Every finding on record at Exira Care Center

Based on observations, resident interviews, family interviews, staff interviews, and policy review, the facility failed to respond to resident call lights within 15 minutes for 4 of 4 residents (#1, #2, #5, #6). The facility also assigned an uncertified nursing aide to direct resident care alone, used agency staff to orientate a newly hired Certified Nurse Aide, and failed to respond timely to a request for assistance in a locked memory-care unit. The facility reported a census of 35 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 01 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, anxiety, and hospice. It indicated she was independent with eating, required setup assistance with oral hygiene, supervision with bed repositioning and personal hygiene, was dependent with lower body dressing and footwear, and required moderate assistance with all other Activities of Daily Living (ADLs) and forms of mobility.An undated Care Plan indicated the resident had impaired cognitive function/dementia or impaired thought processes related to dementia and directed staff to monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. The care plan also documented a risk for falls and an ADL self-care performance deficit related to dementia. A document titled Location Event Report dated 4/05/26 - 5/05/26 revealed 34 of Resident #1's call light requests were answered more than 15 minutes after initiated. Eleven (11) of the response times were greater than 20 minutes with six (6) of those exceeding 30 minutes.On 5/03/26 at 1:15 PM, the resident's relative stated the resident's call light has been on for 23-24 minutes before staff have responded.2. Resident #2's MDS dated [DATE] identified a BIMS score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of cancer, heart failure, and a left leg fracture. It indicated she was independent with eating and oral hygiene, required setup assistance with upper body dressing and personal hygiene, required maximal assistance with all other ADLs and was dependent with all forms of mobility.An undated Care Plan indicated the resident had an ADL self-care performance deficit related to fractures and required one staff assistance with toileting.A document titled Location Event Report dated 4/05/26 - 5/05/26 revealed 23 of Resident #2's call light requests were answered more than 15 minutes after initiated. Twelve (12) of the response times were greater than 20 minutes with three (3) of those exceeding 30 minutes.On 5/03/26 at 2:35 PM, the resident's relative stated staff frequently come turn the call lights off, leave, and not return.3. Resident #5's MDS assessment dated [DATE] identified a BIMS score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of high blood pressure, diabetes mellitus, seizure disorder, and asthma. It revealed he required moderate assistance with bathing and was independent in all other ADLs and repositioning and transfer mobility. It further revealed he used a walker or wheelchair as a mobility device.An undated Care Plan indicated the resident has an ADL self-care performance deficit related to activity intolerance, fatigue, musculoskeletal impairment and directed staff to encourage the resident to use bell to call for assistance.A document titled Location Event Report dated 4/05/26 - 5/05/26 revealed seven (7) of Resident #5's call light requests were answered more than 15 minutes after initiated. Three (3) of the response times were greater than 20 minutes with one (1) of those at 30 minutes.On 5/03/26, Resident #5 stated staff don't always come when he pulls the call light.4. Resident #6's MDS assessment dated [DATE] identified a BIMS score of 00 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia and arthritis. It revealed he required supervision with eating, moderate assistance with oral and personal hygiene, maximal assistance with upper body dressing, and was dependent with all other ADLs and mobility.An undated Care Plan indicated the resident was at risk of acute on chronic pain secondary to risk of diabetes mellitus and immobility. It directed staff to monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician.A document titled Location Event Report dated 4/05/26 - 5/05/26 revealed four (4) of Resident #2's call light requests were answered more than 15 minutes after initiated. Four (4) of the response times were greater than 20 minutes with two (2) of those exceeding 30 minutes.A document titled Staffing Sheet dated 5/03/26 Sunday revealed Staff A, Training Nursing Aide (TNA - uncertified nurse aide) was assigned for direct resident care along on a resident hall. Another Staffing Sheet dated 4/26/26 revealed Staff A, TNA, Staff K, Certified Nurse Aide (CNA), and an agency CNA were scheduled for resident care. Staff A, TNA was assigned a resident hall alone, the agency CNA was assigned to one of the other resident halls, and Staff K, CNA was assigned to work in the separated Memory Care Unit (MCU). There was no documented assigned staff for the 3rd resident hall. On 5/03/26 at 11:00 AM, Staff I, Licensed Practical Nurse (LPN) confirmed the current shift assignment and stated the Director of Nursing (DON) was coming to work at 2:00 PM due to a staffing shortage. She confirmed residents have complained to her about delayed call light response times.A document titled Nurse Schedule May 2026 revealed the DON was scheduled to work at 2:00 PM on 5/03/26.At 11:10 AM, Staff J, LPN stated residents have complained to her about delayed call light response times.On 5/03/26 at 3:38 PM, the Social Services Coordinator/ (CNA) stated she helps feed breakfast five (5) times per week to the residents who require eating assistance and stated she believes other CNAs are giving baths and/or getting other residents up during that time. She also stated she helps residents go to the restroom with assistance and helps with CNA duties when CNAs aren't available. She further stated she checks Resident #2's leg immobilizer 1-2 times per day and readjusts it if needed.During a continuous observation on 5/04/26 that began at 12:12 PM, Staff K, CNA used a walkie-talkie to request a nurse right away to the MCU three (3) times. When she did not receive a response, she used the telephone in the MCU nurses' station to call the Long-Term Care (LTC) nurses' station telephone. When no one answered the telephone, she attempted to call the CNAs documentation room twice; the first attempt did not connect. On the second attempt, Staff M, CNA answered the telephone at 12:18 PM.On 5/04/26 at 12:18 PM, the DON stated she entered the MCU right after the surveyor left at 12:18 PM.On 5/04/26 at 3:40 PM, the DON stated the TNA should not have been assigned to a resident hall by herself on 5/03/26.On 5/04/26 at 5:32 PM, Staff L, CNA stated she has worked in the Memory Care Unit (locked unit) since [DATE] and requested staff assistance for a resident fall. She stated it took staff approximately 5 minutes to respond to the MCU.On 5/05/26 at 1:53 PM, Staff I, LPN stated she assigned Staff A to a resident hall by herself on 5/03/26 because the shift had a staffing shortage.A document titled Nurse Schedule April 2026 indicated Staff D, CNA was scheduled in orientation on 4/26/26.A document titled Facility Assessment dated 5/01/26 revealed the facility staffing was based on census and acuity of the resident population. It indicated the facility would staff 3-5 CNAs per day shift; 3-5 per afternoon shift; 2-3 per night shift during the week and weekends.On 5/05/26 at 3:25 PM, the Assistant Director of Nursing (ADON) confirmed Staff D worked on 4/26/26 based on her timecard entries and stated Staff D was in orientation with the agency CNA. She further stated she understood the staffing concern with the assignment because of the CNA orientation with an agency CNA and a TNA assigned to a hall alone.On 5/05/26 at 3:35 PM, the DON stated she felt the facility didn't have sufficient staffing based on the limitations of TNAs.A policy titled CCDI Unit Policies and Procedures dated 11/01/24 indicated there shall be at least one member of the nursing staff on the unit at all times. Other staffing will be provided according to the needs of the residents on the unit at a given time.An undated policy titled Call Lights: Accessibility and Timely Response indicated all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.On 5/07/26 at 10:33 PM, the DON stated staff should respond to call lights within 15 minutes. She also stated TNAs should be assigned to certified staff members. She further stated staff should respond to MCU staff assistance requests immediately.

Based on observations, clinical record review, staff interview, and policy review, the facility failed to maintain dignity for 2 of 3 residents (#6, #7) by leaving a resident's blood-stained sheets on his bed for 4 1/2 hours (#6) and by reaching across the front of a resident's face to pick up a clothing protector off the table (#7). The facility reported a census of 35 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia and arthritis. It revealed he required supervision with eating, moderate assistance with oral and personal hygiene, maximal assistance with upper body dressing, and was dependent with all other ADLs and mobility.An undated Care Plan indicated the resident had an ADL self-care deficit related to dementia and was at risk for infection related to a suprapubic catheter (urinary catheter surgically placed directly into the bladder).On 5/03/26 at 10:20 AM, Resident #6's bed had dried, red stains on the bottom half of his sheets. Resident #6 was observed sitting in his room in his wheelchair.On 5/03/26 at 12:31 PM, the red-stained sheets were still on Resident #6's bed.On 5/03/26 at 3:00 PM, staff were heard in his room with the door shut.On 5/03/26 at 3:10 PM, the bed sheets did not have a dried, red stain.2. Resident #7's MDS assessment dated [DATE] identified a BIMS score could not be obtained due to the resident being rarely or never understood. It included diagnoses of a stroke without residual deficits, one-sided severe weakness, and bilateral hearing loss. It revealed she was dependent with all ADLs and mobility.An undated Care Plan directed staff to work with nursing staff to provide maximum comfort for the resident.During a dining observation on 5/03/26 at 11:28 AM, Staff F, Certified Nurse Aide (CNA) reached directly in front of Resident #7's face, from the left side to the right side of the table, grabbed a clothing protector, placed it on the resident, then walked around the resident and sat down to the right of the resident and assisted her with eating.On 5/04/26 at 4:31 PM, Staff G, CNA stated reaching across someone's face to access a [NAME] when it was accessible from the other side would be offensive, embarrassing, and a dignity concern.On 5/04/26 at 4:35 PM, Staff E, CNA stated reaching across someone's face to access an item would be offensive, embarrassing, and not respectful. She confirmed disrespect is a dignity concern.A policy titled Promoting/Maintaining Resident Dignity During Mealtimes indicated all staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes.On 5/07/26 at 10:33 AM, the Director of Nursing (DON) stated the residents' dignity should always be maintained.

Based on observations, staff interviews, and policy review, the facility failed to perform hand hygiene while assisting with meals for 2 of 3 residents (#3, #6) who were dependent with eating. The facility reported a census of 35 residents.Findings include:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease and non-Alzheimer's dementia. It revealed she required moderate assistance with eating and was dependent with all other Activities of Daily Living (ADLs) and all forms of mobility.An undated Care Plan indicated the resident had a self-care deficit related to Alzheimer's disease and directed staff to attempt to participate and provide assistance with eating.2. Resident #6's MDS assessment dated [DATE] identified a BIMS score of 00 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia and arthritis. It revealed he required supervision with eating, moderate assistance with oral and personal hygiene, maximal assistance with upper body dressing, and was dependent with all other ADLs and mobility.An undated Care Plan indicated the resident had an ADL self-care deficit related to dementia and indicated the resident was able to feed himself. It directed staff to encourage the resident to participate to the fullest extent possible with each interaction.During a continuous dining observation on 5/03/26 at 11:25 AM, Staff A, Training Nursing Aide (TNA - uncertified nurse aide) assisted Resident #6 with eating. After she spooned some of his food into his mouth, she wheeled her stool over to Resident #3, spooned food into Resident #3's mouth, then wheeled back over to Resident #6, and spooned food into his mouth. She did not sanitize her hands between touching each residents' utensils.At 11:38 AM, Staff B, Certified Nurse Aide (CNA) got up from the dining table, walked to the sink and washed her hands, then walked back over to Resident #3 who was holding the spoon Staff A used after touching Resident #6's utensils to feed him.A policy titled Hand Hygiene accessed May 2025 indicated all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. It directed staff to perform hand hygiene between resident contacts.On 5/07/26 at 10:33 AM, the Director of Nursing (DON) stated staff should've performed hand sanitization between residents and should followed the hand hygiene policy.

Based on observations, clinic record review, resident and staff interviews, and policy review, the facility failed to maintain competent staff by allowing a Training Nurse Aide (TNA - uncertified nurse aide) to incorrectly transfer two (2) residents (#3, #4), incorrectly apply a leg immobilizer on a resident with a broken leg (#2), and assign a Certified Nurse Aide (CNA) without evidence of dementia training to provide care for dementia residents. The facility reported a census of 35 residents. Findings include: 1. Resident #2's MDS dated [DATE] identified a BIMS score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of cancer, heart failure, and a left leg fracture. It indicated she was independent with eating and oral hygiene, required setup assistance with upper body dressing and personal hygiene, required maximal assistance with all other ADLs and was dependent with all forms of mobility.An undated Care Plan indicated the resident had an ADL self-care performance deficit related to fractures and was non-weight bearing.2. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease and non-Alzheimer's dementia. It revealed she required moderate assistance with eating and was dependent with all other Activities of Daily Living (ADLs) and all forms of mobility.The Care Plan dated 10/15/25 indicated the resident was a fall risk related to chronic confusion and directed staff to use 2-person assistance or a mechanical standing lift for transfers as needed to promote safety.3. Resident #4's MDS assessment dated [DATE] identified a BIMS score of 01 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, fibromyalgia (chronic disorder with musculoskeletal pain, fatigue, and cognitive difficulties), and macular degeneration (blurry or lost central vision). It revealed she was independent with bed repositioning, sit-to-lying, and lying-to-sitting, required setup assistance with eating, moderate assistance with lower body dressing and bathing, and supervision with all other ADLs and mobility. It also indicated she used a wheelchair for mobility in the 7-day look-back period.An undated Care Plan revealed the resident was a risk for falls related to assistive devices for ambulation, chronic confusion, and poor safety awareness and directed staff to use 1-person assistance with transfers.On 5/03/26 at 11:53 AM, Staff A, Training Nurse Aide (TNA - uncertified nurse aide) wheeled Resident #3 to her room by herself in her wheelchair.At 12:07 PM, Staff A wheeled Resident #4 to her room by herself in her wheelchair. While transferring the resident from the wheelchair to her bed, Staff A grabbed the back of the resident's pants with her left hand and under the resident's right armpit with her right hand and assisted the resident out of the wheelchair to a sitting position on her bed.At 12:07 PM, Staff A stated she used the same process to transfer Resident #3 from her wheelchair to her bed except she stated she had to use more muscle to get Resident #3 up and positioned to sit on her bed. She also stated she was off training but wasn't certified yet. She added her trainer told her to put her foot and leg between Resident #3s feet and legs, grab her pants from the back and under an armpit to stand-pivot transfer her.At 12:22 PM, Staff K, Certified Nurse Aide (CNA) stated gait belts are required with every weight bearing, 1-assist transfer resident.At 2:35 PM, Resident #2 stated Staff A, TNA applied her leg immobilizer by herself that morning.At 3:20 PM, Staff F, CNA stated 1-assist residents always require a gait belt because staff need to hang onto the resident.At 3:21 PM, Staff G, CNA stated all 1-assist residents require a gait belt for transfers. She said it was never ok to not use a gait belt for 1-assist resident transfers.At 3:32 PM, the Social Services Coordinator (SSC) adjusted Resident #2's leg immobilizer and confirmed it was on incorrectly.On 5/04/26 at 3:33 PM, the Director of Nursing (DON) stated TNAs should not be applying or removing leg immobilizers.A document titled Staffing Sheets dated from 4/01/26 - 5/03/26 revealed Staff K, CNA was assigned to work in the Memory Care Unit (MCU) on 4/02/26, 4/07/26, 4/11/26, 4/12/26, 4/16/26, 4/23/26, 4/25/26, 4/26/26, and 5/03/26.A document titled Long Term Care Competencies dated 5/05/26 revealed Staff A's competencies did not include resident transfers nor applying leg immobilizers. No other competencies were available for Staff A.An undated document titled Employee Orientation Checklist revealed Staff A had not been oriented to resident transfers nor applying leg immobilizers.An untitled education document revealed Staff K, CNA did not have documentation of the following, state-required specialized training:(1) Explanation of the disease or disorder(2) Symptoms and behaviors of memory-impaired people(3) Progression of the disease(4) Communication with CCDI residents(5) Adjustment to care facility residency by the CCDI unit or facility residents and their families(6) Inappropriate and problem behavior of CCDI unit or facility residents and how to deal with it(7) Activities of daily living for CCDI residents(8) Handling combative behavior(9) Stress reduction for staff and residentsOn 5/07/26 at 10:33 AM, the DON stated staff should know and maintain their scopes of practice and complete their educations timely.

