Every finding on record at Good Samaritan Society - Specialty Care Community

Based on observation, interview, and document review, the facility failed to monitor and develop additional person-centered care plan interventions to protect a resident's right to be free from physical abuse for 1 of 4 residents (R1) resulted in actual harm when R1 who had dementia, hallucinations, agitation, and a habit of wandering into other residents' rooms on eight different occasions leading to resident-to-resident altercations. During the eighth incident, R1 suffered a Subdural Hematoma (a serious condition where blood collects between the layers of the brain after a head injury.) The severity of the injury resulted in the inability to walk, feed himself, and needed total care from staff. His prognosis was poor and required end of life hospice care. Findings include: R1's incident report dated 2/12/26 at 3:30 p.m., indicated R1 wandered into an unidentified resident's room and tried to lay in the bed. When the occupant found R1 he hit him on the right side of his face with a cane. Staff intervened and R1 had a 0.5 centimeter (cm) laceration on the right side of his face. R1's care plan dated 2/13/26, indicated he wandered around the unit and into other residents' rooms. Staff would intervene by removing him from the situation when necessary to protect other residents' rights and safety. Interventions included staff close observation and redirecting him back to the common area, offering food, toileting, letting him lay down for a nap, and providing distractions. R1's incident report dated 2/25/26 at 4:43 p.m., indicated R4 told staff R1 entered his room and he told him to leave. When R1 returned later he punched R4 on the chin. R1's incident report dated 3/3/26 at 5:15 a.m., indicated R1 entered R4's room and told him to get out. He then punched R1 hitting his right back shoulder. R1's incident report dated 4/11/26 at 6:12 p.m., indicated R1 wandered into R2's room. R1 was pushed by R2 causing him to fall backwards landing on his buttocks. R1's incident report dated 5/6/26 at 5:10 p.m., indicated while staff were doing laundry they heard R4 yelling get out of my room. R4 pushed R1 down on to the floor hitting his hip and head. R1's Psychopharmacological med/physical restraint note dated 5/7/26 at 10:32 a.m., indicated Psychotropics team reviewed medication and behaviors. They recommend staff to exercise him around the unit, place objects in front of other residents' rooms to prevent him from entering. In addition, they considered increasing Depakote and decreasing Risperdal to decrease wandering. R1's mood/behavior note dated 5/7/26 at 7:30 p.m., indicated R1 wandered into rooms R4 and R5's. Room R5 told him to get out. R1 was taken to the nursing station and monitored. R1's care conference note dated 5/27/26 at 10:12 a.m., indicated his Risperidone decreased and Depakote dosage was increased on 5/8/26, in an effort to help with his restlessness and wandering. R1's interdisciplinary note (IDT) dated 6/5/26 at 12:20 p.m., indicated R1 had incidents on 5/20/26 at 1:45 p.m., 5/28/26 at 12:45 p.m., and 6/2/26 at 10:30 a.m. Plan of care included sitting in the common area, offer to lay down after lunch, and the gradual dose reduction (GRD) of Risperidone. R1's incident report dated 6/17/26 at 2:15 a.m., indicated R1 opened R4's door which had an alarm. Staff responded to the door alarm and found R1 by the nursing desk when R4 pushed staff out of the way and punched R1 on the cheek leading to a scratch and small laceration. R1's progress note dated 6/18/26 at 3:21 p.m., indicated his Trazadone order changed to 25 mgs at 3:00 p.m. and increased bedtime dose to 150 mgs to improve sleeping patterns. R1's nursing progress note dated 7/12/26 at 6:15 p.m., indicated after dinner he walked into R2's room. R2 was standing in the doorway and pushed R1 down to the floor causing him to hit his head and the left side of his face. R1 complained about a headache and staff noted swelling on the left side of his face close to his eye. Staff provided scheduled Tylenol for pain and an ice pack for swelling. R1's incident report on 7/12/26 at 6:15 p.m., indicated he was wandering around the unit. When he reached R2's room he attempted to enter, but R2 was in the doorway and shoved him out of the room causing him to land on the floor hitting his head, injuring his forehead and the left side of his face. Patient complained about a headache. R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated he had severe cognitive impairment. He required substantial assistance to dress, complete hygiene tasks, move in bed, and toilet. He walked independently and needed partial assistance to eat. His medications included antipsychotic, antidepressant, blood thinners, and anticonvulsant medications. R1's hospital discharge noted dated 8/3/26 indicated R1 presented to the emergency department on 7/14/26 with hip pain and head trauma following an altercation with another resident on 7/12/26. R1 underwent a head CT scan, which showed a four-millimeter subdural hematoma. R1 prognosis was poor and he discharged back to the nursing home on hospice on 7/31/26. R1's care plan dated 8/3/26, indicated prior to returning from the hospital his status changed to a terminal diagnosis, and the facility planned for hospice care to start when he returned. R1's face sheet dated 8/5/26, indicated he was admitted to the facility on [DATE]. He had Alzheimer's disease, dementia with behavioral disturbances, on blood thinners for stroke prevention, high blood pressure, peripheral vascular disease (damaged blood vessels causing reduced blood flow to the legs and feet.) In addition, he had visuospatial deficit and neglect (caused by a stroke when the brain ignores all sensory input from one side of the brain). R2's mood/behavior progress note dated 4/14/26 at 3:26 p.m., indicated R2 told facility staff R1 walked into his room weekly. Staff offered to place a stop banner across his doorway to prevent further incidents, but he declined. Staff encouraged him to call for help if it happened again. R2's care plan dated 5/26/26, indicated he had impaired cognition, memory, process, and decision-making ability. Staff would monitor his condition and update the provider as needed. His care plan was not updated after the two incidents when he pushed R1 down on 4/11/26 and 7/12/26. R2's quarterly MDS dated [DATE], indicated he had moderate cognitive impairment. He used a walker for ambulation. He was able to eat, toilet, move in his bed, transfer from chair to bed, and complete hygiene activities independently. He needed substantial help with showering and partial help with dressing. R2's face sheet dated 8/5/26, indicated he was admitted to the facility on [DATE], he had Huntington's disease with Chorea (involves cognitive decline, inability to focus or make decisions.) In addition, he suffered with depression, mood swings, altered personality, trouble walking, speaking, and eating related to his spastic movements. During an interview on 8/5/26 at 11:11 a.m., nursing assistant (NA)-A stated he took care of R1. He was able to verbalize all the residents who did not get along with R1 caused by him walking into their rooms. He said the unit was laid out in a way for him to keep an eye on all the rooms and resident activities except when he was providing resident care. R2's observation and interview on 8/5/26 at 11:22 a.m., found him lying on his bed. His movements were very rigid, and he needed to rock back and forth several times to sit up in bed. He denied having an incident with R1. There were no warning signs on his door to alert staff and residents not to enter his room. The unit was a locked memory care unit and built in an oval shape. The center of the unit was dining and common areas, and the outer edges were where the residents' rooms were located. The nursing station was in the middle with a view of the entire unit and directly across from R2's room. During an interview on 8/5/26 at 12:05 p.m., registered nurse (RN)-A stated after the 4/11/26, incident they tried to get R2 to add a stop banner that would go across his door to prevent future issues with R1. He declined because he liked to keep his door closed and it would interfere with his ability to close the door. After the 4/11/26, incident she was unsure why the residents were not placed on different units. She thought it was related to both residents needing a memory care unit and the facility only had one. When R1 returns from the hospital after his head injury he will be transferred to a different unit because he could no longer walk. During an interview on 8/5/26 at 2:07 p.m., the director of nursing (DON) stated after each incident they reviewed the facts during an Interdisciplinary Team (IDT) meeting. Even though R2 had pushed R1 down on 4/11/26 and identified R1 goes into his room weekly they thought R2's behavior was a one off and did not require further care plan interventions. She added after each incident they should have reviewed R2's behavior and developed interventions to prevent further physical abuse incidents with R1 and potentially other residents on the unit who might enter his room. During an interview on 8/5/26 at 2:17 p.m., family member (FM)-A stated R1 received intensive care for a couple of weeks at the hospital after falling and hitting his head on 7/12/26. Now R1 was unable to walk, required a pureed diet, total care, and slept most of the time. The hospital provider told him his outcome was poor and hospice care was initiated. He did not feel great about the incident and sadden R1 was no longer responsive and unable to return to his baseline prior to the fall. During an interview on 8/5/26 at 4:14 p.m., the administrator stated both resident's care plans should have been updated with individualized interventions to prevent further incidents. The facility policy Abuse and Neglect-Rehab/Skilled, Adult Day Services, Therapy & Rehab dated 4/7/25, indicated all residents would be free from abuse. After the incident staff would separate the residents, remove them from the location, call local police and 911 as needed. After the incident the facility would investigate the situation while preventing further incidents. For resident-to-resident abuse staff would separate immediately to ensure a safe environment. Assign staff to complete an investigation and develop new care plan interventions.

Based on interview and document review, the facility failed to complete neurological assessments as indicated after a head injury sustained during a resident-to-resident altercation for 1 of 1 resident (R1) who sustained a significant head injury. R1 suffered actual harm resulting in a subdural hematoma (a collection of blood between the brain and its outer covering) and was sent to emergency department and returned on hospice care. Findings include: R1's July medication administration record (MAR) dated [DATE] through [DATE], indicated he received his scheduled Tylenol order for 1000 milligrams (mg) at 8:00 a.m. and 8:00 p.m. In addition, R1 had an order for additional as needed (PRN) Tylenol 1000 mgs once a day for pain but, no additional doses were given from [DATE] through [DATE]. R1's nursing progress note dated [DATE] at 6:15 p.m., indicated after dinner he walked into R2's room. R2 was standing in the doorway and pushed R1 down to the floor causing him to hit his head and the left side of his face. He complained about a headache and staff noted swelling on the left side of his face close to his eye. Staff provided scheduled Tylenol for pain and an ice pack for swelling. R1's skin assessment dated [DATE] at 6:49 p.m., indicated he had bruising on the left side of his face, left thigh, and hip. In addition, staff observed scratches on the left and right side of his face. R1's first neuro check on [DATE] at 7:39 p.m., indicated blood pressure was elevated at 182/65 (normal 90/60 to 120/80,) heart rate was 82 (60-100,) respirations were 18 (12 to 18,) and oxygen saturation was 96% (95 to 100) on room air. His pain level was eight (pain scale from zero the least amount of pain to 10 the worst). Pupils were reactive to light and level of consciousness was unchanged from his baseline. R1's second neuro check on [DATE] at 8:16 p.m., indicated his pain was at a five. Pupils were reactive to light, and his level of consciousness was at his baseline. R1's third neuro check on [DATE] at 8:56 p.m., his pain level was five. His pupils were reactive to light, and current level of consciousness was at baseline. R1's health status note dated [DATE] at 9:24 p.m., indicated he suffered a facial injury around his left upper eye and complained about a headache. He was given PRN pain medication. R1's fourth neuro check on [DATE] at 6:04 a.m., indicated during the overnight shift he did not have any pain, and his vital signs were within normal limits. His pupils were reactive to light, speech was clear, and he was able to move all extremities. R1's fifth neuro checks on [DATE] at 12:27 p.m., indicated his pain level was one, heart rate was 90, and the blood pressure was 103/43. He had spontaneous movement upon command. R1's health status note dated [DATE] at 6:56 p.m., indicated he had severe pain after the [DATE], fall. They administered PRN medication with poor results. The whole shift he was in bed with pain and significant discomfort during cares. He would scream out with movement. The provider was notified, and a portable x-ray was ordered. His change in status required feeding assistance in bed and he continued to verbalize severe pain. R1's provider note dated [DATE] at 7:30 a.m., indicated he had uncontrolled pain. The provider ordered staff to send him to the emergency room for an evaluation. R1's SBAR (situation, background, assessment, and recommendation) note dated [DATE] at 7:37 a.m., registered nurse (RN)-B indicated R1's left hip pain worsened. He did not have any changes to his mental status or mobility. Signs of pain included occasional moaning, facial grimacing, and fidgeting. His POLST (Physician orders for Life-Sustaining treatment) indicated no CPR, allow for a natural death. Nursing care would focus on comfort only during last stages of life. Do not transfer to the hospital for life-sustaining treatment except in the event when pain control was not effective at the facility. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had severe cognitive impairment. He required substantial assistance to dress, complete hygiene tasks, move in bed, and toilet. He walked independently and needed partial assistance to eat. His medications included antipsychotic, antidepressant, blood thinners, and anticonvulsant medications. R1's hospital discharge noted dated [DATE] indicated R1 presented to the emergency department on [DATE] with hip pain and head trauma following an altercation with another resident on [DATE]. R1 underwent a head CT scan, which showed a four-millimeter subdural hematoma. R1 prognosis was poor and he discharged back to the nursing home on hospice on [DATE]. During an interview on [DATE] at 10:30 a.m., RN-D stated on [DATE], she found R1 on the floor and could not believe how much facial swelling had already occurred. She updated the family, her manager, and the provider who just wanted to monitor him. She was worried about R1 because he was on a blood thinner and she focused on his vital signs for any indication of internal bleeding. His cognition had not changed from baseline, and he complained about a headache for which she gave him Tylenol for pain. On [DATE], during afternoon shift report she was told R1 was okay. She informed the nursing assistant to call her for incontinent care so she could assess his injuries. When they turned him onto his side, he was in significant pain and held onto his left hip. She thought he had a possible hip fracture. She called primary care provider (PCP)-A who ordered a portable hip Xray. She attempted to contact the Xray company but could not send the fax or reach them online. She then left a message for her manager and updated the next shift nurse the Xray was not completed as ordered. During an interview on [DATE] at 1:08 p.m., RN-B stated she cared for R1 on [DATE], during the dayshift. She did not have any concerns regarding R1's fall because he was at his baseline. He was placed in a wheelchair, and if he attempted to get up, they stopped him. She became concerned the next day on [DATE], when he did not get out of bed, had left hip swelling and was in excruciating pain. When they attempted to raise the head of the bed he yelled out and had tears in his eyes. She updated PCP-A on his current status and received an order to send him to the hospital for further treatment. During an interview on [DATE] at 1:26 p.m., PCP-A stated he was notified by staff on [DATE], after the fall. He could not recall the conversation with nursing staff but remembered R1's cognition was at his baseline. He ordered the staff to complete neuro checks and continue to monitor. On [DATE], staff updated him regarding worsening hip pain. He ordered a portable Xray to be completed at the facility. If the staff were unable to get an Xray he would have expected them to call him back for further instructions. He added, R1 could tell staff if he had pain but was difficult to assess related to his severely impaired cognition. During an interview on [DATE], at 1:40 p.m., regional clinical director (RCD)-A indicated R1 had a bad outcome and they lost a resident. He reviewed R1's chart and found a few missing neuro checks. The completed neuro checks did not indicate signs of a brain injury. Staff focused on his left hip pain and updated the provider. During an interview on [DATE] at 2:50 p.m., the director of nursing (DON) stated the nursing staff could have done a better job caring for R1 after his fall. When RN-B was unable to get the Xray completed she should have called the provider back. During an interview on [DATE] at 9:04 a.m., RN-C stated she cared for R1 from 11:00 p.m. on [DATE] through 7:00 a.m. The previous nurse told her she called the provider but was unable to complete the portable Xray. She knew at that time the Xray company was closed. Her primary concern was a possible hip fracture and pain. Because of his POLST she knew if she called a provider at that time, they would not do anything, so she attempted to reach R1's family to get permission to send him to the hospital. R1's family did not answer the phone or return her call. The facility policy Change in Condition Evaluation dated [DATE], indicated when assessing for a change in condition, the nurse would review the residents:Medical diagnosis, and recent provider/consultation/interdisciplinary notes.Speak with other staff who cared for the residents along with family members.Next review the advanced directives and contact the family if clarifications were needed.Update the provider. The facility policy Neurological Evaluation-Rehab dated [DATE], indicated after an injury to a resident's head staff would:Document a baseline neuro check.Update the provider as needed.Process any new orders and continue to do neuro checks every 30 minutes for 2 hours, then every eight hours for 3 days.Compare current neuro check with the previous one for worsening symptoms.Notify the provider of any change in condition.

