Every finding on record at Fair Oaks Lodge

Based on observation and interview, the facility failed to ensure the medications were secured for 2 of 3 medication storage rooms. In addition, the facility failed to secure a medication cart in public space for 17 residents. (R15, R62, R52, R57, R65, R64, R63, R53, R54, R55, R13, R56, R58, R59, R61, R60, R33)Findings include: During observation on 3/9/2026 at 5:36 p.m., with registered nurse (RN)-A of medication storage room the mini-fridge that contained liquid lorazepam (controlled medication used as sedative, antianxiety medication)) was unlocked. RN-A confirmed that it should have been locked and reported the reason being so no one can come in and take it. During observation on 3/09/2026 at 5:46 p.m., an unlocked, brown, five drawered medication cart was identified in the facility chapel. In the top drawer: -one medication cup contained a variety of forty-seven full pills and four half pills -One bottle of over the counter (OTC) allergy relief 60mg. -One bottle of melatonin (sleep aid) 3mg expires 2/26, one bottle B12 2500 mcg. -One bottle of anti-fungal powder miconazole nitrate 2% (helps treats rashes). -One bottle diclofenac sodium top gel 1% (for minor pain). -One medication for R15: Refresh Classic lubricant eye drops (for dry eyes) 29 single droplet vials. In the third drawer: - One medication card for R62: hyoscyamine sulfate (for stomach and intestinal disorders) 0.125mg 30tablets. - One medication card for R62: Xarelto (helps the blood from clotting) 20mg 14 tablets. - One medication card for R62: cyclobenzaprine (muscle relaxant) 10mg 29 tablets. - One medication card for R62: famotidine (helps control stomach acid) 20mg 19 tablets. - One medication for R62: Refresh Classic (for dry eyes) lubricant eye drops 29 single droplet vials. - One medication card for R52: sertraline (antidepressant) HCL 50mg 27 tablets. - One medication card for R52: trazadone (antidepressant) HCL 50mg 14 tablets. - One medication card for R57: metformin (for diabetes) 1000mg 25 tablets. - One medication card for R65: furosemide (helps body remove excess fluid) 20mg 14 tablets. - One partial bottle for R64: of Antacid EL 300mg tablets. - One bottle for R64: liquid Guaifenesin-DM (helps control coughs) 100-10 MG/5ml. - One bottle for R63: Geri-[NAME] (helps with constipation). - One bottle for R63: mag chloride 64mg ([NAME] stomach acid). - One bottle for R63: ibuprofen 20mg (for minor pain relief). - One bottle for R63: aspirin 325mg (for minor pain relief). - One bottle for R63: vitamin E 450mg. - One box for R63: labeled Acetaminophen suppository which contained: two suppository of Acetaminophen 650mg (for pain relief), four bisacodyl 10mg suppositories (for constipation). - One tube for R63: Skin Repair Cream - One bottle for R63: of Neilmed Clearcanal Earwax Softner. In the fourth drawer: -One Spiriva Handihaler (inhaler to help lungs be healthier). -One box of Novofine 30 needle tips. In the fifth drawer -One medication card for R65's: amlodipine besylate (heart medication) 5mg 14 tablets. - One medication card for R65: furosemide (helps body remove excess fluid) 20mg 15 tablets. - One medication card for R62: metoprolol SU (heart medication) 25mg 12 tablets. - One medication card for R62: gabapentin (treats nerve pain) 300mg 29 tablets. - One medication card for R62: oxybutynin cl (helps the bladder control urine flow) er10mg 12 tablets. - One medication card for R62: famotidine (helps control stomach acid) 20mg 22 tablets. - One medication card for R62: furosemide (helps body remove excess fluid) 40mg 12 tablets. - One medication card for R62: metformin HCL (helps with diabetes) 500mg 28 tablets. - One medication card for R62: omeprazole (helps with stomach acid) 40mg 29 caps. - One medication card for R53's: lisinopril (helps with high blood pressure) 40mg 24 tablets. - One medication card for R53's: furosemide (helps body remove excess fluid) 40mg 25 tablets. - One medication card for R53's: Glipizide (to help with diabetes) ER 10mg 25 tablets. - One medication card for R53's: amitriptyline (antidepressant) HCL 25mg 25. -One medication card for -R53's: Tamsulosin (helps with prostate) HCL 0.4mg 25 caps. - One medication card for R53: metformin (helps with diabetes) HCL 1000mg 24 tablets. - One medication card for R53's: metoprolol succinate (for the heart) 50mg 24 tablets. - One medication card for R53's: metoprolol succinate (for the heart) 50mg 24 1/2 tablets. - One medication card for R54: Fluoxetine (antidepressant) 40mg 6 caps. - One medication card for R55's Ramelton (helps people fall asleep faster) 8mg 13 tablets. - One medication card for R13's: oxcarbazepine (for seizures) 600mg 28 tablets. - One medication card for R13's: oxcarbazepine 9for seizures) 600mg 28 and a half tablets. - Three medication card for R52: divalproex sodium DR (used for seizures or mental illness) 125mg 26 total tablets, - One medication card for R52: divalproex sodium DR 125mg 9 caps. - One medication card for R52: divalproex sodium DR 125mg 11caps. - One medication card for R52: divalproex sodium DR 125mg 25 tablets. -One medication card for R52: divalproex sodium DR 125mg 30 tablets. - One medication card for R52: divalproex sodium DR 125mg 23 tablets. - One medication card for R52: Gabapentin (used for nerve pain) 300mg 23 tablets. - One medication card for R56: levothyroxine (to help the thyroid gland) 88mcg 13 tablets. - One medication card for R58: Quetiapine (treats mental illness) 25mg 13 tablets. - One medication card for R59: ketorolac tromethamine (used for moderate pain) 10mg tab 4 tablets. - One medication card for R60: Eliquis (helps blood from clotting) 2.5mg 14 tablets. - One medication card for R33: metoprolol tart (heart medication) 100mg 29 tablets. - One medication card for R61: tamsulosin HCL (helps the prostate) 0.4mg 14 caps. - Twelve sealed Quick Cath needles. - Three sealed TB Safety Syrine 25 gauge needles. - One sealed Safety Syringe 1ml needle. - Three loose safety needles. - One sealed 25g butterfly catheter. During an interview on 3/09/2026 at 7:00 p.m., DON confirmed that the medication cart was unlocked and should not be stored in chapel. DON confirmed that there were medications from current and discharged patients. DON indicated her expectation was medications should be destroyed after discontinued or resident was discharged , unless pharmacy identified medication could be returned. DON stated it was important to lock up medications, so residents, staff and visitors did not have access to medications or needles stored in the medication cart, which could harm or injure them. DON reported that the Associate Director of Nursing (ADON) used the med cart for training purposes. During an interview on 3/09/2026 at 7:08 p.m., ADON confirmed medication cart was being used as training material for a trained Medication Administration (TMA) course. ADON confirmed the medication cart was unlocked and they did not have a key to lock it. ADON confirmed there was medication from current and discharged residents in the med cart. ADON confirmed medications of current and discharged residents should not be used for training purposes due to privacy violations and risks of medication diversion. ADON reported medications had been stored in the unlocked medication cart since 3/4/26. During interview on 3/11/2026 at 12:22 p.m., with consulting pharmacist (CP) she confirmed that lorazepam should be double locked. CP confirmed med room door should be locked with a lock on the fridge door. During interview on 3/11/2026 at 1:03 p.m., Director of Nursing (DON) reported the expectation was that the fridge should be locked per Policy. DON reported this is because medication could be diverted to either residents or staff if it is not double locked. During a phone interview on 3/11/2026 at 12:22 p.m., CP confirmed expectation was med carts should be locked when not being used and discontinued medication should be destroyed and not be used for training purposes. CP reported that she was not aware there was an unlocked med cart in the chapel with discontinued medications being used for training purposes. CP confirmed that having unsecured medications in a public space could lead to medication diversion. During a follow up interview on 3/11/2026 at 1:03 p.m., Director of Nursing (DON) reported the expectation was that the mini fridge with lorazepam should be locked per Policy. DON reported this is because medication could be diverted to either residents or staff if it is not locked. The facility policy title Controlled Substance Management revised 8/7/24, identified storage of medications listed in Schedules II, III, IV, and V under double lock, separate from other medications. Observation on 3/9/26, at 12:22 p.m. third floor there was a nurses station, to the left of the nurses desk was a medication room, the door to the medication room was observed to be open, there were no nurses observed in the area. Observed full size and mini refrigerators (fridge) in the medication room, there was no locks observed on either refrigerator. Observation on 3/9/26, at 12:25 p.m. facility administrator office was next to the medication room, administrator walked out of the office past the open medication room. No nurse was observed in the area. Observation on 3/9/26, at 12:37 p.m. facility dietary manager walked past the open medication room. No nurse was observed in the area. Observation on 3/9/26, at 12:39 p.m. licensed practical nurse (LPN)-A walked past open medication room into nurses room, grabbed a meal tray, walked back past open medication room, door remained open. LPN-A left view of medication room. Observation on 3/9/26, at 12:39 p.m. nursing assistant (NA)-C walked past open medication room, sat at the desk across from the open medication door. No nurse was observed in area of medication room. Observation on 3/9/26, at 12:40 p.m. LPN-A walked back past the open medication room door to the nurses room, sat down at desk. On 3/9/26, at 12:42 p.m. resident wheeled past nurses station in power wheelchair. When interviewed on 3/9/26, at 12:47 p.m. LPN-A stated the medication room contained treatment supplies and extra medications for residents. LPN-A stated the medication room door was usually left open when the nurses were near the room, so nurses were able to enter the room without having to repeatedly use the key to unlock it. Reviewed content of medication room with LPN-A after entering the room through the open door, directly in front of the open door there was a black medication disposal bin, next to the black bin was a full-size fridge that contained supplements. To the left of the full-size fridge was a cabinet with a mini fridge on top, there was no lock located on the mini fridge. Reviewed contents of mini fridge with LPN-A, located bottle of liquid lorazepam (controlled medication used as sedative, antianxiety medication) in the door, no lockbox was located inside the mini fridge. LPN-A stated lorazepam was able to be stored in the unlocked medication fridge When asked about open medication room door LPN-A stated Oh was it then stated the door should have been shut when not in view of the medication room. When interviewed on 3/11/26, at 11:15 a.m. director of nursing stated the medication room door was expected to be closed when the nurse was not in the room or within direct eyesight of the medication room. DON stated the only staff authorized to have keys and access the medication was the nurses and trained medication aides (TMAs). DON stated narcotics/controlled medications that included lorazepam were not to be stored in the third floor medication room, there was not lock on the mini fridge on that floor. Those medications were to be stored in the second floor medication room that did have a locked medication fridge. DON stated without the locked fridge the lorazepam was not secured with two separate locks, it definitely was not secured with two different locks with the medication room door being left open with no nurse/TMA in the room or in direct eyesight. DON stated it was important to secure the medication room and narcotic/controlled medications for safety and to decrease risk of diversion by a resident or an unauthorized staff member. When interviewed on 3/11/26, at 12:30 p.m. consultant pharmacist (CP) stated doors to medications were expected to be shut and locked if nurse/TMA is not inside the room or in direct view of the room. CP stated lorazepam was required to be in medication fridge with either a locked fridge door or a secured lock box located inside the fridge for safety, decrease diversion. CP stated medication room doors left open was an unacceptable process. Facility Medication Storage policy revision date of 2/12/24, indicated compartments containing medications should be locked when not in use. Medications that required refrigeration should be stored in the refrigerator. All controlled drugs are stored under double-lock and key.

Based on observation, interview and document review the facility failed to assess for restraints for 2 of 2 residents (R29 and R47) reviewed for use of a seatbelt.R29's quarterly minimum data set (MDS) dated [DATE], indicated R29 was cognitively intact, R29 was dependent on staff for activities of daily living. MDS section P indicated R29 had no wheelchair restraint in use. R29 had diagnoses that included diabetes, hypertension, history of transient ischemic attack (TIA- mini stroke), and hemiplegia (loss of voluntary movement) and hemiparesis (weakness) following cerebral infarct (stoke). R29's care plan dated 2/21/26, indicated R29 was able to safely use power wheelchair with interventions that included provide verbal cues and reminders when approaching elevator and use seat belt. A therapy recommendation to nursing dated 2/19/26, stated assist R29 to get into her power wheelchair use seat belt, tilt power chair back slightly elevate legs/feet pedals. However, review of R29's electronic medical record (EMR) failed to indicate a restraint assessment was completed to ensure seat belt was not considered a restraint for R29, in addition, R29's EMR lacked a physician order for seat belt use when in power wheelchair. On 3/9/26, at 1:25 p.m., R29 was observed in power wheelchair with seat belt fastened. R29 stated she has it on when in the power wheelchair. R29 was observed with seat belt fastened when in wheelchair on 3/10/26, at 11:51 a.m.; 3/10/26, at 2:02 p.m.; 3/11/26, at 7:29 a.m. and 3/11/26, at 10:16 a.m. When interviewed on 3/11/26, at 10:17 a.m. nursing assistant (NA)-B stated R29 required assistance to grab the seat belt when putting on but R29 was able to fasten and release the seat belt. When interviewed on 3/11/26 at 10:30 a.m., registered nurse (RN)-B stated the expectation was to obtain a physician order for seat belt use in wheelchairs. RN-B reviewed R29's EMR lacked evidence of an order for a seatbelt. RN-B stated she did not complete the assessments, that would have been the director of nursing (DON). When interviewed on 3/11/26, at 10:52 a.m. DON stated when a resident utilized a seat belt in the wheelchair the expectation was there would be an order from the physician and a restraint assessment to ensure the resident was able to apply and remove the seat belt independently to ensure it would not be considered a restraint. DON reviewed R29's EMR stated there was no physician order, no documentation regarding an assessment was completed. DON stated the therapy recommendation to use the seatbelt in the power wheelchair should have triggered the assessment to completed and the physician order to be obtained. R47's quarterly MDS dated [DATE], indicated R47 was cognitively intact and was dependent on staff for ADLs. R47's diagnoses included hemiplegia and hemiparesis following cerebral infarct, cerebral palsy (movement and posture disorder affects muscle tone, coordination and balance), epilepsy, spondylosis (age related degeneration of spine), and osteoarthritis. Review of R47's EMR failed to indicate a restraint assessment was completed to ensure seat belt was not considered a restraint for R47, in addition, R47's EMR lacked a physician order for seat belt use when in power wheelchair. R47's care plan did not address seat belt use when in power wheelchair. When interviewed on 3/10/26, at 3:20 p.m. NA-A stated R47 used a seat belt when in the power wheelchair, R47 was able to remove it independently but had difficulty applying the seat belt due to limited use of one arm. When interviewed on 3/10/26, at 3:23 p.m. trained medication assistant (TMA)-A stated R47 was unable to apply the seat belt, had use of one hand but R47 was able to remove the seat belt independently. When interviewed on 3/11/26 at 10:52 a.m., DON stated when a resident utilized a seat belt in the wheelchair the expectation was there would be an order from the physician and a restraint assessment to ensure the resident was able to apply and remove the seat belt independently to ensure it would not be considered a restraint. DON reviewed R47's EMR stated there was no physician order, no documentation regarding an assessment was completed. DON stated the therapy recommendation to use the seat belt in the power wheelchair should have triggered the assessment to completed and the physician order to be obtained. Facility restraint policy was requested; however, none was received.

Based on observations, interviews, and document review, the facility failed to ensure that the residents' ability to self-administer medications (SAM) was assessed prior to leaving medications with the resident for 2 of 2 residents (R11, R34), reviewed for medications left at the bedside.Findings include - R34's Medical Diagnosis page (print date of 3/11/26) documented the following diagnoses: morbid obesity, major depression, generalized anxiety, female stress incontinence. A review of R34's last quarterly Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact, moderate level of depression, and required dependent with bathing / showering and toileting hygiene. During observation and screening of R34, on 3/9/26 at 1:26 p.m., it was noted R34 had a bottle oy Nystatin powder (a prescription antifungal medication used primarily to treat Candida infections (yeast infections) of the mouth (thrush), skin, and esophagus by disrupting fungal cell membranes) on a table next to her bed. The bottle was noted to have had a prescription label, now removed with only a strip of yellow colored label left. R34 stated she uses it for the rashes she get between the folds of her skin. During further observations on 3/10/26 at 10:46 a.m. the bottle was missing from resident's bedside table, but on 3/11/26 at 8:22 a.m. the bottle of Nystatin powder was again observed in R34's room. A review of R34's electronic medical record, documented a medication Self-Administration Safety Screen (SAM) - V 3 (dated 4/29/24) had been completed. However, R34's was only approved for the following: cough drops, Arnuity Ellipta Inhalation Aerosol Powder (reduces airway inflammation to improve breathing, with a typical dosage of one inhalation once daily), Albuterol Sulfate Nebulization Solution (a prescription bronchodilator used in a nebulizer machine to treat asthma and COPD) and Flunisolide Nasal Solution (a prescription corticosteroid spray used to treat seasonal or perennial allergy symptoms). In review of R34's Care Plan last revised 2/20/26, documented the following: I am at risk for alteration in skin integrity related to: risk for skin fold intertrigo - morbid obesity, altered gait and decreased mobility . AND Resident wished to self administer inhalers after staff set up. A review of R34's current Physician Orders, the physician wrote: Ok to self administer inhalers after staff set up (dated 1/26/26), where as the prior order, which was still listed May administer all medication after nurse has prepared, including oral, inhalers and topical medications (dated 3/25/24). Although, with the current Physician's Orders did include R34 being able to self-administer her Nystatin Powder with the order for topical medications, R34's SAM assessment lacked identification of Nystatin being listed in the assessment. During interview on 3/10/26 at 3:24 p.m., trained medication assistant (TMA)-A stated R34 is only allowed to self-administer her inhalers. When asked about the bottle of Nystatin powder in resident's room, TMA-A stated she can have 'sticky fingers' after taking a shower, when to powder is applied. The facility's director of nursing (DON) approached during this interview and confirmed R34 had only been assessed for cough drops and her inhalers. During a further interview on 3/10/26 at 3:30 p.m., DON had just returned with the bottle which only had the yellow part of the pharmacy label attached. DON stated not only did her current order not allow topical medication, with the pharmacy lable missing, was the bottle really hers. DON stated when she asked R34 where the bottle of Nystatin came from, R34 stated a nurse gave it to her 3 days ago. DON stated no resident unless assessed should be administering any medication, for their safety. I R11 Findings include: R11's admission Minimum Data Set (MDS) dated [DATE], identified R11 cognition was intact and diagnoses, which included gastroesophageal reflux disease (GRD), depression, and anxiety. R11 required moderate assistance with activities of daily living (ADLs) and transferring. R11's care plan dated 12/16/25, identified R11 needed assistance with ADLs related to decreased mobility and uses antidepressant, antipsychotic, and anticonvulsant medications. Care plan lacked information regarding the ability to leave medications at the bedside. R11's order summary report dated 2/5/26 lacked information regarding an order for self-administration of medications. R11's order summary report for the month of March lacked orders regarding a self-administration of medications. R11's medical chart lacked evidence of a self-administered medication assessment. (SAM). During an observation on 3/9/26 at 4:29 p.m., R11 was lying in bed with a blanket, eyes closed. A medication cup with medications was on the side table. No nursing staff were in R11's room or outside the room. During an observation on 3/9/26 at 4:49 p.m., R11 was lying in bed with a blanket and eyes closed. The medication cup continued to be on the side table next to the bed. No nursing staff were in R11 room or outside the room. During an interview on 3/9/26 at 4:37 p.m., registered nurse (RN)-A verified she gave R11 medications but did not watch her take her medications. RN-A was unable to locate a SAM for R11. During an observation and interview on 3/11/26 at 8:34 a.m., R11 was lying in bed with a medication cup with medications in the cup next to the bed. Trained medication aid (TMA)-A was located in another hallway and was notified of resident who had medications next to her bed. TMA-A said R11 was awake and had the medication cup in her hand when she left the room for an emergency across the hallway. TMA-A went to R11 room and woke up R11. TMA-A handed R11 the medication cup and watched R11 take her medications. TMA-A verified R11 did not have a SAM completed or an order to self-administer medications. TMA-A verified the normal practice was to watch residents take their medications for safety. During an interview on 3/9/26 at 4:49 p.m., director of nursing (DON)-A verified R11 did not have a SAM completed. DON-A expectation would be to perform a SAM to ensure the resident was capable of taking medications correctly and safely. During a follow-up interview on 3/11/26 at 8:41 a.m., DON confirmed a self-administration medication assessment had not been completed for R11. During an interview on 3/11/26 at 12:30 p.m., pharmacist consultant (PC) verified medications were not to be left in a resident's room without an assessment done and an order from the primary care provider to ensure a resident is able to administer medications safely. A policy titled medication self Administration, revised on 2/12/24, identified: the resident shall have a screen completed by a licensed nurse to determine factors that impact the self administration of medications. The ability to self-administer medications will indicated, able to self-administer medications independently, able to self-administer medications with supervision, cueing, and/or set-up, not able to self-administer medications safely. Residents who have been deemed appropriate to self-administer medications independently or with supervision/, cueing and/or after setup, shall have a physician's order to do so. The self-administration of medications will be care planned with interventions specific to the individual resident. Medications to be self-administered shall be secured in a locked are in the resident's room or stored in the medication cart for provision to the resident to self-administer.

Based on observation, interview and document review, the facility failed to ensure the required nurse staffing information was posted daily. This deficient practice had the potential to affect all residents who resided in the facility and/or any visitors who may have wished to view the information.Findings include: During observation on 3/9/25 at 11:30 upon entry of the survey, the staff posting for Friday March 6th was observed in the facility. During observation on 3/9/26 at 1:00 P.M., the staff posting for Friday March 6th was observed in the facility. During interview with Administrator on 03/09/2026 3:49 P.M. confirmed that staff list posted in the facility was wrong date. Administrator confirmed that posted list should be updated but that the person who posted it daily was gone out for the day. She confirmed that she should have updated the staffing A facility policy titled Staff Posting revised 10/19/23 indicated the facility shall post daily, for each shift, the actual hours and total number of hours worked by licensed and unlicensed nursing staff who are directly responsible for resident care on each shift in the facility. At the beginning of each shift, the facility will verify that the hours are posted in a clear and readable format: the name of the facility, current date, facility census for nursing home residents, facility specific shifts for the 24-hour period, total number of licensed nursing staff worked per shift, total number of unlicensed nursing staff worked per shift, actual time worked for the specific categories of nursing staff, including split shifts.

Based on observation, interview and document review the facility failed to ensure safe transport with a facility van for 1 of 3 residents (R1). This resulted in an immediate jeopardy (IJ) for R1 when she slid out of wheelchair during transport, resulting in fractures. The immediate jeopardy (IJ) began on 6/11/25, at approximately 10:00 a.m., when the transport driver (TD) transported R1 in the facility van without the use of a seatbelt. R1 slid out of her wheelchair during transport resulting in closed fractures to the right and left tibias (the larger bone of the lower leg) and closed fracture of left femur (the main bone in your thigh that connects your hip to your knee and is your body's largest and strongest bone). The IJ was identified on 6/18/25, the administrator was notified of the IJ on 6/18/25, at 1:32 p.m. The IJ was removed on 6/12/25, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's admission Record indicated she admitted to the facility 12/2/2004. R1's diagnosis included anxiety, morbid obesity and muscle weakness. R1's annual Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she had upper and lower extremity impairments on both sides. The MDS indicated R1 was dependent on staff for all activities of daily living including wheelchair mobility. R1's care plan revised 6/17/25, identified a low risk for falls as she was dependent on staff for significant movements. Potential for falls due to staff error during positioning/transfers. R1 had an actual fall during transport 6/11/25, with injuries. The care plan indicated R1 must be transported by stretcher for out of town appointments and may use local transport for in town appointments. A facility Incident Summary indicated on 6/11/25, during routine transport, R1 was transported in the facility van in a wheelchair. Due to R1's size, the driver was unable to secure the seatbelt. Based on prior guidance from a former administrator, the driver believed that securing only the wheelchair was sufficient for safety. While in transport, R1 began sliding from her wheelchair and ultimately ended up on the floor of the van. The driver immediately stopped the van and contacted emergency services. R1 was transported the Emergency Department (ED) for further evaluation. Initial medical evaluation did not identify any injuries and R1 returned to the facility. Driver received immediate education regarding facility transportation safety policy which mandated the use of appropriate restraints for all residents during transport. R1' facility Progress Notes indicated the following: 6/11/25, R1 returned from hospital via ambulance. R1 returned with a new order for Hydrocodone-Acetaminophen 5 milligrams(mg)-325 mg to be given as needed every six hours for pain. 6/13/25, R1 reported pain in both hips rated 10/10 on pain scale. 6/14/25, R1 had pain on outer side of right leg when rolling in bed and transferring into wheelchair. 6/15/25, R1 had outer right leg pain when rolling and being lifted into chair. 6/15/25, R1 had a greenish bruise on her right leg below the knee with pooling color going towards inner right leg. The same area the pain was in. The bruise was first notices on the p.m. shift on 6/14/25. 6/16/25, R1 continued to have complaints of pain in legs and yelled out when being moved. R1 to be sent by ambulance to the emergency department (ED). 6/16/25, R1 returned form the ED with diagnosis of closed fracture of medial portion of right and left tibia and closed fracture of left femur. New order for Hydrocodone-Acetaminophen 5-325 mg, 1 tablet every four hours as needed for pain. R1 returned with knee immobilizers to right and left lower extremities. R1's ED notes dated 6/16/25, indicated diagnosis of closed fracture of medial portion of right tibial plateau, initial encounter. Chief complaint: extremity pain. The notes indicated R1 admitted from nursing home with right lower leg and bilateral hip pain. R1 was paraplegic, was in a wheelchair last week and fell out onto the floor and has had increased pain in the hips since. Today at the nursing home she was having pain again and staff noticed bruising about the proximal right lower leg which had not previously been x-rayed. On 6/17/25 at 1:37 p.m., R1 was interviewed along with family member (FM)-A. FM-A stated the day of the incident, she had been told the TD had secured the chair to the floor but had not placed a seat belt around R1. R1 stated she remembered the fall and pointed to the floor with her finger and said boom. When asked if she had been injured R1 stated, oh yeah. FM-A identified after the incident, R1 went to the clinic near where the incident had occurred where they did only a hip x-ray. FM-A stated R1 went to the ED the previous day and both of her legs were fractured; adding; she knew on the 12th that something was wrong because R1 was in so much pain when transferred in the lift. During interview on 6/17/25 at 1:58 p.m., the director of nursing (DON) stated the TD was the only person who drove the van. She added, she was not aware of any training completed when the TD was hired but said he was educated on the transport policy after the incident. During interview on 6/17/25 at 2:37 p.m., the TD stated he had been driving for the facility since February of 2024. The TD stated he remembered a lot of policy stuff the first few days but did not remember receiving any education specific to the transport of residents. He stated on 6/11/25, R1 had an appointment in the cities and said when he went to load her into the van, he wasn't very optimistic. The TD stated the wheelchair was very big and unless the chair was smaller it was hard to get the chair positioned facing forward. The TD said the ideal position in the van was to face the person forward, connect the straps to the wheelchair and place the seatbelt on the resident. He revealed he was not able to get the seatbelt on R1 and was unable to tilt the chair back. The TD stated while on the highway, R1 was asleep then suddenly yelled out as if she were startled and she slid forward out of the chair. The TD stated he could hear the concern in R1's voice so he pulled over, R1 was still in motion so he tried to block her from falling to the floor. TD added, in hindsight he should not have transported R1 without a seat belt, received education and training after the incident and was the DON had been auditing as he loaded residents into the van. During observation on 6/17/25 at 2:50 p.m., R1 was transferred from wheelchair to bed using a total body lift. During the transfer, R1 was saying, it burns, I can't stand it. R1 displayed facial grimacing and said ayy, yaay, yaay, ouch. R1's legs were wrapped from ankle to mid-thigh in immobilizers. During interview on 6/18/25 at 10:06 a.m., the human resources director stated she had worked at the facility for four years and had never provided any policies, procedures or training related to transporting residents in the facility van. Facility policy, Transport Driver Policies and Forms dated September 2023, indicated; ensure all residents and wheelchairs are safely secured. Facility Transportation Driver Job Summary, September 2023, indicated; transports residents to and from appointments in a safe and responsible manner. The past noncompliance immediate jeopardy began on 6/11/25. The immediate jeopardy was removed 6/12/25, and the deficient practice corrected after the facility implemented a systemic plan that included the following actions: - Implemented education and audits for safe transport for the TD. - The administrator and human resources director received education on training and polices to be completed upon hire of anyone transporting residents in the facility van. - Education and audits were verified through interview and document review.

