at care conferences. R4: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had diagnoses which included depression, chronic pain, adjustment disorder, adult physical abuse, alcohol dependence, anemia, iron deficiency, migraines, and convulsions. In addition, R4's MDS identified R4 was cognitively intact and took antipsychotic medications, antidepressant medications, antianxiety medications, and opioids. R4's Order Summary Report dated 3/19/26, identified the following orders: -monitor for potential side effects from opioid analgesics dated 7/2/25 -monitor/document/report as needed any risk for harm to self-dated 7/2/25 -psychotropic medication side effect monitoring dated 2/13/26 -resident will need to be monitored for over sedations due to increased suboxone and gabapentin dated 1/25/26 -buspirone 10 milligrams (mg) twice a day used for anxiety disorder -duloxetine 20 mg in the morning for chronic pain -gabapentin 600 mg three times a day for chronic pain -mirtazapine 30 mg at bedtime for depressive disorder -quetiapine 100 mg at bedtime related to post traumatic stress disorder -risperidone 0.25 mg twice a day for depressive disorder -suboxone 2 mg three times a day for chronic pain -trazadone 50 mg at bedtime for sleep disorder R4's care area assessment (CAA) dated 7/8/25, revealed the following: Section 7. Psychosocial Well-Being identified depression, the care plan consideration was checked as yes. Section 17. Psychotropic Drug Use, the classes of medications checked were antipsychotic, antidepressant, antianxiety, sedative/hypnotic. The care plan consideration was checked as yes. R4's care plan identified the following: Activities of daily living related to self-care dated 8/21/25 Diagnosis of stress bladder incontinence dated 7/10/25 At risk for falls dated 6/21/25 Nutritional problem dated 7/8/25 Shortness of breath dated 7/10/25 Fall dated 7/29/25 R4's care plan did not have any care plan considerations related to high-risk medications and/or interventions. R12: R12's annual MDS dated [DATE], identified R12 had diagnoses which included insomnia, fibromyalgia (chronic long-term condition characterized by widespread musculoskeletal pain, fatigue, and sleep disturbances), osteoarthritis (chronic degenerative joint disease where cartilage breakdown causes pain, stiffness and reduced mobility), and trigeminal neuralgia (chronic pain condition affecting the trigeminal nerve in the face causing sudden, intense, electric shock-like pain). In addition, R12 was cognitively intact, and took antianxiety, antidepressant, diuretic, opioid, and anticonvulsant medications. R12's Order Summary Report dated 3/19/26, identified the following orders: -monitor for potential side effects from opioid analgesics -psychotropic medication side effect monitoring -amitriptyline 25 mg daily for depressive disorder -buspirone 10 mg three times daily for anxiety disorder -duloxetine 60 mg twice a day for depressive disorder -gabapentin 100 mg three times daily for trigeminal nerve pain -oxycodone 2.5 mg every 12 hours as needed for moderate to severe pain -prednisone 5 mg every 24 hours as needed for trigeminal nerve pain -Wellbutrin 150 mg daily for depressive disorder R12's CAA dated 2/6/26, revealed the following: Section 17. Psychotropic Drug Use, the classes of medications checked were antidepressant, antianxiety, sedative/hypnotic. Care plan considerations were checked as yes. R12's care plan revealed the following: Falls dated 12/4/25 Vulnerable adult dated 5/2/25 Activities dated 3/17/26 ADL self-care performance deficit dated 11/8/24 Urge incontinence dated 5/27/23 Depression dated 2/13/23 Nutritional problem dated 2/10/23 Skin integrity dated 8/12/25 Diabetes Mellitus dated 5/27/23 Asthma dated 4/6/23 R12's care plan did not have any care plan considerations related to psychotropic, opioid or antianxiety medications and/or interventions. During an interview on 3/19/26 at 8:27 a.m., registered nurse (RN)-B reviewed R4 and R12's care plans and identified their care plans were missing information on high-risk medications. RN-B stated the care plan alerts staff to be aware of potential concerns and to monitor those concerns. During an interview on 3/19/26 at 10:18 a.m., the director of nursing (DON) stated the care plans should be updated quarterly with every care conference. The DON stated it was important to keep the resident care plans updated because they drive the resident's care. Comprehensive Person-Centered Care Policy dated 10/25/25, identified the purpose of the care plan was to ensure each resident had an individualized, person-centered care plan that reflected their needs, preferences, and goals. In addition, the policy identified the care plan would be updated routinely and with changes in condition. The policy identified the care plan guides daily care delivery. R6: R6'6 significant change Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact with the diagnoses of diabetes, atherosclerotic heart disease, chronic kidney disease stage 4, major depression, and hypertension. Review of R6's electronic medical record (EMR) lacked evidence to show a care conference had been held in conjunction with R6's significant change MDS dated [DATE]. R6's most recent care conference documented in the EMR was documented as 11/26/25. During an interview on 3/16/26 at 10:06 a.m., R6 stated they could not recall attending or being invited to a meeting about their care or their care plan. During an interview on 3/19/26 at 1:09 p.m., the social worker (SW) stated they scheduled resident care conferences. Conferences were scheduled quarterly, for significant changes and then as needed or requested by residents/family. SW looked in the computer and stated R6 did not have a care conference scheduled. R6's last care conference was held on 11/26/25. The social worker confirmed R6 had not had a care conference when they had a significant change, R6 was overdue for a care conference. During an interview on 3/19/26 at 11:32 a.m., the director of nursing (DON) stated care conferences were required with quarterly and/or significant changes. The facility policy Care Conference (Interdisciplinary Team) dated 10/25/25 directed care conferences were to be conducted, if possible, quarterly, in conjunction with annual MDS assessments, within 14 days of a significant change, and within seven days of admission. Failure to adhere to the policy could result in citations.

Based on interview and record review, the facility failed to ensure all sections of the minimum data set (MDS) were completed for 2 of 4 residents (R5, R8) reviewed for MDS accuracy.Findings include:Section C of the MDS focuses on cognitive patterns and includes a staff assessment for mental status and signs and symptoms of delirium. It assesses the resident's ability to make decisions, orientation and ability to register and recall new information.R5's quarterly MDS dated [DATE], identified section C was not assessed.R5's electronic medical record (EMR) didn't contain a progress note regarding the incomplete section C.R8's quarterly MDS dated [DATE], identified section C was not assessed.R8's electronic medical record (EMR) didn't contain a progress note regarding the incomplete section C.During an interview on 3/19/26 at 8:35 a.m., registered nurse (RN)-B looked at section C for R5 and R8 and confirmed they were not assessed. RN-B stated a note should be made in the chart as to why something wasn't assessed.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan for a resident's sensory losses and devices, including the potential for skin impairment related to devices for 1 of 3 residents (R8) reviewed for pressure ulcers. In addition the facility failed to update and incorporate significant change Minimum Data Set (MDS) triggered care areas into the comprehensive care plan for 1 of 3 residents (R6) reviewed for comprehensive care planning. Findings include: R8: R8's admission minimum data set MDS dated [DATE], identified moderately impaired cognition, ability to hear with hearing aids, clear speech, the ability to make himself understood, and R8 wore corrective lenses. R8's care plan dated 4/3/25, didn't contain a focus statement for communication, hearing, vision, hearing aids, or glasses. The care plan identified R8 was at risk for skin impairment but didn't contain interventions for routine skin inspections by a licensed nurse or to provide guidance for assisting with the routine removal, or to address R8's refusal of removal of devices. During an interview on 3/19/26 at 1:28 p.m., the director of nursing (DON) stated R8 did have hearing aids, and confirmed hearing wasn't included in R8's care plan and it was probably something they missed with their process. R6: R6'6 significant change Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact with the diagnoses of diabetes, atherosclerotic heart disease, chronic kidney disease stage 4, major depression, and hypertension. Section V. indicated the following care areas had been triggered on the 1/21/26 MDS. The associated care area worksheets indicated the following care areas were to be addressed on the care plan as well. Mood state Psychosocial wellbeing – functional status psychotropic drug use functional abilities self-care nutritional status urinary incontinence pressure ulcer/injury at risk for developing Review of R6's care plan at time of facility entrance on 3/18/26, identified target goal dates in the month of May and August 2025 for all focus areas with the exception of nutrition which had the goal date of 4/16/26. The care plan did not address the following care areas identified by the facility for care planning: pressure wound prevention, mood, psychotropic meds, or psychosocial wellbeing. In addition, the care plan had not been updated to reflect appropriate care interventions related to the changes in R6's lower extremities and resulting changes in abilities. During an interview on 3/19/26 at 11:32 a.m., the director of nursing (DON) stated care plans were updated as needed and with required quarterly or significant change care conferences. The DON stated they primarily updated the care plans. The DON stated triggered care areas like pressure ulcers did not always get updated in the care plan. Things like psychosocial and mental health should be incorporated into the care plan. The status of R6's lower extremities, and mental health should also be reflected in the care plan. The DON confirmed they had updated the goal dates on R6's care plan during the survey period but indicated they had not yet updated the content of the care plan. The facility policy Comprehensive Person-Centered Care Plan dated 10/25/25, instructed the facility will develop and maintain a comprehensive, interdisciplinary, person-centered care plan that will be initiated upon admit, is based on MDS/RAI assessment findings, reflects resident preferences and goals, is reviewed and updated routinely and with changes in condition and guides daily care delivery.

Based on observation, interview and document review, the facility failed to ensure a safe smoking area, safe extinguishing of cigarettes in designated container, and monitoring of designated smoking area for 1 of 3 residents (R46) reviewed for smoking.Findings include:R46's quarterly Minimum Data Set (MDS) dated [DATE], identified R46 had diagnoses which included heart disease, low back pain, left knee pain, heart failure (a disease in which the heart muscle doesn't pump blood as well as it should), anticoagulant use, hyperlipidemia, and nicotine dependence. In addition, R46's MDS identified that she was cognitively intact.R46's care plan dated 5/13/24, identified R46 had chosen to smoke cigarettes despite the risks to her health. Interventions included the following:-licensed staff had educated R46 on the risk versus benefit of smoking-licensed staff would educate R46 that smoking was only allowed outside in the designated smoking area- a smoking assessment would be completed quarterly to include the ability to light the cigarette safely, smoke it and discard it in the appropriate receptacle-any time the resident had a condition change they would be re-assessed for safe smokingDuring an observation on 3/17/26 at 5:48 p.m., R46 stated she was going out to smoke.On 3/17/26 at 5:52 p.m., R46 was returning from having a cigarette, she stated the door was coded but she knew the code so she could always get back in.During an interview on 3/18/26 at 10:37 a.m., the maintenance director (MD)-A stated residents who smoked had the code to the employee entrance. MD-A stated there were random items in the garage. MD-A stated there was lots of stuff in the garage that needed to go to the reclamation center. Inside the garage door there was a semi-circle of chairs, a stool with a number ten can that had several cigarette butts in it. Outside of the garage there was an official receptacle for cigarette butts.On 3/19/26, a continuous observation of the smoking area was started at 8:58 a.m. the continuous observation ended at 9:51 a.m.-8:58 a.m. R46 was seated on the bench seat of her wheeled walker in the open garage. There were five chairs in a semi-circle with a step stool in the middle with a rusted number ten can on top of the stool with cigarette butts in the can. There were two employees seated in the area (they were not smoking) one was seated in a cloth armchair. The garage had a large car door that was open to the outside. Outside of the garage there was an official butt disposal receptacle. Inside the garage there were wheelchairs, machinery, stacks of air conditioners, cardboard boxes on a shelf, computer stands, a full-sized chest of drawers and a smaller chest of drawers, a cloth covered recliner, folding chairs, plastic wheeled carts, stackable chairs, Christmas lights, shovels, and some type of wooden spinning game. The area was too crowded with items to list all and was too crowded to walk past the semi-circle of chairs. To the right of the garage door there was also a staircase going to an upper level. The garage was too crowded with items to get to the stairs to see if there was anything stored in the upper area. R46 was using the number ten can to put her cigarette ashes in. There was a lighter for lighting candles on the stool next to the number ten can. No evidence of a fire extinguisher or a fire blanket.-9:12 a.m., R46 remained seated in the garage, she appeared to put her hand into the number ten can, her hand went into her pocket.-9:19 a.m., R46 lit another cigarette and smoked again.-9:25 a.m., R46 lit another cigarette and continued to smoke.-9:30 a.m., R46 knocked ashes from her cigarette into the number ten can.-9:37 a.m., R46 put her cigarette out in the number ten can.-9:38 a.m., R46 lit another cigarette.-9:47 a.m. R46 stood up used and used her walker to leave the area, she did not put her cigarette butt into the receptacle outside of the garage.During an interview on 3/19/26 at 9:53 a.m., the administrator stated the smoking area was currently in the garage area. The administrator stated staff had been permitted to smoke in the area and then residents started to use the area too. The administrator stated he was unsure if there were any items in the garage that were combustible, if there was a fire extinguisher, or if there was a fire blanket in the smoking area. The administrator stated there would be a risk of fire if residents were smoking in an area with combustible materials.During an interview on 3/19/26 at 10:38 a.m., the administrator volunteered he had looked at the area where residents were smoking and decided to close the area as there were too many items that were flammable. He also verified there was not a fire extinguisher or fire blanket in the area.The Tobacco and Nicotine Product Restrictions dated 3/10/26, identified they were a Tobacco-Free Campus with the exception of residents who were permitted to smoke prior to the implementation of the Tobacco-Free Campus free policy would be grandfathered under a Smoking and Nicotine Device Safety Agreement.Resident Smoking and Nicotine Device Safety Agreement signed by R46 on 3/5/26, identified smoking or vaping would need to be outside and in the designated smoking area (identified by Aftenro Home). Cigarette butts would be fully extinguished and disposed of in the designated receptacle. A lighter would be maintained by nursing staff and would be returned immediately after use.