Based on observation, interview, and document review the facility failed to ensure staff consistently wore hair restraints and gloves while serving food. Additionally, the facility failed to maintain food temperatures within the desired range. The facility also failed to consistently cover food items placed in the freezer and date the items with the date placed and the date food items were to be used by. This had the potential to affect all 88 residents who resided at the nursing home. Findings include: On 6/1/26 at 5:11 p.m., dietary aide (DA)-A was observed setting up kitchenette area for evening meal service. DA-A had her hair pulled back in a ponytail, with strands of hair hanging free from the ponytail on the sides of her head. DA-A was wearing a standard uniform top. Further, Dietary manager (DM)-A delivered a tray of sherbet to the kitchenette without a hair net in place. At this time, DA-A removed the aluminum foil from the chafing dishes, stirred the chicken noodle soup, and began to prep for food service. DA-A applied a glove on the hand which handled the bread for the egg salad sandwich. DA-A removed the glove and replaced it with another glove, however, did not perform hand hygiene in between. At 5:16 p.m. DA-A had gloves on both hands while she removed the crusts from bread to prepare a sandwich. At 5:17 p.m., DA-A removed the second glove and did not perform hand hygiene. On 6/1/26 at 5:19 p.m., DA-A proceeded to check temperature of food items. DA-A reported the temperature of the egg salad filling for sandwiches was 56.8 degrees Fahrenheit (F). The egg salad sandwich filling was observed to be in a stainless serving container, sitting on the counter, and was not placed in an ice bath. DA-A also checked the temperature of the mashed potatoes and reported them to be at 115.5 degrees Fahrenheit. DA-A stated she was unaware of what temperatures food items were to be at. On 6/1/26 at 5:21p.m., DM-A returned to the kitchenette, wearing a hairnet, covered by a cloth visor. DM-A had brought out an apron for DA-A to wear. DM-A was informed of food temperature of egg salad filling and removed food item to take down to kitchen to chill. On 6/1/26 at 5:28 p.m., DA-A stated if staff wore a ponytail holder, a hairnet was not needed. DA-A stated her hair had not fallen out of the ponytail holder. DA-A stated she did not typically use a hairnet as she pulled her hair back into a ponytail. On 6/1/26 at 5:39 p.m., egg salad filling was brought back up to kitchenette in the stainless-steel serving container, placed in an ice bath. DM-A stated this was blast chilled, placed in a salted ice bath, while in freezer. The egg salad filling was temped at this time and was noted to be at 36.4 degrees F. DM-A stated temperature of cold food should be 40 degrees or less. DM-A stated there was no concern regarding salmonella for residents who had previously received sandwiches prior to temping as the filling was not out long enough in the danger zone. The potatoes were temped again at this time upon request and were noted to be at 160 degrees F. DM-A stated all hot food should be at 145 degrees F. DM-A stated when aware potatoes were at 116 degrees F., they should have been pulled, and a fresh batch made. DM-A stated she had realized she was not wearing a hairnet when delivering sherbet and went to obtain one. DM-A stated she had not noticed DA-A was not wearing a hairnet but should be. DM-A stated a hairnet was to be used to keep hair out of food. DM-A stated the expectation for those behind the serving line was to wear hairnets, aprons, and gloves on both hands. DM-A stated a ponytail was not adequate as a hair restraint. On 6/4/26 at 8:54 a.m., an observation was made during the breakfast service process in which DA-B was served breakfast while wearing a stocking cap which ended just under ears, and his hair was shoulder length and extended down to the neckline of shirt. On 6/4/26 at 9:35 a.m., DM-A stated DA-B should have worn a hairnet underneath the knit cap to restrain hair extending beyond the edge of the cap. The facility policy, Food Temperature Monitoring-Food and Nutrition Services, reviewed/revised 3/23/26, identified food temperatures are taken and recorded before each meal service. The policy also identified temperatures are taken at other times during or at the end of meal service to ensure temperatures are held within acceptable ranges. The policy indicated that food was served at proper serving temperatures, and further identified proper temperatures as below 41 degrees Fahrenheit for cold foods or above 135 degrees Fahrenheit for hot foods. The facility policy, Employee Hygiene and Dress Code-Food and Nutrition Services, reviewed/revised 5/27/25, identified hairnets or hair restraints and beard nets or beard restraints were to be used when cooking, preparing, assembling food or ingredients. This includes dish rooms and storage areas. See specific state guidelines. Hair is to be covered completely. The policy further states aprons are to be put on a clean apron at the beginning of each shift. The facility policy, Hand Washing and Glove Use-Food and Nutrition Services, reviewed/revised 6/6/25, hands are washed thoroughly before putting gloves on and after taking gloves off. On 6/1/26 at 1:06 p.m. initial kitchen tour was conducted with dietary manager (DM)-A. The walk-in freezer had egg rolls on second shelf on right side of freezer. The egg rolls were wrapped with plastic wrap with one end opened to the air of the freezer. There was no date on the plastic wrap. There was a package of unidentified meat wrapped with aluminum foil, there was no date observed on the package. The walk-in cooler had a jar of Grey Poupon mustard with no date opened indicated, In addition there were hot dogs wrapped with plastic wrap and no date indicated on the wrap. On a shelf below a counter there was a large plastic tub of panko that was not dated when opened and placed into the plastic tub. DM-A stated items were expected to have an opened date and placed into appropriate containers; there was to be no items left open to the air. On a follow-up visit to the kitchen on 6/3/26 at 12:28 p.m. there was an opened undated package of pizza crust and a plastic bag of carrots in the walk-in freezer. DM-A stated the staff were usually good about dating items when opened. Facility Food-Supply Storage–Food and Nutrition Services policy dated 3/13/26 indicated foods that had been opened or prepared were placed in an enclosed container, dated, labeled and stored properly.

Based on interview and document review the facility failed to implement routine surveillance of signs and symptoms of illness/infection which were not currently being treated with antibiotic therapy or other treatment. This had the potential to impact all 88 residents who resided at the facility, as well as staff, and visitors. Findings include: A review of the Infection Surveillance Reports was completed for the months of March, April, and May of 2026. The documents included the total number of infections, whether facility or community acquired infections, the facility acquired infection incidence rates, and the number of multidrug resistant organisms (MDROs). The surveillance logs further classified the types by category of infection. The data gathered on this log included resident name, room number, infection type, signs and symptoms reported, and status (active or resolved). The log also included the type of treatment or antibiotic, antifungal or antimicrobial in place. The log lacked identification of completed testing (labs, chest x-ray, etc.). Although the logs contained an area for comments, this area was not utilized for reporting any completed lab results.During interview on 6/3/26 at 2:07 p.m., the Infection Preventionist (IP), also director of nursing (DON), stated she currently used the Point Click Care electronic medical record (EMR) for surveillance tracking. IP stated the PCC EMR was able to pull data up and input the information into the Infection Surveillance Report. The log lacked capability to pull testing and lab results into the form as they were not hyperlinked to the surveillance report. IP stated this information may be entered into the comment section, however, had not implemented this process. The infection control surveillance log lacked tracking instances of signs and symptoms presented which were not being treated with antibiotics, antifungals, or antimicrobials.IP stated although not tracked on the surveillance log, signs and symptoms of potential illness or infections were reviewed daily Monday through Friday by running reports and reviewing the documentation based on the control f (find) feature of the progress notes. IP stated when she reviewed the progress notes, she looked for things such as an increase or decrease in temperatures and vital signs, symptoms of cough, shortness of breath, altered respiratory status, nausea, vomiting and diarrhea. The progress notes were also monitored for new admissions, indwelling devices, history of MDRO's, and new wounds. In addition to symptoms of illness/infection, a review of new orders was also completed. Upon demonstrating this process for the day of interview, the report generated 99 pages. Although the information was culled out for the day of review, this data was not recorded or compiled for subsequent review for trending of current trends of symptoms (urinary tract infections, upper respiratory symptoms, or gastrointestinal symptoms) or tracking for patterns of symptoms or trending of illnesses. IP stated she monitored the daily progress notes for symptoms of upper respiratory infections and if symptoms were noted, testing would be performed. IP stated the same process was used for symptoms of vomiting or diarrhea, and testing for c. diff (clostridium difficile). IP stated there were no formalized logs of those who were currently being monitored only and that data was captured only by running daily reports or review of individual progress notes. At the time testing was performed due to persistent symptoms, the individual would then be tracked on the suspected log.IP acknowledged the benefit of monitoring via the surveillance log signs and symptoms of infections and illness to capture any potential trends which would allow the opportunity to implement training, education, and placement of interventions to help decrease the potential for spread of illness and infection.The facility policy, Infection Prevention and Control Program, All Service Lines-Enterprise, reviewed/revised 3/25/26 identified the purpose of the infection control program was to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable diseases and infections. The policy identified the surveillance system was to be implemented to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable diseases and infections.

Based on interview and record review, the facility failed to ensure residents receiving psychotropic medications were adequately monitored for potential adverse consequences, including failure to implement side effect monitoring for 4 of 6 residents (R7, R10, R41, and R91) reviewed for psychotropic medication monitoring, and failure to obtain and document orthostatic blood pressures as ordered for 3 of 6 residents (R10, R41, and R91) reviewed for psychotropic medication use.Findings include:R7R7's comprehensive Minimum Data Set (MDS) dated [DATE], identified R7 had moderate cognitive impairment and required assistance with activities of daily living (ADL)'s. R7's diagnoses included deep vein thrombosis (DVT; a blood clot that forms in a deep vein, usually in the leg), hypertension (high blood pressure), benign prostatic hyperplasia (BPH; enlargement of the prostate gland that can affect urination), renal insufficiency (reduced kidney function), diabetes mellitus (a condition in which the body has difficulty regulating blood sugar levels), and cerebrovascular accident (CVA; a stroke caused by interrupted blood flow to the brain). The MDS further identified R7 received psychotropic medications.R7's physician orders identified Escitalopram Oxalate Oral Tablet 20 mg (milligram) by mouth one time a day for depression, initiated on 1/14/25.R7's electronic health record (EHR) failed to identify evidence side effect monitoring had been implemented to assess for potential adverse consequences related to the psychotropic medication. R10R10's comprehensive MDS dated [DATE], identified R10 had severe cognitive impairment and required assistance with ADL's. R10's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by a physical injury), atrial fibrillation (an irregular and often rapid heart rhythm), hypertension (high blood pressure), and non-Alzheimer's dementia (a decline in memory, thinking, and reasoning abilities not caused by Alzheimer's disease). The MDS further identified R10 received antipsychotic medications.R10's physician orders identified Brexpiprazole Oral Tablet 1.5 mg by mouth two times a day for agitation related to dementia, initiated on 3/23/26, and Haloperidol 2 mg by mouth one time a day for delusions related to unspecified dementia, initiated on 6/1/26.R10's EHR failed to identify evidence side effect monitoring had been implemented to assess for potential adverse consequences related to the antipsychotic medications.R10's physician orders further identified an order to document orthostatic blood pressure one time a day, starting on the 1st and ending on the 1st of every month, for antipsychotic medication monitoring, including blood pressure and pulse readings in the lying, sitting, and standing positions. The order was initiated on 4/1/26.Review of orthostatic blood pressure documentation identified: 4/1/26: Lying blood pressure was documented as 110/76 with pulse 72. Sitting and standing blood pressures were both documented as 118/70 with pulse 90. 5/1/26: Lying, sitting, and standing blood pressures were all documented as 120/66 with pulse 90. 6/1/26: Lying, sitting, and standing blood pressures were all documented as 147/98 with pulse 98.R10's EHR failed to identify evidence orthostatic blood pressures were obtained as ordered. The identical blood pressure and pulse readings documented for multiple positions called into question whether separate measurements were obtained in the lying, sitting, and standing positions. R41R41's quarterly MDS dated [DATE] identified R41 had severe cognitive impairment and required assistance with ADL's. R41's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by a physical injury), hypertension (high blood pressure), peripheral vascular disease (PVD; a condition involving reduced blood flow through blood vessels outside of the heart and brain), hyperlipidemia (elevated levels of fats, such as cholesterol and triglycerides, in the blood), arthritis (inflammation or degeneration of the joints causing pain and stiffness), Alzheimer's disease (a progressive brain disorder that affects memory, thinking, and behavior), stroke (damage to the brain caused by interrupted blood flow), and non-Alzheimer's dementia. The MDS further identified R41 received antipsychotic medications.R41's physician orders identified risperidone Oral Tablet 0.25 mg by mouth three times a day for hallucinations, initiated on 5/8/26.R41's EHR failed to identify evidence side effect monitoring had been implemented to assess for potential adverse consequences related to the antipsychotic medication.R41's physician orders further identified an order to document orthostatic blood pressure one time a day, starting on the 3rd and ending on the 3rd of every month, for antipsychotic medication monitoring, including blood pressure and pulse readings in the lying, sitting, and standing positions. The order was initiated on 2/3/26.Review of orthostatic blood pressure documentation identified: 2/3/26: Not obtained. Documentation indicated the resident refused. The record failed to identify evidence the monitoring was attempted again at a later time. 3/3/26: Sitting blood pressure was documented as 120/50 with pulse 82. Lying and standing blood pressures were both documented as 126/56 with pulse 76. 4/3/26: Not obtained. Documentation indicated the resident refused. The record failed to identify evidence the monitoring was attempted again at a later time. 5/3/26: Lying, sitting, and standing blood pressures were all documented as 112/70 with pulse 78. 6/3/26: Lying, sitting, and standing blood pressures were all documented as 128/56 with pulse 72.R41's EHR failed to identify evidence orthostatic blood pressures were obtained as ordered. The identical blood pressure and pulse readings documented for multiple positions called into question whether separate measurements were obtained in the lying, sitting, and standing positions. R91R91's quarterly MDS dated [DATE], identified R91 had severe cognitive impairment and required assistance with ADL's. R91's diagnoses included schizophrenia (a chronic mental health disorder that affects a person's ability to think clearly, perceive reality, manage emotions, and interact with others). The MDS further identified R91 received antipsychotic medications.R91's physician orders identified Olanzapine Oral Tablet 5 mg by mouth two times a day related to paranoid schizophrenia, initiated on 3/25/26 and discontinued on 6/1/26; Olanzapine Oral Tablet 2.5 mg by mouth two times a day related to paranoid schizophrenia, initiated on 6/1/26; and risperidone Oral Tablet 2 mg by mouth two times a day for paranoid schizophrenia, initiated on 6/9/25.R91's EHR failed to identify evidence side effect monitoring had been implemented to assess for potential adverse consequences related to the antipsychotic medications.R91's physician orders further identified an order to document orthostatic blood pressure one time a day, starting on the 17th and ending on the 17th of every month, for antipsychotic medication monitoring, including blood pressure and pulse readings in the lying, sitting, and standing positions. The order was initiated on 7/17/25.Review of orthostatic blood pressure documentation identified: 1/17/26: Lying and sitting blood pressures were both documented as 136/78. No pulse readings were documented, and no standing blood pressure was documented. 5/17/26: Lying, sitting, and standing blood pressures were all documented as 142/68 with pulse 66.R91's EHR failed to identify evidence orthostatic blood pressures were obtained as ordered. The identical blood pressure and pulse readings documented for multiple positions, as well as incomplete documentation, called into question whether separate measurements were obtained in the lying, sitting, and standing positions. During an interview on 6/4/26 at 9:41 a.m., licensed practical nurse (LPN)-B stated nurses or TMA's completed orthostatic blood pressure monitoring. LPN-B stated that for residents who were unable to stand, staff would obtain sitting and lying blood pressures.During an interview on 6/4/26 at 12:14 p.m., RN Case Manager (CM)-C stated orthostatic blood pressures should be completed monthly and include blood pressure measurements in the lying, sitting, and standing positions. CM-C stated orthostatic blood pressures were important because antipsychotic medications could cause side effects that increased a resident's risk for falls. CM-C stated they would not expect blood pressure readings to be exactly the same in all three positions because some variation would typically occur. CM-C further stated that if a resident refused the monitoring, staff should document the refusal and attempt the monitoring again later. CM-C reviewed the orthostatic blood pressure documentation for the identified residents and confirmed several readings were identical in all positions. CM-C stated they would ensure nursing staff were educated on the correct procedure for obtaining orthostatic blood pressures.During an interview on 6/4/26 at 12:59 p.m., a call was placed to the consultant pharmacist and a message was left requesting a return call regarding psychotropic medication monitoring and orthostatic blood pressure monitoring. As of survey exit, the consultant pharmacist had not returned the call.During an interview on 6/4/26 at 12:59 p.m., director of nursing (DON) stated psychotropic medication monitoring should be completed monthly and include blood pressure measurements in the lying, sitting, and standing positions. DON stated that if a resident refused the monitoring, staff should allow time, reapproach the resident, and, if the resident continued to refuse, reschedule the monitoring in the TAR and document the interventions attempted. DON stated staff would not expect blood pressure readings to be exactly the same in all three positions.During an interview on 6/4/26 at 1:16 p.m., CM-C stated the facility did not have anything in place for monitoring psychotropic medication side effects. CM-C stated there was no documentation of side effect monitoring for residents receiving psychotropic medications and acknowledged there probably should have been documentation so staff would know whether the medication was having a negative effect on the resident.During an interview on 6/4/26 at 1:29 p.m., DON stated documentation for monitoring medication side effects was something the facility was just beginning to implement. DON stated the facility had begun reviewing medication side effects during morning meetings. DON stated side effect monitoring was important so staff would know whether residents were experiencing adverse effects from psychotropic medications.The facility's Psychotropic Medications - Rehab/Skilled policy, reviewed/revised 12/9/25, identified that each resident's drug regimen must be free from unnecessary medications, including medications used without adequate monitoring or in the presence of adverse consequences that indicate the dose should be reduced or discontinued. The policy required ongoing monitoring throughout the administration of psychotropic medications, including continued mood and behavior documentation to evaluate the medication's effect on behaviors, monitoring for medication side effects, and monitoring for effectiveness and potential adverse consequences. The policy further directed nursing staff to document side effects, notify the physician and family/legal representative when side effects occurred or worsened, and complete ongoing assessments to evaluate resident response to psychotropic medications. The policy also required the reduction committee to review psychotropic medications at least every three months, including evaluation of target symptoms, medication effectiveness, and any medication-related adverse consequences experienced by the resident during the previous quarter.