Based on observation, interview and document review the facility failed to implement interventions to provide adequate monitoring and supervision for 2 of 3 residents (R1, R2) who reside on a memory care unit. R1 and R2 identified with wandering, elopement behaviors, and left the facility without staff being aware of where they were. Findings included: R1's elopement risk assessment completed on 1/5/25, identified he was ambulatory, had a history of wandering/elopement/exit seeking, dementia, wandered within the home without leaving grounds, and experienced sundowners (increased confusion, difficulty sleeping, anxiety, agitation, hallucinations, pacing and disorientation people living with dementia may experience from dusk throughout the night). He scored 10 on the assessment (0-8 low risk, 9-10 at risk to wander, 11-above high risk to wander) and was at risk to wander. R1's care plan dated 1/6/25, identified activity of daily living (ADL) self-care deficit and high risk for falls related to weakness, blind in right eye, hearing difficulty, and impaired cognition. He was independent with straight care (walker per DON) in halls, room, and transfers and required guidance for orientation. He was an elopement risk/wanderer/at risk to leave facility without notice/unauthorized related to dementia. Staff were directed to monitor for exit seeking, wandering, talking about leaving facility, document episodes, and offer activities for distraction, toileting, walking inside/outside, call family, structured activities, food, conversation, television, and books. He lived in the special care/secured unit and staff were directed to monitor for tailgating when visitors were in the building and provide a safe and secure environment. R1's Cognitive Performance Test (CPT) (a standardized occupational therapy (OT) assessment initially developed as a research instrument to assess cognition in daily tasks performance and change over time with Alzheimer's disease) dated 1/8/25, identified and an average CPT score of 4/4 out of 5/6 and indicated the need for 24-hour supervision. R1's admission Minimum Data Set (MDS) dated [DATE], identified continent of bowel and bladder. His diagnoses included congestive heart failure (CHF), kidney failure, diabetes mellitus (DM), dementia, anxiety, and no falls. admitted to facility on 1/3/25, from a hospital. He had moderately impaired cognition, no behaviors, and sometimes socially isolated himself. He required set-up/clean up assistance with toileting hygiene, supervision/cues for eating, independent with oral hygiene, dressing himself, sit to stand, all transfers, ambulated up to 150 feet in corridor, walking on uneven surface and steps/curbs not attempted due to medical condition or safety concerns, used a walker for mobility. His medications included antipsychotic, antidepressant, diuretic, opioid antiplatelet, and hypoglycemic (lowers blood sugar). A wander guard or alarm system was not used. R1's OT evaluation dated 2/7/25, identified he had demonstrated a physical decline and OT services would be restarted to improve activities of daily living (ADLs) participation and safety. History included legally blind right side, high risk for falls, moderate/severe cognitive performance, moderately impaired decision making, and impaired safety awareness. He moved slowly and demonstrated impaired balance at evaluation. OT was started three times a week with a duration of 30 days. R1's physical therapy (PT) evaluation dated 2/7/25, identified he had difficulty this week with sit to standing and order was placed for evaluation to be completed. Medical history identified gait abnormalities, unsteadiness on feet, and dementia with behavior disturbances. PT was started three time a week with a duration of 30 days. R1's progress notes from 2/26/25 through 2/27/25, identified: -On 2/26/25 at 9:54 a.m. R1 stated to writer his legs were not working and needed help getting up. He was able to get up out of bed with assist of two. Once he was up out of bed was able to ambulate and used front wheeled walker, gait belt, and standby assist. Hard of hearing (HOH) wore hearing aids in both ears and refused to wear . continued to work the physical/occupational therapy during the week. -On 2/27/25 at 6:51 p.m. nurse noticed R1's walker at the end of the hallway. This nurse started to look for him and alerted other staff to search for him. When this nurse came up towards the nurse's station the phone rang, answered phone and the caller stated I believe I have one of your residents here (she was from the apartments next door). This nurse immediately sent a staff member over to the apartments to bring him back to the facility. Once he was back into the facility, this nurse asked him how and where he ended up outside. He stated he pressed the numbers, and it turned green, so opened the door and went out. This nurse asked him where he was going and he replied I do not know, nowhere. Skin was checked for injuries, none noted. Maintenance still here in the building and changed the code on the door. He was placed on 15-minute checks until further notice. Director of nursing (DON) was updated via phone call. This nurse called guardian (phone message stated she was on vacation). Did attempt to call the stand in guardian, unable to reach her. Will attempt to reach her tomorrow. Physician will be updated via fax. -On 2/27/25 at 9:32 p.m. R1 had been started on 15-minute checks this earning. He has been wandering the hallways with his walker and sitting in recliner chairs in a variety of areas. When he was seen going down to the east hallway with the walker, staff had asked him to go to the lounge area or his room to get his mind off going towards the door at the end of the hallway. He has been closely monitored by staff of his whereabouts. R2's PT evaluation dated 7/22/24, identified was discharged from PT a few months ago, placed on walking program with caregivers assist of one and front wheeled walker (FWW), had not been walking anymore and had declined in his mobility. He required supervision or touching assistance with ambulation up to 50 feet and unable to attempt 150 feet due to medical conditions or safety concerns. His gait pattern included a very short and shuffling steps where his feet caught on each other, walked very narrow base of support (BOS), and flexed knees. R2's OT evaluation dated 12/11/24, identified moderately impaired decision making, impaired safety awareness, and muscle weakness. He had fallen once in the past year and felt unsteady when he walked. R2's care plan dated 1/2/25, identified limited physical mobility, unsteady gait, weakness, and other abnormalities of gait and mobility. Staff were instructed to have provide assistance of one with ambulation/locomotion and independent with wheelchair-based pivot transfers in room. R2 had purpose driven wandering and tried to get outside to smoke. Staff were directed to monitor for exit seeking or wandering behaviors, attempting to push on doors, type numbers into mag lock, and threatening to leave. Additionally, staff were directed to redirect, assess for needs, take outside for a walk as able, and offer food/drink. R2 had a history of delusions of needing to go to court and wandering/exit seeking increased when someone visited and then left. R2 lived in the special care unit that was secured and staff were directed to monitor for tailgating when visitors were in the building, identify when pattern of wandering was purposeful, aimless, or escapist and intervene as appropriate. R2 had impaired cognition function related to dementia and short-term memory loss. Staff were directed to cue, reorient, and supervise as needed. R2 benefited/required a secure memory care unit due to impaired cognition, dementia with psychotic disturbances, and behaviors. Staff were directed to monitor for changes in behaviors and provide a safe environment. R2's CPT dated 1/8/25, identified an average CPT score of 4.0/5.6 and indicated moderate cognitive impairment and the need for 24-hour supervision and assistance. R2's quarterly MDS dated [DATE], identified admitted to facility on 10/4/22. from a hospital. He had severely impaired cognition, sometimes socially isolates self, rejection of care happened 4 to 6 days out of 7 during look back period, and delusions (misconceptions or beliefs that are firmly held, contrary to reality). He had bilateral lower extremity impairment and used a wheelchair for mobility. He required supervision/touching with toileting hygiene, upper, lower body dressing, sit to stand, and all transfers, wheel 150 feet once seated in wheelchair in corridor or similar space, set-up or clean-up for personal hygiene, and walk at least 10 feet once standing was not attempted due to medical condition or safety concerns. He was frequently incontinent of bladder and always continent of bowel. R2's diagnoses included cancer, dementia, and psychotic disorder. Medications included antipsychotic antiplatelet, and no falls. A wander guard or alarm system was not used. R2's elopement risk assessment completed on 2/12/25, identified he could move without assistance while in wheelchair, had a history of wandering/elopement/exit seeking (past hospitalization or history from resident/family), dementia diagnosis and severely impaired cognition, several times a week making statements of leaving for [NAME], Montana wheeling self in wheelchair to the exits. He scored seven on the assessment and identified at low risk to wander. R2's progress notes from 2/24/25 through 3/4/25, identified: -On 2/24/25 at 11:13 a.m. activities brought him up to the main floor for church services in the chapel. He did fine during the service, when it was time to go back downstairs, he had behaviors. He wanted to go down the stairs to go outside and leave. He did not want to go on the elevator, activity director (AD) said Well, we will go up, she pressed the lower floor button, and he noticed that they were going down and not up. He swore at the AD and tried to get out of wheelchair. AD got him off elevator and blocked the elevator until it shut. He wanted to go back up; AD told him that she did not remember the code. He got upset, swore at the staff member again and AD walked away. -On 2/26/25 at 1:36 p.m. he came up to nurse's station several times this shift wanted to speak with business office and call was made per his request. He stated he needed money to get to [NAME], Montana to pick up his car parked in [NAME], and he was going to need gas money. -On 2/27/25 at 5:54 p.m. at approximately 4:57 p.m. AD stated to this nurse R2 was outside. This nurse alerted staff and two staff went to bring him back into the facility. At 5:04 p.m. R2 and staff are back into the facility, and he was asked where and how her got out. He replied he knew the code to the door and opened the door and went out. He stated I was going to the sheriff's office to go report his care missing. This nurse checked skin for injuries, none noted. He was placed on 15-minute checks. Door code was changed by maintenance . DON updated via phone. -On 2/27/25 at 9:14 p.m. he was on 15-minute checks this evening (p.m.) shift. He had been in his room playing cards, watching television (TV) and up to nurse's station for pop several times. he told the nurse he was on his way to [NAME], Montana to go get his car and just stopped here for the night to get some rest, did not think he would be arrested. The nurse stated he was not under arrest this was not a jail, and he was in the nursing home. He stated you could have fooled me this is not a jail; then why could he not have left earlier like he did. Those two girls ran right towards him, and he did not know what he was going on. The nurse stated again he was not in jail or under arrest they brought you back so you could eat supper. He was ok with this explanation and continued his card game. -On 3/4/25 at 9:18 p.m. He had his all belongings packed in a suitcase in his room. He stated he was going to [NAME], MT in the morning. He was going to check out the casinos there and get his car. During an interview on 3/6/25, at 12:13 p.m. licensed practical nurse (LPN)-A stated she had worked 2/27/25 day shift, gave report, and left for the day. She returned to facility at approximately 4:45 p.m. and entered the memory care unit through the east hallway door located at the end of the hallway. R1 stood at the end of the hallway with his walker by the exit door when she entered, dressed in a flannel shirt, jeans, shoes, and was legally blind in one eye. He frequently told staff he wanted to go home and tried to exit the facility. R2 was in the hallway by the nurse's station in his wheelchair, was delusional, frequently asked for his car, wanted to leave the facility, and told us he was going to [NAME], Montana. No wander guards were used in the memory care unit. Two NAs were at the nurse's station and the evening nurse was in the medication room located across from the nurse's station. She entered the medication room, talked with the nurse, and signed some papers for a total of about 15 minutes. She walked down to the exit door located at the end of the east hallway and R1 remained standing with his walker by the exit door. She stood in front of the exit door and located on the wall on the left side of the door was a code pad. R1 stood approximately seven feet behind her. She used her left hand, covered the code pad, punched in the numbers with her right hand, the light on the pad turned green, pushed the door open, entered the stairwell. The door sounded like it latched, kept walking, did not look back to see where R1 was located, opened the outside exit door, and walked out of the building in two seconds, and did not see a resident. She did not look through the window located in the inside door before she left, the door closed and latched, and she thought it was locked. She was unaware the door had taken up to three to five seconds to be locked. The east end hallway exit door was not a designated employee entrance/exit door. She was in a hurry, had parked close to that door, and ran in and out quickly. The exit door was not to be used by staff or visitors after the incident on 2/27/25. She heard R1 had caught the door before it locked, placed his foot, and held it while he flagged down R2. R1 and R2 exited the facility together and when they were found and brought back to the facility and placed on every 15-minute checks for at least five days. She was aware R1 and R2 had talked about leaving and tried to exit the memory care unit. The east hallway and exit door were not visible from the nurse's station. The staff would be expected to monitor and keep the resident within site so that they were kept safe. During an interview on 3/6/25 at 12:33 p.m. nursing assistant (NA)-B stated the memory care unit was a locked unit and when a resident indicated they wanted to leave they would be monitored frequently every 15 to 30 minutes. R1 was admitted to the memory care unit not too long ago, paced the hallways and talked about leaving. Recently R1 talked more about leaving and pushed on exit doors. R2 was admitted quite a while ago and stated frequently, he did not have to be there, was held against his will, and had not signed any papers to be there. R2 talked almost daily about leaving. On 2/27/25 R1 was restless at 2:45 p.m. and provided a snack. Just after 3:45 p.m. R2 requested to go outside to smoke and was informed by LPN-B he no longer smoked. NA-A had asked LPN-B if R 1 was able to go outside. LPN-B stated R1 could not go outside alone. At 4:15 p.m. NA-A went on a short break, and she completed cares with a resident from 4:15 p.m. to 4:30 p.m. NA-A returned to the memory care unit at 4:30 p.m. and along with her walked back to nurse's station. She stated the last time she saw had R2 was between 4:00 p.m. and 4:30 p.m. Between 4:30 p.m. and 4:45 p.m. AD informed us R2 had gotten out of the building. NA-B along with NA-A immediately went outside to get R2. We found R2 in the front of the building by the archway off the side of the road stuck in a mud puddle in his wheelchair. R2 was angry, fought staff, stated he planned on calling the police station to get his keys to his truck, and had taken three staff to get him back to the building. R2 was unable to walk. We arrived back to the building at about 5:00 p.m. LPN-A had received a phone call from the apartments located on campus approximately 200 feet away. NA-A and NA-B stood in the apartment entry way with two female residents without his walker. R1 had poor vision, could only see out of one eye, unsteady gait, would fallen if he had taken a wrong step, and required the assistance of a walker when ambulating. R1 would not be safe out in the community by himself, had dementia, and a poor memory. The double doors were closed earlier in the shift, tried to redirect him, he had placed hand sanitizer on his hands, and attempted to put a code in to open the exit door. There could have been more supervision of the residents during that time on 2/27/25. The nurse that exited the door at the end of the east hallway should have checked the door prior when she left the building. Staff needed to be more aware of their surroundings to keep the residents safe in the memory care unit. We are not able to see the exit door in the east hallway from the nurse's station. During an interview/observation on 3/6/25 at 1:17 p.m. R2 sat in his wheelchair in his room, well groomed, fully dressed in shoes, and television and radio on. He played cards by himself on a small desk. He stated he had waited for the sheriff to come and visit, trying to get out of here. He stated he stopped in here about one year ago and did not get sent here. He had parked his car here, was stolen, someone rolled it and got wrecked. They changed the combination on the door at the end of the hallway and he was unable to get out of the building. During an interview on 3/6/25 at 3:54 p.m. NA-D stated R1 ambulated independently with a walker and staff were expected to redirect him if he showed signs and/or talked about exit seeking. Today R1 told me he did not want to be here and tried to get out through the locked 1/2 door located at the entrance of the memory care unit, redirection was provided. Staff were expected to monitor R1 at least every 20 minutes when he walked the hallways and/or sat down by the exit door to keep him safe. R1 was at risk for elopement, falls, frequently confused, and would have not been safe outside, in a parking lot or ambulating on uneven ground by himself. R2 frequently talked about wanting to leave the building. We were expected to redirect him with snacks and acknowledge his whereabouts, both usually worked. She checked on him at least every hour and he often visited the nurse's station. She had seen him frequently down at the end of the east hallway by the exit door. R2 attempted self-transfers, unable to walk independently, used a wheelchair for mobility, refused assistance with cares, and required help with hygiene. During an interview on 3/7/25 at 9:15 a.m. activity director (AD) stated she clocked out for the day between 4:50 p.m. and 5:00 p.m. She left the facility building, got into her car, drove north to leave the parking lot, and when she went around the corner saw R2. He was located between the front and the east parking lot on the side of the road in his wheelchair approximately 100 feet from the building. He had pushed himself backwards with his feet going north. R2 wore a coat, tennis shoes, pants, and a shirt. She did not talk to him, re-entered the facility building and once she reached the memory care unit she saw LPN-B, NA-A and NA-B located in the nurse's station. She informed the staff R2 was outside, and they stated were surprised and unaware he had been missing. NA-A and NA-B ran down to the end of the east hallway and out the exit door. R2 had pushed himself 100 more feet down the road when she arrived back outside. R2 resisted and refused to come back inside the building, locked his feet down on the ground, one shoe came off, and staff pushed him back to the facility. Earlier in the week he had talked about going to [NAME], Montana to get his car, was frequently confused, and at risk for elopement. Once they returned to the memory care unit, LPN-B stated she had received a phone call from the apartments located approximately 300 feet away, R1 had left the memory care unit also and walked over there. Along with NA-A and NA-B, she walked over to the apartments and assisted the staff. The NA's stood on each side of R1, placed their arm underneath his arm pits and walked him back to the facility. During an interview on 3/7/25 at 9:49 a.m. administrator stated she was notified on 2/27/25 at 4:50 p.m. by DON R2 was located outside of the building. She received another phone call shortly after that and R1 was located at the apartment building next door. R1 and R2 were appropriately dressed, outside temperature was around 45 degrees and both were outside for approximately 12 minutes. She had reviewed the video recording of the incident and LPN-A exited the east hallway door, R1 stood close by, door looked closed but slightly gaped/open. R1 reached for the door may have caught it before it latched (took three seconds to lock). R1 was a pacer and walked the hallways frequently but she was unaware he had exiting seeing behaviors prior to this incident. Three staff had worked the shift on the memory care unit, NA was on a short break, nurse and NA were on the floor. Staff were unaware R1 and R2 were missing or when they were seen last. Staff provided sufficient supervision on 2/27/25 and continued to. She was unsure whether staff were able to see residents from the nurse's station in the east hallway. Her focus was on how the residents got out of the facility. Staff would be expected to monitor residents with an elopement risk located by an exit door with staff entered and exited the door. There should have been increased supervision prior to this incident when R1 was located by the east hallway exit door. R1 would have not been safe outside by himself, walking on uneven ground, and was at risk for falls. Review of a camera recording on 3/7/25 at 10:39 a.m. with human resource director (HRD) of the facility memory care unit recorded on 2/27/25, from 4:33 p.m. to 5:03 p.m. identified: -At 4:33 p.m. LPN-A and LPN-B were in the medication room across from the nurse's station and both exited the room. -At 4:34 p.m. R1 was seen ambulating independently with a walker down the east hallway towards the exit door and no staff were seen in this hallway until he reached the end of the hallway. LPN-A walked down to the end of the east hallway where there was an exit door located on the left side. R1 was standing with his walker approximately four feet away from the exit door fully dressed in a cap, striped shirt, pants, and shoes on. LPN-A positioned herself in front of the exit door, did not cover up the pad while she punched in the code on the pad located off to the right of the exit door on the wall. HRD verified LPN-A did not cover up the code pad while R1 stood close by looking over her shoulder. The code pad light turned green, and LPN-A glanced to her right briefly, pushed the inside door open, and two seconds later could be seen exiting the building from the outside exit door. There was a window located on the inside exit door approximately 12 inches long by 6 inches wide. LPN-A did not look back or check to see if the resident was tail gating. R1 let go of his walker and grabbed the inside exit door handle and pushed it open. R1 stood in the doorway, held door open, his lips moved, and appeared he talked to someone. LPN-B and NA-B were at the nurse's station. -At 4:35 p.m. R2 pushed himself in the wheelchair out of his room located in the same hallway and down to the end of the hallway to the exit door. No staff was seen in the hallway at this time. R2 wore a black jacket, gray t-shirt, jeans, and shoes. R2's approached R1, and his lips were moving and appeared he talked to R1. NA-A and NA-B were at nurse's station. -At 4:36 p.m. R1 held open the inside exit door while R2 pushed himself in his wheelchair out into the stairwell entry. R2 opened the exit door and pushed himself with his feet on the ground outside of facility building. R1 looked toward his unreachable walker located inside the building at the end of that hallway in front of a couch below the large window, then paused for a few seconds. -At 4:37 p.m. R2 was located outside, pushed himself in the wheelchair with his feet over to the white railing on his left side, grabbed a hold of and tried to control how fast he went down the sloped sidewalk. Once he reached the end of the railing released his grip, turned to the left, and tooled down the road. Snow was observed on the ground. R1 closed the inside door, opened the outside exit door, and stood in the doorway. R2 turned wheelchair around and pushed with his feet backwards down the parking lot road. -At 4:38 p.m. R1 let go of the outside exit door and slowly walked away to from the building without his walker to the right. The outside exit door closed and R1 was no longer viewable on the camera. R2 continued to push himself away from the building while he sat in the wheelchair with his feet, turned himself around, went forward then turned himself backwards again. HR stated he moved faster going backwards. R2 followed the parking lot road that ran alongside the facility building. -At 4:39 p.m. R2 pushed himself in the wheelchair down the center of the parking lot. There was parked vehicle located on both sides of him: white truck and a black car parked on the left side and an SUV, white van, and a car parked on the right side. R2 went off camera at 4:40 p.m. -At 4:40 p.m. LPN-B pushed a cart out of the nurse's station and entered the medication room and exited the medication room at 4:41 p.m. -At 4:41 p.m. NA-A walked off the elevator located next to the exit door at the end of the east hallway, turned right, and walked towards the nurse's station. NA-B walked from the nurse's station area down the east hallway approximately two doors down and entered a resident's room. LPN-B sat at nurse's station. -At 4:42 p.m. activity director (AD) walked outside to her van located in the parking lot. NA-A and NA-B entered nurse's station together. LPN-B sat in a chair by a computer. NA-A sat in a chair and NA-B prepared ice and water for residents, both located in the nurse's station. HRD stated staff are unable to see residents in the east hallway while the staff where in the nurse's station. -At 4:45 p.m. LPN-B, NA-A and NA-B were in the nurse's station and AD approached them (per HRD was when AD informed staff she had found R2 located outside in his wheelchair). NA-A and NA-B ran down the east hallway and left the building through the exit door. LPN-A walked out of the nurse's station, down the east hallway, looked in R2's room, and to the exit door at the end of the hallway. LPN-A lifted a walker (R1's, confirmed by HRD) located by the exit door, moved it aside then sat down on the couch located below the large window, and looked outside. -At 4:48 p.m. LPN-B stood up from the couch, walked quickly down the hallway towards the nurse's station. -At 4:50 p.m. LPN-B turned around in hallway, walked back down to the end of the east hallway and looked in the last room located on the right side of the hallway across from the exit door. She walked back down the east hallway to the other end, turned left then right into the nurse's station. She looked through the open window located between the nurse's station and the lounge/dining room/commons area. At 4:51 p.m. she sat down in front of computer in the nurse's station on the telephone. -At 4:54 p.m. staff pushed R2 in a wheelchair back into the facility building through the exit door located at the end of the east hallway. R2's right foot did not have a shoe on it. -At 4:56 p.m. LPN-B was located at the nurse's station hung up phone and NA-A and NA-B ran back out of building through the east hallway exit door. LPN-B stood in east hallway next to R2 located just outside his room in his wheelchair. -At 4:57 p.m. LPN-B walked back to nurse's station -At 4:49 p.m. LPN-B walked down to the end of the east hallway, gave the door a push, did not open, and sat down on the couch located underneath the window at the end of the hallway. -At 5:00 p.m. NA-C approached the outside exit door located at the east end of the hallway, unable to enter building, LPN-B opened inside and outside exit doors and allowed NA-C entrance. LPN-B pulled the exit doors closed and sat back down on the couch. -At 5:02 p.m. LPN-B pushed R1's walker down the hallway from the end of the east hallway located by the exit door towards the nurse's station. R1 entered the memory care unit escorted by five staff without a walker. An unidentified female staff held his left hand while he walked down the hallway towards his room. -At 5:03 p.m. LPN-B, NA-A, and NA-B were at the nurse's station. During an interview on 3/7/25 at 2:15 p.m. NA-A stated the memory care unit was a locked unit and staff were expected to have checked on residents at least every 15 to 20 minutes. There were at least three residents in the unit that were at risk for elopement. R1 and R2 sat together at the end of the east hallway and had conversations. She had noticed R1 pressed numbers on the code pad by the exit door many times located at the end of the east hallway days prior to the incident on 2/27/25. She informed the nurse and closely watched R1 and R2 when they talked about leaving the facility. R2 talked about leaving the facility at least two to three times a shift, wanted to get his car back. R1 had told her he thought he was in jail and wanted fresh air. R1 and R2 move around the unit frequently and when they saw someone leaving, one of them, tried opening the door. She stated the day of the 2/27/25 incident, R1 had approached her and asked to be let outside, continued to walk the hallways, sat at the end of the east hallway by the exit door. She updated LPN-A and was informed R1 was not allowed go outside by himself, and staff would be expected to stay with him in the courtyard. R2 had a visitor/volunteer and had requested to go outside and smoke. LPN-A informed the volunteer he no longer smoked. R2 would not be safe outside by himself, was frequently forgetful, unable to walk independently, and dependent upon a wheelchair for mobility. At approximately 4:20 p.m. she informed LPN-A and NA-B she was taking a quick break, left the floor, and returned approximately 4:30 p.m. LPN-A sat at the nurse's station and AD stopped by the memory care unit and yelled out R2 was outside. Prior to her break R2 was in his room visiting with a volunteer. NA-A and NA-B ran down the east hallway and left the building through the exit door located at the end of the hallway. She located R2 at the front of the building in his wheelchair off the side of the road stuck in the snow. R2 was upset, refused to go with back inside building, spit on her, and stated he was a grown person, did not have to stay, and wanted to go. Just after 4:30 p.m. R2 was brought back to the facility and entered the building through the east hallway exit door. R1's walker was left at the end of the hallway. LPN-A was on the phone and informed her and NA-B R1 was out of the building also and found at the apartments next door. Along with NA-B she ran back down the hallway and exited the building through the east hallway exit door. R1 was walked back to the facility and all residents in the memory care unit were checked on. She was not aware R1 and R2 were missing. During an interview/observation on 3/7/25 at 2:30 p.m. maintenance (M) stated and demonstrated on the end of the east hallway exit door when the code was entered into the code pad located on the wall right side of the inside exit door at eye level, the button turned green, within three seconds the button turned red and the door latched and locked. M pushed on door and demonstrated the door locked within three seconds. M verified all the codes were changed on 2/27/25 immediately after the incident with R1 and[TRUNCAT