Based on interview and record review, the facility failed to ensure a resident maintained acceptable nutritional status when they experienced significant unplanned weight loss, despite known dissatisfaction with meals, dietary restrictions, and repeated complaints impacting intake. The facility failed to implement and revise interventions to address their nutritional needs resulting in continued weight loss and psychosocial distress for 1 of 3 residents (R5) reviewed for nutrition. Findings include:The Resident Assessment Instrument (RAI) manual at chapter three identified Section K of the minimum data set (MDS) considered weight loss or gain significant if there was a change of 5-percent or more in a month, or 10-percent or more in six months.R5's quarterly MDS dated [DATE], identified intact cognition, a diagnosis of diabetes mellitus (DM) and unplanned weight loss. R5 needed set-up assistance with eating.R5's quarterly MDS dated [DATE], identified R5 had unplanned weight loss and needed set-up assistance with eating.R5's care plan dated 1/8/25, identified a focus statement related to DM and included interventions to:have a dietary consult for nutritional regimen and ongoing monitoring, anddiscuss mealtimes, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, and compliance with nutritional regimen, andoffer substitutes for foods not eaten.On 1/30/26, the registered dietician (RD) added interventions for:monitoring for signs of dysphagia, andmonitoring and reporting signs of malnutrition including weight loss of three pounds (lbs.) in a week, more than five percent in a month, or more than 7.5 percent in three months, or more than 10% in six months.Review of R5's electronic medical record (EMR), identified the following:5/2/24, a provider order for magic cups (a calorie-dense frozen snack) as needed and if blood sugar was less than 80 milligrams per deciliter.5/2/24, weight 273 lbs.5/4/24 for a regular diet, regular texture, thin liquids, and low potassium.8/21/26, weight 263 lbs.9/30/25, a progress note, R5 reported, I haven't had anything to eat in over a week. When asked why he wasn't eating, he stated Cuz the food here is terrible. They give me tuna fish when I'm allergic to fish! I don't have any appetite, and they aren't giving me as much of the juice I like either. Encouraged R5 to speak with kitchen manager and or the administrator, however he refused, stating It doesn't do any good. Reported this information to assistant director of nursing (ADON) and Clinical Coordinator.10/23/25, weight 246.7 lbs.11/11/25, a progress note R5 stated I think I'm getting sick. He reports eating poorly because he hated the food. Writer will report this information to R5's provider and to the next shift as well.11/20/25, weight 236 lbs.A dietary review couldn't be found in R5's EMR from 9/30/25 until 11/24/25.On 11/24/25, a registered dietician (RD) progress note for a quarterly review. R5 was served a regular, low potassium diet and was independent at meals. Recorded meal intakes have been 50 to 100 percent. Despite good oral intake, weight has trended downward. Net weight loss of 37 pounds or 13.5 percent in the past six months. Significant loss. Nursing staff, provider aware. Additional work-up planned. RD attempted to meet with R5 during round visit this date. R5 was out of his room. Will ask dietary manager to follow up with resident to discuss food preferences. Proceed with diet per order. Resident remains obese; however, rate of weight loss is a concern.11/24/25, a progress note R5 was extremely upset tonight. He stated he was very unhappy with the administrator. Took a clonidine. Tried to calm him down with talk therapy with very little results.11/27/25, a progress note, R5s' level of anxiety seems to be increasing over the past week. He states that This place is trying to kill me!, and I'm dying, and it's all the administrator's fault. Why is he punishing us all?. Resident was referring to his strong dislike of the food and that he is losing a lot of weight. He might benefit from another psychiatric evaluation and medication change. Writer will place a note in provider rounding book.11/27/25 at 5:45 p.m., a progress note, R5 was very agitated and yelling at kitchen staff, using inappropriate language. He stated that they did not send any milk with his supper tray and did not include his special silverware.11/27/25 at 6:10 p.m., a progress note, R5 was sent to emergency room (ER) at 6 p.m. per his request. He stated, 'I am having a panic attack; I need to go in right away.' Writer called for an emergency ambulance, and the paramedics transported him to the ER.11/28/25 at 11:50 p.m., a progress note, R5 returned via transportation with ER discharge paperwork, resident has hypomagnesemia (low blood magnesium levels) and an order for magnesium chloride 64 milligrams (mg) sent to the pharmacy. Also stated he received Clonidine and Trazadone in the ER. Staff assisted R5 to his chair, he was still frustrated regarding previously noted issues of administration, therapy, food, cost. No behavior towards staff.11/28/25 at 10:00 a.m., a progress note, R5 came to writer and yelled at writer that the kitchen had sent the wrong silverware and threw his silverware roll down the hallway causing silverware to separate from the roll and land scattered on the floor. Writer educated R8 that it was not appropriate to throw objects, and if he received the wrong silverware to put his call light on and staff would get him the correct silverware. R5 then yelled I need to get out of here and left the area. Writer called the kitchen to request the correct silverware. After five minutes writer went to kitchen to collect the correct silverware. Writer then saw R5 on first floor in the entry way and let R5 know writer had the correct silverware and was going to put it in his room. R5 stated I don't need it anymore!.11/28/25, a progress note, at approximately 1:30 p.m., R5 came to writer and apologized for yelling earlier. Writer accepted apology and validated R5's feelings of frustration. While discussing lunch writer explained that hot dogs were the alternate for fish today. R5 stated he has been eating hot dogs all week because I am allergic to fish, writer told R5 writer was not aware of any other lunch meals this week being fish and R5 didn't reply. R5 allowed writer to reheat his lunch and bring it to his room. R5 stated don't they have any milk here? and I never get any milk. Writer showed R5 his meal ticket and milk was not listed, writer explained since it was not on the ticket it is not being put on his tray, and writer would go get milk now, and alert the kitchen that he would like milk with all meals. R5 was pleasant throughout the interaction and thanked writer. Dietary Department Communication Form was completed and given to the kitchen.11/29/25, a progress note, R5 requested as-needed (PRN) Clonidine, I need it. I'm having anxiety because of him (administrator). He's playing head games! That's what it is, he's playing head games with everyone here. I can't sleep because of him and this whole place. They don't know what the f*ck they're doing! They've taken everything! I'm going to get every one of you guys fired! Resident hyper and frustrated, he was speeding up and down hall in his power chair. Allowed CNA to help him back into bed.12/9/25, an RD progress note, identified R5 was served a regular, low potassium diet. R5 was independent at meals, with recorded meal intakes at 50 to 100 percent. R5's weights, in pounds, 12/4/25 235, 11/6/25 240, 9/19/25 257.2, 6/1/25 271. R5's net weight loss was 36 pounds or 13 percent in the past 6 months. Significant weight loss despite relatively good recorded meal intakes. Has colonoscopy scheduled. Proceed with diet per order. Update provider and responsible party of continued weight loss.During an interview on 3/16/26 at 12:26 p.m., R5 stated his frustration with the removal of the snacks from resident areas, R5 was also frustrated with the removal of soda pop from resident access, and stated the administrator removed them due to costs and then opened a country store for one hour a week where residents can purchase pop. R5 stated he was a diabetic and needed a bedtime snack, sometimes he would ask for an extra hamburger and then eat that later. Also, R5 stated he was tired of the rotating menu, they had the same things, like chicken, all the time and it was processed chicken. R5 demonstrated his lunch tray, there was processed and breaded chicken meat, vegetables and about half the plate full of rice. R5 shared he hid a clothing cover in his room because they didn't' ever send it up. R5 also stated he was allergic to fish and they kept sending it to him, he demonstrated date and time-stamped pictures on his phone of a lettuce salad with dressing on it. He stated that was Cesear salad and he can't have it because of the dressing. He stated one time last fall he was served fish, he normally calls the kitchen on a day fish will be served to ask for a burger. R5 stated the facility didn't have an alternate menu. Furthermore, depending on the cook R5 stated his burger patties were often burned and demonstrated several different pictures of blackened patties. R5 admitted he had gotten frustrated with asking for substitutes. During an interview on 3/17/26 at 1:37 p.m., R5 reported he got two spoiled milk this morning, their expiration date was for today and it tasted sour. R5 stated he told everyone who would listen about the milk. Also today, R5 received small spoons with built-up handles and not the larger one for eating soup at lunch. Most people can't get to the little fridge by the nursing station. He doesn't go there anymore because there is no soda. He had emailed the dietician about the food but never got a response. R5 stated one of his concerns was the processed chicken not real chicken, like yesterday's chicken at lunch was processed. R5 stated this was often the case, they didn't get real chicken, and they had it a few times a week. R5 demonstrated the freezer in his room had several frozen dinners, the refrigerator had naan bread, condiments, and protein supplement drinks. R5 stated he had his friend start buying him the shakes, so he had something when he didn't want the food here.During an interview on 3/19/26 at 9:10 a.m., the dietary manager (DM) stated she was aware R5 had weight loss, but he could have magic cups if he wanted and they did try to accommodate his preferences. The DM explained R5 would call down during the meal to say he didn't like what he got and then they would make him something on the fly and he may or may not like it, and R5 didn't eat breakfast at the regular times because he slept in. The DM stated they worked with him, and it ended up he wanted his tray to go up on the cart and sit there in the hot cart while staff served everyone else and then put the tray in his room before they took the hot cart back downstairs. The DM stated the RD had seen him several times, and R5 visited with the administrator and assistant administrator. The DM added R5 was upset the V8 juice he liked was no longer available from their new distributor, but they weren't able to go out and purchase individual things for each resident. During an interview on 3/19/26 at 11:00 a.m., registered nurse (RN)-A stated R5 complained about the food all the time; he complained about repetitiveness, portion sizes, or he just doesn't like the taste. RN-A stated R5 could get a cheeseburger whenever he wanted, they could call down to the kitchen and ask. Regarding R5's behaviors, RN-A stated nothing was that frequent or all the time, most of the time for him it was understandable because it was out of frustration, he would use a stronger tone, but never physical. Didn't know him to be delusional. During an interview on 3/19/26 at 11:24 a.m., the RD stated she would pull weight reports around the middle of the month and identified weights that needed to be taken or retaken, and then she did her monthly charting on those residents with weight loss and email it to nursing leadership. The RD stated she would consider R5 nutritionally at risk and she did try meet with him in December when he met criteria for significant weight loss, despite having good recorded intakes which didn't match weight loss, but she wasn't sure meeting with him would help so she did discuss concerns with the DM. The RD hadn't considered the intake recordings may not be accurate. The RD stated she wasn't aware if his medical work-up had any findings and was just recently made aware of the dissatisfaction of snacks here, when they used to have a very nice snack situation, she didn't know what changed and when this change had occurred. The RD stated there needed to be snacks residents wanted, and she would suggest something with protein and some milk would be helpful snacks in the event of low blood sugars, and as far as juice from concentrate being any healthier than soda, the RD felt it was a perception and the juice may be fortified with vitamins. During an interview on 3/19/26 at 12:44 p.m., R5 demonstrated the pictures of Cesar salad on his phone, the most recent was dated 2/14/26 with the dressing already on it, and again on 1/13/26. During an interview on 3/19/26 at 12:53 p.m., the director of nursing (DON) stated R5's provider had ordered a diagnostic work-up for his weight loss, and it had been negative for findings. The DON stated his expectations would be for the kitchen to send the modified diet to residents, but R5 had always been mad about the food and he can request something else if he would like.Food committee minutes dated 10/23/25, identified the administrator and dietary manager were in attendance. Concerns included the transition to more nutritious snack options with plans to phase out less healthy snack items. Residents mentioned staff members were witnessed helping themselves to resident snacks. Additionally, residents raised concerns about diabetic snacks and snack requests being unmet, after witnessing staff eating snacks.Resident council minutes dated 11/24/25, identified new business included a statement about snacks and soda, Aftenro is not going to supply everyone with soda and unhealthy snacks on a regular basis, only at special events such as bingo or happy hour. To do so would be outside the budget and mission. The facility will look at putting soda for sale in the country store for those residents who didn't leave the building. Residents requested [NAME] cookies and [NAME] Krispie treats and were informed these suggestions could go to the dietary manager. Sandwiches, fruit, vegetables are snacks that Aftenro can provide to residents. Items listed under the topic of kitchen included too many carbs at meals, 4-week menu cycle very repetitive, meat is too stringy, not many homemade meals, many things come out of a package, green beans and carrots are often undercooked and difficult to eat, diabetics need a more substantial snack between dinner and breakfast, snack situation still needs to be remedied, residents requested the administrators presence at the next food committee citing nothing gets done otherwise. There were noted discrepancies to the time, temperature and order correctness of items delivered to the floors.A document, Resident Problem/Concern Form dated submitted 11/28/25, identified R5 made a complaint regarding the food, mentioned he kept getting turkey which upsets his stomach, that he didn't receive the correct silverware when he needed his adapted silverware. R5 stated he had gotten raw food over the weekend and kept it to show it wasn't cooked. R5 also shared he didn't think all the cooks were very nice and that he hated this place and wanted to leave and has been trying very hard to do that. R5 felt dietary had not gotten better and that in his words, he and other residents are being subjected to abuse. The abuse was in the form of removing their snacks. R5's dietary ticket information identified as regular, allergy-shellfish, low potassium, seafood allergy, soup, no fish wants hamburger instead, fresh fruit, prefers grapes. Under the resolution or action taken, identified R5 met with the administrator to discuss dietary changes, that R5 was appreciative of the conversation and he encouraged R5 to keep filling out concern forms. Food Committee minutes dated November 2025, identified the dietary manager was in attendance. Residents requested snacks and egg salad to have for midnight snacks. The decision was identified, the nutrition director will coordinate with dietary cooks to prepare egg salad to be stored in a container on each floor along with a loaf of bread, and residents can request assistance from on-duty staff to ensure optimal freshness.Food committee meeting minutes dated December 2025, identified the administrator and dietary manager were in attendance. Noted was a follow up on snacks, including a decision by the nutrition director to make the following snacks available at the nurse's station on each floor: microwave popcorn, crackers with peanut butter, granola bars, fig newtons, fresh fruit, pudding, Jello, popsicles, cheesy crackers, crackers with cheese. Noted for the next meeting was a discussion with residents about potential scheduled snack pass.Review of the four-week rotating fall and winter 2025 menu revealed Caesar salad on one Tuesday lunch on the menu labeled week four.Additional Food Committee minutes were requested for January and February 2026 but were not received.Policies on specialty diets, alternative foods were requested but not received.

Based on interview and document review the facility failed to have the appropriate funds available for Medicare/Medicaid residents on the evening shift and weekends for 7 of 8 residents (R42, R24, R36, R1, R21, R46, R13) reviewed for personal funds. This had the potential to affect 39 residents who had funds held by the facility in a trust account.Findings include:Aftenro's Trust Transaction History report dated 3/18/26, identified there were 39 residents who had accounts including R42, R24, R36, R1, R21, R46, and R13.R42's quarterly Minimum Data Set (MDS) dated [DATE], identified R42 was cognitively intact.During an interview on 3/16/26 at 2:09 p.m., R42 stated they could not get their money at the weekend because the money was kept in the business office and the business office was not open on the weekends.R24's quarterly MDS dated [DATE], identified R24 was cognitively intact.During an interview on 3/18/26 at 2:18 p.m., R24 stated she had money in an account that the facility managed but stated she had no idea how to get any of the money.R36's quarterly MDS dated [DATE], identified R36 was cognitively intact.During an interview on 3/18/26 at 2:23 p.m., R36 stated if she wanted money from her account she would need to go to the business office. R36 stated she was not sure what she would do if she wanted money on an afternoon shift or a weekend.R1's quarterly MDS dated [DATE], identified R1 was cognitively intact.During an interview on 3/18/26 at 2:31 p.m., R1 stated she would have to wait for the business office to open to take money out of her account.R21's comprehensive MDS dated [DATE], identified R21 was cognitively intact.During an interview on 3/18/26 at 2:39 p.m., R21 stated her kids had put money into an account. R21 stated if she wanted money she would go to the business office and ask for money. R21 stated she had never tried to get money on an evening shift or the weekend.R46's quarterly MDS dated [DATE], identified R46 was cognitively intact.R13's quarterly MDS dated [DATE], identified R13 was cognitively intact.During an interview on 3/18/26 at 2:45 p.m., R46 and R13 both stated they needed to go to the business office to get money out of their accounts Monday through Friday during the day shift. Both stated if they needed money for the weekend, they would need to get it out during business hours before the weekend.During an interview on 3/18/26 at 10:13 a.m., business office manager (BOM)-E stated residents needed to come and see her in the business office Monday through Friday between 8:00 a.m. and 4:30 p.m., to remove money from their personal accounts. BOM-E stated if residents wanted money after hours or on the weekend they would tell the staff on the floor and the staff would leave her a note and she would get them their money when she was back. BOM-E stated money from the personal accounts was available Monday through Friday during business hours.On 3/18/26 at 11:33 a.m., BOM-E stated there was a process for residents to get money from their personal accounts after hours and weekends, she had just been made aware of this process. BOM-E stated there was a cash box in the medication room with $80.00 in the box. BOM-E stated the charge nurse had the key, the process was for staff to sign out the money requested and to fill out the transaction in a receipt book.During an interview on 3/18/26 at 1:40 p.m., registered nurse (RN)-C stated she learned about the cash box in the medication room for resident's who wanted money from their accounts today. RN-C opened the box which was locked in the medication room and checked the receipt book, the last time money had been signed out was on 7/2/22. During an interview on 3/18/26 at 1:44 p.m., trained medication aide (TMA)-B stated he was unaware there was money for residents available when the business office was closed.During an interview on 3/18/26 at 1:47 p.m., TMA-C stated they were unsure if there was money available for residents' requesting money after hours but would ask the charge nurse.During an interview on 3/19/26 at 10:25 a.m., the director of nursing (DON) stated there was money available after the business office was closed. He thought maybe residents knew about the money from resident council meetings and from the admission process.During an interview on 3/19/26 at 1:33 p.m., the social worker (SW)-A stated the trust account/personal account was discussed with resident's verbally prior to admission, the day of admission and at the first care conference. SW-A stated all of this information was verbal. SW-A reviewed the resident admission folder and verified there was no information regarding the trust account and how to access the money in the admission folder. A review of the Resident Trust (Personal Funds) & Procedure no date, identified residents would have access to their funds upon request. In addition, residents would have same-day access to small amounts (petty cash best practice).

Based on observation, interview and document review, the facility failed to ensure resident rights provided to residents on admission and posted in the facility were up to date. In addition, the facility failed to ensure residents were provided with resident rights during their stay. This deficient practice had the potential to affect any resident in the facility.Findings include:The Combined Federal and State [NAME] of Rights for residents in nursing facilities or skilled nursing facilities was updated effective 1/1/26.During an interview on 3/18/26 at 10:00 a.m., the resident council noted staff didn't review the resident rights at resident council meetings and hadn't for about a year, but they did note the rights were posted on the wall by the elevator.During an observation on 3/18/26 at 11:13 a.m., a resident rights poster, dated December 2015, was posted by first floor elevator. During an interview on 3/18/26 at 1:48 p.m., social worker (SW)-A stated they gave new residents the bill of rights at admission and demonstrated a form, Combined Federal and State [NAME] of Rights dated December 2017, as the form currently in their admission packet. SW-A stated they hadn't been reviewing resident rights at resident council but were going to be restarting that as they have done in the past.

Based on interview and record review the facility failed to develop an infection prevention control program with an annual review that included written standards, policies and procedures that included when and to whom possible incidents of communicable disease or infections should be reported, when and how transmission-based precautions (TBP) and enhanced barrier precautions (EBP) should be implemented to prevent infections, and hand hygiene procedures to be followed by staff involved in direct resident care. This had the potential to affect all 54 residents who reside in the facility. Findings include: On 1/6/25, at entrance the infection control program was requested. A document titled Nursing Services Policy and Procedure Manual for Long-Term Care Infection Control dated 10/2023, was provided. The document was a policy and procedure manual. During an interview on 1/8/25 at 12:56 a.m., with the director on nursing (DON) and the assistant director of nursing (ADON) both verified they did not have an infection control program that they reviewed annually. On 1/9/25 at 9:55 a.m., the DON stated they did not have a formal written program for infection control that was reviewed annually. The DON stated the benefit of an infection control program would be to see what changes for infection prevention would be needed to be made year to year.

Based on interview and document review, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment. This deficient practice had the potential to affect all residents in the facility who used a bed. Findings include: During an interview on 1/9/25 at 12:49 p.m., the assistant director of nurses (ADON) stated if a resident requested a side rail, the first thing they did was get physical therapy involved to see if that would be functional for that resident. If that was affirmative, then they do the side rail and grab bar assessments. The ADON stated she was not responsible for this task and wasn't as familiar with the process for measuring. During an interview on 1/9/25 at 1:12 p.m., registered nurse (RN)-B stated she was responsible for performing resident assessments and measurements for bed rails. RN-B stated she followed the FDA guidelines and compressed the mattress and measured the gaps. RN-B stated she would involve maintenance if something didn't seem right or wasn't working properly. During an interview on 1/9/25 at 2:06 p.m., maintenance worker (MW)-A stated they put together the beds and did the initial measuring using the Food and Drug Administration's (FDA) guide for measurements, making sure the space between the head and footboards and any rails didn't measure more than four and three-quarter inches when compressing the mattress. MW-A stated nursing looked at the beds after they were put together. MW-A stated they didn't do any routine inspecting or measuring of beds, mattresses, or bed rails. During an interview on 1/9/25 at 2:28 p.m., the director of nursing (DON) stated the nursing department didn't have a program for inspecting beds on a routine basis. During an interview on 1/9/25 at 2:46 p.m., the administrator stated it would be important to have an ongoing system for inspecting and maintaining beds to avoid entrapment. Maintenance records for bed inspections was requested but not received. Side Rail Use Policy dated March 2023, identified its purpose to ensure the safe, appropriate, and compliant use of side rails in the care of residents while balancing safety, dignity, and individual needs in accordance with federal and state regulations. Under item number 4, Monitoring and Evaluation, the policy identified staff will perform routine checks to ensure the side rails were properly maintained and securely fastened.