Based on interview and record review, the facility failed to revise comprehensive care plans to reflect significant changes in resident status, conditions, preferences, and interventions, for 3 of 3 residents (R111, R7, and R75) reviewed for care plan revision. Further, the facility failed to update the care plan with specific interventions for 2 of 2 residents (R1 and R122) reviewed for privacy of care. Findings include: R111 R111's discharge return anticipated MDS dated [DATE], identified R111 had moderate cognitive impairment and required assistance with ADLs. R111's diagnoses included cancer (a disease in which abnormal cells grow uncontrollably), septicemia (a serious bloodstream infection), and non-Alzheimer's dementia (a decline in memory and cognitive functioning not caused by Alzheimer's disease). The MDS further identified R111 was receiving hospice services. R111's EHR identified hospice services were discontinued on 5/11/26. R111's care plan printed of 6/2/26, identified a focus area which stated, The resident has a terminal prognosis R/T prostate cancer E/B on Optage Hospice, with an initiation date of 12/9/25. However, the care plan continued to indicate R111 was receiving hospice services after hospice services were discontinued on 5/11/26 and failed to be revised to reflect the resident's discharge from hospice. R111's care plan printed 6/4/26, further identified The resident requires Enhanced Barrier Precautions (EBP) R/T wound. R111's EHR identified the wound had healed and R111 remained on EBP due to the presence of a urinary catheter. The care plan failed to be revised to reflect the resident's current need for EBP precautions and continued to identify the healed wound as the basis for the intervention. R7 R7's comprehensive Minimum Data Set (MDS) dated [DATE] identified R7 had moderate cognitive impairment and required assistance with activities of daily living (ADL)'s. R7's diagnoses included diabetes mellitus (a chronic condition that affects how the body uses blood sugar) and cerebrovascular accident (CVA; damage to the brain caused by interrupted blood flow). The MDS further identified R7 received insulin, an anticoagulant, and an antidepressant. R7's care plan printed 6/2/26, identified a care plan focus titled, The resident has respiratory infection: Influenza A, with an initiation date of 12/25/25. R7's electronic health record (EHR) failed to identify ongoing signs, symptoms, treatment, or diagnosis of Influenza A. The care plan continued to identify Influenza A as an active care plan focus despite resolution of the condition and failed to identify revision or discontinuation of the focus area. R75 R75's comprehensive MDS dated [DATE], identified R75 had severe cognitive impairment and required assistance with ADLs. R75's diagnoses included non-Alzheimer's dementia (a decline in memory and cognitive functioning not caused by Alzheimer's disease) and post-traumatic stress disorder (PTSD; a mental health condition that can develop after experiencing or witnessing a traumatic event). The MDS further identified R75 displayed physical and verbal behavioral symptoms directed toward others, as well as other behavioral symptoms not directed toward others, one to three days during the assessment period. The MDS also identified wandering behavior one to three days during the assessment period. R75's care plan printed 6/2/26, identified dining preference interventions indicating the resident preferred to sit alone during mealtimes and liked to sit in the dining room by the television next to the window. R75's EHR further identified behavior management interventions had been implemented, including placement of a bookshelf sticker on the resident's door and installation of a door chime to alert staff when residents entered or exited the room. Review of the care plan failed to identify either intervention. Observation on 6/2/26 at 12:13 p.m. identified R75 exited his room and sat at a dining room table with another resident while waiting for lunch. A door chime sounded when the resident's room door opened. Observation on 6/2/26 at 12:20 p.m. identified R75 ate lunch with two other residents and engaged in conversation with them. Observation on 6/2/26 at 12:22 p.m. identified another resident sat at the table with R75, and R75 greeted the resident. Observation on 6/3/26 at 8:13 a.m. identified R75 exited his room for breakfast and a door chime sounded when the door opened. R75 then sat in the dining room with two other residents in the main dining room. During an interview on 6/4/26 at 9:27 a.m., nursing assistant (NA)-E stated R111 was on hospice and was on EBP precautions due to having a urinary catheter. During an interview on 6/4/26 at 9:31 a.m., NA-D stated R75 was easily agitated and was protective of his personal space. NA-D stated a door chime alerted staff when the resident's door opened so staff could ensure other residents did not enter the room. NA-D further stated a bookshelf sticker had been placed on the resident's door approximately one month earlier. NA-D stated R75 initially sat in the small dining room when he was admitted to the facility but had been sitting in the main dining room with other residents for quite some time. NA-D also stated R7 had not been sick in quite a while. During an interview on 6/4/26 at 9:33 a.m., licensed practical nurse (LPN)-B stated R111 had graduated from hospice services and the facility had discussed the possibility of restarting hospice services; however, R111 did not meet the criteria. LPN-B stated R111 was on EBP precautions due to a urinary catheter and had not had a wound for several months. R75 previously exhibited exit-seeking behaviors but had mellowed considerably and spent more time outside of his room. To address those behaviors, a door chime and bookshelf sticker had been implemented approximately one month earlier to alert staff if another resident wandered into R75's room. R7 had not had Influenza since the previous year. LPN-B stated care plans should be updated to reflect changes in resident conditions and interventions and could be updated by nursing staff, although the nurse manager completed most care plan revisions. During an interview on 6/4/26 at 12:32 p.m., registered nurse case manager (CM)-C stated R75 was territorial regarding his personal space and could be paranoid at times, although his behavior had improved. CM-C stated a bookshelf sticker and door chime had been implemented on 5/7/26 and had been effective interventions; however, neither intervention was included in the care plan. CM-C stated it was important for staff to be aware of the interventions and confirmed they should have been care planned. CM-C further confirmed R75 initially sat in the small dining room but currently sat in the main dining room with three other residents and stated the dining preference intervention should have been revised to reflect the resident's current preference. R111 was discharged from hospice services on 5/11/26 following hospitalization. CM-C reviewed the EHR and confirmed hospice services continued to be identified in the record and on the care plan despite the hospice discharge. CM-C further confirmed R111 no longer had a wound and remained on EBP precautions due to a urinary catheter and stated the care plan should have been revised to accurately reflect the resident's hospice status and current reason for EBP precautions. R7 no longer had Influenza A and that the care plan continued to identify Influenza A as an active respiratory infection despite the diagnosis occurring in 2025. CM-C stated the care plan should have been revised to remove the resolved condition. During an interview on 6/4/26 at 12:59 p.m., director of nursing (DON)-A stated hospice discharge notifications should prompt review and revision of the care plan and that a significant change MDS should be completed following discharge from hospice services. DON-A stated care plans should be updated whenever a resident experienced a new diagnosis, condition, intervention, preference change, or other significant change in status. DON-A further stated care plans served as the primary communication tool for staff and should accurately reflect the resident's current needs, interventions, and preferences to ensure staff understood how to provide appropriate care. The facility's policy, Care Plan - R/S, LTC, Therapy & Rehab, revised 12/1/25, indicated each resident would have an individualized, person-centered comprehensive care plan that addressed the resident's medical, nursing, physical, functional, emotional, psychosocial, and educational needs. The policy indicated care plans would be based on assessments, the Resident Assessment Instrument (RAI), physician orders, and identified resident problems, needs, and concerns. The policy further indicated the comprehensive care plan would be modified to reflect the care currently required and provided to the resident. Care plans were to be reviewed at least quarterly and reviewed, evaluated, and updated whenever there was a significant change in the resident's condition. R1 R1's significant change assessment of 3/24/26 indicated R1 had moderate cognitive impairment. The assessment identified R1 was able to communicate his needs and wishes and was able to understand information relayed to him. R1 was identified as needing assistance with activities of daily living (ADL's-dressing, grooming, and bathing). R1's medical diagnoses included headaches, cardiorespiratory debility (lack of function related to heart and respiratory problems), heart failure, hypertension (high blood pressure), renal chronic kidney disease (alteration in kidney function related to removal of waste through the kidney), diabetes (alteration in the way the body processes sugar), CVA (cardiovascular accident-stroke), hemiplegia/hemiparesis (loss of use/mobility of one side of the body), and anxiety. R1's care plan from admission of 1/3/26 lacked indication of use of camera, rationale for use, and placement by family for monitoring and interaction with R1. A facility document, titled Electronic Monitoring Notification and Consent Form (GSS 686) dated 11/17, identified R1 would like camera placed on 3/15/26, and would include video and audio. The form was not signed by family member and staff member until 4/6/26. R1's progress notes of 4/6/26, identified staff had discussed video surveillance in progress and provided the GSS 686 for completion. At that time the document was reviewed and completed with signatures of both family member and staff. The progress notes reflected a sign was placed on door to indicate to staff/visitors electronic monitoring was in place. R122 R122's admission Profile indicated admission on [DATE], medical diagnoses included: Wernicke's encephalopathy (neurological symptoms (impaired vision and confusion) caused by lesions of the central nervous systems after exhaustion of B-vitamin reserves, alcohol dependence (in remission), anemia (low red blood cells or hemoglobin) and osteoarthritis (inflammation of joints). R122's care plan initiated 4/2/26, and last revised 4/24/26, lacked indication of use of video camera with audio capability for resident, as well as rationale for use, and other interventions related to this (signage, staff awareness, interaction with family through audio). A facility document, titled Electronic Monitoring Notification and Consent Form (GSS 686) dated 11/17, identified R122 would like camera placed on 4/6/26, and would include video and audio. The form was signed by family member and staff member on 4/6/26. R122's progress notes of 4/6/26, identified staff had discussed video surveillance in progress and provided the GSS 686 for completion. The note indicated staff member had left document for signature by family member. The documentation indicated once consent was signed, the camera was to be plugged in, and consent turned into the nurse's station. A copy of the signed consent was on file. A subsequent note of 4/10/26, indicated family was observing via camera and alerted staff of R122s need for help. During interview on 6/4/26 at 12:57 p.m. licensed social worker (LSW)-A, stated R1 had cameras found in his room without staff awareness. LSW-A stated family was contacted, a GSS-686 consent was completed, and the camera was put into place by family members. The appropriate signage was placed on the door to advise staff and visitors of the camera use. LSW-A stated the use of cameras should have been outlined in the care plan, and this task was the responsibility of the nurse manager in charge of R1's care. On 6/4/26 at 1:31 p.m. Social Services Director (SSD)-A stated the GSS 686 for R1 was obtained right away for consent for use of the camera, a sign was posted on the door, and administrative staff was notified. SSD-A stated R122's family member was contacted on 4/6/26 as well, and a consent was left for signature. The note left for family was to provide nursing staff with consent and were then able to proceed with use of the camera. SSD stated social services were responsible for obtaining the consent and posting the signage for camera use, however, nursing staff was responsible to update the care plan to reflect the use of the camera. On 6/4/26 at 10:55 a.m. registered nurse/clinical manager (CM)-B stated she was not working at the facility when the cameras were put into place. Both R1 and R122 had involved family members who had requested cameras to be put into use. CM-B stated signage was posted on the door to alert staff and visitors of the use of the camera. CM-B stated she had not completed the care plan process with R1 and R122. The facility policy, Electronic Monitoring in Resident/Client/Patient Rooms-Enterprise, date reviewed/revised 5/18/26, initially referred to a separate policy: Photography and Video Imaging, Patient, Visitor, Workforce Member-Enterprise. This policy is broken by states which allows this monitoring. The document reflects for Minnesota, residents or, under certain circumstances, their authorized resident representative, may conduct electronic monitoring in a resident's room or private living space after certain conditions are met (such as written consent and notification, including that of any roommate). The procedure identified the electric monitoring device may be used by the resident, or their authorized representative if appropriate, after requirements have been met. This includes review of information required, and signature of a consent to allow such use. The procedure directs staff to have signs posted to inform staff/visitors of use. The policy lacks indication regarding placing the information in the care plan, or subsequent documentation in follow up regarding ongoing use of the video camera. A review of the policy, Photography and Video Imaging, Patient, Visitor, Workforce Member-Enterprise, date reviewed/revised 5/18/26, was completed and also reviewed the perimeters in which this was allowed, along with consent required for use. The facility policy, Care Plan-R/S, LTC, Therapy and Rehab, date reviewed/revised 12/1/25, indicated that each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. The policy stated further: This plan of care will be modified to reflect the care currently required/provided for the resident.

