Every finding on record at Hopkins Restorative Care Center

Based on observation, interview, and record review the facility failed to ensure fall interventions were care planned and implemented for 1 of 3 residents (R3) reviewed for change in condition. Findings include: R3's admission Record dated 8/7/26, indicated R3 had Parkinson's Disease, Dementia, and history of falls. R3's Fall Risk assessment dated [DATE], indicated R3 was at a high risk for falls due to having 1-2 falls in the last 90 days, moderately impaired vision, unsteady balance with or without assistive devices, incontinent, had health conditions that were risk factors, and took medications that increased risk for falls. R3's Nursing-Admission/readmission Observation dated 8/8/26, indicated R3 was alert and oriented to self, was confused and forgetful, was non-ambulatory, and required transfer assistance. R3's fall care plan dated 8/8/26, lacked fall interventions after R3's fall on 8/11/26. R3's progress note dated 8/12/26 at 6:34 a.m., indicated on 8/11/26 at 11:30 p.m., R3 was found on the floor next to R3's bed. R3 was assessed with no injury and was placed back into bed with full body mechanical lift. Progress note lacked interventions implemented post fall. R3's progress note dated 8/13/26 at 11:31 a.m., an interdisciplinary team (IDT) meeting indicated R3 had a fall from bed and interventions would include the bed to be in low position and a floor mat next to bed. During an observation on 8/18/26 at 11:23 a.m., R3 was seen in her bed, in a low position, sleeping. R3's husband was in her room sitting in a stationary chair next to R3's bed. There was no fall mat next to R3's bed or in her room. During an interview on 8/18/26 at 11:25 a.m., family member (FM)- A stated he was aware of R3's fall. He stated the facility put a low bed in R3's room but never put the fall mat in place. FM-A stated he was aware there should be a fall mat but had not seen one. During an interview on 8/18/26 at 12:04 p.m., nursing assistant (NA)-A stated she knew R3 had fallen and had a low bed that needed to be lowered when R3 was in bed. NA-A stated she looks in resident care plans for all interventions and was not aware of R3 having a fall mat as a fall intervention as it was not in R3's care plan. During an interview on 8/18/26 at 12:11 p.m., registered nurse (RN)-A stated she was aware R3 had fallen and that a fall mat was part of the intervention because they always put one in place after a fall from bed. RN-A was not sure why the fall mat was not in R3's room or who was responsible for putting the fall mat in the room. RN-A indicated that all fall interventions should be care planned and the director of nursing (DON) was responsible for ensuring the interventions were care planned for all residents. During an interview on 8/18/26 at 12:22 p.m., maintenance worker (MW)-A stated he puts interventions after a fall in residents' rooms. He stated he was not aware R3 needed a fall mat in her room until a few minutes prior to his conversation with state agency (SA). MW-A stated he was going to put a fall mat in R3's room today. During an interview on 8/18/26 at 1:07 p.m., DON stated the interventions put into place after R3's fall were to have a fall mat and low bed. The low bed request was put in for maintenance to complete but the fall mat was not. DON stated she should have been the one to put the request in, but did not. DON stated she was still learning the process of what needed to go into a care plan after a fall and knows now that the fall mat and low bed should have been care planned so staff could see the interventions and follow them. During an interview on 8/18/26 at 1:41 p.m., the administrator stated the DON was expected to make sure all fall interventions were in place and care planned. He was not sure why the interventions were not care planned and he was not sure why the fall mat was not in place for R3. The facility Fall Prevention Program Policy revised 2/2023 indicated the facility would implement fall interventions and if a resident experienced a fall the facility would review and update the residents care plan as indicated.

Based on interview and document review, the facility failed to ensure a comprehensive baseline care plan was developed and implemented within 48 hours of admission for 1 of 3 residents (R1) to guide the interdisciplinary team in providing safe, effective, and person-centered care. Findings include: R1's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated admission to the facility on 7/29/26 with intact cognition, dependence upon staff for activities of daily living (ADL)s, an indwelling catheter (flexible tube inserted into the bladder to drain urine), an ostomy (a surgical opening in the colon that allows stool to exit the body through a stoma into an external pouch) , seven Stage 4 (severe, full-thickness wound where skin and tissue are lost, exposing underlying muscle, tendon, ligament, or bone) and pressure ulcers (PU) that were present on admission. R1's diagnoses included paraplegia, neurogenic bladder (lack of bladder control caused by brain, spinal cord, or nerve problems), malnutrition, neurogenic bowel (loss of bowel control caused by brain, spinal cord, or nerve problems), and arthritis due to bacteria. R1's progress notes dated 7/29/26 at 10:55 p.m., indicated the resident came to the facility by emergency medical services, and admitted on a regular diet with a Foley catheter, colostomy bag, and multiple wounds. R1's care plan was reviewed on 8/6/26 and indicated the following focus areas for a baseline care plan: 7/30/26 Enhanced barrier precautions related to wounds, an ostomy, and a Foley catheter 7/30/26 Risk for constipation 7/31/26 Activities of daily living (ADL) deficit 7/31/26 Risk of dehydration 7/31/26 Risk for further impaired skin integrity with interventions to consult a dietician, consult a wound/ostomy nurse, educate the resident/representative about the causes of PU The baseline care plan lacked focus areas for care of the colostomy and indwelling catheter, the prescribed diet, pain management, and care for the wounds/PU with interventions for how to treat the current pressure ulcers and interventions for how to prevent additional PU. During an interview on 8/7/26 at 12:42 p.m., the licensed practical nurse (LPN)-A stated the nurse manager was supposed to do the baseline care plan and the facility did not currently have a nurse manager (NM). R1 should have a baseline care plan for all the initial care items staff would have to care for such as wounds, the ostomy, catheter, and ADLs. The LPN-A stated the facility was lacking the systems and leadership in place, the system was skewed, and the work wasn't getting done because the previous director of nursing (DON) and NM quit, and the new DON was on vacation and didn't have systems in place yet for baseline care plans. During an interview on 8/7/26 at 3:28 p.m., the registered nurse (RN)-A stated she performed R1's admission assessment and acknowledged R1 had PU, a catheter, and an ostomy when he was admitted . The care for each should be included on the baseline care plan. The baseline care plan should have been completed within 48 hours of admission for staff to know how to care for the resident. During an interview on 8/10/26 at 9:20 a.m., the LPN-C stated the DON or the NM were supposed to develop a resident's baseline care plan, but the facility did not currently have a NM. R1 should have had a baseline care plan for wound care, ostomy care, pain management, and catheter care right after admission. The nurses could ask the DON to add them to the care plan. During an interview on 8/10/26 at 9:41 a.m., the LPN-D stated R1 should have had a baseline care plan for his catheter, ostomy, pain, PU prevention, and wound care right after admission. During an interview on 8/10/26 at 9:48 a.m., the LPN-E stated the baseline care plan was supposed to be developed with the first 48 hours after admission. R1's baseline care plan should have contained information about his catheter, wounds, and ostomy. If these items were not on the care plan it would be hard to know how to care for him. During an interview on 8/10/26 at 11:38 a.m., the DON stated the baseline care plan was generated within 48 hours after admission from reviewing the initial nursing assessment and was based off of the resident's diagnoses. The baseline care plan should include information about transfers, ADLs, nutrition, bowel and bladder care, pain, skin integrity, and PU prevention. During an interview on 8/11/26 at 11:00 a.m., the LPN-B stated the baseline care plan should have been initiated 7/29/26, and should have included focus areas: wounds, colostomy, catheter, and pain management. The LPN-B stated the admitting nurse could have added to R1's baseline care plan. Any nurse caring for R1 after admission could have as well. R1 did not have an adequate baseline care plan for staff to know how to care for R1. The Baseline Care Plan policy dated 2023 indicated the baseline care plan would be developed within 48 hours of a resident's admission and could include the minimum healthcare information necessary to properly care for a resident including initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and preadmission screening.

Based on interview and document review, the facility failed to ensure nursing staff accurately and comprehensively performed clinical assessments upon admission and subsequent readmission for 1 of 3 residents (R1) reviewed for wound care.Findings include: R1's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated intact cognition, dependence upon staff for activities of daily living (ADL)s, an indwelling catheter ( a tube inserted into the bladder to drain urine to a receptacle outside the body), an ostomy, (a surgical opening in the colon that allows stool to exit the body through a stoma into an external pouch), and seven Stage 4 pressure ulcers (severe, full-thickness wound where skin and tissue are lost, exposing underlying muscle, tendon, ligament, or bone) that were present on admission. R1's diagnoses included paraplegia, neurogenic bladder (lack of bladder control caused by brain, spinal cord, or nerve problems), malnutrition, neurogenic bowel (loss of bowel control caused by brain, spinal cord, or nerve problems), and arthritis due to bacteria. R1's initial nursing assessment dated [DATE], indicated the following:Section H - Bowels - lacked assessment of frequency, color/consistency, date of last bowel movement (BM) and lacked indication appliance: colostomy and type of appliance, and the date of the last change.Section I - Bladder - indicated Foley catheter (type of indwelling catheter) but lacked information about the size, balloon size, and appliance type. Section J - Extremities - indicated no paralysis even thought R1 had diagnoses of paraplegiaSection L - Skin evaluation - indicated skin was dry, warm, and intact, even though R1 admitted with seven Stage 4 PU. Section M- Other relevant concerns - 1a. indicated no precautions other than universal, even though the resident entered with an ostomy, catheter, and wounds which would indicate enhanced barrier precautions (EBP - precautions that stipulate workers wear a gown and gloves during high-contact activities) were required. 5a indicated no psychoactive medications, but R1 was prescribed an anti-anxiety medication (Mirtazapine). R1's progress notes dated 7/29/26 at 10:55 p.m., indicated the resident came to the facility by emergency medical services, and admitted on a regular diet with a Foley catheter, colostomy bag, and multiple wounds. R1's provider orders indicated the following:7/29/26 Mirtazapine oral tablet 15 milligrams (mg) at bedtime for anxiety7/30/26 0.5 Dakin soak - daily, soak Kerlix, wet to dry dressings to all areas of open wounds, cover with abdominal pad and tape one time a day During an interview on 8/7/26 at 3:28 p.m., the registered nurse (RN)-A acknowledged she performed R1's initial nursing assessment on 7/29/26 and omitted several areas on the assessment. The RN-A stated she missed the colostomy, the size and type or urinary catheter R1 had, and incorrectly indicated R1's skin was dry, intact, and warm. Further, the RN-A acknowledged she indicated on the assessment R1 had no paralysis even though R1 was paralyzed. The RN-A did not assess R1's medications to accurately reflect the use of psychotropic medications. The RN-A stated her assessment of R1 was not accurate and could have affected the care R1 had after admission. During an interview on 8/10/26 at 11:38 a.m., the director of nursing (DON) stated R1's initial assessment was not accurate in several aspects as follows:Section H - Bowels - lacked assessment of frequency, color/consistency, date of last bowel movement (BM) and lacked indication appliance: colostomy and type of appliance, and the date of the last change.Section I - Bladder - indicated Foley catheter but was missing other dataSection J - Extremities - indicated no paralysisSection L - Skin evaluation - indicated skin was dry, warm, and intact Section M- Other relevant concerns - 1a. indicated no precautions other than universal and the medications for antianxiety was not checkedAdditionally, the DON stated R1's assessment should have included more information about R1's BMs, the urinary catheter size, type, and balloon size, R1 had paraplegia, multiple wounds and was prescribed medication for anxiety. The DON further stated R1 should have been on EBP due to the catheter, ostomy, and wounds. The DON stated she expected an initial nursing assessment to be accurate so staff would know how to care for a resident properly, and so an accurate comprehensive care plan could be developed. During an interview on 8/11/26 at 11:00 a.m., the licensed practical nurse (LPN)-B stated some of the facility nursing staff first knew R1 had a colostomy when he returned from the hospital on 7/31/26, after a nursing assessment was completed. It was missed prior to that because the initial nursing assessment omitted the colostomy. The Conducting an Accurate Resident Assessment policy dated 11/25 indicated all residents would receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded, with the potential for inaccurate federal reimbursement and resident care planning for 1 of 3 residents (R1) reviewed for wound care.Findings include: R1's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated intact cognition, dependence upon staff for activities of daily living (ADL)s, an indwelling catheter, an ostomy, (a surgical opening in the colon that allows stool to exit the body through a stoma into an external pouch), and seven Stage 4 pressure ulcers (severe, full-thickness wound where skin and tissue are lost, exposing underlying muscle, tendon, ligament, or bone) that were present on admission. R1's diagnoses included paraplegia, neurogenic bladder (lack of bladder control caused by brain, spinal cord, or nerve problems), malnutrition, neurogenic bowel (loss of bowel control caused by brain, spinal cord, or nerve problems), and arthritis due to bacteria. The MDS lacked any information for section D - Mood, and indicated pain should be assessed, but each subsequent question was not assessed. During an interview on 8/10/26 at 11:38 a.m., the director of nursing (DON) stated R1's MDS assessment was not complete as it did not contain a pain assessment or a mood assessment (sections D and J) but should have been because R1 was taking antidepressant and had many wounds that may have caused pain. The Conducting an Accurate Resident Assessment policy dated 11/25 indicated all residents received an accurate assessment, reflective of the resident's status at the time of the assessment.