Based on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed, accurate, and revised to assure assessed care needs were implemented for 2 of 2 residents (R32, R17) reviewed for care planning. Findings include: R32: On 1/6/25 at 6:14 p.m., R32 stated blood sugars were up and down and sometimes low at night. R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had diagnoses which included chronic kidney disease stage 3 (a moderate level of kidney damage where the kidneys are less efficient at filtering waste from the blood, causing mild to moderate loss of kidney function), coronary artery disease, hypertension, and diabetes mellitus. R32's MDS identified R 32 was cognitively intact and received insulin injections. R32's Order Summary Report dated 1/9/25, identified R32's orders included the following: -consistent carbohydrate diet, regular texture, thin consistency -blood glucose test before meals and at bedtime -consistent carb (carbohydrate) every evening -for blood sugar less than 70 milligrams (mg) per deciliter (dl) administer six ounces fruit juice, milk, regular pop or other high carbohydrate beverage: like Ensure or Boost. Repeat blood sugar after 10 minutes, if blood sugar less than 70 mg/dl, give 15 grams glucose. Repeat blood sugar after 15 minutes, if below 70 repeat glucose oral gel 15 grams. Repeat blood sugar in another 15 minutes and if below 70 call -glucose 15 oral gel 40 percent, give 15 gram by mouth as needed for blood sugar less than 70 -Humalog insulin 100 units/milliliter (ml), inject seven units subcutaneously (injection into the fatty tissue beneath the skin) with meals -lantus insulin, inject 32 units subcutaneously in the morning R32's care plan initiated on 2/10/23, and revised on 9/24/24, identified R32 had nutritional problem or potential nutritional problem related to impaired skin integrity, new to this setting, therapeutic diet. Interventions included provide, serve diet as ordered. Monitor intake and record every meal. Consistent Carbohydrate. During an interview on 1/9/25 at 10:35 a.m., R32 stated her blood sugars were running at about 250 and she was unsure what they should be. During an interview on 1/9/25 at 12:32 p.m., the director of nursing (DON) verified R32 was diabetic and verified her current care plan did not address diabetic care. The DON verified the care plan would alert staff on what signs and symptoms they should be looking for for high and low blood sugars. The DON stated the care plan should have directions for diabetes care. 49878 R17: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction(stroke), acute transverse (extending from side to side) myelitis (inflammation of the spinal cord) in demyelinating (loss of protective fatty layer on nerves) disease of central nervous system, type 2 diabetes mellitus, and congestive heart failure. R17's care plan last revised on 12/18/24, contained a focus on activities of daily living (ADLs) deficits due to R17's medical condition. R17's care plan did not specify resident's level of functioning, level of assistance needed for ADLs, number of staff needed to assist with ADLs, or frequency of assistance needed for ADLs. During interview on 1/9/25 at 2:39 p.m., the DON stated care plans were typically reviewed quarterly with care conferences. DON stated being unsure of how R17's care plan did not get completed. DON further stated expectation of care plans needed to be complete to correctly care for the resident. 'Policy and Procedure: Care Plans for Aftenro Home' dated March 2023, identified it's purpose to ensure that all residents receive consistent, person-centered care tailored to their unique needs and preferences and care plans will address the physical, emotional, social, and medical needs of each resident.

Based on interview and document review, the facility failed to comprehensively reassess and develop interventions to reduce/prevent continued weight loss for 1 of 3 residents (R19) reviewed for nutrition and weight loss. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition, and diagnoses of dementia, chronic kidney disease, and type 2 diabetes mellitus. MDS further identified R19 needing set-up and clean-up assistance with eating, and was ordered to have a consistent carbohydrate diet. R19's care plan last revised 11/19/24, identified resident having a potential nutritional problem and having a goal of maintaining an adequate nutritional status as evidenced by maintaining weight within 5% of 178 pounds (lbs). Care plan further identified interventions of consistent carb diet, record daily meal intakes, weight per protocol, notify registered dietician (RD) and provider with significant weight change, and to encourage activity as able. R19's last quarterly nutritional assessment progress note dated 5/1/24, identified R19's current weight on 5/1/24 was 172.8 lbs. There were no follow up nutritional notes or assessment identified in R19's record. R19's medical record, identified on 12/2/24 R19 weighed 173 lbs., and on 1/2/25 R19 weighed 163.6 lbs. R19 had a significant weight loss of 9.4 lbs or a 5.4% loss in one month. R19's orders included on 9/24/24, 'weights must be obtained in AM prior to food/drink, attempt to use same scale/technique to ensure accuracy. Notify TCP if weight gain of >3 pounds in 24 hours or 5 pounds in one week.' During interview on 1/9/25 at 8:47 a.m., nursing assistant (NA)-C stated nursing assistants weigh residents and chart weights in the resident's chart. NA-C further stated the resident's chart would show the resident's previous weight and aides would alert the nurse if there was a change. During interview on 1/9/25 at 9:46 a.m., registered nurse (RN)-A stated nursing assistants entered weights into the resident's chart. RN-A further stated the resident's chart would show the previous weight taken. RN-A stated if there was a significant weight change the nurse would notify the provider. During interview on 1/9/25 at 9:54 a.m., NA-D stated nursing assistants weighed residents and charted the weight in the resident's chart. NA-D further stated it was possible to see the last weight taken for a resident and if there was a big change the nurse would be notified. During interview on 1/9/25 at 2:44 p.m., director of nursing (DON) stated staff were expected to pass on significant weight changes to the provider. DON stated tracking weight changes was important to make sure resident's were getting enough nutrition and if their care plan needed to be modified. DON confirmed R19's care plan identified a maintenance weight of 178 lbs and expectation staff would notify provider with significant weight changes.

Based on observation, interview and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 6.7 percent with 2 errors out of 30 opportunities for error involving 2 of 5 residents (R50, R22) who were observed during the medication passes. Findings include: R50's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and a diagnosis of acute respiratory failure with hypoxia. R50's care plan dated 9/18/24, identified R50 had shortness of breath related to respiratory failure with interventions to administer inhaler medications as ordered. R50's provider order dated 3/11/24, identified an order for Symbicort two puffs two times per day. Rinse mouth after use. During an observation and interview on 1/8/25 at 8:25 a.m., trained medication aid (TMA)-A primed and handed R50 the Symbicort inhaler. R50 took two puffs close together. TMA-A stated she always took her inhaler like that but sometimes she rinsed her mouth afterward. R22's quarterly MDS dated [DATE], identified intact cognition and a diagnosis of chronic obstructive pulmonary disease (COPD). R22's care plan dated 5/7/24, identified R22 had shortness of breath related to emphysema with interventions to administer inhaler medications as ordered. R22's provider order dated 5/6/24, identified an order for Wixela one puff two times per day. Rinse mouth after each use. During an observation and interview on 1/9/25 at 8:36 a.m., TMA-B primed and handed R22 the Wixela inhaler. R22 took one puff and then a sip of water. TMA-B stated he didn't know if this was an inhaler you needed to rinse your mouth after using. After looking at the order, TMA-B confirmed the mouth should be rinsed after using the inhaler. During an interview on 1/9/25 at 12:54 p.m., the assistant director of nursing (ADON) stated it was her expectation would be that the TMA offer and encourage the resident to rinse their mouth after using the inhaler, and to follow the directions on the order, to help prevent complications like thrush. Facility policy and procedure regarding administration of inhaled medications requested but not received.

Based on observation, interview and document review, the facility failed to ensure therapeutic diets per physician's orders were followed for 2 of 2 residents (R1, R32) reviewed for therapeutic diets. Finding include: R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and was receiving insulin injections. In addition, R1 had diagnoses which included diabetes mellitus with hyperglycemia and mild nonproliferative diabetic retinopathy without macular edema, hypertension, depression, and chronic pain. R1's Active Orders as of 1/9/25, identified the following: Consistent Carbohydrate diet regular texture, thin consistency 2 a.m., finger poke if greater than 400 or less than 70 as needed Check blood sugar four times a day Humalog insulin 100 units per milliliter (ml) inject 32 units subcutaneously (sq [an injection that delivers medication into the fatty tissue beneath the skin]) in the evening insulin glargine inject 45 units sq in the morning insulin glargine inject 50 units sq in the evening Trulicity 1.5 milligrams (mg) per ml inject 1.5 mg sq one time a day every Friday R1's care plan dated 1/1/25, identified R1 had a nutritional problem or potential nutritional problem related to diabetes. Interventions included to administer medications as ordered to explain and reinforce to the resident the importance of maintaining the diet ordered. To provide, serve as ordered consistent carbohydrate diet. R1's blood sugars for January 2025 revealed the following: 1/1/25, highest 321 mg per deciliter (dl) lowest 163 mg/dl 1/2/25, highest 236 mg/dl lowest 198 mg/dl 1/3/25, highest 361 mg/dl lowest 270 mg/ dl 1/4/25, highest 326 mg/dl lowest 234 mg/dl 1/5/25, highest 316 mg/dl lowest 262 mg/dl 1/6/25, highest 272 mg/dl lowest 199 mg/dl 1/7/25, highest 350 mg/dl lowest 280 mg/dl 1/8/25, highest 339 mg/dl lowest 273 mg/dl 1/9/25, highs 309 mg/dl lowest 200 mg/dl During an interview on 1/6/25 at 1:35 p.m., R1 stated she was diabetic but wasn't getting diabetic meals, just getting what everyone else is eating. During an observation and interview on 1/8/25 at 2:40 p.m., R1 stated she thought her blood sugar goal was 100-300, then said maybe it was 100-200. R1's lunch tray was in her room she had not eaten yet, she had a large portion of ravioli, salad and regular french dressing, soup, and vanilla ice cream. Her lunch was late because she had been at a meeting at 1:00 p.m R1 looked at her meal ticket which listed her diet as Regular, LCS. R1 stated she did not know what LCS meant. R32: R32's quarterly MDS dated [DATE], identified R32 had diagnoses which included chronic kidney disease stage 3 (a moderate level of kidney damage where the kidneys are less efficient at filtering waste from the blood, causing mild to moderate loss of kidney function), coronary artery disease, hypertension, and diabetes mellitus. R32's MDS identified R 32 was cognitively intact and received insulin injections. R32's active orders as of 1/9/25, identified R32's orders included the following: -consistent carbohydrate diet, regular texture, thin consistency -blood glucose test before meals and at bedtime -consistent carb (carbohydrate) every evening -for blood sugar less than 70 mg/dl administer six ounces fruit juice, milk, regular pop or other high carbohydrate beverage: like Ensure or Boost. Repeat blood sugar after 10 minutes, if blood sugar less than 70 mg/dl, give 15 grams glucose. Repeat blood sugar after 15 minutes, if below 70 repeat glucose oral gel 15 grams. Repeat blood sugar in another 15 minutes and if below 70 call -glucose 15 oral gel 40 percent, give 15 gram by mouth as needed for blood sugar less than 70 -Humalog insulin 100 units/ml inject seven units subcutaneously with meals -Lantus insulin, inject 32 units subcutaneously in the morning R32's care plan initiated on 2/10/23, and revised on 9/24/24, identified R32 had nutritional problem or potential nutritional problem related to impaired skin integrity, new to this setting, therapeutic diet. Interventions included provide, serve diet as ordered. Monitor intake and record every meal. Consistent Carbohydrate. R32's blood sugars for January 2025 revealed the following: 1/1/25, highest 245 mg/dl lowest 131 mg/dl 1/2/25, highest 211 mg/dl lowest 135 mg/dl 1/3/25, highest 206 mg/dl lowest 120 mg/dl 1/4/25, highest 227 mg/dl lowest 120 mg/dl 1/5/25, highest 243 mg/dl lowest 139 mg/dl 1/6/25, highest 212 mg/dl lowest 114 mg/dl 1/7/25, highest 185 mg/dl lowest 107 mg/dl 1/8/25, highest 128 mg/dl lowest 119 mg/dl 1/9/25, highest 234 mg/dl lowest 101 mg/dl During an interview on 1/6/25 at 6:14 p.m., R32 stated her blood sugars where up and down and sometimes low overnight. R32 stated she had to regulate her own diet and was not getting a diabetic diet. During an observation and interview on 1/7/25 at 11:55 a.m., R32 was seated in the dining room, she had been served lemon chicken, a double portion of rice, mixed vegetables, jello with whipped cream, milk, juice, and water. During an observation on 1/7/25 at 12:40 p.m., R32 had eaten 100% of her meal. She stated she did not think the jello or juice was sugar free. During an interview on 1/8/25 at 10:20 a.m., dietary aide (DA)-A reviewed R32's diet ticket. The ticket had the resident's name and room number in the upper left corner. The diet was listed as Regular, CCHO. In the bottom right corner was a picture of what appeared to be a spoon with a white substance on it and a red circle with a red line through the picture of the spoon. DA-A stated she was not sure what the picture meant. DA-A was not sure which residents were diabetic. DA-A stated juices were not sugar free and the jello that was served was regular jello not sugar free. DA-A verified both R1 and R32 received regular juice and regular jello and the diabetic residents were served the regular meal and dessert. During an interview on 1/8/25 at 1:46 p.m., cook (C)-A stated a diabetic diet was no different than a regular diet. C-A stated if a resident was diabetic they should not have the dessert, instead they should receive fresh fruit. C-A stated there would not be any portion size changes for residents with diabetes. C-A stated the process was the DAs would pick up the meal tickets from the tables and bring them to the serving window. The residents who did not eat in the dining room would have their meal tickets placed on trays that were placed in the carts, C-A would not see those meal tickets. The DAs would just tell her regular, soft and bite sized, or minced and moist. During an interview on 1/8/25 at 2:08 p.m., registered dietician (RD)-D stated the facilities menu system would have specialty diets and it would be her expectation that the facility would follow those. RD-D stated a consistent carbohydrate diet would be about 60-75 grams of carbohydrate per meal and tracking the carbohydrates would be figured into the menu system. RD-D stated she would expect to be alerted if blood sugars were not being controlled. During an interview on 1/8/25 at 2:51 p.m., licensed practical nurse (LPN)-A stated he thought R1's blood sugar goal was 150. During an interview on 1/9/25 at 8:51 a.m., DA-B reviewed R1's meal ticket, she thought the picture of what appeared to be a spoon with a white substance on it and a red circle with a red line through the picture of the spoon meant no sugar but then said could mean no sodium. DA-B stated the cooks did not see any of the meal tickets for residents who did not eat in the dining room. The DA staff would just tell the cook how many regular diets, pureed, they needed. DA-B was asked what Regular, CCHO meant and regular LCS meant, she was not sure. DA-B thought CCHO might have something to do with cholesterol. During an interview on 1/9/25 at 9:04 a.m., cook (C)-B stated she would see the meal tickets for residents who ate in the dining room. C-B was asked what Regular CCHO meant, she was unsure and said they would just be given the regular meal. When asked what Regular LCS meant she thought it might mean lactose intolerant and again the resident would receive the regular meal. C-B stated they would not give a resident a half portion of the dessert unless they requested a half portion. C-B stated there were a couple of residents who only wanted half portions (R13, R31 and R44). C-B stated fresh fruit was available at breakfast and then any time a resident requested fresh fruit. C-B stated the juices were not sugar free and the jello served at lunch was not sugar free. Sugar free jello came from a company and was usually served at the evening meal. C-B stated diabetic residents received fruit or a small dessert but couldn't think of any residents who were diabetic. C-B stated the cooks would not see the meal tickets on the cart. The DAs would tell them how many they needed starting with the cut ups, minced and moist, then regular diets. During an interview on 1/9/25 at 9:35 a.m., dietary manager (DM)-E stated diabetic residents would receive a smaller portion of the entree and a larger portion of the non-starchy vegetables. DM-E stated the cooks would look at the meal ticket, see the ordered diet and then the resident would get a smaller portion if they were diabetic. DM-E stated diabetic residents would get the same dessert just a smaller portion. DM-E stated it was his expectation that the cooks would see every meal ticket at meals. During an interview on 1/9/25 at 1:03 p.m., the administrator stated residents received a therapeutic diet based on the their orders. The administrator stated she was unsure if the cooks looked at each resident meal ticket at every meal, but stated the dietary aides would call out the order. The administrator declined to say if this was best practice. A review of the meal tickets for 1/9/25, lunch revealed: Ten residents were receiving a Regular, CCHO diet, one of which was R32 Three residents were receiving a Regular, LCS diet, one of which was R1 Optima Solutions 2 Dietary Management Systems dated 2024-25 Fall/Winter Menus identified the following diets: Regular, Mechanical Soft, Puree, Low Con Sweet, Liberal Renal. No CCHO diet was identified in the definitions. Regular diet no restrictions, no definition for Low Con Sweet. The Low Con Sweet did however specify ounces to be served which were not different from the regular diet. The dessert however was indentified to be one half of pie or would identify seasonal fresh fruit. No definition or explanation for the picture of the spoon with the white substance and red circle and line through the red circle. Resident Council notes no date, identified residents were being served to many carbs, too many noodles, and identified they had many diabetic residents. An additional comment was, fruit is not a dessert. Therapeutic Diets dated 3/2023, identified the purpose was to ensure the nutritional needs of residents requiring therapeutic diets are met in accordance with their medical conditions, preferences, and physician orders while promoting optimal health and well-being. The policy further indicated residents would receive individualized meal plans. Definition of a therapeutic diet was as follows: A meal plan prescribed to manage a medical condition, which may include alterations in nutrient content, texture, or volume. The policy identified there would be regular training for dietary and nursing staff on therapeutic diet preparation and delivery. In addition, the registered dietician would review therapeutic diets monthly and adjust plans as needed.