Based on observation, interview and document review the facility failed to demonstrate safe patient handling to reduce the risk for accidents for 3 of 4 residents (R1, R2, R3) reviewed for safety with mechanical lift assisted transfers. Findings include: R1's Admission Record indicated she admitted to the facility 4/26/24. R1's diagnosis included functional quadriplegia, impaired cognitive function, cognitive communication deficit and weakness. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and indicated Bilateral upper and lower extremity impairments. The MDS indicated R1 was dependent on staff for transfers. R1's Transfer and Mobility Evaluation dated 2/18/25, indicated the use of a mechanical lift for transfer using an extra-large sling. R1's care plan dated 1/22/25, identified a self-care deficit related to obesity, pain, and weakness. The care plan directed staff to assist with transfers utilizing a mechanical lift and XL sling. The care plan identified a fall from a mechanical lift on 2/5/25. R1's undated Kardex indicated she transferred using a total lift and XL sling. R2's Admission Record indicated she admitted to the facility 1/17/25. R2's diagnosis included polyneuropathy, gait and balance abnormalities, unsteadiness, and muscle weakness. R2's quarterly MDS dated [DATE], identified intact cognition and indicated Bilateral lower extremity impairments. The MDS indicated R2 was dependent on staff for transfers. R2's Transfer and Mobility Evaluation dated 2/20/25, indicated the use of a mechanical lift for transfer using a medium sling. R2's care plan dated 7/5/24, identified a self-care deficit related to spinal fusion, gait abnormalities and weakness. The care plan directed staff to assist with transfers utilizing a mechanical lift and medium sling. R2's undated Kardex indicated transfer using a mechanical lift and medium sling. R3's Admission Record indicated she admitted to the facility 6/14/18. Diagnosis included polyneuropathy, unsteadiness, deformities of foot, stiffness in hands and pain. R3's significant change MDS dated [DATE], identified intact cognition and indicated Bilateral upper and lower extremity impairments. The MDS indicated R3 was dependent on staff for transfers. R3's Transfer and Mobility Evaluation dated 11/28/24, indicated the use of a mechanical lift for transfer using an extra-large sling. R3's care plan dated 2/19/25, identified limited physical mobility related to muscle weakness, deformities of foot and fibromyalgia. The care plan directed staff to assist with transfers utilizing a mechanical lift and large sling. R3's undated Kardex indicated R3 transferred with a mechanical lift and large sling. An EZ Way Sling Sizing Chart for use with EZ Way mechanical lift device identified the following color-coding system: -Gray - small, 70-100 pounds (lbs.) -Beige- Medium, 91-220 lbs. -Burgundy- Large, 190-320 lbs. -Green- Extra-large (XL) - 280-450 lbs. -Black- XXL- 400-600 lbs. -Brown- XXXL- 600 + lbs. -Color coding was used on the binding of the slings. During observation on 2/26/25 at 1:19 p.m., nursing assistants (NA)-A and NA-B transferred R1 using a mechanical lift. The sling used to transfer R1 had a beige binding which indicated a medium sling. R2 was seated in a wheelchair in the room with a sling underneath her. NA-A and NA-B transferred R2 using the mechanical lift and the sling with beige binding which indicated a medium sling. During observation on 2/26/25 at 4:59 p.m., NA-C and NA-D prepared to transfer R3 in a mechanical lift using a sling with split legs. As the lift started to rise, R3 stopped the NA's and said the leg straps were not crossed. NA-C stated, I did it again. During observation on 2/27/25, at 9:11 a.m., R1 and R2 were in bed. R1 had a sling underneath her in the bed that had a burgundy binding which indicated a large sling. During observation and interview on 2/27/25 at 8:59 a.m. R3 stated she had stopped the transfer the previous evening because the legs of the sling should have been criss/crossed and they were not. R3 stated one time she had almost fallen through the sling as it was in the air because of the same thing. R3 stated she had to remind the staff frequently to cross the straps between her legs. R3 further stated, a few weeks before, staff had put her in her recliner and started to pull the lift from the room without unhooking the straps causing her to pull her whole body forward. R3 was seated in a wheelchair on top of a large sling. During interview on 2/27/25 at 9:22 a.m., NA-A stated the residents did not have their own slings. NA-A stated sling size depended on the residents weight. NA-A stated she did not know where to find the sizing guide and said she just guessed the size based on her experience and said there was not anything that told them what size to use. During interview on 2/27/25 at 9:31 a.m., NA-E stated the sling size should be in the care plan and was based on the residents weight. NA-E said, staff just knew what size to use. NA-F was also present and said there used to be a chart on the wall in the linen room but was not there anymore. NA-F stated, when you have been here long enough, you know what size. During observation with NA-B on 2/27/25 at 9:37 a.m., NA-B confirmed both R1 and R2 currently had large slings under them and confirmed both R1 and R2 had been transferred using medium slings the previous day. During interview on 2/27/25 at 9:56 a.m. the director of nursing (DON) stated residents were assessed for sling size on admission. The DON said residents do not have their own dedicated slings and said the size was listed on the Kardex and said they could also go by the color of the sling. At 11:46 a.m., the DON stated lift training were completed on the computer and in person training as well as with their mentor during orientation. Facility policy and procedure Total Mechanical Transfer dated 8/1/15, indicated to safely transfer residents who have been assessed per the safe patient handling program to requires the use of a total lift. The procedure directed staff to assemble the needed supplies, including the sling. The policy did not include identification of the appropriate sling and/or sling size. Facility Provided checklist titled United Heartland Total Lift, dated 8/2016, indicated; brings equipment to the bedside. Uses the proper size sling for the resident.

Based on interview and document review, the facility failed to ensure sufficient staffing to provide routine and assessed needs for toileting for 2 of 2 residents (R3) who resided on the main level and (R41) who resided on the memory care unit. In addition, 2 of 3 family members (FM-A, FM-B) voiced concerns with inadequate number of staff to provide resident care/needs for (R37, R41). Further, 4 of 4 residents (R3, R14, R20, R30) and 5 of 5 staff members (NA-E, NA-H, NA-I, AD, LPN-A) voiced concerns with the lack of sufficient staff in the facility. This deficient practice had the potential to affect all 49 residents who resided in the facility. Findings include, Refer to F565 R3, R14, R20, R30 During a resident council meeting on 2/11/25 at 11:01 a.m., R3, R14, R20, and R30 voiced wait time for staff to answer a call light was at least one and half hours at times. The residents further stated staff may come and turn off the call light and say they would return however, do not come back. During an interview on 2/12/25 at 1:56 p.m., licensed practical nurse (LPN)-A stated the facility worked short staffed every weekend and at least twice a week Monday through Friday. LPN-A further stated the facility would have staff float (work in a different area) than originally assigned due to staff call-ins or an open shift resulting in resident cares taking longer to complete or longer to answer call lights. LPN-A verified the facility utilized agency staff at times and rarely mandated staff to work. LPN-A confirmed it was exhausting to work short staffed and tough on the residents. During an interview on 2/12/25 at 3:38 p.m., scheduler stated staffing levels were determined on resident acuity and census. Scheduler further stated staff would float to other areas of need within the facility if there was a call-in or scheduled short staff instead of mandating staff to cover the open shift. Scheduler verified the facility utilized supplemental nursing agency staff at times. Scheduler confirmed the facility had 61 call-ins in the past 30 days and even though 61 call-ins sounded like a lot, that was an average number of call-ins for the facility. Scheduler verified the following model was used when scheduling staff: Memory Care first floor; -Day shift two nursing assistants (NA), one nurse. -Evening shift two NA's and one nurse. -Night shift one NA and one nurse. Second floor; -Day shift three NA's and two nurses. -Evening shift three NA's an two nurses. -Night shift two NA's and one nurse. Scheduler further verified the current staffing hours; -Day shift 6:00 a.m., to 2:30 p.m. -Evening shift 2:00 p.m., to 10:30 p.m. -Night shift 10:00 p.m., to 6:30 a.m. Review of the facility master schedule identified on a weekly basis less than the facility recommended staffing levels: Memory Care first floor; -Five out of seven days on 1/12/25 through 1/18/25. -Seven out of seven days on 1/19/25 through 1/25/25. -Five out of seven days on 1/26/25 through 2/1/25. -Six out of seven days on 2/2/25 through 2/8/25. -Six out of seven days on 2/9/25 through 2/15/25. Second floor; -Seven out of seven days on 1/12/25 through 1/18/25. -Seven out of seven days on 1/19/25 through 1/25/25. -Six out of seven days on 1/26/25 through 2/1/25. -Six out of seven days on 2/2/25 through 2/8/25. -Seven out of seven days on 2/9/25 through 2/15/25. Review of the facility call light alarm response report 1/28/25 through 2/11/25, identified the following: -fifteen and twenty minutes: 135 times. -twenty and thirty minutes: 136 times. -thirty and forty minutes: 62 times. -forty and fifty minutes: 24 times. -fifty minutes and one hour: 11 times. -one hour and one and a half hours: 17 times. -one and a half hours and two hours: four times. -over two hours: two. A resident call light was on for two hours and forty seven minutes and another call light was on for two hours and twenty five minutes. 37905 R3 R3's quarterly MDS dated [DATE], identified R3 was cognitively intact and had diagnoses which included heart failure, peripheral vascular disease (restricted blood flow to limbs) and depression. R3's MDS also identified R3 was dependent on staff for dressing, bathing, and toileting and personal hygiene. R3's CAA dated 9/19/24, identified R3 was dependent for toileting hygiene, to shower/bathe self, upper and lower body dressing, and required substantial/maximal assistance with personal hygiene. Staff would review and update care plan as needed. R3's care plan revised 12/16/24, identified R3 had an activities of daily living (ADL) self-care performance deficit related to immobility and related to amputation of one lower extremity. R3 required assistance of one for toilet use, personal hygiene, dressing and bathing. During interview on 2/10/25 at 2:13 p.m., R3 indicated she had concerns with sufficient staffing and stated last week in the afternoon, staff assisted her onto a bed pan. R3 stated she had put her light on to be removed from the bed pan, but they did not answer her call light for four hours. Review of the facility call light alarm response report dated 1/28/25 through 2/11/25, identified the following: -2/2/25 at 5:23 p.m., R3's rooms call light on for two hours and forty seven minutes. -call lights for R3's room were not answered for longer than fifteen minutes multiple times. Refer to F584 During an interview on 2/12/25 at 9:48 a.m., nursing assistant (NA)-H stated she felt they were not able to get all cares done due to staffing. NA-H indicated they tried their best to get all residents repositioned, and checked on, but felt they did not have time to get everything done, including do the cares the way the would like to do them, or straighten up the rooms. NA-H stated their call lights were heavy and if NA-H was unable to answer the light, she would ask for help. NA-H stated she had noticed a call-light had been going off earlier for a half an hour, so she let the resident know they were on their way. NA-H indicated some staff would never answer a call light, and the floor nurses usually did not answer call lights. NA-H stated some nurses were good to assist the nursing assistants with cares such as transfers however, others would not. NA-H gave an example, a nurse came to tell them while they were providing cares to a resident, that another resident wanted a drink of water, instead of getting them a drink of water themselves, which she felt was frustrating. 48583 Refer to F679 R37 During a telephone interview on 2/10/25 at 4:27 p.m., family member (FM)-A stated R37 spent a lot of time in R37's room throughout the day and FM-A did not feel the facility had the staffing to meet each residents needs on the memory care unit. During a telephone interview on 2/10/25 at 4:59 p.m., FM-B stated FM-B on a few occasions over the past couple months, had came to see R41 and had to assist R41 in the bathroom. FM-B further stated R41 had been left in the bathroom at times due to not having enough staff to assist R41 while R41 was using the restroom. FM-B indicated R41 was a high fall risk and FM-B felt R41 was going to have another fall because the unit was understaffed. R41 was to be monitored at all times due to several previous falls. During an interview on 2/12/25 at 8:23 a.m., nursing assistant (NA)-E indicated activities aids were responsible for completing activities on the memory care unit but at times activities did not get completed. NA-E further indicated nursing staff had been told they were responsible to complete activities but stated nursing staff did not have the time or staff to complete activities. NA-E stated nursing staff did not have the staff to meet the needs of the residents in the memory care unit. NA-E further stated nursing staff were not able to complete all their required tasks because the unit was usually short staffed. NA-E indicated there were times when the memory care unit had one NA and one nurse because the second NA had been pulled to another floor. NA-E there were times when the facility only had three NAs on staff at one time. NA-E stated nursing staff had to ask for help but it usually did not change anything. NA-E further stated nursing staff did not have enough staff to answer call lights in a timely manner. NA-E indicated residents had long wait times due to short staffing. NA-E stated nursing staff did not have time to complete exercises with residents and often did not have time to walk residents. During an interview on 2/12/25 at 8:30 a.m., NA-I stated there were many times when NA-I was the only NA on the floor to care for all the residents. NA-I further stated if other floors were short staffed or there was a call in, a NA would be pulled from the memory care unit to help on that floor. NA-I indicated the weekends were worse for staffing. NA-I stated nursing staff were not able to get their tasks completed because nursing was constantly working short staffed. NA-I indicated nursing staff were not able to complete the interventions for residents because of working short staffed. NA-I stated if activities aids did not complete activities, nursing staff were responsible to complete them. NA-I stated nursing staff did not have the time to complete activities especially when one staff had been pulled to another until. NA-I further stated residents did not have exercises and were not walked because of being short staffed. During an interview on 2/12/25 at 2:42 PM activity director (AD) indicated AD was trying to ensure activities were being completed on the memory care unit but AD did not have enough staff at all times. AD further indicated AD was working on getting more staff so activities could be done consistently on the memory care unit. During an interview on 2/12/25 at 1:18 p.m., director of nursing (DON) stated they would like call lights to be answered within 10 minutes. DON stated an hour on a bed pan could feel like four hours, and R3 was lucky she did not have skin breakdown if was left on the bed pan that long. DON stated it was the facility's expectation that everybody answer call lights, and indicated all staff could not do the cares needed, but all staff could answer the call lights. During a follow-up interview on 2/12/25 at 5:06 p.m., DON stated the facility would float staff from a scheduled area to a different area of need within the facility resulting in staffing shortages. DON stated the expectation would be the schedule would be complete rather than float staff to other areas of need and the expectation would be to mandate staff to work until the facility could get someone else to cover the shift instead of working short staffed. Review of the facility Call Light Use and Response policy, revised 7/18/23, DON verified the expectation that call lights were to be answered promptly within ten minutes. DON confirmed that it was important to have sufficient staff to answer call lights promptly to ensure resident care was completed timely and safely. During an interview on 2/12/25 at 5:35 p.m., administrator verified the facility assessment updated 9/5/24, had a contingency staffing plan to utilize contract/agency staff and all nursing staff including nursing management would be the back-up to work the floor due to inclement weather or other incidents. A facility policy titled Sufficient Staffing, revised 10/19/23, identified the facility would have sufficient qualified nursing staff available at all times to provide nursing and related service to meet the residents' needs safely and in a manner that promoted each resident's rights, physical, mental and psychosocial well-being. The policy further identified daily reviews of staffing patterns would be completed by the scheduler, human resources, administrator, and director of nursing. Nursing direct care staffing ratios would be recalculated based on census and level of care needs.

Based on observation, interview and document review, the facility failed to maintain sanitary conditions for mechanical lifts for 2 of 2 residents (R20, R31) observed who used a mechanical lift. In addition, the facility failed to implement hand hygiene for 3 of 3 residents (R1, R3, R20) observed during cares. In addition, the facility failed to ensure safe delivery of beverages during dining observation. In addition, the facility failed to ensure proper signage for 1 of 3 residents (R25) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Findings include: LIFTS AND HAND HYGIENE R20, R31 During an observation on 2/10/25 at 1:12 p.m., nursing assistant (NA)-A took the mechanical lift without sanitizing it before into R20's room. NA-A and NA-B R20 hooked R20's lift pad to the lift and lifted R20 out of the wheelchair and placed R20 into her recliner and unhooked R20's lift sheet from the mechanical lift. During the transfer, R20 touched the mechanical lift. NA-A took the mechanical lift into R31's room. NA-A and NA-B did not sanitize their hands or the mechanical lift During an observation on 2/10/25 at 1:18 p.m., NA-A and NA-B assisted R 31 to roll onto her side while touching R31's back. NA-B placed the hoyer sheet under R31. NA-A and NA-B hooked the hoyer sheet to the mechanical lift and lifted R31 into her wheelchair. During the transfer,r both R31's arms came into contact with the lift. NA-A and NA-B unhooked the hoyer sheet from the mechanical lift. NA-A took the mechanical lift into the hallway and walked to R1's room with the mechanical lift. NA-A and NA-B did not sanitize their hands or the mechanical lift. During a joint interview on 2/10/25 at 1:28 p.m., NA-A and NA-B verified they had not sanitized their hands or the mechanical lift after assisting R20 and R31. NA-A and NA-B both stated they should have sanitized their hands and the lift to prevent the spread of infection. NA-A stated she would sanitize the lift prior to using it for R1. 37905 R3 R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact and had diagnoses which included heart failure, peripheral vascular disease (restricted blood flow to limbs) and depression. R3's MDS also identified R3 was dependent on staff for dressing, bathing, and toileting and personal hygiene. R3's Functional Abilities Care Area Assessment (CAA) dated 9/19/24, identified R3 was dependent for toileting hygiene, to shower/bathe self, upper and lower body dressing, and required substantial/maximal assistance with personal hygiene. Staff would review and update care plan as needed. R3's care plan revised 12/16/24, identified R3 had an activities of daily living (ADL) self-care performance deficit related to immobility and related to amputation of one lower extremity. R3 required assistance of one for toilet use, personal hygiene, dressing and bathing. During observation on 2/12/25 at 7:37 a.m. nursing assistant (NA)-F, wearing a gown and gloves, was assisting R3 while in bed with morning cares. NA-F had a basin of water on bedside stand next to R3's bed, rinsed it out with water, then offered the washcloth to R3 to wash her face and offered her a towel to dry. NA-F proceeded to remove R3's shirt, washed R3's chest and underarms with soap and water and used a washcloth to dry the areas. NA-F assisted R3 to apply a sweater top and asked R3 if she wanted lotion on her leg, which R3 said yes. NA-F applied lotion with her gloved hands to R3's foot and leg and asked her if she wanted any on her hands. NA-F did not sanitize hands or apply new gloves and NA-F applied lotion to R3's hands. NA-F assisted R3 to roll to her side, after unfastening R3's brief tabs. NA-F proceeded to use the soap and water from basin on the washcloth, and proceeded to wash R3's perineal area. NA-F then proceeded with same washcloth used on perineal area, to wipe buttocks, wiped incision scar area and wiped away the ointment from that area. NA-F did not sanitize hands or change gloves after washing R3's perineal area, or change washcloth. NA-F called for a nurse to come to room using her walkie talkie, while she wore the same gloves. At 7:47 a.m. registered nurse (RN)-A entered the room wearing gown and gloves and applied powder to R3's skin folds. RN-A removed gloves, washed hands, applied new gloves, then applied an ointment to R3's incision scar. NA-F continued to wear same gloves, applied a new brief to R3, pulled up R3's pants and placed a mechanical lift sling under R3. NA-F called for assistance to come to the room for transfer assistance using her walkie talkie. NA-F took R3's basin to the bathroom, and put R3's soiled linen in a bag. At this point, NA-F removed her gloves and sanitized her hands. NA-F informed R3 she was going to leave to get the mechanical lift. At 7:58 a.m. NA-F returned to room with the mechanical lift after applying a gown and gloves. NA-F assisted R3 to put in her dentures, removed her gloves and applied new gloves. NA-F did not sanitize her hands between glove use. At 8:09 a.m. NA-H entered the room wearing a gown and gloves and NA-F and NA-H assisted R3 from her bed to her wheelchair using a mechanical lift. During a phone interview on 2/12/24 at 3:54 p.m., NA-F indicated her usual practice was to change her gloves after assisting residents after washing, before brushing their teeth, or if they had to apply a cream. NA-F indicated it was a habit to just leave on the gloves during resident cares. NA-F confirmed she left the same gloves on while assisting R3 with bathing, lotion application, perineal cares, and dressing. NA-F also verified she had washed R3's perineal area and washed R3's incision area with same gloves and washcloth. NA-F stated she had not received any education on how to wash using clean to dirty, verses dirty to clean areas. NA-F indicated not sanitizing hands or changing gloves when needed could be a problem, because the gloves and hands could be considered soiled. 48583 EPB: According to the Centers for Disease Control and Prevention (CDC) dated 4/2/24, EBP are required for residents who receive wound care: any skin opening requiring a dressing. R25 R25's quarterly MDS dated [DATE], identified R25 had moderate cognitive impairment and diagnoses which included diabetes mellitus (DM), dementia and a pressure ulcer of the right heel. Identified R34 required moderate assistance with ADL's which included toileting, transfer, and dressing R25's care plan revised 2/1/25, indicated R25 had an alteration in skin integrity related to pressure. Care plan directed staff to administer treatments and assess/monitor skin integrity weekly. R25's care plan lacked documentation related to R25 being on EBP. R25's comprehensive CAA dated 9/27/24, indicated R25 had an unhealed pressure ulcer on the right heal. The CAA further indicated R25 required moderate assistance with bed mobility, transfers, toileting. R25's wound assessment dated [DATE], identified R25 had a pressure ulcer that measured 1.5 centimeters (cm) by 1.9 cm by 1.4 cm. The wound assessment further indicated R25's pressure ulcer had moderated exudate (fluid released from the wound) and it was unknown how R25 obtained the pressure ulcer. During an observation on 2/10/25 at 12:19 p.m., there was no PPE located near R25's room for staff to wear while providing care for R25 (who was on EBP). Further, there was no sign to identify R25 was on EBP. During an observation on 2/10/25 at 7:01 p.m., a three drawer bin containing PPE was located outside R25's door for staff to wear while providing cares for R25 (who was on EBP). Further, there was a sign attached to R25's door that identified R25 was on EBP and provided guidance on what PPE staff were required to wear while providing cares for R25. During an interview on 12:20 p.m., NA-D stated R25 had a wound on her right heel and R25 was on EBP. 49620 DINING OBSERVATION During an observation on 2/10/25 at 4:40 p.m., dietary aide (DA)-A and (DA)-B delivered two food carts to the memory care unit and placed them near the kitchenette area. The food carts were setup with a tray for each resident labeled with the resident name, food preferences, silverware and meal. DA-B removed two clear plastic drink glasses from the kitchenette area, filled the glasses with juice, milk or water and carried the glasses holding the top rim with his bare hands back to the tray on the cart. DA-B removed a coffee cup from the kitchen, filled the coffee cup with coffee and carried the cup holding the top rim with his bare hands back to the tray on the cart. DA-B filled a glass with milk, handed the glass to DA-A who proceeded to carry the glass holding the top rim with her bare hands back to the tray on the cart. DA-B filled another glass with juice, handed the glass to DA-A who proceeded to carry the glass holding the top rim with her bare hands back to the tray on the cart. During an interview on 2/10/25 at 4:56 p.m., DA-A and DA-B confirmed they both touched the top rim of the glasses with their bare hands and DA-B confirmed he touched the top rim of the coffee cup with his bare hands. DA-A and DA-B stated this practice could spread bacteria to the residents and cause illness. During an interview on 2/10/25 at 5:04 p.m., dietary manager (DM) confirmed the expectation of staff was to hold onto the handle of a coffee cup and to not touch the rim of the glasses or coffee cup with bare hands. DM verified that was important not to touch the top rim of glasses to prevent cross contamination and the spread of germs. Review of facility policy titled Hospitality and Dining Services effective 1/1/20, indicated the facility would provide safe and sanitary storage, handling and consumption of all foods. The policy indicated servers would handle eating utensils and plates, utilizing sanitary precautions; glasses handled by base, flatware by handles, plates kept away from clothing or aprons when serving. During an interview on 2/11/25 at 2:38 p.m., infection preventionist (IP) verified R25 should have been on enhanced barrier precautions. IP stated her expectation was that proper signage was posted for all residents on transmission based precautions(TBP), lifts were sanitized between residents, hand hygiene to be performed when appropriate and staff not to touch the top of glasses during meal service to prevent the spread of infection. During an interview on 2/12/25 at 8:31 a.m., director of nursing (DON) verified mechanical lifts were to be sanitized between residents. Further verified staff were to sanitize hands when appropriate. DON stated her expectation was that lifts were sanitized between residents and hand hygiene was performed to prevent the spread of infection. During a follow-up interview on 2/12/25 at 4:43 p.m., DON stated her expectation was that staff washed their hands before and after glove use. DON also stated she would expect gloves to be changed after going from a dirty task, such as changing a brief. DON stated residents should always be washed from clean to dirty, and to use different gloves and wash cloths for infection control purposes. During a follow-up interview on 2/12/25 at 5:01 p.m., DON indicated she was unaware R25 did not have an EBP sign on the door and no PPE near R25's room prior to 2/10/25 at 7:01 p.m. DON indicated R25 was to be on EBP due to the open wound. Review of a facility policy titled Disinfection of Resident Care Equipment revised 5/8/24, identified Reusable equipment will be cleaned and disinfected after use of one resident and before use of another resident Review of a facility policy titled Hand Hygiene revised 5/8/24, identified Staff will perform hand hygiene by washing hands for at least twenty (20) seconds with antimicrobial soap and water should be performed after providing direct resident care. Review of a facility policy titled Personal Cleanliness and Hygienic Practices revised 11/28/22, identified all plates, utensils and drinking cups would be handled in a way to avoid touching eating surfaces.

Based on interview and document review, the facility failed to ensure continuation of appropriate discharge planning was implemented for 4 of 4 residents (R42, R41, R15 and R13) who remained at the facility. Findings include: R41 R41's significant change Minimum Data Set (MDS) dated [DATE], indicated R41 had diagnoses which included cancer, epilepsy (seizure disorder), anxiety and depression and was severely cognitively impaired. R41 required minimal assistance with activities of daily living (ADL's) which included bed mobility, transfers, and eating. R41's care plan revised on 9/9/24, indicated R41's discharge plans were undecided. R41 or R41's representative would meet with care plan team to identify discharge potential on a quarterly basis. R41's care plan conference summary dated 1/21/25, indicated R41's spouse would like R41 moved closer to spouse or R41's brothers. Review of R41's progress notes dated 12/12/24 to 2/12/25, lacked discharge planning documentation. R15 R15's quarterly MDS dated [DATE], indicated R15 had diagnoses which included cancer, anxiety and depression and had mild cognitive impairment. R15 required extensive assistance with ADL's which included bed mobility and transfers. R15's care plan revised on 9/11/24, indicated R15's discharge plans were to return to assisted living facility (ALF) if able. R15 required a discharge care conference needed closer to discharge and expected to be discharged to another facility. R15's care plan conference summary dated 2/6/25, indicated R15 required assistance 24/7. Review of R15's progress notes dated 12/12/24 to 2/12/25, lacked discharge planning documentation. During a telephone interview on 2/10/25 at 5:01 p.m., family member (FM)-B indicated FM-B had requested R41 to be moved closer to FM-B however, had not heard back from the social work (SW) regarding placement options for R41. 37905 R42 R42's admission MDS dated [DATE], identified R42 was cognitively intact and had diagnoses which included: diabetes mellitus, arthritis, anxiety, and depression. Identified R42 was dependent on staff for oral cares, hygiene, dressing and bathing. R42's Identified R42 participated in goals and had an overall goal to discharge to the community at time of assessment. R42 had no active discharge plan and R42's expected discharge date was three or fewer months away. R42's Care Area Assessment (CAA) dated 12/22/24, identified R42 had a self-care performance deficit related to weakness. Identified R42's care plan would be completed for self-care deficit and impaired mobility and staff would assist with ADL completion. R42's care plan revised 1/13/25, identified R42 had an ADL self-care performance deficit related to weakness. R42's interventions included personal hygiene/oral care assist of one. Discharge Planning, R42 planned to return home when R42 was stronger. Interventions included to coordinate and assist in communication with outside or home services, and to discuss with family and resident discharge options. During an interview on 2/10/25 at 1:11 p.m., R42 stated no one had talked to her about her wishes to move to the Mahnomen nursing home to be closer to family. R42 indicated a family member had informed her she was second in line on their admission list at the Mahnomen facility. R42's Initial Care Conference form dated 12/12/24, identified information was collected from R42. R42 previously lived at home with spouse prior to hospitalization . R42 would like to return back home, and realized had a lot of work to do to go home. R42 was willing to look at long term placement closer to home. Review of R42's progress notes from 12/16/24 to 2/12/25, identified the following: -12/16/24 4:18 p.m., discharge planning: R42 was living with spouse at home prior to hospitalization . R42 was willing to look for long term placement closer to home. -1/16/25 1:04 p.m., nurses note: writer received call from Mahnomen nursing home requesting information, as spouse would like resident closer to home. Writer called back and left message that they needed a from sent and gave licensed social worker (LSW) name as contact as LSW facilitated discharges. R42's medical record lacked further follow up on R42's wishes to be moved to Mahnomen facility. 49620 R13 R13's quarterly MDS dated [DATE], identified R13 had intact cognition with diagnoses of chronic obstructive pulmonary disease (COPD), (an ongoing lung condition caused by damage to the lungs), atrial fibrillation (abnormal heart rhythm), lymphedema (swelling caused by build up of too much fluid), hypertension (high blood pressure), obesity. Identified R13 required extensive to total assistance with ADL's such as bathing, toileting, transfers, and personal hygiene. R13's care plan revised 9/11/24, identified R13's discharge plan from the facility was to discharge to a different facility closer to family. The care plan identified staff were to assist/arrange for tours of facilities and discuss with family and resident discharge options. R13's care plan created 4/4/24, identified R13 had an actual/potential psychosocial well-being problem due to being in a nursing home away from family and friends. The care plan identified staff would initiate referrals as needed. R13's Care Plan Conference Summary dated 12/13/24, identified R13 would like to discharge from the facility to be closer to family. The summary lacked documentation on a discharge plan for R13 to move to a facility closer to family. R13's significant change comprehensive CAA dated 8/29/24, lacked documentation on discharge planning. During an interview on 2/12/25 at 12:53 p.m., licensed social worker (LSW) stated she had sent R42's referral to Mahnomen nursing home right after R42 was admitted , which was before Christmas, and she had also sent them an updated referral form last week. LSW stated the first referral they rejected, because they did not have a bed. LSW stated she had called Mahnomen nursing home 1/16/25, and they were unable to meet R42's needs at that time. LSW confirmed she did not document any follow up to discharge planning for R42. LSW also confirmed she did not always discussed the discharge planning progress with R42. During a follow-up interview on 2/12/25 at 3:20 p.m., LSW stated the discharge planning process started when residents were admitted into the facility. LSW further stated discharge goals were set based on resident's needs and services prior to admission. LSW indicated discharge planning continued throughout the residents stay and was discussed at all care conferences. LSW further indicated she did not always put a note in the resident's chart regarding discharge planning. LSW verified R41's and R15's electronic medical chart lacked current discharge plans. During an interview on 2/12/25 at 4:36 p.m., director of nursing, confirmed she was aware LSW had not documented follow up regarding R42's discharge planning, and she expected LSW to document all progress regarding discharge planning in R42's medical record. DON indicated they had been aware that discharge planning and follow up was a concern the facility was aware of, and was important to document so others may follow up, and it was important because discharge planning should begin when residents were admitted . The facility policy titled Charting And Documentation revised 11/13/24, identified it's purpose to maintain a medical record to serve as a legal document that details the services provided to the resident, or any changes in the resident's medical or mental condition, through charting and documentation. Documentation would include information on assessment, notifications, interventions and evaluations which included: status updates/summaries as required. Requested facility policy on discharge planning however, one was not received.