Based on observation, record review, staff interviews, and policy review, the facility failed to use a gait belt while transferring a resident who required assistance with mobility for 2 of 3 residents (#3, #4) and failed to lock a wheelchair while transferring a resident without a gait belt for 1 of 3 residents (#4). The facility reported a census of 35 residents.Findings include:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease and non-Alzheimer's dementia. It revealed she required moderate assistance with eating and was dependent with all other Activities of Daily Living (ADLs) and all forms of mobility.The Care Plan dated 10/15/25 indicated the resident was a fall risk related to chronic confusion and directed staff to use 2-person assistance or a mechanical standing lift for transfers as needed to promote safety.2. Resident #4's MDS assessment dated [DATE] identified a BIMS score of 01 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, fibromyalgia (chronic disorder with musculoskeletal pain, fatigue, and cognitive difficulties), and macular degeneration (blurry or lost central vision). It revealed she was independent with bed repositioning, sit-to-lying, and lying-to-sitting, required setup assistance with eating, moderate assistance with lower body dressing and bathing, and supervision with all other ADLs and mobility. It also indicated she used a wheelchair for mobility in the 7-day look-back period.An undated Care Plan revealed the resident was a risk for falls related to assistive devices for ambulation, chronic confusion, and poor safety awareness and directed staff to use 1-person assistance with transfers.On 5/03/26 at 11:53 AM, Staff A, Training Nurse Aide (TNA - uncertified nurse aide) wheeled Resident #3 to her room by herself in her wheelchair.At 12:07 PM, Staff A wheeled Resident #4 to her room by herself in her wheelchair. While transferring the resident from the wheelchair to her bed, Staff A grabbed the back of the resident's pants with her left hand and under the resident's right armpit with her right hand and assisted the resident out of the wheelchair to a sitting position on her bed.At 12:07 PM, Staff A stated she used the same process to transfer Resident #3 from her wheelchair to her bed except she stated she had to use more muscle to get Resident #3 up and positioned to sit on her bed. She also stated she was off training but wasn't certified yet. She added her trainer told her to put her foot and leg between Resident #3s feet and legs, grab her pants from the back and under an armpit to stand-pivot transfer her.At 12:22 PM, Staff K, Certified Nurse Aide (CNA) stated gait belts are required with every weight bearing, 1-assist transfer resident. At 3:20 PM, Staff F, CNA stated 1-assist residents always require a gait belt because staff need to hang onto the resident.At 3:21 PM, Staff G, CNA stated all 1-assist residents require a gait belt for transfers. She said it was never ok to not use a gait belt for 1-assist resident transfers.At 5:50 PM, Staff N, CNA wheeled Resident #4 to her room in her wheelchair. Once beside the bed, the resident put her hands on the armrests and stood up while Staff G stood beside the wheelchair. The wheelchair was unlocked while the resident stool up without staff assistance or a gait belt.An undated policy titled Safe Resident Handling/Transfers indicated mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies. It also indicated handling aids may include gait belts, transfer boards, and other devices and staff members are expected to maintain compliance with safe handling/transfer practices.On 5/07/26 at 10:33 AM, the Director of Nursing (DON) stated staff should perform duties within their scopes of practice and ensure they are supervised.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to appropriately complete assessments for 3 of 3 residents (#1, #6, #7) who fell at the facility. The facility reported a census of 35 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 01 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, anxiety, and hospice. It indicated she was independent with eating, required setup assistance with oral hygiene, supervision with bed repositioning and personal hygiene, was dependent with lower body dressing and footwear, and required moderate assistance with all other Activities of Daily Living (ADLs) and forms of mobility.An undated Care Plan indicated the resident had impaired cognitive function/dementia or impaired thought processes related to dementia and directed staff to monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. The care plan also documented a risk for falls related to assistive devices for ambulation and a history of falls. An Incident Note Progress Note dated 8/02/25 at 9:50 PM revealed the resident was found sitting on the floor beside her bed with one leg in the bed and one out of bed. It indicated the fall was unwitnessed.A document titled Neurological Assessment Flow Sheet dated 8/02/25 beginning at 9:50 PM revealed the resident moved all extremities between 10:15 PM until midnight but lacked a pupil response, hand grasp strength, or pain assessment during the time the resident was documented as sleeping.An Incident Note Progress Note dated 9/22/25 at 6:45 PM revealed the resident was found on the floor next to her bed after trying to self-transfer to her bed. It indicated neurological checks were initiated per facility protocol.A document titled Neurological Assessment Flow Sheet dated 9/22/25 beginning at 6:45 PM lacked the signature of the staff who performed the assessments.An Incident Note Progress Note dated 10/20/25 at 11:30 PM revealed the resident was found sitting upright on her bathroom floor. It indicated the resident admitted to sliding off the edge of the toilet seat and was documented as a non-unwitnessed fall.A document titled Neurological Assessment Flow Sheet dated 10/20/25 beginning at 10:30 PM lacked completed level of consciousness, pupil response, hand grasp strength, extremity movement, pain, or vital signs assessments.2. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia and arthritis. It revealed he required supervision with eating, moderate assistance with oral and personal hygiene, maximal assistance with upper body dressing, and was dependent with all other ADLs and mobility.An undated Care Plan indicated the resident was at risk of acute on chronic pain secondary to risk of diabetes mellitus and immobility. It directed staff to monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. The care plan also documented a risk for falls related to altered mobility secondary to chronic confusion, history of falls, poor safety awareness, relocation stress and weakness. A Health Status Progress Note dated 12/06/25 at 9:58 PM revealed the resident was found on the floor sitting next to his bed. It indicated neurological checks were initiated due to fall being unwitnessed.A document titled Neurological Assessment Flow Sheet dated 12/06/25 included neurological assessments from 9:30 PM through 11:15 PM. No further neurological assessments were documented from 11:45 PM through 12:45 PM the next day.3. Resident #7's MDS assessment dated [DATE] identified a BIMS score could not be obtained due to the resident being rarely or never understood. It included diagnoses of a stroke without residual deficits, one-sided severe weakness, and bilateral hearing loss. It revealed she was dependent with all ADLs and mobility.An undated Care Plan indicated the resident had impaired visual function and directed staff to monitor/document/report PRN (as needed) any signs or symptoms of acute eye problems: Change in ability to perform ADLs, decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, complaints of halos around lights, double vision, tunnel vision, blurred or hazy vision. The care plan also documented a risk for falls related to a history of falls, poor safety awareness and weakness. An Incident Note Progress Note dated 8/04/25 at 3:00 AM revealed the resident was found on the floor beside her bed. It did not indicate neurological checks were initiated.A document titled Neurological Assessment Flow Sheet dated 8/06/25 included 30-minute vital signs from 3:30 AM through 5:30 AM but did not include pupil response, motor function, or pain assessments during those times.On 5/04/26 at 10:43 AM, Staff H, Licensed Practical Nurse (LPN) was unable to verbalize the neurological assessment frequency guidelines. She also stated all columns on the form must be completed; otherwise, it is considered incomplete assessments.On 5/04/26 at 10:58 AM, the Assistance Director of Nursing (ADON) stated if an unwitnessed fall was reported to her, she'd perform an initial assessment with vital signs and then complete the neurological assessment form every 15 minutes (min) x 4; then every 30 min x 2; then every hour x 4, then every shift x 72 hours. She stated all columns must be completed and if any information was missing, it would be considered an incomplete assessment.An undated document titled Falls directed the nurse to complete a thorough head to toe assessment for injury. If any head involvement, complete neuro checks as per policy. If an unwitnessed fall and resident has cognitive problems complete neuro checks as per policy. No other fall assessment documentation was provided.On 5/07/26 at 10:33 AM, the Director of Nursing (DON) stated staff should follow the policy.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide baths for 2 of 3 residents (#1, #3) who required bathing assistance. The facility reported a census of 35 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, anxiety, and hospice. It indicated she required supervision with eating and bed repositioning, required moderate assistance with oral hygiene, lying-to-sitting, and sitting-to-lying, required maximal assistance with all other Activities of Daily Living (ADLs) and forms of mobility.An undated Care Plan indicated the resident had an ADL self-care performance deficit related to dementia and directed staff to provide sponge bath when a full bath or shower cannot be tolerated.A hospice document titled Aide Visit Note dated 3/01/26 - 4/29/26 revealed the resident received a bath on 3/01/26, 3/19/26, 3/21/26, 4/10/26, 4/22/26, and 4/24.An untitled document dated March 2026 used for resident bath documentation revealed the resident received a bath on 3/03/26, 3/06/26, 3/10/26, 3/20/26, 3/24/26, and 3/31/26. Collectively, the documents indicated the resident missed a scheduled bath on 3/13/26 and 3/27/26. It also indicated she received one (1) bath in a 13-day period from 3/06/26 through 3/19/26. The facility did not provide this resident's bath log for April 2026.2. Resident #3's MDS assessment dated [DATE] identified a BIMS score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease and non-Alzheimer's dementia. It revealed she required moderate assistance with eating and was dependent with all other Activities of Daily Living (ADLs) and all forms of mobility.An undated Care Plan indicated the resident had a self-care deficit related to Alzheimer's disease and directed staff to attempt to participate and provide assistance with bathing.An untitled document dated March 2026 used for resident bath documentation revealed the resident received a bath on 3/02/26, 3/10/26, 3/16/26, 3/23/26, 3/26/26, and 3/30/26. It indicated the resident missed a second, weekly bath during the 1st, 2nd, 3rd, and 5th weeks in March 2026. The facility did not provide this resident's bath log for April 2026.On 5/03/26 at 1:40 PM, Staff C, Certified Nurse Aide (CNA) stated the resident-assigned CNA or the bath aide was responsible for bathing the resident. She added that sometimes baths are missed due to staffing shortages.On 5/03/26 at 1:42 PM, Staff D, CNA stated the resident-assigned CNA or bath aide was responsible for bathing the resident.On 5/03/26 at 1:44 PM, Staff E, CNA stated CNAs take turns assigned as bath aides.A policy titled Activities of Daily Living (ADLs) revised 2025 indicated a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.On 5/07/26 at 10:33 AM, the Director of Nursing (DON) stated staff should complete the task and document it appropriately.

Based on clinical record review, policy review, and staff interviews, the facility failed to accurately document resident medication administration for 2 of 13 residents (Resident #1 and #2). The paper Medication Administration Record (MAR) for Residents #1 and #2 showed many days blanks, indicating that the medications had not been given. The facility reported a census of 44 residents. Findings include: 1) The Minimum Data Set (MDS) dated [DATE], showed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). The resident was totally dependent on staff for toileting hygiene, dressing and transfers. He had an indwelling catheter, diagnoses included: atrial fibrillation, coronary artery disease, heart failure, Benign Prostatic Hyperplasia (BPH) septicemia.The Care Plan, last reviewed on 7/7/25, showed that Resident #1 used antidepressant medication and was on diuretic therapy. Staff were to administer medication as ordered by the physician. The resident was at risk for complications related to diabetes mellitus and congestive heart failure. A review of the April 2025 MAR for Resident #1 revealed that on April 18th and 19th the chart lacked documentation of administration of 16 different morning medications. 2) According to the MDS dated [DATE], Resident #2 had a BIMS score of 3 (severe cognitive deficits). He required substantial assistance for dressing, and was totally dependent for transfers. Resident #2 was frequently incontinent of bowel and bladder and his diagnoses included: cancer, anemia, hypertrophy of kidney, macular degeneration and arthritis. The Care Plan updated on 6/26/25, showed that Resident #2 was on antidepressant and antianxiety medication, staff were to observe for and report indications of adverse effects. The resident was on hospice services related to end stage disease. Review of the MAR/TAR for Resident #2 for the month of May 2025, showed that on the 19th, 20th, and 21st, 10 different morning medications had not been given. The chart lacked explanation of the missing documentation. On 8/6/25 at 9:32 AM, Staff A, Licensed Practical Nurse (LPN) acknowledged that the medication documentation was not always accurate. She said she could not be sure, but she thought it was a documentation problem and the medications were given. Staff A said that the cassettes with the pills have a day of the week on them so if a day was missed, they would know because the pills would still be in the cassette. On 8/06/25 at 12:08 PM, the Director of Nursing (DON) said that they became aware that some of the documentation was not being completed so they did an audit in June. They were in communication with the pharmacy to ensure that the medications were actually being given and it was a documentation issue, she said that the cassettes went back to the pharmacy weekly and the pharmacy reported that they didn't have unexplained left-over pills. They have addressed the issue with the nurses that they identified that have missed documentation. According to the facility staff education for Medication Administration Monitoring Tool, the expectation was that medication would be charted immediately after administration.

