Every finding on record at Highland Chateau Health and Rehabilitation Center

Based on observation, interview, and document review, the facility failed to ensure the walk-in cooler remained functional and in good repair which had the potential to affect all 44 residents who received perishable food from the kitchen. In addition, the facility failed to maintain safe working air temperatures in the kitchen which had the potential to affect 2 of 2 shifts daily/ 6 of 6 staff members working per day.Findings Include: On 6/10/26 at 4:30 p.m., cook-A was observed reading the temperature inside the walk-in cooler in the main kitchen. The thermometer read at 50 F. Cook-A stated the walk-in cooler was currently broken down and had periodically broken down, particularly during the last few weeks which has caused the temperatures to be too high. During interview and observation on 6/11/26, at 2:30 p.m., the Food Service Director (FSD) stated when the staff arrived on 6/10/26, at 5:55 a.m., the power was found to be out. The walk-in cooler temperature was already too warm to maintain safe food temperatures. An action plan was implemented which included throwing away all perishable foods not maintained at a safe and appropriate temperature, and alternate meals were planned. The walk-in cooler temperature was 46 degrees Fahrenheit (F.) and was noted to have a missing/broken gasket around the door, as well as a large 1/4 to 1/2 inch deep and 5-inch-wide gap between the kitchen and the cooler floor. A large towel was inserted into the gap so that food carts could be pushed across the threshold. The reach-in freezer was noted to be off and the FSD stated the freezer had not worked for about a week. FSD stated she had talked to the administrator, who had approved replacing this freezer unit with a reach in cooler, but she was unsure when the new reach in cooler unit would arrive, or if that meant it had been ordered yet, or not. The FSD stated the walk-in cooler was always breaking down, so the maintenance company was frequently at the facility to defrost it and add coolant to get it working again. When asked, the FSD stated the kitchen runs two shifts per day with each including one cook and two dietary aides.During an observation on 6/11/26, at 4:00 p.m., the walk-in cooler was again inspected. The rubber gasket around the door was ripped in several places with several missing sections and hanging loosely from the door as well as from the door frame. The towel covering the kitchen and cooler transition piece was removed and revealed a rusty, dirty area.During interview with the refrigerator repair technician on 6/10/26, at 12:30 p.m., he stated he was able to do a temporary fix on the walk-in cooler. However, it was not a long-term solution to the ongoing issues. During interview on 6/11/26 at 4:30 p.m., the FSD reported this was week three of a three-week of excessively hot weather temperatures. The FSD stated yesterday, 6/10/26, the kitchen temperature was 119 degrees F. The staff were intermittently leaving the kitchen area to cool off and maintenance staff had been making rounds in the kitchen to monitor the temperatures and get the equipment functional again. Due to the power outage, the menu was changed to a BBQ meal cooked on a grill which will also allow for the kitchen air temperature to cool down. The power came back on in the kitchen around 11 a.m. at which time the maintenance staff provided additional fans and portable AC unit. During interview on 6/12/26 at 1:00 p.m., the FSD stated the walk-in cooler had been repaired, frozen coils were defrosted, and refrigerant was added. A Custom Refrigeration invoice dated 2/16/26, (pdf 81213) indicated the company was called out due to the walk-in cooler running in the mid 50's. A slight leak in the evaporator fan area was noted. Refrigerant was added. A Custom Refrigeration invoice dated 6/1/26, (pdf 825975) indicated the unit had been worked on the previous week. However, an invoice for this visit was not provided. The invoice revealed the evaporator unit was iced over, the floor drain was clogged, the door gasket was severely torn, and the door sweep was almost nonexistent creating a huge air gap causing the unit to have to run longer to maintain adequate temperature. Given the temperature was noted to be dropping, and the condition of the equipment, the unit was doing everything it could to maintain temperature. A Custom Refrigeration invoice (pdf 83274) dated 6/12/26, identified ice-up issues including the fan motor, and the door seal is in really rough shape. The undated facility Standard Operating Procedure (SOP): Walk-in Cooler Failure Response form directed the staff to notify maintenance of malfunction so the approved refrigeration company could be contacted for immediate emergency service and to also alert management of the issue. The AC Outage Incident Report-Table Top Exercise (true event) indicated on 6/27/26, indicated a power outage of the AC/Chiller system had occurred which affected indoor ventilation and temperature. The report did not address an action plan for staff, specifically kitchen staff.

Based on observation, interview and document review, the facility failed to maintain comfortable temperatures for 4 of 10 residents reviewed (R2, R4, R5 and R6), which had to potential to affect all 44 residents who resided in the facility. Findings include:R5's Minimum Data Set (MDS) dated [DATE], indicated he was cognitively intact, required staff assistance for dressing and mobility tasks, required oxygen therapy and a non-invasive mechanical ventilator. R5's care plan last revised 6/9/26, indicated R5's diagnoses included acute respiratory failure with hypoxia (insufficient oxygen for the body to function properly), moderate persistent asthma, and sleep apnea.During observation and interview on 6/11/26 at 3:00 p.m., R5 was observed sitting in the dining room with portable oxygen in use via nasal cannula. R5 was wearing a t-shirt, shorts, and socks. R5 stated in the past month, the facility had been very hot, so much so, that he had an increase in shortness of breath with the feeling of gasping for air. R5 stated the facility utilized portable fans and air conditioners but they did not help that much. R6's MDS dated [DATE], noted R6 was cognitively intact and was independent with mobility tasks. R6's care plan last revised 5/14/26, indicated R6 had diagnoses of chronic obstructive pulmonary disease (COPD) and anxiety.During interview and observation on 6/12/26 at 1:18 p.m., R6 was observed sitting in their room with a standing fan on. A portable fan and air conditioning unit was located outside R6's room and were on. When it was on, the fan made a constant noise which was heard in R6's room when the door was open. R6's room had a private connected bathroom. R6 stated it had been very hot since the last day of May 2026 and he would ask his personal smart sensors, positioned on his windowsill, what the temperature was. The sensor responded with a temperature ranging between 85F and 113F. R6 reported the previous weekend was especially brutal because it was so hot in here that he felt as if he was breathing through cotton and would profusely sweat when just walking from his bed to the bathroom. R6 reported the excessive heat made him irritable and cranky. R6 said his standing fan helped some, but not enough, and noted it didn't always stand up straight, pointing to one of the four fan legs missing. R6 stated his room was near the portable air conditioner and fan and sometimes he would open his door for increased airflow. However, the fans created a lot of noise, so he had to choose between adequate airflow or quiet and privacy. R6 reported the fans and portable air conditioners did not help cool his room and unit much when it was very hot. R4's MDS dated [DATE], indicated R4 was cognitively intact and was dependent for upper and lower body dressing.During observation and interview on 6/11/26 at 3:07p.m., R4 was observed in R4's room wearing a long sleeve shirt and an incontinence brief. R1 reported it was not hot today but had been the last couple of days. R2's MDS dated [DATE], indicated R2 had intact cognition, was independent with activities of daily living, and diagnoses included COPD, cellulitis, diabetes, and neuropathy.During interview on 6/12/26, at 11:30 a.m., R2 stated that although today was comfortable in the building, as soon as it heats up outside again, it will get uncomfortable in here. R2 stated the beginning of this week and last it was pretty uncomfortable in the building. An undated AC Outage Incident Report - Tabletop Exercise (true event) for Wednesday May 27th, 2026, was emailed by the administrator on 6/15/26. Review of the incident report revealed, At approximately 11:05am on Wednesday, May 27th, 2026, the facility experienced an outage of the AC/chiller system, affecting indoor ventilation and temperature. Vendor contacted regarding repair status and estimated restoration time - communicated temporary industrial sized AC Units could be delivered 5/30/26, and noted lead time for new chiller would be 10-12 weeks out. COO met with vendor to place portable AC units throughout the facility on Saturday, 5/30/26. Monday, 6/1/26, multiple vendors began arriving at facility to give quotes on chiller or other options to resolve system failure. 20 additional portable AC units to be delivered 6/16/26. Vendor finalized agreement with HVAC for new chiller to arrive around 6/30/26According to the National Weather Service's website, for the Twin Cities in Minnesota, the high temperature on June 7, June 8, and June 9, 2026, was 89 degrees Fahrenheit (F), and Jun10, 2026, was 91 degrees F, all with high humidity; and June 11, 2026, was 73F; and June 12, 2026, was 82F. Review of the facility's Room Temperature Audit forms for 6/3/26, through 6/12/26, indicated temperatures were measured and recorded between 7:00 a.m. and 7:30 a.m. The audits revealed the following resident room and care area temperatures: 6/3/26:-room [ROOM NUMBER]E was 82F,-room [ROOM NUMBER]W was 82.1F-the beauty salon was 83.7F. 6/4/26:-room [ROOM NUMBER]E was 82.6F,-an illegible room number was 82.1F. 6/5/26:-room [ROOM NUMBER]E was 83.F. 6/9/26:-room [ROOM NUMBER]E was 83.1F-room [ROOM NUMBER]E was 81.7F-room [ROOM NUMBER]E was 81.3F-2C shower was 84.2F,-room [ROOM NUMBER]E was 82.1F-room [ROOM NUMBER]W was 85.1F.-room [ROOM NUMBER]E was 81.7F,-room [ROOM NUMBER]E was 82.1-room [ROOM NUMBER]W was 85.1F. There were no temperature audit logs for 6/6/26 and 6/7/26. During interview on 6/11/26, at 2:30 p.m. the Food Service Director (FSD) stated on 6/10/26, when staff arrived around 5:55 a.m. yesterday morning, the power was out. The outage affected kitchen equipment and the fans and portable AC units. The FSD stated the power was restored by 11 a.m. Yesterday, the temperature in the kitchen was 119 degrees F. and when the power returned, an additional portable AC unit was brought in to assist with cooling the kitchen. The FSD verified the weather had been very hot the past three weeks. During observation on 6/11/26 at 2:22 p.m., the temperature in the first-floor dining area was 82 degrees F. First floor [NAME] was 84 degrees F. The front portion of the kitchen was 79 degrees F. During observation on 6/11/26 at 3:00 p.m., the temperature in the back of kitchen was 78 degrees F. During interview on 6/11/26 at 2:40 p.m., health unit coordinator (HUC)-A stated the residents were complaining of how hot it was the previous few days. There were portable air conditioning units in the hallway that helped somewhat, but also created some heat of their own, along with residents having windows open letting heat in. HUC-A stated the residents asked her when the air conditioning would be fixed and she directed them to speak to administrator and maintenance staff, which was not a satisfactory response for many residents. Some of the residents were wearing minimal clothing to keep cool. During observation on 6/12/26, at 9:38 a.m., the first floor [NAME] hallway was 77 degrees F. The East hallway was 75 degrees F. During interview on 6/11/26 at 2:51 p.m., a registered nurse (RN)-B stated the facility had been using fans and portable air conditioners to help cool the building but, some residents still found it to be too hot. During interview on 6/11/26, at 3:55 p.m., a licensed practical nurse (LPN)-A reported it was not hot today, but it had been in the building the last few days, and residents had complained about the heat and how it made it hard to sleep. During interview on 6/11/26, at 4:00 p.m., a nursing assistant (NA)-A reported it was not hot today, but it had been hot in the building the three previous days. NA-A reported residents had complained about the heat. During interview on 6/11/26, at 4:09 p.m., NA-B reported in the previous few days, the residents had complained about the heat. During interview with community member (C2) on 6/12/26, at 10:55 a.m., stated the temperature in the building and resultant living conditions due to the heat, was quite concerning. C2 stated when she was at the facility on Monday 6/8/26, it was 85 degrees F. in the common areas, and it was uncomfortable. The second floor temperature was even hotter. C2 reported the staff had told her the indoor temperature at the facility could be pretty bad and uncomfortable for them, but they were more concerned about the resident's comfort. C2 stated although the staff were providing the residents with popsicles, extra ice water, and cool cloths in an attempt to minimize the effects of the heat, it was still very uncomfortable. C2 stated every year when the outside temperature gets warm, the AC unit has not been able to cool the building. When asked, C2 stated she did not know how many years the AC unit was not able to maintain a comfortable inside temperature during warm weather months. During observation on 6/12/26, at 11:45 a.m., the temperature in the second floor main lounge area was 78 degrees F. The second floor [NAME] nurses station was 74 degrees F. Review of an email correspondence from C1 received 6/12/26, at 12:20 p.m. read: The most current concern is the air conditioning that has been reported by residents to not be working. This was an issue last summer as well. I was just informed by resident via email yesterday that it's been extremely hot with the recent warm weather. Residents have been complaining, and they do have some portable AC units going but they are not getting to the rooms . Staff were reportedly doing hourly checks and nurses were doing heat assessments, but I don't know what else was offered, besides popsicles. During interview on 6/12/26 at 1:30 p.m., a registered nurse (RN)-A reported the current day, and the previous day was comfortable, but the previous Friday, Saturday and Sunday were very hot. During interview on 6/12/26, at 1:33 p.m., NA-C reported the facility air conditioning system recently broke and during the past few days, the residents had been complaining about the heat. During interview on 6/12/26, at 2:08 p.m., the administrator stated the facility temperature was to be maintained between 71F and 81F. The administrator stated around May 28th or 29th, was when the chiller went out and the residents started to report to her that the temperature in the facility was too high. During this time the facility started renting fans and portable air conditioning units to help lower the inside temperature. The administrator verified that room temperature audits had not been conducted over the previous hot weekend, and she had not been notified of the facility being too hot over the weekend. Document review of a proposed project agreement with a heating, ventilation and air conditioning (HVAC) service company, was created 6/2/26, and signed by both the HVAC service company and facility administration on 6/12/26, read The existing remote air-cooled chiller system has long exceeded its useful life. Current condition warrants complete replacement. The Quality of Life-Homelike Environment policy last reviewed 6/12/2026, read The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .Comfortable and safe temperatures (71 F - 81 F).

Based on interview and document review, the facility failed to sufficiently prepare for discharge 1 of 2 residents (R57) reviewed for discharge. R57 was sent home without sufficient home care services, which led to emergency services assisting her twice and resulting in transfer to the emergency department and hospital readmission.Findings include:R57's face sheet printed 3/3/26, indicated admission date of 12/24/25, diagnoses of malignant neoplasm of parts of nervous system (cancer), repeated falls, muscle weakness, and schizoaffective disorder, and a previous stay in the facility from 11/13/25 through 12/12/25.R57's care plan revised 1/13/26, indicated risk for falls, limited to extensive assistance for dressing, independent for eating, extensive assistance for personal hygiene and toilet use. Care plan further indicated discharge planning: resident will attain their highest quality of life at discharge. Case manager and interdisciplinary team determine the next most appropriate setting of care and expected discharge interval. Resident will be prepared to return to community upon discharge. Determine resident and representative goals for discharge, prepare and provide resident with a discharge summary document upon discharge from facility.R57's discharge return not anticipated Minimum Data Set (MDS)dated 1/9/26 , indicated intact cognition, no rejection of care, independent with eating, dependent for toileting hygiene, partial/moderate assistance for upper body dressing, lower body dressing, footwear, set up or clean up assistance for personal hygiene, partial/moderate assistance for going from sitting to lying, lying to sitting, sit to stand, and transfer to and from wheelchair, substantial/maximal assistance for tub/shower transfer.Facility electronic health record (EHR) social services admission note dated 12/30/25, indicated: Overall summary: resident wishes to discharge home once she is able to meet her goal of walking again with a walker.Facility EHR nursing note dated 1/1/26, indicated R57 fell outside when she went out to smoke. Will continue to monitor.Facility EHR nursing note dated 1/1/26, indicated R57 fell for the second time in the hallway. According to staff, resident ran into another resident wheelchair and fell over, staff was able to lower to the ground. Will continue to monitor.Facility EHR nursing note dated 1/5/26, indicated R57 was found going up a hill in her scooter (motorized wheelchair), appeared to be very confused, and did not know where she was. People (unknown) driving by helped her back to the facility.Facility EHR nursing note dated 1/6/26, indicated R57 refused her shower and stated she was going home for the day. R57 left at 10:06 a.m. and her expected return time is 7:00 p.m.Provider order by NP-A dated 1/5/26 at 5:48 p.m., indicated urinalysis (UA) with culture per new onset change in level of consciousness (LOC)/confusion. Provider order by NP-A dated 1/6/26 at 9:35 a.m., indicated: Labs: collect urine sample for UA/Culture. Diagnosis: Rule out urinary tract infection (UTI). Per email provided by RN-F dated 3/5/26, the urine sample was not collected as ordered and the lab had no record of the facility providing urine for urinalysis. Urinalysis results were provided from R57's M Health Fairview Southdale hospital encounter note dated 1/10/26, the time of her arrival to the emergency department following her discharge home.Social Service note titled Discharge Conference dated 1/8/26, indicated the following: Resident requested to discharge home (patient driven) and has met minimum requirement and able to complete ADLs. Resident has handicap shower, hospital bed, walker, electric scooter. Resident has PCA services through quality life.Provider note titled Discharge Summary written by nurse practitioner (NP)-A dated 1/8/26, indicated R57 was seen by psychiatry during a recent hospital stay and deemed not to have decision making capacity, R57 appointed her daughter as her designated decision maker. Note further indicated overall plan: discharge home with home health, registered nurse, and physical therapy.During interview on 3/3/26 at 1:45 p.m., R57's family member (FM)-A stated she was a personal care assistant (PCA) for R57 through All Home Health. FM-A stated she lived across the street from R57 and was made aware R57 was home when neighbors notified her on 1/9/26. FM-A was able to stay with R57 for a short time in the evening and returned the next day. FM-A further stated she and another family member provided services to R57 nine and a half hours per day, seven days per week prior to R57's admission to the facility. FM-A stated after she knew R57 was home, she called the PCA company on 1/10/26, to verify arrangements had been made and was told they were not aware R57 was returning home on 1/9/26, and services were not yet arranged. FM-A stated R57 had been discharged from the facility twice with no services arranged, and each time had ended up back at the facility or in the hospital. FM-A stated on 1/9/26, R57 had emergency medical services at her home two times for assistance with a fall to the floor and assistance with getting out of her chair. FM-A stated emergency medical services deemed R57 unable to be alone safely and transported her to the emergency department on 1/10/26. FM-A stated due to R57's decline over the past two months, PCA services were not sufficient to provide her care at home.During interview on 3/4/26 at 11:10 a.m., R57's daughter (FM)-B stated she was the primary decision maker for R57. FM-B stated she was not made aware of R57's discharge from the facility and services were not arranged for her return home. FM-B stated she was not included in discharge planning or a care conference to discuss R57's discharge. FM-B stated she would have liked to know R57 was returning home because it was not safe for her to be home alone. FM-B stated R57 was admitted to a different facility and passed away last week.Review of facility provided document titled Care Plan Report dated 1/8/26, indicated R57 was present at her discharge care conference. No family representative was listed on the attendance form.During interview on 3/5/26 at 9:18 a.m., occupational therapist (OT) stated R57's plan was to go home with daily PCA support. OT stated when she discharged a resident from therapy, social services were supposed to make arrangements for needs at home. OT stated at the time of R57's discharge from therapy services she required supervision with bed mobility, partial assistance with transfers, moderate assistance to get off the toilet, partial assistance with sit to stand and chair to bed transfers. OT further stated R57 would have been appropriate for long-term care based on her needs. OT stated R57's discharge was not safe for her but they could not force her to stay.During interview on 3/3/26 at 1:29 p.m., NP-A stated she signed discharge orders for R57 on 1/8/26, for a discharge date of 1/9/26. NP-A stated she was unaware R57 did not have services arranged prior to leaving the facility and would have expected her services to be started prior to her going home. NP-A stated she can not always guarantee the facility is doing what they say they are going to do, especially with the amount of agency staff at the facility. NP-A stated she thought R57 had services, and the facility should have done a better job of arranging those for her. NP-A stated I'm sure something got dropped somewhere, I honestly believe in my heart of hearts, it had to slip through the cracks somewhere.During interview on 3/4/26 at 4:21 p.m., social services designee (SS)-A, who is new to the facility since R57's discharge and was not involved in her care, stated the correct process for discharging a resident included discussing with the interdisciplinary team, arranging any recommended services, contacting case managers and family, and making sure services are in place prior to discharge. SS-A stated she would recommend residents stay at the facility until services are arranged. During interview on 3/3/26 at 12:11 p.m., RN-F also known as vice president of clinical services stated R57 kept coming in and out of the facility, had no guardian, and the facility could not hold her there against her will. RN-F stated the facility could not stop her from going home. RN-F stated prior to her admission to the facility, R57 had PCA services for nine and a half hours per day, seven days per week. RN-F stated the facility tried to set up services for R57 but she was denied late in the day on 1/8/26, and R57 went home the next day. RN-F stated R57 should have stayed at the facility but was driving her own discharge. RN-F stated she knew the discharge was not safe, and a discharge against medical advice (AMA) would have been the better option. RN-F stated she did not see in the electronic health record (EHR) that R57's family was contacted and did not see that R57's previous PCA service provider was contacted.During interview on 3/5/26 at 12:07 p.m., administrator stated she did not have any additional information regarding R57's discharge but would see what she could provide. Administrator further stated services should have been arranged and the facility was working on the discharge process. Administrator stated the discharge process has been a mess, and she recognized that.During interview on 3/5/26 at 10:18 a.m., financial manager and owner (FM)-C of All Home Health stated he was not made aware of R57's discharge until he heard from FM-A on 1/10/26. FM-C stated he did not receive a referral or any discharge information prior to R57's facility discharge date of 1/9/26. FM-C stated All Home Health provided services for R57 until 12/15/25, when she was hospitalized and then admitted to the facility. FM-C stated he expected to be notified of a resident discharge so services could resume.An email provided by registered nurse (RN)-F, also known as vice president of clinical services, dated 1/8/26, indicated Nightingale (home health agency) denied R57 for services. No other evidence of attempted arrangements for services by the facility was provided. The email provided by RN-F further stated R57 was a resident driven discharge, and I (RN-F) and the team did not complete the dc assessment. An email thread provided by administrator on 3/5/26, indicated conversations between redeemerservices.com (Hennepin County Contracted Case Managers) and allhomehealth.org discussing R57's care and staffing needs, but did not indicate the facility had made them aware of R57's discharge or that the facility was involved in any of the conversations. The email thread indicated on 1/10/26, All Home Health was contacted via phone by FM-A and made aware of R57's return to her home the previous day 1/9/26.Facility provided document from M Health Fairview Southdale emergency department dated 1/10/26 at 10:48 a.m., indicated R57 presented on 1/10/26 with concerns for generalized weakness, recurrent falls, and failure to thrive and was admitted under observation status. M Health Fairview Southdale note further indicated R57 returned home from nursing facility on 1/9/26, continued to fall and called emergency medical services (EMS) on two occasions prior to presentation. R57 admitted to sleeping on the floor prior to calling EMS. R57 denied acute injury or pain.Facility Discharge Summary and Plan policy undated, indicated the following: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. The post-discharge plan will be developed by the interdisciplinary team with the assistance of the resident and his or her family and will include: Arrangements that have been made for follow-up care and services, the degree of caregiver/support person availability, capacity, and capability to perform required care, what factors may make the resident vulnerable to preventable readmission, and how those factors will be addressed. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. A member of the interdisciplinary team will review the final post-discharge plan with the resident and family at least 24 hours before the discharge is to take place.

Based on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, for 2 of 2 residents (R2, R3) reviewed for psychotropic medication use.Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition with no hallucinations, delusions, behaviors, or rejection of care. MDS indicated R2 was on an antipsychotic, antidepressant, antianxiety and opioid medication.R2's medical diagnosis report, printed 3/5/26, included the following diagnoses: post-traumatic stress disorder (PTSD-mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events like violence, disasters or abuse), schizoaffective disorder (chronic mental health condition that is characterized by combination of schizophrenia symptoms such as hallucinations or delusions along with a major mood disorder including depression or mania), and adjustment disorder with mixed anxiety and depressed mood (mental health condition caused by a specific stressor).R2's Order Summary Report, printed 3/5/26, included the following orders:-olanzapine (antipsychotic medication) 5 milligram (mg) oral tablet - give one (1) tablet by mouth one time a day for schizoaffective disorder with a start date of 2/17/26.-sertraline (psychotropic medication) 75 mg oral tablet - give one (1) tablet by mouth one time a day for anxiety with a start date of 1/21/26.-Lyrica (psychotropic medication) 100 mg oral capsule - give one (1) capsule by mouth two times a day for neuropathic pain with as start date of 1/30/26. R2's March Medication Administration Record (MAR) was reviewed and indicated medication orders listed above (olanzapine, sertraline and Lyrica) were administered as ordered.R2's February MAR was reviewed and indicated orders listed above (olanzapine, sertraline and Lyrica) were administered as ordered. The MAR did include 2 other orders for olanzapine which were as follows: -olanzapine 2.5 mg tablet - give one (1) tablet by mouth one time a day for psychotic disorder with a start date of 1/22/26 and discontinue date of 2/14/26. The MAR indicated it was administered as ordered.-olanzapine 2.5 mg tablet - give one (1) tablet by mouth one time a day for F43.3 with a start date of 2/14/26 and discontinue date of 2/17/26. The MAR indicated it was administered as ordered. R2's progress notes, dated 9/1/25 to 3/5/26, were reviewed and lacked evidence of consents for psychotropic medications that included risks and benefits of medications listed aboveR2's electronic medical record (EMR) was reviewed and lacked evidence of a signed consent for psychotropic medications which would include risks, benefits and alternatives.During an observation and interview on 3/2/26 at 12:28 p.m., R2 was observed laying in bed. R2 stated she was just waking up from a nap and was going to eat lunch. R2 did stated she had been up and ate breakfast earlier.R3R3's admission MDS, dated [DATE], indicated R3 had moderately impaired cognition with no hallucinations, delusions, no behaviors, wandering or rejection of care. MDS indicated R3 was on an antipsychotic, antidepressant, and hypnotic along with opioid medications.R3's medical diagnosis report, printed 3/5/26, included the following relevant diagnoses: schizoaffective disorder (chronic mental health condition that is characterized by combination of schizophrenia symptoms such as hallucinations or delusions along with a major mood disorder including depression or mania), dementia (cognitive decline in memory, language, and problem solving that impairs daily life), restlessness and agitation and dislocation of right hip. R3's Order Summary Report, printed 3/5/26, included the following orders:-divalproex sodium (psychotropic medication)125 mg oral tablet - give five (5) tablets by mouth one time a day related to unspecified dementia without behavioral disturbance with a start date of 12/22/25.-fluoxetine (psychotropic medication used to treat depression) 20 mg oral tablet- give one (1) tablet by mouth one time a day for depression with a start date of 12/22/25. -lamotrigine (psychotropic medication) 25 mg oral tablet - give two (2) tablets by mouth one time a day related to unspecified dementia without behavioral disturbance with a start date of 12/22/25.-olanzapine (antipsychotic medication) 2.5 mg oral tablet - give one (1) tablet by mouth two time a day related to schizoaffective disorder and unspecified dementia with a start date of 1/22/26.-trazodone (psychotropic medication) 100 mg oral tablet - give one (1) table by mouth one time a day for insomnia with a start date of 12/22/25. R3's February and March MAR's was reviewed and indicated medications listed above (divalproex sodium, fluoxetine, lamotrigine, olanzapine, and trazodone) were administered as ordered.R3's progress notes, dated 12/22/25 to 3/5/26, were reviewed and lacked evidence of consent for psychotropic medications that included risks and benefits of medications listed above.R3's EMR was reviewed and lacked evidence of signed consent for psychotropic medications which would include risks, benefits and alternatives.During an observation and interview on 3/3/26 at 8:22 a.m., R3 was observed lying in bed and had just finished eating breakfast. R3 stated he had not gotten ready for the day yet.A voicemail was left for R3's guardian on 3/04/26 at 10:48 a.m. requesting a return call. No return phone call was received.During an interview on 3/4/26 at 1:30 p.m., registered nurse (RN)-A stated, we don't do consents for medications. Furthermore, RN-A stated she had never done any sort of consent for medication for any resident in the building.During an interview on 3/4/26 at 3:06 p.m., director of nursing (DON) stated the facility does not complete any consent forms for any medications. DON verified there were no signed consents for any medications including psychotropic medications for R2 and R3. During an interview on 3/5/26 at 9:24 a.m., with RN-F also know as vice president of clinical services stated the facility does not obtain consents for medications. RN-F stated we do not do consents for psychotropics.A facility policy on consents for medication use was requested and not received.Facility Antipsychotic Medication Use policy, revised 4/26/25, indicated the following: Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. In addition, the hospital, previous nursing home or assisted living resident record must include provider diagnosis, indication for use and documentation that resident acknowledged consent to receive prescribed psychotropic medications.

Based on observation, interview and document review, the facility failed to ensure preferences for clothing and getting out of bed were honored and implemented for 1 of 1 resident (R46) reviewed for choices.Findings include:R46's face sheet printed 3/3/26, indicated diagnoses of cerebral infarction due to occlusion of small artery (stroke), hemiplegia (loss of use of left side of body, blindness, and communication deficit.R46's care plan dated 12/16/25, indicated total assistance for dressing, personalized care: staff will accommodate/support resident's activities in care routine as able.R46's Resident Preferences Evaluation dated 12/18/25, indicated it was very important for R46 to get up and go outside to get fresh air when the weather is good, and participate in religious activities. R46's Preferences for Customary Routine and Activities assessment dated [DATE], indicated it was somewhat important for R46 to choose what to wear.R46's part A PPS discharge Minimum Data Set (MDS) dated [DATE], indicated intact cognition, dependent for eating, toileting hygiene, and transfers, and use of wheelchair.During interview and observation on 3/2/26 at 3:58 p.m., R46 was alone in her bed, wearing a hospital gown. R46 stated she was always in bed in a hospital gown. R46 stated she would prefer to get dressed each day, rather than wear a hospital gown. R46 further stated she would like to get up in a wheelchair during the day. R46 stated staff did not offer these things or ask her about these things.During interview and observation on 3/3/26 at 8:45 a.m., R46 was alone in her bed, wearing a hospital gown. R46 stated she would wear clothes and get up in a wheelchair if staff offered.During interview on 3/3/26 at 9:15 a.m., licensed practical nurse (LPN)-A stated R46 did not usually like to get up into a wheelchair because she was scared of transfers to the chair. LPN-A was unsure if R46 had clothes to wear at the facility.During interview on 3/3/26 at 4:35 p.m., LPN-B stated he was unsure of R46's preferences for dressing and getting up in her wheelchair. LPN-B stated he did not see anything on her care plan about those topics.During interview on 3/3/26 at 5:10 p.m., NA-G stated she had not ever gotten R46 dressed or out of bed and was not aware that was her preference.During interview and observation on 3/4/26 at 1:48 p.m., R46 was in her bed, wearing a hospital gown, and being assisted with eating by nursing assistant (NA)-F. R46 stated she would like to get up and it felt like she had been in bed for four years. NA-F asked her if she would like to get in her wheelchair. R46 stated she did not like her wheelchair because last time she was in it, she felt like she passed out. R46 stated she would like a wheelchair that reclined back. NA-F stated she would see what she could do.During continued interview on 3/4/26 at 1:53 p.m., NA-F stated she was unsure if anyone had ever asked R46 why she wouldn't get up in her wheelchair. NA-F said she frequently worked on R46's hallway and was not aware she wanted to wear clothing or get out of bed. NA-F thought registered nurse (RN)-F, also known as vice president of clinical services, had asked R46 about it, but nothing had been done yet.During observation on 3/4/26 at 2:38 p.m., R46 was observed up in a reclining wheelchair out in the common area. Occupational therapist (OT) stated she had not from staff until today that R46 was not getting dressed or getting up in her wheelchair, didn't fit correctly in her chair, couldn't sit up independently in her chair, and hadn't seen the wheelchair in so long she thought it had disappeared. OT stated she was going to try to get R46 approved for her own reclining wheelchair.During interview on 3/4/26 at 2:25 p.m., NA-A stated she worked with R46 sometimes and was unaware of her preference for clothing and getting up to her wheelchair. NA-A stated she had not asked R46 about getting dressed or getting up to her wheelchair.During interview and observation on 3/5/26 at 10:00 a.m., R46 was in a reclining wheelchair in the common area. R46 was wearing a hospital gown. R46 stated she was happy to be up in a wheelchair and she enjoyed being out of her room.During interview on 3/5/26 at 10:18 a.m., RN-F, also known as vice president of clinical services, stated she would expect resident preferences for getting dressed and getting up during the day to be known and honored.Facility Dignity policy printed 3/4/26, indicated: The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.

Based on interview and document review, the facility failed to provide notification of discharge to family/representative for 1 of 2 residents (R57) reviewed for discharge. In addition, the facility failed to promptly notify the provider of low blood pressure and medication errors occurring for 1 of 1 resident (R1) reviewed for physician notification of change.Findings include: R57's face sheet printed 3/3/26, diagnoses of malignant neoplasm of parts of nervous system (cancer), repeated falls, muscle weakness, and schizoaffective disorder. R57's care plan revised 1/13/26, indicated risk for falls, limited to extensive assistance for dressing, independent for eating, extensive assistance for personal hygiene and toilet use. Care plan further indicated discharge planning: resident will attain their highest quality of life at discharge. Case manager and interdisciplinary team determine the next most appropriate setting of care and expected discharge interval. Resident will be prepared to return to community upon discharge. Determine resident and representative goals for discharge, prepare and provide resident with a discharge summary document upon discharge from facility. R57's discharge return not anticipated Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no rejection of care, independent with eating, dependent for toileting hygiene, partial/moderate assistance for upper body dressing, lower body dressing, footwear, set up or clean up assistance for personal hygiene, partial/moderate assistance for going from sitting to lying, lying to sitting, sit to stand, and transfer to and from wheelchair, substantial/maximal assistance for tub/shower transfer. Social Service note titled Discharge Conference dated 1/8/26, indicated the following: Resident requested to discharge home (patient driven) and has met minimum requirement and able to complete ADLs. Resident has handicap shower, hospital bed, walker, electric scooter. Resident has PCA services through quality life. Provider note titled Discharge Summary written by nurse practitioner (NP)-A dated 1/8/26, indicated R57 was seen by psychiatry during a recent hospital stay and deemed not to have decision making capacity, R57 appointed her daughter as her designated decision maker. Note further indicated overall plan: discharge home with home health, registered nurse, and physical therapy. During interview on 3/4/26 at 11:10 a.m., R57's daughter (FM)-B stated she was the primary decision maker for R57. FM-B stated she was not made aware of R57's discharge from the facility and services were not arranged for her return home. FM-B stated she was not included in discharge planning or a care conference to discuss R57's discharge. FM-B stated she would have liked to know R57 was returning home because it was not safe for her to be home alone. Review of facility provided document titled Care Plan Report dated 1/8/26, indicated R57 was present at her discharge care conference. No family representative was listed on the attendance form and there was no documentation to indicate FM-B was made aware of R57's upcoming discharge from the facility. During interview on 3/4/26 at 4:21 p.m., social services designee (SS)-A stated the correct process for discharging a resident included discussing with the interdisciplinary team, arranging any recommended services, contacting case managers and family, and making sure services are in place prior to discharge. During interview on 3/3/26 at 12:11 p.m., registered nurse (RN)-F also known as vice president of clinical services stated R57 kept coming in and out of the facility, had no guardian, and the facility could not hold her there against her will. RN-F stated the facility could not stop her from going home. RN-F stated the facility tried to set up services for R57 but she was denied late in the day on 1/8/26, and R57 went home the next day. RN-F stated she did not see in the electronic health record (EHR) that R57's family was contacted about the discharge from the facility. Facility Discharge Summary and Plan policy undated, indicated the resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. R1 R1's admission MDS, dated [DATE], indicated R1 had intact cognition with no hallucinations, delusions, no behaviors, wandering or rejection of care. MDS indicated R1 was independent with all activities of daily living (ADLs) except for transfers ambulation, and picking items off the floor which required supervision R1's medical diagnosis report, dated 3/5/26, included the following diagnoses: type 2 diabetes with diabetic nephropathy, legal blindness, acute kidney failure, and chronic kidney disease. R1's care plan, printed 3/2/26, included R1 was at risk for falls with the following interventions: -ensure call light is available to resident -evaluate fall risk on admission and PRN -if fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol The care plan lacked identification R1 was on blood pressure medication. Furthermore, lacked any intervention to monitor for low blood pressures or signs/symptoms of low blood pressures. R1's Order Summary Report, as of 3/2/26, included the following orders: -antihypertensive medication: Hold parameters: Hold 100 or HR less than 50 and with an order date of 12/15/25. -Daily vitals one time a day with an order date of 2/14/26, and a start date of 2/15/26. - lisinopril (medication used to treat high blood pressure) 10 milligram (mg) tablet – give one tablet by mouth one time a day for high blood pressure with an order date of 12/11/25, and start date of 12/12/25 R1's March Medication and Treatment Administration Record (MAR/TAR), printed 3/3/26, included the following: -Antihypertensive medication Hold parameters: Hold 100 or HR 1ess than 50 -lisinopril (antihypertensive medication used to treat high blood pressure) 10 milligram (mg) tablet – give one tablet by mouth one time a day for high blood pressure with a start date of 12/12/25. The record identified the medication was administered 3/1/26, 3/2/26, 3/3/26. -daily vitals one time a day with a start date of 2/15/26 with the following readings: -3/3/26: BP was 102/60 and pulse was 88 -3/2/26: BP was 112/76 and pulse was 76 -3/1/26: BP was 101/61 and pulse was 85 R1's February MAR/TAR included the following: -Antihypertensive medication Hold parameters: Hold 100 or HR 1ess than 50 -lisinopril 10 mg tablet – give one tablet by mouth one time a day for high blood pressure with a start date of 12/12/25. The record identified the medication was administered every day in February except 2/25 which was marked with a 4 indicating vital signs out of parameters. -daily vitals one time a day with a start date of 2/15/26 with the following readings: -2/28/26: BP 98/60 and pulse 78 (hold parameters met, medication administered) -2/27/26: BP 101/62 and pulse 75 -2/26/26: BP 104/67 and pulse 72 -2/25/26: BP 99/57 and pulse 73 (hold parameters met, medication held) -2/24/26: BP 94/64 and pulse 77 (hold parameters met, medication administered) -2/23/26: BP 87/58 and pulse 85 (hold parameters met, medication administered) -2/22/26: BP 70/47 and pulse109 (hold parameters met, medication administered) -2/21/26: BP 159/87 and pulse 68 -2/20/26: BP 105/66 and pulse 72 -2/19/26: BP 103/68 and pulse 72 -2/18/26: BP 96/59 and pulse 62 (hold parameters met, medication administered) -2/17/26: BP 98/61 and pulse 66 (hold parameters met, medication administered) -2/16/26: BP 126/77 and pulse 78 -2/15/26: BP 101/64 and pulse 81 For the month of February, since the daily vital sign order was entered, R1's blood pressures were low enough to meet the parameters to hold the blood pressure medication 7 of 14 possible medication administrations, was held one time and administered 6 times. R1's progress notes, dated 2/1/26 to 3/3/26, were reviewed and lacked evidence of notification to provider of low blood pressures or medication being held on 2/25/26. During an interview on 3/2/26 at 2:19 p.m., R1 was interviewed via interpreter. R1 had no complaints of dizziness or lightheadedness. R1 stated the nurses take his blood pressures. During an interview on 3/3/26 at 9:45 a.m., RN-A stated if a resident was on a blood pressure medication, then their blood pressure was taken before administration. RN-A stated the resident should have an order for parameters meaning if the blood pressure or pulse are not at a certain level then the medication should be held. RN-A stated it is important to follow those orders. RN-A stated if they hold the medication due to vital signs, they would notify if the vital signs are very dangerous such as the bottom number of the blood pressure being in the 30or 40's . RN-A stated they monitor their residents every day. RN-A stated if a resident was having lower blood pressures or the medication was held for a few days in a row without dangerously low vital signs, they would notify the provider to update them. RN-A stated they would put a progress note in about notifying the provider. During an interview on 3/3/26 at 11:51 a.m., nursing assistant (NA)-H stated they are familiar with R1. NA-H stated that R1 has not complained of any dizziness, nor had NA-H heard that R1 had reported dizziness or lightheadedness. During a follow up interview on 3/3/26 at 1:34 p.m., RN-A stated they are familiar with R1 and use an interpreter for communication with him. RN-A stated R1 had not complained of any dizziness or lightheadedness that they were aware of. RN-A verified R1 medication orders and parameters to hold medications. RN-A verified R1 had been receiving antihypertensive medications with low blood pressures. During an interview on 3/3/26 at 1:45 p.m., director of nursing (DON) stated the expectation would be antihypertensive parameters would be followed, and providers would be updated. DON stated they would expect the provider to be notified each time the blood pressure was low, and medication held. DON reviewed R1 chart and verified the dates listed above and medication should have been held, and provider should have been updated. DON reviewed the chart and verified the provider had not been notified. DON was going to follow up to see if she could find additional information. During an interview on 3/3/26 at 2:05 p.m., NP-A stated she would expect to be notified with each low blood pressure so she can make the appropriate changes if needed. NP-A stated she had not been notified of any low blood pressure reading for R1 and stated she should have been. NP-A stated she would see R1 during rounds tomorrow (3/4/26). NP-A stated there are risks involved with giving antihypertensive medications to a person with low blood pressure such as dizziness, cognitive changes, increased risk of falls, syncope and altered level of consciousness. During a follow up interview on 3/4/26 at 8:14a.m., DON verified the provider had not been notified about the low blood pressures for R1. DON stated she talked to NP-A yesterday, after talking to surveyor about R1 blood pressure and medication. DON stated the medication should have been held and the provider should have been notified with the first low pressure. During an interview on 3/5/26 at 9:26 a.m., RN-F also known as vice president of clinical services stated the expectation would to be follow the orders, hold the medication and call the physician. Facility Acute Condition Changes-Clinical Protocol policy updated 3/16/25, indicated: the nursing staff will contact the physician based on the urgency of the situation.

Based on observation, interview and document review the facility failed to monitor for resident specific target behaviors related to antipsychotic medications use for 1 of 4 residents (R3) reviewed for antipsychotic medications.Findings include: R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 had moderately impaired cognition with no hallucinations, delusions, no behaviors, wandering or rejection of care. MDS indicated R3 was on an antipsychotic, antidepressant, and hypnotic along with opioid medications.R3's medical diagnosis report, printed 3/5/26, included the following relevant diagnoses: schizoaffective disorder (chronic mental health condition that is characterized by combination of schizophrenia symptoms such as hallucinations or delusions along with a major mood disorder including depression or mania), dementia (cognitive decline in memory, language, and problem solving that impairs daily life), restlessness and agitation and dislocation of right hip. R3's care plan, printed 3/2/26, identified the R3 at risk for depression with the following interventions: if depression screen is positive, contact provider for suggestion, and perform depression screening evaluation. Furthermore, the care plan identified the resident uses psychotropic medication with the following interventions: administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift, and monitor/document/report any adverse reason of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person.The care plan lacked mention of target behaviors for antipsychotic use or identification of what, if any, target behaviors R3 exhibited for the use of either olanzapine or fluoxetine.R3's Order Summary Report, printed 3/5/26, included the following orders:-fluoxetine (psychotropic medication used to treat depression) 20 mg oral tablet- give one (1) tablet by mouth one time a day for depression with a start date of 12/22/25. -lamotrigine (psychotropic medication) 25 mg oral tablet - give two (2) tablets by mouth one time a day related to unspecified dementia without behavioral disturbance with a start date of 12/22/25.-olanzapine (antipsychotic medication) 2.5 mg oral tablet - give one (1) tablet by mouth two time a day related to schizoaffective disorder and unspecified dementia with a start date of 1/22/26.The Physician Order Report lacked documentation or any direction to monitor target behaviors or identification of target behaviors.R3's February and March Medication and Treatment Administration Records (MARs) reviewed and indicated medications listed above (fluoxetine, and olanzapine were administered as ordered. The document lacked evidence of target behaviors identified or monitored.During an observation and interview on 3/3/26 at 8:22 a.m., R3 was observed lying in bed and had just finished eating breakfast. R3 stated he had not gotten ready for the day yet.During an interview on 3/3/26 at 11:43 a.m., nursing assistant (NA)-H stated they are not very familiar with R3 and unsure if they have any behaviors.During an interview on 3/3/26 at 1:24 p.m., registered nurse (RN)-A stated they are not very familiar with R3, and they are not sure if R3 has any behaviors or target behaviors. RN-A stated if a resident has aggressive behaviors would be monitored for this.During an interview on 3/4/26 at 1:22 p.m., director of nursing (DON) stated all psychotropic medication should have side effect monitoring and target behaviors identified. DON verified R3 did not have any target behaviors identified for olanzapine or fluoxetine.During an interview on 3/5/26 at 9:23 a.m., RN-F also known as vice president of clinical services stated if target behaviors can be identified they would be put in the order and in the care plan. A policy on psychotropic medication was requested and not received.Facility Antipsychotic Medication Use policy reviewed 4/26/25, indicated The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others.

Based on interview and document review the facility failed to ensure appropriate discharge documentation was in the medical record for 1 of 2 residents (R57) reviewed for discharge. R57's medical record was missing a recapitulation of stay, a final summary of their status and reconciliation of all pre-discharge and post-discharge medication (both prescribed and over the counter medications).Findings include:R57's face sheet printed 3/3/26, included diagnoses of malignant neoplasm of parts of nervous system (cancer), repeated falls, muscle weakness, and schizoaffective disorder.R57's care plan revised 1/13/26, indicated risk for falls, limited to extensive assistance for dressing, independent for eating, extensive assistance for personal hygiene and toilet use. Care plan further indicated discharge planning: resident will attain their highest quality of life at discharge. Case manager and interdisciplinary team determine the next most appropriate setting of care and expected discharge interval. Resident will be prepared to return to community upon discharge. Determine resident and representative goals for discharge, prepare and provide resident with a discharge summary document upon discharge from facility.R57's discharge return not anticipated Minimum Data Set (MDS) dated [DATE], indicated intact cognition, no rejection of care, independent with eating, dependent for toileting hygiene, partial/moderate assistance for upper body dressing, lower body dressing, footwear, set up or clean up assistance for personal hygiene, partial/moderate assistance for going from sitting to lying, lying to sitting, sit to stand, and transfer to and from wheelchair, substantial/maximal assistance for tub/shower transfer.Social Service note titled Discharge Conference dated 1/8/26, indicated the following: Resident requested to discharge home (patient driven) and has met minimum requirement and able to complete activities of daily living (ADLs). Resident has handicap shower, hospital bed, walker, electric scooter. Resident has PCA services through Quality Life.Provider note titled Discharge Summary written by nurse practitioner (NP)-A dated 1/8/26, indicated R57 was seen by psychiatry during a recent hospital stay and deemed not to have decision making capacity, R57 appointed her daughter as her designated decision maker. Note further indicated overall plan: discharge home with home health, registered nurse, and physical therapy.During interview on 3/4/26 at 11:10 a.m., R57's daughter (FM)-B stated she was the primary decision maker for R57. FM-B stated she was not made aware of R57's discharge from the facility and services were not arranged for her return home. FM-B stated she was not included in discharge planning or a care conference to discuss R57's discharge. FM-B stated she would have liked to know R57 was returning home because it was not safe for her to be home alone.Review of facility provided document titled Care Plan Report dated 1/8/26, indicated R57 was present at her discharge care conference. No family representative was listed on the attendance form and there was no provided documentation that R57 or representative were provided with a discharge summary or discharge plan.During interview on 3/3/26 at 1:29 p.m., NP-A stated she signed discharge orders for R57 on 1/8/26, for a discharge date of 1/9/26. NP-A stated she could not always guarantee the facility was doing what they said they were going to do, especially with the amount of agency staff at the facility.During interview on 3/4/26 at 4:21 p.m., social services designee (SS)-A stated the correct process for discharging a resident included discussing with the interdisciplinary team, arranging any recommended services, contacting case managers and family, and making sure services are in place prior to discharge. SS-A stated she would recommend residents stay at the facility until services are arranged.During interview on 3/3/26 at 12:11 p.m., registered nurse (RN)-F, also known as vice president of clinical services, stated R57 kept coming in and out of the facility, had no guardian, and the facility could not hold her there against her will. RN-F stated the facility could not stop her from going home. RN-F stated the facility tried to set up services for R57 but she was denied late in the day on 1/8/26, and R57 went home the next day. RN-F stated she did not see in the electronic health record (EHR) that R57's family was contacted and did not see that R57's previous personal care assistant (PCA) service provider was contacted. An email provided by RN-F dated 1/8/26, indicated Nightingale (home health agency) denied R57 for services. No other evidence of attempted arrangements for services by the facility was provided. The email provided by RN-F further stated R57 was a resident driven discharge and RN-F and the team did not complete the discharge assessment. A discharge summary, recapitulation of stay, and medication reconciliation upon discharge was not found in the electronic health record (EHR) and when requested, was not provided by facility staff.Facility Discharge Summary and Plan policy undated, indicated the discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's current diagnosis, medical history, course of illness, treatment, and therapy at the facility, current diagnostic results, physical and mental functioning status, ability to perform activities of daily living, mental and psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, medication reconciliation. The resident or representative will be provided with an evaluation of resident's discharge needs, the post-discharge plan, and the discharge summary.

Based on interview and document review, the facility failed to ensure a comprehensive care plan including pain interventions, had been developed for 1 of 5 residents (R48) reviewed for medications. Findings include:R48's face sheet provided on 3/5/26, included diagnoses of osteoarthritis of right shoulder identified on 7/20/25; peripheral vascular disease (a slow, progressive disorder of blood vessels which caused pain) identified on 12/7/18; chronic tension-type headaches identified on 6/12/15.R48's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, clear speech, usually understood and could usually understand. R48 was dependent upon staff for all activities of daily living, did not walk and used a wheelchair for mobility. R48 had almost constant pain which did not affect sleep or day to day activity. R48's significant change MDS dated [DATE], did not identify a CAA (Care Area Assessment) for pain. A CAA is an in-dept evaluation process which guides a facility in developing personalized care plans to improve or maintain a resident's well-being. R48's physician orders included the following medications for pain:--Order dated 11/25/25, indicated gabapentin 600 mg (milligrams) three times a day for pain.--Order dated 12/1/25, indicated baclofen 5 mg by mouth two times a day for pain.--Order dated 1/19/26, indicated Belbuca Buccal Film 600 mcg (micrograms) place and dissolve one film buccally (area of the cheek) two times a day for pain. R48's care plan initiated on 11/4/24, did not include a focus area for pain. Review of pain scores for February and March 2026, indicated variable pain scores of 0 to 8/10. During various observations over the course of four days from 3/2/26 to 3/5/26, R48 was primarily seen in his wheelchair on the smoking patio with other residents. During an interview on 3/5/26 at 10:08 a.m., nursing assistant (NA)-D stated R48 had complained of pain more often lately - he was stiff all over when getting up in the morning and when changing his clothes. NA-D stated R48 received pain medications, but she did not know about non-medication measure for his pain, such as ice or massage, adding she did not do that. During an interview on 3/5/26 at 10:49 a.m., registered nurse (RN)-A stated R48 had pain and saw pain-clinic providers twice a week, who adjusted R48's pain medication up or down. RN-A stated R48's pain medications were scheduled, rather than as needed; to keep on top of his pain and felt they were effective for him. RN-A was not aware of non-medication measure utilized for pain, stating R48's non-medication pain relief was smoking. RN-A verified R48's care plan did not include a focus area for pain. During an interview on 3/5/26 at 12:13 p.m., RN-F also know as vice president of clinical services verified R48 experienced pain and had been seen by providers from the pain clinic on an on-going basis. VPCS verified R48's care plan did not include a focus area for pain. VPCS stated she would expect to see pain interventions including non-pharmacological interventions. Facility Comprehensive Care Plans policy with revised date of 3/4/22, indicated the comprehensive care plan was based on a thorough assessment that included but was not limited to, the MDS. Each resident's comprehensive care plan was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems and reflect the resident's expressed wishes regarding care, treatment goals and preferences. The care plan would identify the professional services that were responsible for each element of care and reflect currently recognized standards of practice for problem areas and conditions. Areas of concern that were triggered during the resident assessment were evaluated using specific assessment tools (including Care Area Assessments) before interventions were added to the care plan. Care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and their causes.

Based on interview, and document review, the facility failed to provide the opportunity to attend and participate in a care conference for 1 of 1 residents (R2) reviewed for care conferences.Findings include: R2's significant change Minimum Data Set (MDS), dated [DATE], identified R1 had intact cognition with no hallucinations, delusions, rejection of care, or behaviors present.R2's Medical Diagnosis Report, dated 3/5/26, included the following diagnoses: chronic obstructive pulmonary disease (a progressive long-term lung disease that make is difficult to breath due to damaged air sacs and airways), adjustment disorder with mixed anxiety and depressed mood (mental health condition caused by a specific stressor), lymphedema (chronic condition that causes painful swelling, usually in the arms or legs, due to the lymphatic system not being able to drain properly), prediabetes (condition where blood sugar levels are higher than normal but not high enough to be diagnosed with diabetes), schizoaffective disorder (chronic mental health condition that is characterized by combination of schizophrenia symptoms such as hallucinations or delusions along with a major mood disorder including depression or mania), post-traumatic stress disorder (PTSD-mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events like violence, disasters or abuse) and hypertension (high blood pressure).R2's Social Service Care Conference form, dated 10/1/25, indicated a care conference was held with R2 along with nurse manager, social services and re-location. The form included information from the following departments: dietary, nursing, activity, social services and therapy.R2's progress notes dated 9/1/25 to 3/4/26, were reviewed and lacked indication of any care conference. During an interview on 3/2/26 at 12:36 p.m., R2 stated that she had not had a care conference in a long time. R2 stated she would like to have a care conference, would attend the care conference and had attended care conferences in the past. During an interview on 3/4/26 at 8:32 a.m., social services (SS)-A stated she was unsure how often care conferences for long term residents should be held as she was new to the position but would find out. SS-A stated care conference notes would be documented in the progress notes or assessment section of the electronic medical record (EMR). SS-A verified the last documented care conference for R2 was 10/1/25. SS-A requested to follow up with supervisor for additional information. No additional information was provided to surveyor.During an interview on 3/4/26 at 1:19 p.m., director of nursing (DON) stated the expectation would be care conferences are held quarterly and as needed for change of condition. During an interview on 3/4/26 at 1:41 p.m., registered nurse (RN)-A stated floor nurses do not attend or participate in care conferences. RN-A stated she had not attended any care conferences.During an interview on 3/5/26 at 9:24 a.m., RN-F also known as vice president of clinical services stated the expectation was care conferences are completed at least quarterly and as needed. RN-F reviewed R2's EMR and verified via email on 3/5/26 at 1:19 p.m., we are a bit behind on care plan meetings. Her care plan was reviewed on 2/22/2026. She should have one coming up soon. We also lost our social services designee which delayed our care plan schedule.Facility Resident Care Conference/Care Plan Review policy, reviewed 6/27/22, was provided. The policy indicated The purpose of the care conference is to develop a plan of care and to ensure that the resident goals and preferences are discussed and established with one of processes being: For quarterly care conference, social services will utilize the social service care conference assessment.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., shaving) were completed for 1 of 1 resident (R3) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.Findings include: R3's admission Minimum Data Set (MDS) , dated 12/28/25, indicated R3 had moderately impaired cognition with no hallucinations, delusions, no behaviors, wandering or rejection of care. MDS indicated R3 required maximal staff assistance for personal hygiene (i.e., shaving, combing hair, washing/drying hands) and dressing, was dependent on staff for oral hygiene, and required moderate staff assistance for toileting hygiene. R3's medical diagnosis report, printed 3/5/26, included the following relevant diagnoses: schizoaffective disorder (chronic mental health condition that is characterized by combination of schizophrenia symptoms such as hallucinations or delusions along with a major mood disorder including depression or mania), dementia (cognitive decline in memory, language, and problem solving that impairs daily life), restlessness and agitation and dislocation of right hip. R3's care plan, printed 3/2/26, indicated R3 required supervision/one-person physical assistance for personal hygiene which was created on 2/22/26.During an observation and interview on 3/2/26 at 1:12 p.m., R3 stated that he would like to be shaved and stated he needed staff assistance. R3 stated when he asks to be shaved, staff tell him they don't have time, or they don't have a razor. R3 stated he prefers to be shaved daily or at least every other day. R3 stated they do not ask him if he wants to be shaved with morning or bedtime care or with showers. R3 was observed to have facial hair - a beard and mustache - approximately 1/4 (quarter) inch long. On 3/03/26 at 8:22 a.m., R3 was observed lying in bed with head elevated with breakfast tray on the bedside table. R3 stated he had not gotten ready for the day yet. At 9:28 a.m., staff were observed going into R3's room, asked if he was ready to get up for the day and offered to assist him. At 9:53 a.m., R3 was observed sitting in the dining room. R3 appeared to not have been shaved since 3/2/26's observation. When asked, R3 stated the staff did not ask him this morning if he wanted to be shaved. R3's Weekly Bath Audit, dated 3/2/26, reviewed and identified R3 received a shower. The audit form lacked evidence of facial shaving being offered or completed. R3's progress notes, dated 2/1/26 to 3/5/26, were reviewed. The notes identified the following: -2/9/26: resident declined having a shower/bath stating, I am too tired and refused to have the shower rescheduled. The progress notes lacked evidence of refusals of shaving or completion of shaving. During an interview on 3/4/26 at 8:16 a.m., registered nurse (RN)-D verified she completed the weekly bath audit for R3 on 3/2/26. RN-D stated she could not remember if he was shaved or not when she completed the weekly bath audit. During an interview on 3/3/26 at 11:43 a.m., nursing assistant (NA)-H stated that morning care includes washing a resident up, changing their brief, combing their hair, and changing their clothes. NA-H stated shaving facial hair would typically be done on shower days unless a resident wanted it done daily or if it is long and bothering them. NA-H verified they were working with R3. NA-H stated R3 need assistance of 1 staff with all cares. NA-H stated they helped R3 with some cares this AM but did not offer to shave R3. NA-H verified R3 had longer facial hair and should have asked him. During an interview on 3/03/26 at 1:31 p.m., registered nurse (RN)-A stated shaving facial hair should be offered during morning cares based on resident preferences (whether they want facial hair). RN-A stated the facility had razors for residents if residents do not have their own. RN-A stated they are not very familiar with R3. During an interview on 3/3/26 at 1:53 p.m., director of nursing (DON) stated shaving facial hair would be based on resident preference which would be on their care plan. DON stated the expectation would be that if residents needed assistance with shaving, staff would be offering assistance with cares. During a follow up interview on 3/4/26 at 8:14 a.m., DON stated she followed up with R3 and updated his care plan per his preference of shaving. DON stated that she requested staff shave him yesterday after meeting with surveyor. DON did not know when R3 was last offered to be shaved or last shaved. A facility policy on activities of daily living was requested but not received.

Based on observation, interview and document review, the facility failed to ensure individualized activities were provided for 1 of 2 resident (R46) reviewed for activities. Findings include:R46's face sheet printed 3/3/26, indicated diagnoses of cerebral infarction due to occlusion of small artery (stroke), hemiplegia (loss of use of left side of body), blindness, unspecified mood disorder, and communication deficit.R46's Resident Preferences Evaluation completed by activity director dated 12/18/26, indicated listening to music was very important to R46. Preferred music genre: reggae and rock.R46's care plan dated 12/16/25, indicated total assistance for dressing, personalized care: staff will accommodate/support resident's activities in care routine as able, but did not address any individualized activities preferences. R46's part A PPS discharge Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, dependent for eating, toileting hygiene, and transfers, and use of wheelchair. R46's admission MDS assessment dated [DATE], indicated it was very important to R46 to listen to music she enjoyed.During interview and observation on 3/2/26 at 3:58 p.m., R46 was alone in her bed with no music on. R46 stated she liked listening to music and her favorite type of music was pop music. R46 further stated she liked to listen to the TV and preferred to have sound rather than silence in her room. R46 stated most staff did not offer to turn on her music or television. R46 was blind, had a communication deficit, and was unable to locate a TV remote independently. During observation on 3/3/26 at 8:45 a.m., R46 was alone in her room with no music or TV on.During observation and interview on 3/4/26 at 9:38 a.m., R46 was alone in her room with no music or TV on. R46 stated she would like to listen to the TV, but no one had offered to turn the TV on for her.During interview on 3/3/26 at 9:15 a.m., licensed practical nurse (LPN)-A stated she was aware R46 liked music and enjoyed listening to crime shows on the TV. LPN-A stated she knew that because she worked often but was not sure how other staff would know R46's activity preferences. LPN-A stated R46's activity preference was not on her care plan.During interview on 3/3/26 at 4:35 p.m., LPN-B stated he was not aware of any specific activity preferences for R46 and did not see any preferences documented in her electronic health record (EHR).During observation on 3/4/26 at 1:48 p.m., R46 was in her room with no music or TV on.During interview on 3/4/26 at 1:53 p.m., NA-F stated R46 sometimes asked her to turn on her music or TV. NA-F stated she would not know that was an activity R46 enjoyed if R46 did not ask. NA-F stated she was unsure how to know residents' activity preferences.During interview on 3/4/26 at 2:25 p.m., NA-A stated she was not aware of R46's activity preferences and did not locate her preferences in the EHR. NA-A stated she could ask the activity director about R46's activity preferences.During interview on 3/5/26 at 10:18 a.m., registered nurse (RN)-F, also known as vice president of clinical services, stated she would expect resident activity preferences to be available to all staff in the EHR so resident preferences could be honored for activities. RN-F stated due to R46's dependence on staff, she would expect staff to offer R46 her activities.Facility Activity Programs policy printed 3/4/26, indicated: Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Activities are not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents and family members may also provide the activities.

Based on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complications for 1 of 1 resident (R4) reviewed for dialysis care. In addition, the facility failed to ensure adequate weight monitoring was implemented for 1 of 1 resident (R4) reviewed for dialysis.Findings include: R4's quarterly minimum data set (MDS) dated [DATE], indicated R4 had intact cognition and was diagnosed with heart failure, hypertension, kidney failure, and diabetes. The MDS indicated R4 was receiving dialysis (use of a machine that filters waste, salts, and fluid from the blood when the kidneys are no longer healthy enough to do so) treatments. R4's care plan dated 12/18/25, indicated R4 received hemodialysis due to kidney failure on Tuesdays, Thursdays, and Saturdays. The dialysis care plan included information such as monitoring (excluding resident weight) related to dialysis, contact information for the dialysis center, as well as instructions related to the dialysis access line. In the nutrition care plan dated 1/27/26, it was indicated that R4 had a diagnosis of congestive heart failure and kidney failure with dialysis use, and that weight would be taken per facility policy, but the care plan did not include further instruction on its frequency. R4's Order Summary Report dated 1/27/26, included an order dated 10/20/25 and instructed staff to send a referral with R4 to each dialysis appointment (if applicable). An additional order dated 1/27/26, indicated that staff were to send a copy of the order summary, face sheet, and pre-dialysis assessment for all dialysis appointments. The order summary did not include instructions for the frequency of resident weight measurement. R4's progress notes dated:-2/26/26, indicated R4's weight on 2/5/26 was 348 pounds, but did not reference a more current weight. -2/14/26 at 8:29 p.m., the note indicated R4 had dialysis and reported fatigue with no other complaints. The note indicated no new order received. The note did not indicate if communication from the dialysis center had been received or requested. -R4's progress notes dated 2/3/26 to 3/3/26 were reviewed and did not indicate further weights (than outlined above) were taken or that communication from the dialysis center was received on treatment days. The notes also did not indicate if communication forms were received from the dialysis center, or if facility staff had reached out to the dialysis center if these forms were not received, to ensure continuity of care. R4's weight and vitals summary dated 3/4/26, indicated for the period of 2/3/26 to 3/3/26, two weights were taken. On 2/5/26, R4's weight was 348 pounds (lbs), and on 3/3/26, his weight was 352.8 lbs. R4's medical record was reviewed, and dialysis forms dated 2/3/26 to 3/2/26 were not found on survey entrance. During an interview on 3/3/26 at 1:30 p.m., R4 stated that when he went to dialysis, the staff normally sent him with a packet of papers, but he did not usually bring any papers home with him. During an email communication on 3/3/26 at 2:54 p.m., dialysis communication reports were requested from registered nurse (RN)-F also known as vice president of clinical services, for the last month for R4. At 4:32 p.m., an email was received with a document containing a fax face sheet from the dialysis center dated 3/3/26 at 4:26 p.m., as well as Treatment Details Reports for 2/24/26, 2/26/26, 2/28/26, and 3/3/26. During a follow-up interview on 3/4/26 at 1:48 p.m., RN-F confirmed they had not been receiving the communication forms from dialysis regularly for R4, so she had to request the forms yesterday from the dialysis clinic.During an interview on 3/4/26 at 8:28 a.m., RN-C, the dialysis center charge nurse, stated that the dialysis center usually received communication forms from the facility, but the paperwork didn't include a form requesting information, so they had not been sending communication back to the facility. During an interview on 3/4/26 at 9:32 a.m., registered nurse (RN)-B stated that nursing staff were to send a communication form with R4 to dialysis, but were unsure if they were receiving forms back from dialysis, as she hadn't worked with him in a while. RN-B stated that if facility staff were not receiving the forms back from dialysis, she would expect them to call dialysis for an update and then enter a progress note to demonstrate they had done so. At 11:35 a.m., when asked how often weights were supposed to be taken for R4, RN-B stated she checked the medication administration record (MAR)/orders, but did not see that an order was in for measuring R4's weights. RN-B stated after reviewing R4's medical record that she could only find that weights were taken monthly.During an interview on 3/4/26 at 10:24 a.m., nurse practitioner (NP)-A stated she would expect nursing staff to be receiving forms from dialysis so his weights at dialysis can be reviewed three times a week, and then would expect facility staff to be monitoring the resident's weights on the days he was not at dialysis. The NP stated that these weights were important, given his dialysis treatment as well as his diagnosis of congestive heart failure, to ensure timely provider notification and treatment in the case of weight gain that could be caused by fluid.During an interview on 3/5/26 at 9:28 a.m., RN-F stated she expected dialysis to take weights at dialysis and those forms to be sent over after treatment. RN-F stated that if the provider wanted more frequent weights than the ones that were taken at dialysis, she would expect the provider to put an order in for this.Facility Dialysis Care- External Facility policy dated 11/3/21, indicated that shared communication between the dialysis center and the nursing home would be coordinated by the director of nursing and/or the designee. The policy indicated this communication should include post-weight, blood pressure, and dialysis site. The policy did not include the expected frequency of weight measurement at the facility for residents receiving dialysis treatments.

Based on observation, interview and document review, the facility failed to ensure provider orders for weekly weights were implemented and maintained for 1 of 5 residents (R33) reviewed for unnecessary medication. In addition, the facility failed to ensure non-pharmacological interventions were attempted and recorded before administration of as-needed (PRN) pain medication to reduce the risk of potential complications for 2 of 3 residents (R2, R27) reviewed for pain management.Findings include: R33's admission Minimum Data Set (MDS) dated [DATE], indicated R33 was admitted [DATE], no cognitive impairment, no rejection of care, dependent on toileting hygiene, shower/bathe, chair to bed transfer; required substantial/maximal assistance with personal hygiene and roll left and right; diagnoses included obesity, and medications included diuretic increase the excretion of water from the body). R33's care plan dated 1/5/26, indicated risk for malnutrition and interventions included: evaluate exact height obtain weight per facility policy. R33's order summary dated 2/8/25 at 10:14 p.m., registered nurse (RN)-F, known as vice president of clinical services, indicated the weekly weights discontinued, communication method: prescriber written order by: nurse practitioner (NP)-A, reason for discontinue: no longer needed. R33's medication administration record (MAR) dated 2/1/26-2/28/26, indicated weekly weights one time a day every seven days start date 2/2/26, and d/c date 2/8/26. R33's MAR dated 1/1/26-1/31/26, indicated start date 1/1/26, furosemide (diuretic) oral tablet 40 mg (milligrams) give 1 tablet by mouth one time a day for edema. R33's MAR dated 2/1/26-2/28/26, and 3/1/26-3/31/26, indicated start date 1/1/26, furosemide oral tablet 40 mg give 1 tablet by mouth one time a day for edema and start date 2/27/26, furosemide oral tablet 20 mg give 1 tablet by mouth one time a day for edema. R33's provider progress note dated 1/5/26, NP-A indicated orders placed today: weekly weight. R33 provider progress note dated 2/26/26, NP-A indicated orders placed today: increase Lasix to 40 mg PO (oral) QAM (every morning) and Lasix 20 mg PO daily at 2:00p.m., edema. R33's weights and vitals summary indicated the following weights: -12/31/25, 319.5 pounds -2/4/26, 327.6 pounds On 3/5/26 at 8:05 a.m., R33 was observed lying in bed eating breakfast. R33 stated she had not been weighed for quite some time. R33 reported staff had previously weighed her using a Hoyer lift (mechanical lift) scale, but she had not been weighed recently. The resident stated she had not refused weights when offered and stated, It would be nice to be weighed. I don't know how much I weigh and I'm curious too. On 3/5/26 at 8:09 a.m., nursing assistant (NA)-A, stated the nurse provides a list of residents requiring weights. NA-A stated if the resident is on daily weights the nurse informs the NA and reported R33 was previously on daily weights but would refuse and further stated she was not provided R33's name for a weight recently. On 3/5/26 at 8:16 a.m., registered nurse (RN)-E, stated the nurse provides nursing assistants a list of residents requiring weights based on physician orders in the computer. RN-E stated she was not aware of any current weight orders for R33 and upon reviewing the electronic medical record RN-E confirmed no documentation of any recent weights. RN-E further stated that because R33 received Lasix, she would expect more frequent weights. On 3/5/26 at 8:48 a.m., the director of nursing (DON) stated physician orders were entered by the provider into an electronic portal, printed at the nursing station, and entered into the electronic medical record by nursing staff, and then a second nurse verifying the entry. The DON stated the paper copy is placed in the health unit coordinator's office and scanned into the electronic record. The DON stated she had worked at the facility for three weeks and was unable to find documentation of a provider order of R33's weights discontinued. On 3/5/26 at 9:14 a.m., nurse practitioner (NP)-A, stated orders were entered in the portal and transmitted to the nursing floor, where nursing staff enter them into the electronic system. NP-A confirmed that R33 had an order for weekly weights written on admission and confirmed they never wrote an order to discontinue weights. NP-A stated R33 had edema and requires monitoring through weights. NP-A further stated R33's Lasix dose was increased on 2/26/26, due to edema, and she would expect weights to monitor the effectiveness of the medication. NP-A stated if R33 was refusing weights she would expect to be notified, and she would discuss the need for weights with R33 and document any refusal prior to discontinuing the order. NP-A stated she did not know why R33's weights were discontinued and indicated she would place a new order for weekly weights. On 3/5/26 at 9:36 a.m., RN-F, known as the vice president) of clinical services, stated she would clarify the discontinuation of the weight order. On 3/5/26 at 11:04 a.m., RN-F indicated in an email she spoke with NP-A and was unsure why the weight order had been discontinued and stated she would attempt to speak with the nurse who discontinued the order. On 3/5/26 at 11:28 a.m., RN-F stated she thought the weight order may have been discontinued due to R33 refusing weights, however stated there was no documentation in the electronic medical record (EMR) to support this. RN-F stated she would expect documentation in the EMR regarding the refusals, communication to the provider regarding the refusals, and the provider documentation addressing the resident's refusals. RN-F further confirmed she was the nurse who discontinued the weight order, however stated she was not sure why the order was discontinued and reported she thought it may have been due to a telephone conversation she had with NP-A. RN-F stated she would expect a telephone order and documentation in the EMR reflecting the conversation with NP-A. RN-F confirmed there was no current physician order for weights for R33. On 3/5/26 at 1:40 p.m., RN-F indicated in an email and provided a screenshot of her incoming call log with NP-A. The call log indicated a 17-minute telephone call with NP-A on 02/08/2026 at 3:05 PM. However, record review for R33 failed to indicate documentation of this conversation and failed to indicate a physician order authorizing discontinuation of the resident's weight monitoring order. Facility Weight Assessment and Intervention Policy dated 1/4/24, indicated: Resident weights are monitored for undesirable or unintended weight loss or gain. Policy Interpretation and Implementation Weight Assessment 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. 4. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. R2 R2's significant change MDS, dated [DATE], indicated R2 had intact cognition with no hallucinations, delusions, behaviors, or rejection of care. MDS indicated R2 was on an antipsychotic, antidepressant, antianxiety and opioid medication. R2's medical diagnosis report, printed 3/5/26, included the following diagnoses: post-traumatic stress disorder (PTSD-mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events like violence, disasters or abuse), schizoaffective disorder (chronic mental health condition that is characterized by combination of schizophrenia symptoms such as hallucinations or delusions along with a major mood disorder including depression or mania), and adjustment disorder with mixed anxiety and depressed mood (mental health condition caused by a specific stressor). R2's care plan, printed 3/2/26, identified R2 had chronic pain and listed the goal of resident will report satisfactory pain control. The care plan listed interventions to help R2 meet this goal which were the following: - Administer pain medications per order, if non-medication interventions are Ineffective - Apply hot or cold packs for comfort - Evaluate effectiveness of pain-relieving interventions (non-medication and medication) - Utilize non-medication interventions for pain relief R2's March Medication/Treatment Administration Record (MAR/TAR), printed 3/4/26, included the following: -methocarbamol (medication used to treat muscle pain and stiffness) 750 milligram (mg) tablet- give 750 mg by mouth every 6 hours as needed for muscle spasms and cramping pain with a start date of 1/12/26 which had been administered 6 times so far in March. Administrations documented with an e indicating effective. There was no documentation on the MAR of a pain scale prior to administration of the medication. In addition, there was no documentation on the MAR of nonpharmacological interventions prior to administration. R2's February MAR/TAR, printed 3/4/26, included the following: -methocarbamol (medication used to treat muscle pain and stiffness) 750 milligram (mg) tablet- give 750 mg by mouth every 6 hours as needed for muscle spasms and cramping pain with a start date of 1/12/26 which had been administered 57 times. All administrations documented with an e indicating effective except 2 were documented with u indicating unknown. In addition, there was no documentation on the MAR of nonpharmacological interventions prior to administration. R2's progress notes, dated 2/1/26 to 3/4/26, were reviewed and lacked evidence of nonpharmacological interventions being offered or attempted prior to administration of medication for pain. R2's medical record was reviewed and lacked evidence of what, if any, nonpharmacological interventions were officered or attempted prior to administration of PRN pain medication. During an interview on 3/2/26 at 12:46 p.m., R2 stated she has arthritis all over and hurts. R2 stated she has bursitis in her hips. R2 stated she has not been offered any nonpharmacological interventions for her pain and would like to be. R2 stated she thinks it might be helpful with some of the pain. During an interview on 3/4/26 at 1:24 p.m., DON stated the expectation would be nonpharmacological interventions would be offered prior to giving any medication for pain. DON stated it would be documented in the progress notes or on the MAR. DON stated she could not find that nonpharmacological interventions were offered prior to administration for R2 and should have been. DON stated she would provide additional information if able to find it. No additional information was provided. During an interview on 3/4/26 at 1:33 p.m., RN-A stated they would offer a nonpharmacological intervention for pain depending on the resident's condition and if they thought it was appropriate. RN-A stated if they offered a nonpharmacological intervention, they would document it in the progress notes. During an interview on 3/5/26 at 9:25 a.m., RN-F also known as vice present of clinical services stated the expectation would be if a medication was given for pain, then a nonpharmacological intervention should be offered and documented prior to that administration. R27 R27's significant change MDS dated [DATE], indicated R27 had intact cognition and was diagnosed with heart failure, kidney failure, diabetes, and arthritis. MDS indicated R27 received scheduled pain medications, PRN pain medications, and did not receive non-medication interventions for pain. MDS indicated the resident had pain or hurting frequently in the past 5 days of the look back period (LBP) and had almost constantly limited her day-to-day activities related to pain during the past five days of the LBP. R27's care plan dated 12/18/25, indicated R27 had a history of chronic pain. The care plan identified the following interventions:-Apply hot or cold packs for comfort.-Encourage times of rest and relaxation between care activities.-Medicate with as-needed medications if non-medication interventions are ineffective.-Utilize non-medication interventions for pain relief. R27's medication administration record dated 2/1/26 to 2/28/26, included the following as-needed pain medications:-Five mg of oxycodone daily as needed started on 12/30/25 and discontinued 2/5/26. This medication was given under this order five times during this period.-Five mg of oxycodone started on 2/5/26 and discontinued on 2/13/26. This medication was given under this order seven times during this period.-Five mg of oxycodone (a narcotic pain medication) every 12 hours as needed, started on 2/18/26. This medication was given under this order 12 times during this period.-500 mg of methocarbamol (a muscle relaxer) twice a day as needed, started on 1/12/26 and discontinued on 2/13/26. This medication was given under this order 10 times during this period. -500 mg of methocarbamol every eight hours as needed for muscle spasms started on 2/18/26. This medication was given under this order seven times during this period.-This totals to 24 doses of oxycodone and 17 doses of methocarbamol during this period. R27's progress notes dated 2/1/26 to 2/28/26 were reviewed and included the following notes:-Dated 2/7/26 at 3:32 p.m., indicated R27 was repositioned, and as needed, methocarbamol was given.-Dated 2/10/26 at 4:42 p.m., indicated R27 had reported leg pain, so as needed, methocarbamol was given, and R27 was repositioned.-The admission note dated 2/18/26 at 3:30 p.m., indicated R27 was repositioned, and as needed, methocarbamol was given.-dated 2/18/26 at 8:55 p.m., indicated R27 was repositioned and requested as needed methocarbamol.-dated 2/20/26 at 3:23 p.m., indicated R27 was repositioned and requested as needed methocarbamol. At 3:25 p.m., R27 was repositioned and requested as needed oxycodone.-No further progress notes regarding attempting or offering nonpharmacological interventions before administering as-needed oxycodone or methocarbamol were found. Notes indicating heat or ice were attempted to assist in pain management per the care plan were not found. R27's medical record was reviewed and lacked further documentation of attempting or offering nonpharmacological interventions before administering as-needed oxycodone or methocarbamol. R27's Weights and Vitals Summary dated 2/2/26 to 3/2/26, included pain scores taken almost daily, ranging from zero to ten, with 57 total scores recorded. R27 had a pain score of seven or higher 24 times during the period. During an interview on 3/2/26 at 12:35 p.m., R27 stated she has had chronic pain for a long time and has been on narcotics for pain management for about 12 years. R27 stated she got pain from spasms in her back and occasional pain in her shoulders and legs. R27 stated she got as-needed pain medications, but they didn't do much of anything. R27 stated that facility staff had only offered her nonpharmacological pain interventions, such as ice or heat, once since she was admitted to the facility, but would be willing to try it. During an interview on 3/3/26 at 10:33 a.m., RN-D confirmed she was R27's nurse for the day. RN-D stated when R27 when R27 complained of pain, she administered as-needed pain medications. RN-D stated R27's pain was usually in her shoulders, in her muscles, or all over. When asked about non-pharmacological interventions, RN-D stated she did not usually attempt non-pharmacological pain interventions with R27 and was unaware of what non-pharmacological interventions worked for R27's pain. When asked where information regarding R27's preferred non-pharmacological pain interventions could be found, RN-D was unsure. During an interview on 3/5/26 at 9:28 a.m., RN-F also know as vice president of clinical services stated she would expect nursing staff to attempt non-pharmacological pain interventions prior to administering as-needed pain medications. Facility Pain- Clinical Protocol policy dated 6/9/25, indicated the provider would order non-pharmacological and medication interventions to address an individual's pain. The policy indicated that generally and to the extent possible, the pain regimen should utilize the simplest regimen and lowest risk medications before using more problematic or higher risk approaches.

Based on interview and document review, the facility failed to ensure antihypertensive (blood pressure) medication were administered or held per physician orders for 1 of 1 resident (R1) reviewed.Findings include:R1's admission Minimum Data Set (MDS, dated [DATE], indicated R1 had intact cognition with no hallucinations, delusions, no behaviors, wandering or rejection of care. MDS indicated R1 was independent with all activities of daily living (ADLs) except for transfers ambulation, and picking items off the floor which required supervisionR1's medical diagnosis report, dated 3/5/26, included the following diagnoses: type 2 diabetes with diabetic nephropathy, legal blindness, acute kidney failure, and chronic kidney disease.R1's care plan, printed on 3/2/26 lacked identification R1 was on blood pressure medication. Furthermore, lacked any intervention to monitor for low blood pressures or signs/symptoms of low blood pressures.R1's Order Summary Report, as of 3/2/26, included the following orders:-antihypertensive medication: Hold parameters: Hold 100 or HR 1ess than 50 and +MRSA/Nares with an order date of 12/15/25.-Daily vitals one time a day with an order date of 2/14/26 and a start date of 2/15/26.- lisinopril (medication used to treat high blood pressure) 10 milligram (mg) tablet - give one tablet by mouth one time a day for high blood pressure with an order date of 12/11/25 and start date of 12/12/25R1's March Medication and Treatment Administration Record (MAR/TAR), printed 3/3/26, included the following:-Antihypertensive medication Hold parameters: Hold 100 or HR 1ess than 50 -lisinopril (antihypertensive medication used to treat high blood pressure) 10 milligram (mg) tablet - give one tablet by mouth one time a day for high blood pressure with a start date of 12/12/25. The record identified the medication was administered every day in March. -daily vitals one time a day with a start date of 2/15/26 with the following readings:-3/3/26: BP was 102/60 and pulse was 88-3/2/26: BP was 112/76 and pulse was 76-3/1/26: BP was 101/61 and pulse was 85 R1's February MAR/TAR included the following:-Antihypertensive medication Hold parameters: Hold 100 or HR 1ess than 50-lisinopril 10 mg tablet - give one tablet by mouth one time a day for high blood pressure with a start date of 12/12/25. The record identified the medication was administered every day in February except 2/25 which was marked with a 4 indicating vital signs out of parameters. -daily vitals one time a day with a start date of 2/15/26 with the following readings:-2/28/26: BP 98/60 and pulse 78 (hold parameters met, medication administered)-2/27/26: BP 101/62 and pulse 75-2/26/26: BP 104/67 and pulse 72-2/25/26: BP 99/57 and pulse 73 (hold parameters met, medication held)-2/24/26: BP 94/64 and pulse 77 (hold parameters met, medication administered)-2/23/26: BP 87/58 and pulse 85 (hold parameters met, medication administered)-2/22/26: BP 70/47 and pulse109 (hold parameters met, medication administered)-2/21/26: BP 159/87 and pulse 68-2/20/26: BP 105/66 and pulse 72-2/19/26: BP 103/68 and pulse 72-2/18/26: BP 96/59 and pulse 62 (hold parameters met, medication administered)-2/17/26: BP 98/61 and pulse 66 (hold parameters met, medication administered)-2/16/26: BP 126/77 and pulse 78-2/15/26: BP 101/64 and pulse 81For the month of February, since the daily vital sign order was entered, R1's blood pressures were low enough to meet the parameters to hold the blood pressure medication 7 of 14 possible medication administrations, was held one time and administered 6 times. R1's progress notes, dated 2/1/26 to 3/3/26, were reviewed and lacked evidence of notification to provider of low blood pressures or medication being held on 2/25/26.During an interview on 3/2/26 at 2:19 p.m., R1 was interviewed via interpreter. R1 had no complaints of dizziness or lightheadedness. R1 stated the nurses take his blood pressures.During an interview on 3/3/26 at 9:45 a.m., registered nurse (RN)-A stated if a resident was on a blood pressure medication, then their blood pressure was taken before administration. RN-A stated the resident should have an order for parameters meaning if the blood pressure or pulse are not at a certain level then the medication should be held. RN-A stated it is important to follow those orders as not following orders would be an error. RN-A stated if they hold the medication due to vital signs, they would notify if the vital signs are very dangerous such as the bottom number of the blood pressure being in the 30or 40's . RN-A stated they monitor their residents every day. RN-A stated if a resident was having lower blood pressures or the medication was held for a few days in a row without dangerously low vital signs, they would notify the provider to update them. RN-A stated they would put a progress note in about notifying the provider.During a follow up interview on 3/3/26 at 1:34 p.m., RN-A stated they are familiar with R1 and use an interpreter for communication with him. RN-A stated R1 had not complained of any dizziness or lightheadedness that they were aware of. RN-A verified R1 medication orders and parameters to hold medications. RN-A verified R1 had been receiving antihypertensive medications with low blood pressures and should not have been as was not following the orders.During an interview on 3/3/26 at 1:45 p.m., director of nursing (DON) stated the expectation would be antihypertensive parameters would be followed, and providers would be updated. DON stated they would expect the provider to be notified each time the blood pressure was low, and medication held. DON reviewed R1 chart and verified the dates listed above and medication should have been held, and provider should have been updated. DON verified this was an medication error. DON reviewed the chart and verified the provider had not been notified. DON was going to follow up to see if she could find additional information. During an interview on 3/3/26 at 2:05 p.m., nurse practitioner (NP)-A stated she would expect to be notified with each low blood pressure so she can make the appropriate changes if needed. NP-A stated she had not been notified of any low blood pressure reading for R1 and stated she should have been. NP-A stated she would see R1 during rounds tomorrow (3/4/26). NP-A stated there are risks involved with giving antihypertensive medications to a person with low blood pressure such as dizziness, cognitive changes, increased risk of falls, syncope and altered level of consciousness.During a follow up interview on 3/4/26 at 8:14a.m., DON verified the provider had not been notified about the low blood pressures for R1. DON stated she talked to NP-A yesterday, after talking to surveyor about R1 blood pressure and medication. DON stated the medication should have been held and the provider should have been notified with the first low pressure. DON stated she had started providing re-education to the nurses on the floor, in light of the error, on holding blood pressuring medications when the parameters are not met, notifying the provider and the steps that need to be taken. During an interview on 3/5/26 at 9:26 a.m., RN-F also known as vice president of clinical services stated the expectation would to be follow the orders, hold the medication and call the physician. Facility Medication Errors policy, updated 8/13/22, identified the policy was to To provide guidance for identifying and reporting medication errors. A root cause analysis will be identified and changes to the policy and procedure will be reviewed and implemented as needed to prevent future errors.

Based on interview and document review, the facility failed to ensure provider's orders for urinalysis were completed for 1 of 2 residents (R57) reviewed for discharge. Findings include: R57's face sheet printed 3/3/26, indicated admission date of 12/24/25, diagnoses of malignant neoplasm of parts of nervous system (cancer), repeated falls, muscle weakness, and schizoaffective disorder.R57's care plan revised 1/13/26, indicated risk for falls, limited to extensive assistance for dressing, independent for eating, extensive assistance for personal hygiene and toilet use.R57's discharge return not anticipated Minimum Data Set (MDS) dated [DATE], indicated intact cognition, no rejection of care, independent with eating, dependent for toileting hygiene, partial/moderate assistance for upper body dressing, lower body dressing, footwear, set up or clean up assistance for personal hygiene, partial/moderate assistance for going from sitting to lying, lying to sitting, sit to stand, and transfer to and from wheelchair, substantial/maximal assistance for tub/shower transfer.Facility electronic health record (EHR) nursing note dated 1/5/26, indicated R57 was found going up a hill in her scooter (motorized wheelchair), appeared to be very confused, and did not know where she was. People (unknown) driving by helped her back to the facility.Provider order by nurse practitioner (NP)-A dated 1/5/26 at 5:48 p.m., indicated urinalysis (UA) with culture per new onset change in level of consciousness (LOC)/confusion. Provider order by NP-A dated 1/6/26 at 9:35 a.m., indicated: Labs: collect urine sample for UA/Culture. Diagnosis: Rule out urinary tract infection (UTI).Facility was unable to confirm urine was collected per order and did not provide results. In an email provided by RN-F, also known as vice president of clinical operations, on 3/5/26, stated It appears that it wasn't collected. The lab has no record either. RN-F then provided urinalysis results from R57's M Health Fairview Southdale hospital encounter note dated 1/10/26, the time of her arrival to the emergency department following her discharge home.During interview on 3/5/26 at 10:18 a.m., registered nurse (RN)-F also known as vice president of clinical services stated she would expect provider orders to be followed promptly to ensure proper treatment for residents.Facility Acute Condition Changes-Clinical Protocol policy undated, indicated: The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results. If necessary, the physician will order diagnostic tests and evaluate the patient directly. In addition, the nurse shall assess and document/report the following baseline information: Recent labs.

Based on interview and document review, the facility failed to ensure identified dental concerns (i.e., broken missing teeth, need for appointment) were acted upon and, if needed, referred to the appropriate resource in a timely manner for 1 of 1 resident (R2) reviewed who voiced dental complaints during the survey.Findings include:R2's significant change Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition with no hallucinations, delusions, behaviors, or rejection of care. Furthermore, MDS indicated in Section L: Oral/Dental Status: R2 had obvious or likely cavities or broken natural teeth.R2's care plan, printed 3/2/26, lacked identification of R2's needs with oral hygiene. Furthermore, R2's care plan lacked evidence of R2's dental needs. R2's Social Service Care Conference Note, dated 10/1/25, indicated R2 attended the care conference along with staff. In the Social Services section, a note indicated dentist and ostomy referral.During an interview on 3/2/26 at 12:44 p.m., R2 stated she needed to go to the dentist to get her teeth fixed. R2 stated she had not been to the dentist since being at the facility and the facility had not offered to assist with any dental appointment. R2 stated she doesn't have dental pain but has many upper teeth that are missing and broken. R2 stated she also has many teeth on the bottom that are broken.During an interview on 3/3/26 at 1:33 p.m., registered nurse (RN)-A stated the health unit coordinator (HUC) sets up all the appointments for residents. RN-A stated nursing does not set up any appointment. During an interview on 3/4/26 at 8:08 a.m., HUC-A verified she was the health unit coordinator for the facility and was responsible for appointments for residents. HUC-A stated she was new to the position. HUC-A stated following any appointment, including dental appointments, the notes would be uploaded into the resident's medical record. HUC-A stated she was going to follow up with supervisor regarding any dental appointments for R2. During a follow up interview on 3/4/26 at 9:35 a.m., HUC-A stated residents are referred out for dental visits as the facility does not have a dental provider that comes to the facility. HUC-A stated residents are seen on individual needs and requests. HUC-A stated the facility was unaware that R2 wanted to go the dentist or had dental concerns. HUC-A stated they would schedule an appointment for her. HUC-A stated was not able to locate any documentation when R2 was last seen by a dentist. During an interview on 3/4/26 at 1:20 p.m., director of nursing (DON) stated the facility does not have a dentist that comes to the facility and residents are referred to the community for dental appointments. DON stated the expectation would be residents are seen annually for dental appointments and more frequent if there are concerns. DON reviewed R2's care conference note and verified R2 was to be referred to be seen be a dentist. DON stated it would be expected that R2 would seen by a dentist at the appointment and should have been done by this time as the care conference was dated 10/1/25 which was 5 months ago. DON stated she would follow up to see if she could find additional information. No additional information was provided.During a follow up interview on 3/4/26 at 1:42 p.m., RN-A stated she was not aware of any dental pain complaints from R2. RN-A was unsure of any recent dental appointments for R2. During an interview on 3/5/26 at 9:24 a.m., RN-F also known as vice present of clinical services stated the expectation would have be a resident would be seen within a couple of months if they expressed a desire to see a dentist at a care conference. Facility Dental Services policy, revised 12/2016, indicated the following: Routine and 24-hour emergency dental services are provided to our residents through:a contract agreement with a licensed dentist that comes to the facility monthly;referral to the resident's personal dentist;referral to community dentists; orreferral to other health care organizations that provide dental services. Furthermore, all dental services provided are recorded in the resident's medical record. A copy of the resident's dental record is provided to any facility to which the resident is transferred.

Based on observation, interview and document review, the facility failed to ensure identified preferences for menu selection were honored for 1 of 3 residents (R27) reviewed for nutrition. Findings include:R27's significant change Minimum Data Set (MDS) dated [DATE], indicated R27 had intact cognition with no behaviors exhibited. The MDS indicated R27 was diagnosed with heart failure, kidney failure, diabetes, and arthritis. The MDS indicated R27 was independent with the ability to use utensils to bring food or liquids to her mouth once the meal was placed in front of her. R27's registered dietician note dated 1/6/26 at 5:11 p.m., indicated R27 had a diagnosis of diabetes, and her blood sugars were mostly less than 200 milligrams/deciliter (mg/dl), indicating adequate control. and R27's only concern at that time was that her blood sugars were higher and she would prefer to have a diabetic diet instead of a regular diet. The note indicated the dietician recommends providing a diabetic diet and notified nursing and the dietary manager. R27's care plan dated 1/24/26, indicated R27 had impaired nutrition based on congestive heart failure, diabetes, kidney disease, etc. The care plan indicated staff should encourage resident participation in meal planning and provide the diet as ordered. R27's Order Summary Report dated 2/18/26, included a diet order for a consistent carbohydrate (a food nutrient that turns into blood sugar when processed by the body) diet dated 2/18/26.The facility [NAME] Chateau Weekly Menu dated 3/2/26 to 3/8/26, indicated the noon meal on Monday (3/2/26) was a Philly cheesesteak, crinkle cut fries, chef's choice vegetable, dessert, and milk. The menu indicated the noon meal on Tuesday (3/3/26) was a baked chicken drumstick, twice-baked potato, chef's choice vegetable, garlic bread, dessert, and milk.R27's Noon Meal slip dated 3/2/26, indicated R27 would receive a Philly beef sandwich, seasoned fried, chef's choice vegetable/mixed vegetables, chef's choice dessert, and milk. R27's Noon Meal slip dated 3/3/26, indicated R27 would receive a baked chicken drumstick, twice-baked potato, blended vegetables, garlic bread, chef's choice dessert, and milk. During an observation and interview on 3/2/26 at 12:43 p.m., R27 was observed lying in bed with a meal tray in front of her. The meal consisted of a cup of mixed vegetables that appeared to be peas, green beans, and corn. The meal also included a hot dog-style bun with what appeared to be strips of cooked dark meat and green peppers, a chocolate chip cookie, a side of crinkle-cut French fries, a four fluid ounce container of apple juice, and a small carton of low-fat milk. R27 stated she was supposed to be on a consistent carbohydrate diet, but felt she was not getting this as all of her meals were high in carbohydrates. R27 stated she never asked for juice and wished that she would stop receiving it, as it was high in carbohydrates. R27 stated she felt the diet she was receiving was affecting her ability to control her blood sugars, so she wanted a lower-carbohydrate diet. R27 stated she had talked with the dietician and thought that she was going to get a diabetic diet, but that never happened. During an observation and interview on 3/3/26 at 12:18 p.m., R27 was observed with a meal tray in front of her. The meal consisted of a small carton of two percent milk, a four fluid ounce container of apple juice, two chicken drumsticks, half of a baked potato that appeared to have additional potato stacked on top, a full piece of bread, and a piece of cake. Additional resident trays, with correlating regular diet meal tickets, were reviewed with similar-sized portions and meal items on all trays. During an interview on 3/3/26 at 12:27 p.m. with cook (C)-A and the dietary director (DD), CC-A stated she would go off the diet slips to determine what menu items and portion sizes residents got on different diets. CC-A stated that sometimes the slips might have them change what items are given, such as giving a chicken breast instead of a chicken drumstick. The DD stated that although the facility does utilize diet slips for giving instructions to staff on what food items to give residents, they did not yet have this set up for a consistent carbohydrate diet/ diabetic diet. The DD stated that at this time, if a resident was on a consistent carbohydrate diet, they would receive the same food as a resident on a regular diet, as she had not set up a different menu with the vendor yet. The DD stated she would call the vendor's dietician and get a menu set up so a resident on a consistent carbohydrate diet would receive a menu that aligned with this. During an interview on 3/5/26 at 8:41 a.m., dietician (D)-A stated the biggest difference between a regular diet and a consistent carbohydrate diet was ensuring the carbohydrates were consistent for these residents, would generally include fewer carbohydrates than a regular diet, and could help assist a resident in managing their blood sugars. Facility Therapeutic Diet policy dated 2/23/23, indicated that when necessary, the facility would provide a therapeutic diet that was individualized to the resident's needs and desires to assist the resident in achieving their goals of care. The policy indicated that the therapeutic diets should coincide with the therapeutic diets on the facility's menu extensions.

Based on observation, interview, and record review, the facility failed to assess and implement individualized interventions to ensure safe independent community access for 1 of 3 residents (R1) who had expressive aphasia and cognitive impairment and went on community outings independently placing R1 at risk for inability to effectively communicate needs or obtain assistance while unsupervised in the community.Findings include:A vulnerable adult maltreatment report dated 2/14/26 indicated R1 had been out in the community independently without staff or family escort. R1 was unable to articulate clear responses to questions or needs, and information could not be obtained easily.R1's diagnoses list dated 2/20/26 included stroke, bipolar disorder, aphasia (a communication disorder resulting from brain damage), diabetes type II, anxiety disorder, other symptoms and signs involving cognitive functions and awareness, and encephalopathy. R1's admission Minimum Data Set, dated [DATE] indicated R1 had moderate cognitive impairment, had no speech but could be understood by others (verbally and non-verbal). R1 did not have functional range of motion deficits and did not use assistive devices to ambulate. The MDS identified R1's ability to ambulate functional community distances, navigate uneven surfaces, manage curbs/steps, or perform car transfers were marked Not assessed/no information. R1's care plan dated 12/19/25 indicated R1 was independent with all activities of daily living, transfers, and ambulation. R1's care plan included a focus of resident is a vulnerable adult due to communication impairment with an intervention of provide clear, simple instructions and a focus of risk for impaired communication evidenced by aphasia with intervention of incorporate visual prompting, cues or gestures.R1's nursing note dated 2/12/26 at 11:22 a.m., informed R1 had left for an outing at 10:45 a.m. to be back at 12:30 per R1.R1's nursing note dated 2/14/26 at 9:54 a.m. informed R1 had left for an outing and had received breakfast and morning medications.R1's nursing note dated 2/19/26 at 9:54 a.m. informed R1 had left the facility at 9:00 a.m. and was expected to return at 1:00 p.m.In review of R1's record between 12/19/25 through 2/19/26, there was no documentation of a completed assessment determining R1's ability to safely navigate community environments, manage emergencies, or obtain assistance while outside the facility.During an observation and interview on 2/19/2026 at 1:42 p.m., R1 was observed walking independently in his room. During interview, R1 was slow to respond with words. He used arm gestures to assist with communication. R1 indicated through hand gestures he had left the facility (pointed to himself in place of the word me and stated, I can do everything. R1 would use his cell phone to call family if he needed help and demonstrated how to call two family members. R1's contact list did not contain a phone number and address for the facility. (R1 ended the interview before any other questions could be asked.) During an interview on 2/19/2026 at 4:13 p.m., nursing assistant (NA)-A stated if a resident could walk, was independent and did not wear a Wander guard (a device used to alert staff when a resident attempted leave the facility) the resident could leave the facility independently if they signed out. NA-A would alert the nurse if a resident wanted to leave the facility. NA-A did not know if there was a list of residents who were safe to go into the community independently.During an interview on 2/20/2026 at 10:30 a.m. NA-B stated he would look in a resident's care plan to learn if the resident was safe to leave the facility independently. NA-B did not find any information about leaving the facility in R1's care plan. NA-B would ask a nurse if R1 wanted to go out of the facility.During an interview on 2/19/2026 at 4:00 p.m. registered nurse (RN)-A stated a resident could leave the facility with a responsible person. RN-A did not know if there was an assessment used to determine if a resident was safe to go into the community independently. RN-A indicated R1 would be vulnerable in the community because R1 was difficult to understand and could get agitated quickly when other people did not understand what he was trying to say. If R1 wanted to go into the community, RN-A would ask him where he wanted to go, try to convince him to stay at the facility, and call R1's son.During an interview on 2/20/2026 at 9:11 a.m., RN-B stated she would look to see if a resident had a provider order to leave the facility. RN-B confirmed R1 did not have a provider order instructing R1 could leave the facility independently nor was there any information in his care plan. When a resident wanted to leave the facility, they needed to tell a nurse and sign out. R1 went out of the facility frequently. He was good at caring for himself but had trouble with speaking. R1 would get angry with staff when staff did not understand what R1 was saying. RN-B stated to assist with communication an information sheet could be created for R1 to take with him when he leaves the facility with R1's name, basic information like he has trouble speaking, family phone numbers and facility name and phone number.During an interview on 2/19/2026 at 4:21 p.m., speech therapist (ST-A) stated R1 had a form of expressive aphasia where the brain knew which word to say but the processing was not occurring in the brain to tell the mouth how to say the word. When provided with a short, written list of possible answers, R1 would point to the correct answer after thinking for a short time. ST-A had not been consulted regarding R1's ability to go into the community independently but ST-A would have concerns related to communication. ST-A stated a written list of words to point to might assist R1 with communication while in the community.During an interview on 2/20/2026 at 12:12 p.m., occupational therapist (OT-A) stated she had never been asked to assess a resident for safety in the community. During an interview on 2/20/2026 at 2:42 p.m. vice president of clinical services (VP) stated she looked at a resident's hospital history and physical, the elopement assessment and a resident's cognition to assess if a resident was safe to go into the community safely. VP would document in a resident's care plan if they were not safe to leave the facility safely by themselves. During an interview on 2/20/2026 at 3:50 p.m. nurse practitioner stated she would expect the facility to do an assessment including cognition, mobility, and ability to do things for themself like cross the street, get on a bus or use money before a resident goes out into the community independently.Facility policies did not address protocols and criteria for residents to leave the facility independently.The Resident Leave of Absence policy dated 1/13/2026 instructed a resident can choose to leave the facility for limited periods for therapeutic reasons. Residents leaving the facility must sign the designated leave of absence book with time leaving the facility, expected return time and purpose for the pass. Residents who have responsible parties will be contacted for approval. The Care Plans, Comprehensive Person-Centered policy dated 11/13/25 instructed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs must be developed and implemented for each resident. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

The facility failed to ensure appropriate interventions to prevent elopement for 1 of 3 residents (R1) who was assessed to be an elopement risk. This resulted in an Immediate Jeopardy (IJ) when R1 was able to leave the facility, get on a city bus where she was found three hours and 15 minutes later at the Mall of America (5.8 miles away). The immediate jeopardy began on 2/10/26 at approximately 2:30 p.m. when R1 was able to leave the facility after demonstrating exit seeking behaviors without appropriate individualized interventions to prevent elopement. The immediate jeopardy was identified on 2/13/26, and the administrator and director of nursing were notified of the immediate jeopardy at 2/13/26 at 4:10 p.m. The immediate jeopardy was removed on 2/10/26, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's face sheet dated 2/12/26, identified she was admitted to the facility on [DATE] with diagnoses of repeated falls, dizziness and giddiness, unspecified mental disorder and dementia with other behavioral disturbance. R1's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated R1 was cognitively intact, would reject care 1-3 days of the week and required partial or moderate assistance for activities of daily living. R1 used a wheelchair. R1's elopement risk assessment dated [DATE] indicated R1 was an elopement risk (score of 3) because she had verbally expressed the desire to go home, had wandering behavior, was recently admitted to the facility and was not accepting the situation. Clinical suggestions included notifying staff of wandering and elopement risk, utilizing exit alarms, and monitoring location frequently. R1's care plan dated 2/3/26 had a focus section for wandering/elopement. Goal of R1 would not leave the facility unattended and would remain safe. Interventions as follows; -2/3/26 identify wandering/elopement de-escalation behaviors -2/3/26 provide reorientation to surroundings, environment R1's nursing order dated 2/4/26, directed to check R1's wander guard on her wrist daily and check wander guard function weekly. R1's progress note dated 2/3/26 included R1 indicated she wanted to go back to where she was before, could not elaborate where that place was. Elopement assessment completed. Wander Guard placed. R1's progress note dated 2/6/26 included returned from hospital alert with confusion. R1's progress note dated 2/7/26 included R1 was wandering, attempting to elope and hitting staff. R1 was sitting on floor, said she was looking for husband. R1 is alert and oriented to self with confusion at baseline. R1's progress note dated 2/8/26 included R1 was one on one previous shift, attempted to leave facility. R1 became aggressive toward staff when redirected, refused to go to bed. R1's progress note dated 2/10/26 at 10:00 a.m., included R1 came out to the hallway undressed and started kicking and cursing at staff. At 2:08 p.m. staff could not locate R1. R1 was waiting in the common area for her transportation that did not show up. Management was notified and staff started a search. R1 was found safe at the Mall of America and transferred to the new facility. R1's incident report dated 2/10/26, included the following description of the incident; The DON was informed that resident was not in the facility. Facility search was initiated in and outside of the facility. The DON called the transportation company; the representative reported the driver went to the wrong address. 911 and metro police were called. Camera footage was reviewed. Elopement education was initiated. R1's predisposing physiological factors were impaired memory. R1's predisposing situation factors was being an active exit seeker. R1's predisposing situation factors was being a wanderer. R1's progress note dated 2/10/26 at 8:42 p.m., indicated R1 was admitted to the receiving facility and had chronic disorientation and some confusion. R1 had chronic short term memory loss. During a facility tour on 2/12/26 at 3:00 p.m., the nursing home is located off of 7th Street [NAME] in Saint [NAME]. There are several bus stations within walking distance. On 2/10/26 at 3:00 p.m., the temperature in Saint [NAME] was 35 degrees Fahrenheit per Timeanddate.com During an interview on 2/13/26 at 9:45 a.m., nursing assistant (NA)-A stated she was assigned to R1 during the morning of 2/10/26. R1 had previous exit seeking behaviors and on 2/10/26 R1 had behaviors with not wanting to get dressed. NA-A said it was difficult to keep track of residents during shift change and could not explain how R1 eloped from the building while assigned to NA-A. R1 would not be safe by herself in the community. R1 could have had an accident going down the hill in her wheelchair. NA-A had received re-education following the elopement pertaining to monitoring residents with wander guards or exit seeking behavior. During an interview on 2/13/26 at 12:19 p.m., NA-B stated he was working with R1 during the 2/10/26 day shift and she kept trying to get out of her wheelchair. R1 kept approaching the exit and setting the wander guard off. NA-B had been assigned to watch R1 in the common area from around 12:10 p.m. to 1:30 p.m. At 1:30 p.m., it was RN-A and NA-A's turn to watch R1 while NA-B took a break. NA-B returned from break at around 2:00 p.m. and R1 was missing. NA-B joined the search; other staff were trying to determine why the wander guard alarm did not go off. Re-education was given to check wander guards, be aware of who was coming in and out of the building. NA-B thought the issue was the business of shift change, staff may have forgotten to watch her while giving her a hand off report. During an interview on 2/13/26 at 10:15 a.m., RN-A stated on 2/10/26 at 12:30 p.m. she had been communicating with management about R1's scheduled transportation that did not show up to transfer her to a sister facility as previously arranged. R1 was being watched by staff in the common area right before the elopement. That day R1's demeanor was that she was ready to go to the new facility, she had packed her things and was waiting. Around 2:00 p.m. at shift change, staff left to find replacement to supervisor her, but when they returned R1 was unable to be located. Management and police were notified. Staff were unsure if R1's wander guard alarmed or not, if someone helped her out the door or how she was able to exit the building. R1 was still wearing her wander guard when she was found. R1 would not be safe by herself in the community, she was sometimes only alert to herself. RN-A was not aware of R1's previous exit seeking behavior. RN-A had received re-education following the elopement pertaining to monitoring residents who are elopement risks and how to complete the elopement risk assessment form. During an interview on 2/13/26 at 10:45 a.m., licensed practical nurse (LPN)-A, stated that she arrived at her shift on 2/10/26 at around 2:30 p.m. RN-A gave report- explained R1 went missing. RN-A and LPN-A helped with the search for R1. LPN-A explained R1 was very confused at times and was at high risk of falling. R1 was not easy to re-direct and would refuse cares. R1 was often kept at the nursing station for increased supervision. R1 would not be safe by herself in the community. LPN-A received re-education following the elopement pertaining to monitoring residents who are elopement risks and how to complete the elopement risk assessment form. During an interview on 2/13/26 at 12:05 p.m., director of nursing (DON) stated R1 demonstrated confusion in the days prior to the elopement. On 2/3/26, the DON was talking to R1 when she made elopement related comments. The DON then put the wander guard order in and updated R1's care plan. R1 had been increasingly confused, staff were trying to determine if her dementia was worsening or if she had a urinary infection. on 2/10/26 she helped with the search and confirmed staff did not know how R1 got out of the building. The DON had been in contact with the transport company; the transport company had arrived at the wrong address. At around 5:30 p.m., R1 was located at the mall and at around 6:30 p.m., R1 arrived at the new nursing home. The DON was working on providing education, which consisted of making sure staff are checking each wander guard alarm, completing midnight census to make sure all residents are accounted for and completing the elopement risk assessment accurately. During an interview on 2/13/26 at 11:34 a.m., the administrator in training stated she helped direct staff on where to start searching for R1. The administrator looked at the facility's cameras, but the inside of the exit door was not within view of the cameras. R1 could be viewed from outside of the facility, she could be seen talking to other residents who were smoking. R1 then saw some turkeys and began to follow them down the hill. The administrator was unable to determine if another person helped R1 get out of the facility or if she was able to herself. The administrator verified the police officer involved did not create a police report for the incident. During an interview on 2/13/26 at 11:51 a.m., the administrator stated she was notified of the elopement almost immediately. The administrator directed staff to check the cameras, make a report to the state agency, update the provider and family members and start any immediate re-education for staff. The administrator contacted the regional team who started calling the local hospitals and police. One staff member looked at bus routes and noticed most of the bus lines ended at the Mall of America. The Mall of America security team was contacted, and they were able to locate R1 within about 20 minutes. The administrator identified several areas of improvement including supervision while waiting for transport and checking the wander guard alarms. Leadership was looking at getting another camera so the inside of the exit door can be viewed on security footage. Staff were unable to determine how R1 got through the back exit door. During an interview on 2/13/26 at 1:07 p.m., representative (REP)-A from the wander guard system company stated staff should be checking the wander guard bracelets weekly and the doors weekly. REP-A was unable to verify if the specific model on the exit door had alarm logs or not. On 2/13/26 at 8:33 a.m., an alarm log for the wander guard system was requested but not provided. During an interview on 2/13/26 at 1:50 p.m., maintenance staff (MAIN)-A stated he tests the wander guards monthly, floor staff would be responsible for the weekly checks of the door and bracelets. Staff would alert maintenance if the wander guard system was not working. There had been no issues with the wander guard system prior to the elopement. After the elopement, the wander guard system was tested, and no issues were found. MAIN-A was able to demonstrate that the exit door wander guard system alarmed and locked properly when a wander guard bracelet approached the door. MAIN-A was unsure if there was an alarm log for the wander guard system. The facility policy Resident Elopement last reviewed 6/7/22 directs that if an employee observes a resident leaving the premises, they should attempt to prevent the departure. The facility policy Wander Management System last reviewed 1/29/25 directs that a wander management alarm system may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident's care plan that the resident is at risk for elopement. The past noncompliance immediate jeopardy began on 2/10/26. The immediate jeopardy was removed, and the deficient practice was corrected on 2/10/26, after verification the facility implemented a systemic plan that included the following actions: -Facility began immediate investigation. -Once R1 was located, R1 was transferred to a sister nursing facility with the capacity to keep her in a secured memory unit. -All staff mandatory education was completed. Education included: elopement, missing residents, facility policies and procedures and the specific elopement event was discussed. -Nursing staff were re-educated on completing the elopement risk assessment accurately and completely. -Wander guard system was checked and in working order for all residents actively an elopement risk. -Other at-risk resident charts and care plans were reviewed and interventions added as needed.

Based on observation, interview and document review, the facility failed to ensure smoking safety interventions were identified, implemented, and monitored for 1 of 1 resident (R29) reviewed who used oxygen and smoked. The facility also failed to provide adequate supervision to ensure oxygen was not taken into the designated smoking area, which resulted in an immediate jeopardy (IJ) when R29, who had oxygen present and was observed smoking and in close proximity to others who were smoking and present in the smoking patio, which posed a serious safety risk of fire or explosion and endangering R29 and others.The IJ began on 9/15/25 at 6:46 p.m., when R29 was observed on the outdoor smoking patio with a portal oxygen tank and in close proximity to other residents smoking. The chief operation officer, administrator in training, vice president of clinical services were notified of the immediate jeopardy on 9/15/25 at 9:18 p.m. The IJ was removed on 9/16/25 at 3:30 p.m., but non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include:R29's admission Minimum Data Set (MDS) assessment dated [DATE], indicated tobacco use and oxygen therapy.R29's significant change in status MDS assessment dated [DATE], indicated R29 was admitted [DATE], cognitively intact, utilized a manual wheelchair, independent with upper body dressing, personal hygiene, transfers, diagnoses included diabetes, respiratory failure, chronic pain, no current tobacco use, no oxygen therapy.R29's care plan indicated:Revision on 6/23/25, impaired gas exchange; administer oxygen as prescribed or per standing order 2L (liter) per NC (nasal cannula) to keep sats greater than 90%.6/25/25, tobacco use and educate on risks and health effects of tobacco useRevision on 7/30/25, indicated R29 does not harm self or others, vulnerable adult due to physical limitations and traumatic life events, interventions included: if poses a potential threat to injure self or others notify provider, room smelled like smoke, cigarettes and lighter were taken, must request cigarette from nurse and smoke the entire cigarette outsideR29's medication administration record dated 9/1/25-9/30/25, indicated O2 (oxygen) via nasal cannula 2L/min every evening and night shift related to acute and chronic respiratory failure. Wean 02 off patient during the day. Keep 02 sats greater or equal to 90%.R29's Smoking and Safety assessment dated [DATE], indicated R29 used tobacco, lethargic/falls asleep easily during tasks or activities, drops ashes on self, unable to use ashtray to extinguish tobacco or marijuana, unable to smoke safely, fails to follow facility's smoking policy, seen smoking in room with oxygen.R29's Smoking and Safety assessment dated [DATE], indicated R29 used tobacco, lethargic/falls asleep easily during tasks or activities, unable to use ashtray to extinguish tobacco or marijuana, keep cigarette and lighter at the nurse station and give when out to smoke only, resident is compliant.R29's smoking observation dated 9/16/25 at 11:14 a.m., indicated R29 was a current smoker, gets up at night to smoke, able to smoke independently, smoking material kept at the nurse station, educated to wait for the nurse to deliver cigarettes, R29 verbalized understanding, R29's nursing progress notes:6/24/25 at 9:57 p.m., R29 has been smoking in his room this evening even though he has oxygen tank in his room when asked, resident stated that the smell came from outside. Meanwhile residents window is shut tight writer found a pack of cigarette and lighter on resident's table ashes on the floor and bed linen, cigarettes removed from resident's room and put in narcotic box resident is unable to smoke safely at this time nursing to follow through and assist.6/25/25 at 8:35 a.m., late entry for 6/24/25, writer was informed by both nurse and maintenance that there was a very strong smell of cigarettes coming from the residence room, writer then to talk to residents about the smoking policy. Resident acknowledged and stated he was not smoking and that he would not smoke in the room.6/30/25 at 9:36 a.m., late entry social service note indicated, writer was informed by a nursing assistant that resident was smoking in his room while wearing his O2. Resident eventually gave up his cigarette to the COO (chief operating officer) and other boxes of cigarettes were taken from him as this is not his first incident of smoking in his room when he was asked who gave him the cigarettes he responded I'm not telling you anything and I don't give a [explicit] who you are , resident was educated then not to smoke in his room and his response was I don't [explicit] care what you say. will have social worker meet with resident regarding behavior.6/30/25 at 12:15 p.m., social service note indicated writer was informed by staff that resident was smoking in his room writer followed up with the resident and he stated that he smoked in his room due to panic attack writer encouraged him to reach out for help during the panic attack instead of smoking. Writer also educated resident on the risks of smoking in his room with the oxygen in use smoking policy was provided resident acknowledged and said that he will not smoke in his room anymore, writer shared that if his this continues he'll be given a 30 days eviction notice which he said he is OK with and would not mind getting discharged to a homeless shelter if placement is not found, writer reached out to his mother informed her of the concern and requested their support.8/14/25 at 6:10 a.m., indicated R29 insisted to have his cigarettes given to him to keep in his room, he said he can go out now so he would not smoke in his room ever again, he kept the box of cigarettes and the lighter with him.9/15/25 at 8:35 p.m., administrator note indicated right there met with the resident to review facility smoking policy, specifically regarding the safety risk of smoking for being in the designated smoking area with oxygen in place. Resident was educated that oxygen must be removed and stored at the nurses station prior to exiting the building near the smoking area following education right to remove cigarettes and lighters from their residence room a room search was completed and additional loose tobacco and cigarette tubes were located and removed.9/16/25 at 9:16 a.m., the director of nursing progress note indicated writer met with resident to speak with him regarding the safety incident that occurred on 9/15/25, writer asked the resident if he understood the severity of the incident to which the resident stated no, I wasn't even smoking writer educated the resident on the dangers of having oxygen near open flame and explained that it included having the oxygen on or near the other smokers the resident stated he now understood and would no longer bring the oxygen to the smoking area, the resident also asked for his tobacco and tubes backEmail dated 9/15/25 at 1:18 p.m., registered nurse (RN)-C, who was known as the vice president of clinical services, provided entrance information to the surveyor and the residents who smoked included R, R4, R9, R10, R26, and R35. The list did not contain R29. RN-C sent an updated on 9/15/25 at 9:20 p.m., and added smokers R36, R39, and R43.On 9/16/25 at 8:33 p.m., RN-C indicated in an email confirmed the residents who smoked included: R9, R10, R4, R2, R26, R29, R35, R36, and R39.On 9/15/25 at 6:46 p.m., R29 was observed in the designated smoking patio seated in a wheelchair with a portable oxygen tank on the back of the chair, connected to oxygen via nasal cannula at 2 liters per minute. R29 was not actively smoking at this time, and stated his oxygen was off and then observed R29's oxygen at 2 liters and R29 used his hand to turn the knob to 0 on the oxygen tank. Three other residents (R36, R39, and one unidentified) were observed actively smoking cigarettes in close proximity (3 to 6 feet) of R29. R29 was confronted and admitted to smoking while oxygen was on, stating, I'm willing to take the risk if I blow up, and If oxygen was that flammable, the whole world would be on fire.On 9/15/25 at 6:55 p.m., R29 was seated in a wheelchair with the oxygen tank on the backside of his wheelchair and turned off and R29 was observed to smoke a cigarette. RN-C (vice president of clinical services) was walking by the inside doors of the smoking patio and confirmed there was risk of oxygen use in proximity to smoking, stating poof everyone could be gone. RN-C was observed to discuss the safety concerns with R29, when R29 became upset and was observed and threw the oxygen tank to the ground. The oxygen tank was observed to be whistling under pressure.On 9/15/25 at 7:32 p.m., the administrator, who served as the chief operating officer, stated that R29 was known to keep cigarettes and a lighter in his room. The administrator acknowledged being unaware of current unsafe smoking practices involving R29 but confirmed that oxygen tanks were not supposed to be outside where smoking occurred, as things could blow up. The administrator further stated that if a resident was known to smoke in their room, cigarettes and lighters should not be in their possession or in the room.On 9/15/25 at 7:34 p.m., RN-C stated upon admission a smoking assessment was completed on all residents and expected the smoking assessment followed and stated care plans should address residents who used oxygen. RN-C stated the risk of oxygen use near smoking was things could blow up.On 9/15/25 at 7:44 p.m., licensed practical nurse (LPN)-D stated R29 kept his cigarettes and lighter on himself in his room and stated it was terrible if residents brought the oxygen tank outside when smoking. LPN-D was observed in R29's room and confirmed R29 had cigarettes, tobacco and lighters in his room. On 9/15/25 at 7:57 p.m., the administrator stated after reviewing R29's progress notes she remembered speaking with R29 previously and stated R29 was found smoking in his room previously and education was given to him at that time and stated the cigarettes and lighter were expected to be in the med cart and not in R29's room, due to the R29's previously smoking in his room. The administrator stated R29 would not be allowed to go out and smoke again until another smoking assessment was completed.On 9/15/25 at 8:37 p.m., the administrator stated that she did not search his room for other smoking materials but does know he has a bag of tobacco in his room. The administrator left to ensure all smoking materials were moved from his room.On 9/15/25 at 8:46 p.m., the administrator stated R29's room was searched and no more lighters were found but two bags of tobacco were removed from R29's room and locked and secured.On 9/19/25 at 10:25 a.m., during a telephone interview the medical director stated no residents should have oxygen present where other residents are or could be smoking as was a safety risk.The facility policy titled Smoking Policy - Residents dated 3/21/24, indicatedThis facility shall establish and maintain safe resident smoking practices.Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences.Smoking is only permitted in designated resident smoking areas, which are located outside of the building (2nd floor, east exit). Electronic cigarettes may be permitted outside in designated areas only. Otherwise, smoking is not allowed inside the facility under any circumstances.Oxygen use is prohibited in smoking areas.The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: current level of tobacco consumption; method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); desire to quit smoking, if a current smoker; and ability to smoke safely with or without supervision (per a completed Smoking Observation).A resident's ability to smoke safely will be evaluated upon admission/readmission, quarterly, upon a significant change (physical or cognitive) and as determined by the staff.Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely. Current smoking times are from 7:00am until 9:45pm. These times are subject to change.Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a family member, visitor or volunteer worker (if available) at all times while smoking.Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited.Residents are not permitted to give smoking articles, assist with lighting another resident's cigarette or sharing tobacco or lighters to other residents.Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision.This facility maintains the right to confiscate smoking articles found in violation of our smoking policies.Confiscated resident property will be itemized and ultimately returned to the resident, or his or her legal representative. When the property is returned will be determined during a meeting with the resident or representative regarding the circumstances that led to the confiscation.The IJ was removed on 9/16/25 at 3:30 p.m , when the facility developed and implemented a systemic removal plan which was verified by interview, observation, and document review. On 9/15/25, the smoking policy and procedure was reviewed by the facility leadership. On 9/15/25, signage was posted indicating no oxygen was allowed at the exit point to the designated smoking area. On 9/15/25 at 8:46 p.m., R29's room was searched and tobacco and lighters were removed from the R29's room. On 9/15/25, and 9/16/25, all current residents who smoke had a smoking assessment completed and care plans were reviewed and/or updated. No other residents who smoke utilize oxygen. On 9/16/25 at 11:14 a.m., R29 had a smoking assessment completed, which indicated R29 was able to smoke independently, and smoking material kept at the nurse station. The facility-initiated training on 9/15/25, with a mass electronic message sent to staff, along with verbal education beginning on 9/15/25. On 9/16/25, the vice president of clinical services, chief operating officer and administrator in training conducted in-service education with staff regarding oxygen use was prohibited in smoking areas. The facility plans to continue education process with on-coming staff and all staff are required to sign attesting education was received.

Based on interview and document review, the facility failed to appropriately monitor and comprehensively assess complaints of pain for 1 of 3 residents (R1) reviewed for pain management. Additionally, the facility failed to assess or monitor blood glucose levels and for 1 of 1 resident (R1) reviewed with blood glucose monitoring. R1 complained of pain rated as 9/10 (pain that is extremely severe or excruciating) four assessments in a row, was not administered pain medication as ordered, and R1 waited approximately 9 hours for prescribed pain medication. This resulted in harm when R1 called 911 for himself, and returned to the hospital for pain management, assessment, and monitoring. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, admitted to the facility on [DATE], and had diagnoses that included multiple fractures, trauma, respiratory failure, and diabetes. R1's hospital Discharge Orders dated 5/17/25, indicated the following for pain management: - Acetaminophen (pain medication used for mild to moderate pain) oral tablet 500 milligrams (mg), give 1000 mg by mouth three times a day for pain, max (maximum) 4000 mg in 24 hours - Oxycodone (narcotic pain medication used to treat moderate to severe pain) 5 mg, take 1-2 tablets (5-10) mg by mouth every 4 hours as needed for pain - Lantus Solostar (long acting insulin used to manage blood glucose) 100 unit (U)/milliliter (ml), inject 45 U subcutaneously (subq) two times a day - Aspart FlexPen (short acting insulin used to manage blood glucose) 100 U/ml, inject 10 U subq once [daily] as needed if glucose >180 [milligrams/deciliter] - Mounjaro pen (medication used to treat blood glucose) 7.5 mg/.5 ml, inject 7.5 mg subq once weekly on Fridays R1's Provider Orders dated 5/17/25 directed: - Acetaminophen oral tablet 500 mg, dated 5/17/25, give 1000 mg by mouth three times a day for pain, max 4000 mg in 24 hours - Oxycodone HCl 10 mg give 10 mg by mouth one time only for pain - Oxycodone HCl 5 mg give 10 mg by mouth every 4 hours for pain rated 6-10/10 - Oxycodone HCl 5 mg give 5 mg by mouth every 4 hours for pain (5 out of 10), discontinued 5/17/25 - Oxycodone HCl 5 mg to start 5/18/25, give 5 mg by mouth every 4 hours as needed for pain rated 1-5/10 - NovoLog (short-acting injectable medication used to treat diabetes) to start 5/18/25 inject 10 U subcutaneously as needed for diabetes if blood glucose is over 180 [milligrams/deciliter (mg/dl)] R1's Provider Orders dated 5/18/25 directed: - Lantus Solostar (long-acting injectable medication used to treat diabetes) subcutaneous (under the skin) solution, inject 45 units (U) subcutaneously two times a day for diabetes. R1's Provider Orders dated 5/19/25 directed staff to check blood glucose three times a day with meals and at HS (bedtime) related to type II diabetes. R1's care plan dated 5/20/25 indicated R1 had acute pain, and staff should administer medications as ordered. The care plan for unstable blood glucose was initiated on 5/20/25, and indicated monitor for signs and symptoms of hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose). R1's progress notes dated 5/17/25 at 3:43 p.m., indicated R1 admitted to the facility at 1:00 p.m., and arrived by ambulance on a stretcher after an open reduction and internal fixation (ORIF - a surgical procedure that uses metal implants to hold broken bones in place while they heal). The progress note indicated R1's pain was rated as 7/10 on admission. The progress note banner indicated R1 had type II diabetes, chronic obstructive pulmonary disease (lung disease), and acute and chronic respiratory failure withy hypoxia (absence of enough oxygen to sustain bodily functions). The progress note further indicated R1 had focal complaints of pain rated as 9/10 with spasms. R1 was offered non-medication interventions for pain, but the note did not specify what was tried, and indicated the non-medication interventions were not successful. The progress note indicated see the MAR (medication administration record) for details, which indicated R1 was given Tylenol. The admission progress note included a full set of VS. The progress notes lacked indication VS were assessed again until 5/20/25 at 9:55 p.m., or blood glucose was assessed on admission or until 5/19/25 at 10:57 p.m. R1's progress notes dated 5/17/25 at 11:28 p.m., indicated staff contacted an on-call provider at 8:15 p.m., for an order for a one-time order for oxycodone HCl 10 mg for pain rated as 10/10, and at 11:30 p.m., indicated R1 received the first dose of oxycodone HCl 10 mg. R1's progress notes dated 5/18/25 at 10:40 p.m., indicated at around 5:30 p.m., R1 called 911 and reported to paramedics the facility failed to manage his pain. He told them when he came to the facility, he had to wait over 8 hours before he received pain medication. R1 took his belongings, declined a bed hold, and was transported to the hospital. R1's progress notes dated 5/19/25 at 1:50 a.m. indicated he returned from the hospital. R1's progress notes dated 5/19/25 at 10:11 a.m., indicated R1 was out of prescribed pain medications, had pain rated as 8/10, and had gone to the emergency room the prior night. R1's progress noted dated 5/19/25 at 8:22 p.m., indicated R1 received oxycodone HCl 5 mg, 2 tablets by mouth for pain. The progress notes lacked indication oxycodone was administered between 5/19/25 at 10:11 a.m., and 5/19/25 at 8:22 p.m. R1's May 2025 Medication Administration Record (MAR) and progress notes indicated the following: - Oxycodone HCl 5 mg 2 tablets, were administer for the first time on 5/17/25 at 11:30 p.m. - Acetaminophen 500 mg 2 tablets were administered on 5/17/25 at 9:00 p.m., and were ineffective. - Oxycodone HCl 10 mg, give 10 mg by mouth one time only for pain 5/17/25, between 8:20 p.m., and 11:59 p.m., but the dose was not administered until 5/18/25 at 3:33 a.m., and was rated ineffective. During that time R1's pain ratings were as follows: 5/17/25 at 2:27 p.m., pain rated as 9/10, and was not administered pain medication. 5/17/25 at 4:14 p.m., pain rated as 9/10, and was not administered pain medication. 5/17/25 at 4:28 p.m., pain rated as 9/10, and was not administered pain medication. 5/17/25 at 4:34 p.m., pain rated as 9/10, and was not administered pain medication. - Oxycodone HCl 5 mg, give 2 tablets (for a total of 10 mg) by mouth every 4 hours as needed for pain rated 6-10/10 mg was administered as follows: 5/17/25 at 11:30 p.m., for pain rated as 7/10, and was rated effective. 5/18/25 at 5:13 a.m., for pain rated as 8/10, and was rated effective. 5/18/25 at 8:14 a.m., for pain rated as 10/10, and was rated effective. 5/18/25 at 2:28 p.m., for pain rated as 10/10, and was rated ineffetive. 5/19/25 at 8:22 p.m., for pain rated as 10/10 and was rated ineffective. R1's blood glucose records indicated R1's blood glucose was not tested until 5/19/25 at 10:57 p.m., even though R1 was admitted on [DATE]. On 6/5/25 at 10:01 a.m., R1 stated he was not able to get the prescribed oxycodone HCl after he was admitted [DATE] around 1:00 p.m., until around 11:30 p.m., and laid suffering in agony until he got the medication. He was given Tylenol [acetaminophen] but it did not help, nor did he think he should have Tylenol as he was a life-long drinker [of alcohol] and he thought Tylenol was not good for his liver. His VS were not assessed, and his blood glucose levels were not checked until a couple of days after admission. He was concerned about why staff wasn't checking his blood glucose or VS and stated, How will they know if I am going to tank it and die? R1 stated he felt like he was not being assessed or cared for properly. On 6/5/25 at 1:18 p.m., licensed practical nurse (LPN)-B stated diabetic residents should have blood glucose checks per the physician orders, and any resident who used insulin should have blood glucose checks. Every resident on the Transitional Care Unit (TCU) should have VS daily. R1 had not had VS assessed after admission until 5/19/25, and had not blood glucose checks until 5/19/25, but didn't know why. On 6/5/25 at 2:12 p.m., registered nurse (RN)-A stated blood glucose checks were done according to the provider orders, but typically before meals and before bed. VS were checked more often for residents who had medications with specific parameters, but otherwise daily to weekly, but required an order. On 6/6/25 at 9:32 a.m., RN-B stated the process for obtaining narcotic pain medications upon resident admission was to fax the order to the pharmacy, and if the resident didn't come with the prescription, the nurse would call the hospital. The call could be transferred all over to get the prescription, and instead the nurse would call the pain management provider for medication. R1's pain was assessed to be 9/10 four times, and then 7/10, and stated, That's a lot of pain. He could have shock. With ongoing pain, staff should check VS, and the provider should have been notified, but there was no indication the provider was notified. If a resident had diabetes, and there were no orders to check blood glucose, the facility standing orders indicated check blood glucose once a day. R1 admitted on [DATE], and blood glucose was first checked on 5/19/25, but should have been checked 5/17/25 and 5/18/25 also. With ongoing pain, staff should check VS, and the provider should have been notified. There was no indication the provider was notified. R1 would have been frustrated if he had ongoing pain without relief, and was not getting VS or blood glucose checks. On 6/6/25 at 10:30 a.m., the pharmacy technician (PHT)-A stated the pharmacy provided the medications for the e-kit, and the facility staff was responsible to fill the e-kit with the medications provided by the pharmacy. Oxycodone HCl 10 mg was supposed to be supplied in the e-kit. On 6/6/25 at 10:34 a.m., PHT-B stated R1 had a prescription for oxycodone HCl 5 mg, and the pharmacy received it on 5/17/25 at 3:15 p.m., by fax. The prescription was filled for eight tablets and was delivered on 5/17/25 at 10:34 p.m., on the scheduled delivery. The facility called for a code to use the e-kit (an emergency stock of medications used to quickly address urgent or unexpected symptoms that may arise in residents) earlier, but the e-kit was out of the dose prescribed. When the e-kit was reduced to four tablets, it would trigger the pharmacy to refill, but that had not happened, and the PHT-B didn't know why. The facility could have ordered the medication stat (immediately) by phone, but had not. On 6/6/25 at 10:55 a.m., the pharmacist (PH)-A stated on 5/17/25, the facility did not have oxycodone HCl 10 mg tablets in the e-kit, as requested in a one-time order. The facility sent an order for oxycodone HCl 5 mg initially, not 10 mg. Facility staff should have requested oxycodone HCl 10 mg tablets re-restock before running out. On 6/6/25 at 11:57 a.m., the director of nursing (DON) acknowledged when R1 first reported pain, there should have been immediate interventions, and VS should have been completed as part of the assessment followed by a report to the provider. She did not know why that was not done. Additionally, R1 should have had a blood glucose check on admission as an insulin-dependent diabetic and stated it also got missed. R1 could have had low or high blood glucose, and staff would not have known. The emergency kit was out of the prescribed pain medication, and the pharmacy did not deliver the medication right away. The Automated Dispensing Machine for First Dose and Emergency Medications policy dated 5/22, indicated the automated dispensing machine (ADM also known as e-kit) was used for emergency medications, and the contents were the property of the pharmacy so authorization from the pharmacy was required prior to use. The policy indicated replenishment of medications in the ADM was scheduled so that no medication supply was exhausted. The Pain-Clinical Protocol dated 2001, directed the staff and physician would evaluate how pain affected mood, activities of daily living, sleep, and the resident's quality of life. The Medication and Treatment Orders policy dated 7/17, directed drug orders must be recorded on the physician's order sheet in the resident's chart. Such orders were reviewed by pharmacy monthly. The Administering Pain Medications policy dated 10/7/21, directed the pain management program was based on a facility-wide commitment to appropriate assessment and treatment of pain. The Diabetes - Clinical Protocol was requested and not provided. A policy for Quality of Care was requested and not provided.

Based on observation, interview, and record review the facility failed to protect the residents' rights to be free from neglect when the facility did not provide care, comfort, and safety. This resulted in immediate jeopardy (IJ) for 3 of 4 residents (R1, R2, R3) who experience mental anguish, and emotional distress when care and services were not provided to assist these dependent residents to get out of bed. In addition, the facility failed to provide care and services for R5 who was dependent on staff to get out of bed. The immediate jeopardy began on 2/28/25, when the facility failed to provide care, comfort, and safety. This resulted in mental anguish, and emotional distress when care and services were not provided to R1, R2, and R3 to get out of bed. These residents were dependent on staff for bed mobility. The Chief Operating Officer, the [NAME] President of Clinical, the Director of Nursing, and Administrator were notified of the IJ on 2/28/25 12:42 p.m. and the immediacy was removed on 3/3/25 at 4:10 p.m. However noncompliance remained at the lower scope and severity level 2 (D isolated.) which indicated no actual harm with potential for more than minimal harm Findings include: R1's nursing progress note dated 12/12/24, taken from a hospital encounter on 12/10/24, indicated R1's podiatrist recommended R1 to be non-weight bearing and to use a wheelchair or a foot scooter. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had a Brief Inventory of Mental status (BIMs) score of 15 indicating R1 was cognitively intact. R1 was dependent upon staff for toileting hygiene. He required moderate assistance with dressing the upper body and personal hygiene. Lower body dressing, sitting to lying position change, lying to sitting position change, and sit to stand were not attempted due to medical condition or safety concerns. R1 was occasionally incontinent of urine and frequently incontinent of bowel. R1's pertinent diagnoses were chronic ulcer of the left foot with necrosis (death) of the muscle, diabetes, and morbid obesity. R1's weight was 547 pounds (lbs.). R1's care plan dated 1/2/25, indicated R1 was a total assistance of two staff and the use of a full body lift for transfers. The care plan did not identify what lift to use or the sling size to be used. R1's care plan dated 1/4/25, indicated staff were to assist R1 with ambulation and transfers, and utilize therapy recommendation. The care plan did not indicate what the therapy recommendations were. Upon interview with R1 on 2/26/25 at 2:12 p.m., R1 began crying stating he needed help; he had not gotten out of bed since December. R1 stated when he first came to the facility, the staff tried to get him out of bed, but the machine did not work, and no one has tried since. R1 was told he was non-weight bearing and had made two appointments with his doctor to find out why and if he could get cleared to bear weight. On both occasion the facility was not able to get him to his appointment because there was something wrong with transportation due to his size. R1 did not think he had any skin impairments. R1 continued to cry throughout the interview. R1 stated the only activity he has been provided is the television in his room and on occasion the facility will offer bingo or a group activity, but he is unable to get there since they can't get him out of bed. R1's wife brought him a handheld game device and a book. R1 expressed the need to be outside with access to fresh air. Upon observation and interview on 2/27/25 at 10:12 a.m., R1 put on his call light and requested to sit in his wheelchair. Nursing assistant (NA)-A told R1 she was not sure how to get him up and left to get the nurse. NA-A and registered nurse, (RN)-A returned to R1's room telling R1 they needed more assistance and the mechanical lift. t. NA-A, NA-B, RN-A and the certified occupational therapist (OTA)-A returned with a different mechanical lift, rolled the resident from side to side placing the sling for the mechanical lift under R1. When the staff connected the sling to the mechanical lift, the mechanical lift base would not fit under the bed frame. Staff again left, returned with the director of nursing (DON) who directed staff to use a different mechanical lift to see if the base of that lift would fit under R1's bed. Staff returned with a different mechanical lift, connected the sling to the lift, and were able to begin lifting R1. R1 screamed in pain stop, stop, my legs are being pinched R1 was laid flat in bed, staff placed towels between R1's upper thighs and the sling and retried the lift. R1 told staff that is not helping, the sling is too small. Staff laid R1 back in bed and said they were not able to transfer him out of bed because the sling was too small. The sling size was XXXL, which is the largest size the facility had. After the failed attempt to lift R1 out of bed, R1 began crying again stating he did not feel safe at the facility. If there was an emergency, he would not be able to get out. The director of nursing on 2/27/25 at 3:10 p.m. stated she was not aware R1 had not been transferred out of bed since admission in December 2024. The facility would need a new mechanical lift and a sling size that fit R1 to move him from his bed. If there was an emergency or a fire the facility would not be able to transfer or move R1, the facility would need to call 911 for assistance. Upon interview on 2/27/25 at 12:07 p.m., the physician assistant (PA) stated the beginning of 2/2025 was the first time he saw R1 and was aware staff hadn't been walking him. Instead of having R1 leave the facility to see Podiatry he ordered an in-house x-ray of R1's foot to ensure there were no fractures. R1's order was changed from a non-weight bearing status to ok to bear weight. The PA was not aware staff had not been getting R1 out of bed at all. There was no reason he could not have gotten up to his wheelchair, even with a non-bearing order. PA stated The facility should not admit a bariatric resident if they can't take care of them. Upon interview on 2/28/25 at 9:35 a.m., R1 stated after the staff attempted to get him out of bed on 2/27/25 he panicked and lost sleep due to feelings of anger and anxiety that he should have been getting out of bed to his wheelchair daily despite being told he could not due to a non-weight bearing status. He had been having thoughts of self-harm over the past month due to feeling isolated and being in bed. The self-harm thoughts increased after the attempt to get him out of bed on 2/27/25. Upon interview on 2/28/25 at 10:27 a.m. the Social Worker designee (SW) stated R1 had always maintained a happy and positive attitude until about a week ago he expressed feelings struggling that he hadn't gotten out of bed since December. He didn't mention suicidal ideation to the SW, she did not ask him specifically if he was suicidal. R2 R2's re-admission MDS dated [DATE], indicated R2 had a BIMs score of 15 indicating R2 was cognitively intact. R2 used a wheelchair. MDS did not indicate R2's functional mobility. R2 was frequently incontinent of bowel and bladder. R2's pertinent diagnoses were morbid severe obesity due to excess calories, reduced mobility, chronic pain and pre-diabetes. R2's weight was 435 lbs. Upon observation and interview on 2/26/25 at 12:56 p.m., R2 was an obese lady dressed in a hospital gown in bed who had just finished lunch. She stated the only time she had been out of bed was when she was transferred to the hospital in early February. She stated she feels the reason is because of her obesity. Staff cannot handle her because at times it takes four staff members just to assist her to wash up. She cried during the visit stating the only thing she had in her room is her bible. She wanted to at least see the facility she is living in and get some fresh air. Upon observation and interview on 2/27/25 at 11:26 a.m., R2 pressed her call light and requested to licensed practical nurse (LPN)-A answered the call light and R2 requested to get her out of bed. LPN-A explained to R2, she was unable to get her out of bed until she spoke with the therapy department. Also, R2 didn't have a wheelchair to sit in, and LPN-A didn't know what size sling, for the mechanical lift, to use on R2. Upon interview on 2/27/25 at 12:07 p.m., the PA stated there was no reason R2 should not be getting out of her bed daily. Upon interview with R2 on 2/26/27 at 12:12 p.m., R2 stated she has not gotten out of her bed since admission until she had to go to the hospital for respiratory distress. Staff attempted to use the mechanical lift once and set her back down on the bed because the lift was not stable. R2 stated she worked with physical therapy upon admission, they were able to sit her up in bed, which she said, felt wonderful. Staff have not gotten her out of bed since that one time on early admission. R2 stated she put on her call light to request getting out of bed, the staff turn off her call light, tell her they are going to get staff, then never come back. R2 stated she wanted to return to physical therapy and be able to get out of bed. R2 became tearful stating she lived in fear because the only time she was out of bed was when the paramedics took her to the hospital. PT stopped working with R2 due to her getting to her optimum level and when her arm strength was good enough PT would see her again R3 R3's care plan dated 7/1/24, indicated R3 required a full body lift and two staff members. The care plan did not identify what type of lift or what size sling to be used on R3. R3's quarterly MDS dated [DATE], indicated R3 had a BIMs score of 15 indicating R3 was cognitively intact. R3's pertinent diagnoses were muscle weakness, acute respiratory failure, and morbid obesity. R3's activities of daily living were not identified. Upon interview on 2/27/25 2:18 p.m., R3 stated he hadn't been out of his bed since 12/2024. He stated he would like to get up, but he is transferring out of the facility soon and was tired of arguing with staff every day. R3 pointed to a small wheelchair and stated he couldn't get up if he wanted to because he didn't fit in the chair. R3 began to cry and stated it was a daily fight with the staff to even ask to sit in his chair and if discharge to an assisted living facility does not happen soon, he will throw himself to the floor and crawl out naked. R3 stated he did not feel safe, in the event of an emergency he would be on his own and have to crawl out to safety. Upon interview with the 2/27/25 at 12:07 p.m. the P.A. was concerned with R3 being in bed all the time and wrote orders for a prophylaxis antibiotic for concerns of returning cellulitis, a pressure relieving mattress, and every other day bathing since he found out R3 had not had a bath or shower in over three months. Upon observation and interview on 2/28/25 at 10:15 a.m., R3 was in bed in hospital gown, five urinals were on a garbage can next to his bed, three of them had urine in them, there was an odor of urine in the room. R3's hair appeared greasy. He stated he felt like a, beast in a cage losing health every day. He stated in the fall of 2024 he was standing and able to ambulate a few steps and that was the last time he ambulated. He believed staff had gotten him out of bed in December of 2024, but could not recall a specific date. Currently his legs could not hold him and required the use of a mechanical lift. Upon interview on 2/26/25 at 4:08 p.m., the director of nursing (DON) stated she was aware that in 12/2024 R1 had difficulty with the full body lift rated to lift 500 lbs., so she instructed the staff to use the full body lift rated to lift 600 lbs. She hadn't heard anything since she instructed the staff to use the lift rated for use at a higher weight. DON was not aware they had not gotten R1 out of bed. The DON also stated she wasn't aware that R2 wasn't getting out of bed, and she wasn't certain of the status of R3, if he was a full body lift or if he was transferring on his own. Staff had not reported any concerns to her about R1, R2 or R3. Her expectation was staff would report an inability to get residents out of bed and/or equipment concerns to her immediately. R5 R5's admission MDS dated [DATE], indicated a BIMs score was nine indicating moderate cognitive impairment. R5 was dependent on two or more staff for toileting hygiene, shower/bathing, and upper body dressing and all transfer activity. Lower body dressing was not attempted. R5's pertinent diagnoses were morbid obesity and heart failure. R5's weight was 377 lbs. R5's nursing progress note dated 2/17/25 at 12:29 p.m., indicated R5 was sent to the hospital for confusion, extreme fatigue, and pulse oximeter saturation of 80% (normal 92-100%). Upon interview on 2/28/25, R5's family member (FM)-A stated R5 left the facility due to a stroke and would not be returning to the facility because the entire time she was at the facility she did not get dressed or out of her bed. When FM-A visited in the late morning or afternoon R5 would not be dressed and was still in bed. R5 was a joyful happy person, but the isolation at the facility made her depressed. FM-A would call the facility and attempt to speak with staff but would not be able to speak with anyone. Her reason for calling was to find out if R5 had gotten up for the day, but never received an answer. Upon a telephone interview on 2/28/25 at 4:42 p.m., R5 stated she never got out of bed while at the facility. She felt the staff couldn't handle a bigger gal. She refused to go back to the facility after her hospital stay because she recalled crying everyday at the facility. Upon interview on 3/3/25 at 9:05 a.m., nursing assistant NA-B stated he didn't recall R5 getting out of bed, and she was a full body lift resident. He couldn't recall the reason. He stated, he didn't know if it was a therapy concern, if she refused or if they didn't have a sling for her. Upon interview on 3/3/25 at 4:05 p.m., the OTA, therapy manager stated R5 required the use of full body mechanical lift. She was not certain if staff was getting R5 up or not. She stated she didn't feel the facility should have admitted such heavy residents if staff can't get all the residents out of bed in a given day. The residents should be getting up daily unless they have a special circumstance such as an illness. -On 1/17/25 at 3:40 p.m. the immediate jeopardy was removed when the facility: -Had Physical therapy reassess R1, R2 and R3 on their transfer status -Updated R1, R2, and R3's care plans. -Educated staff about the need to follow the care plan. -Ensured the facility had the proper equipment in working order. A facility policy titled Abuse and Neglect - Clinical Protocol indicated neglect is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on interview and document review, the facility failed to follow dietary orders for a resident who was NPO (nothing by mouth) for 1 of 3 residents (R1) reviewed for diet modifications. This resulted in an immediate jeopardy (IJ) when R1 received a regular textured meal on [DATE], which caused R1 to choke, lose consciousness, require the Heimlich maneuver, cardiopulmonary resuscitation (CPR), and resulted in death. The facility immediately implemented corrective action so the deficient practice was issued at past non-compliance. The IJ began on [DATE], when R1 received a regular textured meal, which caused R1 to choke, lose consciousness, require the Heimlich maneuver, CPR, and died as a result of choking. The administrator was notified of the past non-compliance IJ on [DATE], at 1:29 p.m. The facility implemented immediate corrective action on [DATE], prior to the start of the survey and was issued as past non-compliance. Findings include: R1's Face Sheet dated [DATE] indicated R1 had a diagnosis of dysphagia (difficulty in swallowing food or liquid). R1's care plan dated [DATE] indicated R1 was NPO, and required all nutrition through tube feeding due to dysphagia. R1's Provider Orders dated [DATE] indicated R1 was NPO, and received nutrition through his gastrostomy (G)- tube. R1's Occupational Therapy (OT) note dated [DATE] indicated R1 was on strict NPO, had limited insight into the NPO status, and was uncertain of outcomes. On [DATE] at 11:15 a.m., a progress note written by licensed practical nurse (LPN)-A indicated around 8:40 a.m. LPN-A was checking diabetic patients' blood sugars, and saw nursing assistant (NA)-A passing meal trays. LPN-A heard someone coughing or trying to cough from R1's room. She opened the door and saw a meal tray in front of R1, and R1 trying to cough. LPN-A documented it came to her that R1 was NPO, and a meal tray should not have been in his room. She encouraged R1 to keep coughing to get whatever was blocking his airway out. R1 coughed a little, and LPN-A heard no more coughing. R1 was in obvious distress, and placed both hands around his neck. LPN-A called out for the trained medical assistant (TMA) who was in the hallway and told her someone was choking. LPN-A got behind R1 and started doing the Heimlich maneuver. No food was dislodged, and after a couple of thrusts, R1 started turning blue and sliding down. LPN-A's arms were still around R1, so she assisted R1 to the floor. LPN-A checked for a pulse and there was none, and she started CPR. LPN-A told TMA to call 911 and to get help. Nurse Practitioner (NP)-A took over CPR from LPN-A, and LPN-A applied the automated external defibrillator (AED). On [DATE] at 12:18 p.m. a progress note written by LPN-A indicated R1 had passed away. On [DATE] at 8:14 a.m., cook-A (C)-A stated he worked on [DATE] and he did not make a plate of food for R1 as there was no meal ticket or communication form regarding R1's meals. C-A stated staff from one east (not R1's unit) did call the kitchen and stated they were missing a tray for a resident. C-A stated the kitchen wouldn't provide any food to residents without a communication form or a meal ticket. On [DATE] at 8:33 a.m., LPN-A stated she heard someone coughing and opened R1's door, R1 was sitting in his room with a tray of food. LPN-A stated she knew R1 was NPO, so she got R1 standing and encouraged him to keep coughing. R1 stopped coughing and grabbed his throat. LPN-A stated she started doing the Heimlich maneuver, and yelled for help. She lowered R1 to the floor as he was turning blue. LPN-A stated she checked for a pulse and there was not one, so she told staff to call 911 and get help. She then started CPR. The assistant director of nursing (ADON), director of nursing (DON), and the nurse practitioner (NP)-A entered the room with a crash cart. NP-A took over CPR. LPN-A placed the AED on R1. LPN-A stated it looked like a hard-boiled egg was lodged in R1's throat, and there was one hard boiled egg on the plate. LPN-A stated staff should know what diet a resident has by looking at the chart. LPN-A stated she felt if R1 had not gotten the tray of food he would be alive right now. On [DATE] at 9:05 a.m., NP-A stated on [DATE], at around 8:30 a.m. she went into R1's room and saw LPN-A giving CPR to R1. NP-A stated R1 was pulseless and cyanotic on the floor. Emergency medical services (EMS) arrived and took over CPR, so she went to the hall and started looking at R1's chart. NP-A stated R1 had recently admitted , and she was supposed to see him that day. NP-A stated R1 had severe dysphagia and was not supposed to have anything by mouth. EMS staff then pronounced R1's death at around 9:25 a.m. NP-A stated R1 getting a meal tray contributed to his death, and if that tray was not given to him he would be alive today. On [DATE] at 9:13 a.m., NA-A stated she was the only one passing trays on [DATE]. NA-A stated she thought there was a piece of paper with R1's name on it and his room number on R1's tray. NA-A stated she put the meal on the side table in R1's room, and told him she would be back as she was going to look for clothes for him to wear. Once she got back to R1's room staff where in his room doing CPR. NA-A stated she was told he swallowed an egg and choked. NA-A stated she was unaware of R1's diet, and she didn't check the computer or ask the nurse what R1's diet was. NA-A stated if staff doesn't know a resident diet, they were supposed to look in the computer or ask the nurse. On [DATE] at 9:19 a.m., the DON stated LPN-A told her that R1 was choking on [DATE]. She stated she ran to grab the crash cart and then started placing oxygen on R1. NP-A then took over CPR, they continued to do compressions and placed the AED on R1 until EMS arrived. EMS staff called R1's death at around 9:25 a.m. The DON stated staff should look at the meal tickets and make sure the meal is for the correct resident. The DON stated she believed this step did not happen as there was no meal ticket for R1 because he was NPO. On [DATE] at 9:29 a.m., the administrator stated NA-A told her she had provided R1 with the meal tray on [DATE]. The administrator stated she talked with a dietary staff member, and was told a tray for another resident was accidentally placed on the wrong cart. The administrator stated the kitchen received a call from one east unit informing them they were missing a tray for a resident who had a regular diet. That tray was accidentally placed on the unit cart where R1 resided and it was believed it was the meal tray R1 received. The staff from the kitchen stated they did not make a meal tray for R1. The administrator stated staff passing meals were expected to look at the meal ticket and make sure they are passing the correct tray to the correct resident. The administrator stated this was not completed for R1. On [DATE] at 10:10 a.m., the dietitian (D)-A stated the kitchen staff would not give meals out to anyone unless they had a communication form which has the provider information on it for each resident diet. The facility Dining Room Service policy revised [DATE], directed staff should check individual name and diet on the meal identification card/ticket to verify that the meal is served to the correct person. The past noncompliance IJ began on [DATE]. The IJ was removed, and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: -The facility re-educated all staff who pass meal trays on reading meal tickets. Re-educated nursing staff and dietary staff on diet changes and communication forms on diets. Education was completed [DATE] through [DATE]. -Dietary staff reviewed and revised their plating process, now the meal tickets are checked by three kitchen staff prior to going to the unit. - The facility completed a full house audit on diet orders in point click care (PCC) and ensured the nursing care sheets and care plans matched the order and the meal ticket for all residents. -No other residents residing in the facility are currently NPO. -Interdisciplinary team members will be on the floors at mealtimes to assist with meal trays as needed. - Audits initiated on [DATE], to ensure staff are checking meal tickets to make sure residents are receiving the correct meal tray and diet. This was completed on [DATE] prior to the survey. Verification of corrective action was confirmed by observation, interview, and document review on [DATE], from 2:35 p.m. to 4:30 p.m. and [DATE], from 7:00 a.m. to 1:30 p.m. Kitchen staff were observed during plating of meals and three staff where checking to ensure the diet order was correct on the meal tray. Nursing staff were observed during meal service to verify the meal tickets matched the meals on the trays, and the resident they were bring the meal to. Nursing and kitchen staff interviewed confirmed education was provided regarding checking meal tickets to ensure the right diet and right resident was getting the correct meal tray. Sign-in sheets for reading a meal ticket education confirmed education began on [DATE]. Meal ticket and tray audits reviewed and confirmed appropriate interventions initiated and deficient practice corrected on [DATE], therefore this was cited at past non-compliance.

Based on observation, interview, and document review the facility failed to comprehensively assess fall risk factors, implement effective fall prevention strategies, and re-evaluate the fall interventions effectiveness to prevent falls for 1 of 3 residents (R2) reviewed for falls when R2 suffered multiple falls since 11/17/22 resulting in injuries and hospitalization . Findings include: During observation on 2/16/23, at 1:15 p.m. R2 stood up from his wheelchair and began walking down a hallway different from the one his room was on. His gait was unbalanced, and he appeared to be walking side to side on his toes not the balls of his feet. He walked approximately 10 feet before the NA-C who was sitting on the other side of the dining room saw him. He was already down the hallway when she caught up to him. She ran back to the dining room to grab his wheelchair. A few minutes later she pushed him in his wheelchair back to the dining room, locked his wheelchair and walked away. He was not wearing shoes at the time of the incident. R2's care plan dated 8/17/22, identified he had a risk for falling related to his poor balance and an unsteady gait. Interventions included a pharmacist review to identify potential medication interactions affecting his gait and stability. In addition, staff would continue to monitor and encourage him to use his assisted devices (wheelchair or walker) when he was up moving around his room and the unit. R2's care plan dated 9/12/22, identified staff were to keep the wheelchair's footrests (a movable footplate extending outward in front of the wheelchair) off to prevent tripping and monitor him to ensure he is sitting in the chair. In addition, staff were instructed to encourage him to keep his wheelchair or walker close by when he gets up to move about his room and unit. R2's fall therapy assessment dated [DATE], identified he was impulsive and had poor safety awareness leading to frequent falls. R2's witnessed fall report dated 11/17/22 indicated R2 fell in the hallway, 2nd floor west. R2 fell trying to go outside to smoke. R2 was walking behind, pushing his wheelchair. R2 was assessed and reminded to sit in the wheel when using and ask for assistance when needed. R2 was not injured. R2's nursing progress note dated 11/17/22, at 2:36 p.m. identified he fell to the ground while he pushed his wheelchair through the main facility door on his way out to smoke a cigarette. He required staff assistance to get up. He denied suffering an injury from the fall. R2's witnessed fall report dated 11/19/22 indicated R2 fell in R2's room, 2nd floor west. R2 fell while coming out from the bathroom. R2 was in bed and bleeding from the right eye. R2's nursing progress note dated 11/19/22, at 2:20 a.m. identified when he walked out of his bathroom he fell to the ground. He sustained a laceration by his right eye causing bleeding at the site. R2 was transferred to the hospital's emergency room for evaluation and treatment. R2's nursing progress note dated 11/19/22, at 2:07 p.m. identified the emergency room treated his laceration with five stitches. He returned to the facility the same day. R2's nurse practitioner (NP)-A's visit note dated 11/21/23, identified the purpose for the visit was to follow up on yet another fall. NP-A stated it would be a benefit for R2 if he had transferred to a memory care unit where a facility would have more staff to provide additional care and monitoring. R2's NP-A's visit note dated 11/22/23, identified the purpose for the visit was to assess his right knee wound caused from a fall. In addition, NP-A identified R2 continues to have multiple falls at the facility. R2's witnessed fall report dated 11/24/22 indicated R2 fell in the hallway, 2nd floor west. The incident description indicated R2 was calling for help. Staff arrived and found R2 on the floor with his wheelchair tipped over. R2 was pushing his wheelchair. R2 was assessed and had no injuries. R2's nursing noted on 11/28/22, at 9:47 p.m. identified the resident was restless, impulsive and noncompliant with directions. R2 fell in his room and his upper right eye lid was bleeding. His medical provider was notified about the fall and placed an order for the facility to send him to the hospital for an evaluation. R2's witnessed fall report dated 12/3/22 indicated R2 fell in R2's room, 2nd floor west. The incident description indicated R2 was yelling for help in his room. Staff arrived and four R2 lying on the floor face down in the bathroom with his legs in the room. R2 was sent to the hospital. R2's nursing note on 12/3/23, at 11:03 a.m. identified he fell on the floor in his room. He was found lying halfway in the bathroom face down. R2 was confused and complained of a headache. Nursing staff updated the NP and received orders to send him to the emergency room for an evaluation. R2's hospital discharge document on 12/8/23, identified he was admitted to the hospital on 12/5/22, for severe malnutrition (when the daily protein intake is less than their body's daily requirement) and low blood glucose levels (when blood glucose levels drop below 70 and cause blurred vision, confusion, slurred speech, and drowsiness. If the condition is not treated the brain would be starved from a lack of glucose leading to seizures, coma, and death.) R2 had a recent hospital visit on 11/22/22, for a vulnerable adult assessment, on 11/28/22, again for frequent falls, and on 12/3/22, after another unwitnessed fall leading to a closed head injury (when the brain is injured from a rapid forward or backward movement up against the skull leading to a bruise or tearing of the brain tissue.) While he was hospitalized the nursing staff identified he had poor balance, decreased low extremity (legs) strength, and was not safe to walk independently. The recommended hospitals' plan for discharge after his nutrition and blood sugar levels improved was to transfer him to a memory care unit. R2's facility's nurse admission and readmission document dated 12/9/23, identified he had a recent hospitalization related to a fall. R2 was found impulsive and required staff's physical assistance to get up. R2's physical therapy (PT) evaluation and plan of treatment dated 12/10/22, identified he had a lack of ability to identify risky situations. In addition, he had a Parkinson's disease gait (when the body leans forward causing him to take rapid, small steps in attempt to maintain his center of gravity.) R2 required partial or moderate assistance to stand up, transfer from bed to a chair, and to use the toilet. R2's nursing note dated 12/14/23, at 4:06 a.m. identified he was sitting on the floor with his head resting against the seat of his wheelchair. R2 was incontinent of urine at the time of the fall and reported a headache. R2's fall risk summary dated 12/14/23, identified he had a high risk for falls. R2's NP-A visit summary on 12/15/22, identified an order to Please place on fall precautions and monitor patient routinely. R2's nursing progress note dated 12/26/22 at 9:25 p.m. identified R2 fell around 7:00 p.m. in the dining room injuring his head and left shoulder. Staff identified a scrape on the top of his left shoulder, and he complained about both of his shoulders hurting. R2 received pain medication and NP-A was notified about the incident and she ordered an Xray of the left shoulder. R2's annual Material Data Sheet (MDS) dated [DATE], identified R2 was able to understand conversations, but had difficulty speaking. There was no history of R2 rejecting cares from staff. R2 had malnutrition, Parkinson's disease, history of falls, dysphagia, muscle weakness, dementia, CVA (cerebral vascular accident also referred to as a stroke), anxiety, orthostatic hypotension (his blood pressure dropped when he stood up causing lightheadedness), high blood pressure and depression. R2 could move independently in bed but needed one staff member to help him transfer from one surface to another and walk. He needed extensive assistance from one staff member to dress and complete his hygiene needs. In addition, he only needed staff supervision (oversight, encouragement, or cues) and set up help when he used the toilet. R2's neurology after summary visit note on 1/19/23, at 11:00 a.m. identified a referral made for PT to evaluate him for falls and develop preventative interventions. R2's nursing progress note on 1/26/23, at 3:15 p.m. identified he had an unwitnessed fall. He did not sustain an injury from the fall and the NP, and his family were updated about his condition. R2's medical follow up appt dated 1/30/23, at 9:54 a.m. identified R2's gait was unstable, and he was unable to get up without physical assistance. R2's care plan dated 1/31/23, identified a goal for him to be continent of urine and bowel during waking hours. The only intervention listed was for staff to check him for incontinence. The space for SPECIFY REQ where the staff would know how often and when they should check him was left blank. R2's PT functional assessment (a test designed to determine a resident's level of functioning and ability to complete various tasks safely) dated 2/1/23, identified his self-care functioning score was zero (on a score between 0-12, in which 12 being the highest score.) R2's witnessed fall report dated 2/10/22 indicated R2 fell in R2's room, 2nd floor west. The incident description indicated staff were passing by R2's room when the R2 was walking in the room and fell forward by his bedside. R2 was assessed and monitored. R2 had a bruise to his left shoulder. R2's nursing progress note dated 2/10/23 at 11:52 a.m. identified he was found by the housekeeper in his room on the floor trying to get up. In addition, he sustained a small cut on his left forehead. R2's resident fall risk assessment dated [DATE], identified he had a high risk for falling and required staff assistance and a mobility device such as a walker or wheelchair to ambulate. In addition, R2 received a medication known to cause an increased confusion and alertness. R2's bowel and bladder program screener dated 2/10/23, identified he was never able to use the toilet independently without being incontinent (the inability to control the flow of urine). He required the assistance from one person to get into the bathroom and transfer safely to the toilet. The assessment summary identified he was not a candidate for bladder training. R2's witnessed fall report dated 2/12/23 indicated R2 fell in the dining room, 2nd floor west. The incident description indicated R2 was using his wheelchair as a walker. The resident tried to sit in the wheelchair but did not put on the breaks and fell . R2 was assessed and encourage the resident to put on the brakes before sitting in the wheelchair. R2 was not injured. R2's occupational therapy evaluation dated 12/12/22, identified he had impaired balance, poor coordination, unsteady gait, poor problem-solving skills and the inability to assess for environmental hazards. R2's medical providers after visit summary on 2/13/23, identified he had a recent fall, and required sutures to a facial laceration. During interview on 2/15/23, at 3:53 p.m. Department of Human Services (DHS)-A stated he visited resident R2 on 2/8/23, to conduct a survey for the Department of Human Services. When he asked R2 about the care he received from the staff he started to profusely cry. R2 told him about a recent fall where he hurt his shoulder. R2 ask the staff for pain medication, and they told him he could not have any at that time and instructed him to lay down in bed. R2's NP-A visit note on 2/15/23, identified the purpose for her visit was to evaluate and treat his left eyebrow laceration from a fall. She identified R2 was very, very, very impulsive and fell at the facility many times. In addition, she suggested to the facility several times he needed to transfer to a memory care unit for his safety. R2's NP-A visit note on 2/16/23, identified the purpose for her visit was at the request from the nursing staff related to his complain of left shoulder pain. She ordered fall precautions and to continued routine monitoring. R2's care plan was not updated and did not reflect any new interventions to reduce the risk of falls or re-evaluate the fall interventions effectiveness to prevent falls R2's care plan had two staff interventions: ensure R2 is in his chair and continue to keep assistive devices close when ambulating. During interview on 2/16/23, at 9:16 a.m. FM-A stated R2 fell at least once a week. FM-A stated he is getting weaker, and he was falling because he cannot get any help. R2 knows how to use his call light but when he is in a wheelchair, he cannot reach it. Observed his call light mounted on the wall about four feet above his bed. In addition, the push button call light extending from the wall mount was on the floor behind his bed. R2 was naked and observed both of his shoulders had various wounds at different stages of healing. In addition, he had scabs on both of his knees. R2's toenails were thick, dry, and extended away from his toes at various lengths up to one inch. He was not wearing shoes and stated the shoes cause pain when his nails rubbed up against it. His wheelchair was not in the room or hallway. There were two walkers in his room, both were folded up, one was placed in his closet and the other one was wedged between the window and his dresser. During interview on 2/16/23, at 12:32 p.m. the administrator stated R2 only fell in the hallway because he was very impulsive not in his room. During interview on 2/17/23, at 11:37 p.m. nursing assistant (NA)-A stated R2 can stand and turn but if staff are not with him, he would fall down. During an interview on 2/21/23, at 1:45 p.m. NP-A stated she assessed him on 2/16/23. She stated given the number of falls he had it is not OK for him to toilet himself without help. she stated it has been frustrating trying to work with the staff and leadership regarding the amount of falls he had endured. She stated at one point she had him on a list to transfer to a higher level of care at a memory care unit, but the facility cancelled the transfer. She feels R2 it's not an appropriate patient for that facility because of his wandering and falls but the facility did not agree with her assessment and canceled the transfer. She stated the facility will not collaborate with her to develop a plan of care and interventions to prevent falls. She has arranged several meetings with the administration to discuss the situation and they failed to show up for the appointment. The Falls Clinical Protocol dated 10/4/21, identified the staff and medical providers would work together to identify why a resident would continue to fall and document their findings in the resident's medical record within 90 days. Falls would be categorized by the event leading up to the fall. For an example, getting up from a seated position, or trying to walk. If a resident continued to fall despite the interventions set in place, the medical provider would identify any associated medical causes to the fall. The medical provider would evaluate the resident's gait, balance, and medication side effects. If the resident continues to fall despite the attempts to prevent a fall, staff will continue to assess, and develop new interventions until the incidents of falls are reduced or eliminate. Preventing repeated falls are essential related to frail elderly residents have a greater risk for serious adverse reactions after a fall.

Based on observation, interview and document review, the facility failed to ensure residents were free from abuse for 4 of 4 residents (R2, R4, R7, R10) who were verbally and/or mentally abused by R1. This resulted in psychosocial harm for R4 who reported not feeling safe and isolating in his room due to incidents of abuse by R1. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was independent with wheelchair propelling, was free of behaviors and was free of cognitive impairment. R1's care plan, printed 1/19/23, identified R1 is/has the potential to be physically and verbally aggressive related to poor impulse control. R1's interventions directed staff to assist R1 to alleviate his stress, to encourage him to seek out the director of nursing (DON), to intervene before agitation escalated and to guide him away from sources of distress. In addition, staff were directed to calmly walk away if R1 became aggressive and to reapproach later. R1's care plan lacked identification and interventions related to R1's aggressive electric wheelchair use when he was upset, or interventions that directed staff to intervene to protect the rights and safety of other residents. R2's admission MDS dated [DATE], identified R2 was independent with wheelchair propelling and was free of cognitive impairment. R4's quarterly MDS dated [DATE], identified R4 was cognitively intact and was independent with wheelchair propelling. R7's quarterly MDS dated [DATE], identified R7 was cognitively intact and was independent with wheelchair propelling. R10's quarterly MDS dated [DATE], identified R10 was independent with wheelchair propelling and was diagnosed with a cognitive communication disorder. R7 R1's progress note, dated 11/5/22, identified R7 updated the nurse that R1 ran him over four times with his wheelchair earlier that week while R7 used the elevator. In addition, R7 informed the nurse, it continued all day and [R7] was threatened by [R1] . The nurse advised R7 to speak with administration. R1's medical record lacked evidence the incident was reviewed, and interventions were care planned and implemented to prevent future incidents of abuse as protection for residents. Review of R7's medical record lacked documented evidence R7 was involved in an incident the week of October 31st with R1, or that R7 was monitored and assessed for potential psychosocial harm outcomes following the report to staff. During an interview on 1/19/23, at 2:26 p.m. R7 stated he tried to avoid R1 as R1 had an attitude and often has scream fests with staff and other residents. R7 acknowledged history of altercations with R1 and explained an elevator incident. R1 attempted to get past R1 to enter the elevator; however, R1 would not move when asked. R1 proceeded to get snippy with R7 in which R1 may have threatened him with violence; however, he could not remember the exact words used but remembered R1 swore at him with much vulgarity. R7 considered R1 a threat due to R1's verbalizations and the aggressive wheelchair movements R1 made where R7 thought R1 was going to run into him. During this interaction, R7 stated he felt his blood pressure going up. Since then, R7 was worried about repeat altercations and thus attempted to avoid R1 and would not feel safe riding in the elevator with R1. R7 indicated he does self-isolate more to his room and does not come out as often as he had compared to before the elevator incident. R10 R1's progress note, dated 12/1/22, at 1:57 a.m. identified R1 entered the facility and passed by another [unidentified] resident who sat in the hallway listening to music. R1 started to pick at the resident; however, the resident ignored R1. Following, R1 proceeded to threaten the other resident that he would beat him up and have some of his family member[s] to come and beat him up. The note indicated the police were called. R1's progress note, dated 12/1/22, at 2:58 a.m. identified R1 presented to the second floor (R1 resided on first floor) around 10:45 p.m. to fight another [unidentified] resident who was in the dining area. R1 cursed and yelled at this resident, while he also threatened him. In addition, R1 tried to run [the other resident] over with his electric wheelchair. Both residents were exchanging words with each other and using abusive language. Police were called and visited with both residents. Both residents were advised to stay away from each other. Administrator was notified. During interview on 1/20/23, at 1:23 p.m. nursing assistant (NA)-D stated R10 was listening to music and minding his own business on 12/1/22, when R1 began yelling at everyone. At first R10 did not say anything but then later R1 started getting after R10, wanting to fight, police had to be called. NA-D stated the police talked to both the residents and told them to stay separated before leaving. R10 was approached for an interview on 1/20/23, at 2:36 p.m. and declined. R2 A Facility Reported Incident (FRI), submitted to the State Agency (S.A.) on 1/8/23, at 8:55 p.m. identified staff observed R1 punch R2 in the head after R1 was witnessed screaming at his niece and punching her while outside the facility. R1 also appeared intoxicated. R1 stated to staff he was going to shoot her with a gun. Police were called. R1 was placed on 15-minute checks to ensure safety. In addition, the FRI identified R4 witnessed the event. R1's progress notes were reviewed and lacked documented evidence on 1/8/23, R1 experienced a behavioral altercation with R2 that required police intervention. R1's medical record lacked evidence the incident was reviewed, and interventions were care planned and implemented to prevent future incidents of abuse as protection for residents. An investigation interview form provided by the facility was reviewed. The form stated the interviews were from 1/9/23 incident and the interviews were conducted on 1/10/23. The interviews were conducted with NA-A, R1, R2 and R4. [per interviews and FRI report, this incident occurred on 1/8/23, and identified resident interviews were not conducted on the day of the incident.] R1's progress notes dated 1/9/23, at 8:30 a.m. identified R1 became agitated and screamed and swore at staff in which he accused them of ransacking his room. When R1 became more verbally abusive and threatened staff with a his gun, administration was contacted, police were called, and R1's NP was contacted for a 72 hour hold because of homicidal ideation. Interviews confirmed no gun was ever physically found on R1's person. R1's progress notes, dated 1/9/23, at 11:02 a.m. identified an ambulance arrived in the facility at 9:30 a.m. and brought R1 into the hospital for a psychiatric evaluation. R1's hospital record dated 1/9/23, indicated R1 was seen for an encounter for behavioral health screening, treated for stress management and to schedule a follow up visit with nurse practitioner as soon as possible. Hospital record lacked evidence R1's medications were reviewed or R1 was reviewed for a psychiatric hold. R1's records indicated a follow up appointment with his NP on 1/12/23, where an order for psychology follow up was placed and an order to initiate psychotropic (mood altering) medications to assist with potential depression and anxiety he may be experiencing. R1's record lacked evidence of an immediate behavioral care plan interventions to reduce verbal, physical and threatening behavior or measures the facility implemented to protect residents from R1. R1's progress notes, dated 1/9/23, at 3:47 p.m. identified R1 returned at 3:00 p.m. where he remained in his room a short while and then proceeded to go to the second floor around 3:15 p.m. to visit with friends. R1's progress notes, dated 1/11/23, at 1:46 p.m. identified R1 spoke with the director of nursing (DON) where coping mechanisms were discussed if R1 became upset he was to find her and they would work together to find a solution to his problem(s). R1 and DON conversation occurred three days after the 1/8/23, resident to resident incident and two days after 911 call on 1/9/23. A follow-up FRI report, submitted 1/12/23, at 3:54 p.m. identified R1 was sent to the hospital for a psych evaluation on 1/9/23. Education was provided to staff to keep residents in eye site [sic] and intervene if they came within arm's length of each other. If staff were unable to keep in eye sight, they were directed to encourage R2 to stay on his side of the facility, away from R1. R1 was placed on 15-minute checks, which were decreased to one hour checks after he returned from his psychological evaluation (on the same day 1/9/23). R1 and the DON met and discussed his coping strategies and it was determined he would speak with the DON when he was upset with others which was care planned. During a facility interview with R2, he stated he felt safe. The report identified this was an isolated event. R2's medical record lacked documented evidence R2 was involved in the 1/8/23, incident or that he was monitored and assessed for potential psychosocial harm outcomes after. R2's care plan, dated 1/8/23, identified he was at risk for potential abuse due to his vulnerable adult status. R2's interventions directed to ensure he was safe around others that might take advantage of his confusion and to remove him from potentially dangerous situations. R2's care plan lacked documented evidence related to the incident or interventions to keep in eyesight of R1 or encourage him to stay on his side of the facility as needed. During an interview on 1/19/23, at 3:24 p.m. R2 stated that on 1/8/23, R2 came at him like he was really drunk. He started cussing me out and started to use his power chair to attack me and got in my face like he was going to hurt me. R2 continued, He seems like an alcoholic, drug user crack head who threatened him, like he would hurt me .belittled me. R2 explained R1 pushed him with his wheelchair and hit him on the arm he used to block the hits. R2 was unsure if R1 hit him on the head as it happened so quick. R2 stated this was not the first time R1 had screamed at or threatened him but this was the first time he threatened him with gun violence. R2 stated he does not avoid R1 or self-isolate to his room as R2 does not scare easily; however, he does have a fear of him and felt such a situation could happen again and thus he did not want R1 in his space. R1's medical record from 8/11/22, through 1/19/22, lacked documented evidence all of R1's resident-to-resident behavioral incidents were investigated, his behaviors were comprehensively assessed and/or analyzed, his target behaviors were monitored, his medical provider was updated on behaviors prior to 1/8/23, or that his care planned behavioral interventions were evaluated and/or adjusted to decrease the risk of resident directed behaviors. R4 R4's medical record was reviewed, and the following progress note was identified: On 1/8/23, at 8:43 p.m. (late entry) identified R4 voiced he did not feel safe at the facility because of another resident. Staff offered him a room change, which he declined. The record lacked a reason for the decline or alternative interventions to help improve his feeling(s) of safety. R4's medical record lacked documented evidence staff monitored or assessed him for potential psychosocial harm outcome(s) following his statements and the witnessed 1/8/23 incident. During an interview on 1/19/23, at 11:55 a.m. R4 stated he has had three altercations with R1. His first altercation occurred about four to five months ago when R1 threatened him with a gun after they agreed to switch personal electronics. After, R1 approached him and demanded his device back; however, R4 wished to clear the search history and thus did not return it right away. R1 threatened R4 with a gun as R1 kicked on his door throughout the night which R4 stated was known by staff and the administrator. R4 did not feel anything was done about the incident. The second altercation occurred around November when they were outside unobserved and R1 threatened him with gun violence when R1 acted like he was going through drug withdrawal and R4 must have said something to piss him off. R4 denied he updated staff on this incident as he felt it was pointless to tell anyone, as nothing was done after the first incident. The third altercation occurred on 1/8/23, when they were outside smoking. R4 stated when R1 came back up to the facility, after he fought with his niece, R1 yelled at both him and R2 for not stopping his niece from taking his money. R1 instructed R2 to get out of his way as he approached the entry door. When R2 was unable to move fast enough, R1 threatened R2 that he was going to hit him. R4 explained R1 then told him he was going to hit him also and that he was going to fuck both of you up and threatened them with gun violence. After this, R2 started to propel his wheelchair toward R1 and stated to R1 he was not going to threatened them like that. In response, R1 hit R2's head and shoulder regions with a closed fist at least a couple times while R2 attempted to block R1's strikes with his raised elbow. In addition, R4 explained R1 was aggressive in his electric wheelchair propelling and had episodes where it appeared R1 was intentionally going to hit him; however, at the last second he swerved away. R4 stated due to these incidents, and R1's wheelchair actions, he did not feel safe around R1 and experienced massive anxiety when he heard or saw R1, and was nervous R1 would come into his room. In addition, R4 self-isolated in his room and kept his door shut as he felt threatened by R1, especially as R1 was allowed to freely wheel around the facility and their rooms were close to each other. R1 acknowledged he would come out of his room more often if R1 were not a resident. On 1/19/23, after the interview with R4, R1's room was observed to be across the hallway, one room to the left. On 1/19/23, at 1:09 p.m. R4 was observed propelling his wheelchair down the first floor hallway towards his room. R4 continued to look around and behind him. When R4 approached the area of his and R1's room, he sped up his propelling and kept his head turned toward R1's room until he passed R1's closed doorway. Once passed, he entered his room and quickly shut the door. R4's medical record was reviewed after the interview and indicated, on 1/8/23, staff identified his safety was at risk and there was a potential for abuse due to his vulnerable adult status. The care plan directed staff to remove him from potentially dangerous situations. R1's care plan lacked documented evidence he was threatened by another resident and/or interventions to protect him from R1's abuse. In addition, R4's medical record lacked documented evidence of the first or third altercation with R1 or that R4 was monitored and assessed for potential psychosocial harm outcomes related to his interactions with R1. When interviewed on 1/19/23, at 4:09 p.m. the assistant director of nursing (ADON) stated she was unaware of the incidents on 11/5/22, and 12/1/22, despite her managing these residents. She confirmed these three incidents were resident-to-resident abuse. The ADON explained R1 was un-supervised at times but identified staff were to monitor R1 when inside the facility. She was unsure of any behavior interventions when R1 was outside with other residents, and she was unable to identify any other interventions to protect residents related to R1's behaviors. She stated she expected any behavioral interventions for R1 to be care planned. During an interview on 1/19/23, at 4:39 p.m. the DON stated she was hired on 11/7/22, and since then every time abuse occurred it was reported to her right away; however, she was unaware of the incident which occurred 12/1/22. The DON stated R1 liked to get in your face and his electric wheelchair goes very fast. She explained it was not R1's intent to run you over with it .he would not risk breaking his wheelchair and because of this others misinterpreted his wheelchair actions when R1 was upset. She identified R1 was referred to psychology services after the 1/8/23, incident; however, she stated she was unsure if he had agreed to participate. Further, she stated interventions to protect other residents from R1's behaviors were for him to come to her office if he was upset so that he could yell at her instead of other residents and if she was not in the facility, he could call her. Additionally, R1 was to be placed on routine interval checks if he displayed behaviors and staff were to intervene if R1 and other specified residents were too close to each other, or staff encouraged them to remain in their respective areas. The DON stated R1 typically was a nice guy without any significant behaviors; however, R1's behaviors appeared to increase after he received his monthly stipend as he left the facility more and had increased presentation of appearing intoxicated which made her think R1 was possibly drinking and or smoking crack at those times as he had a history of big explosions when he drank or did drugs. The DON denied knowledge R1's behaviors were comprehensively assessed and/or analyzed to decrease R1's behavioral risks. When asked what R1 was directed to do when the DON was out of the building or unavailable during the work day, the DON stated, he could contact her by cell. When interviewed on 1/20/23, at 12:27 p.m. NA-A stated she witnessed R7 attempting to get onto the elevator and R1 was going ballistic. R1 called R7 names and threatened him. NA-A assisted R7 to the first floor with R1 following shortly after. R1 again started to yell and threaten R7, along with making aggressive movements towards R7 with his electric wheelchair. R7 told R1 he would have someone bring a gun to the facility and shoot him. In addition, NA-A stated she witnessed R1 punch R2 in the head on 1/8/23, and heard R1 state to her and R4 he would blow us away. She stated R4 had felt unsafe and called 911 himself. NA-A stated she talked with R2 after the incident and R2 stated he was mad and did not understand why R1 acted as he did towards him. During telephone interview on 1/20/23, at 1:19 p.m. licensed practical nurse (LPN)-A stated R7 informed her R1 attempted to run him over on the elevator. LPN-A explained she encouraged R7 to update administration as he had to speak up. LPN-A acknowledged she had witnessed R1 go after other residents and verbally threaten and abuse them which required police intervention multiple times. LPN-A stated, other than standard interventions, she was unsure of any R1 specific behavioral interventions to keep other residents safe. When interviewed via telephone on 1/20/23, at 1:49 p.m. the administrator stated he expected any resident-to-resident altercation to be reported to him right away; however, he denied knowledge of the 11/5/22 incident. He stated he was aware of an incident between R1 and R10 and he assumed at least one of the incidents on 12/1/22, occurred between these two. He also acknowledged the incident reported by R4. He explained both R1 and R10 threatened each other with violence and the police were called. The administrator verified neither R1 or R10 wanted any official police actions completed and the incident involved two adults that were just yelling because they were upset. He stated the incident between R1 and R4 occurred over a disagreement after they exchanged electronics and one wanted theirs back. Both residents had words in which both threatened the other. The police were called to intervene; however, additional follow-up was not completed because it was a resident-to-resident with property and we knew what the stem [of the problem] was. The administrator stated R1 was easily set off if another resident made a snide comment which made the situation escalate to a whole other level. He stated R1 appeared to have increased behaviors later at night when management was not present in the facility. During telephone interview on 1/20/23, at 2:59 p.m. R1's NP stated R1 was not appropriate for a nursing home setting related to his behaviors which tended to be erratic and impulsive .wild and was someone who used alcohol. She was concerned he also used other substances; however, she was not able to confirm this as he declined past attempts at testing. NP stated R1 definitely has a mental health diagnosis where at a minimum he had a bipolar diagnosis but again he would not consent for any past medical record releases for her to review to confirm. During the interview the NP was updated on R1's 11/5/22, and two 12/1/22, incidents and she expressed this was the first time she heard about them. NP explained she provided an order to send R1 to the hospital for a 72-hour hold related to homicidal ideation. After the hospital sent him back the same day, she followed up with him on 1/12/23, and placed an order for psychology follow up and initiated psychotropic (mood altering) medications to assist with potential depression and anxiety he may be experiencing. NP stated she was not involved in a comprehensive behavioral assessment/analysis process with facility staff related to R1's behaviors and interventions to decrease R1's behavioral risks. During a follow-up interview on 1/20/23, at 4:35 p.m. the DON stated she would expect staff to monitor residents' mood after resident-to-resident altercations or if staff saw changes in mood/behavior a psychology referral and nurse practitioner (NP) follow-up would be completed. If the incident/altercation was significant enough then she would expect a cognitive assessment (BIMS) and mood assessment (PHQ-9). A policy titled Identifying Types of Abuse, reviewed 10/18/22, defined abuse as the willful infliction of injury .intimidation .with resulting physical harm, pain, or mental anguish which included resident-to-resident abuse. In addition, the policy identified Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Examples of mental and verbal abuse included harassing, insulting, mocking, yelling or hovering behavior, and threats. Further, the policy identified some situations of abuse do not result in observable physical injury or the psychosocial effects of abuse may not be immediately apparent in which the victim may not report abuse due to shame, fear, or retaliation or they may not express outward signs of physical harm, pain, or mental anguish. Psychosocial, psychological, or behavioral outcomes may present as fear of a person or place, withdrawal, and/or self-isolating. The policy indicated the following situations were recognized to likely cause psychosocial harm which may take months or years to manifest and have long-term effects on relationships with others: Any resident-to-resident physical abuse this is likely to result in fear or anxiety.

Based on observation, interview, and document review, the facility failed to implement interventions to prevent pressure injuries for 1 of 1 resident (R23) who was at risk for pressure ulcers. This resulted in actual harm for R23 who developed multiple stage II pressure injuries. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): - Stage II pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ ruptured blister.) R23's admission Minimum Data Set (MDS) dated [DATE], indicated R23 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further identified R23 was at-risk for pressure injuries, however, had no documented pressure ulcers. R23 required extensive assistance with bed mobility and toileting. Additionally, R23 required mechanical assistance with transfers. A progress note dated 2/23/22, at 3:18 p.m. indicated R23 had a left buttock wound which measured 1.4 centimeters (cm) by 1.2 cm. A subsequent wound provider note dated 2/27/22, indicated staff reported R23 had a new wound to their left buttock and R23 was not eating well. It was documented R23's wound was a stage II pressure ulcer which measured 1.4 cm x 1.3 cm. No additional skin concerns were noted. treatment recommendations included cleansing the area and application of a foam dressing daily and as needed. Additionally, staff were to offload pressure every two hours, optimize glycemic control (blood sugar management), provide a pressure relieving mattress, offload heals, and optimize nutrition. The wound note further indicated the plan was discussed with facility staff. A wound provider note dated 3/6/22, indicated R23's left buttock wound had no changes and no new skin concerns were noted. Further, recommendations remained unchanged from 2/27/22. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Despite the aforementioned wound interventions being recommended, R23's care plan which was dated 2/2/22, lacked indication of the stage II pressure ulcer and directed staff to follow facility policies/procedures for skin breakdown, monitor R23's food intake, and conduct a weekly skin check on bath day. A wound provider note dated 3/13/22, indicated R23's left buttock wound had no changes and staff reported no new skin concerns. On exam, a new wound on R23's scrotum was identified. Barrier cream to the scrotal wound would be trailed. The aforementioned treatment recommendations remained in-place in addition to application of barrier cream to the scrotum and peri area twice daily and with incontinent cares, protein supplement twice daily for wound healing. It was documented the plan was discussed with facility staff. A progress note dated 3/15/22, indicated R23 had multiple open areas to their buttocks and scrotum area. A note was left for the provider in a communication folder for follow-up. During an observation on 3/14/22, at 1:33 p.m. R23 was observed in bed. The head of the bed was elevated and R23 was eating lunch. R23's lower legs had pillows under them, however, heels were resting on the bed. No pressure relieving mattress was in-place. On 3/15/22, at 1:01 p.m. a continuous observation was started and R23 was in bed. The head of the bed was elevated approximately 45 degrees. At 1:09 p.m. R23 lowered the head of his bed and was groaning and yelling out; no staff was present in the hallway at this time. At 1:44 p.m. R23 appeared to be sleeping, however, again yelled out at 1:52 p.m. Staff was observed delivering laundry outside of R23's room and did not respond. Additionally, licensed practical nurse (LPN)-V was seated at a desk near R23's room and had not responded. At 2:41 p.m. R23 yelled out and LPN-V and LPN-D responded. LPN-V adjusted and applied lotion to R23's legs. LPN-D exited the room to obtain pain medication. R23 verbalized, need change. LPN-V continued to lotion R23's legs and feet. Subsequently, LPN-D returned and assisted LPN-V apply lotion to R23. LPN-D discovered a reddened blister on the outside of R23's left heel. LPN-V confirmed the area was a new blister. LPN-V applied skin prep to the blister and measured the wound which was 1 cm x 3 cm. A pillow was then placed under R23's legs, however, heels were not floating off the mattress. LPN-J then assisted and covered R23 with a sheet and put a bedside tray within reach. R23 again requested incontinence care. LPN-J informed R23 they would notify a nursing assistant to which appeared to upset R23 who verbalized, You go, and they never come change me, you say you tell them, they never come. I have told them to clean and wash me and they say they will come back and don't come back. R23 then stated, I call long time; nobody come. LPN-J reassured R23 a nursing assistant would come. At 3:05 p.m. nursing assistant (NA)-T entered R23's room and turned R23 to his left side. A wound to R23's left buttock, left lower buttock/thigh, and scrotum were noted as R23 provided incontinence care. All three wounds were open and a small amount of pink drainage was noted. No dressings were noted on any of the wounds. At 3:16 p.m. LPN-D and LPN-V stated R23's left buttock wound was new, but the scrotum and left lower buttock/thigh wounds were new. R23's left lower buttock/thigh wound measured 2 cm x 1.5 cm and the scrotum wound measured 1 cm x 2 cm. R23's wounds were cleaned and the buttock and thigh wounds were covered with a foam dressing. R23 was repositioned to left side and the continuous observation ended at 3:22 p.m. R23 still did not have a pressure relieving mattress. During an interview on 3/15/22, at 3:25 p.m. NA-T stated R23 needed to be turned every few hours, but repositioning residents was not happening due to being short staffed. NA-T stated when skin problems were seen, it needed to be reported to the nurse, but sometimes agency staff did not report these issues. NA-T again stated she was not able to follow the skin policy as there was not enough help. NA-T stated, The residents are suffering. During an interview on 3/15/22, at 3:30 p.m LPN-D stated R23 should be repositioned more frequently and it was hard to complete cares as there was not enough staff to do so. During an observation on 3/16/22, at 12:51 p.m. R23 was assisted back to bed by NA-A and NA-B using a mechanical lift. As R23 was lifted, R23's incontinence product was noted to be half opened and frank blood dripped onto the floor and bed sheets. R23 was placed and bed and was repositioned side-to-side as the soiled linens were removed and replaced. R23's wounds were again not covered with a dressing and no barrier cream was seen. R23's wounds were observed to be oozing bloody drainage. NA-A cleaned R23's wounds with a disposable wipe and NA-B exited the room to notify LPN-V. NA-A then placed a clean incontinence product on R23 without applying a barrier cream. NA-B then returned to the room and stated LPN-V would complete a dressing change when dining was completed. The resident was on his back with the head of bed elevated. Pillows were also placed under R23's legs, however, R23's heels remained in contact with the bed. During an interview on 3/16/22, at 10:22 a.m. nurse practitioner (NP)-II stated R23 had a stage 2 pressure ulcer on left buttock and stage 2 pressure ulcer on scrotum. NP-II stated they had not been notified R23 had a new open area on left lower buttock/thigh, nor the blister on R23's left foot. NP-II stated barrier cream needed to be placed on R23's scrotum and a foam dressing to their buttocks. NP-II stated the blister also needed to be protected or the skin was at-risk for further deterioration. NP-II expected staff to carry out any wound treatment orders for R23. During an interview on 3/17/22, at 9:14 a.m. the director of nursing (DON) stated staff were expected to provide barrier cream and dressings to R23's wounds as directed. The DON stated, typically, nurse managers rounded with the wound provider to ensure an understanding of recommended treatments and recommendations. The managers then updated the resident's orders and care plan. The DON stated it had been months since there was unit leadership at the facility therefore this was her responsibility. The DON confirmed the wound provider recommendations were not follow-up on as she needed to understand what interventions were recommended as there was not a unit manager. Facility policy titled Pressure Injury/Skin Integrity/Wound Management revised 11/16, directed residents who were at risk for or who have loss of skin integrity would receive appropriate treatment and services which may include specific physician ordered treatments, pressure relieving equipment, and repositioning as per resident assessment and care plan. The policy also directed an avoidable pressure injury means the resident developed a pressure injury and the facility did not do one or more of the following: evaluate the residents clinical condition and risk factors, implement interventions that are consistent with the residents needs, goals and standards of care, monitor and evaluate the impact of the intervention.

Based on interview, and document review, the facility failed comprehensively assess and implement pressure ulcer interventions for 1 of 3 residents (R1) reviewed for risk of pressure ulcers development. R1 was harmed when he developed two stage 2 pressure ulcers after admission to the facility. Findings include: R1's Admit/Readmit tool, dated 1/6/2022, noted R1's skin was normal, warm, and dry. No skin [CONDITION(S)] were present. R1 was totally dependent on staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. R1 required a wheelchair for mobility and was incontinent. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had a score of 13 on the Brief Interview for Mental Status (BIMS) assessment tool indicating he was cognitively intact. The MDS further indicated R1 needed extensive or total assistance with cares, bed mobility, transfers, feeding, and personal hygiene. R1 was incontinent of bladder and bowel and needed to be turned every 2 to 3 hours. The MDS indicated R1 did not have a pressure ulcer present when admitted to the facility. R1's care plan dated 1/21/22, indicated R1 had potential impairment to skin integrity related to incontinence. Interventions included identification and documentation of possible causative factors and keep skin clean and dry. Care plan depicted two sections entitled the resident needs (Specify: pressure relieving to protect the skin in bed) and the resident needs (Specify: pressure relieving to protect the skin while up in chair). No devices or interventions were listed in either of these sections. R1's care plan was last reviewed on 1/25/22. Medical record review revealed a referral response letter was sent to the facility on [DATE] from nurse practitioner (NP)-A who examined R1 on 2/23/22. NP-A described two wounds which were debrided. The two wounds were described as wound #1: stage 2 pressure injury location left buttock Length:5.3 cm width: 4.2 cm depth: 0.2 cm debrided and dressed, total surface area debrided was 22.26 sq cm, and wound #2: stage 2 pressure injury location coccyx Length:1.1 cm width: 1.2 cm depth: 0.1 debrided and dressed, total surface area debrided 23.58 sq cm. Treatment recommendations to R1's stage 2 pressure ulcers to the left buttock and coccyx indicated to cleanse and pat dry, apply skin prep to periwound skin, cover with foam dressing, change daily and as needed prn drainage, and may use barrier cream to surrounding buttocks, pressure offload, and avoid shearing or dragging. R1 is a type 2 diabetic, optimize glycemic control for wound healing, encourage protein intake, supplements daily for wound healing, a dietary consult. R1 to be turned and repositioned every two hours, float heels, incontinence care as need, weekly wound rounds, and follow-up in week. Due to R1's [CONDITION(S)] weakness a pressure offload mattress was recommended. A photograph of both wounds was added to the medical record. R1's medical record was reviewed and lacked evidence of monitoring or prevention attempts instituted prior to NP-A's letter dated 2/27/2022 that identified two wounds. Also, there was no indication a Braden Scale (an assessment tool used for predicting pressure risk) or other comprehensive pressure ulcer assessments completed even though R1 was identified at risk for development of pressure ulcers based on their limitations and functional ability. R1's Face Sheet reviewed 3/3/2022, indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/3/22, at 10:36 a.m. Registered Nurse (RN)-A was interviewed and stated the standard for turning residents at risk for pressure ulcers was every 2 to 3 hours. Stated R1 screamed and yelled out frequently, if asked what is wrong, stated was OK. Restless, difficult to position. Alert but not always oriented. Stated no ulcers or skin [CONDITION(S)] were noted upon transferred to the second floor from the transitional care unit on 1/31/22. No ulcers or skin [CONDITION(S)] were noted upon return from the hospital on 2/6/22. First heard about the pressure ulcers when NP-A evaluated pressure ulcer on 2/23/2022. Stated the note from NP-A was received on the day R1 transferred to the hospital. On 3/3/22, at 11:07 a.m. Certified Nursing Assistant (CNA)-A was interviewed and stated she discovered R3's skin had become loose and discolored over R3's coccyx. The skin was soft, pliable, and discolored. Stated she reported findings to the shift nurse who placed a dressing over the area to prevent the skin from tearing. CNA-A stated the nurse was from an agency, she did not recall her name, did not recall the name of the agency, and has not seen the nurse. Stated this occurred more than 2 weeks ago, sometime in February, stated she does not know or recall exactly when this happened. On 3/3/22, at 11:47 a.m. Director of Nursing (DON) stated was not aware R1 had any [CONDITION(S)] or ulcers on the skin. DON agreed these preventive care/treatments nor skin assessments were performed. Stated the ulcers were facility acquired. The facility's Skin Integrity policy, Pressure Injury/Skin Integrity/Wound Management-HDGR, dated as revised on 11/2016, indicated staff were to prevent pressure ulcers by following the following procedures. Upon Admission: i. A head to toe skin assessment will be conducted by a licensed nurse. It is recommended that this assessment is completed within the shift that the resident was admitted ; however, it must be completed within 24 hours of admission. A tissue tolerance test (both lying and sitting) must be completed per state requirements and/or facility policy within 24 hours of admission. Assessment information should identify specific factors that might increase the risk of pressure injury development or affect healing of a pressure injury. A Norton or Braden skin assessment will also be completed upon admission. ii. All residents are preventatively placed on pressure reduction mattresses and cushions in wheelchairs based on the skin assessments. Those residents who represent a high risk will have further preventative interventions put in place. Appropriate turning and repositioning schedules will also be put in place per assessment. An initial/immediate care plan will be initiated. b. Weekly: i. A weekly skin check will be conducted and documented for at-risk residents. ii. This is a hands-on, direct visual assessment. c. Quarterly: i. A Norton or Braden skin assessment will be completed in conjunction with the RAI/care plan process. ii. Assessment information should identify specific factors that might increase the risk of pressure injury development or affect healing of a pressure injury and documentation to reflect reassessment including any changes to the care plan. d. Re-admission or Significant Change in Condition per MDS: i. Follow process for admission and complete all admission assessments. ii. All residents are preventatively placed on pressure reduction mattresses and cushions in wheelchairs based on the skin assessments. Those residents who represent a high risk will have further preventative interventions put in place. Appropriate turning and repositioning schedules will also be put in place per assessment. An initial/immediate care plan will be initiated. 4. Documentation b. Care Planning: i. For new admission/readmissions, an immediate plan of care will be developed to address the immediate interventions to preserve and/or treat skin integrity issues. This should be communicated to staff. ii For the resident at risk for developing a pressure injury or who has a pressure injury, an individualized care plan will be developed per the RAl/care plan timelines. iii. The care plan should address prevention of any skin breakdown, including sheering or friction, repositioning or off-loading; pressure relief equipment; and the care and treatment to be provided to the resident for a pressure injury or non-pressure wound behaviors and preferences.

Based on observation, interview, and document review, the facility failed to re-order scheduled pain medication and implement non-pharmacological interventions to reduce or prevent increase pain for 2 of 3 residents (R161, R42) reviewed for pain management. This practice resulted in actual harm when R161 did not receive pain medication timely causing uncontrolled severe pain that lasted several hours. Findings include: R161 admission record dated 8/4/21, indicated R161 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R161 admission Minimum Data Set (MDS) assessment dated [DATE], indicated R161 was cognitively intact and reported almost constant pain that limited day to day activities and sleep. R161's care plan did not address pain interventions to prevent and/or decrease R161's pain to include medications and non-pharmacological interventions. R161's order summary report dated 8/4/21, indicated R161 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R161's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility narcotic book indicated R161 received his last dose of [MEDICATION(S)] 15 mg ER at 5:04 p.m. on 8/1/21. During observation on 8/2/21, at 4:34 p.m. surveyor heard trained medication aide (TMA)-A inform R161 he did not have any pain medicine available. Further, TMA-A informed R161 he would have to wait until pharmacy brings the medication because the computer indicated its been ordered. R161 was doubled over in his wheelchair crying and moaning in pain. During interview on 8/2/21, at 4:37 p.m. R161 stated he asked for pain medicine at 8:00 a.m. and the staff told him the medication would arrive in the facility at noon and now TMA-A was telling him the pharmacy may bring the medication around 5:00 p.m. Further, R 161 stated he has been in pain all day with a pain level of 9 on a pain scale of 0-10 with 10 being the worst pain. During observation on 8/2/21, at 4:37 p.m. R161 was holding onto his back and side moaning loudly, grimacing, and crying out in pain. During interview on 8/2/21, at 4:43 p.m. TMA-A stated when a pain medication runs out Tylenol would be substituted if the resident is able to take it. However, TMA-A did not offer R161 Tylenol. Further, TMA-A stated they were waiting on pharmacy to bring R42 and R161 scheduled pain medications and the pain medication had not arrived yet due to a possible insurance issue. Additionally, TMA-A stated there was nothing that could be done about the pain medications not available. During interview on 8/2/21, at 4:55 p.m. R161 stated the pain was in his lower back and both upper shoulders. During observation on 8/2/21, at 5:20 p.m. R161 remains by the nurse station holding onto his back and side, moaning loudly, grimacing, and crying out in pain. No staff were observed to inquire about R161's pain or offer any type of pain interventions. During observation on 8/2/21, at 6:17 p.m. R161 in bed moaning and curled up into a fetal position and stated he was in extreme pain. During observation on 8/2/21, at 6:36 p.m. R161 continued in bed moaning and curled up into a fetal position. R161 stated TMA-A just came in and gave his scheduled pain medication since it had just arrived from pharmacy. Further, R161 stated he wasn't able to finish therapy today, didn't eat, and stayed in bed most of the day due to the pain. During observation on 8/2/21, at 7:25 p.m. R161 remained in bed moaning and restless. R161 stated his pain level remained at a 9 on a pain scale of 0-10 with 10 being the worst. During interview on 8/2/21, at 7:34 p.m. TMA-A stated, I just gave R161 his pain medicine and he told me he was still in pain. During interview on 8/2/21, at 7:41 p.m. TMA-A stated was going to let R161 rest and if he needs anything else he will let me know. Further, stated no non-pharmacological interventions were attempted. During interview on 8/3/21, at 8:32 a.m. R161 stated when he received his pain medication timely his pain level was at 3 on a pain scale of 0-10 with 10 being the worst. Further, R161 stated he felt better around 2:00 a.m. after receiving his pain medicine and his pain level was back to a 3. R42's admission record dated 8/4/21, indicated R42 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R42 was cognitively intact and reported frequent pain with no non-pharmacological interventions performed. R42's care plan dated 8/4/21, indicated R42 has a pressure ulcer to unidentified area with an intervention to treat pain as per orders prior to treatment/turning and etc. to ensure R42's comfort. However, no other pain interventions were included on the care plan. R42's order summary report dated 8/4/21, indicated R42 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation on 8/2/21 at 6:14 p.m. R42 was observed grimacing and rubbing her right leg above her foot. Upon interview on 8/2/21 at 6:14 p.m. R42 stated her foot hurts real bad and rated the pain an 8 on a pain scale from 0-10 with 10 being the worse pain. Further, R42 stated, well it's really a 10 but if I say it's a 10 then they will send me to the hospital and I don't want to go to the hospital. Additionally, R42 stated she's been hurting since last night because the staff didn't give her prescribed scheduled pain medication and the staff also did not attempt any non-pharmacological interventions. During interview on 8/4/21, at 10:15 a.m. director of nursing (DON) stated the nurse should reorder pain medications five to seven days before the pain medication runs out. Further, DON stated if the pain medication does run out the nurse should then call the doctor to get an order to remove the medication from the narcotic emergency kit (e-kit). Additionally, DON stated if the pain medication isn't in the e-kit then the nurse should call the pharmacy to get a stat medication delivered. DON verified the staff did not attempt to get pain medication out of the e-kit nor call the pharmacy to get a stat delivery. Further, DON verified if a resident doesn't receive their scheduled pain medication the resident's pain wouldn't be managed and could have possible complications. The pain management policy dated May 2020, indicated residents would be observed during the day for any signs and symptoms of pain, pain unresolved would be reported to the physician, and relaxation, heat, cold, massage, positioning, and distraction would be used to supplement pharmacological interventions. The reordering, changing, and discontinuing orders policy dated 10/31/16, indicated facility staff should re-order a resident's medications and review the re-orders for status, potential issues, and pharmacy response.

Based on interview and document review, the facility failed to comprehensively assess, reassess and develop interventions to minimize the risk of harm for 1 of 1 resident (R2) who was consuming alcohol in an unsafe manner. This resulted in an immediate jeopardy (IJ) situation for R2 who remained at risk of serious injury, impairment or death related to unsafe alcohol use in the community. The IJ began on 7/1/21, when R1 was observed to be alone in the street outside of the facility in a median area between two busy roads. R2 slid out of his wheelchair as he tried to get back to the facility. R2 was noted to be intoxicated. The facility had knowledge of R2's unsafe behaviors in the community related to alcohol consumption but did not comprehensively assess his alcohol use or develop interventions to minimize the risk of injury to R2 who continued unsafe alcohol use while in the community. The director of nursing (DON) and administrator were notified of the IJ on 7/7/21, at 5:20 p.m. The IJ was removed on 7/8/21, at 5:20 p.m., however, noncompliance remained at a lower scope and severity of isolated with no actual harm with potential for more than minimal harm (Level D). Findings include: R2's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition and was independent with transfers and locomotion on the unit. R2 required set up for locomotion off the unit. R2 relied on a wheelchair and walker for mobility. Diagnoses included heart failure, depression, and [CONDITION(S)] (medical term used to describe a disease that affects brain structure or function which resulted in altered mental state and confusion). R2's Associated Clinic of Psychology (ACP) neuropsychiatric evaluation dated 5/25/21, indicated R2's conceptualization was below average, spatial abilities scored moderate cognitive impairment and memory was severe cognitive impairment. The summary and recommendations included: court ordered guardian for assistance with healthcare and financial decisions due to significant issues with memory. Additionally, R2 was diagnosed with major neurocognitive disorder due to vascular disease and alcohol use disorder. R2's care plan last revised 6/28/21, indicated R2 was vulnerable because he ignored personal safety, had impaired family relationships, irritated others, and had mobility limitations. The care plan also identified R2 had poor decision making and impaired cognitive status r/t [related to] continued outings in the community and had returned to facility intoxicated with alcohol in his possession. R2's progress notes identified the following: -7/1/21, at 8:00 p.m. R2 was noted by medical doctor (MD)-A to sit in the street in front of the building. MD-A alerted staff in the facility and R2 was assisted off the ground with assist of four staff. R2 was noted to be intoxicated. R2 was not injured. R2 was started on 15 minute checks. -7/3/21, at 12:47 p.m. a local business called the facility to report R2 was at their place of business and told them he could not get home. The facility then sent a nursing assistant to the business to bring R2 back to the facility. On 7/7/21, at 9:27 a.m. licensed practical nurse (LPN)-A stated R2 left the facility routinely to go to the liquor store on the other side of the road. LPN-A stated on 7/3/21, she had not known R2 had left the facility as he had not signed out. LPN-A thought R2 was out smoking and did not know how long he was gone. Staff were sent over to assist R2 to get back to the facility. LPN-A stated R2 was not on safety checks at that time. LPN-A confirmed R2's medical record lacked documentation of any safety checks on 7/6/21, and 7/7/21. R2's medical record lacked evidence follow up was completed after the above incidents. R2's medical record lacked any assessment related to unsafe drinking behaviors and meaningful interventions to reduce the risk of harm related to drinking unsafely in the community. On 7/7/21, at 11:47 a.m. LPN-B stated she had worked with R2 on 7/1/21, when R2 fell in the street. LPN-B stated R2 was really drunk when he left the facility to go outside, and she had thought R2 was only outside to smoke and not to leave the facility grounds. R2 had not signed out of the sign out book. LPN-B stated R2 does not listen when asked to stop drinking. LPN-B stated R2 was started on 15 minute safety checks upon his return on 7/1/21, and assessed after the fall. LPN-B stated she was unaware of any interventions after the 15 minute safety checks were stopped the following day 7/2/21. A review of the facility sign out log for R2 indicated he did not sign out on 7/1/21, nor 7/3/21. On 7/7/21, at 12:34 p.m. social services director (SSD) stated they rely on the BIMS (Brief Interview of Mental Status cognitive evaluation) to determine community safety. SSD stated if a resident had physical limitations then therapy could help evaluate. SSD was not sure if therapy had evaluated R2 recently. SSD stated R2 goes out in the community often and comes back intoxicated. In those moments R2 was at risk for injury and not safe in the community. SSD stated R2's cognition would fluctuate based on his intoxication level. On 7/7/21, at 1:28 p.m. nursing assistant (NA)-A stated R2 usually went to the mall across the street, because there was a liquor store there. R2 would self-propel himself using his feet and could also turn the wheelchair wheels with his hands. NA-A stated she did not think R2 was safe in the community and should be evaluated by someone. NA-A stated R2 would not have listened to staff if they told him to stop drinking alcohol. NA-A stated R2 used to be on safety checks but was not at this time. NA-A confirmed R2's medical record lacked documentation of any safety checks on 7/6/21, and 7/7/21. On 7/7/21, at 1:32 p.m. the director of nursing (DON) stated to determine community safety they would look at a resident's BIMS score. If a resident had intact cognition they were safe to go out of the facility. The DON added R2 was generally safe in the community, however, once he was intoxicated he was not safe. The DON stated she was aware of the incident on 7/1/21, when R2 was in the street and on 7/3/21, when R2 was at a local business and the business called the facility to help R2 get back to the facility. The DON stated after 7/1/21, R2 was put on 15 minute checks and that was discontinued on 7/2/21, and she did not know why the checks were stopped. The DON stated after learning of the event on 7/3/21, R2 was placed on hourly checks starting 7/6/21. The DON was not aware of any changes to R2's plan of care to ensure safety in the community. On 7/7/21, at 2:00 p.m. MD-A stated on 7/1/21, she left the facility and had observed R2 in the street outside of the facility in a median area between two busy roads. R2 was not in a crosswalk area. MD-A watched R2 slide off his wheelchair onto the street. MD-A stated she did not think R2 was safe in the community and that his underlying cognition had been poor due to alcohol induced dementia. MD-A stated R2 was determined to need a guardian and was not sure what the status was on that referral. On 7/7/21, at 3:17 p.m. the administrator stated a risk and benefit analysis needed to be completed immediately to ensure R2 understood community safety risks. On 7/7/21, at 3:51 p.m. the DON stated R2's guardianship referral had not been completed. The DON stated her expectation was for guardianship referrals to have been completed more timely and that a delay of over a month was not acceptable. On 7/7/21, at 4:11 p.m. SSD stated R2 had a neuropsychological test done with ACP on 5/25/21, and guardianship was recommended. R2's physician signed the orders for guardianship on 6/3/21. SSD stated the next step would have been for SSD to send the completed paperwork to [NAME] County and she had not done that yet. SSD stated the guardianship referral should have been completed more timely. The IJ was removed on 7/8/21, at 5:20 p.m. when it could be verified through document review and staff interviews: the facility comprehensively assessed R2's alcohol use in the community and implemented interventions to reduce the risk of harm. The facility had completed a risk and benefit assessment with R2. R2 was placed on ongoing hourly safety checks. The facility had completed a referral to another nursing home with a chemical dependency treatment program. R2's paperwork for guardianship was faxed to the county. R2's Rule 25 application was followed up on. In addition, the facility discussed the risks of continued alcohol use in the community with R2, updated R2's physician to obtain an order for occupational therapy and implemented a facility-wide policy and procedure to assess for safety in the community. The facility began education to all staff on 7/7/21, and if staff did not work on 7/7/21, prior to the start of their next shift which included: -ensured residents that left the facility were evaluated for safety prior and residents were educated on signing out -Residents with a desire-to, or history of having left the facility independently would be evaluated for community safety upon admission and when unsafe behaviors are noted in the community -Residents having left the facility must have been signed out with a potential return time and a contact number should resident not be back in the facility at potential return time -Residents whom required increased safety checks (i.e. 15 minute, 30 minute or one hour) the resident must have physically been seen by facility staff and needed to be signed off on the sign off sheet or PCC (Point Click Care electronic medical record). -Staff were to notify the director of nursing, or designee, resident representative, physician and local police department when unsafe behavior could not be redirected and the resident safety was at risk in the community -The process for a missing resident included: if resident was not located in the facility the staff must have completed a search of facility, checked the sign out book, notified resident representative, DON or designee, administrator and contacted local police. -Staff were to have reviewed and followed all recommendations from professional referrals for evaluation. Understanding of the above education was verified on 7/8/21, from 3:36 p.m. through 4:20 p.m. by interviews on-site with two trained medication aides, four nursing assistants, three registered nurses, two licensed practical nurses and two physical/occupational therapy staff, the director of nursing and the social services director. The facility had also provided education to other residents about the sign out process and community safety. For residents that were determined to be at risk in the community, an order for occupational therapy and risk and benefit assessment was to be completed. Additionally, audit forms titled Employee-Resident Safety Procedure Audit and Resident Community Safety Sign-Out Procedure Audit were developed by the facility to monitor ongoing compliance. Audits were to be completed five days a week for two weeks and then three times per week for two weeks and weekly for two months. The audits would track: -Staff understanding of safety checks and expectations on whereabouts of residents -Audits of adherence to resident sign out policy -Audits on the need for community safety assessment for residents with the capability to leave the facility campus without assistance -Audits on redirecting residents deemed unsafe to leave the facility without supervision and the process of notifications to clinical management, family and/or police department for noncompliance. Facility policy (developed after identification of the IJ) titled Community Safety dated 7/21, indicated: -Residents deemed independent with mobility are interviewed for their interest-in or history of leaving the facility campus without assistance on admission and/or when incidents of unsafe behavior are reported. -Residents with a history-of or desire-to leave the facility campus without assistance would be referred to occupational therapy for community safety assessment and received education on community safety risks. -Residents with a BIMS score of below (8) which indicated severe impairment and/or deemed unsafe per occupational safety assessment will be offered alternative methods for securing community resources, and a safety plan will be developed for community outings.

Based on interview and document review, the facility failed to ensure medication orders were correctly transcribed and administered in accordance with physician orders [REDACTED]. This resulted in actual harm when R1 required hospitalization as a result of receiving [MEDICATION NAME] (used to treat high blood pressure) and potassium (mineral that contributes to properly functioning kidneys, heart, muscles and nerves) after the order for these medications had been discontinued. The facility further failed to ensure proper medication administration when R1 received [MEDICATION NAME] (used to treat heart rhythm problems), [MEDICATION NAME] (used to treat high blood pressure), and [MEDICATION NAME] (used to treat high blood pressure) after the order for these medications had been discontinued on a separate occasion. Findings include: R1's quarterly Minimum Data Set (MDS) dated , 9/25/20, identified R1 was cognitively intact. R1's [DIAGNOSES REDACTED]. R1's progress noted dated 10/16/20, at 12:28 p.m. indicated, Resident readmitted from (hospital) at 12 p.m. via wheelchair (w/c) with principal problem [MEDICAL CONDITION] (high potassium blood level). Resident denies pain or discomfort at this time. Vitals stable. Will continue to monitor. R1's discharge summary from hospital on [DATE], indicated, STOP taking [MEDICATION NAME] 100 milligrams (mg) 24 hr tablet and potassium chloride 20 (milliequivalent) MEQ tablet. R1's medication administration record (MAR) dated 10/16/20, indicated both [MEDICATION NAME] and potassium were administered on 10/17/20 and 10/18/20. R1's progress note dated 10/20/20, at 15:44 (3:44 p.m.) indicated, Resident was sent to hospital at 0930 (9:30 a.m.) due the following vitals BP, 97/45, pulse of 33, temp, 98.8, oxygen sats 89%. She was also lethargic (unresponsive). R1's discharge summary from hospital on [DATE], indicated R1 presented with a heart rate in the 30s and a potassium level of 7.3 (normal potassium range 3.5-5.0). It was determined that patient was mistakenly receiving [MEDICATION NAME] at NH (nursing home) which was already discontinued. The discharge summary procedure note further indicated, Patient presented with [MEDICAL CONDITION] cardiogenic shock with profound [MEDICAL CONDITION]; sinus node dysfunction (condition affecting heart rate). Was hyperkalemic. Required urgent temporary pacemaker (which) was placed the right internal jugular vein. The discharge summary did not mention that R1 received potassium that had been discontinued. R1's discharge instructions dated 10/27/20, indicated, STOP taking [MEDICATION NAME] 200 mg tab, [MEDICATION NAME] 10 mg tab and [MEDICATION NAME] 0.2 mg/24 hour. R1's progress noted dated 10/27/20, at 15:11 (3:11 p.m.) indicated, Resident returned from hospital prior to writer's arrival. Orders faxed to pharmacy by A.M. nurse. New, corrected orders faxed from discharging hospital. Those orders faxed to pharmacy. Vitals: T 97.5, P 68, R18, BP 159/90, O2 96%. Alert and oriented, able to make needs known. Fully oriented to room. R1's MAR dated 10/27/20, indicated [MEDICATION NAME] and [MEDICATION NAME] were all administered on 10/28/20. During interview on 10/28/20, at 10:41 a.m. medical records administrator (MR)-A stated the normal process for admissions or readmissions was that the hospital would fax the resident's orders to the pharmacy and then the pharmacy would send the updated MAR to the facility. The facility would replace the old MAR with the new one from pharmacy. The new MAR would then be placed in the medication (med) book and the old MAR would be removed and filed in the paper chart. MR-A further stated nurses documented medication administration on the MAR that is stored in the med book. During interview on 10/28/20, at 11:10 a.m. registered nurse (RN)-A stated new orders were faxed to the pharmacy and then the pharmacy sent back the new paper MAR. The nurse on duty when the MAR was received back from pharmacy would check the MAR against the orders. The MAR would sometimes come back from pharmacy with the discontinued orders still listed. RN-A further stated the correct process would be to follow the MAR. If a medication was discontinued, it would be yellowed out on the MAR by the nurse checking the MAR against the orders and the medication would be removed from the med cart. Discontinued medications would then be either returned to the pharmacy or disposed of properly. I gave these meds ([MEDICATION NAME] and [MEDICATION NAME]) this morning (10/28/20) they were not yellowed out. RN-A stated the previous nurse gave report on R1, but did not mention new orders. If there were new orders to be checked, the chart would be on the counter at the nurse's station or on top of the chart cart with the paper orders sticking out of the binder. RN-A could not recall where R1's chart was that morning. During interview on 10/28/20, at 11:52 a.m. RN-B stated R1's orders were faxed to pharmacy on 10/27/20, when R1 returned to the facility from the hospital. Pharmacy sent back R1's paper MAR on 10/27/20. Pharmacy should have checked to make sure all the orders were current. It was the nurse's responsibility to check and there should have been a second nurse to double check all orders against the MAR. Both nurses should sign, date and time the order sheet indicating that the orders have been checked. RN-B further stated the nurse assigned to the med cart when a new MAR was received should remove any discontinued medications from the med cart and return to pharmacy or dispose of properly. During interview on 10/28/20, at 12:02 p.m. R1 stated that staff discovered her oxygen saturation level was in the 80's and was sent to the hospital on [DATE]. R1 further stated staff at the hospital discovered her heart rate was low and her potassium was too high. I was not feeling well. I was sleeping a lot. R1 further stated not knowing what medications were ordered or discontinued upon discharge from the hospital on [DATE]. R1 confirmed and stated a patch ([MEDICATION NAME]) was applied behind her ear this morning (10/28/20) but the nurse just removed it. During interview on 10/28/20, at 12:59 p.m. pharmacy senior triage tech (TT) described the normal process for pharmacy orders. Orders were faxed from the facility to the pharmacy intake department then routed to the order entry department. Order entry would enter new orders or make changes to orders in the resident's profile. Then a pharmacist would check the orders before the MAR was sent back to the facility. During interview on 10/28/20, at 1:14 p.m. pharmacist (P)-A. stated order entry enters the orders into the resident's profile and a pharmacist checks the orders. If a medication was discontinued it should have been checked against the new orders and removed. P-A confirmed and stated R1's [MEDICATION NAME] was listed from a May order, but was not on R1's 10/16/20 orders for readmission to the facility. It should have been removed on the 16th. It should have been double checked. P-A further stated that she could see there were orders to be discontinued for [MEDICATION NAME] and [MEDICATION NAME] from 10/27/20, and were not removed from the MAR. These orders would have gone through order entry and then a pharmacist to be checked. During interview on 10/28/20, at 2:58 p.m. RN-B stated was notified that R1 received some medications in error this morning (10/28/20) and notified the DON and (R1's) primary doctor. RN-B further stated, I took her vitals and she is ok. She is oriented and eating just fine. No adverse effects from those medications this morning. During interview on 10/29/20, at 1:53 p.m. P-B stated the two doses of potassium could have caused the [MEDICAL CONDITION]. P-B further stated that [MEDICATION NAME] could decrease heart rate but could not confirm that two doses given in error was the cause of R1's condition without knowing R1's history. During interview on 10/28/20, at 4:58 p.m. RN-D stated R1's progress note in the hospital written by cardiologist (MD)-B dated 10/20/20, indicated severe [MEDICAL CONDITION] due to overdose of [MEDICATION NAME]. During interview on 10/29/20, at 10:27 a.m. director of nursing (DON) stated R1's new MAR was received by fax at the nurse's station on 10/16/20, at 2251 (10:51 p.m.). The nurse on duty at the time the new MAR was received should have done the first check and the next shift nurse should have done the second check. Both nurses should sign and date the order sheet when they checked it. A check consisted of comparing admission orders [REDACTED]. DON confirmed and stated R1's new MAR and orders had not been checked, That is where our system is broken. During interview on 10/29/20, at 11:15 a.m. license practical nurse (LPN)-A confirmed working on R1's unit on the night shift of 10/16/20. LPN-A stated not being aware that any new MAR came in that night for R1. During interview on 10/29/20, at 5:19 p.m. RN-C confirmed working on R1's unit the day shift on 10/17/20. RN-C stated that if there are were order changes or medication changes the night nurse would include that information in report in the morning. I do not remember getting any report of any changes with R1. I looked at the MAR and gave the meds according to the MAR. RN-C stated the nurse working when the new MAR was received should check the MAR against the orders and then report to the next nurse to do the same for a second check. During interview on 10/29/20, at 3:25 p.m. R1's primary care provider (MD)-A stated the two doses of [MEDICATION NAME] and potassium wrongfully administered to R1 could have contributed to R1's hospitalization due to R1 developing [MEDICAL CONDITION] (low heart rate), heart block, cardiogenic shock and [MEDICAL CONDITION] (high blood potassium level). The facility policy admission orders [REDACTED]. The facility policy Medication Administration Record dated 3/1/14, identified all prescribed medications by the physician were to be listed on the resident's MAR. The policy indicated when a resident was discharge to the hospital, a new MAR must be initiated upon readmission.