Based on interview and document review, the facility failed to update the care plan for 3 of 3 residents (R42, R41 and R15) reviewed for discharge planning. In addition the facility failed to update the care plan for 1 of 1 residents (R37) reviewed for activities. Findings include: R41 R41's significant change Minimum Data Set (MDS) dated [DATE], indicated R41 had diagnoses which included cancer, epilepsy (seizure disorder), anxiety and depression and was severely cognitively impaired. R41 required minimal assistance with activities of daily living (ADL's) which included bed mobility, transfers, and eating. R41's care plan revised on 9/9/24, indicated R41's discharge plans were undecided. R41 or R41's representative would meet with care plan team to identify discharge potential on a quarterly basis. R41's care plan conference summary dated 1/21/25, indicated R41's spouse would like R41 moved closer to spouse or R41's brothers. Review of R41's progress notes dated 12/12/24 to 2/12/25, lacked discharge planning documentation. R15 R15's quarterly MDS dated [DATE], indicated R15 had diagnoses which included cancer, anxiety and depression and had mild cognitive impairment. R15 required extensive assistance with ADL's which included bed mobility and transfers. R15's care plan revised on 9/11/24, indicated R15's discharge plans were to return to assisted living facility (ALF) if able. R15 required a discharge care conference needed closer to discharge and expected to be discharged to another facility. R15's care plan conference summary dated 2/6/25, indicated R15 required assistance 24/7. Review of R15's progress notes dated 12/12/24 to 2/12/25, lacked discharge planning documentation. R37 R37's quarterly MDS dated [DATE], identified R37 had severe cognitive impairment and had diagnoses which included Alzheimer's disease, dementia, anxiety and was currently receiving hospice services. R37 required extensive assistance with ADL's which include bed mobility, transfers, and toileting. R37's care area assessment (CAA) dated 9/16/24, indicated R37 had concerns with cognition and dementia. R36's CAA further indicated R36 did not communicate often and was not responding to conversations as much. R37's care plan revised 11/15/24, indicated R36 had a diagnoses of frontotemporal and vascular dementia with a history of alcoholism with limited R36's ability in leisure involvement. R37's goals were to maintain leisure abilities by actively engaging in structured leisure opportunities once daily three days a week. It further indicated R37 enjoyed music, games, music trivia and animals. Staff interventions were to break down tasks, give praise and provide music in R37's room. R37's care plan conference summary dated 1/21/25, stated R37's spouse offered additional activities that R37 would enjoy. These activities included, music (country, 50's and 60's), one to ones, and conversations. R37's spouse requested staff communicate with R37 even if R37 did not respond. R37's Kardex undated, indication R37 enjoyed music and singing however, preferred to listen to music in room instead of coming out to join a group of people. During an interview on 2/12/25 at 2:42 p.m., activity director (AD) indicated AD was responsible for updating the activities section of the care plan. AD stated AD attended R37's care conference and was aware of R37's spouse's requests. AD stated AD did not update R37's care plan to reflect spouses wishes. AD further stated AD did not know how to update the section in the care plan and would need to work with the MDS coordinator for assistance. 37905 R42 R42's admission MDS dated [DATE], identified R42 was cognitively intact and had diagnoses which included: diabetes mellitus, arthritis, anxiety, and depression. Identified R42 was dependent on staff for oral cares, hygiene, dressing and bathing. Identified R42 participated in goals and had an overall goal to discharge to the community at time of assessment. R42 had no active discharge plan and R42's expected discharge date was three or fewer months away. R42's CAA dated 12/22/24, identified R42 had a self-care performance deficit related to weakness. R42's CAA identified R42's care plan would be completed for self-care deficit and impaired mobility and staff would assist with ADL completion. R42's care plan revised 1/13/25, identified R42 had an ADL self-care performance deficit related to weakness. R42's interventions included personal hygiene/oral care assist of one. Discharge Planning, R42 planned to return home when R42 was stronger. R42's goal- to return to prior living situation upon completion of rehab. Interventions included to coordinate and assist in communication with outside or home services, and to discuss with family and resident discharge options. R42's care plan had not been revised to include discharge planning for long term care placement. During an interview on 2/10/25 at 1:11 p.m., R42 stated no one had talked to her about her wishes to move to the Mahnomen nursing home to be closer to family. R42 indicated a family member had informed her she was second in line on their admission list at the Mahnomen facility. R42's Initial Care Conference form dated 12/12/24, identified information was collected from R42. R42 previously lived at home with spouse prior to hospitalization . R42 would like to go back home however, realized had a lot of work to do to go home. R42 was willing to look at long term placement closer to home. Review of R42's progress notes from 12/16/24 to 2/12/25, identified the following: -12/16/24 4:18 p.m., discharge planning: R42 was living with spouse at home prior to hospitalization . R42 is willing to look for long term placement closer to home. -1/16/25 1:04 p.m., nurses note: writer received call from Mahnomen nursing home requesting information, as spouse would like resident closer to home. Writer called back and left message that they needed a from sent and gave licensed social worker (LSW) name as contact as LSW facilitated discharges. During an interview on 2/12/25 at 1:13 p.m., licensed social worker (LSW) confirmed R42's care plan indicated R42 planned to return home. LSW indicated that was R42's ultimate goal, and it was her alternate goal to go home when she spoke to her a week ago. LSW indicated she had sent out a referral to Mahnomen nursing home last Friday and had not updated R42's care plan. During a follow-up interview on 2/12/25 at 3:20 p.m., LSW stated the discharge planning process started when residents were admitted into the facility. LSW further stated discharge goals were set based on resident's needs and services prior to admission. LSW indicated discharge planning continued throughout the residents stay and was discussed at all care conferences. LSW further indicated she was responsible to update the discharge planning section in the care plan and confirmed LSW did not always update the care plans. LSW verified R41's and R15's care plans had not been updated to reflect R41's and R15's current discharge plans. During an interview on 2/12/25 at 4:36 p.m. director of nursing (DON) confirmed R42's care plan had not been updated to include current discharge planning interventions and goals. DON stated the expectation was care plans would be revised to include any changes or follow up completed regarding discharge planning. Facility policy titled Care Plan - Baseline and Comprehensive revised 6/20/23, to ensure that each resident received care individualized to him or herself and that goals and approaches for care were communicated to all parties including caregivers, the resident, and the resident's representative. Throughout the course of rehabilitation and the resident's stay in the facility, the identified risk factors, goals, interventions, and outcomes on the care plans would be evaluated at least quarterly and revised as necessary.

Based on observation, interview and document review, the facility failed to ensure a clean and sanitary environment when a visibly soiled commode bucket was stored next to a night stand for 1 of 4 residents (R25) and soiled bedpans were left out for 2 of 4 residents (R3, R42) reviewed for environment. In addition, the facility failed to store ADL supplies in a clean and discreet manner for 2 of 4 residents (R16, R25). Further, the facility failed to maintain standing lifts shared by residents in a clean and sanitary manner. Findings include: WASH BASINS & COMMODE BUCKET: R16 R16's Admission Minimum Data Set (MDS) dated [DATE], identified R16 had severe cognitive impact and diagnoses which included anxiety, depression and end stage renal disease (ESRD) (loss of kidney function). Identified R16 required extensive assist with activities of daily living (ADL's) which included toileting, transfer, and dressing. R16's care plan revised 11/14/24, indicated R25 had activities of daily living (ADLs) self-care performance deficit related to weakness. R16's goal was to receive staff assistance with ADLs, have no skin breakdown, have a well-groomed appearance, and no odor present. R16's care area assessment (CAA) dated 11/14/24, indicated R16 had congestive loss and dementia. The CAA further indicated R16 required extensive assistance with bed mobility, transfers, toileting. R25 R25's quarterly MDS dated [DATE], identified R25 had moderate cognitive impairment and diagnoses which included diabetes mellitus (DM), dementia and a pressure ulcer of the right heel. Identified R34 required moderate assistance with ADLs which included toileting, transfer, and dressing R25's care plan revised 2/1/25, indicated R25 had ADLs self-care performance deficit related to pain and weakness. R25's goals were to improve current level of function in bathing/showering and personal hygiene. R25's CAA dated 9/27/24, indicated R25 had cognitive loss and dementia. The CAA further indicated R25 required moderate assistance with bed mobility, transfers, toileting. During an observation on 2/10/25 at 12:22 p.m., R16's room (room [ROOM NUMBER]) had a pink wash basin dated 2/8/25, with R16's name written on the side sitting on the floor under the sink to the right of the doorway. The pink wash basin could be seen from the hallway when walking by. During an observation on 2/10/25 at 12:19 p.m., R25's room (room [ROOM NUMBER]) had three white unused briefs and a pink wash basin dated 2/8/25, with the initials DD written on the side sitting on the floor under the sink to the left of the doorway. The white briefs and pink wash basin could be seen from the hallway when walking by. In addition, there was a grey commode bucket with a white toilet hat (a container used to collect urine) sitting on the floor to the right of R25's night stand. There was a darkened ring on the inside of the grey commode bucket. Also, there was a flaky yellow ring, a cotton ball and a leaf inside the white toilet hat. On the right edge of the white toilet hat was a black power box with a cord plugged into the outlet and a cord going to R25's television. During an observation on 2/10/25 at 6:26 p.m., R16's room remained the same. During an observation on 2/10/25 at 7:01 p.m., R25's room remained the same. During an observation on 2/11/25 at 10:37 a.m., R16 and R25's room remained the same. During an interview on 2/11/25 at 11:20 a.m., housekeeping aid (HA)-B agreed R25 had a grey soiled commode bucket with a white toilet hat sitting on the floor. HA-B indicated it was not housekeeping's responsibility to clean the grey commode bucket up. HA-B further indicated it was the responsibility of nursing to clean the grey commode bucket. HA-B stated R25's room was cleaned and HA-B mopped around the grey commode bucket. During an interview on 2/11/25 at 11:23 a.m., nursing assistant (NA)-E agreed R25 room had a soiled grey commode bucket with a white toilet hat sitting on the floor. NA-E indicated R25 used to use the sit to stand lift and was toileted using the commode. NA-E further indicated R25 no longer used a commode. NA-E stated the grey commode bucket should have been removed when R25 no longer required the use of a commode. NA-E looked into the grey commode bucket and white toilet hat stated whatever is in there is kind of gross. During an interview on 2/11/25 at 12:20 p.m., NA-D went into R16 and R25's rooms and agreed both pink wash basins were on the floor and R25 had 3 white briefs on the floor. NA-D stated the pink wash basins and briefs are to be stored in the night stand drawers. STANDING LIFTS: During an observation on 2/10/25 12:33 p.m., one of the standing lifts located in the hallway on the memory care unit of the facility had a large amount thick amount of white substance and black/brown substance on the standing lift plate of the lift. During an observation on 2/11/25 10:51 a.m., the same lifts located in the hallway on the memory care unit continued to a large amount thick amount of white substance and black/brown substance on the standing lift plate of the lift. During an interview on 2/11/25 11:20 a.m., housekeeping aid (HA)-B stated HA-B had never cleaned the standing lift and had never been told to clean the standing lift. During an interview on 2/11/25 at 11:23 a.m., NA-E stated it was housekeeping's responsibility to clean the standing lift plate. NA-E further stated cleaning of the lifts had never been nursing staffs responsibility. NA-E looked at the lift standing plate and agreed that it was dirty and needed to be cleaned. 37905 BED PANS R42 R42's MDS dated [DATE], identified R42 was cognitively intact and had diagnoses which included: diabetes mellitus, arthritis, anxiety and depression. Identified R42 was dependent on staff for oral cares, hygiene, dressing and bathing. R42's CAA dated 12/22/24, identified R42 had a self-care performance deficit related to weakness. R42's CAA identified R42's care plan would be completed for self-care deficit and impaired mobility and staff would assist with ADL completion. R42's care plan revised 1/13/25, identified R42 had an ADL self-care performance deficit related to weakness. R42's interventions included personal hygiene/oral care assist of one. R3 R3's quarterly MDS dated [DATE], identified R3 was cognitively intact and had diagnoses which included heart failure, peripheral vascular disease (restricted blood flow to limbs) and depression. Identified R3 was dependent on staff for dressing, bathing, and toileting and personal hygiene. R3's CAA dated 9/19/24, identified a toileting program would be initiated if indicated and evaluated it was appropriate at that time due to incontinence, and would continue to monitor quarterly as needed. Staff would assist with toileting needs and would follow toileting plan. Staff would review and update care plan as needed. R3's care plan revised 12/16/24, identified R3 had an ADL self-care performance deficit related to immobility and related to amputation of one lower extremity. R3 required assistance of one for toilet use, personal hygiene, dressing and bathing. During an observation and interview on 2/12/25 at 7:37 a.m., NA-F was completing morning cares for R3. In R3's and R42's shared bathroom, there was a bed pan, with some tan and brown spots on it, face up sitting on the toilet riser in the bathroom. There was a second bed pan, lying on the floor, upside down on the left side of the toilet, with the leg of the toilet riser sitting in the middle of the bedpan. The bedpan on the floor had R42's initials written on the bottom of the bedpan. NA-F verified the bed pans were left out and stated R3 and R42 both used bed pans. NA-F stated the bedpans were supposed to be stored in a clean plastic bag, either on top of a garbage can or on a shelf in the bathroom. NA-F indicated R3 and R42 did not have a garbage can in their bath room, and the shelves were too small to hold them however, they should have been in bags, put on top of a garbage can, and not left out, or left on the floor. NA-F completed R3's cares, left the room, and did not remove the left out bed pans from the bathroom. 45844 STANDING LIFTS: During an observation on 2/10/25 at 12:24 p.m., two of the standing lifts located in the hallway on the main unit of the facility had a large area of dried, yellow/brown food like substance on the lower ends of the standing lift plate of the lifts. During an observation on 2/11/25 at 10:36 a.m., the same two lifts located in the hallway on the main unit continued to have a large area of dried yellow/brown food like substance on the lower ends of the standing lift plate of the lifts. During a joint interview on 2/11/25 at 11:01 a.m., housekeeper (HK) and nursing assistant (NA)-A confirmed the presence of a dried yellow/ brown food like substance on the lower ends of the lift plates on the two standing lifts. HK and NA-A both stated they were unsure who was responsible for cleaning the lifts. During an interview on 2/12/25 at 8:35 a.m., director of nursing (DON) stated all staff should ensure that lifts were wiped between every use including the foot plates when needed. DON stated her expectation was that all lifts would have been cleaned per policy. During a follow-up interview on 2/12/25 at 1:18 p.m., director of nursing (DON) stated expectation were for staff to put away bed pans in a bag in the resident's drawer or closet, and not to leave out or on the floor for infection control reasons. During a follow-up interview on 2/12/25 at 4:46 p.m., DON stated she was unaware of the above findings. DON stated her expectations were the wash bins and briefs were stored in the proper locations and the commode bucket was cleaned and stored in the proper location. DON further stated the white toilet hat should have been thrown away and the power box should not have been sitting on the side of the white toilet hat. Review of a facility policy titled Cleaning and Disinfection of Resident Care Equipment revised 5/8/24, identified reusable equipment such as mechanical lifts would be cleaned and disinfected after use of one resident and before use of another resident.

Based on interview and record review, the facility failed to provide the resident council with responses, actions, and rationale taken regarding their concerns 4 of 4 (R14, R30. R20 and R3) resident council members in the facility. This deficient practice had the potential to affect all 49 residents residing in the facility. Findings include: On 2/11/25 at 11:01 a.m. a resident council meeting was held with surveyors and four residents present which included R14, R30, R20 and R3. Residents stated they had concerns of the facility's lack of providing follow-up responses when concerns were expressed during resident council meetings. All four residents expressed they did not receive any answers after concerns were expressed. Review of resident council meeting minutes provided by the facility from 7/9/24, to 1/7/25, identified the following: -7/9/24, concerns identified on resident council meeting minutes: would like more shower stalls, lack of respect for residents from aids, beds not getting made timely, would like something for watching baseball and spray for bugs outside. Concerns were marked resolved, partially resolved or not resolved and resident council action forms were completed however, follow-up information was not provided to the residents in resident council. -8/13/24, concerns identified on resident council meeting minutes: would like more outside activities, more information about appointments, aids talking about other aids, and a light out in the bathroom by day room. Concerns were marked resolved, partially resolved or not resolved resident council action forms were completed however, follow-up information was not provided to the residents in resident council. -9/10/24, concerns identified on resident council meeting minutes: not getting socks off at night, staff using cell phones, not emptying catheter timely, and shower on wrong day. Concerns were marked resolved, partially resolved or not resolved resident council action forms were completed however, follow-up information was not provided to the residents in resident council. -10/8/24, concerns identified on resident council meeting minutes: pills not being given on time, long time for call lights, supper coming in late, and fixing light in dining room. Concerns were marked resolved, partially resolved or not resolved resident council action forms were completed however, follow-up information was not provided to the residents in resident council. -11/12/24, concerns identified on resident council meeting minutes: not getting finger nails clipped, needing room numbers, room [ROOM NUMBER] call light taped together, not making beds, cold food, food being served late and garbage left in the room with soiled products. No follow-up response was identified with earlier concerns or current concerns brought up. Resident council action forms were completed however, follow-up information was not provided to the residents in resident council. -12/10/24, concerns identified on resident council meeting minutes: no lotion on feet, not always given food alternatives, like to do knitting, crafts, painting and movies. No follow-up response was identified with earlier concerns or current concerns brought up. Resident council action forms were completed however, follow-up information was not provided to the residents in resident council. -1/7/25, concerns identified on resident council meeting minutes: bed not being made, garbage's overflowing, staff loud at night and entryways dirty. No follow-up response was identified with earlier concerns or current concerns brought up. Resident council action forms were completed however, follow-up information was not provided to the residents in resident council. During an interview on 2/12/25 at 3:09 p.m. social worker (SW) confirmed the above findings and indicated she did not have documentation of concerns being resolved. SW further indicated pervious concerns were not discussed with residents in resident council after a resident council action forms were filled out by each department. During an interview on 2/12/25 at 5:01 p.m., director of nursing (DON) stated the SW was in charge of resident council meetings and documentation for resident council meetings. DON indicated follow-up on concerns were to be documented on resident council meeting minutes and action plans. DON stated her expectations were resident council concerns were reviewed and brought to the correct department for resolution. DON further stated she would expect follow-up information be provided to the residents at resident council for each concern. Facility policy titled resident council last revised 2/26/20, the facility would provide residents with the opportunity to air any grievances that they may have and to give suggestions on what they would like. Along with any changes they think should be made. Staff Member would take minutes of meeting using the Resident Council Meeting form. Grievances aired during the meeting should be addressed within the proper department (ex: a nursing concern should be brought to the DON). Record any follow-up, to grievances, so they can be addressed at the next Resident Council meeting.

Based on observation, interview and document review, the facility failed to provide assistance to ensure hearing aids were available to maintain hearing/communication needs for 1 of 1 resident (R3) reviewed for hearing. Findings Include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact and had diagnoses which included heart failure, peripheral vascular disease (restricted blood flow to limbs) and depression. Identified R3 was dependent on staff for dressing, bathing, and toileting and personal hygiene. Identified R3 had moderate difficulty with hearing, and used hearing aide or other hearing appliance. R3's Functional Abilities Care Area Assessment (CAA) dated 9/19/24, identified R3 was dependent for toileting hygiene, to shower/bathe self, upper and lower body dressing, and required substantial/maximal assistance with personal hygiene. Staff would review and update care plan as needed. R3's care plan revised 12/16/24, identified R3 had an activities of daily living (ADL) self-care performance deficit related to immobility and related to amputation of one lower extremity. R3 required assistance of one for toilet use, personal hygiene, dressing and bathing. R3's care plan did not include use of hearing aides or interventions for hearing aide use. During an interview on 2/10/25 at 2:26 p.m., R3 stated her hearing aides needed to be sent to be cleaned, and the facility staff had not done this for her. R3 said she could send them herself if she had a box to mail them in, which she had asked staff for. R3 was not wearing her hearing aides. During a follow-up interview on 2/12/25 at 8:18 a.m., R3 stated she did not wear her hearing aides, because they were broken and they needed to be sent for repair. R3 indicated she had informed four to five different staff members about a month ago, and they have not assisted her to get her hearing aides fixed. In addition, R3 said she had asked for a box, so she could mail them herself however, she had not been provided a box either. R3 stated her hearing aides had not been working well for about two months. During an interview on 2/12/25 at 12:08 p.m., licensed social worker (LSW) stated her usual practice was to call the company to get items repaired, and to discuss with the interdisciplinary team (IDT) to see who was responsible for the cost of repair or replacement. LSW indicated she was unaware that R3 needed her hearing aides repaired. During a follow up interview on 2/12/25 at 12:50 p.m., LSW stated she had spoken to R3 about her hearing aides. LSW indicated R3 informed her she had informed multiple nurses and nursing assistants that her hearing aides were broken. R3 informed her she told a nursing assistant her hearing aides were not working then gave the hearing aides to the nursing assistant, who gave them to the nurse. The hearing aides were kept in the nursing cart for awhile, then R3 finally took them back to her room. LSW stated it was important for R3 to have her hearing aides repaired, so she could hear and communicate with others. LSW stated she would have expected staff to inform her or director of nursing (DON) that they needed to be repaired. LSW stated she would investigate why R3's hearing aides were not repaired, and would have them repaired. During an interview at 2/12/25 at 1:18 a.m., DON stated she expected if staff were aware a resident's hearing aides were broken, they would inform someone so they could be repaired as soon as possible. DON stated she had been informed R3's hearing aides were broken in passing. DON stated LSW or herself could have them repaired as soon as possible, for R3's dignity, respect, and ability to communicate. If R3 had told four to five staff, and no one did anything to fix her hearing aides, it could potentially make R3 feel like no one cared about her. A policy was requested however, was not provided.

Based on observation, interview and document review, the facility failed to provide meaningful and engaging activities for 1 of 1 residents (R37) reviewed for activities. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and had diagnoses which included Alzheimer's disease, dementia, anxiety and was currently receiving hospice services. R37 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R37's care area assessment (CAA) dated 9/16/24, indicated R37 had concerns with cognition and dementia. R36's CAA further indicated R36 did not communicate often and was not responding to conversations as much. R37's care plan revised 11/15/24, indicated R37 had a diagnosis of frontotemporal and vascular dementia with a history of alcoholism with limited R37's ability in leisure involvement. R37's goals were to maintain leisure abilities by actively engaging in structured leisure opportunities once daily three days a week. It further indicated R37 enjoyed music, games, music trivia and animals. Staff interventions were to break down tasks, give praise and provide music in R37's room. R37's care plan conference summary dated 1/21/25, stated R37's spouse offered additional activities that R37 would enjoy. These activities included, music (country, 50's and 60's), one to ones, and conversations. R37's spouse requested staff communicate with R37 even if R37 did not respond. R37's Kardex undated, indication R37 enjoyed music and singing and preferred to listen to music in room instead of coming out to join a group of people. Review of weekly memory care activities schedule for 2/9/25 through 2/15/25, revealed the following: -Monday 2/10/25: 10:00 Card Game: Uno. 10:30 Exercise: Morning Stretches. 11:00 Building Legos. 1:30 Folding Towels. 2:30 Daily Chronicles with Beverages. -Tuesday 2/11/25: 10:00 Folding Towels. 10:30 Exercise: Morning Stretches. 11:00 Pattern Shape Blocks. 1:30 Movie: [NAME] and Hooch. 2:30 Daily Chronicles with Beverages. -Wednesday 2/12/25: 10:00 Card Game: Go Fish. 10:30 Exercise: Morning Stretches. 11:00 Manicures. 1:30 Bingo. 2:30 Daily Chronicles with Beverages. During an observation on 2/11/25 at 2:12 p.m., R37 was sitting in his recliner in his room with his feet elevated and the television was on. Activities were not offered as noted on activity schedule. During an observation on 2/11/25 at 3:45 p.m., R37 continued in the same position as noted above. Activities were not offered as noted on activity schedule. During an observation on 2/12/25 at 1:41 p.m., R37 was sitting in his recliner in his room with his feet elevated and the television was on. R37's television was faced towards the bed and R37 was not able to see the tv. Activities were not offered as noted on activity schedule. During an observation on 2/12/25 at 1:57 p.m., bingo was being offered in the activity room on the memory care unit. R37 remained in his recliner in his room and was not offered to attend bingo. R37's television remained facing away and R37 was not able to see the television. During a telephone interview on 2/10/25 at 4:27 p.m., family member (FM)-A stated R37 sat in his room most of the time. FM-A also stated it had been requested by FM that staff play music and read to R37 during the day. FM-A indicated FM-A had requested the facility to get R37 a white board to help communicate with R37 as R37 had difficulties speaking. FM-A further indicated R37 did not have a white board as requested. During an interview on 2/12/25 at 8:23 a.m., nursing assistant (NA)-E stated activity aids were responsible for the actives on the memory care unit. NA-E further stated activities seldom happened on the memory care unit. NA-E indicated nursing staff were told they needed to complete activities on the unit however, nursing staff did not have the time to complete them. During an interview on 2/12/25 at 8:30 a.m., NA-I stated many times activities did not occur on the memory care unit. NA-I stated there was an activities schedule posted however, often times activities did not get completed. NA-I further stated nursing staff were told they could complete activities however, nursing staff did not have the time to complete activities. During an interview on 2/12/25 at 2:42 p.m., activity director (AD) indicated activity aids were responsible for completing activities on the memory care unit. AD further indicated at times activities did not get completed due to being short staffed. AD stated there was no documentation regarding activities and when residents were invited or attended. AD further stated she would be working on ensuring activities were completed as posted on the memory care unit. During an interview on 2/12/25 at 4:50 p.m., director of nursing (DON) confirmed the above findings and stated she was not aware activities were not being completed on the memory care unit. DON further stated her expectations were that all residents be invited to activities and activities were being completed as scheduled. DON indicated her plan was to have a full time activity aid on the memory care unit from 9am to 5pm Monday through Friday. DON further indicated activities were important especially on the memory care unit. Facility policy titled Activities issued 2/28/20, the facility will provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Based on observation, interview, and document review, the facility failed to ensure oral cares were performed for 1 of 3 residents (R42) who required assistance with hygiene, and were reviewed for activities of daily living (ADL). Findings Include: R42's admission Minimum Data Set (MDS) dated [DATE], identified R42 was cognitively intact and had diagnoses which included: diabetes mellitus, arthritis, anxiety and depression. Identified R42 was dependent on staff for oral cares, hygiene, dressing and bathing. R42's Care Area Assessment (CAA) dated 12/22/24, identified R42 had a self-care performance deficit related to weakness. Identified R42's care plan would be completed for self-care deficit and impaired mobility and staff would assist with ADL completion. R42's care plan revised 1/13/25, identified R42 had an ADL self-care performance deficit related to weakness. R42's interventions included personal hygiene/oral care assist of one. During an interview on 2/10/25 at 1:15 p.m., R42 indicated staff had never once asked her to wash her mouth out. During a follow up interview on 2/12/25 at 7:11 a.m., R42 indicated staff did not do any oral cares, including offering oral swabs or mouthwash and she would like that. R42 stated her dentures were at home. During an observation on 2/12/25 at 7:18 a.m., nursing assistant (NA)-F entered the room wearing gown and gloves. At 7:21 a.m. NA-G entered the room also wearing gown and gloves. NA-F folded up a blanket and placed in chair as R42 requested, then NA-G and NA-F assisted R42 from her bed to recliner with a mechanical lift. NA-G left the room with the lift, then NA-F assisted R42 by combing her hair, getting her a box of facial tissues and her call light. NA-F stated they were done with cares and exited the room. During an interview on 2/12/25 at 10:11 a.m., NA-H indicated R42 had a lot of anxiety, would have panic attacks, and required total assistance from staff. During a phone interview on 2/12/25 at 1:30 p.m., NA-F stated R42 did not have any dentures, and she completed oral cares only when R42 asked and stated otherwise R42 just drank water. NA-F indicated she had only completed oral cares for R42 maybe twice since she had been admitted . NA-F indicated she had not provided R42 oral cares that morning. NA-F indicated she was unaware of what oral cares should have been done when residents wore dentures. During an interview on 2/12/25 at 2:03 p.m., director of nursing (DON) stated expectation for oral cares were for staff to be complete every morning and at bed time. DON stated if residents wore dentures, she would expect the dentures be brushed and oral cares be completed with a toothette (sponged oral swab) with mouthwash or have them swish and spit, to remove food and buildup, which could cause mouth sores and for their dignity. The facility policy titled Oral Assessment And Management revised 3/13/24, identified every resident would have a complete, accurate and comprehensive assessment of oral status and needs. The residents' care plans would include assistive oral care devises, and would include alternative means to address the needs identified in the assessment process if a resident refused oral care. The policy did not include instructions for oral cares.