Based on observation, interview and document review, the facility failed to ensure documentation of each resident's advance directive/code status was consistent throughout their records to ensure the code status reflected resident current resuscitation preferences and physician orders. The facility's failure resulted in an immediate jeopardy, risk of serious harm, injury, impairment, or death for 1 of 16 residents (R27) reviewed for advance directives. The immediate jeopardy began on [DATE], when R27 changed her preference from requesting cardiopulmonary resuscitation (CPR) to do not attempt resuscitation (DNR). R27's electronic record and hard copy record listed discrepancies in R27's most current code status and the facility lacked a system of where staff should look for current code status. The administrator and the director of nursing (DON) were notified of the immediate jeopardy on [DATE], at 5:26 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of a D, isolated harm that is not immediate jeopardy. Findings include: R27's Admission Record printed [DATE], indicated R27's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R27's quarterly Minimum Data Set, dated dated dated [DATE], indicated R27 was cognitively intact and was independent with her activities of daily living (ADL). On [DATE], at 3:27 p.m. R27 stated she would only want CPR if they could revive her with one shock, she further stated she did not wish to be on any life support. On [DATE], at 8:23 a.m., R27's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order in R27's electronic medical record (EMR) created an alert in her EMR banner that indicated DNR. R27's hard chart had a POLST dated [DATE], signed by R27 indicating she wanted CPR. The POLST was signed by R27's provider on [DATE]. In addition, there was a label on the outside of R27's hard chart that indicated full code. R27's hard chart did not include any further POLST forms. On [DATE], at 9:30 a.m. the blue POLST binder on top of the crash cart on the second floor had a copy of R27's POLST dated [DATE], which indicated DNR. On [DATE], at 9:52 a.m. the assistant director of nursing (ADON) stated staff would look for resident's code status in the EMR banner or in the blue POLST binder on top of the crash cart. The code book contained resident's POLST. The ADON stated the POLST could also be found in the hard chart under the advance directive tab and in the EMR scanned into miscellaneous documents. On [DATE], at 10:00 a.m. registered nurse (RN)-B stated she would look for a resident's code status in the EMR (the code status was in the banner and in the orders) or if it was closer (there are two floors with residents on each floor second and third) in the blue POLST binder on top of the crash cart (on the second floor), or check with the charge nurse. RN-B stated she did not think the POLST was in the hard chart. On [DATE], at 10:02 a.m. the director of nursing (DON) stated he would expect staff to look in the resident's hard chart for resident current code status. The DON further stated he trained new staff (nurses and nursing assistants) in CPR and he instructed them to look in the resident's hard chart for the signed POLST to determine code status. In the hard chart the POLST was located under an advance directive tab. The DON stated a copy of the POLST was also located in the EMR but he trained staff to look in the hard chart. On [DATE], at 10:46 a.m. the DON reviewed the facility's CPR Initiation policy and stated he was not in agreement with the policy. He stated again staff should be going to the hard chart to verify a resident's code status. On [DATE], at 12:10 p.m. nursing assistant (NA)-B stated she would check for a resident's code status at the desk in the white book, she further stated she could also look in the hard chart. NA-B was not certain what color the code book was or where it was kept. On [DATE], at 12:13 p.m. licensed practical nurse (LPN)-A stated she would look for a resident's code status in the EMR if she was in the EMR. LPN-A further stated she would check the hard chart to verify that it was correct because in other places she had worked it wasn't always correct in the EMR. On [DATE], at 12:41 p.m. the DON verified R27's code status in the hard chart under the advance directive tab was listed as full code dated [DATE]. He further verified R27's code status in the EMR was listed as DNR dated [DATE]. The DON verified the hard chart had an old POLST and was not current. The DON stated, this is why it should only be in one place. On [DATE], at 12:57 p.m. LPN-B stated she would check the EMR or the blue binder that was kept on top of the crash cart on the second floor for a resident's code status. On [DATE], at 1:00 p.m. registered nurse (RN)-A stated she would look in either the hard chart or the EMR for a resident's code status. On [DATE], at 1:03 p.m. RN-C stated she would look in the EMR for a resident's code status (code status was listed in the EMR banner and in the orders). She further stated if there was a computer failure she would look in the resident's hard chart (the POLST was located under an advance directive tab). On [DATE], at 4:07 p.m. the ADON stated the process for changes in POLST's would be to have the resident and the provider sign the POLST, the health unit coordinator (HUC) would put the order in and that would populate the banner in the EMR. The POLST would then get scanned into the miscellaneous tab in the EMR, a copy would go into the blue binder on top of the crash cart located on the second floor. The ADON stated the process stopped there. She was not aware of any process to update the hard chart with the current POLST. The facility policy titled CPR Initiation dated [DATE], located in the blue POLST binder on top of the crash cart, directed staff on the procedure for CPR Initiation as follows: --Residents that do not have an active DNR order or other advanced care directive specifically declining CPR will be identified by the code status CPR on the resident profile in Point Click Care (PCC) directing they are to receive life-saving efforts per their wishes. Residents who do have an active DNR order will be identified by the code status DNR on the resident profile in Point Click Care. The electronic medical record (EMR) will also have the active orders as either CPR or DNR on PCC terminals on the medicine carts, and the mobile computer work stations, making it efficient for staff to identify the resident's most current wishes very quickly. In the unlikely event that the electronic system is down, all POLST and Advance Directive paper copies can be found in the blue binder labeled POLST/Advance Directives on the facility crash cart on the second floor. The policy did not address the POLST being located in the resident's hard chart. The immediate jeopardy that began on [DATE], was removed on [DATE], at 12:46 p.m. when the facility took the following actions and staff were interviewed to verify as implemented: -The facility removed all resident advance directives and related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The removal of advance directives from all of the locations was verified on [DATE], from 7:47 a.m. to 12:45 p.m -All resident charts were reviewed on [DATE], to ensure the most recent POLST/advance directive were in the resident's hard chart. -All nursing employees (RN, LPN's, and NA's) were educated on the changes. Interviews were completed on [DATE], from 7:47 a.m. until 12:45 p.m. to verify education of staff was complete. -The CPR Initiation policy was updated and reviewed on [DATE], from 7:47 a.m. to 12:45 p.m. with the following changes: * Residents that do not have an active DNR order or other advanced care directive specifically declining CPR will be identified by the code status CPR on their POLST. *All POLST and Advance Directive paper copies can be found in each resident's hard charts at the second floor nursing station. *Reference to blue binder code status and EMR were removed.

Based on interview and document review, the facility failed to perform a comprehensive root cause analysis which identified individualized risk factors to reduce the likelihood of subsequent falls, and failed to develop a comprehensive care plan which identified fall risk factors and/or implement resident centered interventions to reduce the risk of falls for 2 of 4 residents (R1, R4) reviewed for accidents. This resulted in actual harm for R1 who fell and suffered a head injury which required medical intervention. Findings include: R1's Admission Record printed [DATE], indicated R1's [DIAGNOSES REDACTED]. R1's significant change Minimum Data Set ((MDS) dated [DATE], indicated R1 had moderate cognitive impairment. R1's MDS identified she required extensive assistance with bed mobility, transfers, and toilet use. R1's MDS further identified she used a wheelchair and was frequently incontinent of bladder. No behavioral symptoms were identified. R1's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated [DATE], indicated R1 had [MEDICAL CONDITION], restricted mobility, and urinary urgency. R1's Falls CAA dated [DATE], indicated R1 received antipsychotic, antidepressant, opioid (pain), and diuretic (water pill) medication. The CAA further indicated R1 had [MEDICAL CONDITION], cognitive impairment, anxiety disorder, incontinence, and cardiac [MEDICAL CONDITION]. R1 was referred to a hospice agency. R1's care plan revised [DATE], indicated R1 had impaired cognitive function and thought processes related to dementia. R1's care plan further indicated R1 had an activity of daily living (ADL) self-care deficit related to activity intolerance, fatigue, impaired balance, and shortness of breath. R1 had the potential for urinary leakage/bladder incontinence related to diuretic use and impaired mobility. The care plan identified R1 required assistance of one staff for surface-to-surface transfers and directed staff to assist R1 with toileting, as needed, per resident request. R1's care plan revised on [DATE], indicated R1 was at risk for falls related to weakness, gait/balance problems, psychoactive drug use, and hearing problems. The care plan directed staff to perform cares, at bedtime, after [MEDICATION NAME] (antipsychotic medication) was administered (created [DATE]), safety checks every two hours for functionality and placement of silent alarm (created [DATE]), silent pressure alarm to bed and wheelchair (created [DATE]), and increased safety checks dated (created [DATE]). An incident report dated [DATE], at 11:50 p.m. indicated R1 was found on the floor in her room. R1 was dressed, but barefoot. R1's wheelchair was to her left side. The wheelchair backrest was towards the bathroom. R1 was half-way from the bathroom. R1 stated she was going to get oxygen tubing and slipped on a blanket. No blanket was observed near R1. R1's call light was noted to be on. The facility root cause analysis (RCA) dated [DATE], indicated R1 had poor safety awareness and balance. The RCA further indicated R1 walked through her room to get oxygen tubing, leaned on her wheelchair, and fell to the floor as the wheelchair breaks were unlocked. The RCA lacked indication of how long R1 waited for her call light to be answered, or if she needed to use the bathroom. New interventions included assisting R1 to bed after [MEDICATION NAME] administration, and applying gripper socks. The facility did not complete a fall risk assessment for R1. An incident report dated [DATE], at 11:45 p.m. indicated R1 was found on the floor in her room. R1 was sitting with her back up against her bed. R1's wheelchair was pushed to the side of a table. A telephone cord was wrapped around a table. R1 stated she leaned forward to clip her toenails and slipped out of bed. The facility RCA dated [DATE], indicated R1 had, poor safety awareness, cognitive deficit, and poor balance. The RCA further indicated R1 slipped off her bed and was not wearing non-skid footwear. Corrective actions included continuing plan of care. No new interventions were identified. The facility did not complete a fall risk assessment for R1. An incident report dated [DATE], at 11:30 a.m. indicated R1 was found on the floor near her bed. R1 was facedown and her head was at the base of a bedside table. R1's wheelchair was to the left of her. R1 stated she was sitting on her bed and the next thing I knew I was on the floor. R1 had a laceration, to the top of her head, which measured 4 centimeters (cm.). Additionally, R1 had a 5 cm. contusion (bruise) to her forehead. The facility RCA dated [DATE], indicated R1 was sent to the emergency department and it was noted she had an elevated [MEDICATION NAME] (cardiac medication) level. New interventions included daily [MEDICATION NAME] toxicity monitoring. The facility did not complete a fall risk assessment for R1. A progress note dated [DATE], at 12:11 p.m. indicated R1 believed an individual across the hall was attempting to sleep in her bed. The room across the hall was unoccupied. R1's representative expressed concern regarding Trazadone (antidepressant) medication R1 was recently ordered. R1 was scheduled for virtual rounds on [DATE]. An incident report dated [DATE], at 6:45 a.m. indicated R1 was found on the floor in her room. R1's left arm was near the front of the toilet and she was halfway in the bathroom. R1 stated she was attempting to pull up her pants after using the bathroom. R1's oxygen tubing was found on the floor, but not near her. The facility RCA dated [DATE], indicated R1 had weakness, decreased safety awareness, visual limitations, heart conditions, chronic [MEDICAL CONDITION], and cognitive impairment. The RCA further indicated R1 toileted herself and fell trying to pull her pants up. R1 was not wearing non-skid footwear. New interventions included increased safety checks and long-term plan to move R1 to the second floor near the nurses' station. The facility did not complete an assessment of R1's toileting needs. The facility did not complete a fall risk assessment for R1. An incident report dated [DATE], at 12:00 p.m. indicated R1 was found sitting in front of the toilet in her room. R1's wheelchair was near her bed. R1's pants were around her knees. R1 stated she was going to her wheelchair from the toilet. R1 was reminded to call for help when pulling up her pants. The facility RCA dated [DATE], indicated R1 had weakness, decreased safety awareness, cognitive impairment, visual limitations, heart conditions, chronic [MEDICAL CONDITION], and history of falls. The RCA further indicated R1 toileted herself independently and fell while in the bathroom. New interventions included a hospice referral for care and medication management. The facility long-term plan remained moving R1 to the second floor near the nurses' station. The facility was to continue increased safety checks. The facility did not complete an assessment of R1's toileting needs. The facility did not complete a fall risk assessment for R1. A progress note dated [DATE], at 11:59 a.m. indicated R1's representative contacted a hospice agency. The progress note further indicated R1 would be screened for hospice due to failing health related to cardiac issues, cognitive decline, wt (weight) changes, and falls. An incident report dated [DATE], at 11:30 p.m. indicated R1 was found sitting on the floor, and was midway between the bathroom and her bed. R1 was dressed and a wheelchair was beside her. The wheelchair breaks were unlocked and R1 was incontinent of urine. Urine was also noted in R1's toilet. R1 was unable to explain what had happened. R1's room had no clutter on floor and R1 did not have her oxygen on. R1 was reminded to call for help. The facility RCA dated [DATE], indicated R1 had weakness, decreased safety awareness, cognitive impairment, visual limitations, heart conditions, history of falls, and chronic [MEDICAL CONDITION]. The RCA further indicated R1 tried to sit on the edge of her bed and the bed mattress had a dip in it. Additionally, it was noted R1 was admitted to hospice the previous week and R1's room was very cluttered. New interventions included a room cleaning, R1's mattress was turned, and a room change. The facility did not complete an assessment of R1's toileting needs. The facility did not complete a fall risk assessment for R1. An incident report dated [DATE], at 7:15 a.m. indicated R1 was found laying under her bedside table. R1's wheelchair was near a closet. R1 stated she was picking dandelions. The facility RCA dated [DATE], indicated R1 had poor safety awareness, poor balance, weakness, fatigue, recent medication changes, cognitive impairment, was barefoot. The RCA further indicated R1 had end-of-life restlessness and impulsivity. New interventions included a silent pressure alarm to R1's bed and wheelchair. The facility did not complete a fall risk assessment for R1. An incident report dated [DATE], at 9:20 a.m. indicated R1 was found sitting in front of her wheelchair near a television. The facility RCA dated [DATE], indicated R1 had poor safety awareness, poor balance, weakness, fatigue, and recent hospice admission. The RCA further indicated R1 had recent medication changes done by hospice, due to a decline in condition. Additionally, R1 had end-of-life restlessness and agitation. New interventions included adding a silent pressure alarm to R1's bed and wheelchair. Additionally, the facility indicated they would consult with hospice regarding medication changes. The facility did not complete a fall risk assessment for R1. A progress note dated [DATE], at 11:02 a.m. indicated R1 was found on the floor. R1 was seated opposite of her chair and was holding her head. R1's wheelchair was near her. R1 was sent to the emergency department. An incident report dated [DATE], at 10:25 a.m. indicated R1 was found on the floor and was bleeding from the left side of her head. R1 was sitting opposite of her chair. R1 was noted to have a 2-inch (in.) laceration to the side of her head. R1 was sent to the hospital for treatment. The facility RCA dated [DATE], indicated R1 had poor safety awareness, poor balance, altered mental status, and had declining health. The RCA further indicated the facility reached out to the pharmacist and hospice for guidance and medications to reduce anxiety and wandering. Additionally, the incident report indicated nursing assistants (NAs) were to be educated prior to their next shift on silent pressure alarm function. A second silent pressure alarm was installed on R1's wheelchair. The facility did not complete a fall risk assessment for R1. A progress note dated [DATE], at 5:20 p.m. indicated R1 returned from the hospital. R1 was confused and refusing cares. A new silent pressure alarm was placed on R1's wheelchair. R1 had a laceration, to her head, and staples were in-place. R1 was also noted to have bruises on her left shoulder and left hip. Education was provided to NAs on the new silent pressure alarm and expected response. Two-hour safety checks, to ensure silent pressure alarm function, were initiated. An investigation summary dated [DATE], indicated R1 was noted to be a historically poor decision maker and had an [MEDICAL CONDITION] (lack of oxygen) [MEDICAL CONDITION] related to coronary bypass surgery. On [DATE], at 8:30 a.m. R1's bed silent pressure alarm sounded. R1 was cleaned up, dressed, her bed was made, and the silent pressure alarm control box was placed on R1's bedside stand. R1 was seated, in bed, and her breakfast was placed in front of her. Staff left R1's room at approximately 8:45 a.m. R1's status from 8:45 a.m. to 10:15 a.m. was uncertain. At 10:15 a.m. staff walked past R1's room and R1 was found sitting on the floor, near the room entry, and was holding her head. R1 was unable to state what she was doing. R1's silent pressure alarm did not sound. R1 had a laceration to the back-left side of her head, was transferred to the emergency department, and had 16 staples placed to repair the laceration. The investigation indicated it was undetermined if R1's silent pressure alarm was unplugged or malfunctioned. The silent alarm was tested , and it was functional. The facility did not complete a fall risk assessment for R1. An emergency department physician note signed [DATE], at 10:25 a.m. for the ED visit on [DATE], indicated R1 had an unwitnessed fall and was impulsive. R1 was noted to get up without ringing staff. R1 had a large left scalp laceration which was stapled. R1 was noted to have a progressive decline, with minimal intake, and had been sleepy. A progress note dated [DATE], at 5:19 a.m. indicated R1 attempted to crawl out of bed at 11:30 p.m. R1 complained of head pain, was restless, agitated, and aggressive. R1 received [MEDICATION NAME] and [MEDICATION NAME] at 11:50 p.m. R1 went to sleep. At 4:45 a.m., R1 woke up and stated, ouch, ouch. R1 was again attempting to crawl out of bed. [MEDICATION NAME] was administered and R1 slept since 5:15 a.m. A progress note dated [DATE], at 10:36 a.m. indicated hospice was updated of R1's fall. A medication review was requested, and hospice indicated a nurse would evaluate R1 today. Additionally, hospice ordered a different wheelchair for R1. A progress note dated [DATE], at 3:47 p.m. indicated R1 slept most of the shift. R1 was also noted to become restless and [MEDICATION NAME] was administered. R1 was not awake enough to administer oral scheduled medications. A progress note dated [DATE], at 2:36 a.m. indicated R1 complained of pain with repositioning. R1 stated ouch, ouch and grabbed for her hips and legs. R1 had a distant look to her face and was unable to focus. R1's color was dusky. A progress note dated [DATE], at 3:49 p.m. indicated R1 was having apneic (period of not breathing) episodes [MEDICATION NAME] ,[DATE] seconds. Hospice was notified. A progress note dated [DATE], at 4:28 p.m. indicated R1 died at 11:31 a.m. On [DATE], at 10:01 a.m. an interview was conducted with NA-A. NA-A stated from the start, R1's cognition was skewed and R1 hallucinated a lot. NA-A stated R1 would use her call light to request assistance, however, it was hit or miss. NA-A stated R1 was notorious for doing her own thing. NA-A stated R1 was able to self-propel her wheelchair, however, long distances were difficult for her. NA-A stated R1 was historically independent with toileting, however, R1 required assistance toileting around the time R1 was admitted to hospice. NA-A stated R1 needed help pulling her pants up and performing perineal care. NA-A stated she did not remember if R1 was on a toileting schedule and stated she probably was. NA-A stated R1's fall interventions included frequent checks, a silent pressure alarm, and R1 was moved closer to the second-floor nurses' station. NA-A stated she worked on [DATE], and attended to R1 when she fell and hit her head. NA-A stated she heard R1 yell for help and she responded to R1's room. NA-A stated R1 was on the floor, near her wheelchair, and R1's head was bleeding. NA-A stated the silent pressure alarm was located on R1's bed. NA-A stated there was not a silent pressure alarm on R1's wheelchair. NA-A stated R1's silent pressure alarm did not alert staff R1 had gotten up. NA-A stated she asked another staff-person for help, left the room, and found a nurse. NA-A stated a nurse assessed R1, called 911, and R1 was transferred to the hospital. NA-A stated NA-C got R1 ready in the morning. NA-A stated NA-C told her R1 was seated on the bed, with a bedside table in front of R1, when she left the room. NA-A stated she did check R1's silent pressure alarm and it was working. NA-A stated she did not know why R1's silent pressure alarm did not alert staff R1 had gotten up. On [DATE], at 10:21 a.m. an interview was conducted with trained medication assistant (TMA)-A. TMA-A stated R1's cognition was totally gone, and had progressively worsened long before R1 had died . TMA-A stated R1 received hospice services and started to decline in April or May. TMA-A stated it was impossible to administer R1's medications. TMA-A stated R1 was terminally ill and did not understand what was being said. TMA-A stated towards the end of R1's life she would use the call light, however, sometimes she forgot she had it. TMA-A stated, at times, R1 would use her call light and informed staff there was a man in her closet. TMA-A stated R1 was unable to verbalize what she needed. TMA-A stated R1 required the assistance of one staff, with a gait belt, for transfers and toileting. TMA-A stated she did not recall R1 being badly incontinent or wearing a brief for very long. TMA-A stated R1 was known to get up and toilet herself, especially towards the end of her life. TMA-A stated toileting was an additional source of falls for R1. TMA-A stated R1 frequently leaned in her wheelchair like she was too tired to sit up. TMA-A stated R1 spent a lot of time leaning against things and slid out of her wheelchair a couple of times. TMA-A stated everyone had a concern regarding R1's wheelchair, however, she did not believe anyone had assessed it. TMA-A stated facility administration was aware of the wheelchair concern; however, it was not high on their priority list. TMA-A stated R1's fall interventions included a room close to the nurses' station, two-hour safety checks/toileting schedule, supportive shoes, and a silent pressure alarm. TMA-A stated she worked when R1 fell on [DATE], however, she only provided medications to the resident. TMA-A stated she was unsure if R1's silent alarm alerted staff when the R1 got up. TMA-A stated staff had some issues with the silent alarm not alerting staff previously. TMA-A stated the alarm had to be reset when moved from the bed to the wheelchair and it was a hassle. On [DATE], at 1:18 p.m. an interview was conducted with the interim director of nursing (DON). The DON stated R1 had poor cognition/memory and had a history of [REDACTED]. The DON stated R1 was on an ambulation program and did well. The DON stated R1 was able to self-propel her wheelchair, however, towards the end of R1's life it was easier for R1 to propel her wheelchair backwards rather than forward. The DON stated R1 was able to use her call light, and for the most part, used it appropriately. The DON stated, at times, R1 would ask for items which were in front of her. The DON stated towards the end she believed R1 used her call light a little less when she faded physically and mentally. The DON stated R1 was initially able to toilet herself, however, she required assistance of one staff towards the end of her life. The DON stated R1 was occasionally incontinent of bladder. The DON stated R1 told staff when she needed use the bathroom, however, R1 would use the bathroom without staff assistance, at times. The DON confirmed R1 was known to self-transfer and stated it was concerning as R1 had oxygen tubing. The DON stated, at the end, she did not know if a toileting plan would had benefited R1, however, stated a toileting plan may had benefited R1 prior to the last month of her life. The DON confirmed a toileting schedule was not part of R1's care plan. The DON stated she did not recall if R1 leaned to the side of her wheelchair and remembered R1 sliding out of her wheelchair. The DON stated R1 would slump forward in her wheelchair. The DON stated R1 was in a standard wheelchair and verbalized R1 had the capability to get up and out of her wheelchair. The DON stated she did not believe the facility considered auto-lock brakes as part of the root cause analysis. The DON stated R1 received hospice services and had [MEDICAL CONDITION] with significant heart issues. The DON stated R1 was showing signs of terminal restlessness and anxiety towards the end of her life. The DON stated R1's fall interventions included a room near the second-floor nurses' station, increased safety checks, a silent pressure alarm, and scheduled bedtime cares. The DON stated she did not feel R1's behaviors changed. The DON stated as part of a root cause analysis the facility evaluates factors which are noted at the time of the fall, medication changes, and medical diagnoses. The DON stated on [DATE], R1 was found on the floor in her room. The DON stated a blood spot was toward the center of R1's room near the television. The DON stated she did not believe R1 was attempting to the use the bathroom. The DON stated it was hard to figure out what the root cause of the fall was, but there was a thought process that R1 may had went towards her wheelchair. The DON stated R1 hit her head and needed 16 staples to repair a laceration. The DON confirmed R1's silent pressure alarm did not alert staff when R1 had changed position. The DON stated the facility was unable to determine if the device was not plugged in, had malfunctioned, or failed due to user error. The DON stated the silent pressure alarm was tested and determined to be functional. The DON stated she was not in her role when the investigation was conducted. The DON stated, prior to the incident on [DATE], staff needed to move the silent pressure alarm back and forth from the bed to wheelchair. The DON added, after the incident, a second silent pressure alarm was added to R1's room so staff did not need to move the alarm back and forth. The DON stated NAs were also provided education. The DON stated the facility used silent pressure alarms for approximately one year and did not have any similar issues. Two attempts were made to interview NA-C, however, contact was unable to be established. R4 R4's Admission Record dated [DATE], indicated R4's [DIAGNOSES REDACTED]. R4's quarterly MDS dated [DATE], indicated R5 had intact cognition. R4 required extensive assistance with bed mobility, transfers, walking, and toilet use. R4 was not steady moving from a seated to standing position and used a walker and wheelchair. R4 was frequently incontinent of bladder and had one fall without injury. R4's Falls CAA dated [DATE], indicated R4 had difficulty maintaining sitting balance and impaired balance during transitions. R4's CAA further indicated R4 had a cognitive impairment, cardiac [MEDICAL CONDITION], and the overall objective of the care plan was to minimize risks. R4's care plan lacked indication of fall risk factors and associated interventions. An incident report dated [DATE], at 4:45 p.m. indicated R4 was found sitting upright near his bathroom door. R4 stated he was coming out of the bathroom, bent over to pick up a grabber, and fell . An incident report dated [DATE], at 11:45 p.m. indicated R4 was found on the floor in his room. R4 was naked from the waist down and his legs were towards the bathroom. R4 stated he got out of bed, headed for the bathroom, and his legs gave out. An incident report dated [DATE], at 6:19 p.m. indicated R4 was found on the floor near his bathroom doorway. R4 stated he was reaching downward, grabbed the doorway, and fell . On [DATE], at 3:48 p.m. an interview was conducted with R4. R4 stated he used a walker to get to the bathroom. R4 stated at times, he will take himself to the bathroom without assistance. R4 stated he had previously fallen when trying to go to the bathroom independently as he lost his balance. R4 stated staff has told him not to bother them and he does not get any answers when he pushes his call light. On [DATE], at 3:56 p.m. an interview was conducted with TMA-B. TMA-B stated R4 was cognitively intact and used a walker to ambulate. TMA-B stated R4 kept a urinal on his walker and usually would urinate while sitting in his chair. TMA-B stated R4 needed assistance of one staff to use the toilet and he frequently called for help. TMA-B stated a care plan was located at the third-floor nurses' station regarding fall interventions and toileting needs. At 4:02 p.m. TMA-B went to the third-floor nurses' station and confirmed he was unable to locate R4's care plan. On [DATE], at 4:09 p.m. an interview was conducted with the DON. The DON stated R4 was cognitively intact, however, could get a little confused. The DON confirmed R4's care plan did not address fall risks and interventions, nor information regarding R4's bowel and bladder. The DON stated the resident's care plan should be reviewed and updated quarterly. An untitled, undated facility policy directed, The Interdisciplinary Plan of Care (IPOC) team will meet within the same time period of time and discuss the causative factors, interventions to prevent another fall, make therapy referral as necessary and revise the care plan if necessary.