Based on observation, interview, and document review, the facility failed to assure medication labels properly reflected provider orders for 2 of 7 residents (R110, R89) observed during medication administration.Findings include:On 6/1/26 at 4:10 p.m., medication observation was completed with licensed practical nurse (LPN)-A during R110's medication pass. LPN-A provided R110 with quetiapine fumarate 25 mg 1/2 tablet (1/2 tablet to total 12.5 mg-milligram/a unit of measurement) at that time, however, medication label read to give 1/2 tab(let) daily and went on to direct staff to give one tablet (25 mg) at bedtime. LPN-A stated medication administration record (MAR) directed staff to give at 4:00 p.m. LPN-A stated she was unsure if the previous dosing schedule had changed. LPN-A stated the medication label should match the orders on the MAR. LPN-A stated there were stickers available to place on the prescription label to identify a change in orders but acknowledged there was no label in place.Upon review of the orders, it was noted the orders directed staff to give quetiapine fumarate 25 mg 1/2 tablet (12.5 mg) by mouth one time a day for depression at 4:00 p.m. and 25 mg by mouth one time a day for depression at 8:00 p.m.On 6/4/26 at 1:30 p.m., a review of the medication label and the prescription label was completed with the clinical manager (CM)-A. The label directed staff to administer 1/2 tablet (12.5 mg) by mouth once daily. Give one tablet (25 mg) at bedtime. CM-A acknowledged the label lacked indication regarding spacing of doses. CM-A stated there were stickers available to place on label to direct staff to electronic medical record. On 6/3/26 at 7:47 a.m., registered nurse (RN)-B provided R89 with the inhaler, Anoro Elipta, for one puff inhalation. The inhaler was noted to be in a plastic tray, and lacked any labeling to include resident name, medication date of dispensing, date of expiration, or directions for use. The inhaler was dated as opened 4/29/26.Additionally, resident was administered the following doses of insulin:Lantus Insulin (Insulin Glargine Subcutaneous Solution 100 mg/ml) 38 units sub q (within the upper level of flesh, but not into the muscle) however the label directed staff to administer 40 units sub q. Novolog Insulin Aspart Injection 100 unit/ml 11 units, however, the label directed staff to administer nine units of insulin sub q.RN-B stated the insulin labels should have been updated by pharmacy to reflect the current doses ordered, or a sticker should have been placed on the insulin pens to reflect there was a change in orders and to refer to the EMR. RN-B stated the inhaler should remain in the original packaging until supply was depleted.On 6/4/26 at 7:58 a.m., director of nursing (DON) stated all medications should be labeled with the resident's name, name of medication, date dispensed, med dispensed, date of expiration, and directions for use. DON stated the labels on the medication card should match the instructions on the MAR. If there were changes to the orders, there were stickers which would be placed which identify directions were changed and direct staff to refer to EMR.The facility policy, Medications: Administration Including Scheduling and Medication- R/S, LTC, date reviewed/revised 3/30/26, identified with medication pass, the staff were directed to read the label on the medication container and compare with the MAR when removing the container from the supply drawer. The policy lacked direction as to what to do if there were a discrepancy between the label and the prescription label.

Based on observation, interview, and document review, the facility failed to ensure resident grooming needs were met for 1 of 1 resident (R83) in the sample reviewed for nail care. Finds include: R83's admission Record (Face Page - print date of 6/4/26), documented the following diagnoses: Muscle weakness, disorientation, atrial fibrillation and essential hypertension. R83's Comprehensive Minimum Data Set (MDS) dated [DATE], assessed resident to be moderately cognitively impaired and required set-up to maximal assist with activities of daily living (ADLs). R83's Care Area Assessment for ADLs (CAA) dated 3/30/26, documented resident's limiting factors for the need of ADL assistance being causes for being dependent were physical limitations such as weakness, limited range of motion, poor coordination, poor balance, visual impairment or pain. During observation and screening on 6/01/26 at 3:26 p.m., R83 had very long fingernails on all 10 fingers, which looked to be 1/4 inch and longer in length. R83 stated he was unable to cut them himself and stated he wished them to be trimmed. During daily observation from 6/1/26 though 6/4/26, R83 continued to have long fingernails. A review of R83's electronic medical record, under the section of Tasks, it was documented R83 received weekly baths on Wednesdays. In review of R83's car plan (last revised 3/21/26), documented resident's dependence on staff, including the assist of one staff person during bathing task. On the morning of Thursday 6/4/26 (the day after resident's scheduled shower day) at 9:20 a.m., R83 was sitting at the central dining room area table feeding himself breakfast. R83's fingernails were long and uncut. R83 stated he received his shower last evening. No one offered to trim / cut his fingernails.During an interview on 6/4/26 at 9:46 a.m., nursing assistants (NA)-A and NA-B reviewed the electronic medical record task section and verified R83 received his shower the previous day at approximately 4:22 p.m. Both NA-A and NA-B stated residents should have their nails trimmed / cut with their weekly showers / baths. However, both NAs stated the NAs were not to cut fingernails but rather only the nurses. Both NA-A and NA-B stated they were only allowed to use emery boards and use fingernail polish on residents. In an observation and interview on 6/04/2026 at 9:55 a.m., registered nurse (RN)-A verified R83's nails should have been trimmed / cut yesterday with his shower. RN-A stated the NAs were allowed to trim / cut resident nails, as long as they were not diabetic. RN-A estimated 883's fingernails were all at least 1/4 inch in length. RN-A asked R83 if he wished his failed to be cut, with residents stating yes.During a further observation and interview on 6/4/26 at 10:04 a.m., registered nurse care manager (CM)-A stated resident fingernails should be trimmed / cut weekly with baths / showers. CM-A further stated the NAs were to complete this task for residents noted to have long nails, unless they were diabetic. The NAs should inform the nurse of a diabetic needing nail care. When CM-A asked R83 if he wanted his nails cut, R83 responded yes. During a final interview on 6/4/2026 at 12:50 p.m., the director of nursing (DON) stated it was the facility's expectation, resident would have their nails trimmed / cut with their weekly bath / shower if it was needed and/or the resident requested. If a resident refused nail care, staff should report the refusal to the nurse. DON stated all NAs have the ability to perform nailcare except for diabetic residents. In review of the facility's skills checklist), entitled: Nail Care Clinical Skill Checklist (undated), did not indicate when nails should be trimmed / cut but rather only the following:[certified nursing assistants] check with care plan prior to procedure. Licensed nurses see physician orders. [certified nursing assistants] are not to do nail care on residents with diabetic or circulatory problems.The policy went on to indicate the skills required by the facility for staff to perform nail care, what to observed for and what to report to the nurse. In review of the facility's policy entitled: Nail Care (last revised 4/2/26) further clarified which resident the NAs (not diabetic or residents receiving anticoagulants) were able to do, supplies need and the process in performing nail care.

Based on interview and record review, the facility failed to ensure a resident and/or resident representative was informed of and participated in treatment decisions regarding psychotropic medications, including failure to obtain informed consent prior to the initiation of a psychotropic medication for 1 of 5 residents (R41) reviewed for psychotropic medication use.Findings include:R41's quarterly Minimum Data Set (MDS) dated [DATE], identified R41 had severe cognitive impairment and required assistance with activities of daily living (ADL's). R41's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by a physical injury), Alzheimer's disease (a progressive brain disorder affecting memory and thinking abilities), stroke (damage to the brain caused by interrupted blood flow), and non-Alzheimer's dementia (a decline in memory and cognitive function not caused by Alzheimer's disease). The MDS further indicated R41 had experienced two or more falls since admission.R41's physician orders dated 4/7/26, identified an order for risperidone, a psychotropic medication, which had been initiated on 1/29/26, when R41 was admitted to the facility.Review of R41's electronic medical record (EMR) failed to identify documentation that informed consent for the psychotropic medication had been obtained from the resident and/or resident representative prior to the medication being initiated. Further review identified the consent had been obtained after the medication was started.During an interview on 6/4/26, at 12:26 p.m., RN Case Manager (CM)-C stated psychotropic medication consents were obtained upon admission and reviewed with the resident and/or family member. CM-C reviewed R41's EMR and stated she was unable to locate the consent in the EMR, so she contacted the family on 6/2/26 and obtained verbal consent over the phone. CM-C stated the consent form was important to ensure the resident and/or family agreed with the medications being administered and understood the associated risks and benefits of the medication.During an interview on 6/4/26 at 12:59 p.m., the director of nursing (DON) stated consent should have been obtained when the medication order was received, either upon admission if the resident was admitted on the medication or when a new psychotropic medication was initiated. The DON stated the consent should have been signed by the resident or the resident's family member prior to administration of the medication.Review of the facility's Psychotropic Medications Policy, reviewed/revised 12/09/2025, identified residents and/or their family or legal representative were to be notified when psychotropic medications were initiated or when residents were admitted on psychotropic medications. The policy further identified the Permission for Use of Psychotropic Medications (GSS #478) consent form was required to be completed and signed for the use of psychotropic medications.

Based on observation and interview the facility failed to maintain a broda chair (a specialized brand of wheelchair and positioning recliner designed for individuals with limited mobility who require long-term, comfortable sitting) in good repair for 1 of 1 resident (R40) reviewed who utilized a broda chair.Findings include:F40's quarterly Minimum Data Set (MDS) dated [DATE], indicated R40 had moderate cognitive impairment and was dependent on staff for activities of daily living (ADLs). R40's diagnoses included anemia, dementia, Huntington's disease, anxiety, depression and bipolar disorder. On 6/3/26 at 3:13 p.m. R40's broda chair was observed with four cracks on head rest cushion, the cracks were vertical on the cushion about six inches in length with the inner foam visible in the cracks. Cushioning on right side of R40's head was observed to have several cracks of varying length with inner foam visible in the cracks. Cushioning on left side of R40's head was observed to have an area of about eight inches by 6 inches of cracks with a diagonal jagged crack about seven inches in length with an area below about 6 inches by five inches of cracks, foam was visible in all cracked areas. The upper corners of the left side cushion with stuffing and foam observed sticking out. Follow up observation on 6/4/26 at 11:22 a.m. indicated R40 continued to be placed in the broda chair with cracked cushions with inner foam and stuffing visible. When interviewed on 6/4/26 at 11:28 a.m. certified nursing assistant (CNA)-C stated when equipment was broken or in poor repair, they were to complete a maintenance work order or inform hospice if the resident was on hospice for the equipment to be repaired or replaced. CNA-C stated were not aware R40's broda had cracked cushions When interviewed on 6/4/26 at 11:31 a.m. registered nurse (RN)-C stated R40 wore a helmet that had probably caused cracks in the cushions of the broda chair and due to R40 being on hospice they would have to be notified the broda chair cushions required repair or replacement. RN-C stated they were not aware if hospice was informed of the broda chair condition. When interviewed on 6/4/26 at 11:40 AM clinical care manager (CM)-B stated they had noticed several chairs that needed repair or replacement but had not yet informed hospice of the need. CM-B stated the concern with cracked cushions was infection control and the cushions could not be cleaned appropriately. When interviewed on 6/4/26 at 12:53 p.m. director of nursing (DON) stated the expectation was for equipment to remain in good repair, maintenance requests or update to hospice was expected to be completed in a timely manner to ensure cleanliness and infection control was maintained. Facility policy regarding resident equipment was requested, however, none was provided.

Based on interview and record review, the facility failed to provide and document written notice of an involuntary transfer/discharge to a resident and/or resident representative prior to transfer to another facility, for 1 of 1 resident (R100) reviewed for transfer and discharge requirements.Findings include:R100's clinical record identified R100 was transferred from the facility to a sister facility on 8/22/25.Review of R100's electronic health record (EHR) failed to identify documentation that the resident and/or resident representative received written notice of the involuntary transfer/discharge prior to the transfer. The record failed to identify documentation of a Notice of Involuntary Discharge (NOID), notification of appeal rights, evidence of notification to the resident and/or resident representative, documentation of attempted contact with resident and/or resident representative, or notification to the Ombudsman program regarding the discharge.During an interview on 6/4/26 at 11:01 a.m., Social Worker (SW)-A stated when residents were discharged , the facility typically issued a Notice of Medicare Non-Coverage (NOMNC), discussed appeal rights, reviewed discharge information with the resident, coordinated communication with outside providers, and arranged transportation if needed. SW-A stated that for facility-initiated discharges, options were reviewed with the resident and discharge planning was discussed. SW-A stated she was aware there had been months of discussions involving the Ombudsman program and regional staff regarding R100 and issues related to unpaid bills. SW-A further stated she knew a great deal of information leading up to the discharge but did not know all of the events surrounding the discharge. SW-A confirmed there was no documentation regarding attempts to contact the resident's daughter or documentation related to discharge planning. SW-A stated the Administrator ultimately took over management of the discharge process.During an interview on 6/4/26 at 11:26 a.m., the Administrator stated R100 was transferred to the facility's sister facility on 8/22/25 and the resident's long-term care needs continued to be met. The Administrator stated notice of the discharge had been relayed to the resident; however, she could not provide documentation or evidence supporting that notification. The Administrator further acknowledged there were missing pieces in the discharge record and confirmed she could not locate documentation of the required discharge notice.During an interview on 6/4/26 at 11:35 a.m., the Ombudsman stated she had discussed R100's discharge with the facility on 9/18/25 and informed facility staff that the required discharge process had not been followed. The Ombudsman stated she was unable to find evidence that a Notice of Involuntary Discharge had been issued, evidence that the resident and/or resident representative had been notified, or evidence of attempts to contact the resident representative regarding the discharge. The Ombudsman further stated there was no documentation supporting these actions and confirmed the Office of Ombudsman for Long-Term Care had not received notification of the discharge.The facility's Discharge and Transfer - Rehab/Skilled, Therapy & Rehab policy, reviewed 1/15/26, required that before a resident was transferred or discharged , the facility notify the resident and resident representative in writing of the transfer/discharge and the reason for the move using the Notification of Transfer or Discharge (GSS #223A) or other state-required form. The policy further required the facility provide information regarding appeal rights and assistance with obtaining and completing an appeal form. A copy of the transfer/discharge notice was required to be sent to the Office of the State Long-Term Care Ombudsman. For transfers related to non-payment, the policy required at least 30 days' advance notice before the transfer or discharge occurred. The policy also required the facility to provide and document sufficient preparation, orientation, and discharge planning to ensure a safe and orderly transfer or discharge.

Based on interview and record review, the facility failed to timely complete a comprehensive assessment after a significant change in status, including failure to complete a Significant Change in Status Assessment (SCSA) following discharge from hospice services, for 1 of 1 resident (R111) reviewed for MDS assessment requirements.The Resident Assessment Instrument (RAI) User's Manual identified enrollment in hospice services and discharge from hospice services as events that may constitute a significant change in status requiring completion of a Significant Change in Status Assessment.Findings include:R111's most recent Minimum Data Set (MDS) assessment identified diagnoses which included chronic obstructive pulmonary disease (COPD; a chronic lung disease that makes breathing difficult) and chronic respiratory failure (a condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide). The MDS further identified R111 received hospice services.R111's clinical record identified hospice services were discontinued on 5/11/26.Review of R111's electronic health record (EHR) on 6/4/26 identified documentation continued to reflect R111 was receiving hospice services, including on the resident profile and care plan, despite hospice services having ended on 5/11/26.During interview on 6/4/26 at 9:27 a.m., nursing assistant (NA)-E stated R111 was on hospice services and confirmed care plans were primarily updated by the nurse manager.During interview on 6/4/26 at 9:33 a.m., licensed practical nurse (LPN)-B stated R111 had been on hospice services and had graduated from hospice. LPN-B stated the facility had held a care conference regarding the possibility of restarting hospice services; however, R111 did not meet hospice criteria.During interview on 6/4/26 at 12:32 p.m., registered nurse case manager (CM)-C stated R111 was discharged from hospice after a hospitalization on 5/10/26 and was scheduled to be discharged from hospice on 5/11/26. CM-C reviewed the EHR and confirmed it continued to identify R111 as receiving hospice services. CM-C stated the record should have been updated to accurately reflect the resident's current status. CM-C further stated she completed the Significant Change in Status Assessment on 6/3/26 after the surveyor requested information regarding the resident's hospice discharge.During interview on 6/4/26 at 12:59 p.m., Director of Nursing (DON) stated hospice discharges generated notifications to administration staff and required updates to the resident's care plan and clinical record. The DON stated documentation was typically received from the hospice agency at discharge and confirmed a Significant Change in Status Assessment should have been completed following the hospice discharge. The DON stated it was important for the record to accurately reflect the resident's current status and care needs in real time.During interview on 6/4/26 at 1:29 p.m., MDS nurse (RN)-E reviewed the resident's assessment history and stated the Significant Change in Status Assessment was completed on 6/3/26.Review of the facility's MDS assessment history confirmed a Significant Change in Status Assessment was not completed until 6/3/26, approximately three weeks after R111's discharge from hospice services on 5/11/26.Review of the facility's MDS 3.0 (Minimum Data Set) RAI policy, revised 10/27/25, identified when a significant change in a resident's status was identified, staff were to notify the social worker, RN coordinator, or designated employee so a timeline could be established and communicated to interdisciplinary team members. The policy further required documentation of the significant change in the PN-MDS, notification of the interdisciplinary team through the MDS/Care Plan Notification process, and completion of the Significant Change MDS in accordance with the Resident Assessment Instrument (RAI) Manual requirements and timelines.