Based on observation, staff interviews and clinical record review the facility failed to provide adequate urinary catheter care for 2 of 2 residents reviewed. Resident #1 had chronic urinary tract infections and staff failed to monitor his output as ordered. Resident #28 had an order to not insert more than 10 milliliters (ml) of fluid in the catheter balloon. Staff failed to transcribe the specific order and administered fluid according to the catheter package. The facility reported a census of 44 residents.Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #28 had a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive deficit). He required partial assistance with toileting, transfers, and dressing. The resident had an indwelling catheter and diagnoses that included: coronary artery disease, dementia, type 2 diabetes mellitus, Benign Prostatic Hyperplasia (BPH), retention of urine and edema. The Care Plan, updated on 6/5/25, showed that Resident #28 had self-care performance deficit related to dementia. He was at risk for infection related to a suprapubic urinary catheter. Staff were to monitor and document output each shift, and to observe for signs and symptoms of urinary tract infections such as pain, burning, blood tinged urine, cloudiness, no output, and deepening of urine color. According to the orders tab, Resident #28 had a Physician's Order, dated 2/27/24 at 2:00 PM, to document urinary output every shift. A Transfer Report from the primary physician dated 6/5/25, showed that on that date, the doctor place a new 24 French catheter and directed staff to not put more than 10ml in the balloon. The doctor had removed 22ml in the balloon at the appointment, and indicated that if the catheter continued to leak, he will need bladder Botox injections. The catheter order entered in the electronic record on 6/5/25 at 12:36 PM lacked direction on the amount of fluid to insert into the balloon. On 8/05/25 at 7:06 AM, Staff D, Certified Nurse Aide (CNA) said that they documented all output for urinary catheters and reported to the nurses at the end of each shift. On 8/05/25 at 8:06 AM, Resident #28 was in the recliner and said they preferred to sleep in the chair because the bed was not very comfortable. Staff D and Staff C, CNA prepared to get him cleaned up and dressed for the day. The resident was wearing a brief that was heavily soiled and he said that he did have some leaking from his catheter. Further inspection of the catheter site revealed that there was blood at and around the catheter site. Staff C said that they would notify the nurse. On 8/05/25 at 9:57 AM, Staff B, Registered Nurse (RN) said that if there wasn't an order for how much fluid to put in the catheter balloon, she would call the doctor for clarification or she would go by the amount on the catheter bag. She pulled a 24 French catheter from the shelve and demonstrated that it said to use 30 ml.A review of the nursing notes on 8/06/25 at 9:54 AM, showed that the most recent progress note was dated 7/21/25 at 3:31 PM. The chart lacked documentation that the nurse had assessed the issue or that it had been addressed. On 8/6/25 at 9:55 AM Staff A, Licensed Practical Nurse (LPN) said that she was not aware that the catheter site was sore and it was not passed on in report. On 8/6/25 at 9:32 AM, Staff A, LPN She said that the CNA's would come and tell the nurses per shift of the catheter output. She acknowledged that it didn't always get done, or the CNA's would forget to let the nurse know. On 8/06/25 at 10:24 AM, Staff E, LPN said if there was nothing specified on the order for amount to put in the catheter bulb, she would go with whatever was on the package. She said that the CNA's have been getting better about telling them the output but they need a better process that was consistent so they had accurate information. According to the Medication Administration/Treatment Administration (MAR/TAR) for Resident #28, in the month of May, there was no output documented on 7 days. The June MAR/TAR showed no output on 2 days, and the July MAR/TAR showed no output documented on 4 days. 2. The MDS dated [DATE], showed that Resident #1 had a BIMS score of 14 (intact cognitive ability). The resident was totally dependent on staff for toileting hygiene, dressing and transfers. He had an indwelling catheter, and his diagnoses included: atrial fibrillation, coronary artery disease, heart failure, Benign Prostatic Hyperplasia (BPH) and septicemia, The Care Plan for Resident #1, reviewed on 7/7/25, showed that the resident used antidepressant medication and was on diuretic therapy, staff were to administer medications as ordered. The resident had a cerebral vascular accident (CVA), chronic pain, and was at risk for complications related to diabetes mellitus. Staff were to observe and monitor for side effects. Resident #1 had an indwelling catheter related to urinary retention, staff were to monitor and document intake and output as pre facility policy. On 8/04/25 at 1:16 PM, Resident #1 was in his bed. There was a catheter tube draped down the side of the bed and the bag rested in a tub on the floor. The resident said that earlier in the summer, he had been very sick with a urinary tract infection and sepsis. A review of the record revealed an order dated 5/12/25 at 11:14 AM, to record output every shift. The MAR/TAR for July for Resident #1 showed that on 5 days there was no urine output. On 8/06/25 at 12:13 PM, the Director of Nursing (DON) said that she was aware that output for catheters had not been getting monitored as it should. She was not aware that Resident #28 had a specific order for no more than 10ml in the bulb of catheter, and said this should have been entered along with the order. The DON said that the nurses would enter notes when there were any new issues. She acknowledged that the blood around the catheter site for Resident #28, on 8/6/25 should have been noted and addressed. The DON said that given the history of urinary tract infections and sepsis for Resident #1, it was important for staff to be aware of his daily output. An undated facility policy titled: Urinary Drainage Bag-Closed, showed that staff were to record the output in the medical record and to report if there was any change in odor, color, consistency, blood, mucous or leaking bag.

Based on observation, staff interviews and clinical record review the facility failed to adequately supervise residents in the locked Chronic Confusion or Dementing Illness (CCDI) unit for 1 of 6 residents. The facility reported a census of 44 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #30 was severely cognitively impaired and had delusions. She used a walker and required supervision for transfers and toileting. Her diagnoses included: cerebrovascular accident (CVA), dementia and asthma. The Care Plan for Resident #30, updated on 6/18/25, showed that she had self-care deficits, secondary to chronic confusion and dementia. The resident was an elopement risk, disoriented to place and wandered aimlessly. Staff were to distract the resident from wandering and offer diversions. Resident #30 had communication problems, was rarely understood, and was at risk for falls related to altered mobility and unsteady gait. She had poor safety awareness. Staff were directed to anticipate and meet her needs. The following documentation was found in the Nursing Progress Notes: On 6/24/25 at 2:31 PM, the resident was hitting staff with a hanger, her dementia with behaviors was getting more frequent and severe. On 6/16/25 at 7:30 AM, Resident #30 was found sitting on her bottom in her room. She said she was trying to get dressed for the day. On 7/28/25 at 6:30 AM, the resident was found sitting on the floor in her room. On 7/22/25 at 9:28 PM, the resident was combative towards staff and other residents. On 8/04/2025 at 1:13 PM, observed a Certified Nurse Aide (CNA) assist Resident #30 to walk around the CCDI unit. The resident was agitated and insisted on the full attention of the staff member. On 8/05/2025 at 6:26 AM, upon entry into the CCDI unit, 2 residents were sitting in chairs by the television. The door to the nurse's station was open, there was a purse, some papers and sanitizer on the counter. There were no staff members in the area. One resident in a recliner had her eyes closed as she fidgeted with her blanket. One resident was sitting in a high-back chair with her legs resting on the seat of a walker. Resident #30 then walked out of her room with her walker. She was wearing pajamas and had shoes on her feet. She said: I don't know where my family is then asked: do you remember where I sit? She then walked closer to another resident and said: I was thinking of my mother, she's coming? Resident #30 said that her back hurt and she wanted to sit down. At 6:36 AM, the Director of Nursing (DON) came in the door with the treatment cart. The DON said that Staff H was the CNA for the morning and that she was probably in a room giving a resident a shower. At 6:43 AM Staff H came out of the resident's room to the common's area. On 8/05/2025 at 9:53 AM, Staff H said that she usually tried to get the showers done before the other residents got out of bed. She said that one of them had been in the chair by the TV before she started showering another resident. She agreed that Resident #30 tended to get easily agitated and she needed close supervision. On 8/06/2025 at 11:59 AM, the DON agreed that it was a problem to leave residents unattended in the CCDI Unit. She said that going forward, they have arranged for a bath aide to come over to the unit to do the baths and showers to ensure that proper supervision. The DON agreed that Resident #30 was unpredictable and needed supervision. A facility policy dated 11/1/24, showed that there would be at least one member of the nursing staff on the unit at all times. Other staffing would be provided according to the needs of the residents on the unit at a given time. One CNA with appropriate CCDI training would be on the unit at all times.

Based on clinical record review, document review, resident interview, and staff interviews the facility failed to consistently monitor meal intakes for residents for sufficient nutrition to maintain proper weight for 1 of 2 residents reviewed (Resident #6). The facility reported a census of 44 residents. Findings include:Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS further revealed diagnoses of stroke, hyponatremia (low sodium levels in the blood), non-Alzheimer's dementia, and hemiplegia (paralysis or severe weakness on one side of the body).Interview 8/04/25 at 11:23 AM with Resident #6 revealed that she has lost some weight, and that she is on a mechanical soft diet. Resident #6 further revealed that she is on a supplement as well. Review of the Electronic Health Record (EHR) for Resident #6 revealed on 1/12/25 Resident #6 weighed 147 pounds. On 7/27/25 Resident #6 weighed 133 pounds which is a -9.52% Loss.Further review of the EHR page titled, Clinical Physician's Orders revealed an order for a regular diet with mechanical soft texture. Further review revealed an order dated 6/17/25 for house nourishment with protein powder TID (three times a day) with meals and ice cream related to weight loss. Follow up interview 8/05/25 at 11:47 AM with Resident #6 revealed that she did not want to eat breakfast this morning. Resident #6 then revealed that she just isn't that hungry anymore, and does not require that much food. Resident #6 revealed that she does eat her ice cream, and she isn't starving. Interview 8/05/25 at 11:45 AM Interview with Staff G Certified Nurses Aide (CNA) revealed that staff are to document the intakes of residents on a paper in the staff charting room. Staff G then provided the documentation book for the meal intakes. Review of a facility provided document with a date of July 2025 revealed documentation for the intakes of meals and supplements for Resident #6. Review of this document noted intakes for meals and supplements on 9 of the 31 days, with nothing charted on the supper meals or supplements except for one day during the month of July. Review of another facility provided document with a date of August 2025 revealed documentation for the intakes of meals and supplement for Resident #6. Review of this document revealed no documentation on the 1st of August for meal intakes of supplement intake. The document further revealed no documentation for the 2nd, 3rd, and 4th supper entries. Review of the EHR page titled, Progress Notes revealed an entry dated 6/17/25 entered by the contract dietician that Resident #6 had a weight warning. The entry revealed a weight of 136 pounds on 6/13/25. The entry indicates weight loss is 8.7% in the last 90 days, and that Resident #6 remains on a mechanical soft diet plus house nourishment with extra protein powder three times a day at meals. The entry further revealed that the writer would alert the primary care provider to the weight loss, and would add ice cream to the house nourishment. Further review of the progress notes revealed an entry from the contract dietician on 6/26/25 that Resident #6 had a weight of 130 pounds on 6/23/25 with a weight loss of 6 pounds in the past 10 days with an overall loss of 7.8% in the last 30 days. Another entry dated 7/10/25 revealed a current weight of 133 pounds and Resident #6 was up 3 pounds since the provider notification of loss. The note further indicated that meal intake is around 50% with frequent refusal of meals and supplements. Interview 8/05/25 at 1:18 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that meal intakes should be documented to monitor. The ADON revealed that documenting is a requirement. Interview 08/06/25 at 9:40 AM with the Administrator revealed the facility doesn't have a policy related to monitoring meal intakes. Interview 8/06/25 10:00 AM with the dietician revealed that she would expect meal intakes to be monitored, and charted so as to be able to effectively communicate with the physician for residents with weight loss.