Based on observation, interview, and document review, the facility failed to reassess and ensure new interventions were implemented timely following falls, to prevent further falls for 3 of 3 residents (R3, R14, R16) reviewed for falls. This resulted in actual harm for R3, who sustained falls which resulted in emergency room visits for sutures and staples. Findings include: R3's Face Sheet printed 12/12/19, indicated R3 [DIAGNOSES REDACTED]. R3's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R3 was severely cognitively impaired. The MDS indicated R3 needed assistance for bed mobility, walking in the room, walking in the hallway, and transfers. R3's quarterly MDS dated [DATE], indicated R3 was independent with bed mobility, and with walking in his room, but required assistance with transfers, and walking in the hallway. R3's Care Area Assessment (CAA) for Activities of Daily Living/Rehabilitation Potential dated 6/3/19, indicated R3 had generalized weakness, low back pain, impaired balance, and impaired cognition. R3's CAA for Falls dated 6/3/19, indicated R3 was at risk for falls related to impaired cognition, lower extremity weakness, impaired balance, narcotic [MEDICATION NAME], and the new environment. A referral to physical therapy (PT) and occupational therapy (OT) was ordered. R3's Morse Fall Assessment completed on 5/28/19, indicated R3 was at high risk for falling. A Mobility Assessment completed on 8/28/19, indicated R3 was not steady with transitional movements, and needed transfer assist of one. R3's care plan dated 6/13/19, indicated he was at risk for falling related to low back pain, weakness, impaired cognition, poor safety awareness, gait and balance problems, and opioid and psychoactive drug use. R3's goal was to not sustain a serious injury. Interventions included promoting exercise for strengthening and improved mobility such as exercises in the Wellness Center as he was willing, appropriate footwear, and posting signs (at sight level) reminding R3 to use the call light and walker. Revisions dated 8/30/19, and 9/3/19, included a cushion for his recliner, a contoured mattress for the bed, even floors that were free from spills, adequate lighting, and personal items within reach. On 12/9/19, at 1:08 p.m. R3 was observed standing in front of his wheelchair in his room. R3 stated he had come from the bathroom. R3 proceeded to wheel the chair into the hallway leaning on the arms of the wheelchair pushing it backward. R3 then turned and proceeded to sit down in his wheelchair. No staff were observed in the area. On 12/9/19, at 5:01 p.m. R3 was observed standing in the doorway of an office across from his room. The office was dark, R3 was holding onto the doorway, and he did not have his walker or his wheelchair within reach. Licensed practical nurse (LPN)-A and nursing assistant (NA)-D came walking quickly down the hall when they became aware of R3 standing in the doorway. NA-D located R3's wheelchair which was parked in an alcove further down the hallway near a sitting area. R3 was assisted to his chair by the two staff members, and taken to his room. R3's Event Reports for Falls indicated the following: 1) On 8/24/19, at 2:20 a.m. R3 was found lying on his left side against the bed, legs tangled in blankets, and the walker pushed out in front of him. When asked what happened, R3 stated he rolled over in bed. Additional comments included were he tended to sleep on the edge of the bed. R3 sustained a contusion, goose egg size, to his left forehead, and a 1 x 1 inch skin tear to his left elbow. Immediate interventions were to add more frequent checks, to place blankets on his feet not around his feet, and to add a concave mattress top to the bed. R3 was transported to the emergency room (ER) for evaluation and treatment, where he received three sutures to the left side of his head. 2) On 9/2/19, at 10:22 p.m. R3 was found sitting on his bed with an arm abrasion, blood marks on the carpet, and the walker was in front of the bathroom door. When R3 was asked what happened he couldn't recall, but stated he knew he had been on the floor. The immediate intervention was to remind him to use his call light. Interventions identified to prevent another fall were to hang bright signs, to remind him to use his call light, and to use his walker. The root cause analysis identified R3 had poor safety awareness, frequently walked without his walker, and did not use his call light. The root cause analysis lacked insight on why R3 might have fallen. 3) On 9/3/19, at 5:20 a.m. R3 was found in the north hallway on his back, by the medication cart. He had blood on his face, hand, head, shirt, and a laceration on the right side of his forehead. He was found wearing socks, his walker was in his room, his slippers were by the bed, and his call light was attached to the bed. R3 did not know how he fell , or why he was lying on the floor in the hallway. The immediate interventions were to continue to check on resident frequently and toilet, remind him to use the walker. R3 was transported to the ER for evaluation and treatment, where he received four staples and two sutures to the right side of his head. The facility Incident Report indicated the root cause analysis was related to R3's poor safety awareness, and that he would frequently leave his walker and wander in the building. R3 was reminded regularly, but his dementia impaired his ability to retain the reminders. On 12/11/19, at 1:31 p.m. the director of nursing (DON) was interviewed about R3's falls. The DON stated the process with falls was to not move anyone after a fall until they were assessed, to complete an incident report, and to discuss the fall at the stand up meeting on the day after the fall. The DON stated they look for patterns with falls, and implement interventions as soon as possible. The DON stated for R3, the interventions were to place signs in his room and on his walker reminding him to call for assistance, and to use his walker. The DON stated the long term plan was to add a concave mattress however, this did not arrive timely (the mattress arrived on 9/3/19). The DON stated during the 11 days prior to the arrival of the mattress, she thought R3 was on hourly checks, but R3 was not. The DON stated being instructed to call for assistance was not an appropriate intervention for R3 because of his [MEDICAL CONDITION]. The DON confirmed R3 was hurt from his falls, and required treatment in theER on two occasions for sutures and staples. The DON confirmed the intervention to obtain a concave mattress had not been completed timely. The DON stated reminders to R3 to use his walker and to call for help were not appropriate interventions for R3 because of his Alzheimer's diagnosis. A policy on falls was requested, but not provided. R16's Admission Record printed 12/13/19, indicated R16's [DIAGNOSES REDACTED]. R16's annual MDS dated [DATE], indicated R16 was cognitively intact, had no behaviors, and was independent with bed mobility, transfers, and ambulation. R16's MDS indicated R16's balance was not steady, but was able to stabilize self. R16's MDS further indicated R16 had no falls since the previous MDS, dated [DATE]. R16's CAA dated 9/25/19, indicated R16 was unsteady during transfers and moving from sitting to standing position, and was unable to be independent in these activities. R16's care plan initiated 9/26/18, indicated R16 was at risk for falls. Interventions included having R16 participate in exercise activities, ensure appropriate non-skid footwear, and monitoring blood glucose as necessary. Nursing staff was directed to review information on past falls and attempt to determine cause of falls. Additional interventions included: placing R16's call light within reach on bed, recliner, and in bathroom, night lights in bedroom and bathroom, left wall grab bar in bathroom, grab bars for shower transfer, lift chair, walkers, and bed in low position at night, and personal items within reach for bed mobility. R16's care plan further indicated R16 required assistance of one to two staff as needed for bed mobility, assistance of one staff for stand by or guided maneuvering for transfers, and one assist with toilet use as requested. R16 was able to ambulate a few steps only while using a walker and gait belt in the room, and stand by assist with a gait belt in the hallway. R16's Fall Risk assessment dated [DATE], indicated R16 was at high risk for falls due to incontinence, balance problems, change in gait, use of an assistive device for mobility, pre-disposing diseases, and receipt of 1-2 medications that could contribute to falls, such as antihypertensives (for blood pressure), hypoglycemics (for blood glucose levels), and psychoactive (mood altering) medications. R16's incident report dated 8/21/19, for a fall while transferring from the wheelchair into the recliner indicated R16 stated she missed the chair while reaching for it, and fell . R16's incident report indicated R16's blood pressure at the time of the fall was 92/53. The investigation with root-cause analysis for this fall was dated 8/21/19, and lacked identification of R16's low blood pressure, lacked orthostatic blood pressures (blood pressures checked during position changes from sitting to standing to identify a drop in blood pressure that could cause dizziness or falls while standing), and interventions were to provide another night light. R16's incident report indicated the follow up to R16's fall was dated 9/3/19. R16's physician visit notes dated 12/3/19, indicated R16 was seen for heart failure , chronic hypoxic [MEDICAL CONDITION] with [MEDICAL CONDITION] (low oxygen levels), diabetes that was well controlled with current treatment. In addition, R16 was reviewed for persistent [MEDICAL CONDITION] with treatments including [MEDICATION NAME] and [MEDICATION NAME] to treat blood pressure and irregular heart rate, and mood symptoms determined to be controlled with [MEDICAL CONDITION] (mood altering) medications. R16's physician note indicated R16 had no falls in the past 60 days, even though had two falls in 10/19. R16's incident reports indicated R16 had a fall on 10/4/19, while rising from the chair in room. R16's incident report indicated R16's blood pressure was 91/46 at the time of the fall, and the root cause analysis and investigation for this fall identified R16's low blood pressure, but lacked follow up to the concern and an orthostatic blood pressure. The interventions put in place at the time of the investigation, dated 10/7/19, were to remind R16 to use the call light to ask for assistance for transfers from the chair, and to wear gripper socks at bedtime. R16's incident report indicated follow-up to the fall was not completed until 12/6/19. R16's incident report for a fall dated 10/17/19, while transferring from wheelchair to to a chair and slid off the chair during a staff assisted transfer. R16's incident report indicated R16 was wearing socks, and blood pressure was 133/64, though there was no orthostatic blood pressures recorded. R16's incident report further indicated R16 had a laceration on her leg and was sent to the hospital where she was admitted to the cardiac unit. R16's incident report indicated the investigation for this fall was dated 12/5/19, and follow up was dated 12/6/19. R16's progress notes dated 12/6/19, for the follow-up related to R16's fall on 10/17/18, indicated R16 had been treated for [REDACTED]. R16's physician had ordered R16 to go the emergency room at that time, and R16 had refused. R16 fell the following day and was sent to the hospital where she was hospitalized on the cardiac unit. R16's progress notes dated 12/6/19, further addressed follow-up to R16's fall on 10/4/19, and lacked identification of R16's low blood pressure. R16 had not further falls while wearing appropriate footwear. R16's Weights and Vitals Summary dated 10/1/19 through 12/12/19, indicated orthostatic blood pressures had not been taken. R16's blood pressure record indicated R16 had low blood pressure readings on several dates, including: - 10/8/19 was 98/44 at 9:04 a.m. -10/8/19 was 97/55 at 5:25 p.m. -10/11/19 was 98/45 at 6:37 p.m. -10/12/19 was 92/44 at 6:26 p.m. -11/6/19 was 99/52 at 5:33 p.m. -11/22/19 was 98/38 at 6:19 p.m. R16's Weights and Vitals Summary indicated there were no re-checks following low blood pressure readings. R16's progress notes on these dates indicated there was not follow-up addressing R16's low blood pressure readings. On 12/9/19, at 9:42 a.m. R16 stated she slid down when weak, due to shortness of breath, and did a controlled fall. R16 stated she had a large gash in her leg with the last fall. R16 stated she declined therapy after having a few sessions, but may want more now. On 12/12/19, at 12:10 p.m. the DON verified R16's fall reviews had not been done timely, though stated interventions had been implemented at the time of the fall. The DON verified R16 had low blood pressures, and stated orthostatic blood pressures should have been done. The DON stated the post-fall worksheets included vital signs, though the facility did not do orthostatic blood pressures. R14's Admission Record dated 12/12/19, indicated R14's [DIAGNOSES REDACTED]. R14's quarterly MDS dated [DATE], identified R14 had moderately impaired cognition. R14's MDS further identified she required limited assistance with transfers and bed mobility, used a walker, and was not steady walking. R14's CAA for Falls dated 6/14/19, identified R14 had fallen at the facility, and had a history of [REDACTED]. R14's care plan revised 6/14/19, identified R14 was at high risk for falls related to confusion, balance problems, poor comprehension, psychoactive drug use, vision/hearing problems, and unaware of safety needs. Interventions included, Review information on past falls and Remove any potential causes if possible. A progress note dated 10/30/19, at 2:39 a.m. indicated R14 was found to be kneeling at the side of her bed in a position resembling praying. The progress note further indicated R14 was not aware of why she was in the position. No injury was noted. An incident report dated 11/24/19, indicated R14 was found kneeling bedside her bed with blankets wrapped around her. R14 indicated she was unaware of what had happened. No injury was noted. A progress note dated 12/7/19, at 10:46 a.m. indicated a concave mattress was on order in follow-up to falls which occurred on 10/30/19, and 11/24/19. The concave mattress was scheduled to arrive the following week. On 12/9/19, at 11:02 a.m. R14 was observed ambulating from the door near to her bathroom, to the door near the entrance to her room. R14 was not using her walker, which was located near her bathroom door, and used the wall to steady herself. On 12/11/19, at 9:51 a.m. R14 was observed ambulating in the hallway with a front wheeled walker. On 12/11/19, at 1:00 p.m. R14 was observed sitting in a chair in her room. A front wheeled walker was directly in front of R14. On 12/12/19, at 9:58 a.m. an interview was conducted with nursing assistant (NA)-D. NA-D stated R14 had several falls since being admitted to the facility. NA-D stated R14 had dementia, frequently rummaged through items in her room, and used to rearrange her furniture. On 12/12/19, at 10:45 a.m. an interview was conducted with the DON. The DON stated R14 had a long history of falls, and had hit her head a few times prior to being admitted to the facility. The DON verbalized R14's feet fell out of bed, and she ended up in a kneeling position. The DON further verbalized a concave mattress was ordered, and the facility was waiting for the mattress to arrive. The DON stated when a fall occurred, the interdisciplinary team (IDT) usually meets the next day and puts necessary interventions in place, and documentation follows later. The DON further stated the facility had found incident reports in places they shouldn't have been and in some circumstances it was hard to follow up on interventions when the necessary paperwork was not available. The DON confirmed there was delayed follow-up in ordering the concave mattress related to incident reports being found in the prior DON's office.