Based on observation, interview and document review, the facility failed to follow the comprehensive care plan for 1 of 1 residents (R37) whose care plan was reviewed. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified R37 had severe cognitive impairment and had diagnoses which included: Alzheimer's disease, dementia, anxiety and was currently receiving hospice services. R37 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and eating. R37's care plan revised 11/15/24, indicated R37 had an altered nutritional status related to dementia with a history of vascular dementia. R37 was to have soft cut up foods and pureed foods when needed. R37's intervention included: R37 was to have supervision when eating and staff were to encourage R37 to eat in the dining room sitting upright in R37's wheelchair. Review of R37 kardex undated, indicated R37 was a level four pureed, heart healthy diet and R37 required supervision with eating. It further indicated R37 was to be encouraged to eat in the dining room sitting upright in R37's wheelchair. During an observation on 2/12/25 at 8:01 a.m., R37 was laying in bed covered up with a blanket. Nursing assistant (NA)-E entered R37's room and placed R37's breakfast tray on the bedside table and left R37's room. During an observation on 2/12/25 8:03 a.m., NA-E returned to R37's room and asked R37 if he was hungry. R37 shook head up and down to answer NA-E's question. NA-E told R37 NA-E would assist R37 with eating his breakfast. NA-E set R37's bed up into an approximately 35 degree angle and moved the bedside table next to R37's bed. NA-E left R37's room to grab a straw and then returned to R37's room. NA-E continued to feed R37 breakfast in bed. When R37 was finished eating, NA-E removed R37's breakfast tray from the room. During an observation on 2/12/25 at 8:20 a.m., R37 continued to lay in his bed covered up with a blanket. R37's head of bed was lowered approximately 10 degrees and R37 remained in a slightly elevated position. R37 had finished eating and was resting prior to getting up. During an interview on 2/12/25 at 8:23 a.m., NA-E indicated R37 did not like to get out of bed until after breakfast. NA-E further indicated R37 was fed breakfast in bed. NA-E stated NA-E was not aware R37 was to be sitting upright in R37's wheelchair for all meals. NA-E further stated NA-E was unaware it was documented on R37's kardex to be up in R37's wheelchair for all meals. During an interview on 2/12/25 at 1:47 p.m., licensed practical nurse (LPN)-A stated R37 used to be sat straight up to be fed but lately staff had been feeding R37 in bed. LPN-A confirmed R37's care plan indicating R37 should have been up in R37's wheelchair for all meals. LPN-A stated R37's care plan needed to be updated to reflect the current changes for R37. During an interview on 2/12/25 at 4:50 p.m., director of nursing (DON) confirmed the above findings and indicated R37 did not like to get up much. DON stated R37's care plan should have been updated to reflect R37's current wishes. DON stated her expectations were care plans were updated on a continuous basis to ensure each resident was getting the care they required. Facility policy titled Care Plan - Baseline and Comprehensive revised 6/20/23, to ensure that each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative. Throughout the course of rehabilitation and the resident's stay in the facility, the identified risk factors, goals, interventions, and outcomes on the care plans would be evaluated at least quarterly and revised as necessary. Areas of concern that were identified during the resident assessment would be evaluated before interventions were added to the care plan.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) correctly for 1 of 1 residents (R26) reviewed for resident assessment. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024, identified Section . C 0100: to C 0500 Should Brief Interview for Mental Status Be Conducted? SECTION C: COGNITIVE PATTERNS Intent: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions. Section H 0100: Appliances Item Rationale Health-related Quality of Life It is important to know what appliances are in use and the history and rationale for such use. Code this section if an indwelling catheter including a supra pubic catheter is used. R26's quarterly Minimum Data Set (MDS) dated [DATE], Section C Cognitive Patterns Questions C 0100: to C 0500 were blank Sections H 0100 identified R26 did not have a catheter. Identified R26 had an ostomy. R26's care plan revised 9/7/24, identified R16 had a supra pubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen). Review of R26's progress notes dated 10/3/24, identified R16 had a foley catheter in place. During an interview on 2/10/25 at 7:30 p.m., R26 stated he has had a catheter for quite some time because he was not able to empty his bladder. During an interview on 2/11/25 at 3:03 p.m., MDS Coordinator verified R26 had a suprapubic catheter and did not have an ostomy. MDS Coordinator verified section H of R26's MDS dated [DATE], had not been coded correctly. MDS Coordinator stated her expectation was the MDS would have been coded correctly. During an interview on 2/12/25 at 1:43 p.m., social worker (SW) verified R26 was able to be interviewed. SW verified section C of R26's MDS dated [DATE], was blank. SW stated she must have forgotten to do section C. SW stated her expectation was that section C would have been completed to ensure a current cognitive score for R26 was documented. During an interview on 2/12/25 at 1:55 p.m., director of nursing (DON) verified R26 was able to be interviewed and had an indwelling catheter. DON confirmed R26's MDS dated [DATE], section C was blank and section H had not been coded accurately. DON stated her expectation would have been for staff to complete the MDS and code it correctly. Review of a facility policy titled Review of a facility policy titled MDS 3.0 Process revised 2/18/22, identified full MDS assessments will be completed on residents newly admitted , those experiencing a significant change in status and annually. Quarterly MDS assessments will be completed per RAI schedule between full MDS assessments. Indicated each individual who completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment he/she completed.

Based on observation, interview and document review, the facility failed to ensure a complete and comprehensive assessment was completed for 1 of 1 residents (R16) reviewed for braces. Findings include: R16's Admission Minimum Data Set (MDS) dated [DATE], identified R16 had severe cognitive impact and diagnoses which included anxiety, depression and end stage renal disease (ESRD) (loss of kidney function). Identified R16 required extensive assist with activities of daily living (ADL's) which included toileting, transfers, and dressing. R16's face sheet identified R16 had a diagnosis of Parkinson's disease (disease of the nervous system). R16's care plan revised 11/14/24, indicated R25 had an ADL self-care performance deficit related to weakness. R16's goal was to receive staff assistance with ADLs. R16's care plan lacked information regarding R16's ankle-foot orthosis (AFO) brace (to support the ankle and keep the toes aligned with the rest of the foot). R16's care area assessment (CAA) dated 11/14/24, indicated R16 had congestive loss and dementia. The CAA further indicated R16 required extensive assistance with bed mobility, transfers and toileting. R16's electronic health record lacked a comprehensive assessment for R16's AFO brace. R16's signed physicians orders dated 1/14/25, lacked an order for R16's AFO brace. Review of therapy recommendations to nursing dated 11/18/24 and 11/19/24, lacked information regarding R16's AFO brace. Review of R16's treatment administration record (TAR) dated 1/1/25 to 2/12/25, lacked a treatment plan related to R16's AFO brace. Review of R16's progress notes dated 11/7/24 to 2/12/25, lacked documentation related to R16's AFO brace. During an observation on 2/10/25 at 2:30 p.m., R16 was laying in bed with a sock on the right leg underneath the white AFO brace. AFO brace was on the right leg extending from mid calf down the back over the outside of the ankle to the tip of R16's toes. AFO brace was made of hard plastic and was secured with a white velcro strap. During an observation on 2/11/25 at 10:42 a.m., R16 was sitting in her wheelchair in her room. R16 had AFO brace on right leg. R16 did not have a sock on underneath the AFO brace. During an observation on 2/11/25 at 5:17 p.m., R16 continued sitting in her wheelchair. R16 had AFO brace on the right leg. R16 had a blue gripper sock on underneath AFO brace that only extended approximately two inches above R16's ankle. R16's sock did not extend the entire length of R16's leg and AFO brace rested on R16's bare skin. During an observation on 2/12/25 at 1:38 p.m., R16 was sitting at the table with nursing staff eating ice cream. R16 did not have AFO brace on at that time. During an interview on 2/12/25 at 1:22 p.m., nursing assistant (NA)-I stated NA-I did not know why R16 had an AFO brace or when the AFO brace should applied/removed. NA-I further stated R16 did not have orders for the AFO brace. NA-I indicated NA-I had not been trained how to properly apply R16's AFO brace and was not aware R16 should have a sock underneath the AFO brace. During an interview on 2/12/25 at 1:51 p.m., licensed practical nurse (LPN)-A indicated R16 had an AFO brace for her right leg. LPN-A stated R16 used the AFO brace for her Parkinson's disease to help R16's right leg from dropping and retracting. LPN-A identified NA's were responsible for putting R16's AFO brace on. LPN-A indicated R16's spouse brought in the brace for R16 from home. LPN-A further indicated R16 did not have an order for the AFO brace and the AFO brace was not in R16's care plan. During an interview on 2/12/25 at 2:22 p.m., physical therapy assistant (PTA) indicated physical therapy had been working with R16 one time a week. PTA stated R16 had an AFO brace to help with ankle stability when R16 walked. PTA further stated there were no orders for R16 to have the AFO brace. During a follow-up interview on 2/12/25 at 2:45 p.m., PTA confirmed with physical therapy director R16 did not have any orders and no assessment was completed for R16's AFO brace. PTA further confirmed nothing had been communicated to nursing staff on when R16 was to be wearing the brace or how to correctly apply R16's AFO brace. During an interview on 2/12/25 at 4:55 p.m., director of nursing (DON) confirmed the above findings and stated R16 did not have the AFO brace care planned. DON further stated R16 should have been properly assessed and an order should have been received for R16 to have the AFO brace. Facility policy titled resident assessment and examination revised 3/13/24, to assess the resident for any abnormalities in the residents health status to enable the care team to implement interventions to address concerns. Facility policy titled MDS - Quarterly/Annual therapy screens issued 5/1/20, therapy should screen each resident listed as appropriate.

Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 1 resident (R26) who utilized an indwelling catheter. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified cognitive portion of the MDS was not completed. Identified R26 had diagnoses which included Alzheimer, neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it), and benign prostatic hyperplasia (BPH) (enlarged prostate). MDS lacked information regarding R26's indwelling catheter. R26's annual Care Area Assessment (CAA) dated 9/11/24, identified R16 required required extensive assistance with toileting. Indicated R7 had an indwelling catheter related to urinary retention (unable to completely empty the bladder) and BPH. R26's care plan revised 4/1/24, identified R26 had an indwelling catheter due to urinary retention. Care plan identified catheter bag should have been covered at all times for dignity. R26's care sheet undated, identified R26's had an indwelling catheter. Further identified R26's catheter was to be covered at all times for dignity. During an observation on 2/10/25 at 11:35 a.m., R 26 was seated in his recliner in his room and R26's uncovered catheter bag was attached to the lower part of the recliner with 200 cubic centimeters- a unit of measurement for volume (CC) of clear urine in the drainage bag visible to anyone that walked by. During an observation on 2/12/25 at 12:00 p.m., R26 was lying in bed and R26's uncovered catheter was attached to the lower bed frame with about 300 cc of clear yellow urine in the drainage bag. R26's door was open, the uncovered catheter bag was visible and a visitor walked by R26's room. During an interview on 2/12/25 at 12:05 p.m., family member (FM)-A stated she was unsure if it would have bothered R26 to have his catheter drainage bag uncovered. FM-A further stated R16 was able to decide if having his catheter bag uncovered bothered him. During an interview on 2/12./25 at 12:10 p.m., R26 stated he would have preferred to have his catheter bag covered. During a joint interview on 2/12/25 at 12:15 p.m., nursing assistant (NA)-C and registered nurse (RN)-A verified R26's catheter drainage bag was not covered and visible to others. Verified the expectation was that R26's catheter drainage bag was covered. During an interview on 2/12/25 at 1:39 p.m., director of nursing (DON) verified R26 was able to be interviewed and had an indwelling catheter. Verified R26 required extensive staff assistance with his indwelling catheter bag. DON stated her expectation would have been R26's indwelling catheter bag would have been covered. Review of a facility policy titled Foley Catheter Management revised 1/28/25, identified proper care was to be provided for the management of a Foley catheter to drain urine from the bladder and to prevent reflux of urine back into the bladder. Identified catheter bags were to be covered at all times.

Based on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately documented in the clinical record to reflect the residents' current wishes which affected 1 of 43 residents (R34) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R34 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R20's electronic health record (EHR) banner and orders identified R34 was to have CPR however, R34's updated physician's order for life sustaining treatment (POLST) signed on ,d+[DATE]//23, identified R34's wishes of do not resuscitate (DNR). The administrator, assistant administrator and director of nursing (DON) were notified of the IJ on [DATE], at 12:07 p.m. The IJ was removed on [DATE], at 5:51 p.m. when the facility had implemented corrective action, however non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R34's significant change Minimum Data Set (MDS) dated [DATE], identified R34 had intact cognition and diagnosis which included hypertension and chronic obstructive pulmonary disease (COPD) (condition involving constriction of the airways and difficulty breathing). R34's current POLST signed by R34 on ,d+[DATE]//23, identified R34's wishes were DNR. The POLST was scanned into her EHR and signed by her medical provider on [DATE]. Review of R34's EHR Order Summary Report dated [DATE], identified R34 had an order for CPR and the order was signed by her medical provider on [DATE]. Review of R34's EHR banner on [DATE] at 6:07 p.m., identified R34 wanted CPR. Review of R34's face sheet in the EHR undated identified R34 wanted CPR R34's care plan revised [DATE], identified R34's advance directives would be reviewed at each care conference. Care plan directed staff to follow R34's wishes. During an interview on [DATE] at 6:16 p.m., R34 stated in the event her heart stopped or she was not breathing, she would not want staff to perform CPR on her. R34 indicated she signed a paper a few months ago stating her wishes were DNR. During an interview on [DATE] at 9:14 a.m., licensed practical nurse (LPN)-A indicated in the event a resident did not have a pulse or respirations, she would refer to the EHR banner and would have proceeded accordingly. During an interview on [DATE] at 9:15 a.m., LPN-B indicated in the event a resident did not have a pulse or respirations, she would refer to the face sheet in the EHR and would have proceeded accordingly. During an interview on [DATE] at 9:20 a.m., registered nurse (RN)-A indicated in the event a resident did not have a pulse or respirations, she would refer to the EHR banner and would have proceeded accordingly. During an interview on [DATE] at 9:50 a.m., LPN-C indicated in the event a resident did not have a pulse or respirations, she would refer to the EHR banner and proceed accordingly. LPN-C stated she was responsible for updating the POLSTs with the residents and another nurse was responsible for updating the EHR. LPN-C verified R34's EHR banner and R34's POLST did not match. During an interview on [DATE] at 9:57 a.m., director of nursing (DON) indicated LPN-C completed the POLST with each resident upon admission, yearly with care conference and when a resident's wishes changed. DON stated LPN-C should have updated the EHR to match the POLST. DON confirmed there was a discrepancy and R34's EHR banner did not match her current wishes. DON confirmed in the event R34 did not have a pulse or respirations, CPR would have been initiated against R34's wishes. DON indicated she would expect staff to follow the POLST, resident wishes and the facility policy. Review of the facility policy titled, Advance Directives revised [DATE], identified advance directives for all residents were individualized by the resident, documented, and effectively implemented at the facility. Identified, a POLST would be completed upon admission and would be scanned into the EHR and the code status physician orders would have been verified. When a resident became unresponsive, the resident's Advance Directives / POLST would be followed. The code status would be reviewed and verified at quarterly care conferences and when residents return to the facility from a hospital stay. The IJ was removed on [DATE] at 5:51 p.m., when the facility developed and implemented a systemic removal plan which was verified by interview and document review: -All residents' records were reviewed to ensure the POLST form, the electronic medical records were updated to ensure resident's wishes for advance directives, were accurate on [DATE]. -R34's EHR record was updated to match the current POLST. -All current licensed staff were educated on the policy for advance directives, updating the POLST and the EHR to reflect the resident's wishes on [DATE], as evidenced by the education sign in sheet and interviews. -A process was implemented to assure all other nursing staff completed mandatory education prior to the start of their next shift on [DATE], by notification of required education via phone/text. Education to all future shifts would be provided via video. All staff would sign off once education had been completed. -The advance directive policy was reviewed and determined no changes were required.

Based on interviews and document review, the facility failed provide adequate supervision 1 of 3 residents (R1), who resided on the memory care unit and was identified as an elopement risk, was able to leave the facility during freezing temperatures. This result in an immediate Jeopardy. The immediate jeopardy began on 2/14/22, when R1, who exhibited wandering and exit seeking behaviors, was able to leave the memory care unit and exit the facility during freezing temperatures ( zero to two degrees Fahrenheit) which was identified on 2/23/22. The interim administrator and director of nursing (DON) were notified of the immediate jeopardy at 6:07 p.m. on 2/23/22. The immediate jeopardy was removed, and the deficient practice corrected on 2/14/22, prior to the start of the survey and was therefore issued at Past Noncompliance. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses included stroke, [CONDITION(S)] and had moderate cognitive impairment. Further, MDS indicated R1 was independent with ambulation and exhibited wandering behaviors daily. R1's care plan dated 2/5/22, indicated R1 was at risk for wandering, elopement and to leave the facility without notice related to diagnosis of non-traumatic subarachnoid hemorrhage (aneurysm). Further, R1's care plan indicated R1 was very young, mobile and is able to compensate for memory deficits easily and could be mistaken for a visitor. R1's care plan identified interventions to prevent R1 from an elopement from the facility such as placement in a secured memory care unit, code changed on all keypads in the facility, 15- minute checks, provided distractions (folding laundry, washing tables, coloring), and monitor resident for tailgating when visitors are in the building. Review of progress notes for R1 indicated history of significant exit seeking behavior: 2/3/22 -noted to exit seek by doors and elevator on multiple shifts 2/4/22-noted to be frequently exited seeking, attempting to follow visitors out 2/5/22 - noted to be exit seeking frequently, attempting to be following staff and visitors out 2/6/22 - noted to be exit seeking, attempting to follow visitors out exits and elevator, standing by elevator all day with back to the door, pushing key pads. 2/7/22 - noted to continue to exit seek, trying to open doors, punching in key codes at door, hard to redirect. 2/8/22 - R1 attempted to get on elevator with maintenance, staff redirected and educated maintenance. *2/9-2/10 - no exit seeking behavior noted but continue to wander into other resident rooms, demonstrated confusion about being a staff member, asking for her paycheck and attempted to assist other residents by pushing wheelchairs. 2/11/22 - attempting to punch in code for door and elevator, stated she would jump out of the f******g window if I have to. 2/13/22 - staff were informed by housekeeping R1 entered elevator with another resident's family. Staff found R1 on main floor. Review of incident on 2/13/22, facility shortened length of time elevator times remained open but failed to assess other factors that contributed to R1's elopement from the secured unit. Review of facility report to the State Agency dated 2/14/22, indicated R1 had followed a contracted vendor out of the exit door of the secured memory care unit. R1 ambulated independently outside before re-entering the building through another door (in another part of facility, not secured) where she was found by facility staff. R1 was then escorted by facility staff back to the secured memory care unit and no injuries were noted. On 2/23/22, at 11:11 a.m. R1 was observed ambulating independently in the commons area of the secured memory care unit. R1 was not exhibiting exit seeking behaviors at this time, but continued to wander back and forth from room to the commons area. On 2/23/22, at 12:22 p.m. nursing assistant (NA)-A indicated R1 exhibits wandering behaviors continuously throughout the day and had been high risk for elopement since admission. Further, NA-A indicated R1 would attempt to exit with visitors often and many visitors were not aware R1 is a resident (R1 is young and can blend in easily with visitors) and will let R1 out of the secured unit with them. NA-A indicated she observed R1 on 2/14/22, at the end of the hallway and NA-A went to assist another resident and returned approximately 5 minutes later to find R1 was not there. NA-A stated they started looking for R1 right away and at that time R1 was coming down the hall with maintenance. NA-A indicated once she was made aware R1 left the secured unit with the contractors, NA-A followed R1's footsteps outside in the snow where she described the weather as cold and R1 was wearing sweatpants, sweatshirt, socks, and shoes at the time of the elopement. In addition, NA-A indicated R1 was exhibiting wandering behaviors that day prior to the incident. On 2/23/22, at 12:03 p.m. contracted vendor (CV)-A indicated he was working at the facility with CV-B on the lower floor of the facility. CV-A indicated he approached CV-B who was speaking with R1 near the exit door of the secured unit. At this time, R1 had stated to CV-B I will follow you guys out and CV-A indicated they thought R1 was employed at the facility due to R1's appearance of being young and holding a mountain dew in her hand. Further, CV-A indicated the facility did not provide education to the contractors regarding working on a secured memory care unit or being aware of resident's attempting to follow the contractors off the secured unit. In addition, CV-A indicated the contractors were provided education following the incident. On 2/23/22, at 12:09 p.m. CV-B indicated he observed R1 standing next to a housekeeping cleaning cart and appeared to be cleaning. CV-B indicated R1 then stated, I need to go outside. Further, CV-B indicated the contractors were not aware she was a resident until R1 stated she was too cold and continued to walk around the building into another door of the facility. In addition, CV-B indicated the facility staff did not make the contractors aware of high-risk residents or to be aware they were working in a secured memory care unit. CV-B confirmed he was provided education by the facility staff following the incident. On 2/23/22, at 12:36 p.m. maintenance director (MD) indicated R1 was found in another building attached to the facility and was escorted back to the secured unit by another maintenance staff. MD indicated staff were looking for R1 at that time. Further, MD indicated the contracted vendors got fooled since R1 appeared to be a visitor rather than a resident. In addition, MD indicated the contractors were provided education following the incident. On 2/23/22, at 12:57 p.m. licensed practical nurse (LPN)-A indicated R1's had short term memory impairments and exhibited wandering and exit seeking behaviors. Further, LPN-A indicated previously R1 has exited the unit by utilizing the elevator with a visitor and had left the unit following a contracted vendor. LPN-A is aware of interventions in place for R1 following the incident. On 2/23/22, at 2:22 p.m. director of nursing (DON) indicated R1 had cognitive impairments with a memory span of 2-3 seconds and following staff redirection R1 did not have recall. DON indicated R1 exhibited exit seeking behavior and has made attempts to leave the secured unit with visitors. DON indicated on 2/14/22, R1 followed the contracted vendors out of the exit door outside the facility and walked back in the facility through another entrance, where she was escorted by staff back to the secured unit. When asked about facility procedure for educating contracted vendors, DON indicated the facility did not have a procedure in place but stated the facility staff should have been with the contractors to ensure no residents were following them through the secured doors. On 2/23/22, at 3:43 p.m. interim administrator indicated the root cause of R1's elopement was determined to be R1 following the contractors out of the secured doors on the unit. Interim administrator indicated the facility's process was to educate the contractors working on a secure unit with vulnerable adults and be aware of resident's by the exits. Further, administrator indicated he was not sure if the contractors were educated prior to entering the secured unit. In addition, administrator indicated the facility staff responded appropriately after the incident and educated the contractors at that time. Review of facility policy titled Elopement Risk and Prevention revised on 9/2/21, indicated it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible and will be assessed for behaviors of conditions that put them at risk for wandering or elopement. Further, facility policy defines wandering as random or repetitive locomotion, which may be goal directed, for example the resident appears to be searching for something such as an exit. The past noncompliance immediate jeopardy began on 2/14/22. The immediate jeopardy was removed and the deficient practice corrected by 2/14/22, after the facility implemented a systemic plan that included the following actions: contracted vendors involved were educated, signs posted on all exit doors with education for visitors/vendors, exit door codes were changed, R1's care plan was updated, staff were educated and directed to monitor wandering behavior, elopement assessment completed and determined to be at high risk, initiated 15-minute checks for R1 while contractors were in the building, and R1 had a room change so she will have to pass nursing station to get to exit.