Based on observation, interview, and document review, the facility failed to ensure professional standards of practice were followed during administration of crushed medications for 1 of 2 residents (R68) observed during medication administration.Findings include: R68's Annual Minimum Data Set (MDS) dated [DATE], identified R68 as exhibiting severe cognitive deficit and was identified as requiring assist with all aspects of activities of daily living (ADLs-dressing, grooming, bathing, and toileting). R6's medical diagnoses included aphasia (difficulty with speaking), anemia (a low blood count of red blood cells or hemoglobin), hypertension (high blood pressure) and non-Alzheimer's dementia (a condition which may cause alteration in thoughts, cognition, and behavior).R68's admission Profile printed 6/4/26, indicated R68 had diagnoses of generalized muscle weakness.R68's Care Plan revised 2/23/26, indicated R68 had limited physical mobility related to history of a stroke with right side weakness and received antiplatelet therapy. R68's care plan identified an order in place for a texture modified diet. The care plan lacked indication prior to 6/3/26. R28 was okay to have crushed meds.During a medication observation on 6/3/26 at 7:31 a.m. R68 was given the following medications were crushed together and mixed with applesauce and given orally: Clopidgrel 75 mg one tablet; Senexon S 500 mg/8.6 mg one tablet; and Amlodipine 10 mg one tablet. Registered nurse (RN)-B stated R68's medications were crushed and mixed together with applesauce for R68. RN-B stated this was able to be completed as it was ordered by the provider.On 6/3/26 at approximately 10:00 a.m., DON stated all medications which required crushing were to have an order in place. DON stated this was important to assure medications were able to be crushed based on timed release status, protective coating, etc. DON stated she was unaware if there were orders in place for R68, however, affirmed medications were not to be crushed without provider orders.R68's progress notes were reviewed and identified on 6/3/26 at 12:46 p.m., an order was received from the provider that it was okay to crush meds due to history of stroke and seizure.A review of R68's cumulative orders lacked indication of authorization to crush medications prior to 6/3/26.The facility policy, Medications: Crushing-AL, R/S, LTC, date reviewed/revised 1/29/26 identified the attending provider must be aware of the need to crush medications so that the appropriate form of the medication can be ordered. The policy further states best practice would be to separately crush each medication and separately administer each medication with food.

Based on interview and record review, the facility failed to ensure physician-ordered parameters were monitored prior to administration of an antihypertensive medication, including failure to obtain blood pressure readings to determine whether a PRN dose of metoprolol was indicated, for 1 of 1 resident (R91) reviewed for medication administration parameters.Findings include:R91's quarterly Minimum Data Set (MDS) dated [DATE] identified R91 had severe cognitive impairment and required assistance with activities of daily living (ADL)'s. R91's diagnoses included schizophrenia (a chronic mental health disorder that affects a person's ability to think clearly, perceive reality, manage emotions, and interact with others). The MDS further identified R91 received antipsychotic medications.R91's physician orders identified an order for Metoprolol Tartrate 12.5 mg (milligram) by mouth every 24 hours as needed for blood pressure greater than 150 related to paranoid schizophrenia. The order was initiated on 3/30/26.R91's electronic health record (EHR) identified the PRN metoprolol order remained active. Review of the EHR identified the facility obtained R91's blood pressure on a weekly basis; however, the record failed to identify blood pressure monitoring was completed to determine whether R91's blood pressure exceeded the ordered parameter of greater than 150 and whether administration of the PRN medication was indicated. The record further failed to identify documentation the facility evaluated the ongoing need for the medication or whether the ordered blood pressure parameter was ever met.During an interview on 6/4/26 at 9:41 a.m., licensed practical nurse (LPN)-B reviewed R91's physician orders and stated R91 had an order for PRN metoprolol. LPN-B stated he believed the medication was intended for symptoms that occurred during aggressive episodes.During an interview on 6/4/26 at 12:32 p.m., registered nurse case manager (CM)-C stated R91's family did not want R91 routinely receiving metoprolol and a decision had been made during a care conference to change the medication to PRN use. CM-C reviewed the physician order and stated the facility should have obtained clarification from the provider regarding blood pressure monitoring parameters. CM-C further stated the order should have included instructions regarding how often blood pressure readings were to be obtained and acknowledged staff should have been monitoring R91's blood pressure to determine whether the medication was indicated.During an interview on 6/4/26 at 12:59 p.m., director of nursing (DON) reviewed the physician order and stated R91's blood pressure should have been monitored and there should have been an order identifying how frequently blood pressure readings were to be obtained. DON stated staff should have followed up with the physician for clarification regarding blood pressure monitoring expectations related to the PRN metoprolol order.A facility policy regarding monitoring and administration of PRN antihypertensive medications, including blood pressure monitoring expectations and physician order clarification requirements, was requested and was not received.

During interview and record review, the facility failed to ensure all residents were offered and up to date on immunizations for 1 of 5 residents (R29) reviewed for immunizations.Findings include:Information on the CDC website: Pneumococcal Disease link, outlined on the CDC website and dated 2/25/26, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This site identified recommendations for those who had never been vaccinated for pneumococcal disease, as well as those who had started the pneumococcal process. Additionally, the link to Influenza (Flu) site dated 9/18/25, identified everyone six months and older should get a flu vaccine every season with rare exceptions.R29's admission minimum data set (MDS) dated [DATE], included an admission date of 4/29/26, and R29 was identified as being [AGE] years of age. R29's medical diagnoses included coronary artery disease (the narrowing of arteries which decreases blood flow to the heart), hypertension (high blood pressure), and non-Alzheimer's dementia (loss of memory and other intellectual functions, affecting the ability to perform activities of daily living ADL's). R29's electronic medical record (EMR) lacked a review of current immunizations, including those which would have been received prior to admission. This review would have included the current status on pneumococcal immunizations, as well as influenza vaccinations.Additionally, a review was completed to identify if vaccinations had been declined as evidenced by presence of a vaccine consent marked refused. The EMR was lacking any consent for vaccination reviewed with R29 or his responsible party.During interview on 6/3/26 at 2:07 p.m., infection preventionist (IP) stated every resident's immunization status was reviewed by the admission nurse within the first 24 hours following admission. IP stated resident's immunization status was then verified via MIIC (Minnesota Immunization Information Connection-a web-based system to allowing tracking of immunizations given) by IP to assure the vaccine had not been previously given. Once verified, the necessary immunizations were offered. Upon review of R29's immunization tab in the EMR, IP stated R29's immunization status had not been reviewed, and the record lacked a vaccination history, or offering of vaccinations. IP stated this should have been completed at the time of admission.The facility policy, Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, Covid-19, reviewed/revised 11/8/25 identified the purpose of the immunization program was to promote the health and safety of residents/patients, employees, and visitors through protection against vaccine-preventable diseases. The policy identified Skilled nursing facilities (SNFs) are federally required to provide education and offer any influenza, COVID-19, or pneumococcal vaccine a resident is eligible to receive. The process identified resident were to be screened for eligibility and any contraindications to a vaccine following CDC recommendations. The SNF was then to provide the resident and/or their legal medical decision-maker with a vaccine information sheet to educate on the risks and benefits of a vaccine the resident is eligible to receive, and document education provided in the medical record. Once the education was provided, staff were then to obtain consent or declination for the vaccine and document in the medical record. The facility was then to follow up with the provider for orders for vaccination and proceed with vaccination, monitoring, and documentation.

Based on document review and interview, the facility failed to ensure COVID-19 immunization was offered and/or administered in accordance with current standard of practice for 1 of 5 residents (R29) reviewed for immunizations.Findings include:A Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Guidance updated 11/4/25, indicated individuals should receive recommended COVID-19 vaccinations, including booster doses, when eligible, unless medically contraindicated or refused. Long-term care facilities were responsible for assessing vaccination status and ensuring residents were offered recommended vaccines.R29's admission minimum data set (MDS) dated [DATE], included an admission date of 4/29/26, and R29 was identified as being [AGE] years of age. R29's medical diagnoses included coronary artery disease (the narrowing of arteries which decreases blood flow to the heart), hypertension (high blood pressure), and non-Alzheimer's dementia (loss of memory and other intellectual functions, affecting the ability to perform activities of daily living ADL's). R29's electronic medical record (EMR) lacked a review of current immunizations, including those which would have been received prior to admission. This review would have included the current status on Covid-19 vaccinations.Additionally, a review was completed to identify if vaccinations had been declined as evidenced by presence of a vaccine consent marked refused. The EMR lacked any consent for vaccination reviewed with R29 or his responsible party.During interview on 6/3/26 at 2:07 p.m., infection preventionist (IP) stated every resident's immunization status was reviewed by the admission nurse within the first 24 hours following admission. IP stated resident's immunization status was then verified via MIIC (Minnesota Immunization Information Connection-a web-based system to allowing tracking of immunizations given) by IP to assure the vaccine had not been previously given. Once verified, the necessary immunizations were offered. Upon review of R29's immunization tab in the EMR, IP stated R29's immunization status had not been reviewed, and the record lacked a vaccination history, or offering of vaccinations. IP stated this should have been completed at the time of admission.The facility policy, Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, Covid-19, reviewed/revised 11/8/25 identified the purpose of the immunization program was to promote the health and safety of residents/patients, employees, and visitors through protection against vaccine-preventable diseases. The policy identified Skilled nursing facilities (SNFs) are federally required to provide education and offer any influenza, COVID-19, or pneumococcal vaccine a resident is eligible to receive. The process identified resident were to be screened for eligibility and any contraindications to a vaccine following CDC recommendations. The SNF was then to provide the resident and/or their legal medical decision-maker with a vaccine information sheet to educate on the risks and benefits of a vaccine the resident is eligible to receive, and document education provided in the medical record. Once the education was provided, staff were then to obtain consent or declination for the vaccine and document in the medical record. The facility was then to follow up with the provider for orders for vaccination and proceed with vaccination, monitoring, and documentation.

Based on observation, interview, and record review, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was displayed for residents, visitors, and staff to review. This had the potential to affect all 88 residents currently residing in the facility, as well as all staff and visitors.Findings include: On 6/2/26 at 10:13 a.m., it was observed that RBOR poster was displayed in a locked glass case right off the main entrance, near the elevators, which lacked the date of print. A facility combined RBOR was posted next to the entrance of the therapy room, just off the main lobby, which was dated 11/16. On 6/2/26 at 2:15 p.m. the administrator stated she was unaware any changes made to the RBOR form and was unaware of the need to obtain and post the updated version. The facility policy, Posting Information, Social Services-Rehab/Skilled, revised 12/23/25, identified all residents residing in the facility had the right to be aware of a certain location where information concerning it's [the facility] operation, as well as their [the residents] right of appeal and advocacy. The policy indicated it was the responsibility of the location [facility] to keep this information posted in a visible place, accessible to all residents, whether ambulatory or in a wheelchair, and to keep it updated at all times. A listing of the required information to be posted in this location included the Resident's Rights for Skilled Nursing Facilities.

Based on observation, interview, and record review, the facility failed to ensure all recent facility survey results were posted in an accessible location for residents, staff, and visitors. This had the potential to affect all 88 residents residing in the facility as well as staff and visitors.Findings include: On 6/2/26 at 10:13 a.m., a review was completed of the facility survey binder, located on a table on the side wall of the lobby. A review of the binder was completed to ensure all surveys from the last recertification, completed 2/14/25, and subsequent follow up surveys (including complaint investigations and their findings) were available for review. Upon review of the documentation, it was noted that the binder lacked information from the following complaint investigations surveys completed on 12/31/25, 4/2/26, 4/8/26 and 5/15/26.On 6/2/26 at 2:16 p.m. the administrator reviewed the survey binder and acknowledged the above listed survey results were lacking in the binder. Administrator stated the survey results in the binder were to reflect the survey results of the past three years. Administrator stated this was important, so the results were available for residents, visitors, and family members to review if they wished to do so. The facility policy, Posting Information, Social Services-Rehab/Skilled, revised 12/23/25, identified all residents residing in the facility had the right to be aware of certain location information concerning its [facility's] operation, as well as their [the residents] right of appeal and advocacy. The policy indicated it was the responsibility of the location to keep this information posted in a visible place, accessible to all residents, whether ambulatory or in a wheelchair, and to keep it updated at all times. A list of the required information to be posted included the most recent federal or state survey (CMS Form #2567) and, if applicable, plans of correction.

Based on interview, observation, and document review, the facility failed to promote dignity while providing care for 1 of 3 residents (R1) reviewed who required assistance with activities of daily living. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 admitted to the facility on [DATE], was severely cognitively impaired, required staff assistance for transfers, and had diagnoses that included dementia. During an interview on 5/13/26 at 8:32 a.m., R1's family member (FM)-A stated she had a video of staff yelling at R1 when R1 asked for help. The FM-A stated R1 reported being upset after staff yelled at her. The FM-A did not understand why staff would yell at a resident with the diagnosis of dementia. The FM-A stated it was upsetting to see the video and further stated she wanted R1 cared for by people who wanted to help R1. The staff in the video did not seem like they wanted to help. During an interview on 5/13/26 at 4:04 p.m., the nursing assistant (NA)-C stated staff should not call residents grandma or momma because it was not professional, and it was not allowed at the facility. Staff should instead call residents by their preferred name and should treat residents kindly.During an interview on 5/13/26 at 4:17 p.m., the registered nurse (RN)-B stated staff were supposed to be respectful and call resident's by their preferred name, not momma or grandma. During an observation with the administrator and the director of nursing (DON) on 5/14/26 at 11:00 a.m., review of a video from the camera in R1's room dated 4/3/26 at 7:54 p.m., revealed two staff talking to R1. The DON and administrator identified the staff in the video as NA-E and NA-E. NA-E told R1 she was asking for help for no reason, stated R1 was cutting up and it was the last time staff would be in the room. NA-E then addressed R1, grandma. The DON stated staff should treat residents with respect. Also during the observation and review of a video from the camera in R1's room dated 4/3/26 at 8:14 p.m., revealed two staff, the NA-A and the NA-B, transferred R1 with a Stand Aid (device used to assist resident from sitting to standing position and from standing to sitting position). The DON and administrator acknowledged it was NA-A in the video and the NA-A who was standing in front of R1 during the transfer who encouraged R1 to sit. When R1 sat the NA-A stated, There you go momma. During an interview on 5/14/26 at 1:46 p.m., the NA-B stated she had not worked with R1, even though she was identified by the administrator and DON in the video dated 4/3/26 at 8:14 p.m. During an interview on 5/14/26 at 1:48 p.m., the DON stated staff was expected to be respectful towards residents, the preferred name could be added to the care plan. Staff were not allowed to call residents grandma or momma because that was not respectful. The Resident Dignity policy dated 12/18/25 indicated staff would care for residents in a manner that maintained or enhanced each resident's dignity and respect and treat residents with respect and address each resident by their preferred name.