Based on observations, clinical record review, facility document review, staff and resident interviews, and facility policy review the facility failed to supervise a cognitively impaired resident. Staff were unaware Resident #1 left the building on 10/31/24. Staff last saw Resident #1 at approximately 12:45 PM. The door alarm sounded at 1:01 PM, staff responded, took approximately 5 steps outside, did not see anyone, walked back in the facility, disarmed the door alarm and went back to work. At 1:30 PM a different staff member came into the back-parking lot, saw a car backed up against the curb and was blocking the parking lot. Staff realized it was Resident #1 in the driver's seat with the car running and the doors locked. The responding staff member failed to do a thorough check around the facility, failed to notify nursing staff that she did not see anyone, and failed to initiate a head count to ensure all residents were accounted for. The facility reported a census of 38 residents. On 11/7/24 at 4:20 PM the State Survey Agency informed the facility of the staff's failure to supervise a cognitive impaired resident creating an Immediate Jeopardy situation resulting in the resident leaving the building unattended, without the staff's knowledge on October 31, 2024. The facility staff removed the immediacy on November 4, 2024 when the staff implemented the following Corrective Actions: a) On 10/31/24 immediate education and coaching with staff on the facility's door alarm response procedure. b) On 10/31/24 all door alarms and wander guard alarms were checked for proper functioning. c) On 11/1/24 elopement drills were completed successfully. d) On 11/4/24 staff completed door response education. The facility updated the wandering assessment in their Electronic Health Record (EHR) to be completed on admission, 72 hours after admission and quarterly. e) Elopement drills will continue every quarter, alternating shifts for three quarters and reviewed at Quality Assurance (QA) meetings. If the drill is not successfully completed, they will increase the frequency to weekly. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education about their policy and procedure with missing resident exercises. Findings include: On 11/7/24 at 11:32 AM Resident #1 sat at the dining room table with her peers. A wanderguard alarm was visible on her left ankle. At 2:13 PM pushed the 200 hall exit door egress bar. An alarm sounded at the door and increased in sound once the door was opened. Once outside and the door closed, the alarm still sounded. At 2:14 PM staff walked outside, surveyed the area and located the surveyor around the corner of the building. The alarm sounded until staff returned inside and deactivated the alarm. Once out the exit door, a sidewalk led to the street with a wheelchair accessible portion on the sidewalk. There is a parking lot once across the street. The area is flat and visible once around a small curve in the roadway. According to a significant change Minimum Data Set (MDS) assessment tool with a reference date of 10/9/24 Resident #1 had a Brief Interview of Mental Status (BIMS) score of 8. A BIMS score of 8 suggested mild cognitive impairment. Resident #1 had experienced hallucinations and delusions due the review period. The MDS documented she wandered 1 to 3 days during the review period. Resident #1 had no upper or lower extremity impairments, she utilized a walker and wheelchair for mobility. Resident #1 required supervision or touching assistance when going from a sitting to standing position. She was independent when ambulating. The MDS documented she did not utilize a wander/elopement alarm. The following diagnoses were listed for Resident #1: moderate dementia with psychotic disturbance, heart failure, renal failure, diabetes mellitus, thyroid disorder, depression, spinal stenosis, and repeated falls. The Care Plan Focus Area documented Resident #1 had poor safety awareness and dementia that could lead to wandering. The Focus Areas included a hand written note dated 9/4/24 this area was met and will be continued. The care plan documented wanderguard in the intervention/tasks section of the care plan. The care plan lacked interventions for staff to attempt when she is wandering and/or exit seeking. The care plan lacked documentation about her elopement as well. The Progress Notes documented the following for Resident #1: a) On 9/17/24 at 1:26 PM resident left the facility with her daughter for a hair appointment. b) On 10/7/24 at 1:30 PM resident returned to the facility with hospice orders but family stated they are still undecided. c) On 10/9/24 at 11:12 AM hospice at the facility and spoke with family and resident to admit to hospice care. d) On 10/13/24 at 5:36 AM hospice notified due to resident continuing to have severe back pain and her Fentanyl patch is not effective yet for pain control. e) On 10/14/24 at 10:05 AM the resident had some delirium and being off before her hospitalization . Resident #1 still sees little kids in her room but does not say anything because they will think she is crazy. She does still look for her husband occasionally, will pack up her belongings because she believes she is going home soon. She does make delusional statements frequently and wanders prior to her hospital stay. f) On 10/31/24 at 3:01 PM the resident has been extremely confused today (more than normal). Told this nurse that she started her period and wasn't prepared. Her adult brief was checked and there was no sign of blood, she was given a pad insert. After lunch she stated she needed to go to 4H and had already been there this morning. She stated she needed to find her car, wandered down another hallway, eventually opened the exit door and went out into the parking lot. She walked over to a staff's parked car and got inside. The door alarms sounded, staff found Resident #1 in the car and brought her back into the facility. Vital signs completed, no injuries noted, she will be an assist of one moving forward. Her family, hospice, and primary care provided (PCP) were notified. g) On 11/1/24 at 11:36 AM resident was less confused today, came out for breakfast meals, took her medications. No wandering noted, a urine sample was collected. h) On 11/2/24 at 9:27 PM had increased wandering throughout the facility this evening. She looked to be exit seeking. When asked what she was doing, she stated her husband was waiting in the car for her. She then continued to walk down hall one. An hour later, she was found pacing the hallway again, this time she stated my mother is coming to get me. After some convincing from the aides, she went back to her room. Resident is experiencing increased confusion and is becoming irritable. Will continue to monitor. i) On 11/3/24 at 1:22 PM resident has been having increase confusion the past couple of weeks (more than she normally is). Starting to revert back in time, looking for husband, etc. A urine sample was obtained but it showed no Urinary Tract Infection. Staff and family wondered if the Fentanyl patch could be a cause or her dementia is worsening. j) On 11/4/24 at 2:10 AM staff went to check on resident and resident's refrigerator was unplugged and moved away from the wall, everything was out of the closet and in a laundry basket, hangers were all over the floor and resident had bed covered with things, resident had taken the string out of her jacket and knotted it around a bunch of hangers. k) On 11/5/24 at 2:30 PM she was wandering in hall one with a plant, a vase of flowers and a handful of clothes hangers in her arms, saying she was moving across the hall to #109. Redirected her back to her room where she had taken all of her clothes out of closet and had them folded in piles. Advised her to sit in her recliner and rest for a while. She was wandering without walker or cane. Stated her back was hurting she was given Tylenol for pain. The facility's investigation contained the following interviews and summary: a) On 11/5/24 Staff B wrote she witnessed Resident #1 sitting, resting at the top of the 200 hall at 12:45 PM on 10/31/24. She stated she was resting when asked if she needed help. b) An undated note from Staff A Non-Certified Aide documented at 1:30 PM she came into the back parking lot and saw a car tire was backed up against the curb, blocking the parking lot. She realized it was Resident #1 in the driver's seat, so she got out of her car, asked her to unlock the door. Staff A then opened the door, put the car in park and took the keys out of the car. Staff A then called the facility to have someone come out to help. Staff F Registered Nurse (RN) and the Director of Nursing (DON) came out and brought Resident #1 inside. c) An undated note from Staff C Certified Nursing Assistant (CNA) documented she saw the 200 hall exit door go off so she went to check it. She took a couple steps outside to check if anyone was out there but she did not see anyone. She needed help clearing the door alarm, so another staff member got it. d) A note dated 10/31/24 from Staff D CNA documented she saw Resident #1 in the 200 hall at 12:45 PM. Staff D was on her way to eat lunch. She heard Staff B CNA try to redirect Resident #1 and thought the situation was being handled. e) The DON received report from Staff H Licensed Practical Nurse (LPN), that Staff A was on the phone and that Resident #1 was in the employee parking lot in the front seat of an employee vehicle at 1:34 PM, on 10/31/24. Staff F and the DON went to the parking lot to investigate. Resident was sitting in the front seat of an employee vehicle; Staff A was with her. She looked to be unharmed or uninjured. She was escorted back to the building. The DON interviewed Staff A and had her write a statement. It was discovered that Staff C had responded to the door alarm at that 200 hall exit door and did not see anyone. When speaking with other CNAs it was discovered that Staff D and Staff B last saw Resident #1 at 12:45 PM, just before she exited the building. Staff B tried to redirect the resident. When interviewing Staff G she stated that Resident #1 had been more confused than normal possibly related to her recent order of a Fentanyl patch for back pain. Earlier that day she reported the increased confusion to the resident's Primary Care Provider (PCP) and the Hospice Nurse. After Resident #1 was escorted back into the facility, she was assessed; her vitals were normal and no injuries were noted. The facility provided a documented tilted Location Event Report 200 Hall Exit. The door alarm was activated on 10/31/24 at 1:01 PM and deactivated on 10/31/24 at 1:06 PM. On 11/7/24 at 1:01 PM Staff C stated she was working on the 300 hall the day Resident #1 left the building. She was checking on residents when her pager sounded indicating the 200 hall door was opened. She went down to the door, outside about five steps, did not see anyone so she cleared the alarm. She went straight to the door as soon as she saw the message on her pager. She thought the pager went off about 1:45-1:50 PM. When asked where she looked while she was outside, she indicated she peaked around the corner of the building, looked the opposite direction but did not think to look in the cars that were in the parking lot. There were staff member's cars in the parking lot when she went out there but did not look in them. Staff C denied knowing if a head count was completed since this happened at the end of her shift. Staff C indicated Resident #1's confusion has gotten worse; she packs items up in her room and says she needs to get out of here. On 11/7/24 at 1:41 PM call to Staff A with no answer, a message was left on her voicemail and a text message was sent to return the call. At the conclusion of the investigation, Staff A had not returned the call. On 11/7/24 at 1:44 PM Staff B stated after lunch on 10/31/24 Resident #1 was sitting on her walker on the 200 hall at about 12:45 PM. Staff B asked if she needed anything, the resident indicated she was resting. Staff B stated the next thing she knew, Resident #1 was outside in an employee's car. Staff B denied hearing the door alarm sounding because she was on her 15-minute break at approximately 12:50/12:55 PM. Staff B stated while she was out on her break she did not see Resident #1 outside. Staff B indicated she was working on the 200 hall that day, not the 100 hall where the resident resides. When she saw her at dinner she appeared to be a little lost. On 11/7/24 at 1:57 PM Staff F RN stated she got a call from Staff A on 10/31/24, indicating they found Resident #1 in the driver's seat of a staff member's car. When Staff F arrived, Staff A had the driver's side door open as the resident sat in the car. The car was backed up against the sidewalk's curb. Once around the building, there's a curve in the road that comes around the building. The car was not in a parking stall, it looked like it rolled back out of a parking stall. The car was not on and not in gear when she arrived. The resident had placed her walker in the back seat. Staff F stated she went outside about 1:30 PM after Staff A called. Resident #1 was assisted inside to the facility, but did not say anything as to what she was doing. Staff F indicated she was working in the office that day and did not see how Resident #1 was prior to her exiting the building. On 11/7/24 at 2:46 PM Staff E Assisted Living Aide stated she was running late to work on 10/31/24. She parked her car in the parking lot at the back of the facility. She stated there's a curve in the road, to the left was a corn field and to the right was the building. She parked her car facing the corn field in a parking lot. Later in the day, she took the garbage out, noticed there were nursing home staff members at her car and her car was backed up to the curb. Her car was resting on the curb that was behind the parking spot where she parked her car for the day. The resident was already out of her car and in the building with staff members. She was unable to recall where her keys were once she put her car in park, she was running later to her shift and just wanted to get clocked in before it showed she was late. Resident E denied finding damage to her car. On 11/7/24 at 2:35 PM Staff G stated Resident #1 had increased confusing that was worsening on 10/31/24. She indicated it was normal for her to walk around quite a bit and that day she had wandered down to the 200 hall. She indicated the hospice nurse and Social Worker spoke of how confused she was. That morning at breakfast, Resident #1 usually took her morning pills before she would leave the table. That day after breakfast she got up from the table and went to the bathroom. When Resident #1 did not come back done to get her medications, Staff G went down to her room and found her in her bathroom. Resident #1 stated she had started her period then later told her she need to go to the 4H building. She was off from her normal confusion. Staff G stated Resident #1 was very outgoing, independent and would walk around to different halls. While Staff G was in report, someone reported to her Resident #1 was found in a staff member's car that had backed up in a curb. She indicated this was probably about 1:45 PM. Staff were able to get Resident #1 in to the building. She remembered hearing the door alarm sounding and Staff C went to check, stated it was all clear. On 11/7/24 at 3:09 PM Resident #1 was sitting in a chair in her room by the window, wanderguard visible on her left ankle. Resident #1 remembered leaving the facility and getting in to a car. When asked why she was leaving she stated we were leaving to go back to the motel we were staying at. Resident #1 stated her husband was here to pick her up but he was driving the car. Now she's resting in the sunlight waiting for a ride. On 11/7/24 at 3:16 PM Staff D stated she saw Resident #1 on the 200 hall and Staff B redirected her, this was approximately at 12:50 PM. Staff D stated when the 200 hall door alarm sounded, Staff C went to the check to see what was going on, she did not see anyone but was unsure what Staff C did after that as she was answering call lights. Staff D stated this was approximately about 1:00 PM. When asked how Resident #1 was prior to leaving the building that day, she stated she was a little bit confused but did not work her hall that much. She added her behavior was strange that morning; she wanted to know if the facility had stairs to go to the dining room. Staff D assured the resident she just needed to go up the hall to the dining room. When the exit doors are opened staff get a page on their pagers but they can hear the alarm on the door when it's been engaged. On 11/8/24 at 11:40 the DON stated a staff member approached her in the hall and stated she needed to go out to the parking lot because Staff A found Resident #1 in the parking lot. She grabbed Staff F to go outside with her right away. When they arrived to the parking lot outside of the 200 hall's exit door, Resident #1 was sitting in an employee's car with Staff A standing at the driver's side opened door. Staff A had opened the door, put the car in park and shut the car off. The DON noted Resident #1's walker was in the back seat, she looked unharmed so they helped her out of the vehicle and back inside. Resident #1 did have her wanderguard on at that time. Staff G completed the head to toe assessment once back in the facility. After the incident, she read the nurse's note and did not realize she was so confused. They started to decrease her Fentanyl patch dosage as they thought it was causing her confusion. A urine sample was collected to rule out a urinary tract infection, the urine sample came back negative. They have discussed moving her to the memory care unit but they would like to see how she does after they lower her Fentanyl dosage. They have noticed she seems to be doing better, still talks about going out but has not found her near any exits. The facility's Door Alarm Response Policy with an effective date of 7/19/24 and revised date of 10/31/24. The policy is to assure prompt response to door alarms/alerts. Staff to check the system for location of door alarming. Staff to immediately respond to the door that is alarming. Staff to walk to the door, walk outside, scan the facility grounds to identify the source of alarm. If the source of the alarm is a resident, assist the resident back in to the facility and notify the nurse on duty. Once the door is checked and the resident's safety is assured, reset the door alert. If the source of the alarm is not identified, account for location of all residents. If the resident is unaccounted for, immediately implement the missing resident policy. The facility's Missing Resident and Tenant Policy with an effective date of 7/14/24 and reviewed date of 11/1/24. The purpose of the policy is to ensure prompt and appropriate response by the staff and emergency personnel in an effort to maintain resident safety. In the event a resident is missing, the following steps shall be taken: - Search the building thoroughly. Look in closets, bathrooms, non-resident areas and in each and every bed. In the majority of incidents when a resident is missing, he/she is subsequently found in the facility, usually in an unexpected area. - Search the immediate grounds surrounding the building. - Notify the Administrator/DON to assist in the search. - Whoever is in charge of the facility should file a Missing Person's Report with the police.

Based on observations, clinical record review, and staff interviews the facility failed to ensure 2 of 3 residents' (Resident #1 and #3) care plans included interventions for staff to follow should these residents exhibit wandering/eloping behaviors. Resident #1's care plan failed to include that she had eloped from the building on 10/31/24 and was found in a staff member's car. The facility reported a census of 38 residents. Findings include: 1. According to a significant change Minimum Data Set (MDS) assessment tool with a reference date of 10/9/24 Resident #1 had a Brief Interview of Mental Status (BIMS) score of 8. A BIMS score of 8 suggested mild cognitive impairment. Resident #1 had experienced hallucinations and delusions during the review period. The MDS documented she wandered 1 to 3 days during the review period. Resident #1 had no upper or lower extremity impairments, she utilized a walker and wheelchair for mobility. Resident #1 required supervision or touching assistance when going from a sitting to standing position. She was independent when ambulating. The MDS documented she did not utilize a wander/elopement alarm. The following diagnoses were listed for Resident #1: moderate dementia with psychotic disturbance, heart failure, renal failure, diabetes mellitus, thyroid disorder, depression, spinal stenosis, and repeated falls. The Care Plan Focus Area documented Resident #1 had poor safety awareness and dementia that could lead to wandering. The Focus Areas included a hand written note dated 9/4/24 this area was met and will be continued. The care plan documented wanderguard in the intervention/tasks section of the care plan. The care plan lacked interventions for staff to attempt when she is wandering and/or exit seeking. The care plan lacked documentation about her elopement on 10/31/24. The Progress Notes documented the following for Resident #1: a) On 10/14/24 at 10:05 AM the resident had some delirium and being off before her hospitalization . Resident #1 still sees little kids in her room but does not say anything because they will think she is crazy. She does still look for her husband occasionally, will pack up her belongings because she believes she is going home soon. She does make delusional statements frequently and wanders prior to her hospital stay. b) On 10/31/24 at 3:01 PM the resident has been extremely confused today (more than normal). Told this nurse that she started her period and wasn't prepared. Her adult brief was checked and there was no sign of blood, she was given a pad insert. After lunch she stated she needed to go to 4H and had already been there this morning. She stated she needed to find her car, wandered down another hallway, eventually opened the exit door and went out into the parking lot. She walked over to a staff's parked car and got inside. The door alarms sounded, staff found Resident #1 in the car and brought her back into the facility. Vital signs completed, no injuries noted, she will be an assist of one moving forward. Her family, hospice, and primary care provided (PCP) were notified. c) On 11/4/24 at 2:10 AM staff went to check on resident and resident's refrigerator was unplugged and moved away from the wall, everything was out of the closet and in a laundry basket, hangers were all over the floor and resident had bed covered with things, resident had taken the string out of her jacket and knotted it around a bunch of hangers. d) On 11/5/24 at 2:30 PM she was wandering in hall one with a plant, a vase of flowers and a handful of clothes hangers in her arms, saying she was moving across the hall to #109. Redirected her back to her room where she had taken all of her clothes out of closet and had them folded in piles. Advised her to sit in her recliner and rest for a while. She was wandering without walker or cane. Stated her back was hurting, she was given Tylenol for pain. A document titled Elopement Risk Assessment Check List dated 5/2/24 documented Resident #1 had previous history of wandering, at home. Diagnosis of dementia, episodes of disorientation, episodes of non-acceptance of placement. High level of elopement risk, a wanderguard was put in place. 2. The quarterly MDS assessment tool with a reference date of 10/12/24 documented Resident #3 had a BIMS score of 4. A BIMS score of 4 suggested severe cognitive impairment. The MDS documented she wandered daily and utilized a wander/elopement alarm daily. The following diagnoses were documented for Resident #3: dementia with anxiety, stroke and had a pacemaker. The Care Plan Focus Area documented Resident #1 had poor safety awareness and dementia that could lead to wandering. The Focus Areas included a hand written note dated 10/30/24 this area was met and will be continued. The care plan documented wanderguard in the intervention/tasks section of the care plan. The care plan lacked interventions for staff to attempt when she is wandering and/or exit seeking. The Progress Notes documented the following for Resident #3: a) On 9/23/24 at 2:51 PM Resident #3 was out in the 100 hall by the exit door with the door alarm sounding. Staff went to the door and redirected Resident #3 back inside without difficulty. b) On 9/24/24 at 4:36 AM Resident #3 agitated throughout shift periodically. Wandering the halls saying that she has things to do and places to go. Frequently forgetting walker. Redirection made her agitated with staff. Defensive of her daughter when staff was caring for her. Calmed down some by the time staff was done taking care of daughter. This nurse tucked resident in her daughter's recliner in daughter's room. Resident seemed to relax and was thankful to this nurse with tears in her eyes. Has been about 30 minutes since interaction and resident seems to be staying comfortable in daughters recliner at this time. c) On 9/24/24 at 5:42 AM sending facsimile to the primary care provider to advise. Resident has frequent overnights of wandering. Residents daughter if effected by this by resident waking her up and doing things in her room. Staff redirects resident frequently throughout evening and night. Wondering if we could add a medication for sleep or increase melatonin dose. d) On 9/28/24 at 1:15 AM resident was up wandering in the halls most of night, she becomes irritable easily and is writing nonsensical notes. It is difficult for her to follow directions. A snack provided which she did sit down and eat. e) On 10/22/24 at 12:56 AM resident having increased wandering around building, going through her room, and going through her daughter's room. Daughter expressed concern about resident's lack of sleep due to disease process. Daughter states resident has been awake since 3:00 AM on Sunday and hasn't slept. Resident frequently forgets to have walker with her. Staff is redirecting, reminding resident to have walker. Resident favors being with daughter in her room most of the day and night. Staff recently tried to get resident to go to her room to lay down but resident refused. Resident was tucked into daughter's recliner, chair reclined, and warm blanket applied with regular blanket to promote rest for resident. Eyes closed at this time. Daughter in bed by her with call light in reach due to resident's non-use of call light. Frequently checking resident at this time. f) On 10/25/24 at 11:26 AM spoke with Resident #3's family about the benefits of moving the resident to the Chronic Confused Dementing Illness (CCDI) unit. g) On 11/7/24 at 1:12 PM resident alert and pleasant, adjusting well to the CCDI unit. On 11/8/24 at 9:47 AM Resident #3 on the CCDI unit, standing with a staff member talking about wanting to leave out the doors. Staff let the resident know she did not have the code to get out the door. The resident questioned how others were getting in and out. Staff member asked if the resident wanted to sit down to eat her donut. Resident #3 agreed if the staff sat and had a donut with her. Resident #3 sat in her recliner, with her feet reclined and watched television. On 11/7/24 at 11:45 AM the Director of Nursing stated the paper care plans that were found in the binders at the nurse's station were the most current care plans. The care plans in the Electronic Health Record (EHR) are used as a template when creating the resident's care plans. During a follow up interview on 11/8/24 at 11:40 AM stated the interventions for residents that have wandering behaviors or at risk for elopement would be found under the chronic confusion section of the care plans. The care plans of Resident #1 and Resident #3 were reviewed with the DON. Interventions specific for wandering or elopement risk residents were not located on the care plans of the two resident reviewed. The DON stated she did not think to put Resident #1's elopement on her care plan. She indicated the care plans are updated and revised quarterly and as needed per standard nursing practice.