Based on observation, interview and document review, the facility failed to comprehensively assess, thoroughly investigate causal factors, and implement effective interventions in order to minimize the risk of falls and injury for 2 of 4 residents (R26, R39) reviewed for falls. The deficient practice resulted in actual harm for R26 who sustained serious injuries which required medical intervention. Findings include: R26's significant change Minimum Data Set ((MDS) dated [DATE], identified R26 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS identified R26 required extensive assistance of one staff with bed mobility, transfers, walking in room, dressing and toileting. The MDS also identified R26 had balance problems: moving from a seated to a stand position, walking, moving on and off the toilet, and moving surface-to-surface (transfer between bed and wheelchair) R26 was not steady, only able to stabilize with human assistance. The MDS further identified R26 was at risk for falls, but incorrectly identified R26 had no falls since the previous MDS assessment (11/23/16). The MDS identified R26 received daily anticoagulation (blood thinners) medication. R26's Falls Care Area Assessment (CAA) dated 1/23/17, identified R26 was at risk for falls due to a decline in condition, decreased independence in mobility and weakness. The CAA indicated R26 had not fallen, though had shown lethargy and quick sleep pattern, as R26 would fall asleep in a seated position and would lean to one side. The CAA further indicated R26 was unsteady with standing, transfers and ambulation. The CAA identified R26 was forgetful and needed reminders to call for assistance. R26's ADL CAA dated 1/23/17, identified R26 was cognitively intact, had a decline in mobility, and required physical assistance from facility staff for all ADL's including bed mobility and transfers. The CAA identified R26 was unsteady on her feet, was lethargic and slept much of the time. The CAH further indicated R26 had weakness, had periods of lethargy and was at risk for falls. R26's Urinary Incontinence CAA dated 1/23/17, identified R26 had frequent bladder incontinence, required assistance with toileting and was able to request staff assistance when needed. R26's CAA indicated R26 may have urgency due to the use of Lasix (diuretic medication.) R26's care plan revised 2/21/17, revealed R26 was at risk for falls because of a history of falls, she had poor balance, an unsteady gait and required physical assistance from staff with ADLs including transfers and mobility. R26's care plan indicated R26 needed reminders to use the call light for assistance, instruction to wear slippers or shoes and directed staff to assist with ambulation with a walker and transfer belt. R26's care plan indicated staff were not to rush R26 to prevent dizziness, and were to provide appropriate level of supervision. The care plan also indicated anti-skid material was placed under R26's mattress, and blankets were removed from under R26's mattress. R26's care plan further revealed R26 was on anticoagulant therapy and was at for bleeding. R26's most recent fall risk assessment dated [DATE], identified R26 was at high risk for falls related to incontinence, balance problems, use of an assistive device, medications and predisposing diseases. Review of R26's medical record and fall incident reports between 11/10/16, to 2/22/17, indicated the following: -11/10/16. A fax was sent to R26's physician. The fax indicated R26 had reported an unwitnessed fall in her room. R26 had injured her right wrist, the wrist had decreased range of motion (ROM) was swollen and painful. The MD returned the fax with orders for an x-ray of the right wrist. An x-ray was completed on 11/10/16, and no fracture was identified. R26's medical record lacked a fall incident report for this fall. The medical record also lacked documentation of a comprehensive analysis of identified causal factors which contributed to this fall, and no new fall prevention interventions were identified or implemented following this fall, in order to minimize the risk for further falls and/or injury. - 1/11/17, at 11:15 a.m. a fall incident report revealed R26 was found on the floor in her bathroom with her slacks below her knees. R26's slacks and incontinent brief were damp with urine, and R26 was wearing socks. R26 sustained a skin tear to her left elbow and an abrasion to her left knee. R26 was sleepy and difficult to arouse, and staff were unaware if she had hit her head during the fall. R26 was unable to voice what had happened prior to and during the fall. R26 was transported to the emergency department (ED) had x-rays and required a dressing to her skin tear. On 1/11/17, an ED report indicated R26 arrived by ambulance after she had an unwitnessed fall while walking to the bathroom, and it was unknown how long she had been on the floor. The note indicated R26 could not recall the fall, had a bump on the right side of her head, bruises to her right chest, left shoulder and a skin tear to the left elbow and forearm. The note further indicated R26 had increased lethargy in route to the ED. The report indicated R26 had received wound care, lab work and multiple x-rays and a CT scan of her head. The ED note indicated no acute infection, fractures or head injury. The ED report instructed the facility staff to provide assistance with toileting or commode to the bedside for R26. On 1/12/17, an investigation report was completed. Upon return to the facility, R26 needed assistance with toileting, had been educated to use her call light, and signs were posted in her room for reminders to use her call light. On 1/13/17, a progress note indicated R26 was able to follow directions, but appeared more confused as to the time of day and how much help she needed. On 1/22/17, a progress note indicated R22 had a steady decline; general weakness noted, sleeping more during the day, and had to be awakened twice during a meal. R26 was assisted to the toilet, and upon staff return 3-4 minutes later, R26 was dozing off. On 1/24/17, a progress note indicated R26 was assisted to the bathroom at 12:30 p.m. then was assisted back to bed. At 5:10 a.m. R26 was observed sleeping in her recliner, leaning forward with her arms dangling off the recliner and her head on her knees. R26 stated she didn't call for help because she didn't remember going into the recliner. On 1/27/17, a progress note indicated R26 fell asleep often and had increased periods of confusion. On 1/29/17, a progress note indicated R26 required assistance of one staff to the toilet, and she was never left alone in the toilet. On 1/31/17, a progress note indicated the interdisciplinary team (IDT) met to discuss fall on 1/11/17. No further information was documented. R26's medical record indicated interventions were put into place for R26's fall on 1/11/17 (assistance with toileting, reminders to use her call light), however, a comprehensive analysis of identified causal factors and analysis of prior interventions was not completed. - 2/15/17, at 1:35 a.m. A fall incident report revealed R26 had been found by staff at 1:35 a.m. lethargic, seated on her buttocks on the floor of her room. The report indicated R26 had bare feet, and had her walker in front of her. The report indicated R26 had stated she had slipped off of the chair. The report revealed R26 had a 1 centimeter (cm) by 3 cm skin tear on her right forearm and her blood sugar was 78 (low) at the time of the fall. The report further revealed socks were placed on R26's feet as an immediate intervention to prevent the occurrence from happening again. On 2/16/17, an investigative report was completed. The report indicated the facility installed/modified safety/assistive device (no specific interventions were listed). The report further indicated the results of the investigation were R26 had increased lethargy, weakness and had fallen asleep barefoot in a chair, and had lost her footing when she had gotten up. Although causal factors for R26's fall on 2/15/17, were identified as increased lethargy, weakness, and she had fallen asleep barefoot, a comprehensive assessment and a complete analysis including evaluation of current interventions in order to determine appropriateness was not completed. -2/18/17 at 7:40 a.m. a fall incident report revealed R26 had been found by staff on the floor in her room. R26 was barefoot. The report revealed R26 was unable to say for certain what had happened before and during the fall (first stating she fell out of bed, then stating she fell out of the chair). The report revealed R26 had an unmeasured large skin tear to her right hand and had a 1-2 cm of leg length discrepancy. The report further indicated R26 complained of significant pain with passive range of motion (PROM), had voiced buttocks pain, and indicated R26 had hit her head. The report did not indicate which leg had the length discrepancy. The report indicated R26 had been transferred to the ED for evaluation. On 2/18/17, an ED report indicated R26 had arrived by ambulance after she had an unwitnessed fall from a seated position. The report also indicated R26 was on a Coumadin (a blood thinning medication). The report indicated R26 had a head CAT (CT) scan and x-rays of her right wrist. The report revealed R26 had a closed head injury, a right wrist sprain and a skin tear. The report further indicated R26 was transferred back to the facility with the following order; initiate a fall assessment or prevention program if one exists at the facility. On 2/20/17, an investigation report indicated staff were to continue to remind and encourage R26 to use her call light. On 2/20/17, a progress note indicated R26 had 3 falls since 1/27/17. R26's confusion/disorientation had increased, and she was falling asleep during meals. R26 also had a change in her ADLs due to weakness, requiring assistance of one to two staff. The note further indcated R26 was disorientated as to what she needed to do to transfer safely on and off of the toilet. Although a potential causal factor for R26's fall on 2/15/17, had been identified on 2/20/17 as a dream, a comprehensive analysis including evaluation of current interventions in order to determine appropriateness was not completed. -On 2/21/17, at 7:10 a.m. a fall incident report revealed R26 was found seated on the floor of her room, near her bed. R26 stated she had slid off of the bed. There was had no injury. The report indicated a non-skid material had been placed under R26's mattress to prevent sliding. On 2/22/17, an investigative report indicated the causal factor for the fall on 2/21/17, was slippery surfaces of her bedding. The report further indicated facility staff had removed all materials from R26's bed that created a slippery surface and a safety devices was added (non-skid material.) - On 2/22/17, at 5:00 a.m. a fall incident report indicated R26 had been found face down on the floor of her room. R26 was non-responsive and was not moved by staff. The report indicated R26 was transferred to the ED by ambulance. On 2/22/17, a witness statement indicated a nursing assistant (NA) heard a loud noise, went into R26's room and found R26 face down on the floor of her room in a pool of blood. The statement indicated R26 remained on the floor with staff until the ambulance arrived. R26 was unable to state what happened. On 2/22/17, an ED report indicated R26 arrived by ambulance with head and face trauma following an unwitnessed fall at the facility. The ED note identified R26 had frequent falls, received Coumadin, and had been found face down on the floor by facility staff. The report also indicated R26 had been unable to state how the fall had occurred. The ED note further indicated R26 had been seen in the same ED on 2/18/17 for a fall. The ED note identified R26 had a closed head injury, facial laceration, multiple skin tears, frequent falls and congestive heart failure (CHF) exacerbation. The ED note revealed R26 was admitted to the hospital for hospice evaluation. On 2/23/17, R26's hospital physician note identified R26 required an x-ray of her left shoulder which revealed a hairline fracture. The note further identified R26 was unable to speak, had developed pneumonia and had progressive [DIAGNOSES REDACTED] (a broad term used to describe abnormal brain structure or function). On 2/23/17, a hospice note indicated R26 had passed away at the hospital. On 4/26/17, at 12:43 p.m. R26's medical record was reviewed with the director of nursing (DON). The DON confirmed the aforementioned falls and corresponding notes. The DON verified R26 was at a high risk for falls, and recognized R26's falls had occurred with self transfers, however R26's purpose for transferring had not been identified by facility staff. The DON confirmed R26 had an increase in urinary incontinence from November 2016, to January 2017. The DON further confirmed facility staff had not assessed R26's toileting needs in conjunction with R26's repeated falls. The DON confirmed interventions had been implemented following R26's falls on 1/11/17, and on 2/21/17. The DON confirmed no comprehensive assessments, including root cause analysis had been completed for any of R26's falls. The DON stated she had been unaware of R26's [DIAGNOSES REDACTED]. The DON confirmed facility staff had not completed a falls risk assessment for R26 since 9/6/16, and stated she expected a fall risk assessment to be completed following each fall. R39's quarterly MDS dated [DATE], identified R39 was cognitively intact, and had [DIAGNOSES REDACTED]. The MDS identified R39 was independent with ADLs including ambulation and toileting. The MDS identified R39 was frequently incontinent of urine, was not on a toileting program and was continent of bowel. The MDS further identified R39 had no falls since the last quarterly assessment, and was able to maintain her balance during transitions. R39's ADL CAA dated 7/13/16, identified R39 was alert and oriented, and was able to complete her ADLs independently. The CAA further indicated R39 ambulated independently with a cane, toileted herself and was able to change her own incontinent brief. R39's Urinary Incontinence CAA dated 7/13/16, identified R39 had occasional urinary incontinence, wore an incontinent brief, and was able to change her incontinent brief independently. R39's Falls CAA dated 7/13/16, identified R39 was at risk for falls due to use the use of Lexapro (an antidepressant medication). The CAA indicated R39 had no falls since her admission to the facility, though had complained of dizziness at times. The CAA indicated R39 had fall interventions in place such as a low box spring on her bed, grab bars in her bathroom, and she used a cane with ambulation. R39's falls risk assessment dated [DATE], indicated R26 was at risk for falls based on incontinence, use of an assistive device, medications and diagnoses. R39's care plan revised 2/8/17, indicated R39 was at risk for falls due to gait/balance problems. R39's care plan listed various interventions which included use of a cane, ensured proper footwear was in place when ambulating in the hallway and use of glasses and hearing aids. On 4/26/17, at 7:53 a.m. R39 stated she had recently returned to the facility from a short term rehab facility, after having fallen and fractured her right wrist. R39 stated prior to the fall she had been having difficulty walking due to left knee pain, and her leg had given out on her. R39 stated she had fallen about a month prior to fracturing her wrist and stated she had been ill at that time. R39 further stated she had been ill off and on for the past few months, and felt increasingly weak. R39 stated she was right handed, and it was difficult to get around as she was unable to use her cane. R39 stated she had a walker to use, however stated she preferred to use the cane. R39 further stated as of this time, she continued to be independent with her cares. Review of R39's medical record and fall incident reports between 2/24/17, and 3/18/17, indicated the following; -2/24/17, at 9:30 a.m. a fall incident report indicated R39 had been found by staff at 9:30 a.m. seated on the floor of her room, outside of the bathroom door. R39 had been incontinent of loose stool, which had been on the bathroom floor, and she had attempted to cleanse herself. R39 had no injury and R39 had been instructed to use her call light for assistance. On 2/27/17, an investigative report revealed R39's care plan had been updated, and R39 was to call for assistance if she had loose stools and needed help cleaning up. The report indicated the fall was an isolated case. On 2/21/17, a facility fax to the physician indicated R39 had a loose cough, was short of breath, had bilateral wheezes of her lung sounds and reported it was hard for her to breath. The fax indicated R39's physician diagnosed R39 with COPD exacerbation and ordered the following; Zithromax (an antibiotic) 250 milligrams (mg) by mouth daily for 5 days, Prednisone (oral steroid,) 40 mg by mouth for 5 days and directed facility staff to call with any changes or send R39 to the ED. On 2/22/17, a facility fax to the physician indicated R39 had been sent to urgent care for the aforementioned symptoms. The fax indicated R39's order for Prednisone had been changed to Prednisone 20 mg by mouth twice daily for 3 days, then 10 mg twice daily for 3 days and then 10 mg daily for 3 days, then stop. Although this incident was considered an isolated case, R39's medical record lacked documentation of a comprehensive analysis of identified causal factors, and R39's medical condition at the time of the fall. On 4/26/17, at 11:59 a.m. the DON confirmed the above fall. The DON stated she expected facility staff to complete a comprehensive assessment, which would include identifying a causal factors of the fall. She confirmed although R39's investigation had identified loose stools as a potential causal factor, the DON confirmed the report and investigation did not identify R39's acute COPD exacerbation, new medications and her overall medical condition. The DON stated she would expect R39's acute illness to have been identified as the causal factor to the fall on 2/24/17. The DON further stated she would expect facility staff to monitor R39's symptoms of illness as a potential increased risk for falls. -On 2/27/17, a facility fax to the physician indicated R39 had had been found by facility staff seated on the floor of her room. The fax indicated R39 was anxious, jittery, dizzy and was argumentative. The fax further indicated R39 would have a urinalysis and culture to check for a urinary tract infection. R39's medical record lacked a fall incident report for this fall. The medical record also lacked documentation of a comprehensive analysis of identified causal factors which contributed to this fall, and no new fall prevention interventions were identified or implemented following this fall in order to minimize the risk for further falls and/or injury. On 4/26/17, at 12:15 p.m. the DON confirmed the above fall. The DON confirmed R39's medical record lacked an initial incident and investigative report for the above fall. The DON stated she expected the facility staff to complete a fall incident report and investigative report following each fall. -On 3/17/17, at 3:30 p.m. a fall incident report indicated R39 had been found by staff seated on the floor of the hallway by the bathroom. R39 had TED stockings on. R39 had reported she had attempted to turn on her light and fell . R39 had scooted herself to the bathroom to use the call light for assistance. The report revealed R39 had a bruise to the right elbow, and her ROM was within normal limits. The report further indicated staff had removed R39's TED stockings, and educated R39 on proper footwear and to use a walker. On 3/18/17, an investigation report indicated R39 had no previous incidents of this type within the last 180 days (this was incorrect), and indicated R39 had been educated on proper footwear (don't wear TED stockings without shoes). On 3/17/17 an ED report identified R39 had arrived at the ED with her daughters, due to right wrist pain. The report indicated R39 had reported her leg had given out and she had fallen. The report further indicated R39 had significant pain, rating a 10 out of 10 on a numeric scale. The report revealed R39 had an acute non-displaced fracture of the distal right radial metaphysis (right wrist fracture.) The report further indicated R39 was at an increased risk for falls in the facility as she was unable to use her cane, therefore, R39 was admitted to the hospital. On 3/21/17, a hospital discharge report identified R39 had been hospitalized from [DATE], to 3/21/17, with [DIAGNOSES REDACTED]. The report identified R39 was transferred to a short term rehab facility for rehabilitation. Although the investigation identified improper footwear as a root cause the above fall, R39's medical record lacked documentation of a comprehensive analysis of identified causal factors, and R39's medical condition at the time of the fall. On 3/16/17, a facility fax to the physician indicated R39 had complained of increased, ongoing pain of her left knee, which R39 felt limited her walking ability. The fax indicated R39 had requested to see an orthopedic practitioner. An appointment was set up for 3/31/17. On 4/26/17, at 12:39 p.m. the DON confirmed the above fall. The DON stated she felt R39's increased in leg pain and reports of difficulty with walking should have been identified as causal factors to the above fall. The DON stated she felt R39's increase in pain would certainly impact R39's safety, and increased her risk for falls. The DON confirmed R39's medical record lacked a fall risk assessment following the aforementioned falls. The DON stated she would expect facility staff to complete a fall risk assessment after each fall and she expected a comprehensive assessment which would identify causal factors and R39's overall condition. On 4/27/17, at 8:38 a.m. trained medication assistant (TMA)-C stated R39 was independent with all of her cares, and was not aware of any illnesses or changes in R39's overall condition within the past few months. TMA-C stated she was aware R39 had a fracture, and further stated R39 might have slipped in her room, though was not sure. On 4/27/17, at 9:31 a.m. registered nurse (RN)-B stated prior to R39's falls there had been no noted changes in her medical condition. RN-B stated R39 was difficult to assess due to her multiple complaints. RN-B stated R39 was an overall reliable historian, and needed validation on her statements. RN-B stated the usual practice when a resident falls would be to look at the whole picture of what was going on with the resident, which would include any illnesses and new medications.