Based on interviews, observation, and document review the facility failed to implement care plan interventions for 1 of 3 residents (R1) when staff transferred R1 with pivot transfers (technique for moving a resident from one position to another. While standing, resident moves their feet to turn toward the new surface) instead of with the Stand Aid (non-motorized device to assist a person to a standing position), as indicated in the care plan. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 admitted to the facility on [DATE], was severely cognitively impaired, required staff assistance for transfers, and had diagnoses that included fractures, dementia and multiple traumas. R1's care plan dated 3/23/26 indicated R1 required assistance of one staff for toileting and transferred with a Stand Aid.During an interview on 5/13/26 at 8:32 a.m., R1's family member (FM)-A stated she was concerned about the way staff transferred R1. R1 was transferred by two people moving R1 instead of the machine [stand aid] staff were supposed to use. FM-A stated she had videos of R1's transfer from the toilet to the wheelchair, and from the wheelchair to the bed, indicating staff did not use the stand aid for transfers. During an interview on 5/13/26 at 3:56 p.m., the nursing assistant (NA)-D stated she did not recall how R1 was supposed to transfer, but staff would refer to the therapy book on the counter of the nurses' station to know how each resident was supposed to transfer. During an interview on 5/13/26 at 4:04 p.m., NA-C stated she was supposed to use the Stand Aid to transfer R1. The NA-C stated she always used the Stand Aid with R1 and did not transfer R1 without it because R1 could fall using a pivot transfer. During an interview on 5/13/26 at 4:44 p.m., the administrator stated R1's care plan indicated R1 required use of the stand aid and staff assistance for transfers.During an interview on 5/13/26 at 4:49 p.m., the registered nurse (RN)-A stated she did not remember R1. The RN-A stated a resident's care plan directed staff in how to transfer a resident safely and it was unsafe to transfer a resident with a pivot transfer instead of a Stand Aid if the therapy department directed staff to use a Stand Aid. During an interview on 5/14/26 at 10:13 a.m., the licensed practical nurse (LPN)-A stated when a resident's care plan indicated transfer with a Stand Aid, staff should transfer with a Stand Aid. R1 required the Stand Aid because she could not bear weight on both legs. During an observation with the physical therapy assistant (PTA)-A on 5/14/26 at 10:40 a.m., upon review of the video footage from the camera in R1's room, dated 4/4/26 at 8:17 p.m., revealed two staff pivot transferred R1 from the toilet to her wheelchair. The two staff did not use the Stand Aid. The PTA-A reviewed a second video dated 4/4/26 at 8:18 p.m., that revealed the same two staff transferred R1 from the wheelchair to R1's bed with a two-person pivot transfer instead of a Stand Aid. During an interview on 5/14/26 at 10:40 a.m., the PTA-A stated R1 was supposed to be transferred with a Stand Aid, and not with a two-person pivot transfer. The transfers on the video footage was not completed according to R1's care plan. Further, the PTA-A stated the therapy department kept a book at the nurses' station which gave direction how each resident was supposed to be transferred. The PTA-A stated R1 was supposed to transfer with the Stand Aid. During an observation with the administrator and clinical director (CD)-A on 5/14/26 at 11:00 a.m., upon review of the video dated 4/4/26 at 8:17 p.m., revealed two staff pivot-transferred R1 from the toilet to her wheelchair instead of using a Stand Aid. The administrator and CD-A reviewed a second video dated 4/4/26 at 8:18 p.m., that revealed the same two staff transferred R1 from the wheelchair to R1's bed with a two-person pivot transfer instead of a Stand Aid. During an interview on 5/14/26 at 11:00 a.m., the CD-A stated he did not see a Stand Aid in the videos. If the care plan indicated staff were supposed to use a Stand Aid, they should have used a Stand Aid for safety to ensure the resident did not fall. During an interview on 5/14/26 at 1:07 p.m., the director of nursing (DON) and administrator identified the staff from the two videos who transferred R1 from the toilet to the wheelchair and the wheelchair to the bed without a Stand Aid as NA-C and NA-D.During an interview on 5/14/26 at 1:34 p.m., the NA-A acknowledged she worked on 4/4/26 and assisted another staff to transfer R1 with a gait belt from the toilet to the wheelchair. The NA-A was aware R1's care plan indicated use the Stand Aid. The NA-A stated the Stand Aid was not used because R1 wanted to transfer with the gait belt instead. The NA-A stated she preferred to transfer residents with a pivot transfer and gait belt instead of using a Stand Aid, but sometimes R1 was able to stand and sometimes could not. R1 was not always able to remember to stand because R1 had dementia. The NA-A stated if the resident did not want to follow the care plan and use the Stand Aid, the NAs could talk to the nurse and use a two-person assist for transfers instead of following the care plan. During an interview on 5/14/26 at 1:49 p.m., NA-B stated she did not remember working with R1. To know how a resident was supposed to transfer, staff referred to the therapy book at the nurses' station or asked another staff who knew the resident. During an interview on 5/14/26 at 1:48 p.m., the DON stated R1 was supposed to transfer with a Stand Aid and one staff per R1's care plan. Therapy staff determined the residents' ability to transfer and put each resident's transfer status in the therapy book at the nurses' station. If a resident did not choose to follow the care plan the NA would ask a nurse for help to educate the resident about the risks and benefits of not following the care plan for safe transfers. When a resident has dementia, staff should attempt to perform the transfer according to the care plan for safety to prevent falls. The Care Plan for Therapy and Rehab policy dated 12/1/25 indicated the care plan used to provide guidance to the interdisciplinary team. The Safe Resident Handling Program (SRHP) policy dated 7/7/25 indicated the SRHP provided interventions to provide caregivers the guidance for type of equipment, type of size of sling, and number of people to safely complete mobility tasks. The Stand Aid was used for residents who demonstrated leg strength for weight-bearing and were able to hold their torso in an upright position and pull themselves to a standing position. The responsibility of the staff was to eliminate manual lifting whenever possible by utilizing equipment and safe lifting practices.

Based on observation, interview, and document review, the facility failed to assess elopement risk, implement interventions, and prevent an elopement for 1 of 3 residents (R1) reviewed for elopement who successfully eloped from the facility. This deficient practice resulted in immediate jeopardy (IJ) to resident health and safety. R1 eloped from the facility on 10/3/21, at 3:40 p.m. and was found by staff on the street near the facility. In addition, the facility failed to complete elopement assessments, and identify and implement interventions for 2 of 3 residents (R2, R3) who had documented exit seeking behavior, wandering, and/or elopement attempts. The IJ began on 10/3/21, when R1 successfully eloped from the facility through an alarmed door after he removed his RoamAlert bracelet (an electronic device used to monitor and alert a resident's location) and went off the facility grounds, and was found on the street near the facility. The facility was initially unaware R1 was gone from the building. R1 was located outside the building by staff, who followed R1 until the police brought R1 back to the facility. The director of nursing (DON) was notified of the IJ on On 10/7/21, at 9:28 a.m. The IJ was removed on 10/8/21, at 2:00 p.m. but non-compliance remained at a lower scope and severity level of D, isolated, no actual harm, with potential for more than minimal harm. Findings include: R1's Face Sheet printed 10/6/21, indicated R1's diagnoses included dementia with behavioral disturbance, psychoactive substance abuse, and depressive episodes. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had a severe cognitive impairment and displayed wandering behavior 1 to 3 days during the review period. The MDS indicated R1's wandering did not put him at significant risk of getting to a potentially dangerous place (stairs, outside of the facility). R1 required supervision for locomotion on the unit, and did not perform locomotion off the unit during the assessment period. R1's Care Area Assessment (CAA) for dementia dated 8/18/21, indicated R1 had displayed wandering behavior one day during the review period. R1 displayed confusion, forgetfulness, and impulsivity. R1's CAA for behaviors dated 8/18/21, indicated R1's behavior status, care rejection, or wandering had worsened since the last assessment. R1 had a RoamAlert in place which may have exacerbated his behaviors. The objective was to minimize risks for R1, and help him to remain safe on the unit. R1's care plan dated 5/11/21, indicated R1 had impaired cognitive function related to his dementia diagnosis. The care plan indicated R1 was impulsive, with lack of insight into safety. The care plan also indicated R1 had a potential for elopement. The care plan updated 8/4/21, indicated R1 had a history of actual elopement and potential for future elopement. Interventions to keep R1 safe included R1 being on the secure unit, a RoamAlert bracelet on R1's left wrist per preference (which R1 had a history of cutting off), and ensuring that exit door alarms were in working order. R1's Behavior Monitoring Task was reviewed for 7/1/21, through 10/6/21 and R1 displayed wandering behaviors on 16 days, and exit seeking behavior on 4 days. On 6/15/21, at 7:31 a.m. a progress note indicated R1 was moved to the secured (locked) unit. On 7/28/21, a physician progress note indicated R1 displayed some anxiety and heightened concern regarding simply being in a facility and wanting to leave. R1 displayed a flat, intense affect and stare, and repeated frequently he wanted to leave the facility. On 7/31/21, at 11:58 p.m. a progress note indicated R1 left the unit when he followed a visitor out. R1 was found in the elevator. R1 was redirected back to the unit. R1 stated, I am going home. I am going home. The note indicated the facility would continue to monitor R1 closely. On 8/1/21, at 2:44 p.m. a progress note indicated R1 tried to force his way off the unit every time someone came in or went out. The note further indicated R1 did get off the unit one time, and was redirected back to the unit without further incident. On 8/1/21, R1's Physician Orders indicated the following order was placed: Wander Guard (device similar to a RoamAlert) to unit for patient safety, attempts to elope from unit. Check every shift for placement and function. On 8/16/21, a physician progress note indicated definite concerns regarding insight, impulsivity, and consequential thinking. Optimal to consider a surrogate decision maker, guardian/conservator. R1's Elopement assessment dated [DATE], indicated R1 was at risk for elopement due to a history of leaving the building and wandering, anger regarding facility placement, elopement attempts in the past, packed belongings, and verbalized statements about leaving. The assessment further indicated staff should check RoamAlert placement and functionality every shift. Elopement education was not provided to R1 or a representative, as R1 had refused education. On 8/30/21, at 8:54 a.m. a progress note indicated R1 had cognitive loss and required a secure unit per physician order. R1 had lack of insight into deficits and felt he could be in his apartment. In the last 90 days R1 had displayed 12 episodes of pacing, four episodes of exit seeking and 12 episodes of wandering. On 9/13/21, at 11:18 a.m. a progress note indicated there was a discussion with the nurse practitioner (NP)-A that R1 had been cutting off the RoamAlert bracelet, and would not keep it on. A new order was received to discontinue the RoamAlert. On 10/3/21, at 4:56 p.m. a progress note indicated at 3:40 p.m. R1 exited the locked unit when a family member entered. The family member did not alert staff R1 had left until about five minutes later. Both registered nurse (RN)-A and RN-B searched the facility and could not find R1. Trained medication assistant (TMA)-A searched the street and found R1 walking on Broadway Avenue and followed R1. R1 became combative, so TMA-A followed R1 to McDonald's then called RN-A and RN-B, who called the police. TMA-A called the facility again when she and R1 were behind Broadway pizza. The facility updated the police on R1's location, and RN-A and RN-B drove to Broadway pizza at 4:40 p.m. and found R1 and TMA-A together. R1 had a pizza in his hand. The police then arrived at which time RN-A, RN-B, and TMA-A drove back to the facility, and a police officer dropped R1 at the facility entrance. R1 was not handed off to the staff, and again left the building towards Broadway. RN-A followed him. RN-B ran to assist, held R1's shirt, took the pizza, and calmly told R1 to follow her back to the facility. RN-A had already called the police who came when they were almost at the facility and walked with RN-A and R1 back to the floor. R1 was assisted to his room, was given his pizza and a coke. The note indicated they would continue to monitor R1's safety. On 10/4/21, Physician Orders indicated the following: Ok to attempt RoamAlert again. Has history of cutting off. Check placement and function every shift. On 10/4/21, at 12:04 p.m. a progress note indicated RN-D and the social worker discussed R1's elopement from yesterday. R1 was educated on the risk for harm when leaving and the need for a RoamAlert bracelet to ensure his safety. R1 had a history of cutting off the bracelet. RN-D spoke with NP-A regarding trying another attempt of the RoamAlert. R1 agreed to RoamAlert bracelet and promised not to remove it. R1's Elopement assessment dated [DATE], indicated R1 was at risk for elopement due to a history of leaving the building, anger regarding facility placement, elopement attempts in the past, elopement successes in the past, packing belongings, removing RoamAlert device, and verbalizing statements about leaving. Elopement education was provided to both to R1 and other resident's family members. On 10/5/21, at 3:43 p.m. a progress note indicated a room search was conducted for sharp objects that could be used to cut off the roam alert. Scissors were removed from R1's room. R1's RoamAlert remained on, and staff assisted R1 to unpack belongings from suitcases and organize his room. On 10/6/21, at 10:47 a.m. R1 was observed to exit his room and walk past the nursing station toward the dining area. Nursing assistant (NA)-A asked R1 what he needed, and redirected him back towards his room. At 10:56 a.m. a large nail clipper was observed on R1's nightstand. On 10/7/21, at 12:52 p.m. R1 was observed to exit his room, entered another resident room, took a remote control, and returned to his own room and closed the door. At 12:54 p.m. four disposable shaving razors were observed on R1's dresser. On 10/6/21, at 10:35 a.m. NA-A was interviewed and stated R1 had a RoamAlert bracelet in place a few months ago, but he cut it off and would refuse to have it put back on. NA-A stated she was unaware what R1 used to cut off the bracelet. NA-A stated R1 was an elopement risk according to his care plan, and he needed to be checked on frequently. NA-A stated there were no formal frequent checks in place for R1, and only one NA on this unit for 16 residents. NA-A stated she checked on R1 hourly or every two hours. On 10/6/21, at 10:56 a.m. R1 was interviewed. R1 stated he had removed his RoamAlert bracelet in the past. R1 stated, I want to live at home. On 10/6/21, at 11:05 a.m. RN-C was interviewed. RN-C stated R1 was an elopement risk, and needed to be on the locked unit. RN-C stated R1 was an opportunist. RN-C stated a RoamAlert bracelet was placed on R1 in August; however, R1 was real tricky and he removed the bracelet. RN-C stated R1 would attempt to take a table knife and cut it off, and had a fingernail clipper hidden in his cell phone at one point. RN-C stated staff tried not to allow R1 access to clippers, and they had tried using plastic cutlery with R1, which was not effective. RN-C verified R1's RoamAlert bracelet was discontinued, because he would not keep it on. RN-C stated there was no formal monitoring in place for R1; however, staff tried to watch him more closely. At 11:13 a.m. RN-C entered R1's room and verified the presence of a nail clipper on R1's nightstand. R1 stated, That should not be here. RN-C stated staff attempted to complete room checks daily for R1, although there were no formal checks in place. On 10/6/21, at 11:18 a.m. RN-D was interviewed and verified the presence of a nail clipper on R1's nightstand. RN-D stated he completed a room search for R1 yesterday, and the nail clipper was not there. RN-D stated R1 had removed his RoamAlert bracelet in the past, and there was potential for R1 to clip the bracelet off with the clippers. RN-D stated R1 was very mobile and pretty resourceful and the RoamAlert removal was discussed with the NP for R1's safety. RN-D was unaware of additional attempted interventions prior to him removing the bracelet on 9/13/21. RN-D stated R1's interventions for R1 included also included being on the secured unit, and routine checks, which all residents receive. On 10/6/21, at 12:05 p.m. registered nurse (RN)-A stated she was the house charge nurse on 10/3/21. RN-A stated RN-B approached her, and asked if she had seen R1, and informed her he was missing. RN-A stated she had not seen R1, and then went to the first floor to search for him. Neither first floor staff nor the receptionist had seen R1. A call then came in from a community member indicating R1 was at Walgreens. The administrator and 911 were notified. About 20 minutes after R1 left the building, TMA-A called from a community member's cell phone and stated she was with R1 at McDonalds. RN-A stated she called the police to update them on R1's location, and then drove to McDonalds to search for R1. RN-A couldn't find R1 and TMA-A, and she returned to the facility. RN-A stated when she returned to the facility, she was informed by the receptionist that another call came in from TMA-A stating she and R1 were now at Broadway Pizza (0.6 miles from facility). The police were again updated on R1's location and found R1 and TMA-A at Broadway Pizza. RN-A returned to the floor she was assisting on. A few minutes later RN-A saw a police car entering the parking lot and walked down to the reception area to receive R1. RN-A stated before she got to the door, the policeman left, and R1 was standing between the inner, secured facility door and the outer unsecured door. As RN-A went to unlock the inner door for R1, a family member entered through the outer door, and R1 again exited the facility. RN-A followed R1 and attempted to redirect him; however, R1 would not comply. RN-A called 911 from her cell phone. RN-B came to assist RN-A, got the pizza from R1, and walked back towards the building, and R1 followed. RN-A stated the police returned, and walked with herself, RN-B, and R1 back into the facility. RN-A stated R1 was escorted back to his room. An additional staff was called in to work on R1's unit that evening and be an extra set of eyes. RN-A stated she believed R1 had a RoamAlert bracelet placed two prior times, but he kept removing it. On 10/6/21, at 12:31 p.m. TMA-A stated she was working on the secured unit when a family member approached her and reported a resident had gotten out about five minutes prior. TMA-A stated she then went down the elevator to look for R1. Without checking in with RN-A or RN-B, or taking her phone, TMA-A went outside and saw R1 right away walking past a bus station up the street from the facility. TMA-A later identified in a facility conducted interview R1 was at a bus stop bench outside of a church which was approximately 1000 feet from the facility. TMA-A stated she approached R1 and attempted to redirect him; however he refused, became agitated, and continued walking. TMA-A followed R1 past Dairy Queen, to McDonalds, where she borrowed a community members phone to contact the facility. R1 then left McDonalds and TMA-A followed, ending up at Broadway Pizza where she again called the facility. R1 was given a pizza, then the police and RN-B came to the pizza place. R1 was taken by the police back to the facility, RN-B and TMA-A drove back to the facility, and TMA-A returned to the secured unit. TMA-A stated she heard that R1 again left the building, but she was not involved at that time as she had returned to her unit. TMA-A indicated she was not aware of any interactions with a community member at Walgreens. On 10/7/21, at 8:31 a.m. the DON was interviewed and stated elopement assessments were completed upon admission, quarterly, with a significant change and prior to placement of a RoamAlert. The DON stated they do not complete elopement assessments after removal of a RoamAlert, and they did not complete a new elopement risk assessment on R1 after the RoamAlert was removed on 9/13/21. The DON stated R1 had not displayed exit seeking behaviors for a long time. On 10/7/21, at 1:15 p.m. the DON was interviewed again. The DON entered R1's room and verified there were four razors on R1's dresser and stated, He shouldn't have those. The DON removed the razors. The DON stated R1 had a history of exit seeking behavior. The DON stated there were no additional attempted interventions prior to R1 removing the RoamAlert bracelet removal on 9/13/21. The DON verified there was a lack of documentation regarding the rational for removal. The DON verified interventions for R1 included placement of the RoamAlert bracelet, the secured unit, and routine checks which all residents receive. The DON stated they did not implement room searches, 15 minute checks, changing to plastic cutlery, nor did they implement any other interventions after the RoamAlert was removed on 9/13/21. The DON verified scissors were in R1's room on 10/5/21, and a nail clipper on 10/6/21, which could be used to remove the RoamAlert bracelet which could result in another possible elopement. The DON stated daily room checks should be put in place for R1. R2 R2's Face Sheet printed 10/7/21, indicated R2's diagnoses included adult failure to thrive, anxiety disorder, post-traumatic stress disorder, Alzheimer's disease, dementia with Lewy bodies. R2's quarterly MDS dated [DATE], indicated R2 had a severe cognitive impairment, and required extensive assistance for locomotion on the unit. The MDS indicated R2 exhibited wandering behavior 4 to 6 days during the review period. R2's CAA for behaviors dated 7/20/21, indicated behavior symptoms included grabbing, screaming, pacing, wandering, and behaviors had worsened since R2's last full assessment. R2's care plan revised 7/14/21, indicated R2 had a history of laying/sitting on the floor and wandering, and should be reviewed as indicated for significant changes in cognition, safety awareness and decision-making capacity. R2's medical record lacked an elopement risk assessment. R2's Behavior Monitoring Task reviewed for 7/1/21, through 10/6/21, indicated R2 had exit seeking behaviors on 7/26/21. On 7/28/21, at 8:23 a.m. a progress note indicated in last 90 days, R2 displayed the following behaviors: 1 exit seeking, and 31 wandering. On 10/6/21, at 10:45 a.m. R2 was observed wandering in the dining area and common area. At 3:26 p.m. R2 wandered in the common area near the nurse's station and in the dining area. R2 spoke to himself and wandered into the kitchenette area near the exit door, then turned around walked to the nursing station. On 10/7/21, at 2:06 p.m. the administrator and DON were interviewed. The DON verified R2 did not have an elopement assessment, and stated the elopement assessment tool was not implemented until about two months ago. The DON stated R2 wandered on the unit but was not exit seeking, had no history of elopement, and was not at risk for elopement. R3 R3's Face Sheet reviewed 10/7/21, indicated R3's diagnosis included anxiety disorder, [CONDITION(S)] disorder, and [CONDITION(S)] (brain disease that alters brain function). R3's significant change MDS dated [DATE], indicated R3 had a moderate cognitive impairment. R3 required supervision for locomotion on the unit, and had exhibited wandering behavior 1 to 3 days during the review period which did not place him at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). R3's care plan dated 7/19/21, indicated R3 had impaired cognitive function or impaired thought processes related [CONDITION(S)] disorder and anxiety exhibited by impaired decision making, and lacks insight into deficits. The care plan updated 8/4/21, indicated R3 had potential for elopement related cognitive loss exhibited by attempts to go to exit door, and cognitive impairment. The interventions for R3's elopement included providing diversionary activity, snacks, and ensure that exit door alarms are in working order. R3's Kardex printed 10/7/21, directed, Ensure that exit door alarms are in working order. R3's elopement assessment dated [DATE], indicated R3 was at risk for elopement, and exhibited anger regarding facility placement, elopement attempts in the past, resisting redirection from staff, and was verbally abusive. R3's Behavior Monitoring Task reviewed for 7/1/21, through 10/6/21, indicated wandering behavior on the following dates 8/17/21, 8/27/21, 9/9/21 and 9/14/21, and exit seeking behaviors on 8/23/21. On 9/9/21, at 3:46 p.m. a progress note indicated R3 attempted to follow a visitor off the unit but was intercepted by staff who redirected R3 back to the dining area. R3 was agitated and yelling/swearing that he was sick off this and wanted out. R3 was to be seen by psychiatry that day. On 9/13/21, at 11:14 a.m. a progress note indicated R3's elopement attempt was discussed with R3's NP. The progress note indicate R3 was easily agitated, had intrusiveness with peers, and had some altercations with other residents. Staff were awaiting recommendations from psychiatry and felt that at this time R3 still required a secure unit. On 10/6/21, at 10:30 a.m. R3 was observed as he sat in his wheelchair in the common area. R3 stated he was much smarter than most residents on this unit, and had attempted to leave in the past as he did not feel he needed to be in a nursing home setting. On 10/7/21, at 2:15 p.m. the DON was interviewed and stated R3 had the potential to elope based on the information in R3's care plan, but was not aware of R3's prior elopement attempts. The DON stated R3 did not utilize a RoamAlert. The DON stated interventions in place for R3 prior to his elopement attempt on 9/9/21, included consulting with R3's NP, being seen by psychiatry, and being on the secured unit. The DON stated there were no additional interventions put in place for R3 after his elopement attempt. The DON stated the facility could possibly have implemented a RoamAlert and frequent checks for R3 after he attempted to elope. The DON verified an elopement assessment was not completed for R3 until 9/30/21, and should have been done within a day of any significant change, including an elopement attempt. The DON stated social services completed elopement assessments quarterly; however, they could be completed by any staff if needed, and she did not know why it was not completed sooner. The facility policy Elopement - Rehab/Skilled dated 8/2/21, directed all residents would be assessed for risk of elopement through the pre-admission and or admission process, and as needed. Each location would be responsible to identify residents at risk, evaluate/analyze hazards and risks, implement interventions, and monitor/modify interventions as needed. The facility would put measures in place to minimize the risk of elopement that were individualized to resident needs and identified on the care plan. The facility document Attention All Visitors to the Arrowhead Dementia Unit undated, directed: 1) Prior to entering or exiting the unit, look around you and through the door window to determine no one is close to the door or following you. 2) Swipe the badge on the square box to the right side of the door. You will hear a loud sound, and a green light will appear above the door 4-5 seconds later. 3) Push the bar on the right hand double door to enter/exit after the green light appears. 4) Wait for the door to close and the red light to reappear above the door before proceeding or leaving the door area. 5) If anyone tries to exit the unit as you enter or exit the unit, immediately notify a staff member. 6) Return your badge to the front desk upon leaving. The facility implemented corrective action on 10/8/21. The facility reassessed R1 for elopement risk and updated interventions (including a RoamAlert bracelet), R1's room was searched for sharp objects and would be searched twice daily, other residents at risk for elopement were reassessed, a plan was made for family members/visitors on the secured unit to be educated prior to their next visit, staff was educated, the Elopement policy was reviewed, and elopement drills were conducted. These interventions were verified though observation, interview and document review.