Based on observations, clinical record review, and staff interviews the facility failed to ensure 1 of 3 resident's (Resident #1) Minimum Data Set (MDS) assessments were accurately completed. The facility reported a census of 38 residents. Findings include: On 11/7/24 at 11:32 AM Resident #1 sat at the dining room table with peers eating her lunch, wanderguard observed to be located on her left ankle. Review of Resident #1's census tab in her Electronic Health Record (EHR) documented her admitted as 5/2/24. According to the admission MDS assessment tool with a reference date of 5/15/24 it documented Resident #1 wandered daily. The MDS also documented a wander/elopement alarm was not used. According to the Quarterly MDS assessment tool with a reference date of 8/15/14 it documented Resident #1 wandered daily. The MDS also documented a wander/elopement alarm was not used. According to the Significant Change MDS assessment tool with a reference date of 8/15/14 it documented Resident #1 wandered 1 to 3 days during the 7-day review period. The MDS also documented a wander/elopement alarm was not used. The Care Plan Focus Area documented Resident #1 had poor safety awareness and dementia that could lead to wandering. The Focus Areas included hand written documentation dated 9/4/24 this was met and will be continued. The care plan documented wanderguard in the intervention/tasks section of the care plan. A document titled Elopement Risk Assessment Check List dated 5/2/24 documented Resident #1 had previous history of wandering, at home. Diagnosis of dementia, episodes of disorientation, episodes of non-acceptance of placement. High level of elopement risk, a wanderguard was put in place. A facsimile (fax) sent to Resident #1's physician documented the following note: Resident was admitted [DATE], staff noted wandering and exit seeking behavior upon admission, wanderguard placed on 5/6/24, family agreeable. On 11/8/24 at 2:05 PM Resident #1's physician indicated they agreed with the wanderguard being placed. On 11/7/24 at 1:01 PM Staff C Certified Nursing Assistant (CNA) stated Resident #1 had wanderguard on but was unsure how long she has had it. On 11/7/24 at 1:44 PM Staff B CNA stated she thought Resident #1 wore a wanderguard on her ankle but was unsure how long she has had it. On 11/7/24 at 2:45 PM Staff D CNA stated Resident #1 wore a wanderguard but was unsure how long she has had it. On 11/8/24 at 11:40 AM the Director of Nursing was made aware the MDS assessments that were completed since Resident #1's admission did not document the use of a wanderguard/elopement alarm. She acknowledged the MDS assessments should have documented that Resident #1 wore a wanderguard. At 1:53 PM the DON indicated they currently follow the Resident Assessment Instrument (RAI) for MDS assessments.

Based on clinical record review, staff interview and facility policy review, the facility failed to ensure staff followed physician orders to treat an infection and prevent subsequent hospitalization for 1 of 3 residents reviewed (Resident #1). Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating impaired cognition. The MDS included diagnoses of cancer, septicemia (infection in the blood), and urinary tract infection. The care plan last revised on 10/11/23 for Resident #1 did not have a focus area for an actual or potential for urinary tract infection. The MD/Nurse Communication form on 9/8/23 reflected the Primary Care Provider (PCP) ordered a UA with culture. The Health Status Note dated 9/9/23 at 12:12 PM, the PCP ordered a urinalysis (UA) with a culture and sensitivity (C&S) due to behavior concerns. The Health Status Note on 9/11/23 at 10:50 AM, the facility collected the UA, took it to the hospital lab, and faxed the results to the PCP. The Urinalysis Report dated 9/11/23 indicated the PCP ordered Cephalexin 500 mg by mouth twice a day for 5 days. Review of the Order Summary Report for Resident #1 revealed Staff A, Licensed Practical Nurse, entered the antibiotic order for cephalexin 500 mg two times a day for a UTI into the system on 9/11/23. The Order Note dated 9/11/23 at 5:00 PM listed that the system identified a possible drug allergy to the cephalexin 500 milligrams (mg). Review of the September 2023 Medication Administration Record (MAR) lacked the order for the cephalexin 500 mg by mouth twice a day for 5 days initiated on 9/11/23. Resident #1's record lacked documentation related to the antibiotics on 9/12/23. The Health Status Note on 9/13/23 at 9:52 AM, the resident had not started the antibiotic cephalexin due to listed allergies to penicillin and Bactrim. The C&S was to be back on 9/14/23. The facility contacted the Pharmacy, who reported the PCP wanted to go forward with the cephalexin. The facility sent a fax to the PCP for clarification on starting the cephalexin on that date. The MD/Nursing Communications form dated 9/13/23 included the progress note related to Resident #1 not starting her antibiotic and the request on when to start the medication. The PCP responded she did order it and said to give it but since no one did that, she guessed they were awaiting the C&S while her infection builds. The Health Status Note on 9/13/23 at 1:24 PM, the facility received a fax reply from the PCP to wait for C&S to initiate antibiotic. The Health Status Note on 9/14/23 at 3:00 PM, reflected that Resident #1 continued the antibiotic per the orders and displayed no side effects of the antibiotic. The Health Status Note on 9/14/23 at 9:28 PM, indicated Resident #1 continued the antibiotic for UTI. Resident #1 continued having frequency issues and not feeling well. The Health Status Note on 9/15/23 at 11:16 PM, the facility called Resident #1's daughter regarding a changed in condition. She gave approval to send the resident to the emergency room for evaluation. Resident #1 transferred to the hospital at 9:40 PM. The Health Status Note on 9/15/23 at 11:36 PM, indicated Resident #1 admitted to the hospital with a high lactic acid level (indicator of a severe infection), high white count (indicator of an infection), and a low hemoglobin (indication of a decreased supply of oxygenated blood). The Health Status Note on 9/19/23 at 10:45 AM, the resident returned to the facility under hospice care. In an interview on 12/21/23 at 7:55 AM, Staff B, LPN, stated she believed she gave Resident #1 the prescribed cephalexin on the evening of 9/14/23. She stated she knew of an issue with the cephalexin (antibiotic) and possible allergy to it related to her known allergy to penicillin. She stated the PCP had concerns with Resident #1's UTI infection getting worse if they did not give the medication. She added the medication was in the medication cart and she felt she gave the antibiotic to the resident. She stated she signed for the medication on the MAR. When told the MAR did not contain an order for the medication, she stated per appropriate medication administration she should not gave the medication without a written order on the MAR. She acknowledged that she documented giving the medication in the progress notes. In an interview on 12/21/23 at 8:00 AM, the Director of Nursing (DON) stated it was the expectation when an order came in, whether written or faxed, the nurse who received it make a copy of the order and send it to the pharmacy and write the new order on the MAR. The second check was to occur when the assigned staff entered the order into Point Click Care (PCC - the electronic health record). The third check occurred when Staff C, Registered Nurse (RN), went through the copies to ensure the medical record contained an accurate order. The DON stated Staff C checked the orders every other day, unless they worked the floor and then it could take up to a week. The DON expected the staff to complete three checks when giving medication per the facility protocol. The first check occurred when medication staff completed the five rights of medication administration and ensured the medication matched the MAR. The second check occurred when popping the medication out of the cassette to ensure it matched the MAR. The third check occurred right before giving the medication to ensure the accurate medication. The nurse was to sign the MAR immediately after giving the medication. Review of the facility's undated Medication Administration Monitoring Tool directed staff to check the MAR and identify the medications prior to administration and then charted immediately after administration.

Based on interviews, observations, and review of facility policies the facility failed to ensure procedures were developed to ensure water was available when normal water supply was lost. This failure had the potential to affect all 36 residents. Findings include: On 7/11/23 at 11:00 AM observed an emergency water supply consisting of two gallons and two 24 packs of eight-ounce water bottles in a closet in the closed dementia unit. In addition, noted 20 gallons of water and four cases of 16.9-ounce bottled water in the front storage area. The undated Emergency Water Loss Policy reflected that the policy lacked a reference to bottled water storage within the building, how to make use of existing potable and non-potable water stored in the building such as water from toilet tanks or hot water tanks, and a method of distribution. In addition, the policy referred to water storage areas using bathtubs. The facility has two whirlpool bathtubs, all other resident areas utilize showers. On 7/13/23 at 10:15 AM the Administrator acknowledged that the facility lacked water storage areas and a lack of a method of distribution. He also acknowledged that the policy lacked a reference to use of existing water stored within the building.

Based on observations, review of the facility policy, review of menus, and interview with staff, the facility failed to provide a diabetic diet for three of three residents (Resident (R) 14, R25, and R20) with physician orders for a diabetic diet. Findings include: The undated Diet Orders policy instructed that diets will be offered as ordered by the physician. The undated Diets Available on the Menu policy directed the main diet orders that will be offered are regular/no added salt, mechanical soft, puree, gluten free, house diabetic (regular with diet syrup and jellies and half portions of desserts), and small portions. The untitled and undated facility menu with matching spread sheet referred to four diets, a regular diet, a regular diet with small portions, a mechanical diet, and a pureed diet. The facility menu and matching spread sheet lacked a menu for diabetic diets and/or no Regular with half portion desserts, diet syrups, and jellies. The July 2023 physician's orders for R14, R25, and R20 provided by the Dietary Manager included the current physician's orders for a diabetic diet for each of the noted residents. During an interview on 7/10/23 at 12:41 PM, when asked about the food, R20 stated he had to ask for small portions and staff keep loading his plate. R20 stated he was a diabetic and trying to do what is best. On 07/11/23 during lunch meal from 11:10 AM to 11:40 AM witnessed all 36 diets served without a diabetic menu despite three physician orders for diabetic diets. R25 and R20 were served full portions of desserts on 7/11/23 at 11:15 AM and 11:20 AM respectively despite having physician's orders for diabetic diets. On 07/11/23 at 11:30 AM the Dietary Manager reported that she gave R25 the wrong cake from the cart. The Dietary Manager indicated, they would need to make a cart for diabetics. During an interview on 7/13/23 at 9:45 AM, the Registered Dietitian (RD) revealed diabetics were addressed by physician orders calling for a regular diet with half portions of desserts and diet syrups and jellies. The RD went on to verify R14, R25, and R20 had diabetic diet physician orders, not regular diet order with half portions of desserts and diet jellies and syrups. On 7/13/23 at 10:10 AM the Director of Nursing (DON) explained the three diabetic diets were transcribed incorrectly and would be changed.

Based on observation, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident out of 12 sampled residents (Resident (R) 4) had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly can lead to inaccurate federal reimbursements, an inaccurate assessment, and care planning of the resident. Findings include: Review of the RAI Manual, dated 10/1/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the interdisciplinary team (IDT) completing the assessment.'' R4's Face Sheet listed an admitted [DATE]. R4's admission MDS assessment dated [DATE] indicated that they used an anticoagulant for seven out of seven days during the lookback period. R4's Orders lacked documentation of a prescribed anticoagulant. During an interview on 7/11/23 at 2:13 PM, the Assistant Director of Nursing (ADON) reviewed the MDS record for R4 and confirmed the admission MDS documented the use of an anticoagulant for seven days. Review of R4's physician's orders, with the ADON, confirmed R4 did not have a prescription for an anticoagulant during the lookback period. During an interview on 7/11/23 at 2:17 PM, the ADON verified the admission MDS assessment was incorrect and should have a zero for number of days R4 received an anticoagulant.

Based on observation, interview, record review, and policy review the facility failed to update the Care Plan Focus related to a resident's fall risk with new interventions to prevent falls after a resident fell for one of 12 sampled residents (Resident (R)31). This deficient practice placed the resident at greater risk of future falls and injury. Findings include: R31's undated Face Sheet listed an admitted [DATE]. The face sheet included a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbances. R31's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS indicated R31 required limited assistance of one person with walking in her room, walking in the corridor, toilet use, personal hygiene, locomotion on unit and off the unit. R31's Fall Risk assessment dated [DATE] revealed a fall risk of 14, where a risk assessment of greater than 10 indicated a High Risk for falls. Review of R31's Fall Risk assessment dated [DATE] revealed a fall risk of 14. The Incident Note dated 2/25/23 at 3:50 AM indicated that the staff found R31 on the floor complaining of pain in her left leg. The assessment revealed her left leg rotated outward with her right knee bent. After notifying her daughter, the nurse transferred R31 to the emergency room (ER). R31's X-ray report dated 2/25/23 revealed a left hip fracture. R31's Fall Risk assessment dated [DATE] revealed a fall risk of 15. The Incident Note dated 3/30/23 at 9:33 PM reflected that staff found R31 on the floor complaining of pain in her right wrist and ankle. The assessment revealed a hematoma to her right wrist and she had full range of motion to all four extremities. After her assessment, two Certified Nurse Aides (CNAs) assisted her to bed and the nurse applied ice to her right wrist. The Health Status Note dated 3/31/23 at 1:52 PM reflected that the X-Ray revealed a fracture to R31's right wrist. The Incident Note dated 5/10/23 at 10:52 PM indicated that the staff found R31 on the floor, with a three centimeter cut on her temple, her fourth and fifth fingers bleeding. The nurse assessed her and treated her wounds. At the time of assessment, she complained of right hip pain but after her assessment revealed no abnormal findings, R31 walked with assistance to the bathroom. The Care Plan Focus reviewed 3/15/23 listed R31 had a risk for falls due to an assistive device for ambulation, chronic confusion, and a history of falls. The Interventions include: a. Fall risk assessment quarterly or sooner if indicated. b. Orthostatic blood pressure monthly if able and allows. c. Physical Therapy (PT) d. Occupational Therapy (OT) e. 2/25/23 - Sent to ER for further evaluation. f. 3/31/23 - Do not leave alone in room while awake as allows. g. 3/31/23 - Wrap right wrist, use ice, and as needed (PRN) pain medications. h. 5/10/23 - PT to evaluate and treat. The Care Plan lacked interventions following the 5/10/23 addition. On 7/10/23 at 3:49 PM, observed R31's room, with her out of the room, noted the bed in low position with a floor mat positioned in the middle of the room, not near the bed. The Care Plan lacked the observed interventions. On 7/11/23 at 2:15 PM witnessed R31 ambulating in the hallway, with a gait belt around her waist using a front wheel walker with Certified Nursing Assistant (CNA) for support. During an interview on 7/12/23 at 9:40 AM, the Social Services Director explained the Medicare meeting included a review of resident fall incident reports, review of possible causes, go over interventions if adequate and if working, and immediate new interventions. Meeting minutes were documented by the Director of Nursing (DON) and interventions to be added to the care plan. During an interview on 7/13/23 at 2:36 PM, the DON explained the residents' falls were discussed at the Medicare meeting and root causes were identified and interventions put into place. The DON confirmed R31's Care Plan did not reflect the interventions discussed. The DON explained interventions that had been put into place to prevent additional falls following each fall a. R31 received a low bed and fall mat b. R31, when out of her room, was always supervised; c. R31 received close care during the night; however, these were not documented in the medical record. The DON confirmed the discussions about the causes of the falls and new interventions implemented were but documented in the medical record. The undated Falls policy directed that falls will be discussed at Medicare meetings [and will] determine potential causes for the fall, add teaching, and/or interventions to the plan of care to prevent another fall from occurring.