Based on observation, interview and document review, the facility failed to comprehensively assess, develop appropriate interventions and to provide adequate supervision to minimize the risk of harm for 3 of 3 residents (R30, R29, R18) who had repeated falls in the facility. This resulted in an immediate jeopardy (IJ) situation for R30 who remained at risk for serious injury due to frequent self-transferring and history of injury related to falls. The immediate jeopardy began on 2/26/20, at 6:54 p.m. when it was identified R30 frequently self transferred without staff or assistive devices and had a history of [REDACTED]. The immediate jeopardy was removed on 2/28/20, at 10:00 a.m., but noncompliance remained at the lower level of scope and severity but noncompliance remained at the lower G scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings include: R30's significant change Minimum Data Set (MDS), dated [DATE], identified R30 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R30 required extensive assistance with most activities of daily living (ADL's) which included transfers, walking and toileting. R30's MDS indicated she had one fall with no injury since the last assessment. R30's significant change Care Area Assessment (CAA) dated 1/25/20, identified R30's Fall CAA triggered due to balance problems during transitions from seated to standing position, walking, turning around and facing the opposite direction while walking and moving on and off the toilet. The Fall CAA listed R30 had [DIAGNOSES REDACTED]. The CAA identified R30 had a history of [REDACTED]. In addition, the CAA identified R30 had periods of confusion, disorientation and forgetfulness related to [MEDICAL CONDITION]. R30's care plan, revised 1/30/20, identified R30 was at high risk for falls related to altered cognition, weakness and history of frequent falls secondary to her inability to understand her limits and safety. The care plan indicated R30 had impaired cognition and frequently sought her sister Alice, wandered, and was at risk for fractures related to [MEDICAL CONDITION]. R30's care plan listed various interventions which included assistance of one staff and a walker for transfers and locomotion, required verbal cues to keep cane close and off to her side, post reminders in room to use assistive devices with transfers/ambulation, resident uses a wheelchair, place next to bed when resident in bed. Review of R30's Morse Fall Scale (a tool used to determine fall risk) from 5/21/19 to 2/26/20 revealed R30 had history of falls, impaired gait, weakness and mental status and listed the following: - 5/21/19, high risk - 10/6/19, moderate risk - 10/31/19, high risk - 2/26/20, moderate risk On 2/24/20, at 4:20 p.m. R30 walked out of her room independently into the hallway, with an unsteady gait, hunched over slightly and without an assistive device. There were no staff in the area. Trained medication aid (TMA)-C walked out of another resident's room, approached R30, took ahold of her arm and walked her back to her wheelchair in her room. - at 4:28 p.m. R30 was seated in her wheelchair, repeatedly wheeling herself up and down the hallway and asking for her sister Alice and how to get out of the facility to get to Staples. - at 5:27 p.m. R30 was seated in her wheelchair at a table in the dining room with other residents and no staff were present in the dining room. R30 stood up from the wheelchair, stumbled backwards and ended up with her back against the dining room table. TMA-C entered the dining room, approached R30, encouraged her to sit back down in her wheelchair and R30 sat in her wheelchair. On 2/25/20, at 9:14 a.m R30 wheeled herself out of her room to the dining room and R30 informed TMA-B she had to go to the bathroom. TMA-B stated R30 had been in bed and self transferred to the wheelchair prior to wheeling herself to the dining room. - at 2:28 p.m. R30 transferred from her bed to the wheelchair without assistance or supervision and wheeled herself to the nurses station and asked staff where her sister was. A sign was observed posted on the closet door, right next to doorway into room, which read Betty call for help before you move- don't fall. On 2/26/20, at 7:05 a.m R30 was lying on her right side in bed, asleep with the wheelchair parked next to her bed. A quad cane was noted to be on the right side of the bedside table, approximately six feet away from R30's bed. - at 7:13 a.m. R30 was observed lying on her left side on the floor next to her bed. The writer notified nursing assistant (NA)-G, who was in another room, R30 was lying on the floor. NA-G went to the doorway of R30's room, indicated she needed to call the main floor for assistance as there had been no other staff working on the unit with her and walked away. R30 had a stream of blood running down the left side of her face, extending down to her left eye. R30 proceeded to crawl on all four extremities back to her bed, grabbed the siderail and pulled herself up onto the edge of the bed. R30 stood up from the bed, took ahold of the arms of the wheelchair, and walked behind the wheelchair to the doorway of the room. - at 7:14 a.m. NA-G returned to the doorway, assisted R30 to sit in her wheelchair and assisted her to the bathroom. R30's quad cane remained next to her bedside table. After toileting, NA-G assisted R30 into bed. R30 was noted to also have a stream of blood running down the back of her head to her neck area at that time. R30 stated her head hurt and had not been able to recall what had happened. NA-G stated R30 was supposed to be in her wheelchair and was not supposed to use the quad cane for an assistive device. - at 7:23 a.m. licensed practical nurse (LPN)-B entered R30's room and visualized her face and neck area. She confirmed R30 had a blood stream which originated from above her left ear and extended down to her left eye and another blood stream which originated from above her left ear and extended down the back of her head to R30's neck area. LPN-B indicated R30 had a superficial V-shaped laceration above her left ear which measured 2.0 centimeters (cm.) by 1.1 cm., a laceration to the right of the V-shaped laceration and above the left ear which measured 0.9 cm. by 0.5 cm. LPN-B stated she felt R30 was safe to transfer and walk independently and liked to wander up and down the hallways. LPN-B confirmed she had dementia, confirmed a quad cane was present next to the bedside table and was unsure which assistive device R30 was to use to transfer. - at 8:03 a.m. R30 remained in bed, awake and the sign reminding her to call for help remained in place next to the doorway. Assistant director of nurses (ADON) entered R30's room and stated R30 had multiple falls within the past few months and frequently self transferred. The ADON stated she felt R30 was able to safely self transfer and stated R30 should be using the quad cane for transfers and walking. The ADON verified the sign posted by R30's doorway to remind R30 to call, was not visible to R30 from her bed. ADON immediately removed the sign and placed it on the wall facing R30's bed. ADON reviewed R30's current care plan and confirmed R30 required assistance with transfers and walking. Review of R30's Internal Incident Reports from 5/21/20, to 2/26/20, revealed the following: - 5/21/19, 12:45 p.m., found crawling out into the hallway looking for her sister. Assisted up with 2 staff. On 5/24/19, IDT (Interdisciplinary team) follow-up revealed R30 was assisted to the recliner in the day room during the day time and no further falls of this nature noted. - 7/23/19, 12:22 p.m., ambulated to the dining room table with her four wheeled walker, had one hand on the walker, lost her footing and fell to the floor. Skin tear to her right arm noted. PT to continue treatment three times a week for one week. On 7/26/20, IDT follow-up referred to OT for walker safety and pharmacy to review R30's medications. - 7/28/19, 6:45 a.m., heard ladies in the dayroom yelling out and R30 was observed stumbling backwards and fell straight back while hitting her head on the floor. Staff noted bleeding from the back of her head and a lump had started to form. R30 had not been using a walker. R30 stated only initial pain to the head and stood on her own while writer assisted, hematoma and abrasion to occipital area which measures 3.2 cm. by 2.8 cm. Sent to ED and diagnosed with [REDACTED]. - 7/29/19, 10:10 p.m. ambulating without assistance and without a walker from the day room towards common resident bathroom on the main floor. R30 appeared to trip over the edge of the vinyl flooring where the break between the carpet and the flooring was located, landed on her hands and knees and had not hit her head. Previous skin tear to R30's left elbow bleeding through steri-strips with bruising to left hand and wrist which had been purple in color and measured 7.1 cm squared. R30's right hand had a bruise on her third knuckle which measured 2.3 cm. squared and two open areas to R30's upper and lower spine which measured 1.1 cm. squared on upper area and 0.2 cm. squared on the lower area. Staff unsuccessful in redirecting R30. On 8/1/19, IDT follow-up revealed R30 had a fall on 7/30 while self -transferring and walked without a walker. Orthostatic blood pressures (BP) for three days, UA was obtained. - 8/29/19, 2:04 p.m., found on left knee, used end table to get herself up and walked back to bed, skin tear to right area. Assisted to common area for increased staff supervision. - 8/31/19, 5:43 a.m. complained of her arm hurting, noted to be bleeding from her elbow had sustained an open area to her right elbow with a bruise surrounding it. - 8/31/19, 7:30 a.m., night staff reported R30 came to the nurses' station holding her right arm and rubbing it. Noted with a bruise and skin tear to her right wrist, bruise had been purple, swollen and R30 had been unable to move her right wrist without pain. R30 sat in the chair and guarded her arm. Sent to the ED, [DIAGNOSES REDACTED]. On 9/2/19, IDT follow-up revealed had been looking for Alice and knocked herself over. R30 noted to be manic recently and going non-stop during the day and resident always looking for her sister resident. Medication evaluation from Psychiatric services to be done. - 9/18/19, 7:45 a.m., had her legs crossed, propelled self to the dining room and slipped out of her wheelchair to the floor. By the time staff approached, R30 had used the rail in the hallway to get self up and returned to her wheelchair independently. New wheelchair cushion to prevent slipping. On 9/22/19, IDT follow-up revealed R30 propelled self in wheelchair and slipped out. OT lowered the seat in her wheelchair and OT eval completed on wheelchair seat. - 11/15/19, 7:50 p.m., in the hallway ambulating by herself without the walker and had been looking for Alice, fell to her knees, then to her elbows and developed a skin tear to her right elbow. Placed walker at R30's bedside. On 11/19/19, IDT follow-up R30 ambulating without walker and R30's walker was to be placed at bedside, PT and OT evaluation, no patter noted. - 1/12/20, 9:26 p.m., found lying on her left side in dayroom area and did not have her wheelchair or walker with her. On 1/16/20, IDT follow-up revealed R30 ambulated without assistive device or her wheelchair, had poor memory and needed safety cues. PT referral, NP visit planned, sent in for x-rays and no fracture had been identified. A sign had been posted in R30's room by doorway to use her walker or cane when transferring or ambulating. - 1/15/20, 6:50 p.m., found on the floor on all fours crawling around on the floor, confused and looking for Alice. Staff provided one to one supervision and assessed the need for toileting, food and drink. On 1/19/20, IDT follow-up revealed facility had not been able to determine residents' needs and R30 continued to decline, potential hospice services, referral to therapy. - 2/24/20, at 5:45 p.m., witnessed near miss fall. R30 stood up from her wheelchair at the dining room table, started to ambulate, lost her balance and fell into the table. R30 had not hit the ground and had a tendency to self transfer and ambulate without assistance. - 2/26/20, at 7:30 a.m., found lying on the floor next to her bed, got up off the floor and returned to bed without assistance. R30 noted to be lying in bed with a line of blood down the left inside of her face and to the back of her head. R30's clinical record lacked evidence of a comprehensive assessment of R30's falls to determine a root cause of her multiple falls, and lacked documentation of appropriate interventions implemented to minimize her falls. On 2/24/20, at 6:37 p.m. NA-G stated R30 frequently self transferred and verified she required assistance of one with transfers and ambulation. NA-G stated R30 got up and down all the time' by herself and stated it could have happened 50 times a shift. NA-G further stated R30 had several falls within the past few months and R30 had been very forgetful. NA-G stated staff attempted to redirect her and often times had been unsuccessful due to short term memory loss. On 2/24/20, at 7:08 p.m. TMA-C stated R30 self transferred multiple times a shift. TMA-C stated R30 attempted to self transfer twice that shift and attempted 4-5 times the evening before. TMA-C stated a couple of nights ago R30 walked independently into another resident's room when staff were assisting the other resident, asking where her sister was. Additionally, the TMA-C stated a couple weeks ago R30 had walked into another resident room when she was working with that resident, lost her balance and TMA-C had been able to intervene and prevent her from falling. TMA-C stated staff provided redirection and offered laundry to fold with short term effects. TMA-C stated R30 received a one to one visit once in awhile and was not aware how often the visits occurred. TMA-C stated she was not aware of other activities R30 attended. On 02/25/20 at 8:56 a.m. TMA-B verified R30 self transferred as often as 25 times a shift and frequently searched for her sister Alice. TMA-B stated R30 was very forgetful and had multiple falls in the past few months. TMA-B stated the one staff person on the unit could get busy in another resident room for 10-15 minutes at a time and R30 would then be unsupervised. On 2/25/20, at 2:36 p.m. TMA-D stated R30 self transferred non-stop as much as 10 times per shift. TMA-D verified R30 required assistance with transfers and ambulation for safety. TMA-D indicated R30 was forgetful and was not able to remember for a few minutes at a time. TMA-D stated staff provided redirection to R30 and indicated the redirection had not been effective. On 2/26/20, at 7:56 a.m. in a follow- up interview, NA-G stated R30 self transferred frequently and verified R30 had a fall earlier that am. NA-G stated R30 spent 70% of the time wandering in her wheelchair up and down the hallway looking for her sister Alice or asking if someone could have given her a ride to Staples. NA-G stated staff provided redirection or diversion in an attempt to calm her down when anxious or wandering and stated it had been unsuccessful the majority of the time. NA-G stated nursing staff had her fold laundry, although she usually completed the task so quickly, liked to get her hair and nails done and was not aware of any other activities with R30. On 2/26/20, at 8:23 a.m. DON-B stated R30 had short term memory loss and lacked the ability to recall. DON-B stated R30 required constant redirection and frequently displayed anxious behaviors while looking for her sister Alice. DON-B stated R30 had multiple falls in the past and felt there had been no patterns/ trends identified for the falls. DON-B stated R30 had been at risk for fracturing when she fell due to history of [MEDICAL CONDITION]. DON stated the fall reminder sign should have been placed in an area visible for R30, and verified the posting on her closet door by her doorway had not been appropriate. On 2/26/20, at 8:53 a.m. activities aid-(AA) stated the activities staff did not routinely provide organized activites to the memory care unit. AA stated some of the residents residing in the memory care unit had been brought up to the main floor for other activities, however, confirmed that did not occur with all residents residing in the memory care unit. AA stated she felt nursing provided activities to R30 routinely and once a week a one to one visit had been provided to R30 by activities staff. On 2/26/20, at 9:13 a.m. nurse practitioner(NP) stated R30 had advancing dementia and had very poor recall. NP stated R30 required closer supervision due to anxiety and wandering behaviors and that was the reason why R30 had been moved to the locked unit. NP stated R30 had brittle bones and was at high risk for sustaining fractures. On 2/26/20, at 4:19 p.m. in a follow- up interview ADON again confirmed the appropriate assistive device for R30 was the quad cane. On 2/27/20, at 9:49 a.m in a follow-up interview with NP, NP stated she felt the facility should expand the activities on the memory care unit. NP stated the residents on the memory care unit required activities specific to dementia care and stated she was aware the nursing staff had not been able to complete activities and provide one to one supervision. NP stated it had not been possible for nursing staff to monitor all residents residing on the memory care unit with one staff person assigned for resident care. On 2/27/20, at 2:21 p.m. activities director (AD) stated an organized activity program on the memory care unit had been difficult to maintain due to activity staffing limitations at times. The AD stated there had been times only one activities staff had been scheduled for the day in the facility. The AD stated she was aware R30 became anxious frequently looking for her sister, and confirmed activity staff only provided one to one visits weekly. Review of R30's progress notes from 5/21/19, to 2/26/20, revealed the following: -5/21/19, 12:45 p.m., admitted to the facility and noted to be quite confused and fixated on going home. R30 crawled out of her bed and into the hallway independently. - 5/22/19, at 3:22 p.m., therapy staff noted R30 had required limited assistance of one, a walker and gait belt to transfer and walk. -5/24/19, at 5:32 a.m., self transferred, toileted herself and returned to bed. Staff encouraged R30 to call for assistance and noted R30 was unable to be redirected. - 5/25/19, at 5:47 a.m. self transferred once to the bathroom and staff encouraged her to call for assistance. - 5/25/19, at 2:15 p.m. self transferred three times from the recliner to use the bathroom and staff assisted to the bathroom. - 5/26/20, at 3:59 a.m.,self- transferred herself to the bathroom twice during the shift. Staff reminded R30 to use her call light and placed call light along side of bed. - 5/27/19, at 11:03 a.m., self transferred multiple times on the shift from wheelchair to chair and from chair to bathroom. Staff re-educated R30 to use her call light to ask for assistance. - 5/27/19, at 10:31 p.m., self transferred multiple times during the shift from wheelchair to chair, recliner chair to chair and from wheelchair to bathroom. R30 had been found standing up without assistance at the nurses station, walking around in her room and frequently looking for her sister. Staff reminded R30 her sister planned to visit the next day and informed her she should not have been getting up by herself. -5/30/19, at 6:07 a.m. self transferred frequently on all three shifts and had been found walking in her room and had pushed the fall mat which had been on the floor out of her way. At 6:23 a.m. fall mat removed as it was considered a safety hazard for R30. - 5/30/19, at 9:56 p.m. self transferred from recliner to wheelchair, from wheelchair to bed and walked in her room without assistance. Staff encouraged R30 to wait for assistance without success. - 5/31/19, at 5:54 a. m. continued to self transfer on all shifts. Staff provided reminders and education to R30 to call for assistance without success. Floor mat had been removed and bed left at safe height for R30. - 6/7/19, at 9:45 p.m., self transferred and walked per self, frequently asked for her sister and staff attempted to call sister without success. - 6/9/19, at 9:20 p.m., R30 spoke with her sister over the phone and forgot the conversation two minutes later. R30 frequently asked to call sister and asked staff and other residents for a ride to Staples. - 6/11/19, at 11:48 p.m., therapy staff stated R30 had been independent with bed mobility and required supervision with transfers and walking using a walker. - 6/18/19, at 2:54 p.m., attempted to leave the unit via the elevator when visitors got on elevator. Staff intervened at the first three attempts and a visitor informed staff of the fourth attempt for staff to intervene. R30 moved to the main floor. - 6/19/19, at 8:59 p.m. wandered into other resident rooms looking for her sister and inquiring about getting to Staples. Staff intervened and attempted to redirect R30 numerous times. - 6/20/19, at 9:03 p.m., spent most of the evening wandering around asking staff and other residents to use the phone to contact her sister Alice and to find a ride to Staples. Staff attempted to redirect, lasted around three minutes. R30 would stand by the front entrance attempting to get outside and staff had to distract her from that on three different occasions. - 6/23/19, at 9:51 p.m., noted to be wandering into other residents' rooms asking to go to Staples and about her sister Alice. - 7/4/19, at 8:51 p.m., continued to display wandering behavior into other resident rooms and asking questions about her sister Alice. Staff attempted to redirect, however, only lasted a couple of minutes. - 7/23/19, at 12:43 p.m., noted to be walking too quickly to the dining room table and lost her footing and fell to the floor. R30 developed a skin tear to her right arm. - 7/28/19, at 10:54 a.m., staff heard yelling in the dayroom, responded and observed R30 stumble backwards and fell straight down hitting her head on the floor. Bleeding noted to the back of her head and a lump had started to form. R30 sent to the local emergency department (ED). Staff noted R30 continued to get up often without her walker and staff needed to provide frequent reminders for R30 to use her walker. - 7/29/19, at 9:39 pm., stood up from her recliner in the dayroom, maneuvered down the hallway and was found standing in the doorway of another resident's room with blood present on the sleeve of her sweatshirt. Three skin tears to her left elbow were noted over the same area of extensive bruising R30 had received from previous fall and R30 had been unable to explain how the injuries had occurred. - 7/30/19, at 10:10 p.m., ambulating without assistance and without the use of a walker from the dayroom to the common resident bathroom on main floor. R30 appeared to trip over the vinyl flooring and start of the carpet, landed on her hands and knees and had not hit her head. R30 noted to have previous skin tears on the left elbow with bleeding noted at the site. Bruising noted to left hand wrist, right hand third knuckle and two open areas noted to upper and lower spine. R30 was toileted, requested to sit and wait for her sister Alice. Staff had been unable to redirect R30. - 8/2/19, 11:18 a.m., noted to have had two falls with skin tears, wandered looking for sister Alice, exit seeking at times and had confusion. - 8/14/19, at 6: 36 a.m., found entering another resident's room and attempted to crawl into bed with resident. Staff redirected R30 and assisted back to her room. - 8/29/19, at 2:14 p.m., housekeeping staff found R30 kneeling on her left knee and used the end table to get up. R30 stated she had knocked herself over and could not find Alice. Skin tear noted to her right outer forearm. - 8/31/19, at 5:53 a.m., complained of pain to her arm, open area noted to right elbow with bruise surrounding the area. R30 unable to describe what happened. Staff noted R30 had wandered much of the night. A note at 7:04 a.m. indicated R30 came out to dayroom holding her right arm and had not used her walker due to frequently forgetting the walker. Area noted to be deep purple in color and swollen. R30 transferred to the ED at 7:15 a.m. - 8/31/19, at 9:13 a.m., returned from the ED with a splint, orders to ice and elevate and to keep splinted until follow up with orthopedic specialist occurred. R30 stated, I don't understand, did I fall or something? - 9/1/19, at 5:46 a.m., slept good until 3:30 a.m. and then had been up every hour since that time walking without her walker down the hallway. - 9/1/19, at 9:00 a.m., found wandering into other residents' rooms, making beds and rummaging. Assisted out of the rooms many times and escorted to the dining room for breakfast. R30 had been noted to be up walking several times without walker. - 9/2/19, at 1:31 p.m. self transferred many times throughout the day and with the use of the cane. Staff indicated R30 required training on the use of the cane as she placed the cane too far ahead of her. Staff redirection provided. - 9/2/19, at 5:49 p.m. self transferred throughout the shift without the use of the cane. Staff redirection provided. - 9/3/19, at 12:48 a.m., Physical Therapy (PT) mobility status report indicated R30 required limited assistance of one with bed mobility, transfers and walking using a quad cane. The status instructed staff to use a gait belt with verbal cues to keep cane closer and off to her left side. - 9/3/19, at 9:20 p.m., made numerous trips from her room to the nurses station often without the use of the cane. Staff provided redirection and cane use. - 9/18/19, at 10:15 a.m., had her legs crossed while propelling herself in the wheelchair and slipped out of her wheelchair to the floor. Before staff got to her, used the rail on the wall to stand herself up and returned to her wheelchair. A note at 12:57 p.m. indicated R30 had received one to one attention throughout the day due to repeated attempts to look for her sister and inability to redirect. Staff assisted with activities, folding clothes, visiting, toileting, food, and drink. R30 had been unable to complete tasks due to anxiety regarding Alice. - 9/23/19, at 6:38 a.m., Staff were unable to locate R30 and found her lying in another resident's bed. - 9/24/19, at 12:56 a.m., wheeled herself from her room to the nurses station four times looking for her sister Alice. Staff provided redirection. - 9/27/19, at 7:01 a.m., found sleeping in a recliner in another resident's room. Staff redirected her back to her own room. - 10/2/19, at 2:34 p.m., wandered in and out of other resident rooms and attempted to don men's clothing. Staff had been unable to redirect R30. - 10/3/19, at 1:47 p.m., going in and out of other residents' rooms, lying in their beds and attempting to pull down her pants. Staff monitored R30 and assisted with toileting. - 10/30/19, at 8:41 p.m., continued to require nearly one to one attention due to questions regarding her sister Alice and if she could get a ride to Staples. Staff provided tender loving care (TLC), distractions with tasks and activites and answered her questions and was easily distracted. - 11/13/19, at 9:24 p.m., staff observed R30 to be anxious, unable to relax and looking for Alice and John and noted to walk without her walker. - 11/15/19, at 9:24 p.m., fell after walking in the hallway looking for Alice without staff assistance or the use of the walker. R30 fell to her knees and then to her elbows which caused a skin tear to her right elbow. New intervention to leave walker at bedside initiated. - 11/17/19, at 3:44 p.m., anxious, continuously asking about her sister Alice and getting a ride to Staples. Staff attempted to redirect, R30 unable to remember and folding laundry was effective until the task had been completed. - 12/15/19, at 10:29 a.m.,continuously asking other residents about her sister Alice. - 1/3/20, at 10:00 p.m., staff noted R30 had increased confusion to time, place and person. Went into other residents' rooms and up to the nurses station without her wheelchair five times, calling female resident Alice. Staff provided redirection, one to one supervision and removed R30 from others' rooms to no avail. - 1/4/20, at 10:39 p.m. walked three different times to the nurses station looking for her sister Alice and for her glasses. Redirected by staff each time back to her room. - 1/6/20, at 3:22 a.m., wandered up to the nurses station and another resident's room and called out Alice from her bed. Staff provided R30 with something to eat and redirected her. - 1/7/20, at 6:51 p.m., a 1 cm. skin tear to the back of her left hand and had minimal bleeding present. R30 had not been able to state what had happened or what had caused the tear. Staff noted R30 transferred self and propelled self in wheelchair. - 1/8/20, at 11:56 p.m., up multiple times during the shift looking for staff, asking for Alice and asked staff where they would have been going to once she fell asleep. - 1/10/20, at 1:30 p.m., wheeling herself in her wheelchair repeatedly asking for Alice. Staff attempted to redirect and had been unsuccessful. - 1/10/20, at 11:30 p.m., walked herself to the nurses' station and stated staff could have slept in her bed. Staff assisted R30 to the dining room to watch TV. - 1/12/20, at 10:37 p.m., found lying on her left side in the dayroom without her walker or wheelchair present. R30 had been unable to state what she had been doing prior to the fall. - 1/14/20, at 6:29 a.m., complained of hip pain and required assistance to transfer from bed to wheelchair. A note at 12:54 p.m., staff noted R30 had a skin tear to her right elbow, appeared to be a few days old and measured 4.5 cm. by 1.2 cm. - 1/15/20, at 12:20 p.m. right hip x-ray completed related to recent fall and R30's complaint of pain, x-ray negative. If R30 continued to complain of pain, further x-rays to be done. - 1/15/20, at 6:50 p.m., staff found R30 on the floor crawling, looking for Alice. Signs posted in R30's room to remind R30 to use assistive devices with transfers. - 1/24/20, at 3:20 a.m., found going in and out of other residents' room looking for Alice, redirected back to her bed. - 1/25/20, at 12:24 a.m., noted to get up and down several times and unable to redirect her. Staff provided laundry for R30 to fold. - 1/27/20, at 6:47 p.m., in and out of bed looking for Alice. Staff redirected R30 and the behavior ceased temporarily. Staff offered snack and activity of folding clothes and R30 left and returned to room prior to completing the activity. Staff administered [MEDICATION NAME] (a medication used to treat anxiety). - 1/29/20, at 1:28 a.m., up and down four times thus far that shift (TRUNCATED)