Based on observation, interview and document review, the facility failed to implement interventions to prevent the development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.), for 2 of 3 residents (R55, R181) who had been identified as at risk for pressure ulcers. Lack of timely responsive care resulted in actual harm for R55 who had identified pressure ulcer on the heel. In addition, the facility failed to assess wounds to include: stage, size, characteristics of the wound bed, surrounding tissue, or progress toward healing for 1 of 3 residents (R200). Findings include: R55 was observed during morning cares done by two nursing assistants (NAs)-B and NA-C on [DATE], at 9:40 a.m. The NAs entered R55's room to turn and reposition the resident. NA-B explained they were going to lower the bed. The bed was lowered and both NA gloved after washing their hands in R55's bathroom. NA-B next removed pillows from between R55's legs. The right ankle had a loose dressing over a closed area which was pea size. R55 had heel protectors on over skid socks. The two NAs worked together in turning resident using draw sheet from left to right side. The back dressing was checked, dry and intact, dated [DATE]. The left hip area was reddened over the bony prominence which the resident had been laying on (from 7:30 a.m. till 9:40 a.m. A pillow was positioned between the resident's legs, heels were not floating but resting on the pillow. The NAs did not float the resident's heels off a pillow which was in the resident's care plan. RN-C came into resident's room with a rolling computer on [DATE], at 9:53 a.m. RN-C explained to R55 that she was going to check the resident's back dressing first. The admission Minimum Data Set ((MDS) dated [DATE], indicated R55 had no open areas. The Care Area Assessment (CAA) indicated R55 was at risk for developing pressure ulcers related to [MEDICAL CONDITION], pain, weakness, and deconditioning. R55 had impaired mobility and balance and needed assistance with transfers and ambulation. The CAA also indicated R55 was receiving hospice services for additional care during the end of life process. R55 required extensive assist with bed mobility and incontinent care. R55 was on antipsychotics and antidepressants. In addition, R55 had [DIAGNOSES REDACTED]. R55 had a suprapubic catheter and was recently admitted to the facility for inpatient care and hospice care. On [DATE], summary of the hospice visit indicated there was a small red open area mid spine. The hospitc visit notes indicated the nurse had come in and put a Mediplex dressing on it, and would leave a message for case manager (CM), there were no documented measurements. In addition, the notes indicated that on [DATE], there was a new open area on right ankle (no measurements). A Progress Note dated [DATE], indicated the following: R55 had a mid-back open area 1 cm round, open but scabbed over. Covered with Mediplex, had a reddened coccyx with one open area but scabbed over 2 centimeters (cm) length X .5 cm width, had a right lateral ankle bone .5 cm circle open, covered with Band-Aid, scabbed over, and had a new left heel mushy, non-blanching, dark colored area approximately 0.3 cm around non opened. [MEDICATION NAME] and heel protectors applied. On [DATE], a hospice note indicated dressing change times for four areas on R55's back and the heel. R55 had a Progress Note dated [DATE], entered as a Late Entry which documented the following: Dressing changes to all open or suspicious areas of skin on [DATE]. Areas of concern were 1.) 2.2 cm open area on mid back; appears to be larger, dark open are. Cleansed, [MEDICATION NAME] applied. 2.) 2 cm x .5 cm open area on coccyx. Cleansed, Mediplex applied. 3.) Area to lateral right ankle bone healed. 4.) 2 cm unopened, non blanchable, dark circular area on right heel. Foam island dressing and sheepskin heel protectors on. The note the facility would continue to monitor. R55's care plan revised on [DATE], indicated the resident had limited physical mobility related to terminal illness (cancer) evidenced by weakness, deconditioning, pain, impaired mobility and balance. Required staff assistance with mobility by placing equipment nearby and providing weight bearing support. The plan of care did not include interventions for treatment of [REDACTED]. The plan of care did not indicate the resident refused cares. The NA Kardex sheet undated, indicated the following: R55 was at high risk for skin injury, use extra caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, keep skin clean and dry, use lotion on dry skin, do not apply on site of injury, and resident needs protection for the feet i.e. sheepskin boots, float heels. The Kardex did not indicate the resident refused to have the heels floated. During an interview with RN-C on [DATE], at 7:14 a.m., R55 was on hospice care for malignant neoplasm of prostate and secondary malignant neoplasm of bone. R55 was admitted to the facility for palliative care on [DATE]. R55's pain medications were adjusted one week ago by hospice. R55 did not verbalize any longer. R55 had a dressing to an open wound on his mid back over a kyphotic area, one dressing on the coccyx, and on the right heel which was dark in color. R55's dressings were changed on [DATE], and there was an order for [REDACTED]. LPN-A was interviewed on [DATE], at 2:02 p.m. and indicated R55 was more alert that week than last week. When asked about floating the resident's heels, LPN-A stated the resident did not want his feet to float and that the resident liked to sit in the recliner a lot. The NP-A was interviewed on [DATE], at 2:50 p.m. and indicated she had seen R55 for increased pain so she did know the resident. The NP-A was asked if the open areas were avoidable or non-avoidable and the NP indicated the resident started to decline on or about [DATE], due to poor nutrition, increased pain, and increased skin breakdown. The NP-A verified that R55 was admitted to the facility with no open areas. The facility's policy on Skin Assessment, Pressure Ulcers, Prevention and Documentation requirements was revised on ,[DATE]. The purpose of this policy were the following: to systematically assess residents with regard to risk of skin breakdown, to accurately document observations and assessments of residents, and to appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. When a pressure ulcer is present, daily monitoring (with accompanying documentation when complication or change is identified) should include the following: - An evaluation of the ulcer, if no dressing is present - An evaluation of the status of the dressing; if present (whether it is intact and whether draining, if present, is or is not leaking) - The status of the area surrounding the ulcer (that can be observed without removing the dressing) - The presence of possible complications, such as signs of increasing area of ulceration of soft tissue infection(for example, increased redness or swelling around the wound or increased drainage from the wound). The pressure ulcer should be assessed/evaluated at least weekly and documented on the Wound RN Assessment sheet. If the resident is on Medicare, document daily on the Wound Data Collection sheet with every treatment change. Observations of the ulcer's characteristics may be documented by a licensed nurse and should include at least the following: Measurements - length, width, depth; Characteristics of ulcer - including wound bed, undermining and tunneling, exudate, surrounding skin, etc.; Presence of pain; and Current treatments. Progress toward healing and any modifications to the plan of care/treatments should be assessed and evaluated by the registered nurse. The facility failed to implement interventions to prevent the potential development of pressure ulcers or worsening of the right ankle ulcer for R55. R181's significant change MDS dated [DATE], indicated R181 was cognitively intact and had not rejected cares during previous seven days. R181 required extensive assistance of one staff for bed mobility, transfers and toileting and identified R181 was continent of bowel and bladder. R181's MDS indicated R181 did not have any pressure ulcers but was at risk for developing pressure ulcers. R181's MDS indicated R181 had [DIAGNOSES REDACTED]. R181's MDS indicated R181 was on hospice. Progress Note dated [DATE], indicated staff, .found a stage II pressure ulcer (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) on the left side of resident's coccyx. Area was cleansed and [MEDICATION NAME] dressing was applied to keep area clean and protected. Writer hss (sic) placed call to Total Care for seniors to report new open area and need for tx (treatment), voicemail was left and nursing is awaiting return call at this time. The Care Area Assessment (CAA) dated [DATE], indicated R181 was at risk for pressure ulcers related to [DIAGNOSES REDACTED] shortness of breath, weakness, impaired mobility, and need for staff assistance with bed mobility due to declining health condition. CAA indicated R181 did not have a pressure ulcer. CAA indicated staff would proceed to care planning with goal to avoid complications and minimize risks of pressure ulcers. A Progress Note dated [DATE], at 12:42 p.m. indicated, Writer also needs to update on new open area on coccyx. At this time there are a total of four open areas that are 0.25 x 0.25mm (millimeter) in size. Areas are free of s/sx (signs/symptoms) of infection. Writer has cleaned areas and applied [MEDICATION NAME] dressing to area to cover and keep clean. Resident is resistant to repositioning and will turn herself onto her back when in bed and frequently does not wish to get out of bed. Writer has notified RD (registered dietician) of open areas. Writer will request and air mattress for resident. Awaiting return call at this time. A Progress Note dated [DATE], at 1:50 p.m. indicated new orders received from hospice for an air mattress, heel protectors, reposition every one hour and the addition of barrier cream to open areas with dressing changes. The facility care plan printed [DATE], was reviewed for period of time from R181's admission on [DATE], until R181's death on [DATE]. The care plan did not include identification of pressure ulcer risk or development of four stage II pressure ulcers. The care plan lacked any interventions to prevent or treat pressure ulcers. During interview on [DATE], at 3:10 p.m. registered nurse (RN)-B verified a stage II pressure ulcer was first documented on [DATE], and that on [DATE], three new stage II pressure ulcers were identified. RN-B verified there was no pressure ulcer care plan developed upon admission or when the staff identified the pressure ulcers on [DATE], or [DATE]. RN-B stated an initial care plan would have been opened by the admissions nurse within 24 hours of admission. RN-B said the floor nurses were to update the care plan when they found open areas or risks on the Transitional Care unit. RN-B stated Hospice would typically do a paper care plan and then the facility would scan it into the chart. When asked what is part of the care plan? RN-B said, The electronic care plan is the only care plan. RN-B said, I would expect a Wound Data tool to be completed to at least get the assessment done. During interview on [DATE], at 3:35 p.m. director of nurses (DON) said, I would expect wound assessment to be completed for a patient with a pressure ulcer. I would expect the daily skill notes to reflect wound until healed. DON said, If a patient is identified at risk for pressure ulcers would expect a care plan to be developed for prevention. I would expect there to be a care plan for a pressure ulcer. The care plan is the electronic one in PCC (an electronic health care record-PointClick Care). When asked if the care plan includes any other sections of the chart DON said, No just the care plan section. If they are on hospice I would expect an assessment and care plan. It gets harder to heal wounds if they are on hospice. I would expect the care plan to say pressure ulcers are present but not necessarily to indicate goal is to heal the pressure ulcers. The goal is individualized. During interview on [DATE], at 8:51 a.m. RN-C said, I found the pressure ulcer on [DATE]. It was a stage II. She was not eating. RN-C said, It had started out as a reddened bottom because she would not get out of bed. Then she developed four very small open areas. There were two on either side of her coccyx. They were very small. As she got closer to death we did not expect the wounds to heal. I know we encouraged her to get out of bed and to eat but she would not. RN-C said, I did not think to write the care plan, I was more focused on taking care of her. RN-C verified there should have been a care plan. RN-C said, The wounds were pressure ulcers, they were over bony prominences. RN-C verified writing the progress notes but said, I did not do a wound sheet. During interview on [DATE], at 11:23 a.m. the DON said, All of our mattress are pressure reducing and it will not be on the care plan. If someone is at risk for pressure ulcers we do a skin care plan. Requested DON to find any documentation of interventions to prevent pressure ulcers prior to R181's development of pressure ulcers During interview on [DATE], at 11:54 a.m. the medical director stated physician orders [REDACTED]. The medical director said, I do wound rounds on a monthly basis and am there weekly. It is unusual for me to be asked to look at pressure ulcers, because we do a good job preventing pressure ulcers. R181 was admitted to the facility without pressure ulcers but was identified as at risk for development of pressure ulcers. An individualized plan of care with interventions for prevention was not developed. The first pressure ulcer was identified on [DATE], but interventions for the prevention of pressure ulcers worsening or prevention of additional pressure ulcers were not implemented until [DATE], after the development of three additional ulcers. R200's admission MDS dated [DATE], indicated he required extensive assistance of two staff for bed mobility, transfers and toileting and identified R200 was frequently incontinent of bowel and bladder. A CAA dated [DATE], indicated R200 was at risk for pressure ulcers related to dependence on staff for mobility, weakness and frequent incontinence. The CAA did not identify a current pressure ulcer. R200's care plan identified limited physical mobility and an activity of daily living (ADL) self-care deficit and frequent loose stooling and a need for staff assistance. R200's care plan did not address skin condition. A Nursing Admit/ Re-admit Data Collection dated [DATE], identified a red coccyx, but did not include a measurement or an indication if the area was blanchable. The data collection tool further indicated R200 had one of the following: pressure ulcer, venous ulcer, surgical wound, arterial ulcer, diabetic ulcer, surgical wound or suspected deep tissue injury, but did not identify which wound R200 had. A review of R200's Good Samaritan Society Specialty Care treatment record dated [DATE] identified the following treatments initiated on [DATE]: Cleanse coccyx, pat dry and cover with Mepiles (sic) [MEDICATION NAME] dressing (an absorbent dressing) daily in the morning for stage I skin breakdown prevention, Cleanse open area on spine with normal saline, pat dry and apply [MEDICATION NAME] dressing daily. A review of R200's Good Samaritan Society Specially Care Community Progress Notes dated [DATE] through [DATE], identified the following: [DATE] - Resident continued to receive skilled nursing care for management of fragile skin on coccyx and open area on spine. [DATE] - wounds (two) are covered with [MEDICATION NAME] and dressing intact. [DATE] - dressing change to coccyx and mid back. [DATE] - wounds clean, dry and intact with no signs of infection. [DATE] - wounds on mid-back and coccyx clean, dry and intact [DATE] - wound on coccyx is covered with [MEDICATION NAME] and intact. A physician visit Progress Note dated [DATE], indicated R200 had a pressure ulcer along the mid spine. A Nursing Admit/Re-admit Data Collection dated [DATE], indicated R200 had a the following wounds: Sacrum; closed wound 0.5 cm x .75 cm, open to air and Other; mid back closed wound 0.25 cm x 0.5 cm, open to air. During an interview on [DATE], at 1:37 p.m., RN-E stated residents receive a weekly skin check each week on their bath day. She stated if there was a skin concern, it would show up in an assessment on the electronic record. During an interview on [DATE], at 10:33 a.m., RN-B stated she had never seen R200's wounds. She stated when a nurse finds a wound, the nurse should initiate the wound observation tool which would trigger an RN assessment. She stated the nurses should also be completing a skin check each week on bath day. At 11:36 a.m., RN-B stated she was unable to locate any wound assessments for R200 and stated, We have a process, but it was not followed. She further stated the nurses should have informed her of his skin condition because she was responsible for coding the MDS. The DON stated resident's skin condition should be documented at least weekly. She stated if a pressure ulcer was present on admit she would expect the staff to follow up on it and expect a care plan to be developed. While R200 had two separate pressure ulcers, there was no evidence the facility assessed the wounds to include: stage, size, characteristics of the wound bed, surrounding tissue, or progress toward healing, nor was there evidence the facility implemented interventions to prevent worsening of existing ulcers or prevention of new ones.