Based on interview and document review, the facility failed to develop a person-centered Comprehensive Care plan for one of 12 sampled residents (Resident (R) 31). On admission R31's assessment reflected them as high-risk for falls and the Care Plan did not address person-centered interventions for falls. This deficient practice may result in interventions not identified to prevent resident falls. Findings include: R31's undated Face Sheet listed an admitted [DATE]. The face sheet included a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbances. R31's Fall Risk assessment dated [DATE] reflected a fall risk score of 14, where a risk assessment of greater than 10 indicated a High Risk for falls. R31's Care Plan lacked person-centered interventions to address their high risk of falls During an interview on 2/12/23 at 11:16 AM, the Assistant Director of Nursing (ADON) confirmed R31's Care Plan lacked interventions addressing the fall risk score of 14 upon admission. The facility did not provide a policy for Care Planning.

Based on clinical record, facility investigations, staff interview, and facility policy, the facility failed to prevent falls for 3 out of 7 residents reviewed (Resident #0, #244, and #254). The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #244's diagnoses included [CONDITION(S)], [CONDITION(S)], and cardiac arrhythmia. The same MDS revealed that Resident #244 required limited assistance of 2 persons with bed mobility, extensive assistance of 2 persons for transfers and toilet use. Fall Risk Assessments review, a total score of 10 or greater equaled a high risk for falls a. 4/9/21 - score of 17 b. 5/20/21 - score of 20 The Census recorded that Resident #244 admitted to the facility on [DATE], then had a paid hospital leave on 4/12/21. On 4/14/21, the census indicated that Resident #244 discharged on [DATE] and readmitted to the facility on [DATE] on skilled level of care. The Incident Note dated 4/11/21 at 9:57 AM recorded the staff found Resident #244 sitting on the floor near her chair in her room. Resident #244 got up by herself to use the bathroom and fell . Resident #244 didn't hit her head, she had no discoloration or bumps on her head. Resident #244's skin appeared to be intact, she could move all of her extremities, except the left arm in a sling, without difficulty. Resident #244 had no complaints of pain or discomfort. Two staff assisted Resident #244 to her feet and helped her walk to her chair without difficulty. The immediate intervention to prevent further falls included Resident #244's call light within her reach and reminders to use the call light to call for help with all transfers. The Incident Note dated 4/12/21 at 11:37 AM indicated that the staff found Resident #244 on the floor laying on her right side with a large amount of blood under her head. The staff gently moved Resident #244 over to assess her condition. Resident #244 alert and talking to the staff, she had a large hematoma (bruising) with a skin tear on her right forehead. Resident #244 had a large hematoma to her right hand with a skin tear. Resident #4 complained of pain to her right hip. The nurse applied pressure to Resident #244's head and wrapped it with gauze. The nurse called 911 to transfer her to the emergency room (ER) due to a serious head injury. The immediate intervention documented Resident #244 went to the ER to be evaluated. The ED Provider Note dated 4/12/21 at 12:09 PM revealed the following: a. The resident had an unwitnessed fall with head and right hip injury. b. The resident had an unwitnessed fall, the previous week that resulted in a left humerus fracture treated with a sling. c. Hematoma (a collection of blood outside of blood vessels) and laceration to right her forehead. d. Oriented to self only. e. The impression showed an interval development of a mild bifrontal subarachnoid hemorrhage (brain bleed) with a moderate-sized frontal scalp hematoma. f. A consultant recommended a transfer to a higher level of care with neurosurgery. g. Resident #244's family requested a transfer to a bigger hospital. That hospital's trauma physician recommended a transfer to the ER. g. Resident #244 went to the higher level of care hospital by life flight in guarded condition. The Incident Note dated 4/13/21 at 9:28 AM revealed that the facility staff spoke with Resident #244's two daughters. The daughters reported that the doctors at the Des Moines hospital, reported no present bleed. They explained the bleed was from the previous week's fall, and that it had stopped. The nurse attempt to call the Intensive Care Unit (ICU) nurse, who couldn't give any information, but did report Resident #244 as stable. The Admission Summary dated 5/20/21 at 12:18 PM revealed that Resident #244 admitted that day from an inpatient rehabilitation facility, where she received therapy. Resident #244 was familiar to the facility as she stayed there before. Resident #244 showed confusion at the time of assessment as she looked for her husband who passed away. She did know herself and her son with her at the facility that day. Resident #244 came to the facility for skilled care and continued therapy. She did well at the inpatient rehabilitation facility and only required therapy that could be provided at a nursing home. Resident #244 no longer required as intense therapy as provided at the inpatient rehabilitation facility. She does get tired very easily. The future plan per Resident #244's family was to remain in the facility. The family didn't think she could manage herself at an assisted living any longer. The Incident/Accident Form dated 5/22/21 at 4:00 AM reported that the staff found Resident #244 sitting upright at the foot of her bed tangled in oxygen tubing. Resident #244 reported that she tried to walk to the bathroom when she fell . Resident #244's only injury noted as a skin tear to her left forearm. The immediate intervention to prevent further falls listed as to increase checking and changing of her brief. The resident's call light was within reach but Resident #244 couldn't use the call light. The Incident/Accident Form dated 5/25/21 at 3:00 AM documented that the staff found Resident #244 on the floor at the foot of her bed. Resident #244 didn't answer questions, her call light observed within her reach, and floor mats were on both sides of her bed. The immediate intervention to prevent further falls included to schedule toileting and reinforcement on call light use, as Resident #244 knew how to use a call light. The Incident/Accident Form dated 5/27/21 at 11:20 PM indicated that the staff found Resident #244 kneeling near the foot of her bed on the floor mat holding onto the wheelchair arm and bed frame. Resident #244 reported that she didn't know that she couldn't walk. The immediate intervention to prevent future falls listed the staff brought Resident #244 to the lobby area for one-on-one (1:1) observation for the rest of the shift. An additional intervention written on added to assist Resident #244 to the toilet at 3:00 AM as she allowed. The Incident/Accident Form dated 6/2/21 at 6:25 PM revealed the staff found Resident #244 sitting under the dining room table on her bottom with her knees bent upward with no apparent injuries. The immediate intervention to prevent future falls included to have Resident #244 sit in a recliner in the common area for closer monitoring as she allowed. An additional intervention added to place Dycem (nonslip mat) on Resident #244's wheelchair seat. The Incident/Accident Form dated 6/8/21 at 2:10 AM recorded the staff found Resident #244 sitting at the foot of her bed with her drawers pulled out onto the floor with her oxygen tubing removed. Resident #244 had her call light in reach, but she couldn't to use her call light. The immediate intervention to prevent future falls documented the nurse did an assessment of injury, vital signs, and staff helped Resident #244 back to bed. The additional intervention written on the form to increase frequency of overnight checks. The Incident/Accident Form dated 6/11/21 at 3:50 AM read that the staff found Resident #244 lying on her right side face down on the floor beyond her bedside mat. The nurse couldn't find vital signs. Resident #244 had a one centimeter laceration to her right outer eye, a 1.5 CM laceration to her right upper lip, and a swollen right eye lid. Resident #244 had her call light within while in her bed. The Progress Note dated 6/11/21 at 3:50 AM documented that the staff found Resident #244 lying on her right side face down in a puddle of blood on the floor beside the lower end of her bed. The nurse couldn't find vital signs on assessment. After the staff rolled Resident #244 over, they noted her right eye lid swollen with a one centimeter laceration in the outer corner and a 1.25 CM on her right upper lip. Resident #244 had blood in her nose and mouth with a layer of a mucosy phlegm-like substance noted in the blood pool near her mouth. At 5:18 AM, the provider gave an order to release Resident #244 to the funeral home. At 5:45 AM the nurse called the funeral home to pick up Resident #244. The untitled handwritten document dated 6/11/21 written by Staff G, Certified Nurse Aide (CNA), indicated that she last saw Resident #244 at 3:15 AM. Staff G found Resident #244 laying on her front, mats were beside her bed and, she wore gripper socks. The Certificate of Death issued on 6/18/21 documented Resident #244's Immediate Cause of Death as head trauma due to or as a consequence of [CONDITION(S)]. The Certificate labeled the manner of death as an accident. The Description of Injury listed Resident #244 as unsteady in the middle of the night and fell hitting her head at the nursing home. The Care Plan Focus area included a goal target date of 8/18/21 reported Resident #244 had chronic confusion with a self-care deficit related to cognitive loss. The Focus included an undated intervention to offer toileting reminders and assist as needed on a schedule in relation to her daily routine. The Care Plan Focus area included a goal target date of 8/18/21 documented that Resident #244 had a risk for falls related to altered mobility (unsteady gait)secondary to a cerebral vascular accident ([CONDITION(S)], stroke), arthritis, the use of an assistive device for ambulation, chronic confusion, history of falls, lack of awareness, confusion, depression, and poor safety awareness. The Goal listed that the resident would be free of a fall related injury. The Focus included the following interventions: a. mat at bedside (undated) b. oxygen as ordered (undated) c. fall risk assessment quarterly or sooner if indicated (undated) d. low bed (undated) e. 5/22/21 - bed in low position f. 5/25/21 - fall mat at bedside g. 5/27/21 - place Dycem in wheelchair seat h. 6/8/21 - increase frequency of checks overnight The Residents' Bill of Rights revised 11/16 indicated that the residents would receive treatment and supports for safe daily living. 2. Resident #0's MDS assessment dated [DATE], identified a BIMS score of 9, indicating moderately impaired cognition. The MDS coded Resident #0 had delusions (misconception or beliefs that firmly held, contrary to reality). The MDS documented Resident #0 as independent with bed mobility and ambulation in his room. Resident #0 required limited assistance of one person with transfers, ambulation outside of his room, dressing, toilet use, and personal hygiene. The MDS coded Resident #0 as not steady but able to stabilize without staff assistance when turning around, moving on the toilet, moving off the toilet, and surface-to-surface transfers. The MDS documented Resident #0 as occasionally incontinent of urine and not on a toileting plan. The MDS included diagnoses of hypertension, Alzheimer's dementia, and [CONDITION(S)]. The MDS identified Resident #0 fell within the previous two to six months before his admission/entry or reentry to the facility. Resident #0's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severe impaired cognition. The MDS revealed Resident #0 required limited assistance of one person for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. The MDS included diagnoses of hypertension and Alzheimer's disease. The MDS identified Resident #0 fell in the last month prior to recent assessment, reentry, admission and/or entry to the facility. The Care Plan with target date of 9/19/21, identified Resident #0, as a risk for falls related to the use of an assistive device for ambulation, chronic confusion, history of falls, and relocation stress. The care plan interventions included: a. Fall risk assessment quarterly or sooner if indicated (undated) b. Physical therapy (PT) (undated) c. Occupational therapy (OT) (undated) d. Assist to the bathroom as allowed by Resident #0 (10/13/21) e. PT/OT evaluate and treat (10/17/21) f. Bed in the lowest position as allowed by the resident (11/12/21) g. Assist Resident #0 with night time cares as allowed (10/31/21) h. Acute illness (10/27/21) i. Acute illness (11/1/21) The Care Plan Focus reviewed 2/16/22 identified Resident #0 with chronic confusion and self-care deficit related to cognitive loss and a diagnosis of Alzheimer's dementia. The care plan interventions included: a. Offer toileting reminders and assist as needed on a schedule in relation to the daily routine b. Allow to set own daily routine within reason unless a safety or dignity issue involved c. Offer cues to time of day, season, etc. as needed d. Offer communication techniques appropriate for chronically confused residents e. Validation therapy as needed The Progress notes for Resident #0 revealed: a. The Health Status Note (HSN) on 10/31/21 at 11:44 PM, identified Resident #0 as uncooperative, caused nurse to trip by sticking his leg out in front of the nurse during the assessment. The resident's skin warm, dry, breath sounds clear, respirations regular and even. b. The Incident Note (IN) on 11/21 at 10:25 AM, revealed Resident #0's primary care provider (PCP) noted the fall. c. The HSN on 11/2/21 at 1:50 AM revealed Resident #0 went to the bathroom and returned to the recliner without calling for staff assistance. One staff member assisted Resident #0 to bed. Resident #0 appeared alert, pleasant and cooperative. Resident #0 had clear breath sounds, an obese (large) abdomen, active bowel sounds, skin warm, skin dry, and stable vital signs. The Skilled Daily Nurse's Notes for Resident #0 revealed: a. On 10/31/21 at 6 AM - 2 PM, the resident alert and confused at times. The resident assist of 1 with all activities of daily living (ADL's), non-complaint and got up without assistance. The resident in isolation x 10 days and continued on antibiotic with no signs or symptoms of adverse reaction noted. The resident without cough or shortness of breath, and lung sounds diminished. b. On 10/31/21 at 2-10 PM, the nurse documented to see the electronic health record (EHR) for the skilled nurse's note. c. On 11/1/21 at 6-2 PM, the nurse documented to see the EHR for the skilled nurse's note. d. On 11/2/21 at 2-10 PM, Resident #0 observed to be alert to self with confusion at times. Resident #0 was an assist of one with ADL's. Resident #0 documented as incontinent of bladder and wore briefs. Resident #0 under isolation level of care with no complaints voiced. The facility document titled Incident/Accident form dated 11/1/21 at 2:15 PM, identified Resident #0 fell in his room. The staff found Resident #0 lying on his right side on the floor between his bed and his recliner. Resident #0's assessment showed no pain or injury. Resident #0 didn't know what happened and no witness of his incident. Resident #0 had a negative assessment per the facility guidelines with range of motion (ROM) within normal limits. The didn't start neurological checks due to no evidence of head trauma noted, with the initial neurological exam negative. Resident #0's immediate intervention to prevent further falls directed that the staff took him to the bathroom and then to his recliner. Resident #0's call light within his reach, but he couldn't understand how to use. The additional intervention documented an acute illness. The Progress notes for Resident #0: a. On 9/25/21 at 2:36 AM, Behavior note (BN) documented Resident #0 wandered in the halls with ice cream. The staff observed Resident #0 