Based on observation, interview and document review, the facility failed to assess and appropriately supervise 2 of 2 cognitively impaired residents (R52, R26) who had an intimate relationship in the facility. Findings include: R52 and R26 had severe cognitive impairment and had an identified intimate relationship in the facility. The residents were not assessed or appropriately monitored to ensure the relationship remained consensual and safe. R52's [DIAGNOSES REDACTED]. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 1/24/13, indicated R52 had short and long term memory problems with severe cognitive impairment. Interdisciplinary (IDT) progress notes dated 1/24/13, indicated R52 was found in his room on the bed naked with a female resident (R26). IDT progress notes dated 2/11/13, indicated R52 spent most of the p.m. shift in R26's room. Staff attempted to enter the room and a chair was pushed up against the door. After three attempts staff were able to enter the room. R52 then went to supper and R26 stayed in her room and locked the door. After supper R52 became angry when he was unable to enter R26's room, and staff was unable to re-direct as R52 continued to pace in the hallways and check R26's door. On 2/13/13, R52 was kicking and pounding on R26's door. R26 eventually let R52 into her room. Staff were unable to open the door due to a chair blocking the entry to the room. A physician's visit note dated 2/21/13, indicated R52 was confused, pleasant, and a little bit sexually inappropriate. Nursing Documentation (ND) notes dated 2/28/13 and 3/23/13, indicated R52 was intimate with a resident in the facility and attempted to get into her room at night. A physician's visit note dated 3/27/13, indicated R52's psychotropic medications had been changed and the nurses reported R52's "sex drive seems to be somewhat blunted now with the BuSpar, which is good." R52's care plan did not address sexual behaviors, and the medical records lacked any type of assessment or system of monitoring safety of the intimate relationship with R26. On 4/18/13, at 11:35 a.m. the director of nursing (DON) confirmed R52's care plan did not address intimacy with a female resident (R26). The DON stated a registered nurse (RN)-B talked to R52's family and the relationship was OK with them. The DON confirmed RN-B did not document the conversation with R52's family. On 4/19/13, at 12:46 p.m. R52's representative (F)-A was interviewed and stated she was aware R52 was intimate with R26. F-A stated we're not really sure what happened when the door was closed. F-A stated when R52 was admitted R26 spotted him and came right over and hugged him. They would walk down the hall and hold hands and go into each others rooms. "No one really knows what they have done other than he has answered the door naked." F-A stated she could see why an assessment and monitoring for safety of the relationship should have been completed. R26's [DIAGNOSES REDACTED]. The Cognitive Loss/Dementia CAA dated 2/26/13, indicated R26 had short and long term memory problems with severe cognitive impairment. An IDT note dated 1/24/13, indicated R26's representative's spouse was informed regarding "affectionate behavior with male resident."(R52) The spouse agreed to allow the relationship to continue if other family members were not against it. ND notes dated 1/30/13, and 2/28/13, indicated R26 would expose herself to male workers and residents. An Incident Report dated 2/6/13, at 6:30 a.m. indicated R26 was sleeping in R52's room and was found on the floor, lying on the left side in a fetal position, with blood coming from the occipital area, on the pillow, and on the floor. R26 was lethargic and complained of pain in the right shoulder and head. 911 was called and R26 was sent to the ER. R26 had a laceration which required stitches. The Incident report lacked information regarding when R26 had previously been observed prior to the fall, what she was wearing, or a description/measurements of the laceration. The corrective action on the report was to have R26 sleep in her own room with a night light. The vulnerability care plan dated 2/20/13, indicated R26 had dementia, depression, and was at risk for falls. Interventions included "has intimate times with male resident. Residents and both families are agreeable to this relationship. Provide privacy for residents." The care plan did not indicate R26 should sleep in her own room to maintain safety. ND notes dated 4/13/13, indicated R26 wandered, was forgetful to time, place, events, and had "inappropriate behaviors with male residents." The medical records lacked any assessment and system of monitoring of the intimate relationship with R52. On 4/18/13, at 11:35 a.m. the DON stated she talked to R26's family regarding the relationship and it was OK with them. On 4/22/13, at 9:00 a.m. R26's representative (F)-B stated he was "very well aware" of R26's intimate involvement with R52. F-B stated he had an agreement with the facility regarding R26 not spending the night in R52's room after she had fallen. F-B stated he was aware R26 and R52 "hugged, kissed, etc." and he and his wife were very comfortable with geriatric sexuality. F-B stated no abuse had occurred and he had several conversations with the facility regarding the relationship between R52 and R26. R52 and R26 were randomly observed throughout the survey on 4/16/13, 4/17/13, 4/18/13, 4/19/13, and 4/22/13, and were not observed to be together. On 4/18/13, at 1:26 p.m. the DON stated she was unsure what R52 and R26 did once they were in each others rooms with the door locked. The DON stated she "heard" they (R26, R52) were found in bed naked by staff. The DON stated since the residents were observed walking down the halls holding hands she "assumed" it was consensual intimacy, but confirmed no assessment or investigation had been completed. The DON further stated after R26's fall in R52's room an agreement was made with R26's representative that she would sleep in her own room. On 4/18/13, at 2:30 p.m. the licensed social worker (LSW) stated she had not actually seen R52 and R26 naked together but heard it "through word of mouth." LSW stated she had seen them walking down the hall together holding hands. LSW further stated R26 and R52 were together more for the first month or two after he was admitted to the facility (1/14/13). LSW confirmed the relationship between the two residents had not been assessed so monitoring interventions had not been developed. On 4/22/13, at 8:45 a.m. licensed practical nurse (LPN)-C stated she had seen R52 and R26 in the halls holding hands, hugging, and occasionally in each others rooms fully clothed watching television. On 4/22/13, at 9:05 a.m. nursing assistant (NA)-C stated he had only seen R26 and R52 hold hands, hug, and kiss on occasion in the halls and had not seen them in the rooms. On 4/22/13, at 9:10 a.m. the health information coordinator (HIC) stated she had only seen R26 and R52 occasionally hug and hold hands in the hallway.

Based on observation, interview, and document review, the facility failed to provide assessment and appropriate interventions to prevent elopement off the facility campus for 1 of 3 residents (R52). The potential risk of serious harm or injury was determined to place R52 in immediate jeopardy. In addition, the facility failed to ensure a safe environment related to independent use of the stairway for 1 of 1 resident (R10) reviewed at risk for falls. The immediate jeopardy (IJ) began on 6/8/13 at 10:00 a.m. as a result of the facility failing to assess, monitor, and provide interventions to ensure R52 was safe to reside in the facility. The administrator and director of nursing (DON) were informed of the immediate jeopardy with a scope and severity of J (isolated) level at 6/11/13 at 3:04 p.m. The facility initiated an IJ removal plan which included providing one on one, 24 hour, supervision for R52 until a discharge from facility was arranged; reassessment of all residents with the potential for elopement from the facility; and providing education to all staff regarding reporting all resident elopements to ensure tracking, assessment, monitoring and interventions can be implemented. Direct care staff, licensed nurses, dietary staff and, activity staff were interviewed to determine awareness of their responsibility reporting resident elopement and monitoring residents at risk of elopement. The DON and administrator were notified the IJ was removed at 6/13/13 at 12:03 p.m. The scope and severity was reduced to a D level, no actual harm with a potential for no more than minimal harm, isolated. Findings include: R52 had multiple incidents of elopement off the facility campus, which was located on a very busy roadway. Facility staff were aware of R52's daily exit attempts; however, there were no interventions to reduce the risk of elopement. R52 had [DIAGNOSES REDACTED]. The quarterly minimum data set ((MDS) dated [DATE], identified severe cognitive impairment, independent ambulation and indicated no presence of wandering. The current plan of care dated 6/1/13, indicated R52 "wanders. Exits facility looking for his car." The interventions included reminders; escort to meals in dining room and to planned activities; maintain intact code alert bracelet (wander guard) for elopement; approach calmly and redirect to a safe area; and offer alternative activities. On 6/11/13, at 9:25 a.m., R52 was observed on the second floor entering the elevator without an escort and going down to first floor. At 9:35 a.m. R52 was sitting alone, reading the paper in the first floor activity room. R52 had a wander guard bracelet under the sock on the right ankle. At 12:34 p.m. R52 was observed on second floor, wandering through the hallways, opening any unlocked doors. At 2:21 p.m. R52 was wandering without an escort on first floor. R52 walked out the front door and the wander guard alarm system alarmed. The indicator screen for the alarm system was next to the elevator on first floor and indicated R52 had exited out the front door. The DON and the health information manager (HIM)-D followed R52 outside and convinced R52 to come back into the building at 2:27 p.m. The medical record included Interdisciplinary notes as follows: -3/11/13, at 9:15 p.m., "Elopement x2 after supper; difficult to redirect from door ... " There was no further investigation or documentation. -3/15/13 at 8:45 p.m., "...Attempted to exit building x4 less than 2 minutes after supper. Ativan (antianxiety medication) given at 7 p.m. Redirection unsuccessful... " -4/19/13- ... " At times resident needs strong encouragement to not exit seek to find his car. " -5/11/13, at 9:30 a.m., "Resident out front door crossed College Street and into neighboring houses. Stopped at snow bank resistive to male staff. Assist of female to bring back to building. Secure band to right ankle." The documentation did not include investigation of R52's activities and whereabouts prior to exiting the building or how long before staff were able to bring him back. The record included a note dated 5/14/13, indicating, "Addendum to 5/11/13 9:30 a.m. elopement. Kitchen staff member responded to front door alarm and caught up with resident in the front parking area. Staff member was unable to redirect resident and accompanied him across the street and into neighbor's yard, securing his safety. Other staff members intervened and escorted resident back to facility." There is no further investigation or notes regarding this. -5/28/13, at 12:30 p.m., "Writer redirected resident who exit out front door- writer was about 8-10 feet behind him and caught up with him and was able to convince him to come back in; he was just outside door." There was no documented investigation regarding the behavior. -6/6/13, at 9:00 p.m. indicated, "Resident up per usual exit seeking x3 today. Easily redirected back to building ... " There was no further investigation or documentation regarding the exit seeking behavior. -6/8/13, at 10:00 a.m. "Out front door down front side walk across college street to fire station assist of 2 staff to return resident. Looking for his car, staff assisted resident back to building." On 6/8/13, at 3:30 p.m., nursing notes indicated, "Resident out front door across 19th Ave. East then crossed college street down past fire dept through campus of UMD looking for his Triumph motorcycle." The incident report dated 6/8/13, at 10:15 a.m. and 3:00 p.m., indicated, "Secure band responded X2 to door alarm system. 2 staff members working with residents. Kitchen staff assisted to bring resident home." There was no further information provided. During interview on 6/12/13, at 9:10 a.m. LPN-B verified she was the nurse working on 6/8/13 when R52 eloped from the building. She stated by the time she got down to the first floor (she was on 3rd floor) to respond to the alarm R52 was already across the street. She stated she did not document every time R52 attempted to leave the building if he can be redirected and did not get past the parking lot. LPN-B stated R52 had been attempting to leave more often in the last several months. LPN-B stated R52 had been leaving the facility about 2-3 times a day on the day shift. The social worker (SW)-A, interviewed on 6/11/13, at 9:35 a.m., stated R52 had been exit seeking since admission in 1/2013. R52 had more exit attempts within the last few months. SW-A stated there was no elopement assessment and no further investigation of the identified elopements. R52 was at very high safety risk as they did not know how far R52 would go and he had no safety awareness related to severe cognitive impairment. Facility staff had identified the fact that R52 was not safe to be residing in the facility; however, there was no safety assessment of the environment with the facility located near a very busy 4 way highway and next to University traffic. During interview on 6/11/13, at 2:15 p.m. cook (C)-A stated R52 sets off the alarms on the door, "about 4 times a day." C-A stated there were about 13 different exit doors and R52 uses all of them. C-A stated she was working on 6/8/13, when R52 went across the street twice. R52 "moves so fast" he was already across the street by the time staff was able to respond to the door alarm. During the interview the door alarm sounded, indicating a resident with a wander guard had exited the building. C-A looked at the wander guard alert screen and verified R52 had exited the front door. C-A stated R52's elopement attempt had increased since around April. C-A had talked to nursing staff about R52 not being safe in the facility. C-A stated she was not told to report every time she responds to an alarm to bring R52 back into the building. She stated she "usually" just brings R52 back in the building and shuts off the alarm because it happens on such a regular basis. Licensed Practical Nurse (LPN)-A, interviewed at 6/11/13, at 2:30 p.m. stated R52 goes outside to the parking lot a "couple times a week," and the staff just redirect him back inside. She stated staff doesn't chart or report every time R52 exits the building if he is just in the parking lot and is able to be redirected into the building. During interview on 6/11/13 at 2:35 p.m. nursing assistant (NA)-A stated she was not aware R52 was trying to leave the building at all and there was no special monitoring they needed to do with R52. NA-A stated she had worked at the facility for a year. NA-A verified all staff was supposed to respond to any door alarms which are set off by resident wander guards. During interview on 6/11/13 at 3:00 p.m. DON stated R52's elopement attempts has increased in the last several months. She stated that facility administration spoke with R52's family regarding safety and suggested a more secure facility. The family did not want R52 moved to a different facility so it was not pursued. DON verified that complete investigations were not documented regarding R52's elopements and there was no way to determine how often and how far R52 had been away from the facility. The administrator was interviewed on 6/11/13, at 3:00 p.m., and stated the print out alarm history for the wander guard system hadn't worked for several months and there was no documentation of resident exits. The administrator stated R52 was not safe to be in the facility and a discharge notice would be sent to the family. Meetings had been attempted with R52's family to discuss safety and the need for a more secure environment; however, the family did not want to move so it was not pursued further. At 3:57 p.m. the administrator stated that 24 hour one to one supervision would be provided for R52 until discharge from the facility. During observation during the remainder of the survey from 6/11/13 to 6/13/13, R52 had one on one staff with him at all times. During interviews on 6/13/13 from 11:30-11:50 a.m., the office manager (OM)-C, maintenance worker (M)-A, activity director (AD)-A, housekeeping (H)-A, health information manager (HIM)-D, registered nurse (RN)-A, NA-B, NA-C, LPN-A, and LPN-B verified they were provided verbal training on reporting to the nurse all resident elopements from the facility. The facility provided a policy titled, "Elopement" dated 10/12 which indicated the following: The purpose was "To assess and identify residents at risk for elopement. To clearly define the mechanisms and procedures for monitoring and managing residents at risk for elopement. These include identifying environmental hazards and individual resident risk, including need for supervision ... " "Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so." "Residents who attempt elopement after admission: Residents who were assessed to not be at risk for elopement during the pre-admission process, but begin to exhibit wandering behaviors or attempt to elope during their stay in the center will be assessed and monitored in the following ways: Residents physician and legal representative will be notified of any significant changes in the resident status and such notification will be documented in the interdisciplinary progress notes... track wandering behavior/ elopement attempts... staff may make a note using either the Interdisciplinary progress notes or the physician communication progress note..." R10 was using an open stairway to access other facility locations without having been assessed for safety. R10 had [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], indicated R10 had severe cognitive impairment, had no wandering behaviors, and was independent in walking. The current plan of care dated 6/1/13, indicated R10 had walked down stairs without a walker. The interventions included, "Bands will be kept across stairway." During observation on 6/12/13 at 12:03 p.m. R10 was coming off the elevator with a staff person onto the second floor walking with her walker. R10 was bent over her walker and shuffling her feet. On 6/12/13, at 1:32 p.m. R10 was observed wandering around second floor alone and asking, "What do I do? I need to go home." The open cement stairway, leading to both 1st and 3rd floors, was 2 doors down from R10's room. There were 2 bands about 2 inch's thick going across the stairway; one band was about 2 feet off the ground and the other was about 4 feet off the ground. The second open cement stairway on second floor was down the opposite hallway from R10's room and also had 2 bands about 2 inch's thick across the stairway. One of the bands was about 3 feet off the ground, and the other was about 5 feet off the ground. Review of R10's facility Interdisciplinary Notes (IDT) revealed the following: SW-A's interdisciplinary notes on 10/30/12, (time not documented) indicated, ..."Asked to contact family, Reason: Residents safety since she again went down the stairs. Daughter was contacted again on 10/29/12 and again she stated she did not want her mother to move but agreed to meet... daughters stated they of course don't want resident to fall and get hurt but do not want her to leave or move from this facility...daughter stated the bands are not always in place and stated 'I've taken pictures of them being down.' Writer offer to assist with finding openings and daughters refused. Daughters offered to change their visiting time to be here later afternoon to hopefully reduce resident agitation and desire to leave..." Notes on 11/13/12 indicated, "Heard alarms sound. Looked and noted resident had gone out emergency exit in living room and went up stairs with walker. Staff found resident at top of stairwell." On 12/7/13, the nursing note indicated, "Resident was found by another resident trying to take her clothes down stairs...writer told the resident that she could use the elevator whenever she needed to go down stairs. Writer noticed that only one of the safety tape was up (the top one). Resident was sitting on the top stair with clothing basket next to her." Notes on 3/7/13, at 6:05 p.m., indicated, "...HIM (health information manager) came in and said resident (R10) just walked down the stairs by the break room. Walker in room and bands are up in place. On 3/17/13, at 8p, the note indicated "Resident walked down stairs by break room. Was found by writer when writer opened door. Did not have walker with her. Resident un-did the bands on stairway." The note on 5/27/13, at 10:30 a.m., - "Found on stairway by NA carrying 3 sweaters, purse, and a glass jar of candy, stated she is going home." LPN-B, interviewed on 6/12/13 at 10:35 a.m., stated, R10 "constantly" tries to go up and down the stairway. She stated she had spoken to the DON, social worker, and RN's about this, but R10 continued to use the stairway. LPN-B stated she does not feel R10 is safe to use the stairs as she is unsteady, but R10 has not fallen on the stairs. LPN-B also stated the bands across the stairway do not keep R10 from using the stairs as she climbs underneath the bands to go down the stairs. LPN-B stated she had seen R10 climb under the bands, leave her walker at the top of the stairs, and walk down the stairs going sideways. LPN-B stated they don't always chart when R10 attempts to use the stairway. During interview on 6/12/13, at 11:30 a.m. NA-B stated she had never actually seen R10 use the stairway. NA-B stated R10 had walked towards the stairs before but she always intervened to stop her. During interview on 6/12/13, at 11:40 a.m. NA-A stated R10 is always trying to go up and down the open stairways. She stated the bands across the stairway do not prevent R10 from using the stairs as she just goes under the bands. NA-A stated R10 goes up and down the stairs "at least twice a week" that she is aware of, and she stated she reports it to nursing every time it happens. NA-A stated she did not feel R10 was safe to be using the stairs. During interview on 6/12/13 at 12:15 p.m. SW-A stated the facility had spoken to the family in the past regarding their concern with R10 using the stairway and the family had agreed to visit the resident more often to distract her. SW-A stated she only knew of two incidents since October 2012 when R10 had used the stairway. SW-A was not aware of the incidents that were documented in the progress notes. SW-A stated R10 was not safe using the stairway and going under the bands across the stairway could put her at even greater risk of injury. The DON., interviewed on 6/12/13, at 12:30 p.m. stated the facility had spoken to the family regarding the resident not being safe to be at the facility related to use of the stairway, but the family did not want to move the resident to another facility. DON was not aware R10 was using the stairways as much as staff reported during interview. DON verified there was no assessment regarding R10's safety to use the stairway, nor were there any other interventions put into place to ensure R10 did not use the stairway or go under the bands. The DON verified R10 was not safe to be using the stairway. During interview on 6/12/13, at 1:50 p.m. LPN-A stated she had observed R10 going down the stairway before walking sideways and at times will drag her walker with her and carry a bag of her belongings. LPN-A stated the bands across the stairway were there before R10 was admitted but signs were added to direct, "Please use elevator."

Based on observation, interview and document review, the facility did not provide adequate pain management for 2 of 3 residents (R20, R17) reviewed for pain. R20 sustained actual harm with significant acute pain from a fractured left foot that was not identified or treated. In addition, the facility did notify the physician related to an identified change in mental status for 1 of 1 residents (R17) reviewed. Findings include: R20 had significant left foot/ankle pain, swelling and bruising after a fall on 4/14/13. R20 sustained actual harm with untreated pain rated at 7 of 10 (Zero represents no pain at all while 10 represents the worst imaginable pain). An incident report dated 4/14/13, indicated R20 had been found on the floor in his room, and that R20 had stated he'd twisted his left foot when he fell . The report indicated there had been no visible swelling at the time of the fall. R20's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R20 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, and that R20 was independent with ambulation. A nursing progress note from 4/15/13, at 2:00 p.m. indicated R20 was given two Tylenol and had a bruise across the top of his left foot. The progress note did not address pain or the extent of the bruising. No pain management plan or follow up was suggested. The physician was not notified of R20's bruising related to twisting the foot with a fall the previous day. R20 was interviewed about unrelieved pain on 4/17/13, at 9:37 a.m. and stated, "This foot thing has been the main business." At that time, R20 was observed to lean on furniture and walk with a noticeable limp in his room. R20 described his fall while rubbing his knee and lower leg indicating the left foot and toes were very sore, swollen and "dark." On 4/17/13, at 2:00 p.m. R20 was interviewed again. R20 described the pain as, "Pretty bad when I walk on it - almost can't walk on the darn thing." He further stated that he relied on the walker to take some of the weight off his foot. During interview with R20 on 4/18/13, at 10:30 a.m., R20 stated he walked on his foot but, "It hurts like the dickens when I'm up." R20 verified he ambulated independently with the walker and did not utilize a wheelchair. When asked to rate his pain, R20 rated his pain at a 7 out of 10 in his left foot when ambulating, and stated the pain stopped when he stopped walking. Utilizing the same scale, R20 rated his pain at a 4 when at rest. R20 stated the foot pain kept him awake at night because he gets it tangled up in the sheets and said, "Then it hurts quite a bit." R20 stated he gets up to the toilet in the night and it hurts to walk into the bathroom. When asked if he had told facility staff about his foot pain, R20 stated they (staff) were checking on it all the time, that they knew about the fall and, "They didn't seem too concerned about it when they looked at it, so I guess it's fine then." R20 stated staff had not asked him about pain. R20 indicated they gave him medicine for it once but he didn't want to "bother" the staff about it. R20 stated, "I just go slower than I use to." R20 denied being offered any pain relief measures such as medications, ice, heat or temporary use of a w/c for trips to and from the dining room. R20's room was approximately 200 feet from his dining room table and he continued to ambulate independently with his walker to and from all meals and activities. On 4/18/13, at 10:50 a.m. the nursing assistant (NA)-D stated that R20 had not complained of pain. NA-D stated R20 had shown her the bruising on his foot when he was in the tub. NA-D stated R20 had said he was walking slower than normal, "but that was about it." On 4/18/13, at 11:00 a.m. the licensed practical nurse (LPN)-C stated she gave R20 as needed (PRN) Tylenol for complaints of foot pain in the morning. She said she, "thought he tripped on his foot or something a few days ago. I'm not sure; I wasn't here but he was having foot pain." LPN-C reviewed the MAR and verified she was the only staff member who had provided R20 pain medication since 4/14/13. "Nope looks like I'm the only one who has given him anything for pain this month." Registered nurse (RN)-B was interviewed on 4/18/13, at 12:00 p.m. RN-B stated he was unaware of R20's recent fall or the foot pain/swelling/bruising. At 2:30 p.m. on 4/18/13, RN-B acknowledged there was bruising and swelling in R20's left foot and indicated that current pain management was adequate. The nurse practitioner ordered an x-ray. RN-B stated, "Being as you're here, we'll go the extra mile and notify the doctor. It could have waited until rounds were done." When asked specifically about R20's pain, RN-B stated, "He (R20) rated the pain a 7 out of 10 when he's up on it and a 4 when he's at rest." and, "With any injury you're going to have pain. When he's at rest he has relief. The reality is the doc (doctor) was going to round next Tuesday or Thursday and it could have waited as well. But since you're here we'll go the extra mile." The X-ray report dated 4/19/13, indicated, "a minimally displaced fracture extending to the articular surface medially. [MEDICATION NAME] aspect of the 5th proximal phalanx is also suggested. Impression: Probable 4th and 5th proximal phalangeal fractures." The report included a recommendation for an orthopedic evaluation; however, P20 declined further treatment other than pain management. When interviewed on 4/18/13, at 3:15 p.m. the director of nursing (DON) stated the incident report had not been reviewed by the interdisciplinary team. "It should have been done. If it would have been brought to our attention that he was having pain we would have gone up and looked at it. Everybody's bruise, everybody's fall gets followed up that second time so it doesn't get missed, That's the last thing I want is for something like this to get missed. They should have followed up on this fall." The facility pain management policy dated as last revised in 1/09 and provided by the facility as current indicated, "The registered nurse will assess current pain levels and develop with the physician and interdisciplinary team, interventions which may be non-pharmacological as well as pharmacological". The facility non-pharmacological pain intervention policy dated as revised 2/05 and provided by the facility as current identified, "Pain can destroy the quality of life, erode the will to live, impair sleep and decrease appetite while also impeding recovery." R17 was not assessed or treated for [REDACTED]. The most recent pain review dated 1/27/13, identified the pain medications R17 takes routinely and no PRN med use. Identifies highest pain level as a "4". Pain reviews on 10/25/12 and 7/25/12 also identified scheduled pain medications. There was no description of R17's pain, no mention of a pain management program, and no assessment of the effectiveness of the pain management program. The care plan provided by the facility as current, dated 1/30/13, indicated R17 was alert and oriented and had pain related to DJD. The goal was to have R17 express satisfactory pain management. When observed on 4/17/13, at 9:30 a.m., R17 was wheeling herself down the hall using her feet but not her hands/arms. R17 was interviewed on 4/22/13, at 9:10 a.m. and stated her pain was all in her shoulders down into her arms and hands. R17 was rubbing her arms and attempted to lift her arms to display the range of motion in her shoulders. She displayed very limited range of motion in both shoulders while grimacing. "I can't write any more. If I do too much it hurts like heck." R17 was asked to rate her current level of pain on a scale of 0 - 10 and stated the pain was a 5 or 6 "right now". When she gets the extra medicine the pain is "ok". R17 went on to describe her pain as "hurting bad" this morning. "It was about a 10 - it's been that way for awhile now." R17 indicated when she wakes up in the morning her pain is "terrible" and it takes awhile for her to get moving. She went on to say that "One of the nurses" gives her "a couple of pills with her pain pill in the morning and with lunch." R17 stated she only gets the extra medicine when that nurse works, when other nurses work she doesn't get the additional medication and she has more pain. "It's been this way for a long time. Some days are terrible, honey, when I don't get my pills but what can I expect, I'm old. It's been a bad year." R17 indicated the pain kept her awake at night but she gets up to use the bathroom anyway. R17 indicated she would like her pain level to be at 0, "but I know at my age that's just not going to be. I have to live with it that's just the way it's going to be, honey, some days are better than others." LPN-C was interviewed on 4/22/13, at 9:30 a.m. and stated stated R17 had arthritis pain in her upper shoulders on a daily basis. LPN-C went on to state that R17 "does better when she takes Tylenol with the [MEDICATION NAME]." When asked to describe what she meant by that as it was not on the medication administration record (MAR) or physician order [REDACTED]. "She gets [MEDICATION NAME] and Tylenol - she does better when she takes Tylenol with the [MEDICATION NAME] - I'm giving her the PRN Tylenol with the [MEDICATION NAME] at 8:00 a.m. and noon and she does better then." When asked where this is documented, LPN-C stated, "I'm just not documenting it - that's all I can say." When asked when this practice began, LPN C stated she's been giving the noon and 8:00 a.m. doses of Tylenol "forever." LPN C stated she hadn't really asked R17 about her pain after taking Tylenol, "She hasn't really said how bad her pain is, I never really asked a number I guess. I know it's there. She does have relief from the Tylenol. I never put a number on it." LPN-C also stated R17 tries to be very stoic with her pain and believes she has to live with a certain amount of pain. "I tell her she doesn't have to live like that." LPN-C indicated they tried [MEDICATION NAME] "a couple of years ago" to manage R17's pain but she didn't like it due to side effects. They haven't really tried to revise her pain management program since then. RN-B was interviewed on 4/22/13, at 11:00 a.m. and indicated he was unaware of R17's increased pain and need for ongoing use of PRN Tylenol. He was not aware she was receiving routine PRN Tylenol. He indicated he would look into R17's pain and address her medication needs. The DON, interviewed on 4/22/13, at 10:00 a.m., stated she was unaware of R17's pain and verified the lack of documented PRN pain medication. The DON stated that the facility process was to obtain a physician's orders [REDACTED]. The DON verified the last pain review documented was from 1/13.