Based on observation, interview and document review, the facility failed to provide care and services including assessment and range of motion (ROM) for 1 of 3 residents (R73) reviewed for activities of daily living (ADLs) and contractures. As a result of these failures, R73 experienced atual harm, a decline in ROM of the left upper extremity, Findings include: R73 was admitted to the facility on [DATE], and experienced a [MEDICAL CONDITION] (stroke) affecting the left side in October 2010, per the Admission Record. The facility failed to conduct assessment and provide ROM services to R73 to maintain functional ROM and prevent a decline in ROM. As a result R73 developed left upper extremity contractures (including shoulder, elbow, wrist and fingers). During interview on 2/9/16, at 7:25 p.m. registered nurse (RN)-F stated R73 had a contracture to his left hand, left side [MEDICAL CONDITION] (weakness of the entire left or right side of the body) due to a previous stroke, and that the resident did not use any splints or receive any restorative ROM. On 2/9/16, at 4:49 p.m. R73 was observed sitting in a wheelchair in the common area at a table across from his room. R73's left arm was observed to rest firmly against his body with the left hand against his chest, wrist bent at approximately a 90 degree angle at the forearm, and three fingers on the left hand held firmly in a closed fist position. When requested at that time, R73 was unable to open his clenched left hand. There was no splint or rolled wash cloth in place in R73's left hand. On 2/10/16, at 3:08 p.m. R73 was observed to be in bed. R73's left arm rested against his chest with the elbow bent at an angle, and three fingers on the left hand were tightly clenched into a closed fist. There was no splint or rolled wash cloth in place in the R73's left hand. R73 was observed during morning cares on 2/11/16, at 7:03 a.m. Nursing assistant (NA)-B was observed to attempt to pull R73's left arm away from his body enough so as to wash the resident's armpit. In addition, NA-B attempted unsuccessfully to put two different shirts on R73 before stopping cares to go get help. At approximately 7:15 a.m., NA-B and NA-D unsuccessfully attempted to put a shirt on R73 while he remained in bed. R73 fidgeted, grimaced, moaned and yelled ouch approximately six to eight times during cares especially when staff attempted to manipulate or move R73's left arm. Neither NA-B or NA-D attempted to provide any ROM services to R73 during morning cares. During interview on 2/11/16, at 7:12 a.m. NA-B confirmed R73 was very stiff and it was difficult to lift his left arm to wash his armpits, and to get him dressed. NA-B stated whenever she assisted with R73's cares, R73 always moaned and groaned during cares. On 2/11/16, at 9:40 a.m. LPN-C stated R73 had a ROM program, and the care plan directed staff to provide gentle ROM to upper and lower extremities as tolerated with morning and bedtime cares. LPN-C further explained the NAs were responsible for the completion of ROM, and the nurses were responsible to ensuring overall completion of all cares. LPN-C acknowledged she did not know how long R73's contractures had been present. At 10:23 a.m. on 2/11/16, R73 was observed sitting in a wheelchair in the common area at a table across from his room. A licensed practical nurse (LPN)-C unsuccessfully attempted to extend the fingers on R73's left hand to check the nail length and the condition of R73's palm. R73 moaned and yelled ouch when LPN-C attempted to extend his fingers. There was no splint or rolled wash cloth in place in the R73's left hand. During additional interview with NA-B on 2/11/16 at 12:05 p.m., NA-B stated R73 did not receive any ROM services because ROM was not indicated in the Kardex/NA assignment sheet as an intervention. During interview on 2/12/16, at 8:47 a.m. LPN-C stated the nurses were responsible for ensuring R73 had a rolled wash cloth placed in the palm of his left hand. LPN-C verified R73 had not had a wash cloth placed in the palm of his hand on 2/10/16 or 2/11/16. However when R73's treatment administration record (TAR) was reviewed at that time, it indicated LPN-C had documented the rolled wash cloth to the palm of R73's hand had been in place. LPN-C stated she had no explanation for the discrepancy. R73 was observed to receive assistance with morning cares from NA-C on 2/12/16, at 9:05 a.m. R73 fidgeted and moaned whenever NA-C manipulated R73's left upper extremity to wash him, or to get him dressed. NA-C did not provide any ROM services to R73 during morning cares. During interview on 2/12/16, at 11:00 a.m. the physical therapist (PT) stated she had just completed a ROM assessment for R73's upper left extremity. The PT confirmed R73 had contractures to the left upper extremity affecting the joints in the shoulder, elbow, wrist, hand and fingers. The PT further stated provision of ROM services, use of splint devices and/or use of a rolled wash cloth to the palm, would usually helped prevent further decline in contractures. During interview on 2/12/16, at 11:14 a.m. NA-C stated she had worked with R73 regularly for years. NA-C said R73 was very contracted on the left arm which made cares and dressing difficult, and stated R73 did not receive any special treatment for [REDACTED]. NA-C verified the Kardex did not direct staff to provide ROM services for R73. NA-C further stated she had never provided ROM services for R73. An interdisciplinary progress note dated 11/10/11, identified the first documentation related to R73's contracture. The note indicated R73 had weakness to his left hand which looked contracted, and that hospice had been notified and would bring in a splint for R73 to use. A significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R73 had been discharged from hospice on 12/2/10, and was totally dependent on staff for personal hygiene, toileting, bathing, needed extensive assist with bed mobility, transfers and eating. The assessment further noted R73 utilized a splint to his left wrist because it was weaker secondary to his stroke. The record lacked evidence of any assessment related to the noted contracture on the left hand and wrist. R73's care plan dated 1/5/16, indicated the resident had limited physical mobility related to a stroke with [MEDICAL CONDITION] (paralysis of one side of the body). The goal indicated R73 was to remain free of complications related to immobility, including contractures. Care plan interventions indicated nursing staff were to Provide gentle range of motion as tolerated to (L) (left) upper and lower extremities with a.m, (morning) and hs (bedtime) cares. R73's annual and quarterly MDSs from 10/20/10 to 10/18/12, indicated R73 had no functional limitation in ROM. However subsequent annual and quarterly MDSs, from 10/18/12 to 12/17/15, inconsistently identified R73 either had functional limitation in ROM on one side, or had no functional limitation in ROM. The annual MDS dated [DATE], and quarterly MDSs from 9/23/15 and 12/17/15, identified R73 had [DIAGNOSES REDACTED]. Each of these MDSs indicated R73 was totally dependent on two staff with transfers and bed mobility, and had an impairment in ROM to one side, on the upper and lower extremity. The Care Area Assessments (CAA) for the annual MDS related to impaired ROM did not trigger for completion. A medical progress note dated 2/9/16, titled Communication/Visit with Physician, indicated a discussion had occurred with the nurse practitioner regarding a decline to a contracture on R73's left arm which had gotten slightly worse, and identified a goal to ensure comfort for R73. However, review of prior progress notes, including Geriatric Services of Minnesota Progress Notes (the progress notes from R73's primary physician and nurse practitioner), dated 6/16/15, 8/10/15, 8/11/15, 8/12/15, 10/11/15 and 2/9/15 failed to identify any medical assessment or discussion about R73's contractures. On 2/12/16, at 11:43 a.m. during a joint interview with RN-D and RN-F, they verified R73 had been admitted to the facility in May 2010 and had experienced a stroke in October 2010. They stated R73 had developed the contractures after the stroke. Neither RN-D or RN-F were able to state when the staff had first identified R73's contractures. RN-D reviewed the Kardex and verified the ROM program had not been included as care the NAs were to provide. RN-D acknowledged that was likely why R73 had not been receiving any ROM. RN-D reviewed R73's care plan and stated ROM services for R73 had first been identified on the care plan on 10/30/12, but that a K had not been checked next to the care intervention, therefore the ROM services had not transfered to the Kardex/NA assignment sheet as an intervention for the NAs to complete. RN-D and RN-F further explained they completed functional ROM assessments at the time of quarterly and annual MDSs. They said they were then responsible to update the care plan and ensure the interventions were included on the Kardex. However, both acknowledged they had not verified whether the ROM services for R73 had been included in the Kardex for NAs to complete. RN-D acknowledged R73's decline in functional ROM had occurred while he'd resided in the facility. During interview on 2/12/16, at 12:06 p.m. the facility's director of nursing (DON) stated staff were expected to follow each resident's care plan and the nurse managers were to make sure that all appropriate cares were included on the Kardex/NA assignment sheets. The DON also stated the facility should do everything possible to prevent further decline for any resident who has contractures. The DON was unable to state when the facility staff had first identified R73's contractures. The DON acknowledged R73's decline in functional ROM could have been related to lack of assessments and failure to provide care such as rolled wash cloth and ROM services. An effort was made to call R73's primary physician on 2/16/16, at 3:00 p.m. Although a message was left for the physician, no return call was received. Assessments completed since R73's contractures and were first identified by the facility staff were requested but none were provided. The facility's RANGE OF MOTION Policy dated 9/12, indicated that based on the resident's comprehensive assessment, the facility will ensure that a resident entering the facility without a limited range of motion will not experience reduction of motion unless resident's clinical condition demonstrates that a reduction in range of motion is unavoidable. In addition, the facility will ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion as much as possible and to prevent further decrease in range of motion.