Based on interview and document review, the facility failed to provide ongoing cardiac and respiratory assessment/monitoring including fluid retention and failed to accurately transcribe and implement physician orders [REDACTED]. This deficient practice resulted in actual harm for R46, who required re-hospitalization for exacerbation of [MEDICAL CONDITION], and a 28 pound fluid weight gain and shortness of breath. Findings include: R46's admission Minimum (MDS) data set [DATE], identified R46's short term and long term memory was intact, and had independent cognitive skills for daily decision making. The MDS indicated R46 did not reject care, required assistance with transfers, dressing, personal hygiene, locomotion on and off the unit and did not ambulate. Further, the MDS indicated R46 had shortness of breath (SOB) or trouble breathing with exertion, received oxygen therapy, and indicated R46 had active discharge planning for return to the community. R46's Care Area Assessment (CAA) dated 8/9/17, identified R46 required supervision to one assist for most activities of daily living (ADL) tasks related to his limited mobility, weakness and deconditioning secondary to recent hospitalization due to weakness, [MEDICAL CONDITION] [MEDICAL CONDITIONS] with chronic shortness of breath. R46 required a cardiac diet due to [DIAGNOSES REDACTED]. The CAA did not address R46's cardiac status, fluid balance or respiratory status. R46's care plan, revised 8/16/17, identified R46 had [DIAGNOSES REDACTED]. The care plan directed for weights daily, update MD if weight gain of 3 pounds (lb) overnight or 5 lb in a week, cardiac diet, compression stockings, assess breath sounds as necessary, elevate head of bed as necessary, and update MD as needed. The care plan did not address to monitor for [MEDICAL CONDITION]. R46's Discharge Summary dated 7/28/17, identified R46 had been admitted to the hospital with [REDACTED]. The summary indicated R46 had been admitted with [MEDICAL CONDITION], [MEDICAL CONDITIONS], shortness of breath, increased confusion and was given intravenous (IV) diuretics over the hospital course to improve his symptoms. R46's discharge orders included [MEDICATION NAME] ([MEDICATION NAME]) (diuretic) 40 milligrams (mg) daily as needed for [MEDICAL CONDITION], and a low sodium diet. R46's Long Term Care Transfer Form dated 7/28/17, indicated [DIAGNOSES REDACTED]. The form indicated he was stable upon transfer, an order for [REDACTED]. R46's Admit/Readmit Assessment form completed on 7/28/17, indicated R46 had been admitted to the nursing home with [DIAGNOSES REDACTED]. R46's admission assessment form lacked documentation of R46's lungs sounds, 02 sat (oxygen saturation in the blood), vital signs or weight or use of as needed diuretic. Review of R46's Progress Notes from 7/28/19 to 9/4/17 revealed the following: -7/28/17, admitted from hospital with [MEDICAL CONDITION], history of CAD and [MEDICAL CONDITION]. Had become progressively more short of breath and weak, several falls at home and hospital assessment noted to have [MEDICAL CONDITION] and evidence of [MEDICAL CONDITIONS]. Had received IV diuretic therapy in hospital, was alert and answering questions appropriately and was ordered on a cardiac diet. The notes did not address his current [MEDICAL CONDITION], lung sounds or use of oxygen. -8/1/17, 02 SATs 95%, 2 liters per nasal cannula, lung sounds clear, SOB with activity. -8/7/17, Nurse practitioner (NP) here and noted labs from 8/4/17, no changes at this time. -8/8/17, markedly weaker, 02 SATs were 77 percent (%) on room air. 02 was placed and he was reminded to leave it on as the 02 had been found on the floor running in his room. -8/11/17, 02 SATs 96%, 2 liters oxygen per nasal cannula, SOB with activity. Lung sounds diminished, started on nebulizer treatment this shift. -8/12/17, left lower lung has fine crackles, rest of lung field clear. -8/14/17, [MEDICATION NAME] tablet 40 mg administered, give 40 mg by mouth every 24 hours as needed for fluid retention to be given if weight is up 3 lbs over night or 5 lbs in a week, starting weight is 164.7. The note indicated 3 lb weight gain information given to physician's nurse. The notes lacked documentation of response from physician or any follow up done. -8/14/17, R46 found on floor with pain in shoulder, and head, sent to emergency room for evaluation of injuries. -8/15/17, fax had been sent to primary care provider (PCP) appointment, with a note requesting discharge orders. The note indicated the PCP had not signed the discharge orders. No further documentation found regarding notification of R46's weight gain, respiratory status or clarification of current orders. -8/15/17, 1 plus [MEDICAL CONDITION] to lower extremities -8/17/17, 1 plus [MEDICAL CONDITION] to lower extremities, elevating when in bed as tolerated. -8/17/17, 02 SATs 96% on 2 liters of oxygen via nasal cannula, SOB with activity. -8/20/17, 02 SATs 96%, 2 liters oxygen via nasal cannula, lung sounds diminished, SOB with activity, no cough. -8/21/17, 02 SATs 96%, 2 liter oxygen via nasal cannula, lower lung (LL) diminished lung sounds, SOB with activity. -8/23/17, [MEDICATION NAME] tablet 40 mg given, give 40 mg by mouth every 24 hours as needed for fluid retention to be given if weight is up 3 lbs over night or 5 lbs in a week, starting weight is 164.7. A second note indicated the as needed [MEDICATION NAME] had been ineffective, some relief. The notes lacked documentation of notification of PCP or further follow up. -8/23/17, 02 SATs 96%, 2 liter of oxygen per nasal cannula, lung sounds diminished in LL, SOB with activity. -8/23/17, 1 plus [MEDICAL CONDITION] to lower extremity, increase in weight as needed [MEDICATION NAME] given this shift per MD order. The notes lacked documentation of notification of PCP or further follow up. 8/24/17, [MEDICATION NAME] 40 mg given, give 40 mg by mouth every 24 hours as needed for fluid retention to be given if weight is up 3 lbs over night or 5 lbs in a week, starting weight is 164.7. The notes lacked documentation of notification of PCP or further follow up. -8/25/17, weight up 5 lbs from 8/22. The notes lacked documentation of as needed [MEDICATION NAME] administered, or the reasons why the medication had not been administered, notification of PCP or further follow up. -8/25/17, 02 SATs 96% 2 liters of oxygen via nasal cannula, lung sounds diminished LL, SOB with activity. -8/27/17, [MEDICATION NAME] tablet 40 mg given, give 40 mg by mouth every 24 hours as needed for fluid retention to be given if weight is up 3 lbs over night or 5 lbs in a week, starting weight is 164.7. A note later in the shift indicated the as needed [MEDICATION NAME] was effective. -8/27/17, fax sent to physician in relation to weight gain, [MEDICATION NAME] order and weight parameters. -8/28/17, increase in weight, [MEDICATION NAME] 40 mg given, give 40 mg by mouth every 24 hours as needed for fluid retention to be given if weight is up 3 lbs overnight or 5 lbs in a week, starting weight is 164.7. A later note indicated effectiveness unknown. -8/28/17, 02 SATs 96%, 2 liters oxygen per nasal cannula, lung sounds diminished LL, SOB with activity. -8/28/17, orders received to give scheduled [MEDICATION NAME] -8/29/17, nursing assistants report several small fluid filled blisters on bilateral feet, lower legs are [MEDICAL CONDITION], just received new orders for [MEDICATION NAME]. A later note indicated 02 SATs 96%, 2 liter oxygen per nasal cannula, lung sounds diminished in LL, SOB with activity, scheduled neb treatments have been effective. -8/30/17, [MEDICATION NAME] given, weight 189.7, and a later note indicated effectiveness unable to determine until weighed tomorrow. The notes lacked documentation of notification of PCP or further follow up. -8/31/17, weight is up 1 lb, [MEDICATION NAME] 40 mg tablet given, give 40 mg by mouth every 24 ours as needed for fluid retention to be given weight is up 3 lbs over night or 5 lbs in a week, starting weight is 164.7. A later note indicated the as needed medication was effective, swelling in legs went down a little. The notes lacked documentation of notification of continued weight gain, PCP or further follow up. -8/31/17, 02 SATs 94-96%, 2 liter oxygen per nasal cannula, lung sounds diminished LL, SOB with activity. -9/1/17, weight 190, [MEDICATION NAME] 40 mg given, give 40 mg every 24 hours as needed for fluid retention to be given if weight is up 3 lbs over night or 5 lbs in a week, starting weight is 164.7, with a later note the as needed medication was effective. The notes lacked documentation of notification of PCP or further follow up. 9/1/17, 02 sat 96%, 2 liter of oxygen per nasal cannula, lung sounds diminished to LL, SOB with activity, at bed time head of bed sitting in upward position states to help breathing. -9/2/17, 02 SATs 96%, 2 liter of oxygen per nasal cannula, lung sounds diminished LL, SOB with activity. At bedtime, head of bed sitting in a upward position states to help with breathing. -9/3/17, 02 SATs 96% 2 liter oxygen per nasal cannula, lung sounds diminished to LL, SOB with activity, at bedtime head of bed sitting in a upward position states to help with breathing. -9/4/17, additional 2.5 lb weight gain today and total 27.8 lb gain since admit. Hospital called for further direction regarding weight gain. Call received from physician to give [MEDICATION NAME] 20 mg intramuscularly (IM) now and [MEDICATION NAME] (diuretic used to treat [MEDICAL CONDITION] and high blood pressure) 2.5 tab, 2 tabs now and if no improvement see primary care provider. -9/4/17, at 5 p.m. complained of abdominal pain and nausea, 02 sat 88%, lung sounds fine crackles throughout, noted 3-4 plus [MEDICAL CONDITION] to lower extremities has moved up past hips, abdomen is rigid, complain of pain when writer listened to bowel sounds. emergency room called with update on changes, sent at 5:30 p.m. to emergency room via ambulance. A later note indicated the facility had received a call R46 had been admitted to hospital with [DIAGNOSES REDACTED]. Review of R46's physician's orders [REDACTED]. -7/28/17, 02 at 2 liter per nasal cannula to keep 02 above 90% -8/9/17, [MEDICATION NAME] nebulizer four times day (QID) -8/10/17, measure for compression garments -9/4/17, [MEDICATION NAME] ([MEDICATION NAME]) 10 mg/1 ml injection, give 20 mg IM now, [MEDICATION NAME] 2.5 mg tab, give 2 tabs orally now. If no improvement see PCP. No further orders were documented in R46's clinical record for cardiac monitoring, clarification of orders. Review of R46's Medication Administration Record [REDACTED] July, 2017 -[MEDICATION NAME] 40 mg in the morning for [MEDICAL CONDITION], one dose given on 7/29/17 -daily weight, if up 3 lbs overnight or 5 lbs in a week notify PCP, admit weight was 164.7 in the morning. No daily weights documented for 7/29/17, 7/30/17 and 7/31/17. -[MEDICATION NAME] 40 mg, give 40 mg by mouth every 24 hours as needed for fluid retention to be given if weight up 3 lbs over night or 5 lbs a week, start weight is 164.7-no doses given. Documentation of R46's daily weights were requested, facility was unable to provide daily weights for the month of July (7/28 - 7/31/17). August, 2017 -daily weights if up 3 lbs over night or 5 lbs in a week notify PCP, admit weight was 164.7, with daily weights recorded as follows: 8/1/17--no weight documented 8/2/17-165 8/3/17-164.9 8/4/17-164.5 8/5/17-164.6 8/6/17-166.1 8/7/17-168.2 8/8/17-169.4 8/9/17-170.9 8/10/17-168.5 8/11/17-170.2 8/12/17-170.8 8/13/17-171.4 8/4-14/17-174.4 8/15/17-174.5 8/16/17-no weight documented 8/17/17-175.3 8/18/17-178.4 8/19/17-177.2 8/20/17-180 8/21/17-180.7 8/22/17-180.6 8/23/17-no weight documented 8/24/17-185.7 8/25/17-185.3 8/26/17-185.9 8/27/17-186.5 8/28/17-187.1 8/29/17-189.4 8/30/17-189.7 8/31/17-189.5 -[MEDICATION NAME] 40 mg, give 40 mg by mouth every 24 hours as needed for fluid retention to be given if weight up 3 lbs over night or 5 lbs a week, start weight is 164.7 - a dose was given on 8/14, 8/23/17, 8/24/17, 8/27/17, 8/28/17, 8/30/17, 8/31/17. -[MEDICATION NAME] 20 mg tablet by mouth one time a day, with a start day of 8/29/17--given 8/29, 8/30, 8/31/17. R46's August MAR indicated [REDACTED]. September, 2017 -daily weights if up 3 lbs over night or 5 lbs in a week notify PCP, admit weight was 164.7, with daily weights recorded as follows: 9/1/17-190 9/2/17-191.6 9/3/17-190.6 9/4/17-192.5 -[MEDICATION NAME] 20 mg tablet by mouth one time a day - given on 9/2/17, 9/4/17. -[MEDICATION NAME] 40 mg, give 40 mg by mouth every 24 hours as needed for fluid retention to be given if weight up 3 lbs over night or 5 lbs a week, start weight is 164.7 - a dose given on 9/1/17 and 9/4/17. -[MEDICATION NAME] 20 mg IM one time only for weight gain - given 9/4/17. R46's monthly MARs lacked documentation of monitoring of the presence of [MEDICAL CONDITION], lacked documentation of reason(s) the as needed [MEDICATION NAME] had not been given per parameters and lacked documentation the PCP had been notified of R46's ongoing weight gains. Review of R46's Provider Progress Note, dated 8/9/17, written by NP-A, indicated he had been hospitalized with pneumonia prior to coming to the nursing home. The note indicated R46 had bibasilar fine rales, and 02 saturation of 97% on 02. The note indicated R46 had an order for [REDACTED]. Review of R46's After Visit Summary from local hospital, dated 8/14/17, included head injury instructions and list of R46's current medications which included [MEDICATION NAME] 40 mg, take 40 mg by mouth daily as needed (fluid retention). Give 40 mg by mouth every 24 hours as needed for fluid retention, to be given if weight is up 3 lbs over night or 5 lbs in a week, starting weight is 164.7. The physician note indicated R46's 02 SATS 94% on 2 liters of oxygen, no [MEDICAL CONDITION], lungs clear at that time. Review of R46's facsimiles (fax) sent to the physician from 8/15/17 to 9/4/17, revealed the following: -a fax signed on 8/15/17, which indicated therapy had ended, and requested an order to discharge home and a request to sign the attached medication list. The physician had written a note which indicated he recommended R46 remain in the skilled care facility. No further orders documented in the record. -a fax signed 8/28/17, R46 had fluid retention, had lower extremity [MEDICAL CONDITION], had [DIAGNOSES REDACTED]. The writer noted in looking at orders there was not an order for [REDACTED]. His weight was up 22 lbs. (186.5 lb) and writer felt most of R46's weight gain was fluid. The physician had ordered [MEDICATION NAME] 20 mg every day and to continue 40 mg as needed until [MEDICAL CONDITION], abdominal distention resolve and continued the weight parameter at 164.7. On 12/1/17, at 2:54 p.m. the director of nurses (DON) stated she would expect residents with a [DIAGNOSES REDACTED]. She indicated she would expect staff to follow facility protocol and polices for appropriate care of cardiac residents. She confirmed R46's record lacked routine monitoring of [MEDICAL CONDITION] and confirmed staff had not followed directions regarding notifying the primary care provide (PCP) and had not given the as needed [MEDICATION NAME] as ordered. On 12/1/17, at 3:35 p.m. licensed practical nurse (LPN)--D stated the usual facility practice for monitoring of cardiac residents was to routinely monitor [MEDICAL CONDITION] and weights and nurses were to document the findings in the progress notes. She reviewed R46's record at that time and confirmed the record did not include routine monitoring of his [MEDICAL CONDITION] and did not include documentation of the as needed [MEDICATION NAME] given or the reasons it was not given. LPN-D stated the usual practice for monitoring weights included to use the reference weight identified on the order and it was rolling anytime the weight was over 3 pounds (lbs) in one day, staff were to notify the physician and the [MEDICATION NAME] be administered. On 12/1/17, at 5 p.m. a message was left for the nurse practitioner (NP) and medical director and their office, to return call. On 12/4/17, at approximately 9:40 a.m., NP-A and LPN-A returned call and a group interview was conducted. NP-A indicated she felt R46's as needed [MEDICATION NAME] order parameters were the usual practice standard for the local clinic, but not a discharge order from the hospital. She indicated R46's appetite had improved in the nursing home, but did not think all of the weight gain was due to increased appetite and confirmed a 28 lb weight gain in about a month was unusual. She indicated she would expect staff to provide routine monitoring of weights, lung sounds and [MEDICAL CONDITION] for [MEDICAL CONDITION] residents and would consider a fluid restriction. The NP requested a follow up interview on 12/6, when she returned from vacation. On 12/6/17, at 8:52 a.m. a follow up telephone interview was conducted with LPN-A and NP-A. LPN-A confirmed R46's discharge order from the hospital for as needed [MEDICATION NAME] was to be given for [MEDICAL CONDITION] and the order had been transcribed incorrectly. She stated R46 had been admitted with [MEDICAL CONDITION] present and indicated the order was confusing and had not been clarified. LPN-A stated most of the physicians the nursing home dealt with ordered [MEDICATION NAME] according to weight parameters, but R46's discharge physician had not. She could not explain why R46's as needed [MEDICATION NAME] had been transcribed incorrectly and was not aware of the reason R46's as needed [MEDICATION NAME] had not been given when R46 had exceeded the weight parameters listed on the MAR, and physician subsequent orders. LPN-A stated the usual facility practice was to clarify any orders staff questioned at the time the order was transcribed. She indicated the usual practice for all admission orders [REDACTED]. LPN-A indicated she had reviewed R46's record and could not determine if the orders had been double checked at the time of admission. LPN-A confirmed the first time she had contacted the physician for clarification of the [MEDICATION NAME] order had been on 8/27/17, and stated R46's as needed [MEDICATION NAME] order had been confusing and should of been clarified from the start. LPN-A confirmed the fax sent to the physician on 8/27/17, and confirmed she had felt most of R46's weight gain had been fluid related. She indicated R46's PCP did not usually respond to questions from the facility unless it was life or death and had not been contacted regarding the clarifications needed. Further, she indicated she felt nursing was busy, and did not feel there was enough time to complete tasks such as order clarifications. LPN-A indicated she had talked to management in the past about the need for a floor manager to help with this process. NP-A stated the medical director had been aware of the communication problems with certain physicians and also the concern when the nursing home admitted residents from other hospitals other than the local hospital. She indicated these concerns were being worked on and stated R46 fell thru the cracks.