down the hall with his pants and briefs down to his knees. Staff redirected Resident #0 back to his room and assisted him with personal cares due to incontinence. b. On 10/13/21 at 9:15 AM, Incident note (IN) documented the staff found Resident #0 on the floor beside his bed. Resident #0 observed lying on his right side with his head on his right arm, wearing socks but not shoes, with his brief and pants down to his knees. Resident #0 reported that he went to the bathroom. No injuries noted. c. On 10/17/21 at 9:25 AM, IN documented the staff found Resident #0 on his knees beside his bed, on the floor. Resident #0 with pants and briefs around ankles, stated he went to the bathroom. Informed the staff to assist Resident #0 after meals to use the toilet. d. On 10/17/21 at 8:00 PM, BN documented Resident #0 ambulated in the hall with his walker, looking for a drink of water. e. On 10/18/21 at 4:19 AM, IN documented Resident #0 got by himself and went to the bathroom without using his call light. f. On 10/19/21 at 4:45 AM, IN documented Resident #0 ambulated to the lobby area with his walker. The staff offered Resident #0 a snack, but he refused. The staff assisted Resident #0 back to his room and into bed. g. On 10/21/21 at 5:45 PM, Health Status Note (HSN) documented Resident #0 went to the hospital and got admitted with a diagnosis of pneumonia. h. On 10/27/21 at 4:40 PM, Order Note (ON), documented a new order for therapy after his hospitalization . i. On 10/27/21 at 11:35 PM, IN documented at 10:15 PM, recorded that the staff found Resident #0 on his right side next to the bed on the floor. Resident #0 said he fell out of bed. The staff noted the bed in the lowest position with a mat placed beside his bed. j. On 10/31/21 at 8:40 PM, IN documented the staff found Resident #0 sitting in a recliner and slid out of the recliner due to Resident #0 put his chair in the high position. The staff assisted Resident #0 to bed. k. On 11/2/21 at 1:50 AM, HSN documented Resident #0 went to the bathroom and returned to the recliner without calling for staff assistance. l. On 11/8/21 at 3:50 AM, HSN documented Resident #0 ambulated to the dining room unassisted, saying that he wanted ice cream. The staff gave Resident #0 ice cream. Resident #0 returned to room with walker and assist from the staff. Resident #0 noted to be disoriented at the time and didn't remember any safety precautions. m. On 11/12/21 at 4:32 AM, IN documented the staff found Resident #0 on the floor in the bathroom at 3:45 AM. Resident #0 observed in bed at 3:15 AM. The staff found Resident #0 with his brief off and urine under his right lower leg. Resident #0 complained of hip pain and resistive to the nurse's attempt to do an assessment. Resident #0 complained of low back and hip pain. Resident #0 positioned to lay on the floor mat and the nurse notified the local emergency room . At 4:30 AM, Resident #0 went to the hospital for x-rays. n. On 11/12/21 at 8:32 AM, IN documented Resident #0 sustained a left hip fracture and he transferred to an acute care hospital. o. On 11/24/21 at 2:25 PM, No Type Specific Note (NTSN) documented Resident #0 admitted to hospice services. Resident #0 appeared lethargic and unresponsive while lying in bed. p. On 11/24/21 at 3:10 PM, NTSN documented Resident #0 as unresponsive on his return to the facility from the hospital. Resident #0's family member said they planned to move Resident #0 to another nursing facility as the family could visit as they pleased. q. On 11/26/21 at 1:00 PM, Discharge Summary note documented Resident #0 discharged to another facility with his family, as they didn't like the visitation policy. r. On 12/6/21 at 2:27 PM, NTSN documented Resident #0's new facility notified the facility that he passed away on 12/4/21. The Skilled Daily Nurse's Notes for Resident #0: a. On 10/28/21 on the 10 PM - 6 AM shift, recorded Resident #0 fell from his bed at the start of the shift without injury. Resident #0 incontinent at the time and the staff checked him later in the shift. b. On 10/31/21 on the 6 AM - 2 PM, documented Resident #0 as alert, confused at times, and non-complaint with waiting for assistance, and got up without assistance. c. On 11/6/21 at 11:30 PM, documented Resident #0 self-transferred and walked to get himself some ice cream. The staff provided standby assistance back to Resident #0's room. The staff helped Resident #0 to the use the toilet, due to being incontinent, and then the staff assisted him to bed. d. On 11/11/21 10:30 PM, documented Resident #0 lying near the edge of the bed with the bed placed in the lowest position with a mat on either side of the bed on the floor. e. On 11/12/21 at 3:45 AM, documented the staff found Resident #0 on the bathroom floor and the staff sent him to the local emergency room . Resident #0's Fall Risk assessment dated [DATE], documented a score of 15, indicating a high risk for falls related to: intermittent confusion, ambulation with incontinence, medication use of one to two high risk medications, and one to two predisposing diagnoses. The Facility Incident/Accident Forms for Resident #0 reviewed from 10/13/21 - 11/12/21 documented the following falls: a. On 10/13/21 at 9:15 AM, Resident #0 fell in his room. The staff found Resident #0 on the floor with his brief down to his knees, wearing socks without shoes. Resident #0 said that he went to the bathroom. The immediate intervention to prevent further falls indicated the staff re-educated Resident #0 to have his briefs pulled up, his pants pulled up when walking, have his shoes on, and to call for assistance if needed. The reported recorded that Resident #0 could use his call light but he didn't have it within his reach. The additional intervention added to the form documented to assist Resident #0 to the bathroom after breakfast as he allowed. b. On 10/17/21 at 9:15 AM, Resident #0 fell in his room. The staff found Resident #0 kneeling on the floor next to his bed with his pants around his ankles. Resident #0 reported that he went to the bathroom. The immediate intervention to prevent further falls directed to assist Resident #0 away from the table after meals and help him to use the toilet. The form included that Resident #0 could reach his call light and he could use the call light. The form included an additional intervention of PT/OT to evaluate and treat. c. On 10/27/21 at 10:15 PM, The staff found Resident #0 on the floor beside his bed in his room. Resident #0 said that he fell out of his bed. The immediate intervention to prevent further falls indicated to have Resident #0's bed in the lowest position with a mat beside the bed on the bathroom side. The form said Resident #0 could reach his call light and he could use it at times. The form included an additional information as acute illness. d. On 10/31/21 at 8:40 PM, the staff found Resident #0 on the floor in room. The form documented that Resident #0's noted in a raised position with him on the floor. Resident #0 slid out of the recliner, due to the recliner being in the raised position. Resident #0 couldn't remember what happened. The form included the immediate intervention to prevent further falls directed to use an assist of two staff to assist Resident #0 for bed and into bed. Resident #0 could reach his call light but it was questionable if Resident #0 could use it. The form include an additional intervention to assist Resident #0 with cares at bed time as allowed. e. On 11/1/21 at 2:15 PM, the staff found Resident #0 on the floor on his right side between the bed and the recliner. Resident #0 couldn't remember what happened. The immediate intervention to prevent further falls directed to assist Resident #0 to the bathroom and then to his recliner. Resident #0 could reach his call light but he didn't understand how to use it. The form included additional information as an acute illness. f. On 11/12/21 at 3:45 AM, the staff found Resident #0 lying on the floor on his right side in the bathroom, with his right arm under his head without a brief on. Resident #0 complained pain to his lower back and left hip. The nurse notified the local emergency room and sent Resident #0 to the hospital for x-rays. The immediate intervention to prevent further falls indicated to check and change Resident #0's on a schedule. Resident #0 could reach his call light, but Resident #0 didn't usually use it. The form included an additional intervention as Resident #0's bed in the lowest position as allowed. The Facility documents titled Utilization Review Meeting dated 10/21/21 - 10/28/21 revealed Resident #0 had increased confusion and required an assist of one for transfers and ambulation. The Facility documents titled Utilization Review Meeting dated 10/29 - 11/4/21 indicated Resident #0 had increased confusion and required an assist of one for transfers and ambulation. Resident #0 required an assist of one but took himself at times. The Emergency Department Provider Notes for Resident #0, dated 11/12/21 at 5:05 AM, recorded that the staff found Resident #0 on the floor near the bathroom entrance on his left side. Resident #0 complained of left hip and left upper leg pain. Unknown how Resident #0 fell . Resident #0 had a history of dementia with worsening symptoms in the previous two days. The review of symptoms fo Resident #0's musculoskeletal documented him as positive for arthralgia and myalgia (pain and stiffness). The physical exam of the musculoskeletal identified a left hip deformity with tenderness and bony tenderness. The X-Ray report room dated 11/12/21 at 5:29 AM, recorded a nondisplaced left femoral transcervical neck fracture (hip). Resident #0 received [MEDICATION(S)] (controlled medication for sedation and to treat anxiety) intravenously (IV) while in the local emergency room for pain control. Resident #0 transferred out to another acute care hospital or orthopedic surgical consultation. On 5/9/22 at 1:37 PM, the Director of Nursing (DON) expressed that when a fall occurred, the nurse put an immediate intervention on the incident report and when the falls got reviewed during the weekly meetings, she would make notes to the bottom right corner of the incident report with any additional/added interventions after the immediate interventions if the staff felt additional interventions needed. The DON said Resident #0 didn't have a low bed in place at the time of his fall when his hip broke on 11/12/21. The review done with Resident #0's Care Plan with the DON confirmed that the Care Plan failed to identify that Resident #0 required assistance with ambulation and/or transfers. The DON stated Resident #0 got up with the assistance of a walker, when he returned from the hospital on 10/27/21. During the review of the interventions in place to prevent Resident #0 from falling related to his history of noncompliance with waiting for assistance, the DON reported that she checked the weekly meeting notes for interventions and reviewed to see if additional interventions were needed. The DON explained that the night shift increased checks on Resident #0, despite the lack of documentation anywhere. The DON commented that the staff would offer Resident #0 to use the toilet more frequently, as in more than every two hours on rounds. The continued review with the DON on Resident #0's falls and interventions on his care plan, the DON confirmed that Resident #0 fell on [DATE], because he had an acute illness. The DON didn't comment on the additional intervention put into place to prevent further falls. On 5/10/22 at 9:04 AM, Staff G, Certified Nurse's Aide (CNA), explained that they worked on the overnight shift and recalled that they kept a close on eye on Resident #0 due to his increased falls. Staff G added that Resident #0 did not remember, couldn't walk by himself, and would get up without waiting for assistance from the staff. Staff G stated he couldn't remember Resident #0 getting hurt when a fall occurred. Staff G stated Resident #0 attempted to get up at night without waiting for assistance. Staff G reported that the overnight staff kept a close eye on Resident #0. Staff G recalled a mat beside Resident #0's bed and they checked on him every 15-20 minutes. Staff G stated that they would let Resident #0 sleep if observed to be sound asleep during their checks on him. If Resident #0 noted to be awake, they assisted him to the bathroom. Staff G explained they attempted to use a urinal in attempt to keep Resident #0 from going to the bathroom by himself. Staff G denied remembering if Resident could use the urinal by himself. During a follow-up interview on 5/10/22 at 1:56 PM, the DON said that the facility did not have a policy related to falls. The DON added they checked on Resident #0 more frequently, but not on a set schedule. The DON explained that she expected residents to be checked at least every two hours, but more frequently for residents at a high risk of falls. The DON stated Resident #0 didn't have an exact time and/or schedule in place to use the toilet and/or to check for incontinence. The DON explained that the staff would wake up residents to use the toilet on rounds every two hours, but some residents didn't get woke up to use the toilet. The DON reported that if resident's slept in, they wouldn't wake up a resident to use the toilet, but the staff should have woke up Resident #0 to use the toilet due to his history of falls. On 5/11/22 at 8:11 AM, Staff I, CNA, said that Resident #0 would frequently get up without the assistance from the staff. Staff I explained they attempted to check on Resident #0 every 30 minutes. Staff I declared Resident #0 had dementia and could not remember to use his call light. Staff I reported that the residents used the toilet before and after meals. Staff I believed Resident #0 had floor mats beside his bed and he had his bed in low position. On 5/11/22 at 8:20 AM, Staff J CNA stated recalled Resident #0 got up frequently without assistance from the staff, however, did not recall the interventions in place to prevent falls. On 5/12/22 at 10:35 AM, Staff K, Licensed Practical Nurse (LPN), reported that she worked the overnight shift. Staff K explained Resident #0 had floor mats beside his bed due to his history of getting up without assistance. Staff K said Resident #0 had a call light, but he didn't consistently use it. Staff K stated Resident #0 would get up without assistance and go to the bathroom independently. Staff K reported they attempted to keep a walker at his bedside, with a clear path, and the bathroom light on due to Resident #0's history of not waiting for help. Staff K explained that all of Resident #0's fall interventions should have been in place when he fell on [DATE], but they couldn't confirm it. Staff K reported the staff found Resident #0 in the bathroom on the floor, on his opposite side of his fractured hip, with urine on the floor. Staff K said Resident #0 got up without staff assistance. Staff K explained the CNA's found Resident #0 during room checks. Staff K added that Resident #0 immediately complained of hip pain, he didn't move, and then he went to the hospital. Staff K stated the CNA's did frequent checks on Resident #0 due to his history of non-compliance. Staff K stated at 10:00 PM the CNA's would assist Resident #0 with a urinal, then check and change him as necessary. Staff K reported that certain residents were notorious to get up without assist and those residents got checked on frequently, however, not sure how the time frame. Staff K stated the staff assisted Resident #0 with a urinal and/or took him to the bathroom, but only if he was awake, when they checked on him during the night. Staff K denied knowing if Resident #0 woke up to go to the bathroom and/or used the urinal. Staff K stated the staff did not wake up the sleeping giant, if he slept as the resident needed it. 3. Resident #245's MDS dated [DATE] documented a BIMS score of 12, indicating moderate cognitive impairment. Resident #245 needed limited assistance of one person for bed mobility and transfers. She needed extensive assistance of one person for ambulation, dressing, toilet use, and personal hygiene. Resident #245 documented as not steady, only able to stabilize with staff assistance when moving from a seated to a standing position, walking, surface-to-surface transfers, and