Based on interview and document review the facility failed to ensure nursing staff reviewed and transcribed discharge paperwork and physician orders for 1 of 1 resident (R1) who returned to the facility from the emergency department. This deficient practice resulted in a significant medication error when R1 missed multiple prescribed doses of methadone and R1 exhibited clinical withdrawal symptoms. Additionally, the facility failed to ensure medications were administered as ordered for 1 of 1 resident (R2) during a leave of absence (LOA). Specifically, the facility failed to ensure R2's critical chronic medications were properly provided, packaged, or prepared for administration and failed to ensure R2 was educated about taking the medications while on LOA. This failed oversight resulted in R2 missing doses of Xarelto (rivaroxaban - blood thinner medication used to prevent blood clots in the cardiovascular system), ticagrelor (medication used to prevent blood clots in the arteries), and insulin. This deficient practice exposed R2 to clinical risk of stroke, heart attack, arterial blood clots, or elevations in blood glucose levels. Findings include: R1 R1's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated intact cognition, dependence upon staff for activities of daily living (ADL)s, and seven Stage 4 pressure ulcers (severe, full-thickness wound where skin and tissue are lost, exposing underlying muscle, tendon, ligament, or bone) that were present on admission. R1's diagnoses included paraplegia and opioid dependence. R1's provider orders dated 7/29/26, indicated methadone hydrochloride (HCl) five (5) milligrams (mg), give nine (9) tablets, one time a day for opioid dependence until 8/5/26. R1's hospital discharge orders dated 7/30/26, indicated methadone 5 mg tablets, give 9 tablets by mouth daily for seven days for opioid dependence. Make sure to go to your appointment at the addiction medicine clinic as scheduled on 7/31/26 at 7:00 a.m. R1's July 2026 Medication Administration Record (MAR) indicated methadone was not administered on 7/30/26 and 7/31/26. R1's August 2026 MAR indicated methadone was missed from 8/1/26 to 8/3/26. On 8/3/26, R1 was out of the facility at the hospital. R1's progress notes indicated the following:7/31/26 at 2:29 a.m., R1 was alert, oriented, in no acute distress, had mild pain, wound dressings were intact, and had no concerns. 7/31/26 at 11:58 a.m., methadone HCl was on order. 8/1/26 at 11:29 a.m., methadone HCl was in process.8/2/26 at 3:35 p.m., methadone HCl was not available; the nurse would order it. 8/3/26 at 10:13 a.m., methadone HCl was in process. 8/3/26 at 3:42 p.m., the resident complained of pain and a scant amount of emesis. Sent to the emergency room for evaluation. R1's emergency room progress note dated 8/3/26, indicated R1 presented to the emergency department with nausea, vomiting, and fever up to 100.5 degrees Fahrenheit (F) for several days. The patient stated he followed with a methadone clinic but had not been able to go for the past three days due to transportation issues, and had not received methadone, and felt he was in withdrawal. The noted likely diagnosis was methadone withdrawal. R1's care plan reviewed 8/7/26, lacked a plan for R1's methadone administration. During an interview on 8/7/26 at 12:42 p.m., the licensed practical nurse (LPN)-A stated R1 did not get to the methadone clinic as ordered due to a transportation issue. The health unit coordinator (HUC) was responsible for ensuring the residents had transportation for appointments. The LPN-A stated he was not sure why the HUC or the director of nursing (DON) hadn't fixed that issue after R1 missed the appointment the first time on 7/31/26, but R1 missed every appointment afterwards too. During an interview on 8/7/26 at 4:20 p.m., R1 stated before he transferred to the emergency department on 8/3/26, he had not gotten his methadone as prescribed due to transportation issues. R1 experienced symptoms of headache, vomiting, and pain in his lower back and kind of, All over. R1 rated his pain as, eight or nine, on a scale of 0 to 10 before he went to the hospital. I don't have pain but that day I did, all over; I felt so sick. That's what happens when you miss methadone. I was withdrawing and it made me feel sick. R1 stated he got a dose of methadone when he arrived in the emergency room, and it helped relieve his symptoms right away. During an interview on 8/10/26 at 9:48 a.m., the LPN-E stated if a resident missed doses of methadone they could experience withdrawal symptoms including shakiness, anxiety, nausea, and vomiting. The LPN-E acknowledged R1 missed doses of methadone 7/30/26 through 8/3/26. During an interview on 8/10/26 at 9:56 a.m., the hospital social worker (SW)-A stated when R1 was admitted to the hospital he was going through opioid withdrawal. He had a fever, nausea, vomiting, had pain, and was very irritable. During an interview on 8/10/26 at 10:09 a.m., the pharmacist (PH)-A stated when R1 missed prescribed methadone doses he would, feel like he was dying but would not be. R1 would have experienced nausea, vomiting, perspiration, anxiety, felt very sick, and would have had pain if experiencing methadone withdrawal. During an interview on 8/10/26 at 11:38 a.m., the DON stated R1 could have symptoms of opioid withdrawal if he missed doses of methadone which may include nausea, vomiting, pain and confusion. The process was for the hospital to send a supply for the weekend initially, and then the facility would arrange transportation to the methadone clinic for additional doses. The DON acknowledged R1's initial dose was supposed to be on 7/30/26, and stated R1 didn't get any of the doses he was prescribed due to transportation issues. The facility was going to get methadone for R1 from the pharmacy going forward. During a follow up interview on 8/10/26 at 3:10 p.m., the DON stated usually the HUC arranged transportation and if the HUC wasn't working, the nurses scheduled the transportation. The HUC was not working when R1 returned from the hospital on 7/30/26, with orders to ensure R1 made it to the appointment on 7/31/26. The nurses should have entered the orders into the medical record and put the appointment on the schedule but had not. The DON stated the nurses were aware of the process and was not sure where the breakdown occurred but would look into it. During an interview on 8/11/26 at 10:21 a.m., the methadone clinic supervisor (MCS)-A stated R1 had not received methadone from their clinic yet but he did an intake with their clinic on 8/10/26. The methadone clinic had not seen R1 since 7/30/26 when they sent him to the emergency room because he was not feeling well. The MCS-A stated R1 was prescribed methadone for opioid use disorder. Methadone withdrawal would cause nausea, vomiting, sweating, anxiety, and potentially pain that would feel achy all over, like having the flu. R1 had to be admitted to the hospital feeling horrible. R2 R2's admission MDS dated [DATE], indicated intact cognition, dependence upon staff for ADLs and personal hygiene. R2's diagnoses included infection of the foot with a diabetic foot ulcer and surgical wound, diabetes (DM), heart failure, peripheral vascular disease (PVD), high blood pressure (HTN) and heart disease (PAD). R2's medications included insulin, an anticoagulant (medication that prevents blood clots), and opioids (medication that treats pain). R2's provider orders included the following:6/17/26 Aspart insulin (rapid acting insulin used to treat diabetes) injected subcutaneously (subq - under the skin) with a pen injector, 100 units (u)/ milliliter (ml) given by sliding scale, at bedtime6/17/26 atorvastatin (medication used to lower bad cholesterol and fat in the blood stream used to help prevent heart attacks, strokes, and chest pain) 80 mg oral tablet, give 1 tablet my mouth at bedtime for PVD6/17/26 empagliflozin (medication used to treat diabetes) 10 mg oral tablet, give 1 tablet daily6/17/26 rivaroxaban (medication used to thin blood to prevent blood clots) 2.5 mg oral tablet, give 1 tablet by mouth two times a day for arterial bypass thrombus (blood clot in a surgical bypass graft), take with meals in the morning and evening6/17/26 hydralazine hydrocholoride (HCl) (medication used to treat high blood pressure) 25 mg oral tablets, give 1 tablet by mouth every 8 hours6/17/26 valsartan (medication used to treat high blood pressure) 40 mg oral tablets, give one tablet two times a day in the morning and evening. Discontinued 7/16/26. 6/18/26 amlodipine (medication used to treat high blood pressure) 10 mg oral tablets, give one tablet one time a day in the morning 6/18/26 eplerenone (medication used to treat heart failure) 25 mg oral tablet, give 1 tablet daily 6/18/26 ticagrelor (antiplatelet medication used to prevent blood clots, heart attacks, and strokes in people with heart disease) 90 mg oral tablet, give 1 tablet two times daily for PAD, PVD and coronary artery disease (CAD) in the morning and evening7/16/26 dapagliflozin 5 mg oral tablet, give 2 tablets by mouth one time a day 7/16/26 Glargine insulin (a long-acting insulin used to treat diabetes) injected subq one time a day for diabetes, with a pen injector, 100 u/ml, give 15 ml one time a day, in the morning.7/17/26 (medication used to treat high cholesterol) 25 mg oral tablet, give one tablet by mouth one time a day in the morning. R2's progress notes indicated the following:7/1/26 at 1:46 p.m., the resident on leave of absence (LOA) and will be back by 6:00 p.m.7/1/26 at 10:12 p.m., the resident left this morning and told the previous nurse he would be back by 6:00 p.m. Called the resident at 10:03 p.m. and he stated he would return tomorrow by 9:00 a.m. The provider and DON were notified.7/2/26 at 11:11 a.m., the resident returned to the facility at 10:53 a.m.7/3/26 at 9:36 p.m., the resident was observed entering the elevator, did not sign out for LOA, and staff went outside to look, unable to locate resident. The resident did not take scheduled medications this shift. Staff tried to reach the resident on his cell phone. The DON and provider were notified.7/4/26 at 7:40 a.m., staff located the resident sleeping on the patio on 7/3/26 around 10:30 p.m., took him upstairs, checked his blood glucose, offered food, administered medications, and updated the DON the resident was found safe.8/1/26 at 9:54 a.m., the resident was LOA8/1/26 at 10:25 p.m., the resident went out of facility and came back at 9:30 p.m. Evening medications administered.8/2/26 at 10:25 p.m., the resident went out of facility at 2:00 p.m. and did not take evening medication. Nurse called and left voice mail to inquire when he would return. The DON was notified.8/3/26 at 12:51 p.m., the resident called and informed staff he stayed with his daughter and would return that evening.8/3/26 at 11:02 p.m., the resident returned at 9:00 p.m. R2's July 2026 MAR indicated the following:7/1/26 at 12:00 p.m., missed a dose of Aspart7/1/26 at 4:00 p.m., missed a dose of hydralazine7/1/26 at 5:00 p.m., missed a dose of Aspart7/1/26 at 8:00 p.m., missed doses of atorvastatin, empagliflozin, rivaroxaban, valsartan7/3/26 at 4:00 p.m., missed one dose of hydralazine7/3 26 at 8:00 p.m., missed doses of Aspart and valsartan R2's August 2026 MAR indicated the following: 8/1/26 at 6:00 a.m., missed doses of dapagliflozin, glargine, losartan8/1/26 at 7:00 a.m., missed one dose of amlodipine8/1/26 at 8:00 a.m., missed doses of Aspart, eplerenone, hydralazine, rivaroxaban8/1/26 at 12:00 p.m., missed one dose of Aspart8/2/26 at 6:00 a.m., missed one dose of dapagliflozin8/2/26 at 3:00 p.m., missed one dose of ticagrelor8/2/26 at 4:00 p.m., missed one dose of hydralazine8/2/26 at 5:00 p.m., missed one dose of Aspart8/2/26 at 8:00 p.m., missed doses of atorvastatin, rivaroxaban8/3/26 at 12:00 a.m., missed one dose of hydralazine8/3/26 at 6:00 a.m., missed dose of dapagliflozin, glargine, losartan, rivaroxaban8/3/26 at 7:00 a.m., missed doses of amlodipine, 8/3/26 at 8:00 a.m., missed one dose of Aspart8/3/26 at 12:00 p.m., missed one dose of Aspart8/3/26 at 5:00 p.m., missed one dose of Aspart8/3/26 at 8:00 p.m., missed doses of eplerenone, hydralazine, rivaroxaban R2's care plan indicated the following:6/18/26 DM with interventions to administer medication and monitor blood glucose levels as ordered6/18/26 Receives anticoagulation therapy related to PVD and PAD with interventions to evaluate signs and symptoms of bleedingR2's care plan lacked a focus area for LOA. No interventions were included for education to ensure R2 knew how to take his medications correctly and check his blood glucose when he was out of the building during medication and treatment times. During an interview on 8/7/26 at 11:42 a.m., R2 stated he had medications at home that he took when he was on LOA but had not compared them to his current medication list. R2 had not been provided a medication list from the facility, but stated nothing bad happened to him yet. R2 stated he has a blood glucose monitor on his arm and knows if his blood glucose gets too high or too low and takes Aspart accordingly. R2 stated the facility had not provided education about his medications or what happens if he doesn't take them. During an interview on 8/10/26 at 9:48 a.m., the LPN-E stated the process for LOA medications was to send the medications pre-packaged by the pharmacy with the resident. The staff would have to establish whether the resident could take the medications independently by performing a Self-Administration of Medications Assessment with R2, which had not been completed. The LPN-E further stated after R2 left on LOA the first time without medications, the nurses should have prepared for it to happen again. When R2 missed medication on LOA, staff should have checked his blood glucose and vital signs when he returned. This was only done some of the time, not each time. The progress notes would indicate the assessments completed upon return. R2 should have had a head-to-toe assessment when he returned from LOA. If R2 was taking medications he had stored at home, the facility would not know if the medications were current doses, or unexpired medications, so it was important to send medication with him. During an interview on 8/10/26 at 10:09 a.m., the PH-A stated R2 should have a supply of medications when he was going on LOA. The pharmacy was able to bottle medications for R2 for planned LOAs. The facility would not know if R2 had correct and current medications stored at a family member's home. R2 was prescribed medications for blood pressure, medications to treat diabetes, and several medications that were important to not miss, including rivaroxaban, insulin, and ticagrelor. R2 would be at risk for stroke, heart attack, or blood clot formation if he missed ticagrelor. Without rivaroxaban R2 would be at risk of deep vein thrombosis (blood clot), stroke, or pulmonary embolism (a blockage in one of the arteries in the lungs, often caused by a blood clot that traveled from another part of the body). During an interview on 8/10/26 at 12:52 pm., the medical director (MD)-A stated he was aware R1 missed doses of methadone, and without it, R1 would have more pain and would go into withdrawal. The MD-A further stated that when R2 returned from leave without taking his medications, staff should assess vital signs, assess for pain, and perform a general assessment. R2 should be assessed to determine if he could take his medication independently. The MD-A stated some areas of care were a little grey, but this area of care was not. A policy for significant medication errors was requested but not provided.

Based on interviews and document review, the facility failed to ensure physician orders were in place to provide treatment and monitoring for a colostomy (opening to allow waste to exit the body and be collected in a pouch) for 1 of 1 resident (R1) reviewed for ostomy care.Findings include: R1's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated intact cognition and presence of an ostomy (a surgical opening in the colon that allows stool to exit the body through a stoma into an external pouch). R1's diagnoses included paraplegia, malnutrition, and neurogenic bowel (loss of bowel control caused by brain, spinal cord, or nerve problems). R1's progress notes dated 7/29/26 at 10:55 p.m., indicated the resident came to the facility by emergency medical services, and admitted with a colostomy. R1's care plan dated 8/5/26, indicated R1 had a colostomy/ileostomy (surgical opening into the bladder that allows urine to exit the body through a stoma into an external pouch) but didn't indicate which. Interventions included to empty the pouch when half way full, monitor skin around the stoma for breakdown, and provide ostomy care and change the ostomy appliance as needed. R1's provider orders reviewed 8/6/26, lacked orders for R1's colostomy care including the type of appliance, change frequency, skin care regimen, assessment parameters, output documentation parameters, and emergency notification thresholds. During an interview on 8/10/26 at 9:20 a.m., the licensed practical nurse (LPN)-C stated the director of nursing (DON) or the nurse manager (NM) were supposed to enter the admission orders. The facility did not currently have a NM. R1 should have had orders for the ostomy right after admission. During an interview on 8/10/26 at 9:41 a.m., the LPN-D stated R1 should have had orders for his ostomy right after admission so staff could know how to care for R1 and know the supplies he required for care. During an interview on 8/10/26 at 11:38 a.m., the DON stated R1 admitted [DATE] and did not have orders for colostomy care until 8/7/26. The orders for the type of ostomy and appliance type should have been in the orders starting 7/29/26 but were still not present in the orders on 8/10/26 although some of the colostomy care orders were added 8/7/26. The DON stated she would ensure the colostomy orders were complete and would add the required orders. The Ostomy Care - Colostomy, Urostomy, Ileostomy policy dated 2023 indicated it was the policy of the facility to ensure residents who required an ostomy received care according to professional standards and the comprehensive person-centered care plan. The frequency of pouch changes and the products required for changing ostomy devices would be noted in the care plan. Interventions to prevent complications or promote dignity associated with the ostomy will be includedin the person-centered care plan. These may include, but are not limited to:a. Foods to restrict or limit to minimize gas, odor, or obstruction.b. Foods to thicken stool, when applicable.c. Fluid preferences, and need for increased fluid intake.d. Increasing fiber intake.e. Medication changes to improve absorption.f. Monitoring symptoms of blockage, UTI, or abnormal stoma findings.g. Use of filtered pouches, deodorants, ostomy belts, or clothing modifications.h. Physical management of pouches, tubing, and night collection devices to prevent infection.

Based on interviews and document review the facility failed to obtain initial orders for a Foley catheter for 1 of 3 residents (R1) reviewed for wound care.Findings include: R1's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated admission on [DATE] with intact cognition, dependence upon staff for activities of daily living (ADL)s, and an indwelling catheter. R1's diagnoses included paraplegia, neurogenic bladder (lack of bladder control caused by brain, spinal cord, or nerve problems), malnutrition, neurogenic bowel (loss of bowel control caused by brain, spinal cord, or nerve problems), and arthritis due to bacteria. R1's provider orders reviewed 8/6/26, lacked an order for a urinary catheter including the type of catheter, the indications for use, the size of the catheter, and the size of the catheter balloon. R1's care plan reviewed 8/6/26, indicated the use of an indwelling catheter for a neurogenic bladder with interventions for catheter care, but lacked mention of the type of catheter, the size of the catheter, and the size of the catheter balloon. R1's progress notes dated 7/29/26 at 10:55 p.m., indicated the resident came to the facility by emergency medical services, and admitted with a Foley catheter. During an interview on 8/10/26 at 9:20 a.m., the licensed practical nurse (LPN)-C stated the director of nursing (DON), or the nurse manager (NM) were supposed to enter the admission orders, but the facility did not currently have a NM. R1 should have had orders for the catheter upon admission. During an interview on 8/10/26 at 9:41 a.m., the LPN-D stated R1 should have had orders for his catheter right after admission so staff could know how to care for R1 and know the supplies he required for care. During an interview on 8/10/26 at 11:38 a.m., the DON stated R1 was admitted on [DATE] and did not admit with orders for the catheter. The orders for the type of catheter, the size, the balloon size, and the reason to have a catheter should have been in the orders, which should have been entered 7/29/26. The DON stated she would ensure the orders were entered. The Catheter Care policy dated 4/18/24 indicated it was the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care. The policy lacked direction for the care plan or orders for the catheter care.

Based on interview, observation, and document review, the facility failed to ensure pressure ulcer (PU) preventative measures were implemented to prevent the development of or worsening of PU for 1 of 3 residents (R1) reviewed for wounds.Findings include: R1's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated intact cognition, dependence upon staff for activities of daily living (ADL)s, an indwelling catheter, an ostomy, (a surgical opening in the colon that allows stool to exit the body through a stoma into an external pouch), and seven Stage 4 pressure ulcers (severe, full-thickness wound where skin and tissue are lost, exposing underlying muscle, tendon, ligament, or bone) that were present on admission. R1's diagnoses included paraplegia, neurogenic bladder (lack of bladder control caused by brain, spinal cord, or nerve problems), malnutrition, and neurogenic bowel (loss of bowel control caused by brain, spinal cord, or nerve problems). R1's initial nursing assessment dated [DATE], indicated R1's skin was dry, warm, and intact. R1's progress notes dated 7/29/26 at 10:55 p.m., indicated the resident came to the facility by emergency medical services, and admitted on a regular diet with a Foley catheter, colostomy bag, and multiple wounds: right shin 9 centimeters (cm)in length (L) x 4 cm in width (W); right heel L 6 cm x W 3 cm; right ankle L 5 cm x W 0.5 cm; right knee L 2 cm x W 1 cm; right hip L 2.5 cm x W 13 cm; left buttock L 13 cm x W 15 cm; and right buttock L 14 cm x W 13 cm. R1's wound team note by the wound ostomy (WOC) nurse practitioner (NP)-A dated 7/31/26, indicated the following wounds and orders:Wound 1 - Stage 4 PU of the right plantar foot (bottom surface or sole of the foot extending from the heel to the base of the toes), present upon admission, that measured L 5 cm x W 1.9 cm x 1.5 cm in depth (D) with 20% slough (layer of soft dead tissue in a wound) and 80 % granulation tissue (new pink to red connective tissue in a wound that grows from the base of the wound to fill and repair an open injury during the healing process), and moderate serosanguinous drainage (normal drainage that is thin and watery, with a light pink or red color). Wound 2 - Stage 4 PU of the right ankle, present upon admission, that measured L 4.3 cm x W 3 cm x D 0.2 cm with undermining (where the skin pulls away from the tissue underneath and creates a hidden pocket or shelf beneath the out edges of a wound and the surface of the wound may appear small, but the damage is spread under the healthy skin measured like a clock face for the location on the wound) 0.2 cm at 12 o'clock, with 100% granulation tissue, and moderate serosanguinous drainage. Wound 3 - Stage 4 PU of the left plantar foot, present on admission, that measured L 0.6 cm x W 0.5 cm x D 0.9 cm with 100% granulation tissue, and moderate serosanguinous drainage.Wound 4 - Stage 4 PU of the left ankle, present on admission, that measured L 5.9 cm x W 5 cm x D 0.1 cm with 100% granulation tissue, and moderate serosanguinous drainage.Wound 5 - Stage 4 PU of the left, posterior calf, present on admission, that measured L 7.6 cm x W 3.5 cm x D 0.4 cm with 100% granulation tissue, and moderate serosanguinous drainage.Wound 6 - Stage 4 PU of the left, lateral skin, present on admission, that measured L 2 cm x W 0.9 cm x D 0.1 cm with 100% granulation tissue, and moderate serosanguinous drainage.Wound 7 - Stage 4 PU of the sacrum (large shield-shaped bone above the tailbone that forms the back wall of the pelvis), present on admission, that measured L 38 cm x W 37 cm x D 6 cm with 6.8 cm undermining at 9 o'clock, with 10% slough tissue, 10% granulation tissue and 80% muscle, fascia, tendon or bone) and heavy serosanguinous drainage. Wound 8 was not listedWound 9 - Stage 4 PU of the right, anterior, lower, lateral ischium (a paired bone that forms the lower and back part of the hip bone), present on admission, that measured L 12.4 cm x W 4 cm x D 0.6 cm, present on admission, that measured L 12.4 cm x W 4 cm x D 0.6 cm with 2.8 cm undermining at 1 o'clock, with 70% granulation tissue, 30% tendon and bone, and heavy serosanguinous drainage. Wound 10 - Stage 4 PU of the right, anterior, upper, lateral hip, present on admission, that measured L 2.8 cm x W 3.5 cm x D 0.4 cm with 60% granulation tissue and 40% muscle, tendon, and bone, and heavy serosanguinous drainage. Recommendations included float heels in bed, reposition every two hours, limit sitting to 60 minutes, elevate legs, off-load wounds, a low air loss mattress, and dietician consultation. R1's orders were reviewed on 8/7/26, indicated: 7/29/26 0.5% Dakin (diluted bleach solution used to treat wounds) soaked Kerlix wet to dry dressings to all areas of open wounds. The orders lacked recommendations for the pressure ulcer prevention interventions made by the WOC NP-A. R1's baseline care plan was reviewed on 8/6/26, and lacked a focus area for pressure ulcers as well as interventions. During an interview on 8/7/26 at 12:42 p.m., the licensed practical nurse (LPN)-A stated orders for new wound care from the wound nurse should be entered as soon as possible, the same day. The process was for the facility nurse to round with the NP and then enter the verbal orders. During an interview on 8/7/26 at 1:26 p.m., the WOC NP-A stated R1 had 10 wounds and he should have had interventions put in place to protect them. The WOC NP-A further stated, during her assessment of R1's wounds on 7/31/26, she included her recommendations for PU prevention and interventions. When the nursing staff round with her during wound care, the nurse was supposed to take notes of new orders and enter the orders that day, after wound rounds. During an observation on 8/7/26 at 4:20 p.m., R1 was lying in bed on his right side facing the doorway. R1 had bandages on his buttocks, multiple areas of the lower extremities, and heels. His legs were bent at the knees, with his knees together, ankles lying on top of each other and no protection in place for any bony prominences, heel boots, or an air mattress to protect areas that already had wounds or areas that were vulnerable to new wounds. During an interview on 8/7/26 at 4:20 p.m., R1 stated he was admitted to the facility from the hospital with the wounds he developed living at home. R1 was unsure what was being done to protect his skin, but stated the wound team wanted him to have an air mattress and heel protectors, but the facility had not provided them yet. R1 stated he did not have pain in the wounds and couldn't feel them because he was paralyzed. During an interview on 8/7/26 at 4:41 p.m., the regional nurse consultant (RNC)-A stated she was upset about the lack of care R1 received to prevent PU and protect his skin from additional PU. RNC-A stated she didn't see interventions in place to protect R1. The RNC-A stated R1 would have skin protection/PU prevention in place immediately. R1 was currently being readmitted by the hospital and the RNC-A stated she would ensure all the proper orders were in place. During an interview on 8/10/26 at 9:48 a.m., licensed practical nurse (LPN)-E stated R1 should have a plan for PU prevention and if he did not, R1's wounds could get worse, R1 could develop additional PU, and his general health could deteriorate. R1 should have interventions that included repositioning, nutritional supplements, changing the bandages, an air mattress, and heel boots. The LPN-E acknowledged R1 did not have an air mattress or heel boots but should have as R1 already had multiple PU. During an interview on 8/10/26 at 11:38 a.m., the director of nursing (DON) stated PU prevention interventions should have been on R1's care plan and acknowledged it was not. It was a standard of care for a resident to be repositioned every 2-3 hours, and bony prominences should be protected. Orders from wound rounds should be entered the same day by the rounding facility nurse and acknowledged the WOC NP recommendations were not entered. During an observation on 8/10/26 at 1:20 p.m., with the DON, R1 was sitting up in his wheelchair being interviewed by therapy staff. R1 was wearing slippers on his feet and had no cushion under his heels. R1's legs were down with feet rested on the foot pedals, had a basic wheelchair cushion, and did not have an air mattress on his bed. R1 stated he had been sitting in the wheelchair since about 6:30 a.m., when he left for an appointment. During a subsequent interview on 8/10/26 at 1:23 p.m., the DON stated R1 should not still be sitting in his wheelchair after his appointment that morning and should have been laid down when he returned. The DON stated R1 had the worst PU wounds she had ever seen in her career, and R1 should have gurney transport to/from appointments. The DON acknowledged R1's wheelchair cushion was a standard cushion and not a specialized pressure-reducing cushion. The DON stated she didn't know how to arrange that but would find out. The DON stated she didn't know what was being done for an air bed or heel protectors for R1, and didn't know how to order them, but would find out by asking a maintenance worker (MW). The DON identified herself as a certified wound care nurse and stated she would do what she could to relieve the pressure on R1's body to prevent further PU. The DON stated she was unsure what progress had been made to prevent PU on R1 since survey started on 8/7/26 but would work on getting an air bed and heel protectors. On 8/10/26 at 3:10 p.m., during a subsequent interview, the DON stated she had informed the maintenance staff several times R1 needed an air bed and was not sure why he didn't have one yet. On 8/10/26 at 3:23 p.m., the RNC-A stated she was not sure what had been done in the facility to protect R1 from PU since 8/7/26, her focus on 8/7/26 was getting R1 readmitted from the hospital. The DON was responsible for the overall care of the residents and needed to put interventions in place for R1. On 8/10/26 at 4:24 p.m., during an interview with the DON, the administrator and the RNC-C, the RNC-C stated on 8/7/26, she was focused on getting R1 readmitted from the hospital and was unsure what had been done to protect R1 from PU over the weekend but had sent the DON a message about it on 8/8/26 to ensure R1 had PU prevention. The DON stated she didn't know why R1 had no PU prevention until this day, but R1 had heel protectors and an air bed now. The administrator stated he was unsure why R1 had no PU prevention interventions, but he was not aware of the issue until the morning of 8/10/26. During an interview on 8/11/26 at 11:38 a.m., MW-A stated the process for obtaining an air bed for a resident was for the nurses to either enter an order into their electronic work order system, TELS, or to tell a maintenance staff worker a bed was needed for a resident. The MW-A stated he was informed that R1 needed a bed during the stand-up meeting with the interdisciplinary team on 8/10/26 around 9:00 a.m. The MW-A confirmed he was not notified of R1 needing the bed prior to that meeting and checked the TELS work orders to verify he had not received one. During an interview on 8/11/26 at 11:48 a.m., the MW-B stated after nursing staff notified maintenance staff a resident needed an air bed, the maintenance staff would locate one in storage, fill the mattress with air, and deliver it to the room where it was needed. The MW-B stated the DON reminded the maintenance workers in the hallway in passing on 8/10/26 around 1:00 p.m., and the bed was delivered to the room on 8/10/26 at approximately 2:00 p.m. The MW-B stated it was not delivered earlier that day because there was a mix-up about the room number, the maintenance staff was busy installing flooring on first floor, and it was after the DON asked about the bed at 1:00 p.m., that the MW-A verified the room number with the DON. The MW-B stated there was no TELS order for the air bed. During an interview on 8/10/26 at 12:52 p.m., the medical director stated R1 should have pressure reduction interventions in place, or the wounds could become worse. The medical director's expectation was the care plan would reflect the care R1 required. The Pressure Injury Prevention and Management policy dated 2023 indicated the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.Evidence-based interventions for prevention would be implemented for all residents who wereassessed at risk or who had a pressure injury present. Basic or routine care interventionscould include, but are not limited to:Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.);Minimize exposure to moisture and keep skin clean, especially of fecal contamination;Provide appropriate, pressure-redistributing, support surfaces;Provide non-irritating surfaces; andMaintain or improve nutrition and hydration status, where feasible

Based on interviews and document review, the facility failed to develop a comprehensive care plan that addressed all required care needs for 1 of 3 residents (R2) reviewed for wound care.Findings include: R2's admission MDS dated [DATE], indicated intact cognition, dependence upon staff for activities of daily living (ADL)s and personal hygiene, infection of the foot with a diabetic foot ulcer and surgical wound. R2's medications included insulin, an anticoagulant (medication that prevents blood clots), and opioids (medication that treats pain). R2's diagnoses included diabetes (DM), heart failure, peripheral vascular disease (PVD), high blood pressure (HTN) and heart disease (PAD). R2's progress notes indicated the following:7/1/26 at 1:46 p.m., the resident on leave of absence (LOA) and will be back by 6:00 p.m.7/1/26 at 10:12 p.m., the resident left this morning and told the previous nurse he would be back by 6:00 p.m. Called the resident at 10:03 p.m. and he stated he would return tomorrow by 9:00 a.m. The provider and DON were notified. 7/2/26 at 11:11 a.m., the resident returned to the facility at 10:53 a.m.7/3/26 at 9:36 p.m., the resident was observed entering the elevator, did not sign out for LOA, and staff went outside to look, unable to locate resident. The resident did not take scheduled medications this shift. Staff tried to reach the resident on his cell phone. The DON and provider were notified. 7/4/26 at 7:40 a.m., around 10:30 p.m. on 7/3/26, staff located the resident sleeping on the patio, took him upstairs, checked his blood glucose, offered food, administered medications, and updated the DON that the resident was found safe. 8/1/26 at 9:54 a.m., the resident is LOA8/1/26 at 10:25 p.m., the resident went out of facility and came back at 9:30 p.m. Evening medications administered.8/2/26 at 10:25 p.m., the resident went out of facility at 2:00 p.m. and did not take evening medication. Nurse called and left voice mail to inquire when he would return. The DON was notified. 8/3/26 at 12:51 p.m., the resident called and informed staff he stayed with his daughter and would return that evening. 8/3/26 at 11:02 p.m., the resident returned at 9:00 p.m. R2's orders indicated the following:6/18/26 eplerenone oral tablets 25 mg, give 1 tablet daily for diastolic heart failure. 6/17/26 Aspart insulin (rapid acting insulin) injected subcutaneously (subq - under the skin) with a pen injector, 100 units (u)/ milliliter (ml) given by sliding scale, at bedtime6/17/26 rivaroxaban (blood thinner) oral tablet 2.5 mg, give 1 tablet by mouth two times a day for arterial bypass thrombus (blood clot in a surgical bypass graft), take with meals in the morning and evening6/17/26 hydralazine hydrocholoride (HCl) (treats high blood pressure) 25 mg oral tablets, give 1 tablet by mouth every 8 hours for high blood pressure6/17/26 blood glucose monitoring before meals and at bedtime (call doctor if blood glucose is less than 65 mg/deciliter (dl) or greater than 500 mg/deciliter.6/18/26 ticagrelor (antiplatelet medication used to prevent blood clots, heart attacks, and strokes in people with heart disease) oral tablet, 90 mg, give 1 tablet two times daily for PAD, PVD and coronary artery disease (CAD) in the morning and evening6/23/26 check right lower extremity dressing each shift, assure dressing is dry and intact. Change dressing as needed if it is overly saturated or has fallen off.7/8/26 paint right lower extremity wound with betadine, cover with abdominal pad (thick highly absorbent medical dressing), wrap with Kerlix (cotton medical bandage roll used for superior absorbency). Change dressing daily and as needed if soiled or if it has fallen off, in the morning. 7/16/26 dapagliflozin oral tablets 5 milligrams (mg), give 2 tablets by mouth one time a day for diabetes. 7/16/26 Glargine insulin (a long-acting insulin) injected subq one time a day for diabetes, with a pen injector, 100 u/ml, give 15 ml one time a day for diabetes, in the morning. R2's care plan lacked a focus area and interventions for leave of absence. R2's assessments list was reviewed on 8/7/26. R2 lacked an assessment for self-administration of medications. During an interview on 8/7/26 at 11:42 a.m., R2 stated he sometimes goes out overnight, does not take his medications with him, but does take some supplies for wound care. R2 stated he does his wound care himself when he is gone, but staff have not taught him how, nor does staff check the wound when he returns. R2 stated he is supposed to sign out when he leaves and tell staff when he is going to return. Staff does not ask about his medications or if he has his wound care supplies before he goes out and does not check his wound or ask about his medications when he returns. R2 denied receiving education about wound care from staff nor instructions or information about his current medications. R2 stated he does not check his blood glucose when he is gone, but takes insulin from a supply he has at his family members' homes. During an interview on 8/10/26 at 9:20 a.m., the LPN-C stated R2 should have a care plan for LOA. The LPN-C stated a nurse should practice with R2 to ensure he knew how to take his medications, perform his wound care, perform glucose checks but didn't know if that had been done. The LPN-C acknowledged she had not provided that education to R2. During an interview on 8/10/26 at 9:41 a.m., the LPN-D stated all R2's medications were important and he didn't take any of them with him when he left on LOAs overnight. The LPN-D stated the facility has a process to send medications with a resident for a planned LOA. The LPN-D acknowledged he had not provided education to R2 about his medications, had not performed a Self-administration of Medications Assessment (SAM), and had not provided education about how to check blood glucose or perform wound care. The LPN -D stated staff should teach R2, and then have R2 do a return demonstration for each process, and there should be a care plan that included wound care, checking blood glucose, and sending a glucometer and wound care supplies with him when he goes. During an interview on 8/10/26 at 11:38 a.m., the DON stated if R2 had a planned LOA he could take medications with him. R2 has complex health conditions that need to be managed. The DON acknowledged R2 had no documented education about his wound care and medications. Staff should have performed a Self-administration of Medications Assessment but had not. The DON acknowledged R2 had no care plan for LOA but stated he should because he does not always return when he says he will. The Comprehensive Care Plans policy dated 2023 indicated that the facility would develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the resident's comprehensive assessment. The care plan would be reviewed and revised after each comprehensive assessment and quarterly MDS assessment.

Based on interview, observation, and record review, the facility failed to revise and implement the care plan for 1 of 3 residents (R3) reviewed for pressure wounds.Findings include:Stage IV (4) pressure ulcer: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location.R3's face sheet dated 6/4/26, indicated R3 had muscle weakness and a stage IV pressure ulcer of left buttock.R3's care plan dated 6/4/26, indicated R3 was dependent with bed mobility and transfers. Lacked intervention indicating R3 needed to lay down after lunch.R3's admission Minimum Data Set, dated [DATE], indicated R3 was cognitively intact, was dependent for transfers, and had a stage IV pressure ulcer upon admission.R3's orders dated 7/16/26, indicated R3 had to lay down after lunch to offload pressure from sacral wound.During a continuous observation on 7/23/26 starting at 1:11 p.m., R3 was in the dining room eating lunch in her wheelchair. At 1:28 p.m., R3 propelled herself to her room. At 2:49 p.m., an activity staff asked R3 if she was going to the activity, R3 declined and stated staff told her they would lay her down at 2:00 p.m., and she needed to wait for them to come. At 3:33 p.m., state agency (SA)-A, requested that R3 be laid down and a nurse to be present. At 4:02 p.m., R3 was laid down in bed, buttocks and thighs were pink and blanchable (skin that temporarily turns white or pale when pressure is applied and returns to its normal color once the pressure is released, indicating intact blood flow in the capillaries). Director of nursing (DON) completed dressing change with no changes in stage IV pressure ulcer.During an interview on 7/23/26 at 2:52 p.m., R3 stated she was waiting to be laid down since after lunch because R3 had a sore on her bottom and needed to get off of it. R3 stated she had orders put in place last week to be laid down after lunch but no one had followed that order. R3 stated she would sit in her room until someone laid her down and if they didn't, R3 would go to an activity. R3 stated being in her chair for long periods of time did not cause her pain but made her tired.During an interview on 7/24/26 at 10:59 a.m., licensed practical nurse (LPN)-A stated she did not ask staff to lay R3 down and was not sure if anyone assisted R3 to bed right after lunch on 7/23/26. LPN-A stated R3's orders indicated she needed to lay down after lunch. LPN-A stated nurses would be responsible for ensuring orders are followed and R3 did get laid down at 4:00 p.m. on 7/23/26 so LPN-A marked it off on the electronic medication record (EMR) as completed.During an interview on 7/24/26 at 11:29 a.m., nursing assistant (NA)-A stated she would look at the residents care plan to find out what interventions and care was needed for each resident. R3 was not laid down after lunch on 7/23/26 as NA-A was not aware that this was something R3 needed. NA-A stated she did look at the care plan for R3 but did not see the intervention for R3 to be laid down after lunch on 7/23/26.During an interview on 7/29/26 at 1:18 p.m., DON stated all NA staff would look in the resident care plan or Kardex for all care needs. The staff caring for R3 on 7/23/26 should have laid R3 down after lunch. R3 had expressed a preference to be laid down after lunch and it was placed in R3's orders but not in her care plan. DON stated it was her mistake that R3's intervention was not care planned for NA staff to see and DON was responsible for all care plan updates.The facilities Comprehensive Care Plan policy dated 2/2023, indicated resident specific intervention that reflect the resident's needs and preferences would be care planned and qualified staff would carry out interventions specified in the care plan.

Based on document review and interviews the facility failed to ensure a registered nurse (RN) was scheduled for at least 8 consecutive hours a day, seven days a week. This had the potential to affect all 36 residents residing in the facility.Findings include: The Daily Staffing Report dated 2/28/26, indicated 7.5 hours of RN coverage on 2/28/26. The Daily Schedule Report dated 2/28/26, confirmed there was no consecutive eight hours of RN coverage in the facility on 2/28/26. The Pathway Health Invoice dated 2/28/26, indicated the interim director of nursing (DON) at that time had been on site for 2 hours on 2/28/26, therefore not meeting the requirement of eight consecutive hours of RN coverage. On 3/12/26 at 2:01 p.m., the DON confirmed there was only 2 hours of RN coverage on 2/28/26 and stated the importance of having an RN in the building to provide triage assessments and meet federal and state requirements. The facility Nursing Services-Registered Nurse Policy last reviewed 3/5/25, indicated the facility will utilize the services of a RN for at least eight consecutive hours per day, 7 days per week.

Based on interview and document review, the facility failed to ensure binding arbitration agreements were clearly communicated in a form and manner residents understood, prior to signing forms for 3 of 3 residents (R13, R26, R38) reviewed. This had the potential to affect all 12 residents admitted after 10/1/25. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 admitted to the facility on [DATE], had moderate cognitive impairment, and diagnoses included cerebral infarction (stroke). R13's Resident and Facility Arbitration Agreement indicated R13 signed the arbitration agreement on 10/28/25, certifying acceptance of the agreement. The facility's untitled, undated, listing of the 12 residents that had been admitted after 10/1/25, indicated yes. R13 agreed to binding arbitration. On 3/11/26 at 10:37 a.m., R13 denied memory of someone from the facility explaining binding arbitration and/or signing an arbitration agreement. R26's comprehensive MDS dated [DATE], indicated R26 admitted to the facility on [DATE], had severe cognitive impairment, and diagnoses included dementia. R26's Resident and Facility Arbitration Agreement indicated R26 signed the arbitration agreement on 1/7/26, certifying acceptance of the agreement. The facility's untitled, undated, listing of the 12 residents that had been admitted after 10/1/26, indicated yes, R26 agreed to binding arbitration. On 3/12/26 at 12:37 p.m., R26 denied memory of someone from the facility explaining binding arbitration and/or signing an arbitration agreement. R26 stated it doesn't sound familiar. I'm saying no to it. I don't want to give up my rights. I don't want to sign my rights away to this place. R38's comprehensive MDS dated [DATE], indicated R38 admitted to the facility on [DATE], was cognitively intact, and diagnoses included displaced fracture of left tibial spine. R38's Resident and Facility Arbitration Agreement undated, indicated R38 waived acceptance of the agreement. The facility's untitled, undated, listing of the 12 residents that had been admitted after 10/1/25, indicated waived as R38 declined binding arbitration. On 3/11/26 at 10:37 a.m., R38 denied memory of someone from the facility explaining binding arbitration to him. The facility's Resident Listing Report dated 3/12/26, indicated that 12 residents were admitted after 10/1/25. The facility's untitled, undated, listing of the 12 residents that were admitted after 10/1/25, indicated whether they each agreed or declined the arbitration agreement. The list indicated 9 residents agreed, 3 residents waived, and 1 resident's decision was pending. On 3/12/26 at 12:07 p.m., social service director (SS) stated she reviewed the cliff notes version of binding arbitration with each resident upon admission, since the facility started offering binding arbitration in October 2025. SS stated she was not provided any education on binding arbitration but was expected to offer it to each new resident. SS acknowledged she did not fully understand binding arbitration. SS stated she explained that if resident/resident representative had a concern, they were free to seek legal advice, and facility's legal department would step in. SS stated if a resident signed the arbitration agreement, they would still be able to get a lawyer. SS stated she had not explained to residents and/or resident representatives they had 30 days to rescind the agreement. On 3/12/26 at 1:57 p.m., the facility owner stated the facility was purchased in September 2025, the previous owners had not offered arbitration, so binding arbitration agreements were implemented. The owner stated the facility social worker (SS) explained arbitration as a part of the admission process. He expected SS would have received training. Regulations were expected to be followed. Facility policy on arbitration was requested and not received.

Based on record review, interview, and observation, the facility failed to ensure the second-floor east wing common area was kept clean, sanitary, and in good repair which had the potential to affect all residents, staff and visitors who utilized the common area. Findings include:On 3/11/26 at 11:03 a.m., during observation of the second-floor east wing common area a ceiling tile near a large window had a large yellow stain or substance covering the entire tile. The tile was approximately 1.5 feet (FT) wide by 1.5ft long. In the center of the tile was an area of a grey growth type matter covering approximately 8 inches by 6 inches.On 3/12/26 at 10: 36 a.m., the ceiling tile discoloration and grey growth was still in the ceiling.On 3/11/26 at 2:49 p.m., the licensed practical nurse manager (LPN)-A stated the second-floor east wing common area was used for resident activities and family visits. There was a piano for visitors or residents to play if they would like.On 3/12/26 at 9:13 a.m., the activities director (ACT)-A stated they don't use it anymore. However, families used the area to meet with their loved ones, and physicians used the area to chart or dictate. On 3/12/26 at 1028 a.m., the director of maintenance (MAIN)-A observed the above mentioned tile and described the tile to have a yellowing water stain, which was most likely from a water leak, and there was mold growing out of the center of the tile, confirmed the mold was the gray growth in the center of the tile. MAIN-A stated they were unaware of the tile and its condition but would have it replaced as soon as possible. Furthermore, MAIN-A stated the importance of maintaining the building and keeping it in good repair was what was best for the residents.The facility policy Preventative Maintenance last revised 1/2026, indicated a preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Based on interview and document review, the facility failed to ensure 5 of 5 residents (R3, R9, R11, R24, R25) were offered an influenza immunization annually from October 1 through March 31. Additionally, the facility failed to ensure 4 of 5 residents (R3, R9, R11, R24) were offered, educated on, and provided the pneumococcal vaccination series as recommended by the Center for Disease Control (CDC), who were reviewed for immunizations. Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 admitted to the facility on [DATE], was [AGE] years of age, and diagnoses included Wernicke's encephalopathy (acute, serious neurological condition caused by severe vitamin B1 deficiency) and bipolar disorder. The CDC's Adult Immunization Schedule, dated 10/7/25, indicated for persons age [AGE] or older whose previous vaccination history was unknown, one dose of influenza vaccine was recommended annually. Additionally, for persons age [AGE] or older whose previous vaccination history was unknown, one dose of PCV15, PCV20, or PCV21 (used for pneumonia prevention) was recommended. However, R3's medical record lacked evidence an immunization history had been obtained for R3. R3's record lacked evidence the resident and/or resident representative had been offered, educated on, and provided an annual influenza vaccine. Additionally, R3's record lacked evidence the resident and/or resident representative had been offered, educated on, and provided a PCV immunization. R9's quarterly MDS, dated [DATE], indicated R9 admitted to the facility on [DATE], was [AGE] years of age, and diagnoses included encephalitis and encephalomyelitis (inflammation of the brain and/or spinal cord) and seizure disorder. R9's Minnesota Immunization Information Connection (MIIC) report, dated 8/21/25, indicated R9 last received an annual influenza vaccine on 10/31/23. Additionally, the report indicated R9 received the PPSV23 immunization on 3/2/2007, and the PCV13 on 2/18/2020. The CDC's Adult Immunization Schedule, dated 10/7/25, indicated for persons age [AGE] or older, one dose of influenza vaccine was recommended annually. Additionally, for persons who previously received both PCV13 and PPSV23, one dose of PCV20 or PCV21 was recommended at least 5 years after the last pneumococcal vaccine dose. R9 was eligible after 2/18/2025. R9's Influenza Vaccine Consent Form dated 11/6/25, indicated R9 gave consent to receive the influenza vaccine. However, R9's medical record lacked evidence R9 had been provided one dose of influenza vaccine after 11/6/25. R9's Immunization Informed Consent Record dated 8/21/25, indicated resident has agreed for vaccinations as needed. However, R9's medical record lacked evidence R9 had been provided one dose of PCV20 or PCV21. R11's quarterly MDS dated [DATE], indicated R11 was [AGE] years of age, admitted to the facility on [DATE], and diagnoses included atrial fibrillation and vascular dementia. The CDC's Adult Immunization Schedule dated 10/7/25, indicated for persons age [AGE] or older, one dose of influenza vaccine was recommended annually. Additionally, for persons age [AGE] or older whose vaccination history included a PCV13, one dose of PCV20 or PCV21 was recommended at least one year after PCV13. R11's MIIC report dated 8/14/25, indicated R11 had no history of vaccination for influenza. Additionally, the report indicated R11 received the PCV13 on 10/26/22. R11's Influenza Vaccine Consent Form dated 11/6/25, indicated R11 gave consent to receive the influenza vaccine. However, R11's medical record lacked evidence R11 had been provided one dose of influenza vaccine after 11/6/25. Additionally, R11's lacked evidence the resident and/or resident representative had been offered, educated on, and provided a PCV20 or PCV21 immunization. R24's comprehensive MDS dated [DATE], indicated R24 was [AGE] years of age, admitted to the facility on [DATE], and diagnoses included sepsis (infection enters the bloodstream), and pneumonia. The CDC's Adult Immunization Schedule dated 10/7/25, indicated for persons age [AGE] or older whose previous vaccination history was unknown, one dose of influenza vaccine was recommended annually. Additionally, for persons age [AGE] or older whose previous vaccination history was unknown, one dose of PCV15, PCV20, or PCV21 was recommended. However, R24's medical record lacked evidence an immunization history had been obtained for R24. R24's record lacked evidence the resident and/or resident representative had been offered, educated on, and provided an annual influenza vaccine. Additionally, R24's record lacked evidence the resident and/or resident representative had been offered, educated on, and provided a PCV immunization. R25's quarterly MDS dated [DATE], indicated R25 was [AGE] years of age, admitted to the facility on [DATE], and diagnoses included dementia and diabetes. The CDC's Adult Immunization Schedule dated 10/7/25, indicated for persons age [AGE] or older, one dose of influenza vaccine was recommended annually. R25's MIIC report dated 6/6/25, indicated R9 last received an annual influenza vaccine on 10/29/24. R25's Influenza Vaccine Consent Form dated 11/6/25, indicated R25 gave consent to receive the influenza vaccine. However, R25's medical record lacked evidence R25 had been provided one dose of influenza vaccine after 11/6/25. On 3/12/26 at 10:34 a.m., the regional nurse manager/infection preventionist (IP) acknowledged R3, R9, R11, R24, and R25's medical records lacked evidence an annual influenza and/or pneumococcal vaccine had been offered and/or provided as indicated above. IP stated nurses were expected to offer vaccinations per CDC guidelines upon admission and at least annually. IP stated recommended immunizations were important for the overall health of the residents and everyone else in the facility. The facility's Influenza Vaccination policy, reviewed/revised 1/2026, indicated it is the policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. The facility's Pneumococcal Vaccine (Series) policy, reviewed/revised 1/2026, indicated it is the policy of the facility to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations.

Based on interview and document review, the facility's binding Arbitration Agreement failed to offer a neutral and fair arbitration process by ensuring both the resident and/or resident representative and the facility agreed on the selection of a neutral arbitrator (an impartial, or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute). This had the potential to affect all 12 residents that admitted after 10/1/25.Findings include: Review of the facility's Resident and Facility Arbitration Agreement undated, indicated binding arbitration would be conducted at a place agreed upon by the Parties, or in the absence of such an agreement, at the Facility. However, the facility failed to ensure the agreement provided for the selection of a neutral arbitrator agreed upon by both parties. The facility's Resident Listing Report dated 3/12/26, indicated 12 residents were admitted after 10/1/25. The facility's untitled undated, listing of the 12 residents admitted after 10/1/26, indicated whether each agreed or declined the arbitration agreement. The list indicated 9 residents agreed, 3 residents waived, and 1 resident's decision was pending. On 3/12/26 at 1:57 p.m., the facility owner stated the facility was purchased in September 2025, and binding arbitration agreements were implemented. The owner stated regulations needed to be followed and acknowledged the selection of a neutral arbitrator was not addressed in the agreement.

Based on interview and document review, the facility failed to ensure the resident and/or legal representative received written notice of transfer for 3 of 3 residents (R3, R22, R46) reviewed for hospital transfers. Further, the facility failed to provide a written notice of bed hold for 2 of 3 residents (R3, R22) reviewed for bed hold and failed to notify the Ombudsman of transfers and discharges for 1 of 3 residents (R3) reviewed for Ombudsman notification.Findings include: Findings include: R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had severe cognitive impairment and diagnoses included Wernicke's encephalopathy (acute, serious neurological condition caused by severe vitamin B1 deficiency) and bipolar disorder. R3's progress note dated 11/5/25 at 8:29 p.m., indicated R3 was sent to the hospital for right, lower extremity pain following a fall. A subsequent progress note dated 11/17/25 at 9:05 p.m., indicated R3 was readmitted to the facility on [DATE] at 6:00 p.m. R3's medical record lacked evidence a written notice of transfer had been provided to the resident and/or resident representative. Additionally, R3's medical record lacked evidence a written notice of bed hold had been provided to the resident and/or resident representative. The facility's Ombudsman Report for 11/2025, indicated the resident admissions and discharges for 11/2025. However, the report lacked notice of R3's 11/15/25 hospital transfer, and the information was not indicated on subsequent ombudsman reports. On 3/11/26 at 1:17 p.m., the director of nursing (DON) stated R3's record lacked evidence a written notice of transfer and notice of bed hold had been provided to the resident and/or resident representative. Additionally, DON verified R3's hospital transfer was not indicated on the Ombudsman Report for 11/2025. R22's readmission minimum data set (MDS) dated [DATE], indicated R22 was readmitted to the facility 2/24/26, after a brief hospital stay. R22's diagnoses included encephalopathy (a disorder, disease or dysfunction of the brain), dementia, unilateral osteoarthritis, generalized muscle weakness and difficulty in walking. R22's discharge MDS dated [DATE], included R22 had an unplanned discharge, with return anticipated, and was discharged to a short-term acute hospital. R22's bed hold agreement was requested; however, none was provided. R22's written notice of transfer was requested; however, none was provided. During interview on 3/11/2026 at 11:08 a.m. DON confirmed R22's medical record lacked evidence of a bed hold agreement and a written notice of transfer. DON stated he was unsure why these were not provided to R22 by the previous leadership staff. DON stated his expectation was each resident leaving for an unplanned discharge with a hospital stay received both a bed hold agreement and a written notice of transfer. R46's annual MDS dated [DATE], indicated R46 was admitted on [DATE], moderately cognitively impaired, and had the following diagnoses: anemia, heart failure, hypertension (high blood pressure), diabetes, arthritis, and Alzheimer's disease. R46 discharge return anticipated MDS dated [DATE], discharged to a short-term hospital stay with a return anticipated on 5/31/25. R46's medical record lacked evidence of written notice of transfer was provided to R46 or their representative. R46's written notice of transfer was requested; however none was provided. On 3/11/26 at 11:43 a.m., DON confirmed R46's record lacked written notice of transfer for hospitalization. The DON stated the importance of completing the notice of transfer to notify the resident or their next of kin of why they are being transferred to a higher level of care, and to follow current regulations. The facility's Transfer and Discharge policy, revised 4/21/25, indicated the facility's notice of transfer would be provided to the resident and/or resident representative in a language and manner in which they can understand, and copies of the notice of transfer would be sent to the ombudsman. The facility's Bed Hold Notice policy, dated 11/25, indicated the facility would provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of a transfer for hospitalization or therapeutic leave.

Based on observation and interview the facility failed to conduct appropriate hand hygiene during a dressing change for 1 of 1 residents (R4) reviewed for wound care.Findings include: On 3/11/26 at 07:39 a.m., registered nurse (RN)-A conducted a dressing change on a resident. RN-A entered the room, put on a gown, a pair of gloves, and then a second pair of gloves. RN-A gathered items needed to conduct the dressing change. RN-A removed the old dressing, poured saline onto gauze, and dabbed the wound. RN-A removed the 2nd pair of gloves, put cream onto their finger, and applied it to the wound. RN-A then removed the 1st layer of gloves and gown. Put on a new pair of gloves. RN-A left the room to find a sharpie to date/label the dressing. After returning to the room, dated and labeled the dressing, RN-A gathered the garbage and exited the room for the second time. RN-A deposited the bag of garbage in the soiled utility room and washed their hands. RN-A stated during a dressing change, they were expected to wash their hands, before and after the event, when gloves were soiled, and when placing the new dressing. RN-A confirmed they washed their hands before they started the dressing change, and after they were done with everything. RN-A stated they should have washed their hands after they removed their gloves and when entering and exiting the room but she had not. Additionally, RN-A stated they used the 2nd layer of gloves for their convenience, which did not meet the expectation of the facility. RN-A stated it was important to perform hand hygiene appropriately to prevent infection of the wound. On 3/11/26 at 11:43 a.m., the director of nursing (DON) stated their expectation for hand hygiene during a dressing change was staff should be washing their hands upon entering and exiting the room, taking off gowns and gloves, according to facility policy and regulations. Furthermore, the DON stated the importance of hand hygiene to prevent infection, protecting the residents and the staff.The facility policy Hand Hygiene last revised 1/1/26, indicated the use of gloves does not replace hand hygiene. If your task requires gloves, preform hand hygiene prior to donning gloves and immediately after removing them.

Based on observation, interview and document review, the facility failed to ensure target behaviors were adequately monitored for 1 of 5 residents (R9) reviewed for psychotropic medication use. Findings include: R9's quarterly MDS dated [DATE], indicated R9 had moderate cognitive impairment and diagnoses included encephalitis and encephalomyelitis (inflammation of the brain and/or spinal cord) and seizure disorder. R9 had physical and verbal behavioral symptoms directed toward others and rejected evaluation or care less than daily. R9'S Order Summary Report signed by the provider 2/10/26, indicated R9 had the following psychotropic medication orders:Escitalopram (antidepressant) 15mg daily for depressionHaloperidol (antipsychotic) 0.5mg three times a day for anxietyDivalproex (mood-stabilizing drug) 1000mg two times a day for anxietyTrazodone (antidepressant) 50mg at bedtime for insomnia R9's Care Plan Report undated, indicated R9 had target behaviors of calling out loudly multiple times a shift, attention-seeking, and self-limiting with cares/independence, with identified interventions initiated 12/24/25. R9's target behaviors would be monitored and documented every shift. R9's Associate Clinic of Psychology (ACP) visit notes dated 3/10/26, indicated R9 continued to display attention-seeking behaviors such as calling out, screaming, and continued to exhibit behavioral symptoms that affected functioning. Staff should continue to document R9's behaviors, including the time of occurrence, possible triggers, staff interventions, and R9's response to those interventions. Consistent documentation would help identify patterns and allow the care team to develop more effective strategies to address and reduce behaviors. On 3/11/26 from approximately 7:30 a.m. to 9:00 a.m., R9 was heard loudly screaming and calling out help, help numerous times. R9 was heard screaming and calling out from another unit of the facility. R9's Treatment Administration Record (TAR) for March 2026 indicated nurses to document in progress notes every shift resident's behavior: document if resident is screaming or yelling for ACP to eval and treat every shift, with a start dated of 3/9/26. However, nurse documentation on the TAR indicated R9 had not screamed or yelled on 3/11/26 during the day shift (6:00 a.m. to 2:00 p.m.). Additionally, R9's record lacked documentation of R9's observed behavior in progress notes for 3/11/26 day shift. On 3/12/26 at 10:12 a.m., nurse unit manager (LPN)-A stated R9 was heard calling out quite a bit yesterday. LPN-A stated nurses were expected to document every shift if R9 was calling out to help ACP monitor R9 and to help the psych AP (advanced practice provider). LPN-A confirmed the nurse documentation for 3/11/26 day shift indicated R9 had no behaviors and no new behaviors, and stated, but that's incorrect because I sat here and heard her calling out. LPN-A stated accurate documentation was important so providers could monitor and direct care appropriately. On 3/12/26 at 11:54 a.m., director of nursing (DON) stated R9's TAR contained inaccurate charting for 3/10/26 and 3/11/26 day shifts for the target behavior of screaming or yelling. DON heard R9 yelling out repeatedly both days. DON stated nurses were expected to accurately document as ordered by the provider and accurate documentation was important so that any adjustments to medications and/or interventions would be appropriate. The facility's Use of Psychotropic Medication policy, reviewed/revised 4/21/25, indicated psychotropic medications are to be used only when a practitioner determines the medication is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R3, R9, R11, R24) reviewed for immunizations were offered and/or provided the COVID-19 vaccine to help reduce the risk of associated infection(s).Findings include: The Centers for Disease Control (CDC) Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States dated 11/4/25, indicated for adults ages 65 years and older, COVID-19 vaccination was recommended based on individual-based decision-making (also known as shared clinical decision-making) for the prevention of COVID-19 disease and its complications. For adults under age [AGE] years, COVID-19 vaccination was recommended based on individual-based decision-making with an emphasis that the risk-benefit of vaccination was most favorable for individuals who were at an increased risk for severe COVID-19 disease. R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 admitted to the facility on [DATE], was [AGE] years of age, and diagnoses included Wernicke's encephalopathy (acute, serious neurological condition caused by severe vitamin B1 deficiency) and bipolar disorder. R3's medical record lacked evidence an immunization history had been obtained. Additionally, R3's record lacked evidence the resident and/or resident representative had been offered a COVID-19 vaccination(s). R9's quarterly MDS dated [DATE], indicated R9 admitted to the facility on [DATE], was [AGE] years of age, and diagnoses included encephalitis and encephalomyelitis (inflammation of the brain and/or spinal cord) and seizure disorder. R9's Minnesota Immunization Information Connection (MIIC) report dated 8/21/25, indicated R9 last received a COVID immunization on 10/18/24. R9's Vaccine Consent Form undated, indicated R9 consented to the COVID-19 vaccine. However, R9's record lacked evidence the facility had provided the requested COVID-19 vaccination. R11's quarterly MDS dated [DATE], indicated R11 was admitted to the facility on [DATE], was [AGE] years of age, and diagnoses included atrial fibrillation and vascular dementia. R11's Minnesota Immunization Information Connection (MIIC) Report dated 8/14/25, indicated R11 had not received COVID-19 vaccinations. Additionally, R11's record lacked evidence the resident and/or resident representative had been offered COVID-19 vaccination(s). R24's comprehensive MDS dated [DATE], indicated R24 was admitted to the facility on [DATE], was [AGE] years of age, and diagnoses included sepsis (infection enters the bloodstream), and pneumonia. R24's medical record lacked evidence an immunization history had been obtained. Additionally, R24's record lacked evidence the resident and/or resident representative had been offered a COVID-19 vaccine. On 3/12/26 at 10:34 a.m., the regional nurse manager/infection preventionist (IP) acknowledged R3, R9, R11, and R24's records lacked evidence a COVID vaccine had been offered and/or provided as indicated above. RN-A stated nurses were expected to offer vaccinations per CDC guidelines upon admission and at least annually. IP stated recommended immunization was important for the overall health of the residents and everyone else in the facility. The facility's COVID-19 Vaccination policy reviewed/revised 12/2025, indicated it is the policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 by educating and offering our residents and staff the COVID-19 vaccine.

Based on observation, interview, and record review the facility failed to provide activities of daily living (ADLs) for 1 of 4 residents (R9) reviewed for dependent care. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had moderate cognitive impairment and diagnoses included encephalitis, encephalomyelitis (inflammation of the brain and/or spinal cord), and seizure disorder. R9's Care Plan Report undated, indicated R9 did not show potential for discharge to the community due to physical care needs and self-care deficits related to diagnoses. R9 required partial/moderate assistance with personal hygiene, bed mobility, upper body dressing, and substantial/maximal assistance with bathing, toileting, and lower body dressing. R9's Weekly Skin Assessments indicated R9's fingernails were last trimmed on 2/3/26. On 3/9/26 at 3:44 p.m., R9 stated staff were supposed to cut her fingernails, but they did not. They were too long now. R9's fingernails were of various lengths, jagged edges, and several had a brown-colored substance under them. On 3/11/26 at 7:28 a.m., R9's fingernails were of various lengths, up to half inch long. Three fingernails on R9's right hand and three fingernails on R9's left hand had a brown-colored substance under them. On 3/11/26 at 7:33 a.m., regional nurse manager/infection preventionist (IP) verified R9's fingernails were long and jagged, and three fingernails on each hand had a brown-colored substance under them. IP stated staff were expected to provide weekly nail care as a part of regular bathing. IP stated R9's fingernails should have been cleaned and clipped with R9's last weekly skin assessment on 3/9/26. IP stated clean nails were important for infection control. On 3/12/26 at 11:54 a.m., director of nursing (DON) stated staff were expected to look at residents' nails every day since they assist the residents daily. Resident fingernails should be kept clean and trimmed. DON stated it was important for resident safety and infection prevention. The facility's Nail Care policy dated 2023, indicated routine nail care, including cleaning and trimming, would be provided on a regular schedule, and care to residents' nails for good grooming and health.

Based on interview and document review, the facility failed to ensure safety and adequate supervision to prevent a resident from climbing out a window and onto the roof for 1 of 3 residents (R1) reviewed for elopement. This resulted in an immediate jeopardy (IJ) for R1 who climbed out of a hallway window, and onto the facility roof. The IJ began on 3/21/22, when R1 climbed through a window onto the second story roof. R1 was brought back into the facility through the second story window without any injuries by RN-A. The administrator and director of nursing (DON) were notified of the IJ on 3/29/22, at 2:19 p.m. The facility implemented corrective action to prevent recurrence by 3/22/22, so F689 was issued at past non-compliance. Findings include: R1's Face Sheet printed on 3/29/22, indicated R1's diagnosis included dementia, left sided [CONDITION(S)] (weakness or inability to move one side of the body), and unsteady on feet. R1's quarterly Minimum Data Set (MDS) conducted on 3/17/22, indicated R1 was severely cognitively impaired. R1's most recent wandering assessment 1/25/22, indicated R1 was at moderate risk for elopement, with interventions including WanderGuard (a bracelet placed on the resident that will alarm if a resident tries to go out the door) in place, and placement in the facility's memory care (locked) unit. The facility's undated description of the incident indicated on 3/21/22, at approximately 10:45 a.m. R2 informed staff that someone was crawling out of the window. Registered nurse (RN)-A went to check, and saw R1 out on the roof. RN-A called for R1 to come back into the building, and R2 came back. When asked what he was doing on the roof, R1 stated some kid had put a ball on the roof and he was trying to get it. On 3/29/22, at 9:26 a.m. RN-A was interviewed and stated on 3/21/22, she was at the nurse's station when R2 informed her someone had escaped through the window. RN-A stated she went to the window, and saw R1 on the roof, walking away from the window. R1 was near the vents which were approximately 20 feet away from the window. RN-A stated she instructed R1 to come back inside, and after a brief hesitation, he came back and climbed through the window to get back inside. RN-A stated when the incident occurred, she had been at the nurse's station watching three residents who where assessed as high fall risks, and nursing assistant (NA)-A had been assisting another resident with cares. RN-A stated they were the only two staff on the floor for the sixteen residents in the memory care unit. On 3/29/22, at 9:50 a.m. the director of nursing (DON) was interviewed and stated R1 had crawled out the window onto the roof. The DON stated after R1 was back inside the facility, they checked all windows on the unit, and there were two windows on the memory care unit that could be fully opened. The DON stated although R1 wore a WanderGuard, this would not have alerted staff, as the windows were not alarmed. The DON stated the memory care unit was staffed with one licensed nurse and one nursing assistant on day shift. On 3/29/22, at 10:29 a.m. nursing assistant (NA)-A stated she was informed by RN-A that R1 had been found outside on the roof. NA-A stated when the incident occurred, she had been in another residents room assisting with personal cares. NA-A stated she and RN-A were the only two staff working on the memory care unit that shift. On 3/29/22, at 1:00 p.m. the administrator was interviewed and stated the height of the roof was approximately 13 feet from the ground. On 3/29/22, at 1:38 p.m. during a follow up interview, the administered stated as part of the weekly building safety checks and monitoring, the maintenance directors' duties included checking to ensure window safety strips where in place and working properly on all windows located on the memory care unit. The administer stated the maintenance director had verified safety checks on the memory care unit had not been completed per policy, and the last time he had checked the windows was more than 6 months ago. The facility Wandering/Elopement Risk Assessment Policy dated 5/19, directed the facility will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. A policy on resident safety and supervision was requested and not provided. The facility implemented corrective action to prevent recurrence by 3/22/22, when the facility implemented a systemic plan that included the following actions: On 3/22/22, the facility reeducated staff on resident's elopement risk and prevention. All windows were checked to ensure window stoppers where in place, and if a window was identified without a stopper it was corrected immediately. All staff were educated to not open a window unless a safety stopper was in place. The interdisciplinary team (IDT) developed and implemented education for all staff related to room readiness which included evaluation of all windows. R1's medications were reviewed by R1's physician, and R1's elopement risk was reassessed. The facility reviewed all residents residing on the memory care unit on their risk for elopement on 3/22/22. Audits where initiated which included interviewing staff to verify staff knowledge related to residents' safety, as well as audits of 15 window stoppers three times a week by IDT to ensure that windows had working stoppers. This was verified through staff interviews on 3/29/22, from approximately 10:20 a.m. through 2:00 p.m. Policies and facility investigative files were reviewed on 3/22/22, which included staff interview notes, education provided to staff, education sign off sheets, elopement risk and prevention policy, IDT meeting notes, and window stopper audits.

Based on interview and document review, the facility failed to reassess and provide interventions following attempted elopement for 1 of 3 (R1) residents reviewed for elopements who subsequently eloped from the facility. The survey resulted in an immediate jeopardy (IJ) to resident health and safety. R1 eloped from the facility on 8/22/21, at 6:00 p.m. and was returned to the facility by the local police department, after being found 1/3 mile away stranded on a major highway. The IJ began on 8/22/21. The administrator and director of nursing (DON) were notified of the IJ on 8/27/21, at 11:52 a.m. The IJ was removed on 8/30/21, but non-compliance remained at a lower scope and severity of a D, no actual harm, with potential for more than minimal harm. Findings include: R1's Admission Record printed 8/30/21, included diagnoses of unspecified dementia, unspecified symptoms and signs involving cognitive functions and awareness, and Wernicke's [CONDITION(S)] ([CONDITION(S)] of the central nervous system). R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, was independent with ambulation, and required minimal assistance with all activities of daily living (ADLs). R1's care plan dated 7/14/21, identified R1 as an elopement risk. R1's care plan interventions included calmly redirecting to appropriate area, and encouraging socialization with others to provide recreational programming. R1's Wandering Risk assessment dated [DATE], indicated R1 was at high risk for wandering. On 7/2/21, a progress note indicated R1 got off the unit and was found outside of the building. R1 was brought back to the unit. R1's medical record lacked indication a wandering risk assessment was updated, and no new interventions were initiated to prevent elopement. There was no information or investigation into how R1 was able to exit the secured unit. On 8/15/21, a progress note indicated R1 attempted to open the exit doors twice. R1's medical record lacked indication a wandering risk assessment was updated, and no new interventions were initiated to prevent elopement. On 8/22/21, at 10:04 p.m. a progress note indicated R1 was not in his room at dinner time. A building search was completed and R1 was not found. Staff called 911 at 6:40 p.m. R1 was returned to the facility by the local police at 9:55 p.m. who stated R1 was found stranded along a major highway. Hourly checks were initiated on R1. No other interventions were implemented. There was no information or investigation into how R1 was able to exit the secured unit. On 8/23/21, a progress note indicated R1 left his unit and was found on the 1st floor stairwell. R1 was returned to his unit. Several attempts were made to place a Wanderguard on R1 without success. There was no information or investigation into how R1 was able to exit the secured unit. A Wandering Risk assessment was completed on 8/24/21, and indicated R1 was a moderate risk for elopement. On 8/26/21, at 12:20 p.m. registered nurse (RN)-A was interviewed and stated on 8/23/21, R1 was seen going through the stairwell door and she followed him down. RN-A stated R1 made it to the first floor lobby and was redirected by staff. RN-A stated R1 refused to wear a Wanderguard. III On 8/26/21, at 1:06 p.m. RN-B was interviewed and stated she had attempted to put a Wanderguard on R1 without success. RN-B stated the Wanderguard was put in R1's pants pocket, but R1 took it out. On 8/26/21, at 1:53 p.m. the director of nursing (DON) was interviewed and stated after R1 eloped on 8/22/21, the facility performed elopement drills and training with staff. The DON stated the interventions added for prevention of R1's elopement were placing a Wanderguard, having the family provide 1:1 supervision, or sending R1 to the hospital for a psychological evaluation. The DON stated R1's family could not afford to provide 1:1 supervision, and R1 was refusing the Wanderguard. R1 was sent to the hospital on 8/25/21. On 8/26/21, at 2:05 p.m. R1's family member (FM)-A was interviewed and stated staff at the facility called her on 8/22/21, and informed her that R1 had eloped. FM-A stated the facility told her R1 refused to wear a Wanderguard. On 8/26/21, at 3:08 p.m. the activities assistant (AA)-A was interviewed and stated on 7/2/21, R1 was witnessed going down the stairwell off the unit. AA-A stated staff was alerted and R1 was redirected back onto his unit. On 8/26/21, at 4:20 p.m. the administrator was interviewed and stated that on 8/22/21, R1 may have slipped onto the elevator as a visitor was getting off. The administrator stated there were no cameras in the facility. The administrator stated they were unable to determine how R1 eloped from the facility. On 8/26/21, at 4:31 p.m. licensed practical nurse (LPN)-A was interviewed and stated that he was not working on the unit that R1 eloped from on 8/22/21, but helped with trying to find R1. LPN-A, DON, RN-B, the family and 911 had all been called. LPN-A stated another resident had a family member visiting and that family member indicated that a person had walked onto the elevator as he was getting off on the unit. LPN-A stated he had not seen R1 try to leave the unit since 8/22/21. The facility implemented corrective action on 8/30/21. Signs were placed on the elevator door to the locked unit indicating visitors must use the other elevator to gain access to locked unit. The stairwell access on the locked unit was secured and the keypad code was changed. All facility in house residents were re-assessed for risk of wandering or elopement. The residents at risk for wandering had care plans updated to identify interventions. Staff were re-educated on the elopement policy and the wandering/elopement risk assessment. Wanderguard door functionality tests were completed. Elopement drills and audits on wandering risk assessments were initiated. Audits will be brought to quality assurance and performance improvement (QAPI) meetings. Binders with residents photographs were updated. A quality assurance (QA) meeting to review the alleged deficiency and complete root cause analysis was completed. These interventions were verified through observation, interview, and document review. The facility policy Elopement dated 7/7/15, directed to safely and timely redirect patients/residents to a safe environment, a prompt investigation and search will be conducted if a patient/resident is considered missing. Elopement drill would be held quarterly. The policy lacked direction for staff on what to do in the event a resident would not wear a Wanderguard.

Based on interview and document review, the facility failed to adequately assess and intervene in an ongoing change of condition resulting in hospitalization and requiring mechanical ventilation for 1 of 3 residents (R1), reviewed for emergency transfer hospitalization and quality of care. Although noncompliance was present at the time of the event, the facility had implemented appropriate corrective action prior to the survey, resulting in a finding of past-noncompliance harm for R1. Findings include: R1's medical record was reviewed on [DATE] and identified that on [DATE], R1 was noted as sleepy all shift. There were no vital signs recorded and no further assessment completed. On [DATE], the nurse practitioner (NP) conducted a routine visit and noted, Unable to fully arouse for exam. The NP further noted R1's weight was up 14 pounds since admission and indicated, Considered adjusting anti-psychotics. On [DATE], vital signs were completed, however, lacked pulse oxygen saturation (P oxy) (the level of oxygen in the blood, usually measured at the fingertips). On [DATE], medication adjustments were made, and R1 was seen by a physician's assistant (PA) from Associated Clinic of Psychology (ACP). Vital signs were within normal limits. R1 remained lethargic, vital signs were done on [DATE], that showed mildly elevated temperature and respiratory rate, however, lacked a pulse oxy. On [DATE], a pulse, temperature and respiratory rate were done, but lacked blood pressure and/or P oxy. On [DATE], laboratory test showed an elevated AST (liver enzyme test that may indicate the level of liver damage.) Vital signs lacked P oxy. R1 was admitted on [DATE] with baseline vital signs of blood pressure (BP) ,[DATE], pulse (P) 62, temperature (T) 96.6, respiratory rate (R),[DATE], pulse oxygen saturation (P oxy) 95%. On ,[DATE] vital signs were elevated from baseline vital signs. BP ,[DATE], P 88, T 99.1 respiratory rate 20 Medications were again adjusted, however, there was no assessment to determine the cause of the lethargy or cause of the elevated AST level. No vital signs were completed on [DATE], despite the continued lethargy and declining intake of food and fluids. R1's diet was downgraded to honey thickened liquids due to coughing while eating. A voicemail was left for the son, regarding possible hospice consult. On [DATE], at 8:53 a.m., R1's respiratory rate and pulse were very elevated; P 107, RR 36, Blood sugar 368. R1 was not able to be aroused. P oxy was not completed. Chest x-ray showed possible pneumonia. A onetime antibiotic was ordered but not provided. According to licensed practical nurse (LPN)-A staff did not have time to give the antibiotic. R1 continued to deteriorate and was eventually transported to the Veterans Hospital emergency room , where he was placed on a mechanical ventilator (to breath for him) due to very low blood oxygen level. R1 sustained harm related to the low blood oxygen level, pneumonia,[MEDICAL CONDITIONS] (brain damage), was ventilated for 6 days, then placed on hospice and expired on [DATE]. Although the facility failed to immediately assess and ensure treatment was initiated for R1 beginning [DATE], they had developed and implemented a systemic plan to correct this failure by [DATE], which included: education provided for the staff with a focus on using SBAR communication (situation, background, assessment, response); and were able to demonstrate they had initiated effective nurse manager audits daily for identifying changes in residents' conditions; and daily stand up meetings to discuss any ongoing resident health issues as an interdisciplinary team. The facility corrective action was verified during the onsite survey [DATE]. Therefore, this deficient practice is being cited at Past Noncompliance.

Based on interview and document review the facility failed to ensure that residents were free from significant medication errors for 1 of 4 residents (R1) reviewed for medication errors. R1 did not receive [MEDICATION NAME] (a blood thinner medication) for 8 days as ordered by a physician. The resident developed blood clots, had a serious stroke, and died . Findings include: R1's medical record was reviewed. The [DIAGNOSES REDACTED]. R1 relied on the nursing staff to administer medications, and received daily [MEDICATION NAME] ([MEDICATION NAME]). The physician's orders [REDACTED]. The laboratory report dated [DATE] noted a desired clotting level (INR) of 2XXX,[DATE].0 as therapeutic for [MEDICAL CONDITION] diagnosis, R1 had a INR level of 2.1. [MEDICATION NAME] ([MEDICATION NAME]) is an anticoagulant medication given to prevent blood clots, and the blood is periodically monitored for clotting time with a laboratory test of the [MEDICATION NAME] international normalized ratio (INR) to determine the correct dosage (National Library of Medicine). The Medication Administration Record (MAR) for [DATE] for R1 indicated an order for [REDACTED]. The MAR included an order to check the INR on [DATE] in the morning, and a check off at 3:00 p.m. on [DATE] that the blood was drawn and a new order for [MEDICATION NAME] ([MEDICATION NAME]) was received. The MAR did not indicate a new order for [MEDICATION NAME] ([MEDICATION NAME]), and there was no record that [MEDICATION NAME] was administered to R1 in [DATE] after [DATE]. The physician's orders [REDACTED].o. (by mouth) Q.D. (every day), and to check the INR on [DATE] written by the Nurse Practitioner (NP). The laboratory report dated [DATE] noted the INR value at 2.1, this was noted by the NP, and the new order for [MEDICATION NAME] 5 mg QD was also noted. The Medication Error Form dated [DATE] indicated Patient received order to continue [MEDICATION NAME] 5 mg daily on [DATE]. Order was transcribed onto another patient's (R2) electronic MAR by mistake. So patient did not receive [MEDICATION NAME] from [DATE] thru [DATE]. R1's progress note dated [DATE] at 8:30 p.m. indicated that R1 presented with stroke like symptoms evidenced by left sided [MEDICAL CONDITION], slurred speech and impaired vision. R1 was sent to the hospital emergency room . The nurse noted the [MEDICATION NAME] medication omission error at that time. The hospital admission emergency department (ED) note dated [DATE] indicated R1 had a [DIAGNOSES REDACTED]. The INR clotting value was 1.0 on admission which was below the therapeutic value. This was verified with the nursing home and the nursing home notified the hospital that R1 had not received [MEDICATION NAME] since [DATE] when it was discontinued by error. The hospital death report dated [DATE] documented that R1's cause of death was a large acute ischemic stroke. LPN-C was interviewed [DATE] at 2:40 p.m. and stated that he had transcribed the order for R1 on [DATE] for [MEDICATION NAME] 5 mg daily, but had made an error and put the order on the MAR of R2. He stated it was a busy shift with [MEDICATION NAME] orders for 3 different residents, and the health unit coordinator was not on duty. He stated the duplicated orders for R2 was noticed on [DATE] and R2 had not been given extra doses,. The order was removed from R2's MAR but LPN-C stated he didn't realize [MEDICATION NAME] was not administered to R1. LPN-D was interviewed on [DATE] at 3:45 p.m. and stated he had also signed off on the transcription of the [MEDICATION NAME] order for R1 on [DATE]. He said he checked the order and the INR flow sheet, but did not verify the order was on the MAR. The Director of Nursing (DON) was interviewed on [DATE] at 1:50 p.m. and stated the 2 nurses equally shared the error, and that technically the policy was followed. She stated the facility had changed the policy for the second nurse check to include checking the MAR and this had been audited. The Nurse Practitioner (NP) for R1 was interviewed on [DATE] at 11:00 a.m. and verified that the [MEDICATION NAME] order was given on [DATE] to continue [MEDICATION NAME] 5 mg daily. She also stated that R1's medical history put him at risk for blood clots without [MEDICATION NAME] given daily. The facility policy Anticoagulant Therapy Guideline dated [DATE] directed staff to enter the correct order for the anticoagulant (blood thinner) drug on the MAR and complete an order for [REDACTED]. The policy included a facility addendum with step by step instructions to enter the medication order on the resident's MAR. The death certificate for R1 noted the death occurred on [DATE], and the cause of death was indicated to be a large ischemic stroke, a brain hemorrhage, and [MEDICAL CONDITION].