Based on observation, interview and document review, the facility failed to comprehensively assess pain and implement interventions to relieve moderate to severe pain following a surgical procedure to the lower back for 1 of 1 resident (R83) reviewed for pain, and failed to monitor skin condition for 1 of 1 resident (R51) reviewed with multiple bruises. This deficient practice caused actual harm to R83. Findings include; R83's admission Minimum Data Set ((MDS) dated [DATE], identified R83 had [DIAGNOSES REDACTED]. The MDS identified R83 had severe cognitive impairment and required extensive assistance for activities of daily living (ADLs). Further, the MDS identified R83 had occasional, moderate pain, received scheduled pain medications, as needed pain (PRN) medications and non-pharmacological interventions for pain management. The Care Area Assessment (CAA) dated 11/4/14, indicated the goal was for improvement, slow/minimize decline and maintain current level of functioning. The CAA identified a mood decline and physical limitations as contributing/limiting affect. The Pain Data Collection and Assessment form dated 10/31/14, identified R83 did not verbalize pain, but has noted grimacing and frowning with cares and activity, unable to determine R83's pain goal, and irritability and change in mood noted. The MDS dated [DATE], identified moderate cognitive impairment with no change. MDS identified R83 had worsening mild depression and constant, severe pain. The MDS identified that R83 had felt tired or had little energy almost every day. The MDS identified R83 was on scheduled pain medications, and did not identify the use of any PRN pain medications. MDS identified R83 had non-pharmacological interventions for pain management and rated R83's pain at a 10 on a scale of 1-10 (10 being worst pain). R83 was admitted to the hospital on [DATE]. According to the record R83 had been readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. R83 was readmitted with the following pain medications ordered: -[MEDICATION NAME] (narcotic pain medication to treat severe pain) patch 25 mcg [MEDICATION NAME] every 72 hours -Tylenol Extra Strength tablet, 500 mg, 1 tablet by mouth as needed four times daily (QID) for pain -Tylenol Extra Strength tablet, 500 mg, 2 tablets by mouth at bedtime for pain -[MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME] - narcotic to treat moderate to severe pain) on hold since 10/24/14 -[MEDICATION NAME] Patch discontinued 12/23/14 R83's readmission, 5 day MDS dated [DATE], identified moderate cognitive impairment, moderate depression and constant, severe pain. The MDS identified R83's pain to be 10/10. The Admit/Readmit Pain assessment dated [DATE], identified R83 had pain to the lumbar region and R83 indicated pain was severe. R83 indicated on assessment that he had stabbing pain, activity makes it worse, laying down makes it better, the pain awakens him and R83 voiced he wanted to die. The assessment identified that R83 would not contribute to performance of his ADLs. Physical therapy (PT) services were provided for R83 from 12/24/14 to 1/2/15, for back pain. PT's discharge summary from 1/2/15, identified that R83 was significantly limited by pain, and was barely able to complete active range of motion (AROM) in bed without excruciating pain. Occupational therapy (OT) services were ordered for 12/24/14 to 1/24/15. The OT identified a goal of after 4 weeks of OT, R83 would regain maximum level of function to discharge to least restrictive environment. The OT evaluation identified that R83 was unable to wash his face or comb his hair even with set-up and unable to perform ADLs without extensive assistance throughout treatment due to pain. OT identified in therapy notes that R83 was limited by weakness and pain. R83 was discontinued from OT on 1/2/15, and included R83's statement of he wished he could get out of here because anything that's done for him is wrong, and doesn't work for him. The care plan dated 12/8/14, included [DIAGNOSES REDACTED]. ADL interventions included back brace, provide assistance with ADLs and update MD/family with changes. Pain care plan goal identified R83's pain will be relieved in 1 hour of intervention. Pain interventions included: observe for and report signs of pain and discomfort, verbal complaints, restlessness, wincing, moaning, guarding. Pain assessment per protocol and prn. Pain medication as ordered by MD, monitor use and effectiveness. Repositioning and body alignment to aid in comfort as resident allows. Staff to anticipate all pain needs, i.e.. changes in body language and facial grimacing. Care plan also identified to observe use and effectiveness of medications and update family with any changes and to assess for comfort including loneliness and time spent in bed. The facility failed to develop a plan of care for R83 to include non-pharmacological interventions. On 01/13/2015, at 8:54 a.m. R83 was calling out "ow" and groaning in pain in the dining room. R83 told licensed practical nurse (LPN)-B that he wanted to go back to his room. LPN-B continued assisting in the dining room. R83 continued to grimace, tilting his head back, and gnawing his teeth in pain in the dining room. R83 told LPN-B that he wanted to go to bed. R83 continued to call out "ow" and groan in pain in the dining room. LPN-B asked R83 if it was his normal pain or a different pain. On 01/13/2015, at 9:01 a.m. LPN-A told LPN-B that R83 had not had his medication yet, and told LPN-B to park him off to the other side of the med cart because she was busy dishing up other residents' pills. R83 cried out and sighed loudly to LPN-A, "Oh why does my hip hurt so bad," then cried out "ow" again. LPN-A did not acknowledge R83, and continued dishing up other residents' pills. On 01/13/2015, at 9:08 a.m. R83 continued to call out "ow" in pain in the hallway next to the LPN, and LPN-A did not give R83 medication or address R83 in any way. On 01/13/2015, at 9:13 a.m. LPN-A provided medication crushed in applesauce with a spoon. LPN-A told R83 he was not going to go to bed yet. LPN-A told housekeeping there was no one available to transfer R83 to bed yet and he can't go in his room. R83 was seated in the day area with other residents near the TV. On 1/13/15, at 9:31 a.m. R83 stated his back, legs, and chest really hurt, but hips not quite as much. R83 described his pain as shooting pain that comes and goes in his back and his legs. R83 described his pain as it feels like someone is running over his head on the railroad tracks. R83 stated his wrist hurts too. R83 stated that if he lays too long he has muscle pain in his right leg, near his thigh and that it hurt at that time. R83 stated pain goes from 1-10, and when it gets to 10 it lasts for 8-10 seconds. R83 stated he makes noise when he is hurting, he hollers and staff say they will get him some medicine. R83 stated, "Sometimes I get something, and sometimes I don't." R83 was grimacing, short of breath and visibly in pain during the interview. On 01/13/2015, at 9:53 a.m. the surveyor pushed R83's call light after he requested he wanted to lay down because his bottom was hurting. R83 stated the staff seem to think the cushion helps, but it doesn't really help keep his bottom from hurting. R83 stated he use to do therapy exercises for awhile and then they passed him up because he couldn't do the things they wanted him to. R83 stated he had PT and pretty soon they didn't even want to try anymore because it hurt too much, they gave up. On 01/13/2015, at 10:07 a.m. registered nurse (RN)-A and NA-C were observed transferring R83 from wheelchair to bed. R83 was unable to lift his feet and cried out, "I can't." RN-A and NA-C told R83 to lean forward and put a sling under both arms. RN-A and NA-C told R83 to lean forward again, hold on and stand up. R83 cried out "ow" loudly, and NA-C told him to use his legs. R83 continued to cry out, hold his breath, moaning and saying "ow" for the duration of the transfer and was still grimacing, moaning and holding his breath after he was transferred into bed. On 1/13/15, at 3:35 p.m. R83 was observed waking up from a nap. R83 rated his pain 6-8 in his legs with any movement. On 01/14/2015, at 7:50 a.m. NA-B was observed performing R83's morning cares. R83 stated he hurt all over. NA-B did not respond to R83's complaints of pain. R83 went on to say his feet hurt so bad and his heels burned. NA-B touched his leg to put socks on, R83 was grimacing and wincing in pain. R83 calling out "ow" and grimacing and sighing in pain while NA-B attempted to put R83's shoes on. R83 calling out, "Oh my neck, back and legs" when gripper socks were put on. R83 stated his pain was at a 10. NA-B did not respond to R83 about his pain rating of 10 and left the room. RN-A assisted NA-B to transfer R83 into his wheelchair. R83 was grimacing and calling out, "Oh my back." R83 was yelling, "I'm not ready, ow, I cant take this." NA-B told R83, "come on." R83 was calling out his back hurt "so damn bad." RN-A stated, "We'll get you some Tylenol or something." NA asked if R83's back feels better and R83 stated, "No, Oh God no it doesn't feel better." NA-A did not acknowledge R83's pain and told R83 he was going to brush his teeth and RN-A stated she would be back to take R83 to breakfast. R83 continued to cry out, "Oh my back" as NA-A pushed R83 up to bathroom sink and turned the water on. R83 continued to call out "ow, ow, ow", as he was grimacing and panting with teeth brushing. On 01/14/2015, at 8:18 a.m. R83 cried out "ow", and LPN-A did not acknowledge him. LPN-A continued to dish up other residents' pills. R83 continued to say "ow" and grimace and pant. LPN-A told R83, "Hold on, I am just getting it ready here." On 01/14/2015, at 8:21 a.m. R83 yelling out in pain, "ow", gasping. LPN-A gave R83 pills in applesauce. On 01/14/2015, at 8:59 a.m. R83 was grimacing and saying "ow" in the dining room. LPN-A asked R83 if he wanted to go back to his room. R83 stated he did want to go to his room. LPN-A told a staff person that R83 was having pain and R83 was brought to sit in the back of dayroom. On 01/14/2015, at 9:22 a.m. NA-C came to dayroom and told R83 he could lay down in a second. On 01/14/2015, at 9:24 a.m. NA-C and NA-A were observed assisting R83 into bed from wheelchair. R83 stated his shoulders and back really hurt. NA-C stated R83's back had been sore since he came in and the weather was a cause. R83 was holding his breath in the lift, grimacing, trying to catch his breath. R83 was calling out, "Oh my neck." R83 asked the NAs, "Why does everything have to hurt so bad." R83 continued to grimace and cry out in bed. NA-A told NA-C that R83 always does this when you lay him down. NA-A and NA-C confirmed that R83 had a lot of pain and he is the most comfortable in bed. The NAs confirmed that R83 had pain whenever he is in his wheelchair or whenever they move or transfer him. Both NAs confirmed R83 has been in pain since admission and his level depends on the time of day. Both NAs reviewed their care sheet and stated that there was nothing on their care sheets from the care plan about pain. NA-A stated the surgery did not take R83's pain away like it should have, and the pain medications were not working. NA-A stated that the only non-pharmacological intervention for R83's pain was to lay him down in bed. On 1/14/15, at 7:30 a.m. NA-B stated R83 has had pain since his operation and the surgery didn't work. NA-B stated that sometimes R83 looks like he is dying in pain. NA-B stated R83's pain limits his daily activities and R83 likes his bed the most. NA-B feels they control his pain the best they can. NA-B stated R83 always tells him he feels horrible and he wants to fall asleep and die. NA-B stated the non-pharmacological intervention for R83's pain was to try to position him once in a while and he wears a back brace. NA-B stated R83 sometimes asks him for medicine depending on his pain and mood. On 01/14/2015, at 8:28 a.m. RN-A stated R83 has daily pain in his back after back surgery and possible abscess. RN-A stated R83 is in bed more because of his back. RN-A stated R83 mostly has pain with transfers. She added an acceptable pain level for R83 is when he can perform transfers and can perform his daily activities. RN-A stated R83 complains daily of pain and doesn't always ask for pain medication, but felt R83's pan was controlled with prn medications. RN-A stated R83 had been in pain since admission and no longer receives PT, OT or nursing rehab. RN-A stated she is not sure of R83's pain level, but felt it was mild to moderate depending on what he was doing. RN-A confirmed R83's care plan and only contained the non-pharmacological intervention of letting him rest. On 01/14/2015, at 8:40 a.m. NA-J stated that R83 has chronic pain. NA-J stated R83's surgery didn't work and that nothing seems to work. NA-J stated R83 has pain 24/7 and if R83 moves he yanks his body with sharp pain. NA-J stated that R83's pain severely limits his daily living. NA-J stated she felt that R83's pain was not controlled, but they try to do what the doctor says. NA-J stated what helps R83's pain is if he lays in bed. NA-J stated she knows when the medicine is working by talking to him and they can toilet and reposition him without R83 screaming. NA-J stated that every time you move or turn R83 he will tell you he is in pain. NA-J stated that she felt R83's daily pain was between 7-8 and that he is yelling out in pain daily. NA-J stated R83 is to be repositioned every 2 hours and use his back brace for non-pharmacological interventions. On 01/14/2015, at 8:50 a.m. LPN-B stated she sees R83 in pain most days, and that he jumps in pain. On 1/14/15, at 9:45 a.m. LPN-C stated R83 does have pain. LPN-C stated she can tell if R83's pain is controlled depending on his mood, and if he is busy and not bored he won't complain. LPN-C stated an acceptable level of pain for him would be 0, comfortable, pain free. LPN-C stated his pain medication was effective if he was happy and did not want to lay down as much. LPN-C stated if R83 is bored, then he has pain. LPN-C stated R83's average pain if he lays still is 2-3, if he moves 5-8, and it depends on what's wrong. LPN-C stated, "I don't know what more we can do for him, if he has pain medications then he is more of a fall risk." On 01/14/2015, at 12:55 p.m. LPN-A stated R83 complains more when he is up and wants to lay down. LPN-A stated R83 always wants to lay down. LPN-A stated she felt R83's pain was chronic. She stated she would expect R83 to call out during transfers because his back is a sensitive area. LPN-A stated she felt an acceptable level of pain for R83 is none, no one should have pain. LPN-A stated it is hard to do anything for R83's pain, and R83 is sensitive to narcotics. LPN-A stated she felt that R83's pain is not debilitating. LPN-A stated that she felt R83 was calling out more, and he likes attention. LPN-A stated the more you pay attention to him, the more his pain is exaggerated. LPN-A stated that the facility has asked the doctor many times for different pain medications, and the doctor emailed the director of nursing (DON) and told her to quit asking for pain medications, so that is what they were doing. LPN-A stated that R83 had a history of [REDACTED]. On 01/14/2015, at 2:06 p.m. RN-A confirmed that R83 did not trigger for pain on the admission CAA. RN-A stated R83 was reassessed for pain on 12/23/14, and had complaints of continuous, stabbing, lower back pain. LPN-A stated that laying down alleviates his pain and activity makes it worse. RN-A confirmed the pain assessment dated [DATE], that R83 will voice he just wants to die. The assessment also indicated R83's pain prevents R83 from contributing to the performance of his ADLs, limits his activity participation and R83's mobility is decreased because of his pain. RN-A stated that she was aware that R83 was calling out in pain and that (MD name) and the nurse practitioner (GNP) were aware that R83 was calling out in pain. RN-A stated she would not expect R83 to call out in pain. RN-A stated she was not aware that R83's pain was moderate in November 2014, and in December 2014, R83's pain was 10/10 on assessment. RN-A stated she knew that doctor really does not want to make any changes to R83's pain medications until R83 completes his antibiotic on January 30th, 2015, and has a repeat MRI. RN-A stated, "I honestly am not sure of what we can do, we have tried different medications and doses, and heat packs. I cant think of anything else we can do to treat R83's pain." RN-A confirmed R83's pain medication regimen. On 01/14/2015, at 3:11 p.m. RN-C and DON were Interviewed. RN-C stated R83 had fallen and had compression fractures to his vertebrae. RN-C stated R83 had a kyphoplasty procedure for vertebrae and did not get any better. RN-C stated a fax was sent to GNP-A to address R83's pain. RN-A stated they were told 83 was not getting anything else for pain and to stop asking. RN-C stated that R83 came back on [MEDICATION NAME] (narcotic medication for moderate to severe pain).The [MEDICATION NAME] was put on hold due to behaviors and R83 now gets Tylenol and the [MEDICATION NAME] (narcotic medication through patch on skin). RN-A stated R83's doctor was more concerned about R83's kidneys, and less about his liver, meanwhile they keep waiting for improvement. RN-C stated R83's family did not want R83 to receive [MEDICATION NAME] as they did not want R83 confused and falling. RN-A stated R83 has stated to him on and off that he wants to die and this is no way to live. RN-C and DON confirmed that R83 does not have a clinical [DIAGNOSES REDACTED]. DON confirmed there was nothing in R83's medical record diagnosing alcoholism history and rationale for not prescribing other narcotic pain medications. On 01/15/2015, at 8:09 a.m. the DON was interviewed and stated the facility did not get the medical director involved with R83's pain management. On 01/15/2015, at 8:21 a.m. certified occupational therapy assistant (COTA) was interviewed. COTA stated that R83 was discharged from therapy after about a week. The COTA stated that R83's back pain was the main problem. The COTA stated that between therapy and R83's family they decided that therapy was not helping and R83 was not making progress. The COTA stated R83's pain was continuous and limited his ability to participate. The COTA stated R83 does not get nursing rehab and was not on a walking schedule because of pain. The COTA stated R83 was unable to receive range of motion services because of pain. The COTA stated R83's pain was severe, chronic and every day. The COTA stated R83's pain was when he is moving and it is a shooting pain. R83 winces when he just sits in his chair. COTA stated R83 had stated to her that he wishes he would die because of the pain, and wished it would just go away. COTA stated R83's feelings were understandable. COTA stated that the family and doctors limit R83's pain medication because it made R83 disoriented. COTA stated when R83 was admitted he was lost and disoriented and when he was taken off pain medications he was more clear. The COTA stated she would see R83 before he got his pain medication in the morning. COTA stated sitting up in bed was really hard for R83. COTA stated when R83 was rolled on his side he would wince and going from supine to sitting and R83 would say "that kills me doing when your doing that." She stated she let the nurse know he had that much pain and asked if R83 can have pain medication because he was only on Tylenol per the doctor and family, and they decided not to. COTA stated R83 did not improve at all during therapy and R83 was discharged from therapy 1/2/15. On 01/15/2015, at 9:20 a.m. the GNP-A was interviewed. GNP-A stated R83 was in constant pain. GNP-A stated R83 has been on so many things for pain, and stated because of their fear of him falling they took away narcotics and left the pain patch. GNP-A stated the brace was not the best thing in the world and R83 constantly keeps pulling at it. GNP-A stated R83 tells her he would just like to have a drink when she sees him. GNP-A stated R83 was still having pain and the main floor was the best floor for him because when R83 was upstairs he dwelled on his pain. GNP-A stated she talked to his MD about R83's pain and he wanted to wait 6 weeks per the surgeon and do another MRI as R83 could have an abscess, and then surgically they would do something. GNP-A stated, "We have tried everything, at one point we took (R83) off all his pain medication except for Tylenol with no difference. (R83's) pain stayed the same no matter what we give him." GNP-A stated if R83's cognitive level declines and he falls one too many times he will not get better. GNP-A stated, "Nothing we have done has changed (R83's) level of pain. Not sure is he's a surgical candidate, kidneys bad, livers worse. Nothing we have done, nothing has changed the level of pain. R83 is either groggy or his back hurts." GNP-A stated it has been a long haul with R83 and his level of pain staying the same. On 01/15/2015, at 3:25 p.m. family member (FM)-A was interviewed. FM-A stated he was concerned regarding the follow up from the doctor about R83's pain. FM-A stated that if the MD says R83 can do better then R83 would want that. FM-A stated, "I don't know why he is still in this much pain. I was told that after his back surgery he fell down a couple times." FM-A stated R83 has fallen 2-3 times since he got back from the hospital and did not see the doctor. FM-A stated he was concerned after R83 was having falls only a week after back surgery and was complaining of pain, and has not seen the doctor. FM-A stated he was concerned that there was no real way of telling if something happened to R83's back during the falls after surgery. On 01/15/2015, 3:42 p.m. R83 stated he not satisfied with his pain control. R83 stated, "They keep saying they are going to do something, and they don't do anything." R83 stated he was worried about rocking the boat if he talks about his pain. R83 stated his pain was about 5/10 when he was laying down in bed, and 10/10 with shooting pain when he moves. R83 stated it seems like nothing can be done for him. " I don't want to be dead, nobody wants to be dead. There have been different times that I have I talked about and felt I wanted to die." R83 stated he wanted to die because he hurts. R83 also stated that waiting to go to the bathroom makes him sad, and says that's just the way it is. On 01/15/2015, at 4:16 p.m. the administrator and DON were interviewed. Administrator stated they can assess, but asked what they can do when a MD is adamant about not giving something else for pain. DON stated that LSW did not document the statements about wanting to die, but told her that R83 meant he was ready to die versus him wanting to die. On 01/16/2015, at 10:10 a.m. the medical director (MD)-A was interviewed. The medical director stated that R83's primary MD and GNP-A have kept her in the loop, but the facility has not contacted her to step in to assist with R83's pain management. MD-A stated she understands that when R83 is at rest that he is fine, but when he gets up he is wincing in pain. MD-A stated she feels they had relatively controlled his pain, but R83 was not pain free. She was not aware of R83's statements of wanting to die or that he is better off dead. MD-A stated she talked to GNP-A yesterday about R83's pain control, and they are still working on non-med therapies and other interventions for side effects. MD-A stated she was not aware of what the non-pharmacological interventions were being tried. The nursing progress notes following surgery to current documented: -12/23/14, at 15:34 R83 returned to the facility after hospitalization , and the note identified R83 continued to be in pain. No prn medication or non-pharmacological interventions documented for R83's pain. -12/24/14, at 6:26 a.m. identified R83 had complained of back pain with verbal and non-verbal indicators of pain. Writer indicates that R83 has scheduled pain medications. No prn medication or non-pharmacological interventions documented for R83's pain. -12/24/14, at 21:51 identified R83 was showing signs and symptoms of pain with any activity and repositioning when he is up out of bed in wheelchair. No prn medication or non-pharmacological interventions documented for R83's pain. -12/25/14, at 10:35 a.m. R83 requested medication for leg pain rated 8/10. Tylenol given at 10:35 a.m. and documented as effective. -12/25/14, at 14:10 R83 has complaints of bilateral leg pain and stated it was a constant ache. Writer states Tylenol was given, none recorded since 10:35 a.m. R83 got up for dinner and returned to bed right after, still stating he had leg pain after being placed in bed. Writer indicated that R83 was resting with eyes closed since that then. -12/25/14, at 2158, R83 continued to have complaints of pain to his lower back with scheduled Tylenol given at HS with some relief. No further prn medication given or documentation of non-pharmacological interventions for R83's pain. -12/26/14, at 7:21 a.m. R83 was complaining of back pain with verbal and non-verbal indicators of pain. Writer noted that R83 had scheduled pain medications. No prn medication or non-pharmacological interventions documented for R83's pain. -12/26/14, at 22:14 R83 showing signs and symptoms of back pain with facial grimacing and guarding. Writer stated that scheduled HS Tylenol has been helpful. R83 was showing signs and symptoms of pain with any activity and repositioning. No further prn medication or non-pharmacological interventions documented for R83's pain. -12/27/14, at 1458 R83 was grimacing and moaning with transfers using the mechanical lift. No prn medication or non-pharmacological interventions documented for R83's pain. -12/28/14, at 14:28 R83 was showing signs and symptoms of pain with transfers and repositioning. No prn medication or non-pharmacological interventions documented for R83's pain. -12/30/14, at 15:27 R83 requested medication for lower back pain and rated pain 7/10. Tylenol was documented as effective. -12/31/14, at 1840 R83 was showing signs and symptoms of back pain with facial grimacing and guarding. Writer said that scheduled Tylenol was helpful. -1/1/15, at 12:59 R83 yells out in pain with transfers and reported back pain this shift. No prn medication or non-pharmacological interventions documented for R83's pain. -1/1/15, at 20:22 R83 continues to have complaints of lower back pain. Writer indicates that both prn and the scheduled Tylenol provide only minimal relief for R83. Writer also noted that back brace only provided minimal relief. No further prn medication or non-pharmacological interventions documented for R83's pain. -1/2/15, at 21:36 R83 has verbal and non-verbal signs and symptoms of pain throughout the shift and reports pain and weakness to legs. No prn medication documented or any documentation of non-pharmacological interventions for R83's pain. -1/3/15, at 19:11 R83 had back pain rated 9/10, prn Tylenol given. No documentation of Tylenol effectiveness or other non-pharmacological interventions documented. -1/4/15, at 6:38 a.m. R83 continued to have back pain. Writer indicated R83 had scheduled pain medications. No prn medication or non-pharmacological interventions documented for R83's pain. -1/6/15, at 7:31 a.m. R83 was grimacing and has signs and symptoms of pain. Tylenol given, no documentation of effectiveness. -1/6/15, at 8:53 a.m. Call was received from MD's nurse and writer updated her on R83's pain, nurse said that she would update MD. -1/9/15, at 8:57 a.m. R83 was found sitting on his buttocks leaning up against his bed after trying to reach his urinal. R83 complained of back pain the entire time. No prn medication or non-pharmacological interventions documented for R83's pain or medical attention pursued. -1/10/15, at 11:42 R83 was given prn Tylenol and was going out with family to aid in his discomfort to back. Tylenol not documented effective until 15:06. -1/12/15, at 11:06 a.m. GNP visited R83 and noted his fall of 1/9/15. GNP made no changes to R83's medications or orders. -1/13/15, at 9:18 p.m. R83 complained of bilateral hip pain and was given Tylenol. Tylenol documented effective. -1/14/15, at 8:33 a.m. R83 requested medication for back pain, Tylenol was administered and documented effective. R83 stated that as long as he is in bed there is no pain. The Pain Management Policy revised 4/09, identified that residents are screened for pain regularly through observing the resident during daily care and/or observing for signs and symptoms of pain. R51's care plan dated, 3/17/10, directed staff to observe skin with routine daily care, and to report to nurse any changes noted, and to observe for bruising as it is a potential side effect of aspirin therapy. The care plan also directed staff to complete weekly skin inspection with documentation of results. The quarterly MDS dated [DATE], indicated R51 was cognitively intact and required assistance for all activities of daily living. The MDS indicated R51 had [DIAGNOSES REDACTED]. During observation on 1/13/15, at 3:36 p.m. R51 was seated in a wheelchair next to the bed. Observed one large dark purple bruise, approximately 3 x 3 inches on the resident's right forearm, also observed 3 smaller dark purple bruises on resident's left hand and 1 small bruise on resident's left forearm. R51 stated the bruise on the right forearm happened a couple of days ago when her arm bumped the grab bar on the bed. R51 stated the bruises on the left arm and hand also happened a couple days ago and were caused when staff assist her left arm up to the grab bar next to the toilet. R51 stated staff grab her shirt to assist her left arm up to the toilet and by accident get her skin in with her clothes. R51 reported that she does take a daily aspirin and bruises easily. R51 stated she had not told staff about the bruises, then stated she was sure staff had seen the bruises because they help her get dressed and undressed everyday. During medical record review, no documentation was evident to indicate R51 had bruises on the right and left forearms and left hand. Skin assessment dated [DATE], indicated R51 was at risk for skin breakdown related to limited mobility, DM, [MEDICAL CONDITIONS] and bladder incontinence. The skin assessment directed licensed staff to complete weekly skin assessments. During interview on 1/14/15, at 9:57 a.m. NA-B confirmed she assisted R51 with daily cares including dressing on 1/14/15. NA-B reported R51 has real thin skin and staff have to be very careful when moving her arms. NA-B stated she did not notice any new bruises, but did state R51 had black and blue bruises on both arms and hands. NA-B reported the nurses all know about those bruises on R51's arms and hands. When asked if NA-B had reported the bruises to the nurses, she stated, no because the resident has always had those bruises on her skin ever since she came here to this facility. During interview on 1/14/15, at 9:59 a.m. LPN-A reported R51 bruises very easily, but could not confirm if R51 currently had any bruises without reviewing the medical record. LPN-A confirmed she was the nurse for R51 on 1/14/15. LPN-A stated staff would monitor bruises by documenting bruises in the progress notes on the resident's bath days. LPN-A reviewed R51's progress notes, and LPN-A reported the last progress note documented was on 1/2/15, and indicated no concerns to body surface at that time. LPN-A stated R51's last weekly skin inspection would have been on 1/9/15 (R51's bath day) and confirmed that the weekly skin assessment documentation was missing in the record related to skin condition. LPN-A confirmed no staff had reported R51 having any bruising

Based on observation, interview, and document review, the facility failed to ensure adequate interventions had been implemented following falls in an attempt to prevent further falls for 1 of 4 residents (R50) in the sample identified with falls. R50 sustained actual harm related to a right hip fracture following a fall from his bed. Findings include: R50 sustained a fall from his bed on 6/21/11, and the facility had not adequately assessed the fall in order to implement appropriate interventions to try prevent further falls. R50 sustained harm from a second fall from his bed on 9/4/11, which resulted in a right hip fracture which required surgical repair. R50's [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], indicated moderate cognitive impairment and impaired decision making. The MDS also indicated R50 to have experienced a fall in the 2-6 months prior to admission and to require extensive staff assistance with transfers, toileting and ambulation. The Care Area Assessment (CAA) dated 4/21/11, indicated R50 to have short term memory loss and a decreased ability to make himself understood and a decreased ability to understand others. In addition, the CAA indicated R50 to have a potential for falls related to a fall prior to admission and and a history of falls at a prior nursing facility. The plan of care dated 5/3/11, indicated R50 to be at high risk for falls related to impaired balance, cognitive impairment, and poor safety judgment. The interventions included sensor alarms in bed and wheelchair, anticipate and meet resident needs, remove walker and wheelchair when not in use, and gripper socks. An incident report dated 6/21/11, indicated staff discovered R50 crawling on the floor of his room at 10:30 p.m. The sensor alarm on the bed had not sounded. When staff tested the alarm it was found to be functioning normally and was not replaced. R50 received no apparent injuries from the fall. R50 was placed in a recliner and taken to the day room. The fall report indicated to move resident to dayroom if restless. The plan of care did not include this intervention. Additionally, an assessment of the causal factors of the fall was lacking. The plan of care did not include any updates following the fall on 6/21/11. A safety risk evaluation dated 6/2/11, was reviewed and indicated R50 to be at high risk for falls and directed staff to utilize alarms and low bed height to minimize risk for injury in the event of a fall. An additional safety risk assessment was completed on 7/14/11, which indicated R50 had had no falls in the previous 30 days. On 10/7/11, at 10:50 a.m. clinical manager registered nurse (CM)-A verified the 7/14/11, safety risk assessment to be in error. The quarterly MDS dated [DATE], identified R50's memory impairments and need for extensive assistance with bed mobility, transfers and ambulation. The MDS did not identify any falls since the prior assessment. Nursing notes were reviewed and indicated the following: On 7/31/11, R50 attempted to self transfer from the wheelchair to the bed, and staff intervened. On 8/9/11, R50 transferred himself from the wheelchair to the bed. On 8/11/11, R50 was upset with staff due to the bed locked in position, staff explained to resident the bed must remain in locked position as he continued to raise the bed to unsafe heights. A note on 8/14/11, indicated R50 again upset with staff due to not being able to raise or lower the bed. The bed had been found elevated higher that it should have been for safety. An incident report dated 9/4/11, indicated that at 7:15 p.m. staff responded to a call for help and an alarm sounding. R50 was found on the floor of his room next to the bed. The bed was elevated 36 inches off the floor. R50 had attempted to reach for his shoes on the floor and fell . R50 complained of pain in his right hip and was transferred to the hospital by ambulance, and had sustained a hip fracture requiring surgical repair. An investigation by the director of nursing indicated the bed to have been at an inappropriate height of 36 inches. In addition, the investigation stated R50 to have a history of moving the position of his bed as he wished and becomes upset and acts out by yelling and swearing when the bed is locked in the down position. A update to the care plan dated 9/4/11, identified locked controls on bed at normal height, PT (physical therapy) as ordered, and up by 8 every morning. The nurse notes documented: -9/17/11, R50 wanted to sit on bedside. -9/19/11, -R50 was restless, and wanted to sit on the edge the bed. -9/21/11, R50 was sitting on the edge of the bed and calling out for help. -9/24/11, R50 was sitting on the edge of bed, would lay down for a few minutes and then sit up again. -9/25/11, R50 was calling out from bed, wanting a drink, and would sit himself on the edge of the bed and call out for help to lay down. -9/26/11, R50 was sitting on the edge of the bed. -9/27/11, at 3:00 a.m. R50 had reported pain and was sitting on the edge of the bed multiple times. R 50 was observed seated in his wheelchair at 11:22 a.m. on 10/4/11, at the nurses station. R50 was interacting with staff and residents. R50 was observed lying in bed with eyes closed, with bed alarm in place and call light in reach at 11:20 a.m. on 10/7/11 An interview with clinical manager registered nurse (CM)-B was conducted on 10/7/11, at 10:50 a.m. CM-B indicated R50 had a history of [REDACTED]. CM-B indicated that R50 had a history of [REDACTED]. CM-B further indicated that on 9/4/11, a floor mat was not used and R50 continued to raise the bed to unsafe heights prior to his fall and fracture. In addition, CM-B verified the plan of care did not include interventions of low bed, floor mat, remove bed controls out of residents reach or to transfer R50 to a recliner when restless prior to the fall and fracture. Interviews with facility staff were conducted on 10/7/11: At 11:30 a.m. nursing assistant (NA)-A stated R50 was close to the nurse station now so they can hear him. NA-A added R50 was using the bed height controls prior to his fracture. NA-A added R50 did attempt self transfers prior to the fracture, but now sits up and yells. NA-A further stated that she had considered it dangerous for R50 to have the bed controls At 11:40 a.m. NA-B stated stated R50 had constantly tried to get up on his own prior to the fracture, but was better now, and would sit up and yell. The interviews above with the NAs indicated R50's bed control was now locked and although R50 was sitting on the bed edge, had not attempted to transfer himself from the bed since his return from the hospital with the fractured hip. The Fall Prevention policy dated 2/11/11, indicated that on admission or readmission to the facility, or anytime there is a change in status, a fall risk data collection form was to be completed. If a resident is identified at risk for falls the precautions will be reviewed and appropriate cautions implemented.

Based on observation, interview, and document review, the facility failed to provide restorative services to maintain or prevent a decline in range of motion (ROM) for 1 of 1 resident (R60) in the sample identified with range of motion limitations who had experienced actual harm related to the development of lower extremity contractures and increased upper extremity limitations. Findings include: R60 did not receive assistance with range of motion exercises which resulted in a decline in range of motion abilities to all 4 extremities and the development of lower extremity contractures. R60's [DIAGNOSES REDACTED]. R60 was admitted to hospice 4/15/11. The 7/20/11, quarterly Minimum Data Set (MDS) indicated memory deficits with severely impaired decision making skills. In addition, the MDS indicated R60 required extensive to total assist of two staff for all activities of daily living (ADLs). The MDS also identified R60 had impaired functional limitation in ROM bilaterally. The current plan of care dated 8/8/11, indicated R60 had a loss of range of motion abilities. The Voluntary Movement / ROM assessment dated [DATE], and 9/15/10, completed by the restorative aide (RA) indicated R60 had ROM limitations to neck and voluntary movement limitation to one foot. The 7/1/10, quarterly assessment note indicated R60 was resistive to exercises with no changes to ROM abilities. The 9/15/10, written assessment indicated R60 was resistive to exercises. The Weekly IDT Meeting Resident Summary date 11/24/10, indicated R60 was resistive and combative with ROM, therefore, the ROM program was discontinued. The quarterly MDS dated [DATE], indicated R60 had no limitation in range of motion abilities. The Balance During Transition and Walking assessment dated [DATE], indicated R60 had bilateral head limitation with no limitation of extremity range of motion abilities. The Plan of treatment for [REDACTED]. The Weekly IDT Meeting Resident Summary form dated 12/29/10, indicated no current restorative nursing program due to resident resistiveness. The nurses notes dated 1/20/11, indicated increased contractures to both legs. The Plan of treatment for [REDACTED]. The Plan of treatment for [REDACTED]. The 3/2/11, update on the Balance During Transition and Walking assessment indicated R60 had ROM limitations to both upper and lower extremities. The 3/2/11, update note indicated inability to straighten lower extremities with ADLs (activities of daily living) being completed by staff. The 4/21/11, update indicated R60 was resistive to any movement with inability to move upper extremities to required positions, and lower extremities had contractures. The plan was to continue to monitor. The 7/20/11, update indicated R60 was resistive to movement, did not fully extend or bend extremities and began to cry when moving. The annual MDS dated [DATE], indicated R60 had bilateral range of motion limitations on all four extremities. The 3/3/11, Care Area Assessment (CAA) for pain indicated R60 had lower extremity contractures, and had total dependence on staff for all ADLs. The 3/3/11, Cognitive loss/dementia CAA indicated R60 had a memory deficit with severely impaired decision making skills with inability to answer. The 3/3/11, Communication CAA identified R60's communication ability was very limited and indicated R60 was rarely to never understood as well as rarely to never understood by others. At 8:13 a.m. on 10/6/11, NA-F and NA-E was observed providing cares. Each NA was observed to hold a leg and physically pry them apart in order to perform perineal cares. Both NAs stated R60 was very stiff stating it was "nice" to provide cares with two staff. Both NAs verified R60 did not receive range of motion exercises. NA-E stated R60 was getting more stiff since the range of motion exercises was stopped. The NAs were observed to apply R60's shirt. NA-F was observed to apply physical force in an attempt to straighten R60's right arm in order to thread his shirt sleeve. NA-F was observed to extend arm halfway. NA-F again stated R60's upper extremities was "stiffer." At approximately 10:00 a.m. the restorative aide (RA) verified R60 was not on a restorative program stating the facility restorative program was not aggressive with patients receiving hospice services. In addition, RA stated R60 was historically resistive to range of motion and stretching exercises, therefore, rehab services was discontinued. RA stated she was unsure why R60 was resistive to ROM exercises stating she did not know if R60 experienced pain with movement or if it was a muscle contracture causing the resistiveness. RA also stated that she was responsible to inform the nurse if there was a question of pain so that it could be assessed and the resident could be treated with an [MEDICATION NAME] prior to exercises. RA verified pain was not assessed as a causative factor for R60's resistiveness stating she had never reported it. RA went on to state R60 always had upper and lower extremity tightness and verified she was not sure if it was a decline or not. RA stated she performed ROM exercise tests on all residents quarterly and if a change was noted from the previous test she was to inform R60's nurse as well as the restorative therapy program nurse so that further assessment and treatment could be implemented. RA verified she had not informed staff of the noted decline adding she did not believe R60 had been further assessed. At 11:52 a.m. the occupational therapist (OT) verified she had frequently worked with R60 for wheelchair and bed positioning related to pressure reduction and safety. The OT stated she had not worked with R60 related to range of motion abilities. The OT stated she would expect to be notified if a change in abilities occurred. The OT stated she had not been notified of R60's decline in ROM. In addition, the OT indicated the restorative nurse would also notify therapy of a change in status so that a determination can be made regarding the need for therapy services or change in nursing services could be implemented. In addition, OT stated the facility was in a transitional phase with the restorative program. The OT stated she believed physical therapy had not been notified of the decline in ROM. At 12:35 p.m. LPN-A (restorative program nurse) verified R60's upper and lower extremity ROM decline from 12/10, to 3/11. LPN-A stated she had not been made aware of the decline. In addition, LPN-A stated the restorative aide had not indicated why the decline or changes in abilities. LPN-A stated the restorative aide is expected to inform the restorative LPN or RN of any resident decline so that physical or occupational therapy could evaluate the change. LPN-A verified a further assessment to determine causal factors related to R60's resistiveness had not been completed. LPN-A stated she would have talked to OT regarding dressing ROM abilities/needs related to difficulties with dressing. At 1:37 p.m. RN-D (restorative RN, care manager) verified R60's decline in ROM abilities. RN-D stated the restorative aide was expected to inform him and/or physical or occupational therapy of any resident decline in order to create a new plan of care to prevent further loss. RN-D verified he had not been informed of R60's decline. In addition, RN-D verified there would be documentation to show that notification and added there was none. In addition, RN-D stated restorative program services for hospice clients depended on their need for maintenance of abilities. RN-D stated R60 would be a candidate for restorative services in order to maintain or improve resident abilities. RN-D further stated nursing had not taken over range of motion services, therefore, R60 had not been receiving range of motion exercises. At 11:02 a.m. on 10/07/11, LPN-B verified R60 had contractures and that occupational therapy had worked with R60 specifically for positioning. LPN-B also verified nursing was not providing R60 with ROM exercises. In addition, LPN-B stated R60 was much more "tighter" with upper and lower extremity movements. The Fair Oaks Lodge, Inc. Rehabilitation Nurse job description form dated 7/03, indicated the nurse was to update the physician or physical therapist as needed when a change occurred.