Based on observations, clinical record reviews, and staff interviews the facility failed to maintain, restore, or improve the functional ability of a residents's range of motion (ROM) for 3 of 4 residents reviewed (Residents #21, #23, and #45). On 1/4/21, Resident #45 went to a specialty hospital clinic due to pain in their right shoulder with a right upper extremity contracture. The specialty hospital identified Resident #45 couldn't continue private outpatient physical therapy in October 2020 due to the novel Coronavirus 2019 (COVID) outbreak. The facility failed to provide Resident #45 a restorative nursing ROM during that time to maintain their ability and/or prevent a decline. While at an appointment on 1/4/21, Resident #45 reported significant pain with ROM to their right upper extremity and showed no function of the right arm. Documentation indicated Resident #45 developed a significant contracture of the right upper extremity. Resident #21 reported the facility didn't do restorative exercises during COVID. With the exercises Resident #21 reported a decline in function. The facility reported a census of 42 residents. Findings include: 1. Resident #45's Minimum Data Set (MDS) assessment dated [DATE], identified they had a short-term and a long-term memory impairment, with moderately impaired decision making abilities. The MDS coded Resident #45 required extensive assistance of two staff for bed mobility. Resident #45 required total dependence on two persons for transfers, with total dependence of one person with dressing, toilet use, and personal hygiene. The MDS indicated that Resident #45 had no impairments in functional ROM for the upper extremities (shoulder, elbow, wrist, and hand) or the lower extremities (hip, knee, ankle, and foot). The MDS coded Resident #45 used a walker and wheelchair for mobility. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the use of scheduled and as needed (PRN) pain medication due to daily pain. The MDS coded a 0, indicating none or less than 15 minutes daily, related to special treatments, procedures, and programs related to the restorative nursing programs. The Minimum Data Set (MDS) assessment dated [DATE] coded that Resident #45 required total dependence on two persons for transfers, with total dependence of one person with dressing, toilet use, and personal hygiene. The MDS indicated that Resident #45 had impairments in functional ROM to one side of their upper and lower extremities. The MDS listed additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident received scheduled and as needed pain medication due to daily pain. The MDS coded a 0 related to special treatments, procedures, and programs related to the restorative nursing programs. The MDS documented a therapy start date of 9/29/20 for Occupational Therapy (OT). Per the MDS, Resident #45 received 4 days of therapy for a total of 409 minutes in the last seven days of the lookback period. The Care Plan revised 12/9/20, documented Resident #45 with impaired mobility secondary to a [CONDITION(S)]. The included goal indicated that the right hand would be without a decrease in ROM. The interventions included: a. maintain proper alignment with device used to right hand b. wash and dry right hand every morning and place rolled wash cloth to prevent injury to skin, c. right hand splint on in the morning and off during the day, d. therapy ball for hand during the day. The Care Plan revised 12/9/20, identified Resident #45 as a risk for falls related to using an assistive device for ambulation, history of a [CONDITION(S)], assisted ambulation, transfers, and fall mat bedside bed. The interventions included: a. OT and Physical Therapy (PT) as needed (PRN) b. restorative program after breakfast c. assist of 1-2 with transfers d. ambulation with walker and stand by assist to contact guard assist of 1-2 staff e. assist of 1-2 with ADL's (activities of daily living). The CAA (Care Area Assessment) worksheet dated 9/1/20, identified Resident #45 required assistance with bed mobility, transfers, and ambulation with a gait belt. The CAA identified Resident #45 failed therapy, no longer walked distances in the hall, and utilized a right hand splint. The CAA notes recorded Resident #45 with a risk for falls, impaired mobility, and a self-care deficit. The CAA worksheet dated 12/3/20 documented Resident #45 required assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #45 continued to use a right hand splint. The CAA notes recorded Resident #45 with a risk for falls, impaired mobility, and self-care deficit. The review of Resident #45's Restorative Nursing documents from February 2020 through July 2020 included the following interventions a. 3-5 times per week: side stepping b. steps up/down c. kicks d. upper extremity arm bike for 5 minutes e. NuStep (recumbent bike) f. ball catch g. sit to stand 5-10 repetitions - shift trunk forward while maintaining knee flexion using a safe hand placement. The Restorative Nursing documentation for May 2020, identified Resident #45 received upper extremity arm bike for 5 minutes on 5/1/20. The form lacked documentation for the remainder of the month. The Restorative Nursing documentation for June 2020 revealed Resident #45 in isolation and received no restorative nursing. The Restorative Nursing document for July 2020 lacked documentation related to the completion of the programs. The Restorative Nursing document for November 2020 documented that the program discontinued on 11/18/20. The form lacked documentation of completion related to the restorative programs before 11/18/20. The clinical record lacked documentation of a restorative program from August 2020 - October 2020. The Physician Clinic visit note dated 7/2/20, stated Resident #45 had been on 2 week quarantine due to outside appointments at specialty hospital, and would be able to resume physical therapy (PT), needed due to increased weakness and decreased inability to walk further distances. Counseling: resume rehab/PT to help with walking and generalized weakness, 2 person assist until stronger. The Patient Results Report signed by Resident #45's physician on 7/2/20, included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The fax to the physician dated 7/6/20 documented a request for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician responded on 7/6/20 with PT/OT to evaluate and treat for generalized weakness and gait. The PT Evaluation and Plan of Treatment certification period 7/7 - 10/3/20, identified Resident #45 referred to therapy following recent decline with increased weakness, decreased ability to walk, and transfer. The section labeled Range of Motion indicated a impairment of the right lower and left lower extremities with 75-100% PROM (passive ROM) due to increased tone in flexion and extension. Resident #45 could stretch 90-100% with PROM. The PT noted impairment to the right upper extremity with a significant increased flexor tone with 25% or less PROM, able to stretch to 25-50% PROM. The PT documented an impairment to the left upper extremity, moderate increased tone with 50% PROM. The OT Evaluation and plan of treatment certification period 7/8 - 10/3/20, identified a referral to OT for Resident #45 due to a decrease in functional mobility, a decrease in strength, a decrease in transfers, a reduced ability to safety ambulate, a reduced functional activity tolerance, and a decreased postural alignment. The section labeled Range of Motion: right upper extremity impaired, approximately 10% ROM available, Resident #45 resisted PROM, the staff reported he showed signs of pain with PROM. Left upper extremity PROM/Active Assisted ROM only available that day, approximately 50% ROM available. The Fax to the physician dated 7/24/20, requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/27/20, the physician replied they agreed with orders to change the schedule for right hand splint and joint pain cream. The Physician Clinic visit note (from the primary care provider) dated 8/26/20, stated Resident #45 no longer walked due to decreased PT while on restriction during COVID. Resident #45 resumed PT and OT at the facility. The family received notice that they could resume taking Resident #45 to his PT appointment. The Medication Review Report returned with the Clinic visit note showed a handwritten order to continue with PT and OT. The Outpatient PT Initial evaluation dated 9/29/20, identified Resident #45 with signs and symptoms consistent of difficulty walking, abnormality of gait, and generalized weakness. Resident #45's functional ability to assist with transfers and gait significantly decreased since March 2020. The pain scale showed a score of 0/10 with a comment that Resident #45 couldn't verbalize pain but pulled his right upper extremity away while trying to stretch his hand. The Outpatient PT Discharge Summary dated 11/22/20, noted Resident #45 discharged from PT due to not being seen since 10/22/20 due to COVID in the nursing home. Resident #45's Representative received advice to not leave the facility due to the risk of exposure or exposing others. Resident #45 continued to have a significant contracture in his right elbow, right hand, difficulty with transfers, and gait. Resident #45's specialty hospital Clinical Notes dated 1/4/21 identified the reason for the consult as shoulder pain with right upper extremity contracture. History: Resident #45 presented with spastic right [CONDITION(S)] with the right upper extremity contracture. Resident #45 had a complex history that included a stroke four years before resulting in spastic right [CONDITION(S)] (one half of the body is afflicted with weakness, but is not paralyzed) with [CONDITION(S)]. Resident #45 lived in a nursing facility and until the previous two months ago worked with a private PT to maintain stretches, flexibility, and mobility. Resident #45 could walk short distances with the assistance of one person and a walker. Due to the COVID shut down at the facility, Resident #45 stopped going to his therapy services and subsequently developed right upper extremity contractures with the inability to walk. Resident #45 noted to be protective of his right upper extremity, he noted to be unwilling and unable to use it. Resident #45 noted to have significant pain with ROM. Resident #45 had no previous significant orthopedic problems of the arm. An X-ray showed underlying [CONDITION(S)] changes. Resident #45's Family intended to restart his private pay PT in the community as COVID restrictions eased. The section labeled Physical Exam: Strength explained a difficulty to assess due to his limited ability to cooperate. Resident #45 appeared to be able to move the left arm and leg. Resident #45 showed no function in the right arm and unable to assess the right leg. Joint ROM: flexion contractures of the right upper extremity and significant limitation of forward flexion rotation of the right shoulder. The section labeled Assessment and Plan: spastic right [CONDITION(S)] and contractures of the right shoulder, elbow, wrist, and hand. Resident #45 developed significant contractures of the right upper extremity with underlying [CONDITION(S)] changes of the major joints. The Physical Therapy Musculoskeletal Outpatient Evaluation and Treatment dated 1/5/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The section labeled Measures-Tools documented significant [CONDITION(S)] in the right upper and lower extremity The Physician Clinic visit note (from the primary care provider) dated 1/7/21, recorded Resident #45 received an evaluation at the specialty hospital on 1/4/21 for increased right shoulder and arm pain with contractures. Resident #45 had contractures since his stroke in 2018, the contractures worsened during COVID due to not being allowed to leave the care center for private PT. Resident #45 needed PT five days per week and continued splints. The section labeled Discussion/Summary included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #45's Medication Review Report dated 1/7/21, included orders of PT/OT to evaluate his right arm contractures five days a week, discontinue hospice, and [MEDICATION(S)] gel (topical pain reliever) two times a day and up to four times a day as needed for right arm pain. On 5/5/22 at 2:19 PM, Staff B, Registered Nurse (RN), said that Resident #45 received restorative nursing while a resident in the facility. Staff B explained the only time Resident wouldn't receive restorative nursing, was if the resident received skilled level of care. Staff B stated they didn't recall when Resident #45's personal care taker took the resident out for private outpatient PT. Staff B reported that Resident #45 possibly started outpatient PT before COVID hit and then he stopped going when COVID broke out in the facility. Staff B said the facility completed nursing restorative during COVID, as the family wanted Resident #45 to receive all the restorative nursing available. Staff B explained that Resident #45 had PT and OT services within the facility. The review of the monthly Nursing Restorative documentation with Staff B, they confirmed Resident #45 received only one day of restorative nursing from May - July 2020. Staff verified that Resident #45's Restorative Nursing Program discontinued on November 18, 2020 and that he had no monthly restorative sheets from August 2020 - October 2020. On 5/9/22 at 8:55 AM, the Director of Nursing (DON) reported that Resident #45 participated in outpatient PT in July 2019 - November 22, 2020. The DON added that due to the staffing crisis during COVID, the facility had difficulty getting staff and did not have enough staff to do restorative nursing programs. During a follow-up interview on 5/10/22 at 2:07 PM, the DON reported that during the COVID outbreak Resident #45's family member did not want take him out of the facility for outpatient PT. The DON stated the facility missed months of restorative nursing due to the staffing crisis. The DON explained that Resident #45's shoulder pain and contracture not new, as he had issues with pain and moving. The DON added that the family insisted for the facility staff to continue to assist Resident #45 with walking, even when it took physical assistance of two to three staff. The DON stated the family wanted to install a walking track from the ceiling to keep Resident #45 walking. The DON stated the family persisted that Resident #45 could do more than he actually could. The DON added that Resident #45 received PT and OT at the facility at times. The DON stated Resident #45 received scheduled Tylenol (pain medication) three times a day for pain starting August 2020, and tried [MEDICATION(S)] (topical pain medication, non-steroidal anti-[CONDITION(S)] drug) in February 2020 for neck pain. The DON explained that Resident #45 started [MEDICATION(S)] gel on 1/7/21 for his right upper extremity pain. The DON stated Resident #45 admitted to hospice on 8/31/20 and the facility would not have done restorative nursing for Resident #45 while on hospice. On 5/11/22 at 8:05 AM, Staff D, Certified Nurse Aide (CNA)/Restorative aide, reported they went on maternity leave from July 2020 - October 2020 and no other staff provided restorative nursing while she didn't work. Staff D reported that the facility had another CNA who tried to help, but they needed them on the floor. Staff D said the other CNA didn't work during the time Staff D went on maternity leave. The reviewed completed with Staff D of Resident #45's restorative nursing documentation from May 2020 - October 2020, Staff D verified they didn't work during that time. Staff D added that during the COVID outbreak, the facility had staffing issues. 2. Resident #21's MDS dated [DATE] documented a BIMS score of a 10, indicating moderately impaired cognition. Resident #21 required limited assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene, during the lookback period Resident #21 did not ambulate. Resident #21 could eat independently. The MDS coded a 0, indicating none or less than 15 minutes daily, related to special treatments, procedures, and programs related to the restorative nursing programs. The section labeled therapies documented zero minutes for Speech Therapy, PT, OT, Psychological Therapy, Recreational Therapy, and Respiratory Therapy. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21's Care Plan reviewed 3/2/22 included the following Focus topics: a. Activities of daily living, self-care performance deficit related to [CONDITION(S)] (paralysis on one side of the body) and [CONDITION(S)] (weakness on one side the body). b. Disuse Syndrome related to decreased motor agility, muscle weakness, and neuromuscular impairment post stroke. c. Risk for falls related to altered mobility secondary to a stroke d. Risk for impaired skin integrity related to decreased mobility In an interview on 5/4/22 at 10:25 AM Resident #21 reported the facility had no therapy since the start of COVID. Before then, Resident #21 explained that rode a bike and did arm exercises. Resident #21 said that the arm exercises really made a difference, and she felt she declined without them. On 5/4/22 at 10:25 AM observed Resident #21 sitting in a wheelchair with her arms uncovered, noted her left hand and arm contracted up to her chest. Resident #21 had two staff members move her with a pivot transfer and a gait belt to the recliner, she took few unsteady steps in the transfer. 3. Resident #23's Minimum Data Set (MDS) assessment dated [DATE] documented a BIMS scored of 9, indicating moderate cognitive impairment. Resident #23 required extensive assistance of one person for bed mobility, dressing and toilet use. She required limited assistance of one person for transfers and personal hygiene. During the lookback period, Resident #23 did not ambulate, she used a wheelchair for mobility, and she could eat independently. The MDS coded a 0, indicating none or less than 15 minutes daily, related to special treatments, procedures, and programs related to the restorative nursing programs. The section labeled therapies documented zero minutes for Speech Therapy, PT, OT, Psychological Therapy, Recreational Therapy, and Respiratory Therapy. Resident last received PT and OT services on 12/21/21. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23's Care Plan reviewed 3/16/22 lacked documentation related to restorative and PT. On 3/5/22, staff revised the Care Plan to include OT to evaluate and treat for wheelchair appropriateness. On 5/4/22 at 9:30 AM Resident #23 reported that because of [CONDITION(S)] disease, she had a decline in her ability to do things for herself over the last few months. On 5/5/22 at 8:40 AM watched Staff E, CNA, assist Resident #23 from her wheelchair to the recliner. Staff E washed her hands and then applied a gait belt on Resident #23. Resident #23 stood up, shakily, and pivoted while taking a few steps to turn into the chair. Staff E removed the gait belt, gave Resident #23 her call light, and applied her oxygen. Staff E washed her hands and checked if the resident needed anything else before leaving the room. On 5/5/22 at 8:43 AM Staff E explained that she noticed a decline in Resident #23's ability to care for herself and a decrease in her independence. Resident #23 needed more assistance with transfers due to being more shaky and she now used oxygen. Resident #23 needed help to get to her oxygen and put it on. On 5/4/22 at 1:20 PM Staff D, CNA/restorative aide, stated that residents saw physical therapy first then after they discharged from therapy, she receives a plan to work with the residents. Staff D explained that the facility didn't do any therapy or rehab (restorative care) during the facilities COVID outbreak. The day of interview on 5/4/22, was the first day back doing therapy and rehab. Staff D added that she worked three days a week and Resident #21 was on her list of people to visit with about restarting rehab. On 5/5/22 at 9:31 AM Staff B commented that Resident #23 did have a decline in her ADLs but she had [CONDITION(S)] disease so a decline was expected. Staff B added that the facility didn't have therapy or rehab while they had the COVID outbreak. The undated document titled Communal Dining, Group Activities and Resident outings, provided by the DON from the Centers for Medicare and Medicaid Services (CMS), refers the facilities to follow the Center for Disease Control (CDC) for COVID outbreaks. The DON reported that the facility followed that document regarding what could be done during an outbreak. The document lacked information related to the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER]