Every finding on record at Lakehouse Healthcare & Rehabilitation Center

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBPs) were followed for 1 of 1 resident (R1) when medication was administered via enteral tube. In addition, the facility failed to ensure proper infection control practices related to syringes and containers used for flushing enteral tubes for 2 of 3 residents (R1, R4) reviewed for enteral tubes. Findings include R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment and required staff assistance with activities of daily living. R1 had a feeding tube and diagnoses which included stroke, hemiplegia or hemiparesis, heart failure, kidney disease, diabetes mellitus, aphasia, malnutrition, and respiratory failure.R1's infection care plan revised 4/24/26, indicated R1 was at risk for infection due to gastric tube. The care plan directed staff to follow enhanced barrier precautions with all contact cares due to R1's gastric tube.During an observation on 4/29/26 at 8:40 a.m., licensed practical nurse (LPN)-A donned gloves and no gown to administer R1's medications through his gastrojejunostomy tube.During an interview on 4/29/26 at 11:53 a.m., LPN-A stated staff wore gloves and gowns to complete cares, such as dressing and toileting, and foley catheter cares for residents who were on enhanced barrier precautions. LPN-A stated they did not need a gown to administer R1's medications through his gastrojejunostomy tube.R1's physician order dated 5/27/25, directed staff to change out syringe and canister for free water every day during the night shift.During observation on 4/28/26 at 4:13 p.m., R1's nightstand had an irrigation syringe with a plunger in it, and the syringe was in an irrigation container filled with water. The syringe and bottle did not have a date. There was no barrier under the container.During interview on 4/28/26 at 4:27 p.m., LPN-C stated the night shift changed the irrigation syringe and bottle every night. LPN-C verified the irrigation syringe and container were not dated and stated the container should be emptied and the plunger separated from the syringe barrel to allow the equipment to dry.R4R4's quarterly MDS dated [DATE], indicated R4 had moderate cognitive impairment and was independent with activities of daily living. R4 had a feeding tube and diagnoses which included cancer, malnutrition, and depression.R4's physician order dated 3/30/26, directed the staff on the night shift to replace graduate, syringe, and dressing every night. Staff were to replace tubing daily if an open enteral system was used or for up to 48 hours if a closed enteral system was used.During observation on 4/28/26 at 4:49 p.m., R4's nightstand had an irrigation syringe, with a plunger in it, in a gray mug with a handle filled with water and not dated. A clear container with water was labeled with the date 4/28/26 and had a syringe with a plunger in it. There were no barriers under the water mug or clear container.During interview on 4/28/26 at 4:56 p.m., registered nurse (RN)-A verified the observations and stated staff were to empty the water from the containers and separate the plunger from the syringe barrel and rinse out before using again.During an interview on 4/29/26 at 3:59 p.m., LPN-B, the facility infection control nurse, expected staff to wear gloves and gowns to administer medications through a resident's gastrojejunostomy tube. LPN-B stated enhanced barrier precautions protected staff and residents and prevented the spread of germs.During interview on 4/30/26 at 4:25 p.m., LPN-B expected staff to dump out the water from irrigation containers after use. Standing water and used syringes sitting in water caused germs.During an interview on 4/30/26 at 5 p.m., the director of nursing (DON) stated R1 was on enhanced barrier precautions related to his gastrojejunostomy tube and expected staff to wear a gown and gloves to prevent contamination when the tube was accessed. The DON did not want irrigation syringes left in water for infection control reasons, such as prevention of waterborne pathogens.Facility policy Flushing a Feeding Tube dated 10/2024, directed staff to remove plunger from barrel and air dry after administration of water.Facility policy Enhanced Barrier Precautions dated 10/2025, indicated EBP was the use of gowns and gloves during high contact resident care activities to reduce transmission of multidrug-resistant organisms. High contact resident care activities included feeding tube device care and use.

Based on interview and record review, the facility failed to ensure services were provided in accordance with professional standards of nursing practice for 1 of 1 residents (R1) when staff inserted a Foley catheter into a gastrostomy stoma without validated competency for the procedure, without completing appropriate clinical assessment to determine safety prior to insertion, and using improper technique, including inflation of the catheter balloon within the stoma. In addition, the facility failed to ensure feeding tube supplies were labeled according to professional standards to avoid the possibility of feeding tube complications and/or related infections for 1 of 3 residents (R4) reviewed for enteral tube feedingFindings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment and required staff assistance with activities of daily living. R1 had a feeding tube and diagnoses which included stroke, hemiplegia or hemiparesis, heart failure, kidney disease, diabetes mellitus, aphasia, malnutrition, and respiratory failure.R1's nutrition care plan dated 4/24/26, indicated R1 was NPO (nothing by mouth; may not eat or drink) and required tube feeding related to dysphagia following CVA (cerebrovascular accident; blood flow to the brain is interrupted). The goal was to maintain adequate nutritional and hydration status as evidenced by weight stable, no signs and/or symptoms of malnutrition or dehydration through review date of 5/4/26. Another goal was to have minimal complications related to aspiration through review date of 5/4/26. Care plan interventions included a directive to check tube placement and gastric contents per facility protocol; there was no interventions for emergency procedures or facility protocol in the event of tube dislodgment referred to.R1's physician orders from 4/8/26 to 4/11/26 included the following:-dated 5/23/25, medication given though gastrostomy tube (g-tube).-dated 5/27/25, change out syringe and canister for free water every day.-dated 2/11/26 to 4/16/26, Osmolite 1.5 at 85 mL/hr through gastrostomy tube from 6:00 p.m. to 10 a.m. until total volume of 1,360 mL.-dated 2/11/26 to 4/16/26, 180 mL free water flush four times a day to enteral feeding tube to meet hydration needs.-dated 4/8/26 to 4/10/26, monitor enteral feeding site for signs and/or symptoms of infection, patency, and pain. Update provider as needed.R1's physician orders did not include emergency orders or directives for tube dislodgment.R1's Nursing Note on 4/11/26 at 2:59 a.m., indicated R1 pulled out his gastrostomy tube at approximately 1:30 a.m licensed practical nurse (LPN)-F placed a 16 French Foley catheter into R1's stoma to keep patent, as facility protocol. R1 denied pain and vitals obtained with a blood pressure of 73/45 mmHg (millimeters of mercury; standard unit of pressure). R1 was sent to Hospital at approximately 1:45 a.m. A message was left to the on-call provider.Review of the medical record did not identify documentation of a clinical assessment prior to insertion of the Foley catheter, including assessment of tract maturity, duration of dislodgement, or evaluation for potential complications. There was no evidence of a physician order authorizing insertion of a Foley catheter into the gastrostomy stoma.During interview on 4/29/26 at 2:05 p.m., LPN-F stated they found R1's enteral tube out of R1's stoma with the balloon deflated. LPN-F was not sure how long the tube had been out and was directed by registered nurse (RN)-B to insert a Foley catheter into R1's stoma. LPN-F stated they were unaware of the policy to place a Foley catheter into stoma for dislodged enteral feeding tube. LPN-F did not know what size R1's gastrostomy tube was and stated they placed a 16 French Foley catheter into R1's stoma with 5 cc (cubic centimeters; a volume measurement) in the catheter's balloon.During interview on 4/29/26 at 2:40 p.m., RN-B stated they were notified when R1's enteral tube feeding was found dislodged. RN-B watched LPN-B clean R1's stoma and sterilely place the Foley catheter into R1's stoma. RN-B stated the Foley catheter was inserted to avoid stomal closure. RN-B stated staff called the provider and sent R1 to the hospital when they did not hear back from the provider.During interview on 4/29/26 at 4:22 p.m., the director of nursing (DON) did not know what kind or size of gastrostomy tube R1 had at the time it became dislodged on 4/11/26. The DON expected staff to follow their policy to put a Foley catheter in a stoma to keep patent when enteral feeding tube became dislodged. The DON expected staff to be competent related to Foley insertion. The DON expected staff to follow provider orders when an enteral tube feeding became dislodged and stated they did not have a direct provider order to place a Foley catheter in a stoma if a enteral tube feeding became dislodged.During interview on 4/30/26 at 11:37 a.m., primary care provider (PCP)-E agreed the facility should have clear directions in place for a dislodged enteral feeding tube with training and competency for placing a Foley catheter into a stomal opening.During interview on 4/30/26 at 10:25 a.m., the medical director stated enteral feed stomal openings close quickly if tube becomes dislodged, and staff have quick access to hospitals. The medical director stated the size of the Foley catheter did not matter as the purpose was to keep the stoma open. The medical director stated they would not want staff to place a Foley catheter into a stomal opening less than six weeks to two months old, because there was a risk for perforation. The medical director stated staff who were competent to put a Foley catheter into a urethra were capable to place in stomal opening in the case of enteral feeding tube dislodgement.LPN-F's Foley Cather Competency Checklist dated 12/19/23, indicated LPN-F met the actions to insert a foley catheter into the meatus of a male resident. The competency did not include the action to place a foley catheter into a stoma used for enteral tube feeds.RN-B's Inserting an Indwelling Urinary Catheter dated 4/20/26, indicated RN-B met the steps required to insert a urinary catheter into a male and female urinary meatus. The competency did not include the action to place a foley catheter into a stoma used for enteral tube feeds.Facility policy Care and Treatment of Feeding Tubes dated 10/2024, directed staff to insert a temporary tube (e.g. Foley catheter) to prevent tract closure if an enteral feeding tube dislodged and send resident to the hospital as soon as possible for possible replacement of the feeding tube.R4R4's quarterly MDS dated [DATE], indicated R4 had moderate cognitive impairment and was independent with activities of daily living. R4 had a feeding tube and diagnoses which included cancer, malnutrition, and depression.R4's physician order dated 3/30/26, directed the staff on the night shift to replace graduate, syringe, and dressing every night. Staff were to replace tubing daily if an open enteral system was used or for up to 48 hours if a closed enteral system was used.During observation on 4/28/26 at 4:49 p.m., R4's room had a clear Kangaroo enteral feeding bag with between 50 and 100 milliliters of tannish colored liquid in it hanging from a tube feeding pole. R4 was not in the room, and the bag did not have a label to identify what the liquid was.During interview on 4/28/26 at 4:56 p.m., registered nurse (RN)-A verified the observations and stated staff were expected to label the enteral feeding bag with the formula type and date when feeding started.R4's physician order dated 3/31/26, directed staff to give 150 mL tap water flush three times a day and 30 mL before and after intermittent feedings and medication administration via feeding tube unless directed otherwise.The April 2026 medication and treatment administration record marked the order as completed in the morning, afternoon, and bedtime. The record did not reflect the amount used to flush R4's feeding tube.R4's physician order dated 4/15/26, directed for continuous feed of Osmolite 1.5 at 95 mL/hr (milliliters per hour) for 11 hours from 8 p.m. to 7 a.m. and flush tube with 30 mL of free water flush before and after.The April 2026 medication and treatment administration record marked the order as completed at 7 a.m. and 8 p.m. and did not reflect the amount used to flush R4's feeding tube.During an interview on 4/30/26 at 5:00 p.m. director of nursing (DON) reviewed R4's medication and treatment administration record and expected staff to update the orders with flushes to indicate the amount of flushes R4 received. The DON expected staff to label and date tube feeding bags and supplies for infection control reasons.

Based on observation, interview, and record review, the facility failed to ensure ordered hydration interventions were implemented for 1 of 3 residents (R1) reviewed for enteral tubes.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment and required staff assistance with activities of daily living. R1 had diagnoses which included stroke, hemiplegia or hemiparesis, heart failure, kidney disease, diabetes mellitus, aphasia, malnutrition, and respiratory failure. The MDS indicated R1 had a tube feeding which accounted for 51% (percent) or more of total calories R1 received and 501 cc/day (cubic centimeters per day; total volume of liquid per day) or more of average fluid intake per day.R1's nutrition care plan dated 4/24/26, indicated R1 was NPO (nothing by mouth; may not eat or drink) and required tube feeding related to dysphagia following CVA (cerebrovascular accident; blood flow to the brain is interrupted). The goal was to maintain adequate nutritional and hydration status as evidenced by weight stable, no signs and/or symptoms of malnutrition or dehydration through review date of 5/4/26. Another goal was to have minimal complications related to aspiration through review date of 5/4/26. Care plan interventions included the following:-Administer medication one at a time in gastric tube. Follow flushing precautions per order.-Registered dietician to evaluate quarterly and as needed. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed.-Tube continuous tube feeding of Isosource 1.5 at 55 mL/hr (milliliters per hour). 30 mL flush before and after feedings (60 mL). Additional free water flush of 120 mL six time per day to meet hydration needs (total 720 mL).R1's physician order indicated the following:-dated 5/23/25, medication given though gastrostomy tube (g-tube).-dated 5/27/25, change out syringe and canister for free water every day.-dated 4/16/26, Isosource 1.5 continuous feeding at 55 cc/hr (cubic centimeters per hour; total volume of liquid per hour).-dated 4/16/26, use gastric port for medications only and flush port with 30 cc water before and after medication administration to prevent the tube from clogging.-dated 4/16/26, flush 120 cc six times per day to meet hydration needs.-dated 4/16/26, use jejunal port for tube feeding only and flush with 30 cc of water every four hours to prevent clogging.R1's Discharge summary dated [DATE], indicated R1 had acute kidney injury and was admitted to [NAME] Northwestern hospital on 4/11/26 with gastrostomy tube displaced and low blood pressure. Lab work indicated severe hypernatremia (high sodium concentration), hyperkalemia (high potassium levels in blood), and elevated lactate (a substance produced by cells when breaking down carbohydrates for energy). R1 received a new feeding tube and IV fluids to manage electrolyte abnormalities.During observation and interview on 4/29/26 at 8:40 a.m., LPN-A entered R1's room with crushed medications mixed in water. LPN-A paused the feeding which ran through the jejunal port, checked residual for R1's feeding tube, slowly pushed 30 cc of water into R1's gastric port, administered medications through gastric port, and flushed with 30 cc of water through gastric port. LPN-A connected the feeding tube to the jejunal port and restarted the feeding. LPN-A stated the medication administration was her first care for R1 this morning, and her shift started at 7 a.m. LPN-A did not flush R1's according to the physician order during this episode of care.During continuous observation on 4/29/26 from 8:40 a.m. to 11:53 a.m., LPN-A nor other staff administered any additional flushes to R1's enteral feeding tube.R1's medication and treatment administration record printed on 4/29/26 at 11:14 a.m., indicated R1 received 60 cc flush with the day shift medication administration, 120 cc flush ordered for 9 a.m., and 30 cc flush to the jejunal port ordered for 10 a.m During an interview on 4/29/26 at 11:53 a.m., LPN-A reviewed R1's enteral feeding tube orders. LPN-A verified the order for the 120 cc flush six times a day did not specify which port to flush. The water amount given before and after medication administration and the water mixed with the crushed medications combined to count as the ordered 120 cc flush. LPN-A reviewed the jejunal port flush order. LPN-A stated she followed the part of the order which specified to use the jejunal port for tube feeding only and confirmed she did not flush the jejunal port with 30 cc as ordered. LPN-A stated she did not see the part of the order which directed staff to flush the jejunal port with 30 cc of water every four hours.During observation and interview on 4/29/26 at 5:45 p.m., LPN-D and LPN-E entered R1's room. LPN-D put R1's enteral feeding on hold and disconnected tube. LPN-D placed air into enteral tube using a syringe and auscultated abdominal area. LPN-D flushed the jejunal port with 30 cc of water and the gastric port with 30 cc of water. LPN-D was connecting syringe with crushed medication and water mix to the jejunal port, and LPN-E directed LPN-D to stop and administer medications into the gastric port. LPN-D flushed the gastric port with 30 cc of water after medication administration. LPN-D placed additional water in syringe and was directing syringe to jejunal port, and LPN-E directed LPN-D to gastric port. LPN-D flushed the gastric port with 120 cc of water. LPN-D reviewed R1's orders and verified R1's order to flush 120 cc six times per day did not indicate water or what to flush the port with. LPN-D stated R1 used to have gastric ports only and the jejunal port was new.R1's medication and treatment administration record printed on 4/29/26 at 11:14 a.m., directed staff to use gastric port for medications only and flush port with 30 cc water before and after medication administration to prevent the tube from clogging during the day, evening, and night shift. The document included the amount of fluids used to flush R1's gastrojejunal tube and varied between 30 and 60 cc's.During interview on 4/29/26 at 3:59 p.m., LPN-B stated staff documented intakes on the medication administration record if the order directed them to. LPN-B stated all residents were at risk for dehydration, and residents with tube feedings were at an increased risk of dehydration. LPN-B reviewed R1's documents, and the order which had varied documentation of 30 and 60 cc flushes administered. LPN-B stated she would want to educate the staff to ensure they documented and gave the correct flushes.During interview on 4/30/26 at 9:12 a.m., registered dietician (RD)-C completed monthly charting on high-risk residents such as R1. RD-C stated they reviewed resident medication and treatment administration records to ensure nursing provided appropriate interventions to support residents' nutritional needs. RD-C reviewed R1's order documentation which indicated staff varied giving 30 and 60 cc flushes. RD-C stated they would follow up with nursing to ensure the staff provided R1 with the appropriate flushes. RD-C stated inadequate or incorrect flushing of enteral tube feeding ports could cause clogging or dehydration if there were multiple missed flushing opportunities. RD-C stated administration of medications in the jejunal port instead of the gastric port could affect medication absorption and cause interactions between the feeding formula and medication.During an interview on 4/30/26 at 5 p.m., the director of nursing (DON) expected staff to give residents flushes as ordered, with free water flushes considered a separate amount than flushes with medications, to ensure proper hydration and tube patency. The DON expected staff to give medications and flushes in the correct ports to support proper medication absorption and tube patency.

Based on interviews and document review, the facility failed to reassess a resident after a change in condition for 1 of 4 residents (R1) reviewed for quality of care. R1 was assessed after a change in condition about 12:00 a.m., slept through the night, and was not reassessed until a visiting family member requested R1 transfer to the hospital.Findings include: R1's Provider Orders for Life Sustaining Treatment (POLST) dated 8/15/16, Indicated if R1 has no pulse and is not breathing instructions were do not resuscitate (DNR), do not intubate (DNI). When not in cardiopulmonary arrest follow sections in the B Goals for Treatment and C Interventions and Treatment area of the form. Section B indicated provide comfort care - do not intubate but use medication, oxygen, oral suction, and manual clearing of airways, etc. as needed for immediate comfort and in an emergency call the person listed. Section C had both boxes checked for oral and IV/IM antibiotics. R1's revised care plan dated 7/18/25, indicated he could walk independently with a walker. He needed one staff member to help him get out of bed, toilet, bathe, dress, and shower. He was on a toileting schedule for every two to three hours while awake and received incontinent care on the night shift during every two-hour rounds. R1's care conference dated 9/8/25, indicated FM-A was present and his code status was reviewed and confirmed at DNR, focusing on comfort care at the facility. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had normal cognition, no behaviors, and a minimal depression score. He took antipsychotic medication to treat his Schizophrenia diagnosis. R1's oxygen saturation summary document indicated:12/5/25, room air - 95%11/28/25, room air - 96%11/22/25, room air - 93%11/7/25, room air - 91%10/31/25, room air - 95%10/24/25, room air - 94%10/10/25, room air - 94%10/3/25, room air - 95%9/26/25, room air - 96% R1's provider note dated 12/11/25, indicated he was alert and responsive, but had chronic non-comprehensible communication. He had chronic inflammatory arthritis, and lower urinary tract symptoms (LUTS) and altered urination patterns caused by prostate issues. R1's physician order dated 12/13/25 at 11:51 p.m., indicated staff would obtain an Xray today to rule out pneumonia. In addition, staff would test him for influenza. R1's request for an Xray dated 12/13/25 at 11:50 p.m., indicated he needed a chest Xray for a cough. R1's progress note dated 12/14/25 at 00:04 a.m., written by registered nurse (RN)-A indicated dayshift reported a cough. Vital signs at the start of her afternoon shift were normal temperature, heart rate was elevated at 94 (average heart rate for his age was 60-100), respiration rate was 20 (average 12-20 breaths per minute), blood pressure was 100/63 (normal for his age would be 90/60 to 120/80), and his oxygen level was 89-90%. He drank fluids and ate ice cream and yogurt. At the end of the shift his oxygen level dropped to 85 to 90% on room air, and he started on oxygen at 2 liters per minute (LPM). On call nurse practitioner was updated, and they received orders for an Xray. RN-B was updated, and she brought the oxygen to his room. FM-A was updated on his condition. R1 was alert, answering questions while remaining in bed for the rest of the shift. Staff continue to monitor his status. R1's progress note dated 12/14/25 at 7:41 a.m., written by licensed practical nurse (LPN)-A who worked on the night shift indicated she monitored him all night, and he slept. She called the portable Xray company four times to find out when they would come but no one answered. R1's medication administration record (MAR) dated 12/14/25 indicated he took his morning 8:00 a.m. medication. R1's progress note dated 12/14/25 at 11:50 a.m., indicated he was transferred to the hospital related to increased chest congestion and low oxygen saturation less than 81% on 4 LPM. The Xray was not completed because the company did not respond to their calls. The Covid-19 and A/B flu tests were negative. FM-A was at the facility and wanted R1 to go to the hospital. The on-call nurse was updated. R1's late entry progress note dated 12/14/25 at 12:20 p.m. indicated he had a cough and shortness of breath. His oxygen was increased to 4 LPM because his oxygen levels were less than 80%. His blood pressure was 71/45, temperature was 98.1, and heart rate 108. He did take his medication without food. 911 was called because the Xray service was delayed and he was transported to the hospital. During an interview on 3/4/26 at 12:35 p.m., FM-A stated she was R1's cousin and power of attorney. On 12/13/25, around 11:00 p.m. her cousin was notified that he was not feeling well and had a cough. He started on oxygen 2 LPM. She called the provider who ordered a chest Xray and influenza test. When she arrived at the facility around 10:00 a.m. She was told he was able to take his medication in the morning, but they had to crush his pills. When she saw him, he looked like he had a fever, and he was struggling to breathe. He was having delusions, and he did not recognize her. The nursing assistant working at the time told her she had given him a bed bath and made him comfortable. She was very concerned and requested to talk to the head nurse. The head nurse assessed the patient and 911 was called to transport R1 to the hospital. Once at the hospital they were told his oxygen levels were so low that there was nothing they could do for him, and his family should be notified to say goodbye. She was in shock that his condition deteriorated from a cough to death so quickly. She was concerned that the facility did not follow proper criteria when he developed a cough and his condition deteriorated. During an interview on 3/10/26, at 10:39 a.m., the facility medical director (MD)-A stated if a resident indicated comfort care on their POLST, he would not send them to the hospital but treat them at the facility while keeping them comfortable. R1 did not have a fever, and the flu test at the facility was negative. He added this year Influenza A was very deadly because the flu vaccination did not provide sufficient coverage. It was his opinion that R1's condition could rapidly deteriorate from midnight to 10:30 a.m. when he was transferred to the hospital. During an interview on 3/10/26 at 11:29 a.m., RN-A stated on 12/13/25, the only thing she remembered was he needed help to eat. When a resident had a change in condition, they would assess the resident, get a set of vital signs, and update the provider and family. The provider would always ask what their code status was. If he were on comfort care, she would not have expected the provider to send him to the hospital for treatment but treat him at the facility while keeping him comfortable. During an interview on 3/10/26 at 11:37 a.m., RN-B did not remember the details on 12/13/25. As a supervisor she would have been the one to bring oxygen to the room. If the POLST indicated comfort care, she would expect the resident to remain at the facility unless the family wanted him transferred to the hospital. During an interview on 3/10/26 at 12:15 p.m., LPN-B stated comfort care like a hospice resident, if they needed oxygen or develop worsening symptoms, she would have updated the provider and family. During an interview on 3/10/26 at 12:22 p.m., regional director of clinical services (DCS)-A stated she spoke with the triage NP from 12/13/25. The NP indicated based on the POLST and comfort care had I wanted him sent to the hospital I would have. She ordered an Xray and flu test to rule out pneumonia. If positive she would have ordered antibiotics while keeping him comfortable. During an interview on 3/10/26 at 2:00 p.m., the administrator stated the nursing staff document by exception. Protocol on night shift was to check and turn every resident every two hours. Staff were monitoring him, and the nightshift nurse documented that he slept all night. If he had worsened throughout the night, she would have expected her staff to update the provider and family. The staff treated him the same as a hospice resident focusing on managing symptoms and providing comfort. During an interview on 3/10/26 at 2:29 p.m., LPN-A stated she took over R1's care from RN-A on nightshift. She said he was checked on every 2 hours for incontinent care and repositioning. She did check his oxygen levels, and it was above 90% on oxygen. She was surprised to hear his condition worsened and he died. R1 slept all night, and his status did not change enough to warrant calling the family and provider with an update. She added, if the POLST identified comfort care focus she would keep him comfortable, provide oxygen, and medication as ordered. During an interview on 3/10/26 at 2:57 p.m. DCS-A stated she could not find a policy defining comfort care. She added, comfort care was defined on the POLST document on page two. Facility policy Notification of Changes dated 5/23, indicated a significant change would involve a life-threatening condition, complication, or when a provider would need to alter current treatment plan.

Based on observation, interview and document review the facility failed to ensure individualized turning and repositioning programs were based on a completed comprehensive assessment in order to prevent or mitigate the risk of pressure ulcer development and/or deterioration for 1 of 3 resident (R2) reviewed for pressure ulcers.findings include R2's annual Minimum Data Set (MDS) dated [DATE], identified R2 had impaired cognition with diagnoses of Alzheimer's Disease, diabetes and cerebrovascular accident (stroke) and was dependent on staff for all activities of daily living (ADLs) including eating and mobility. R2 was incontinent of bowel and bladder, requiring staff to change incontinent product and perform peri care. R2 had no nutritional risk factors noted. R2 was at risk for PU but did not have a PU. Formal assessment was completed, but no clinical assessment was completed. R2 did not have a turning or reposition program.R2's Braden's assessment dated [DATE] with a score of 14 out of 18, putting R2 at moderate risk for pressure ulcer/injury development. R2's Braden's assessments dated 7/28/25 and 10/28/25 scored 13 out of 18, R2 remained at moderate risk for pressure ulcer development, even though she had a stage 2 on 7/23/25 this wound deteriorated to a stage 3 on 10/2/25. R2's pressure ulcer/injury care area assessment (CAA) worksheet dated 5/5/25, indicated the following triggers incontinent of bowel and bladder, R2 was risk for pressure ulcers and was dependent on staff for turning and repositioning. Under the analysis finding section, there is nothing filed out for the existing pressure ulcer/injury or extrinsic factors. Under intrinsic factors, listed R2 had altered mental status, delirium, with cognitive loss and incontinence. Under diagnoses and condition listed the following, cerebrovascular accident (stroke), chronic or end-stage renal, liver, or heart disease, Alzheimer's disease and other dementia. Under the treatments and other factors section indicated newly admitted or readmitted . There was no family or resident input. Under care plan considerations section, indicated functional status would of pressure ulcer/injury, be addressed in the care plan without any objectives indicated.R2's progress notes between 7/9/25 through 7/22/25 indicated R2 had impaired skin integrity on buttocks/groin. Progress note dated 7/23/25 indicated R2 had an open wound on sacrum. No comprehensive assessment was included. Progress note dated 7/28/25 resident was found with an open area on butt crack, measuring 1.5 cm x 0.5 cm. Progress note dated 7/28/25, indicated the interdisciplinary team met to discuss new pressure injury state 2 to intergluteal theft. The note identified a new interview to turn and reposition every 2-3 hours was added to the care plan, however, the note did not identify how the 2-3 hours was determined and/or appropriate. In review of R2's record, there was no indication a comprehensive assessment was completed to determine tissue tolerance over bony prominences to pressure over time in conjunction with R2's clinical status and other risk factors for pressure ulcer deterioration and/or new development. R2's care plan dated 10/15/25 had a skin integrity focus that identified R2 had an actual skin integrity concern of intergluteal cleft/medial related to impaired mobility, needing assistance with ADLs, incontinence, severe cognitive impairment and severely impaired decision-making needing cues and supervision from staff. R2 had history of moisture associated skin damage (MASD) under both breast and to buttocks. The care plan was revised on 7/28/25 to include the intervention that directed staff to turn and reposition R2 every 2-3 hours and as neededR2's progress noted dated 10/1/25 at 1:24 p.m., R2's coccyx wound was upgraded to a stage 3. In review of R2's record there was no indication of a comprehensive assessment that addressed R2's turning and reposition program and not evident the care plan was revised after the ulcer deteriorated to a stage 3. During an Interview on 11/14/25 at 12:20 p.m., registered nurse (RN)-A indicated that the turning and repositioning schedules were individualized, as with R2, is up for meals and then laid back down in bed and then turned every 2-3 hours. RN-A was not able to articulate how every 2-3 hours for repositioning was determined to be appropriate and/or effective. During an Interview on 11/18/25 at 11:40 a.m. nursing assistant (NA)-Q stated the staff were informed of the turning and repositioning schedules on their daily report sheets, NA-Q stated up for meals otherwise in bed and turned every 2-3 hours. During an interview and observation on 11/18/25 at 1:22 p.m., RN-C described the wound during a dressing change as a stage 3, with moderate serosanguinous drainage. RN-C did not know how the turning and repositioning schedule was determined but the NA taking care of her should know. During an interview on 11/19/25 at 8:30 a.m., director of nursing (DON) indicated R2 was on an alternating air mattress due to her stage 3 ulcer. This device was to assist staff with offloading to the resident. The IDT team meets daily, and they discuss the wounds quickly and then meet once a week at wound rounds and discuss how the wounds are progressing. DON could not articulate how every 2-3 hour turning and repositioning schedule was established or how they were evaluating the effectiveness of the interventions they had in place to relieve the pressure from the pressure ulcer area. During an Interview on 11/19/25 at 10:15 a.m., regional nurse consultant (RNC)-A, stated that the facility did not use a tissue tolerance specific assessment as that had gone by the wayside years ago and indicated there was no formalized process and/or tool to determine a resident's repositioning schedule, and it was more based on the clinical picture however, the determination of which factors were used to determine the schedule were not documented. During an interview on 11/19/25 at 1035 a.m., wound nurse practitioner (NP)-A, stated first made aware of wound for R2 on 7/30/25, when she evaluated the wound and took initial pictures. NP-A described the wound as superficial at that time, and R2 had another area nearby that looked like MASD. R2 had history of MASD in the coccyx area in late June 2025. NP-A put in orders for daily treatments, air mattress and dietary consult for protein supplement. R2's wound was evaluated every week and was improving until 10/1/25, when NP debrided the area and restaged it to a stage 3 out of 4. NP-A put in different dressing orders. They showed improvement and was stable during the evaluations on 10/8/25 and 10/10/25. The wound then deteriorated for the next 5 visits in 3 weeks (10/15/25 through 11/5/25). NP-A kept the same dressing change and encouraged staff to limit R2's time up in wheelchair (up for meals only) on the visits for 10/15/25 and 10/17/25. NP-A further stated the causal factor of the pressure ulcer was pressure from lying on her back and being in the wheelchair prior to the development of the pressure ulcer on 7/25/25.Review of facility policies entitled Pressure Ulcer Monitoring and Interventions did not address turning and repositioning programs based on comprehensive assessments to prevent and/or reduce the risk of pressure ulcers.

Based on interview and document review, the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) to provide cardiopulmonary resuscitation (CPR) for 1 of 3 residents (R1), who wished to have CPR in the event of cardiopulmonary arrest (absence of pulse and respirations). This deficient practice resulted in an immediate jeopardy (IJ) when R1 was found absent of pulse and respirations, no CPR was initiated, and R1 passed away. The facility implemented corrective action prior to survey; therefore, the deficient practice was issued at past non-compliance. The IJ began on [DATE], when R1 was found unresponsive with an absence of pulse and respirations, CPR was not initiated, and R1 passed away. The facility administrator and director of nursing (DON) were notified of the IJ on [DATE] at 2:50 p.m. which was identified at the scope and severity of and isolated IJ. The facility implemented immediate corrective action on [DATE] to prevent recurrence, therefore, the IJ was issued at past non-compliance. Findings include: A nursing note written by licensed practical nurse (LPN)-A dated [DATE], indicated when LPN-A checked on R1 Cheyne-Stokes breathing (an abnormal breathing pattern of deep breathing, shallow breathing and no breathing followed by a gasp, commonly seen during the dying process) was observed. LPN-A requested assistance from another facility nurse and R1's hospice nurse who was in the building. When the nurses returned to R1's room, he was not breathing. The nurses checked for a pulse, finding none. Time of death was called at 2:20 p.m. The nurses cleaned R1's body to prepare for the mortuary to pick up. R1's progress note lacked documentation regarding checking R1's code status and initiation of CPR. R1's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition with diagnoses that included metabolic encephalopathy, type 2 diabetes, and end stage renal disease. R1's POLST dated [DATE], identified R1's wishes were to attempt CPR (full code) with full treatment including intubation, advanced airway interventions, mechanical ventilation and transfer to the hospital if indicated. A Care Conference Summary, locked [DATE], identified R1 was a full code and wished to remain as such. A provider visit note, dated [DATE], identified R1 was seen by nurse practitioner (NP)-A. The note identified R1's advance directive as full code. A provider order dated [DATE], indicated code status as CPR/attempt resuscitation. R1's electronic health record (EHR) indicated R1 elected hospice care on [DATE]. During an interview on [DATE] at 12:52 p.m., LPN-B stated when a resident was found unresponsive and not breathing, a nurse STAT (an emergency page overhead that calls nurses to a specific location) should be called and the resident's chart should be checked for code status. LPN-B stated CPR would be performed if consistent with the resident's wishes. LPN-B confirmed code status would be checked for a resident who had elected hospice care since hospice care did not automatically mean a resident's code status was do not resuscitate (DNR. Allow natural death). During an interview on [DATE] at 1:29 p.m., LPN-C stated a resident's code status needed to be checked for all residents who were found unresponsive and not breathing. LPN-C stated CPR would be performed if consistent with resident's wishes. During an interview on [DATE] at 2:29 p.m., DON confirmed R1's code status was full code, his code status had not checked when he was found unresponsive, and CPR had not been performed. During an interview on [DATE] at 12:18 p.m., Hospice registered nurse (HRN) stated she was at the facility to see R1 on [DATE], because he was having increased pain. When she assessed R1, he was a little confused however, was able to answer basic questions. HRN left the room to call the provider. LPN-A asked HRN to go to R1's room because his breathing was different. When HRN and LPN-A returned to R1's room, he was not responding and was not breathing. HRN checked for a pulse while LPN-A checked for breathing. Finding no pulse and no breaths, time of death was called. HRN did not check the resident's code status, and LPN-A did not leave the room until after time of death was called. HRN confirmed CPR had not been initiated on R1. During an interview on [DATE] at 1:49 p.m., registered nurse (RN)-A stated a nurse STAT page alerted all nurses to respond to a specific location for an emergency. Each nurse would bring equipment based on the location they were working on. Equipment included a crash cart (included supplies needed to perform CPR), vital signs machine, and automated external defibrillator (AED). If a resident was found unresponsive and not breathing, a nurse should check the POLST of the resident and if the resident was full code, CPR should be started immediately. RN-A stated there was no reason CPR would not be started on a resident who elected full code status. During a follow-up interview on [DATE] 2:16 p.m., the DON stated if a resident was found not responding and not breathing, a nurse should check the resident's code status on the POLST. If the resident was full code, the nurse would do chest compressions, give respirations, and use the AED. 911 would also be called. If a resident's code status was DNR, CPR would not be started. DON stated there were reasons CPR would not be started listed in the CPR policy however, those signs take 4-6 hours to develop, and staff would be checking on residents before the signs had time to develop. 3 attempts were made to contact LPN-A with no return phone call. Review of the facility's CPR policy dated [DATE], instructed staff when a resident experienced a cardiac arrest, to provide basic left support, including CPR in accordance with the resident's advance directives. And if the resident did not show obvious signs of clinical death (e.g. rigor mortis [body limb stiffening], dependent lividity [purplish red discoloration to the skin], decapitation, transection, or decomposition). The facility implemented the following actions prior to the survey which were verified through interview and document review and therefore the IJ was issued at past non-compliance:-LPN-A was immediately suspended and communication with hospice company occurred.-House-wide nurse education started including the importance of checking a resident's code status when they were found unresponsive and not breathing, including residents who had elected hospice care. Education completed [DATE].-Nurse STAT (Code Blue) drills started [DATE]. Drills included residents who were full code, DNR, and hospice residents.

During observation, interview and record review the facility failed to ensure facility was kept sanitary and maintained in good repair on all six resident units which had the potential to affect all 225 residents, staff, and visitors of the facility.Findings include: Walls:During observation on 8/12/25 at 8:56 a.m., on the sixth floor, wall outside R184's room had gouges and underlying wallboard exposed. Partial repair was done but not painted to match the wall. The wall across from aviary was tan in color with nine sections or areas of wall covering four feet by two feet with repairs but no matching paint.During observation on 8/12/25 at 9:26 a.m., in second floor dining room, two residents were seated at a dining room table. The wall of the dining room had gouges and scrapes observed with repairs done but no paint to match the wall cover.During observation and interview with the administrator and director of environmental services (D)-ES on 8/13/25 at 8:31 a.m., on the seventh floor, the D-ES and surveyor observed knee wall in dining room with gouges and visible wallboard repaired but did not have any matching paint. D-ES and administrator state we are identifying areas that need repair and replacements. D-ES stated he had not received any maintenance requests from staff to repair and match paint for the dining room.During observation on 8/13/25 at 9:20 a.m., in third floor dining room, all of the walls had wallboard that had been repaired but no paint to match the walls. Several residents were eating breakfast in the area.During observation and interview with licensed practical nurse (LPN)-B on 8/13/25 at 9:36 a.m., LPN-B stated gouges should be looked at. I would like it to be repaired or replaced in my home and It does not look good if there are so many holes and dings in the wall. LPN-B stated process for repairing equipment was for staff to utilize a walkie talkie to the maintenance department or submit request through the computer system. LPN-B stated they had not submitted anything to maintenance for repairs to any resident walls, doors, or carpets.Floors:During observation on 8/12/25 at 9:05 a.m., on fifth floor a long black vinyl piece was resting against the baseboard of the alcove right off the elevator and across from the dining room. The vinyl piece was not attached to anything. A section of carpeting in the dining room was missing the transition piece from laminate flooring of the dining room to the carpeted areas outside the dining room. One resident sitting in wheelchair next to the gap in flooring stated he was concerned for ambulatory residents and staff for risk of tripping.During observation on 8/13/25 at 8:53 a.m., three dark stains were seen on R97's carpet inside door. The black stains on the tan carpet ranged from two to three inches in circumference and was visible from the hallway.During interview with D-ES on 8/13/25 at 12:10 p.m., D-ES stated the missing transition piece on fifth floor dining room was replaced, It is a safety issue. Do not want anyone to trip.During observation and interview on 8/13/25 at1:08 p.m., R191's carpet in their room had large dark stain visible to the hallway. D-ES stated, it should definitely be cleaned. It is stained and had not received a maintenance request to clean the carpet.Ceiling:During observation and interview with nursing assistant (NA)-B on 8/12/25 at 2:06 p.m., in R20's unoccupied bedroom, NA-B looked at the dark stains on his 4 white ceiling tiles and stated, I would not like it in my home. It is not good to see those stains on the ceiling and the unpainted section there (pointing to the unfinished wall repair two feet by three feet in size next to R20's head of bed). NA-B stated process for repairing equipment is for staff to utilize walkie talkie to the maintenance department or submit request through the computer system. NA-B stated they had not submitted anything to maintenance for repairs to R20's wall or ceiling tiles.During observation and interview with licensed practical nurse (LPN)-C on 8/12/25 at 2:42 p.m., LPN-C looked at R20's wall and ceiling tiles and stated, Oh stains and the wall needs to be redone. If it was my house, I would not like to see that. LPN-C stated process for repairing equipment is for staff to utilize walkie talkie to the maintenance department or submit request through the computer system. LPN-C stated they had not submitted anything to maintenance for repairs to R20's wall or ceiling tiles.During observation and interview with R20 on 8/12/25 at 3:06 p.m., R20 stated, I don't like the wall. Its right next to my head when I lay in bed. The paint does not match and it looks unfinished. It is not attractive. No one has mentioned it to me. It was here when I [admitted to facility]. R20 then pointed to ceiling of his room and four white ceiling tiles that were darkly stained. I think it looks crappy.Doors:During observation and interview with nursing assistant (NA)-A on 8/13/25 at 9:01 a.m., NA-A and surveyor observed a missing piece of laminate wood about eight inches long by three inches from R196's bathroom door about 4 feet up from the floor near the hinges. The edges were ragged and sharp. NA-A stated Not in good repair to me. I don't like that. It looks bad and It is dangerous and could hook on someone's clothes and could snag. NA-A stated process for repairing equipment is for staff to utilize walkie talkie to the maintenance department or submit request through the computer system. NA-A stated they had not submitted anything to maintenance for repairs to R196's bathroom door.During observation and interview with R76 on 8/13/25 at 9:24 a.m., R76 pointed to bottom of door jamb which had area pulling away leaving ragged edges. I don't like the look of that. It is unattractive and [sic] piece could hook on something and cut me.During observation on 8/12/25 at 9:01 a.m., R146's door to hall had gouge marks running horizontal about four feet up from floor running entire width of it. During interview with R146 on 8/13/25 at 8:49 a.m., R146 stated, I don't like the line on the door. It is not old, they should cover it. R146 stated the condition of the door had been like that a long time. R146 pointed to ceiling tiles in her bathroom which were darkly stained and said, It is dirty and stained. It does not look good and no one offered to repair or replace it.During interview with administrator and D-ES on 8/13/25 at 12:29 p.m., the administrator stated she agreed that the walls, doors, carpets, ceiling tiles and dining rooms and halls should be repaired or replaced with matching paint. [I] agree it is important for residents to live in [a]space that is in good condition.During resident council meeting interview on 8/13/25 at 10:07 a.m., R233 stated the environmental concerns included stained walls, carpets, ceilings, and unfinished repairs. R233 stated, I would make sure everything is clean and wiped up and finished painted. That is something that someone who visits us should not see. I don't like it. R199 stated facility had started patching them [walls]. Never got around to completing it and I don't think anyone gives a d**n what I think.During interview with D-ES on 8/13/25 at 1:11 p.m., D-ES reviewed facility's maintenance request logbook for 2/2025 to 8/2025 and verified there were no requests for resident dining room wall, door, or carpet repairs. D-ES stated, It isn't fair for them [residents] to see that unfinished work.Facility policy titled Residential Environment dated October 2022 identified All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings upon identification of the issue.

During observation, interview and record review, the facility failed to ensure an effective pest control program was in place to eliminate fruit flies and black flies for 5 residents (R6, R69, R76, R88, and R223) who verbalized concern about flies. This had the potential to affect all 225 residents of the facility.Findings include:R6's admissions Minimum Data Set (MDS) dated [DATE], identified R6 with no physical or verbal behaviors and did not reject cares, no impairment of upper extremity range of motion, impairment of lower extremity range of motion, utilized a wheelchair for mobility, and required assistance with toileting, and dressing.R69's quarterly MDS dated [DATE], identified R69 with intact cognition, no physical or verbal behaviors and did not reject cares, no impairment of upper or lower extremity range of motion, utilized a walker for mobility, and required set up or clean-up assistance with eating, oral hygiene, toileting hygiene, dressing, and personal hygiene.R76's admissions MDS dated [DATE], identified R76 with intact cognition, no physical or verbal behaviors and did not reject cares, no impairment of upper and lower extremity range of motion, utilized a walker for mobility, and required assistance with dressing, and toileting.R88's quarterly MDS, dated [DATE]/25, identified R88's short-term and long-term memory to be intact, no impairment of upper extremity range of motion, impairment of lower extremity range of motion, utilized wheelchair for mobility, and required assistance with toileting, and dressing.R223's significant change in status assessment MDS dated [DATE], identified R223 with intact cognition, no physical or verbal behaviors and did not reject cares, impairment of one side of upper and lower extremity for range of motion, utilized a wheelchair for mobility, and required assistance with toileting and dressing.Review of facility's monthly pest control visit notes, the facility was treated for Cluster Flies, Drain Flies, Flies, Fruit Flies, House Flies on the following dates:2/11/25, 3/14/25 which identified fruit flies throughout the kitchen and garbage collection areas, 4/4/25, 5/14/25, 6/12/25, and 7/11/25 (which identified fruit flies).During observation and interview with R6 on 8/11/25 at 1:06 p.m., R6 pointed to several fruit flies and regular black flies buzzing around her room and said her room is visibly dirty. R6 stated she was upset about it and I am at the point of begging to rid her room of them.During observation and interview with R88 on 8/11/25 at 3:44 p.m., R88 was lying in bed with a fly swatter in her right hand. A fly was buzzing around her, and she was swatting at it. This is bothering me. My friend had to bring in the fly trap (pointing to window with sticky fly strip hanging down from window blind). They need to do something about pests in here. R88 stated she stayed in bed, rarely got out of the bed, and was stuck with the flies.During observation and interview with R76 on 8/11/25 at 4:24 p.m., R76 had multiple flies in room flying around his food tray and legs. R76 was swatting flies away. R76 stated, They come and they go.During observation and interview with director of environmental services (D)-ES on 8/13/25 at 1:16 p.m., D-ES and surveyor walked into R88's room, with permission, and observed two large black flies buzzing around and the fly strip that was attached to the blinds. I know we did not get a work request for the flies in her room. I will have to look at it.During interview with D-ES on 8/13/25 at 1:11 p.m., D-ES reviewed facility's maintenance request logbook for 2/2025 to 8/2025, and stated there were no requests for additional pest control visits to address flies. D-ES also reviewed and verified the pest control visit notes stated facility did not reach out to ask for additional services to address the flies. D-ES stated the services were clearly not effective.During interview with director of nursing on 8/13/25 at 2:10 p.m., DON stated It is really hard to manage [flies].During interview with licensed practical nurse (LPN)-D on 8/14/25 at 8:15 a.m., LPN-D stated she had seen some flies yesterday in a resident's room but was unable to say which room. LPN-D stated expectation of staff to notify nurse manager or maintenance through walkie talkie or submit a request through the computer for issues relating to flies or pests. LPN-D stated she failed to notify anyone of the flies.During interview with nursing assistant (NA)-C on 8/14/25 at 8:23 a.m., NA-C stated, there have been complaints from residents about flies and expectation of staff to notify nurse manager or maintenance through walkie talkie or submit a request through the computer for issues relating to flies or pests. NA-C stated she failed to notify anyone of the flies.During interview with NA-D on 8/14/25 at 8:37 a.m., NA-D stated the appearance of flies, Usually [sic] happens a lot during summertime and they [flies] move around the place. NA-D stated expectation of staff to notify maintenance through walkie talkie or submit a request through the computer for issues relating to flies or pests. NA-D stated she failed to notify anyone of the flies.During interview with NA-F on 8/14/25 at 9:07 a.m., NA-F stated flies appeared in the dining room and sometimes the residents will say they bother them. In the hallway there will be some. NA-F stated he had seen them recently but did not notify maintenance of his observations.During observation on 8/14/25 at 9:31 a.m., R223 was sitting in wheelchair on the fifth floor waiting for the elevator. R223 was swatting a fly buzzing around her. R233 stated, These things are crazy.During interview with R69 on 8/14/25 at 8:51 a.m., R69 stated, there is a few black flies that are around here. No one is doing anything about it. Sometimes the flies come into my room and I hate that. Bothers me. Wish this place would get rid of them. Who wants flies buzzing around them? Especially when I am lying in bed.Facility policy titled Residential Environment dated October 2022, state, Pest control should be scheduled at routine intervals and available should a concern arise.

Based on observation and interview, the facility failed to ensure all staff knocked on individual resident bedroom doors, introduced themselves, and waited for permission to enter room prior to entry for 9 of 9 residents (R69, R77, R106, R119, R146, R167, R178, R196, R252) reviewed for dignity.Findings include: R69's quarter Minimum Data Set (MDS) dated [DATE], identified R69 with intact cognition.R146's quarterly MDS dated [DATE], identified R146 with intact cognition.R252's quarterly MDS dated [DATE], identified R252 with impaired cognition.During observation on 8/11/25 at 1:15 p.m., staff entered R252's room after one knock and did not introduce self or wait for a response or permission to enter. Once the staff entered the room, she looked at surveyor and turned around and left the room without a word. R252 stated, they do that a lot. Don't wait to let me answer or tell me who they are and what they want. I don't like that at all. I think it is rude.During interview with R146 on 8/12/25 at 9:01 a.m., R146 stated, I want people to knock and say who they are before barging into my room. Some of the staff just walk in and I don't like it. I expect them to respect my privacy and ask permission to enter my room.During observation on 8/13/25 at 8:15 a.m., two staff members entered shared resident room of R106 and R178 without knocking and announcing who they were.During interview with licensed practical nurse (LPN)-A on 8/13/25 at 8:21 a.m., LPN-A stated expectation of staff to knock, introduce themselves, and wait for permission to enter the resident room, for privacy [sic] dignity it is their home, and you do not just enter.During interview with registered nurse (RN)-A on 8/13/25 at 8:35 a.m., RN-A stated expectation of staff to knock and wait for response before entering a resident room. If I don't knock before entering it is rude because of dignity and privacy. I would not be happy if someone just walked into my house without knocking or introducing themselves. This is their home, and we need to remember to treat it as such.During observation and interview with nursing assistant (NA)-A on 8/13/25 at 9:01 a.m., NA-A entered R196 room after knocking but did not announce self or wait for response before entering the room. NA-A stated, I should have waited for [R196] to respond before I entered the room.During observation and interview with licensed practical nurse (LPN)-B on 8/13/25 at 9:29 a.m., LPN-B knocked on door of shared room for R167 and R119 but did not wait for a response before entering the room. At 9:36 a.m., LPN-B exited the room and stated, I did not wait for a response before entering. It [sic] important to wait for response due to privacy.During interview with director of nursing (DON) on 8/13/25 at 1:55 p.m., DON stated expectation of staff to knock on the resident door and wait for a response and permission to enter the resident room. They [staff] should be waiting for an invite or at least knock wait and then introduce self before walking in.During interview with NA-C on 8/14/25 at 8:23 a.m., NA-C stated expectation of all staff to introduce themselves after knocking on resident's door and wait for them to give permission to enter their room.During interview with NA-D on 8/14/25 at 8:37 a.m., NA-D stated expectation of all staff to introduce themselves and tell them [resident] what I am there for.During observation and interview on 8/14/25 at 8:46 a.m., NA-E entered shared room for R69 and R77 without knocking or introducing self and waiting for permission to enter. NA-E stated, I did not do that. It is important. During interview with R69 at 8:51 a.m., R69 stated staff do not always knock and introduce themselves waiting for me to give permission to enter. I had an incident with an aide that walked in on me with my pants down while I was taking care of my catheter. I asked her to not do that anymore. I am adjusting to my loss of independence since my admission here. I don't like anyone coming into my room while I am naked. It is a respect thing.During observation and interview on 8/14/25 at 9:07 a.m., NA-F entered resident room without knocking and waiting for permission to enter. NA-F stated, I did not introduce myself. We are to knock and wait for answer before entering room. For privacy.Facility policy titled Resident Rights, dated July 2025, state, The resident has a right to personal privacy and confidentiality of his or her personal and medical records. A. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care.

During observation and interview, the facility failed to implement interventions to ensure residents' personal care information was kept secured and out of public view when stored on 3 of 7 facility units with mobile medication/treatment carts. This had the potential to affect 9 residents on the 2nd floor, 8 residents on the 5th floor, and 11 residents on the 7th floor whose personal information was listed on unattended care sheets.Findings include:During observation and interview starting on 8/13/25 at 8:21 a.m., licensed practical nurse (LPN)-A left an unattended resident care sheet including thirteen resident names, room numbers, information on how they take their medications, bath information, and diagnoses and information on pressure ulcer status, assistance required for transfers and applying ordered adaptive equipment and infection control precautions. The form titled 7G ODD Nurse Census Sheet was left unattended on medication cart while two residents in wheelchairs were pushed past the cart by other staff members. LPN-A returned to cart and stated, [I] left the paper unattended on the med cart. I should flip it over so info [cannot be seen].During interview with registered nurse (RN)-A on 8/13/25 at 8:35 a.m., RN-A stated expectation of staff to protect [resident] information. Because of HIPAA.During interview with LPN-B on 8/13/25 at 9:36 a.m., LPN-B stated expectation of staff, to cover care sheets for privacy. HIPAA.During observation and interview on 8/13/25 at 1:04 p.m., a medication cart was unattended with a resident care sheet titled EVEN SIDE TCU that included nine resident names, including room numbers, diagnoses, personal care preferences, bath and shower days. The Director of Environmental Services (D)-ES and surveyor walked by the unattended care sheet and stopped at the medication cart. D-ES pointed to it and said, [that] should not be available because it is a HIPAA violation and patient privacy. Registered nurse (RN)-C walked past the cart and stated, It should not be left unattended. RN-D approached and stated she left the unattended care sheet prior to leaving the medication cart and entering a resident room. RN-D stated, I left it accidentally and [it] should not be left out here (pointing to the hallway where another staff member and resident were walking past). RN-D stated, [I] should know better.During interview with director of nursing (DON) on 8/13/25 at 1:55 p.m., DON stated expectation of staff to secure care sheets with resident information upside down and not seen. DON stated rationale was Patient privacy.During interview with NA-C on 8/14/25 at 8:23 a.m., NA-C stated, we [nursing assistants] are told to use the computer instead of paper. Concern for patient information [being] displayed. HIPAA.During interview with NA-D on 8/14/25 at 8:37 a.m., NA-D stated care sheets should be private and HIPPA private information not to be visible and not anyone else's business.During observation and interview on 8/14/25 starting at 8:58 a.m., an unattended medication cart was observed with a resident care sheet on top titled 5G ODD Nurse Census Sheet that included eight resident names including room numbers, how they take their medications, bath and shower day details, infection control precautions, and behavior monitoring precautions. Two staff members walked past the cart along with one resident in a wheelchair. RN-E approached unattended medication cart and care sheet and stated, I should not have left it unattended. Important for patient [sic] information is confidential.Facility policy titled Resident Rights, dated July 2025 identified The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

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 5 residents (R218) reviewed for MDS accuracy.Findings include:R218's quarterly MDS dated [DATE] indicated R218 had memory problems and required assistance with personal cares. The MDS indicated under section N0350-A: Insulin injections. R218 received 7 insulin injections during the look-back period (LBP). R218's orders were reviewed and did not indicate orders for insulin, before or after LBP. R218 was diabetic and received two oral agents to treat her diabetes. R218's April and May's medication administration record indicated, R218 did not received insulin during LBP. During interview on 8/13/25 at 2:35 p.m., MDS coordinator verified R218 did not received insulin during LBP. MDS coordinator indicated probably the mistake was done when one of R218's oral diabetic medications was coded as insulin. MDS coordinator indicated she would complete a correction right away, because incorrect coding could affect the federal reimbursement. Facility's administrator indicated, the facility didn't have a MDS policy but followed the RAI manual.

Based on interview and document review, the facility failed to ensure a level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 3 of 4 residents (R40, R9, R6) reviewed for PAS. Findings include: R40’s quarterly Minimum Data Set (MDS) dated [DATE], indicated R40 was admitted to the facility on [DATE] and had intact cognition. The MDS indicated R40 was diagnosed with schizophrenia, post-traumatic stress disorder, and a “psychotic disorder”. R40's PAS notice dated 1/21/25, indicated a copy of the PAS was included with this notice, but the PAS was not final until the lead agency sent a final determination to the nursing home. R40's entire medical record was reviewed and lacked evidence that a final determination had been received. During an interview with the director of admissions (DOA) on 8/13/25 at 9:26 a.m., the final PAS was requested, and the DOA confirmed she would review R40’s medical record and provide the final PAS if able. On 8/14/25 at 10:46 a.m., the DOA stated she oversaw ensuring they had a PAS number for every resident and would sometimes reach out to the entity in charge of completing the final PAS for each resident but was unsure if she had prior to the start of the survey for R40. The DOA confirmed she had not been able to find the final PAS in R40's medical record, so she had contacted the lead agency yesterday. The DOA stated she did not keep documentation of any attempts to obtain the final PAS, so she would be unable to provide any. The DOA stated the director of social services (DOSS) assisted with ensuring the final PAS was received, and he may be able to give further information. During an interview on 8/14/25 at 10:49 a.m., the DOSS stated that admissions oversaw ensuring the final PAS was received, and his department did not assist with this. During an interview on 8/14/25 at 12:19 p.m., the administrator stated the director of admissions oversaw ensuring the final PAS was received before admission. R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R(9) was admitted to the facility on [DATE] and was cognitively intact. R9's Clinical Diagnosis Record dated 8/14/25 indicated, R9 was diagnosed major depressive disorder with severe psychotic symptoms, post-traumatic stress disorder and generalized anxiety disorder. R9's PAS notice dated 11/7/24, indicated a copy of the PAS was included with this notice, but the PAS was not final until the lead agency sent a final determination to the nursing home. R9's entire medical record was reviewed and lacked evidence that a final determination had been received. During interview with the director of admissions (DOA)) on 8/14/25 at 11:54 a.m., DOA stated she was responsible to make sure new residents had a pre-screening done before they were admitted to the facility. DOA stated the social worker was responsible to follow up with Senior Linkage to obtain the final determination. During an interview on 8/14/25 at 12:04 p.m., the social worker director (SWD) verified, R9's medical record did not have the final determination documentation. The SWD stated the admission team followed up to obtain the final determination. R6's admission Minimal Data Set (MDS), dated [DATE], identified R6 admitted to the care center on 6/25/25 and had multiple medical conditions including anxiety, major depressive disorder, bipolar, post-traumatic stress disorder, schizophrenia and traumatic brain injury. Review of R6’s electronic medical record (EMR) lacked any evidence a level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed on R6 prior to admission to the care center. During an interview on 8/13/25 at 12:15 p.m., the director of admission (DOA) stated the care facility required that the hospital submit a PAS prior to the resident admitting to the care facility. The DOA stated the admission department would be responsible for uploading the PAS, and if needed the PASARR and social services would be responsible for reviewing the documents for any needed additional services. The DOA confirmed a PAS was not completed for R6, stating there was a new admission coordinator being trained in who “missed it” [the PAS]. The facility's Pre-admission Screening policy dated 10/22, indicated the facility would ensure a level I screening would be conducted for all applicants before admission.

Based on observation, interview, and document review, the facility failed to develop a comprehensive care plan to ensure correct application of a lower extremity brace for 1 of 3 residents (R178) reviewed for the use of a lower extremity brace. Findings include: R178's quarterly Minimum Data Set (MDS) dated [DATE], indicated R178 had severely impaired cognition, a functional limitation in the range of motion of both lower extremities, and required staff assistance with all activities of daily living. R178's diagnosis report dated 5/21/25, indicated R178 had a diagnosis of right-sided weakness following a stroke.R178's Medical Record Attestation Statement Delayed Certification Statement dated 7/2/25, indicated the provider instructed staff to continue to apply the right AFO brace as R178 tolerated. The statement included no further instructions for brace use. R178's care plan dated 7/3/25, order report dated 8/8/25, and tasks dated 8/13/25, were reviewed and did not include R178's use of a right lower extremity brace. R178's Therapy to Nursing Communication dated 8/13 (with no year included), indicated R178 should wear a right ankle foot orthosis (AFO) brace for greater than four hours a day when up in the wheelchair, and skin should be checked when taking the brace off and putting it back on. During an interview and observation on 8/13/25 at 9:50 a.m., R178 was observed sitting in his wheelchair in his room with an AFO brace on his right lower extremity. Nursing assistant (NA)-I stated R178 required a total assist from nursing staff, and he had helped R178 get ready this morning. NA-I stated R178 had a brace for his right foot that he wore every day, only when R178 was out of bed. NA-I confirmed he had received education on how to apply the brace but was unable to find where the instructions were that confirmed when the brace was to be applied. During an interview on 8/13/25 at 10:31 a.m., the director of therapy (DOT), a physical therapy assistant, stated R178 was being seen by physical therapy earlier this year but was discharged at the end of May. The DOT confirmed R178 was not being seen right now by therapy. The DOT stated therapy had helped to procure the AFO brace for R178 but would need to look into what the discharge instructions were for the use of the AFO. At 12:42 p.m., the DOT stated she had reviewed R178's medical record and was unable to find the initial order for the use of the right AFO brace. The DOT stated she had found the attestation statement dated 7/2/25 saying staff were to continue using the brace but could not find the original order. The DOT stated she was supposed to ensure that when therapy had new orders for brace use, this was added to the resident's care plan, but after reviewing the medical record, this had not occurred. During an interview on 8/13/25 at 11:44 a.m., licensed practical nurse (LPN)-A confirmed that she had received education from therapy staff on when R178 was to use his AFO brace. LPN-A stated R178 was to have his right AFO brace applied when he was out of bed. LPN-A confirmed she had reviewed R178's medical record and could not find that the instructions for the use of the right AFO brace had been added to R178's plan of care. During an interview on 8/14/25 at 1:39 p.m. with the director of nursing (DON) and the DOT, the DOT confirmed the therapy to nursing communication form referenced above was from 8/13/25 and stated staff should be applying the brace when R178 was up in the wheelchair and removing it when he is back in bed. The facility's Comprehensive Care Planning policy dated 10/22, indicated the resident's comprehensive care plan would describe the offered services the resident needed to attain or maintain their highest practicable wellbeing.

Based on observation, interview and record review, the facility failed to update the plan of care 1 of 1 resident (R154) observed for position and mobility. In addition, the facility failed to revise and update a comprehensive care plan for 1 of 1 resident (R222) who had a history of resident-to-resident incidents. Findings include: R154’s quarterly MDS dated [DATE], identified mild cognitive impairment, used a wheelchair, and had impairments on one side to upper and lower extremities. The MDS lacked identification of an adaptive device such as a brace or ankle-foot orthosis (AFO). R154’s orders from admission through 8/15/25 were reviewed and lacked orders for the use of an adaptive device such as a brace or AFO. R154’s occupational therapy and physical therapy evaluations and treatment plans dated 5/6/23, lacked documentation pertaining to an AFO. R154’s provider visit dated 5/8/23, indicated an initial assessment and plan of care related to a history of stroke, and identified R154’s left side was flaccid and an AFO was in place. R154’s provider visit dated 6/5/23, identified R154 used a left boot for foot drop and required a Hoyer lift for transfers. The documentation lacked recommendations to continue to wear a brace on the LLE. R154’s progress notes dated 10/16/23, indicated ibuprofen was administered for pain in the right lower leg and a brace was removed due to pinching. R154’s care plan initiated on 7/25/24, identified a self-care deficit related to hemiplegia, impaired balance and limited mobility. A goal was set for R154 to maintain a current level of function and identified interventions to use a left leg brace for positioning. The plan also identified intervention for dressing with an assist of one staff to apply a left leg brace every morning and take off at night for positioning and protection. A provider visit dated 7/21/25, listed R154 had a diagnosis of left foot drop from 11/11/24 through present and lacked information related to AFO. R154’s progress notes dated 5/5/23 through 8/13/25, were reviewed and lacked documentation related to a left leg brace/AFO. During an interview on 8/12/25 at 9:41 a.m., registered nurse (RN)-F stated R154 wore the left leg brace for positioning. During an interview on 8/12/25 at 1:49 p.m., R154 stated the brace didn’t fit anymore, and they were not wearing it today. During an interview on 8/12/25 at 2:00 p.m., licensed practical nurse (LPN)-E stated R154 was supposed to wear a brace on the left leg, but only when up in the wheelchair. LPN-E stated R154 told staff the brace was bothersome and sometimes they refused to wear it, but R154 had the right to refuse the brace because it was uncomfortable to wear and because it was R154's choice. LPN-E stated therapy assessed the brace a couple of times, and the brace was appropriate for use. During an observation on 8/13/25 at 7:43 a.m., R154 was in bed, and two braces were in the corner of the room on top of a box. R154 stated the brace didn’t fit them anymore, it caused pain, and it hadn’t been worn all week. During an interview on 8/13/25 at 8:12 a.m., nursing assistant (NA)- G stated R154’s Kardex (NA care plan) had not been reviewed but they were aware there was a leg brace on the floor. Sometimes R154 wore it, but most days R154 refused to put it on, and the nurse was notified. During an interview on 8/13/25 at 11:58 a.m., occupational therapist (OT)-J stated R154 had been working with OT since 10/24/25, and was currently working with OT for support and mobility for the motorized wheelchair. OT-J was not aware of a left leg brace. During an interview on 8/13/25 at 12:54 p.m., director of therapy (DOT)-G stated R154’s brace was for foot drop and because R154 was no longer ambulating it was no longer appropriate. DOT-G stated it was likely R154 came to the facility with the brace and stated that type of brace could only be worn a short time, or it could cause skin issues, and it should have been assessed. During an interview on 8/13/25 at 3:27 p.m., family member (FM)-T stated the brace was brought from a previous facility. R154’s progress note entered by the nurse manager dated 8/13/25, identified R154’s admission orders lacked documentation for the diagnosis, purpose, or function of an AFO. Furthermore, the note identified therapy assessed R154 and found the AFO was not clinically or functionally purposeful and therefore, no order was received from a provider. The AFO was determined to be in place per patient preference only and a family member confirmed R154 had the AFO for years and wore the AFO while ambulating prior to admission, however, had been unable to ambulate since admission to the current facility. The provider was updated related to the use and function of the AFO and determined no clinical indication for use, stating no need for AFO. During an interview on 8/14/25 at 12:01 pm., licensed practical nurse (LPN)-E stated R154’s hadn’t worn a brace/AFO for a while and that the order must have been discontinued. LPN-E confirmed there was no active order for a brace/AFO and when she called for a new order the nurse practitioner (NP) told LPN-E the brace was no longer appropriate because R154 wasn’t ambulating and that the brace should be removed from the care plan. R154’s family member was contacted and confirmed R154 brought the brace from a previous facility and wore it only when ambulating. LPN-E confirmed putting the brace on the care plan and that the care plan was incorrect. During an interview on 8/14/25 at 2:57 p.m., director of therapy (DOT) stated the brace for R154 was assessed in May of 2023 for about a month to ensure it wasn’t causing any skin issues. Because R154 was not standing or ambulating the brace wasn’t recommended for use by therapy, it was R154’s preference to wear it. The brace was then assessed for fit and skin issues in May of 2024 as R154 indicated it was causing pain. During an interview on 8/14/25 at 3:21 p.m., physical therapist (PT)-K stated a brace or AFO would need a provider order and therapy would assess the fit. Because R154 required a Hoyer lift and not ambulating the brace would not be appropriate. PT-K stated it was most likely that R154 received the AFO from a previous facility when ambulating. PT-K reviewed R154’s therapy records and confirmed records reviewed from May 2023 lacked documentation regarding any assessment of a brace or AFO upon admission but could confirm the AFO was assessed a year later in May of 2024. During an interview on 8/14/25 at 4:36 p.m., the director of nursing (DON) stated R154's brace was brought from a previous facility, and it was R154’s preference to wear the brace/ AFO. DON verified no provider orders were ever written for the use of the brace/AFO because there were no indications for its use since R154 no longer ambulated. The DON stated R154 chose to be in bed most days and preferred not to wear stockings, so the brace/AFO would be more of a risk than benefit because of the rigidity of the brace and the risk of skin breakdown. The DON stated care plans were created with input from the floor nurse and recommendations made by therapy. The recommendations were discussed with the resident and if the resident agreed the interventions were added to the care plan. The DON confirmed that the expectation was that if a care plan could not be followed or interventions were no longer working the nurse should be notified and the care plan updated. R222’s annual Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment and did not have behaviors. R222 had impairment to both lower extremities and required setup or clean-up assistance for eating, substantial/maximal assistance for transfers, and independent with wheelchair mobility. R222’s diagnoses included aphasia, non-Alzheimer’s dementia, and anxiety. R222’s care plan focus area behavior/mood dated 7/7/25, included interventions dated 1/23/25 which directed staff to prevent opportunities for physical aggression, which may include considering proximity to others at meals, during activities, in the hall, and when moving throughout the unit and dated 7/7/25 which directed R222 to sit at the same table and spot daily and other residents may sit across from R222 but not next to her. R222’s progress notes indicated: -1/16/25, resident had increased behaviors and was combative with another resident and was removed from the common area for her safety. -1/20/25, resident was moved to another floor, and resident and family agreed with the move. -Further progress notes did not mention any other resident-to-resident incidents. R222’s Associated Clinic of Psychology (ACP) Progress Note dated 1/17/25, indicated the facility informed ACP R222 struck another resident on the wrist. The progress note indicated R222 did not recall striking another resident, denied interpersonal stressors, fearfulness, and anger, and may benefit from behavioral monitoring. The progress note encouraged staff efforts to prevent opportunities for physical aggression, which may include considering proximity to others at meals, during activities, in the hall, and when moving throughout the unit. R222’s ACP Progress Note dated 7/15/25, indicated R222’s mood and behaviors appeared “largely stable today”. During observation on 8/11/25 at 11:39 a.m., R222 attended an activity, and residents were on both sides of her within arms’ reach. During observation on 8/11/25 at 12:36 p.m., R222 sat at a square table with three other residents. Residents were within arms’ reach. During interview on 8/13/25 at 1:43 p.m., nursing assistant (NA)-K stated they looked at the electronic care plan to know information about a resident. During observation on 8/14/25 at 8:34 a.m., R222 sat at the end of a table with two other residents within arms’ reach for breakfast. During interview on 8/14/25 at 9 a.m., NA-H verified R222 sat within arms’ reach of other residents and stated R222 had no special interventions in the dining area. R222 stated there were certain people R222 did not like to sit near, such as those who shouted. NA-H stated they verbally communicated to other staff who R222 liked or did not like to sit next to, or other staff already knew about R222’s seating preferences. During interview on 8/14/25 at 10:43 a.m., licensed practical nurse (LPN)-G stated R222 did not have physical altercations with other residents and more often yelled at other residents when behavioral. LPN-G was not aware of the care planned interventions for R222 to not sit next to other residents and only across from other residents. LPN-G confirmed R222 sat next to other residents in the dining area. During interview on 8/14/25 at 5:00 p.m., the director of nursing (DON) stated it was important to honor R222’s seating choices, protect R222, and make sure staff implemented care planned interventions. The DON was not aware of R222’s resident-to-resident incident history and would look further into R222’s history and care planned interventions. The DON stated the interdisciplinary team (IDT) worked together to review and update resident care plans. During a follow-up interview on 8/15/25 at 8:09 a.m., the DON stated R222 no longer engaged in aggressive behaviors, was seen by ACP, and was going to discontinue the intervention(s). The facility’s Comprehensive Care Planning policy dated January 2024, directed staff to develop, review, and revise each resident’s comprehensive care plan based on the results of the comprehensive assessment. The policy directed staff to update the care plan when a problem, goal, or approach was no longer appropriate or resolved.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., nail care) was completed and provided to reduce the risk of complication (i.e., infection, skin scratches) for 1 of 1 residents (R87) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R87's annual Minimum Data Set (MDS) assessment, dated 6/14/25, identified R87 had moderately impaired cognition with physical behavioral symptoms (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurring 1-3 days that do not put resident at significant risk for physical illness or injury and do not significantly interfere with resident's care or participation in activities or social interactions. MDS identified rejection of care was noted 1-3 days during look-back period and there were no changes in behavioral symptoms since last MDS assessment. MDS identified R87 was dependent on staff assistance for shower/bathing needs and required setup/cleanup assistance from staff for personal hygiene needs. R87's care plan, printed 8/14/25, identified R87 required assist of staff for bathing/showering, trim and clean nails on bath days and as needed, and report any changes to the nurse, and for personal hygiene was independent and offer assist of 1 staff as needed. Furthermore, the care plan indicated the resident was resistive to accepting showers from specific staff members with the following interventions: allow resident to make decisions about treatment regime; if resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again; provide consistency in care to promote comfort with ADLs. R87's progress notes reviewed for 7/10/25 to 8/13/25 and indicated the following: -8/5/25: weekly skin evaluation completed and residents' skin intact. No other comments.-7/24/25: the resident refused skin evaluation. Education/encouragement provided to resident regarding skin evaluation, with a comment of resident refused shower. -7/17/25: weekly skin evaluation completed and residents' skin intact. No other comments.-7/10/24: weekly skin evaluation completed and residents' skin intact. No other comments.The progress notes lacked any evidence of offering R87 nail care or refusals of nail care. During interview and observation on 8/11/25 at 1:52 p.m., R87 was observed to have long fingernails that were about a quarter inch long with dark colored debris underneath them. R87 stated, no one has done anything with them for a while.they should do that. R87 stated staff trim his fingernails for him. During an observation on 8/13/25 at 10:14 a.m., R87 was observed ambulating with a walker in the hallway. R87's fingernails were observed to long with dark colored debris underneath them. During an interview on 8/13/25 at 10:29 a.m., licensed practical nurse (LPN)-I stated they were familiar with R87. LPN-I stated nail care was to be done on shower days, and the nursing assistants provided the nail care unless a resident was diabetic, then a nurse trimmed the resident nails. LPN-I stated there was no place in the electronic medical record where it was documented that nail care was completed including on the skin assessment. LPN-I reviewed documentation for nursing assistants and verified that nail care was not documented. LPN-I stated again, I don't document anywhere when I do nail care. During an interview on 8/13/25 at 11:57 a.m., nursing assistant (NA)-M stated they were familiar with R87. NA-M stated R87 needed assist of 1 staff with cares and showers. NA-M stated nail care was done during showers typically but could be done anytime. NA-M stated R87 would refuse assistance at times. NA-M went and met with R87 to observe fingernails. NA-M stated R87 are kind of long, need to be cut, and have dark stuff under his nails. NA-M stated she would have thought they would have been trimmed during his shower last Thursday. R87 told NA-M that NA-M could cut his nails after lunch as lunch was just about to arrive. During an interview on 8/14/25 at 1:22 p.m., quality assurance registered nurse (QA) stated the expectation would be that a resident would be offered to have their nails trimmed during their weekly shower/bath at a minimum. QA stated if they noticed their nails needed to be trimmed in between that time they would reapproach them. QA stated, we don't document this as it is a standard of practice and it's routine. During an interview on 8/14/25 at 3:00 p.m., director of nursing (DON) stated the expectation regarding a resident's nails would be to follow the residents' preferences such as if they preferred to have longer fingernails, that would be ok but staff would support the resident to help keep the nails clean. DON stated she was unaware of a place where nail care was being documented in the electronic medical record but stated if a resident was continually refusing nail care, that would be documented in the EMR. A facility policy titled Activities of Daily Living (ADLs), dated August 2024, indicated a resident who is unable to carry out activities of dial living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview and document review, the facility failed to ensure a therapeutic recreation assessment was addressed in the electronic medical record (EMR) and care planned to ensure a resident was offered appropriate activities for engagement while at the care facility for 1 of 2 residents (R76) reviewed for activities. Findings include:R76 's admission Minimal Data Set (MDS), dated [DATE], indicated R76 was admitted to the care center on 7/22/25 and was cognitively intact. R76's Activity Interview for Daily and Activity Preferences, dated 7/24/25, included a question How important is it to you to listen to music you like? which indicated R76 answered Very ImportantR76's Therapeutic Rec/Life enrichment Assessment, dated 7/24/25, which had boxes to fill in resident information such as past work experience/professions, religious preferences and current or past interest and hobbies, was left blank with will enter info 7/26/25 typed in to the first blank box of the assessment. A completed paper form of the same assessment was received during survey on 8/14/25 with a date of 7/24/25.R76's care plan, dated 8/13/24, lacked an activity section used to inform staff of R76's activity preferences and goals.R76's electronic medical record lacked evidence of life enrichment activities being offered or provided to R76. During an interview on 8/11/25 at 4:18 p.m., R76 stated he would like a radio in his room to keep him entertained as he does not like group activities. R76 stated he informed a few different facility staff members he would like a radio however never heard back. R76 stated, you ask and things never happen.During observation on 8/12/25 at 3:01 p.m., R76 was sitting in his wheelchair in his room, no music or television on in his room, asleep in his wheelchair. During observation on 8/13/25 at 11:16 a.m., and again on 8/14/25 at 8:18 a.m., R76 was sitting in a quiet room, asleep in in his wheelchair without any television, music or other type of activity or stimulation. During an interview on 8/14/25 at 8:28 a.m., the Director of Therapeutic Recreation (D-TR) stated the initial therapeutic recreation assessment was divided between the three therapeutic recreation staff, stating the department was a bit short staff but they tried to ensure everyone was assessed and care planned for appropriate activities. The D-TR stated the department had plenty of leisure activities for residents, including radios, which should be discussed with the resident during the initial assessment. During a follow up interview on 8/14/25 at 9:28 a.m., the D-TR confirmed R76's initial therapeutic recreation assessment in the EMR was blank and the care plan lacked an activities section. The D-TR stated she spoke with R76 that morning, brought him a radio and apologized for the delay. The D-TR also stated she completed his therapeutic recreation assessment. A facility policy titled Activities, dated 10-2024, indicated the admission assessment for therapeutic recreation should be completed within 14 days of admittance to the care facility. The policy further identified the activities department was an integral part of interdisciplinary care planning.

Based on observation, interview, and document review, the facility failed to implement interventions to ensure hearing aids were routinely applied or offered daily for 1 of 1 resident (R20) reviewed who had severe hearing loss. Findings include: R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 with intact cognition, did not reject cares, required hearing aids, and diagnoses of paralysis due to a stroke affecting his non dominant side, hepatitis, seizures, anxiety, and depression.R20's care plan (CP) dated 5/1/25, identified HEARING LOSS: Resident has bilateral hearing loss with Goal of Staff to assist res with placement of hearing aids in bilateral ear.During observation and interview with R20 on 8/11/25 at 1:38 p.m., R20 was lying in bed without hearing aids. R20 asked State Surveyor several times to speak louder. R20 stated he did not know where his hearing aids were. R20 stated, I need to have my hearing aids to hear. No one told me where they are.During interview with nursing assistant (NA)-B on 8/12/25 at 2:06 p.m., NA-B stated expectation of nursing assistants to look at resident care sheet to inform them of what assistance was needed, bath or shower days, oral status, bowel and bladder status, rehabilitation needs and miscellaneous information for each resident in addition to receiving verbal report from outgoing shift. NA-B stated I put hearing aids in if the care plan tells me to. [R20] used to have them. NA-B walked to R20's room and looked around, It is not here. I did not put them in this morning and stated she did not inform the nurse of missing hearing aids. NA-B stated she could not remember when the last time she saw R20's hearing aids. Could have been a few weeks or last month. I don't know.During interview with registered nurse (RN)-I on 8/12/25 at 2:18 p.m., RN-I looked in R20's electronic medical record (EMR) and said, I see it in the care plan. It does say he has hearing aids. RN-I walked to R20's room and looked around and said, not in there. RN-I said she did not check with R20 at start of shift to see if he had his hearing aids. I should have. He went whole day without them. I don't have them in the medication cart either. I do not know where they are. I did not receive report or information that they were missing or put somewhere.During interview with licensed practical nurse (LPN)-C on 8/12/25 at 2:33 p.m., LPN-C stated as her role of nurse manager she had possession of R20's hearing aids. LPN-C stated, I have them in my office. I have had them a couple weeks. LPN-C looked in R20's EMR and verified there was no communication with R20 or staff to inform them of location of R20's hearing aids. LPN-C stated, I forgot to put in note. It should be in the care plan where the hearing aids are. I should update the care plan, so staff know.During interview with Director of Nursing (DON) on 8/13/25 at 2:24 p.m., DON verified R20's EMR failed to identify LPN-C having secured his hearing aids and providing report to staff or to R20 verbally or in a progress note of this action.Facility policy on quality of care was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure residents had received ordered meals to increase calorie intake and weight per provider orders for 1 of 5 resident (R214) reviewed for nutrition and weight loss.Findings include:R214's comprehensive Minimum Data Set (MDS) assessment dated [DATE], identified R214 had intact cognition with no hallucinations, delusions, behaviors or rejection of care present. R214 was dependent on staff for activities of daily living (ADL's) and needed assistance from staff for set up/clean-up for eating. Pertinent medical diagnoses included traumatic brain dysfunction, quadriplegia (a medical condition described as paralysis of all four limbs), diabetes melilites (DM), osteoporosis, cerebrovascular accident (CVA--a sudden interruption of blood supply to the brain that caused brain cells to be deprived of oxygen and nutrients which led to brain damage, loss of function or death), seizure disorder, and malnutrition. R214 had one, stage three and one stage four pressure ulcer as well as one moisture associated skin damage (MASD) wound. R214's assessment documented their height as 66 inches and 128 pounds.R214's provider orders dated 10/14/24, identified a consistent carbohydrate diet, regular texture with thin consistency.R214's weight summary report identified on 7/1/25, R214's weight was 131.1 pounds and on 8/1/25, they weighed 123.1 pounds, a difference of 6.10% weight loss which indicated severe weight loss according to the Centers for Medicaid/Medicare Services (CMS).R214's care plan last reviewed on 5/17/25, identified a self-care deficit and they required total assist of one staff with eating. Additionally, nutrition was identified as a focus with interventions including explain and reinforce the importance of maintaining the diet ordered, encourage compliance, explain the consequences of refusals as it related to obesity/malnutrition risk factors. Food and beverage preferences were small warm milk for breakfast with cornflakes, no lactose in milk/cheese/sour cream/yogurt/pudding. Staff were directed to monitor and record/report to provider any signs of malnutrition, muscle wasting or emaciation. The guidelines for staff were significant weight loss: three pounds in one week, greater than five percent in one month, greater than seven and on half percent in three months, greater than ten percent in six months. Staff to provide supplements as ordered: Argiment (a nutritional supplement) twice daily, ProSource 30 cubic centimeters (cc) three times per day, a sandwich at bedtime and drink of choice, and ensure this was given twice daily. Staff were to provide snacks as needed and as requested, provide and serve diet as ordered, monitor intake, and record every meal. Registered dietician to evaluate and make diet changes recommendations as needed.R214's Nutrition Screen and assessment dated [DATE], identified high risk nutritional status related to multiple pressure ulcers, bilateral wounds, and sacral wounds. R214's diet order was consistent carbohydrate diet, regular textures, thin liquids, lactose intolerant. R214 was mostly independent with set up and assist as needed. R214 liked warm milk with his cornflakes in the morning. R214 spoke Spanish and the kitchen was contacted about menus in Spanish. Nutritional supplements were identified as Argiment twice a day, Prosource 30 cc three times a day, peanut butter and jelly every day. A box labeled unintentional weight loss in past three months was marked YES and documented weight on 5/1/25 was 127.9 pounds and on 4/1/25 weight was 129.8 pounds. R214's goal weight was 145 pounds and had a body mass index (BMI) of 20.6.R214's Nutrition Screen and assessment dated [DATE], identified high risk nutritional status for skin healing. R214's diet order was consistent carbohydrate diet, regular textures, thick liquids. R214 liked warm milk with their cornflakes in the morning. Resident was independent with eating. A box labeled unintentional weight loss was marked NO and indicated weight on 8/1/25, R214 was 123.1 pounds and had a BMI of 19.9. Goal weight was set at maintain weight. A note in the comment section read Gradual weight loss. During an observation and interview on 8/13/25 at 10:13 a.m., R214 had no breakfast tray in the room and dining aid (DA)- B stated breakfast was finished today at 9:15 a.m., all meals were served and pointed to the dining cart pushed back against the wall.R214's Nutrition Amount Eaten/Drank dated 7/31/25 through 8/14/25, indicated the resident refused breakfast on 8/12/25 and refused all three meals on 8/13/25.During an observation and interview on 8/13/25 at 1:30 p.m., R214 was in the dining room seated in a wheelchair. Nursing assistant (NA)-G brought over a tortilla and beans. R214 stated breakfast was never delivered. He stated the aid came in for repositioning at 8:00 a.m., and the meal was requested but never received. R214 identified NA-G as their assigned aid.During an interview on 8/13/25 at 1:31 p.m., NA-G stated R214 didn't generally eat breakfast and was unsure who was supposed to pass the tray, but then stated it was busy, and two rooms did not get trays. NA-G stated the other aid was supposed to pass the trays and they would pick them up.During an interview on 8/13/25 at 1:33 p.m., registered nurse (RN)-A was standing at the medication cart and stated they were not sure who was supposed to pass room trays today.During an interview on 8/14/25 9:45 a.m., the administrator stated if the facility heard a resident wanted a meal staff would get them food. Anyone could call down to the kitchen and get a meal at any time. The staff work closely with the kitchen, a dining ticket could be reprinted, and a new meal could be delivered. The administrator was unsure what would happen if a resident was unable to call the kitchen or advocate for themselves and stated the expectation was that all residents received their ordered meals and that the dining ticket matched what was served.During an interview on 8/14/25 at 10:53 a.m., registered dietician (RD)-L stated R214 was trialing many interventions for weight gain and wound healing. R214 received warm milk and cornflakes for breakfast every day and had agreed to try scrambled eggs. R214 accepted a new supplement this morning to replace the Ensure and has agreed to the new supplement three to four times a day. RD-L stated it was very important R214 received meals and supplements for weight gain and wound healing and was surprised R214 hadn't gained weight with all the interventions and supplements in place.During an interview on 8/14/25 at 11:18 a.m., licensed practical nurse (LPN)-F stated all aids had assigned groups and if they were new the other aids would explain their duties at the start of the shift. LPN-F was not aware of any residents that hadn't received a meal, but ultimately the aid assigned to the group of residents would be responsible for passing the tray.During an interview on 8/14/25 at 12:20 p.m., licensed practical nurse (LPN)-E stated two aids split their assigned group and one passed the trays and the other picked up the trays. There was no document that assigned this task, the nursing assistants communicated the duties. It was very important that residents received their meal trays because everyone needed to eat for weight gain and wounds. The expectation was that staff deliver all meals and document all refusals. LPN-E stated the aid that documented R214 refused breakfast on 8/12/25 and all three meals on 8/13/25 needed education on documentation and confirmed the documentation for this meal was incorrect. A policy, Meals Service dated 1/25, identified the purpose was to ensure all meals are served timely and proper food temperatures and maintained. To ensure that residents have the assistance needed to consume their meals. Procedure: Identify each resident. Check the diet card against the items on the tray for accuracy and food preference. Replace missing food items if necessary.

Based on observation, interview and document review the facility failed to follow care planned interventions to prevent re-traumatization for 1 of 1 resident (R6) reviewed for trauma informed care who was diagnosed with post-traumatic stress disorder and had identified triggers.Findings include: R6's admission Minimal Data Set (MDS), dated [DATE], identified R6 admitted to the care center on 6/25/25 and had multiple medical conditions including anxiety, major depressive disorder, bipolar, post-traumatic stress disorder (PTSD), schizophrenia and traumatic brain injury. R6's brief interview for mental status (BIMS) assessment, dated 7/1/25, indicated R6 was cognitively intact. R6's trauma history assessment, dated 7/1/25, identified R6 had a history of sexual abuse by males at a young age and could not be in the same room as another male with the door closed. R6's care plan, dated 7/1/25, indicated R6 reported childhood sexual abuse at the hands of two older males, making him distrust the majority of males he has worked with since this event. An intervention, dated 7/1/25, indicated R6 preferred to avoid male caregivers due to past abuse. During an interview on 8/11/25 at 1:37 p.m., R6 stated he had been having some anger issues due to feeling like he was not getting the physical care he needed and not feeling like facility care staff were taking his PTSD seriously. R6 stated there were still males entering his room alone. R6's Associated Clinic of Psychology (ACP) note, dated 8/6/25, indicated R6 was very angry with anger issues. The ACP provider stated R6 could not tolerate male staff in his room and preferred female caregivers and physical and occupational staff. The note indicated honoring female staff was important for staff safety. During observation on 8/11/25 at 1:10 p.m., an unnamed male entered R6's room with his lunch tray and closed the door after he entered to discuss R6's lunch choices with him. During an interview on 8/13/25 at 7:54 a.m., nursing aide (NA)-O (a male aide) stated he often helped R6 when he need[ed] it. NA-O stated R6 was fairly independent with his activities of daily living but at times would need assistance in the bathroom and would call for help. During an interview on 8/13/25 at 9:17 a.m., NA-P stated she had been working at the care facility for about one year and was only aware of one resident on the unit (not R6) who had a preference for female caregivers. During an interview on 8/13/25 at 7:58 a.m., NA-Q stated she worked in a different unit but would come over to assist another resident (not R6) who preferred female only caregivers. NA-Q stated there were no other residents on the unit who only wanted female caregivers. During an interview on 8/13/25 at 10:42 a.m., registered nurse (RN)-J, referencing the care sheets (used by staff which contained resident specific information such as diagnoses, bath days and any special treatment such as wound care, oxygen use or preference for specific caregivers), and stated there was only one resident on second floor (not R6) that had a preference for female only caregivers. The sheets lacked any information regarding R6 preferring female only caregivers.During an interview on 8/13/25 at 11:00 a.m., R6 stated I don't feel safe at times further elaborating that male staff continued to come into his room despite him voicing his past trauma and distrust of men. During an interview on 8/14/25 at 10:51 a.m., nurse manager and RN-K confirmed the careplan and kardex (aide care plan) identified R6 as preferring female only staff, stating it would be expected that staff were aware and following R6's preferences.During an interview on 8/14/25 at 11:25 a.m., R6's ACP provider stated R6 often made threatening statements, and his preference for not wanting med in his room was associated with his history of abuse. The ACP provider stated, for his [R6] well-being and staff safety, males should stay out [of his room]. A facility policy on behavioral management and trauma informed care was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure medication errors were prevented for 2 of 2 residents (R138, R30) observed during medication administration. This resulted in a medication error rate of 7.14% (percent) with two errors out of 28 opportunities. Findings include:R138R138's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of anemia, atrial fibrillation, heart failure, hypertension, hyponatremia, hyperlipidemia, non-Alzheimer's dementia, and malnutrition. The MDS indicated R138 had a feeding tube.R138's provider order dated 5/6/25, indicated R138 required potassium chloride (used to treat and prevent low potassium levels in the body) ER (extended-release) 10 mEq (milliequivalents) via PEG-tube (percutaneous endoscopic gastrostomy tube; a tube passed into the stomach through the abdominal wall) one time a day with instructions to dissolve in water.During observation and interview on 8/13/25 at 8:14 a.m., licensed practical nurse (LPN)-H prepared R138's medications. All tablets were crushed, including potassium extended release, and each medication was placed in separate medication cups. LPN-H added water to each medication cup and flushed R138's PEG-tube before medication administration, between each medication, and after medication administration. LPN-H verified they crushed all tablets given to R138 and knew what medications could or could not be crushed based on nursing school and a nursing drug book.During interview on 8/14/25 at 10:39 a.m., (LPN)-G stated extended-release potassium should be dissolved in water if by the book.R30R30's significant change in status MDS dated [DATE], indicated R30 had intact cognition and diagnoses of benign prostatic hyperplasia and kidney disease.R30's provider order dated 4/10/25, indicated R30 required two capsules of tamsulosin hydrochloride (helps to improve urination and reduce discomfort for men with enlarged prostate.) 0.4 mg (milligrams) by mouth one time a day and specified to give after a meal.During medication administration on 8/13/25 between 9:13 a.m. and 9:28 a.m., registered nurse (RN)-B prepared R30's medication which included tamsulosin. RN-B entered R30's room and R30 was still eating breakfast. R30 took all medications and continued his meal.During interview on 8/13/25 at 11:59 a.m., RN-B stated provider orders indicated what medications were given before, during, or after meals. RN-B reviewed R30's orders and stated R30 stated he wanted all his medications at the same time during previous interaction. RN-B stated they would update the provider, and staff would update the care plan.During interview immediately after above interview, LPN-C expected staff to honor resident choices for medications and update the provider.During interview on 8/14/25 at 5:00 p.m., the director of nursing (DON) expected staff to dissolve instead of crush potassium chloride extended release. The DON expected staff to follow the doctor's orders and update a provider if a resident preferred to take medication in a way different than ordered.During interview on 8/15/25 at 7:16 a.m., the consultant pharmacist (CP) stated crushing potassium extended release was advised against or discouraged due to compromising the extended-release function of the medication. CP stated abrupt release of potassium could cause irritation of the GI (gastrointestinal) tract. The CP stated tamsulosin given during a meal instead of 30 minutes after a meal decreased the medication effectiveness by potentially decreasing the absorption rate and peak level of the medication. Tamsulosin given after a meal decreased side effects, such as low blood pressure and dizziness.The facility's Medication Administration policy dated May 2025, directed staff to verify resident name, medication name, form, route, and time. The policy directed staff to administer medications per provider orders and administer medication as ordered in accordance with manufacturer specifications.

Based on interview and document review, the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 resident (R1) reviewed who had post-traumatic stress disorder ([CONDITION(S)]). R1 suffered harm when R1 expressed they were fearful after being cared for by nursing assistant (NA)-A and NA-A was allowed to provide care again creating re-traumatization for R1 resulting in fear of not being able to get help, fear of being targeted by NA-A, increased panic, and crying. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment, did not reject cares, had other behaviors not directed towards others 1-3 days during the assessment period and required extensive staff assistance with bed mobility, dressing and hygiene. The MDS identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 10/27/22, included a risk for abuse and directed staff to provide a safe environment for resident and others. R1's care plan dated 10/27/22, also identified, Trauma Informed Care: Resident has adverse emotional symptoms resulting from trauma. The goal was listed as, The resident will receive care that is tailored to avoid causing re-traumatization. Staff was directed to reference the activity of daily living (ADL) care plan for instructions specific to avoiding re-traumatization. R1's ADL care plan dated 10/20/22, instructed staff to, 2 Care givers at all times with cares, grab bars on bed, and assist of one for dressing, toileting and transfers. R1's care plan for communication related to mild cognitive impairment included staff to allow adequate time to respond, repeat as necessary, and to ensure a safe environment. R1's Psychosocial History and Comprehensive assessment dated [DATE], identified depression, [CONDITION(S)], and Somatization diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment identified a Trauma Care plan goal would be, The resident will receive care that is tailored to avoid causing re-traumatization. Intervention included, Reference ADL care plans for care instructions specific to avoid re-traumatization. When interviewed on 11/9/22, at 12:33 p.m. R1 stated she had several issues with nursing assistant (NA)-A. On 10/21/22, R1 had reported NA-A was neglectful of her needs, and was rude when providing cares, which caused her to fear care from R1. R1 stated staff told her NA-A would not care for her anymore. However, on 10/25/22, NA-A had walked into her room, She was mean, she turned me quickly in bed and I hit my head on the wall. I cried, it shocked me. R1 stated, I know it was on purpose, and after it happened, [NA-A] growled at her, Am I going to get in trouble again? R1 felt it was in retaliation for complaining about NA-A on 10/21/22. R1 stated NA-A has come back into her room since this episode when she wasn't supposed to. She is now fearful of putting on her call light to request help in case NA-A is the one to answer it and seeks further retaliation. R1 stated, on 11/2/22, she had put on her call light to go to the bathroom and NA-A came in, shut off her call light and told her she could not help her, and no one would help her. No one did come in her room again, and she was fearful of putting the call light back on. As a result, she urinated in her brief. Then on 11/7/22, she had put on her call light, and no one came for over an hour, NA-A came in and told her she had to urinate in her brief because there was no one to help her. Then on 11/8/22, during the night she had put on her call light to go to the bathroom, no one came, so she hollered for help and had to urinate in her pants again because of no help. R1 stated she had been told no one came to help because they always needed two caregivers to help her and at night, they never had two that could help her at the same time. A facility Vulnerable Adult Maltreatment Investigation Checklist dated 10/27/22, identified an interview with R1. Came in had to go to the bathroom, turned me over, banged me on my head the day before yesterday, now I suppose you're going to report me again, irritable, 'what do you want now' she was always grumbly. The statement went on to say, felt scared and vulnerable, I'm really afraid of what she might do, when I try to be nice to her, I'm just mocked. When interviewed on 11/9/22, at 12:03 p.m. NA-A stated she went in to care for R1 on 10/25/22, R1 had her legs off the side of the bed and when NA-A put R1's legs back on the bed and turned her over hitting R1's head on the wall. Then R1 had put her call light on again to get help to the bathroom, but NA-A was the only NA available and told R1 she would be back to help, but then got busy and forgot. Then on 11/2/22, R1 had her call light on, and NA-A answered it, but could not help at this time and told R1 to urinate in her incontinent brief if she didn't get back in time, which did happen. NA-A stated they were instructed not to go into R1's room after the 10/25/22 incident but has answered R1's call light since then because no one else does and thought they would get in trouble for not answering it. When interviewed on 11/9/22, at 2:50 p.m. the social worker (SW)-A stated R1 had told him she had concerns about care from NA-A, and felt NA-A was, rushed and rough. SW-A was aware R1 had [CONDITION(S)] but had not assessed what R1's triggers for re-traumatization would be. R1 had a private therapist and they had not reached out to find out what the triggers may be and how to avoid them. SW-A acknowledged not answering the call light, being rough or rushed may trigger R1. When interviewed on 11/9/22, at 3:20 p.m. registered nurse (RN)-C stated NA-A had been told not to care for R1 anymore after the 10/25/22, incident. Then, NA-A was told again after the 11/2/22 incident. NA-A was not to go in R1's room. RN-C did not know if NA-A was prohibited from entering R1's room after the 10/21/22 incident. When interviewed on 11/9/22, at 3:58 p.m. R1's private psychotherapist (TH)-A stated, When R1 was first admitted to the facility she had some [CONDITION(S)] and felt she had been kidnapped. Then R1 had the incident with NA-A on 10/21/22, and R1 was under the impression NA-A would not go in her room anymore. However, on 10/25/22, the NA-A told R1 they had gotten in trouble because of R1's reporting, then NA-A purposefully turned her roughly and hit her head. NA-A's presence has been threatening and R1 is very afraid. R1's history was that she was in an abusive situation before and felt she could not get help and is now feeling the same way. R1 is now having trouble focusing on recovery with NA-A around. R1 feels NA-A is targeting her and wants retaliation. It is her own trauma history that makes this scary for her and makes her feel punished by having to see the aide. In terms of trauma-informed care, when she can't get up on her own, this mimics the torture she had a as a child. It has complicated her care. In subsequent interview on 11/10/22, at 11:03 a.m. TH-A stated R1 had been calling for support more since the episodes with NA-A, she has feelings of panic, has been more tearful and crying which is not normal for her. It seems in direct response to the situation she finds herself in and is feeling more unsafe. Usually, we have weekly sessions and now it is every other day, if not daily. The Social Services Policy dated 11/1/22, indicated [NAME] Methodist shall provide to residents the necessary services to attain to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and individual care plan. The policy further indicated the facility staff would develop a person-centered care plan which includes approaches to care that are culturally competent and reflect the resident's preferences and goals for care. Additionally, the policy indicated the interdisciplinary treatment team (IDT) would provide ongoing monitoring and assessment of the interventions and may include monitoring for signs and symptoms of [CONDITION(S)].

Based on observation, interview, and record review, the facility failed to place a newly admitted resident who was not vaccinated for COVID-19 into quarantine and failed to ensure personal protective equipment (PPE) was used when direct care was provided for 1 of 4 residents (R263) who required transmission based precautions (TBP). This deficient practice resulted in an immediate jeopardy (IJ) when R236 was to be on TBP and staff did not follow the practice. In addition to the resident in immediate jeopardy, the facility failed to ensure staff consistently wore face masks covering the nose and mouth and eye protection to aide in preventing the spread of COVID-19 for 4 of 22 staff (NA-K, NA-J, NA-E and RN-L) observed for source control measures. In addition, the facility failed to perform hand hygiene when providing personal cares for 1 of 10 residents (R61) observed for personal cares. The IJ began on 9/27/21, at 1:56 p.m. when R263 was in the dining room, unmasked and close to other residents, physical therapy aide (PTA)-A did not wear gloves or gown, brought R263 to the therapy room and worked with her without wearing appropriate PPE. The administrator and director of nursing (DON) was notified of the IJ on 9/28/21, at 4:30 p.m. The facility implemented corrective actions on 9/29/21. The IJ was removed on 9/29/21, at 11:53 a.m., but noncompliance remained at the lower scope and severity level of a D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The current Center for Disease Control (CDC) guidance for COVID-19 with new admissions to long term care include: All unvaccinated residents who are new admissions or readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The guidance also requires staff to wear full personal protective equipment (PPE), including gowns, gloves, eye protection and an N95 or higher-level respirator for residents on the 14 day quarantine. R263's admission Minimum Data Set (MDS) dated [DATE], included severe cognitive impairment, had a [CONDITION(S)] and required extensive staff assistance for locomotion. R263 was not on isolation or quarantine for an active infection. R236's Admission Record identified R236 had been admitted on [DATE], and had not been vaccinated against COVID-19. R263's care plan dated 9/20/21, included, The resident requires transmission based precautions related to potential pre-admission COVID-19 exposure for the first 14 days from admission and/or an actual positive COVID-19 test result. Staff were directed, Follow DROPLET PRECAUTIONS when caring for this resident. R263's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Encourage patient to wear mask in common areas. Wear observation PPE with close contact. Socially distance resident at meal times, every shift until 10/4/21. R263's nursing assistant worksheet, 3 Gamble Group 1, dated 9/24/21, included R263 was to be on observation until 10/4/21. During observation on 9/27/21, at 1:56 p.m. R263 was in the dining room with other residents and was not wearing a mask. Physical therapy aide, (PTA)-A entered the dining room and took R263 to the therapy room and transferred her to an exercise table with no gown or gloves on. PTA-A assisted R263 with table exercises, then assisted up and ambulated R263 in the hallway around several other residents. R263 was never offered a mask to wear and PTA-A never put on a gown or gloves. During observation on 9/28/21, at 8:19 a.m. R263 was at the dining room table with another resident, neither resident wore a face mask for source control and they were not 6 feet apart. When interviewed on 9/28/21, at 8:29 a.m. RN-A stated R263 was on transmission based precautions (TBP) due to being a new admission that was not vaccinated for COVID-19. Further, stated there should be a sign on the door that allows the staff to know what TBP the resident is on and what PPE to use. The door to R236's room did not indicate she was on any sort of precautions. During observation on 9/28/21, at 9:23 a.m. PTA-B took R263 from the dining room into the therapy room and completed leg exercises without wearing a gown or gloves. Further, PTA-B ambulated R263 in the hallway using a walker and holding onto the gait belt while ambulating R263 in close distance of 5 other residents. R263 did not have a mask on throughout the therapy session. Directly after working with R263, PTA-B went into R500's room and completed exercises with the resident. PTA-B wore the same clothing, mask and eye protection as they did with R263. When interviewed on 9/28/21, at 9:45 a.m. PTA-B stated wasn't aware of R263 being on any type of precautions. Further, verified R263 should have worn a mask while out of the room and PPE such as a gown and gloves should have been worn while working with R263. During observation on 9/28/21, at 10:17 a.m. R263 was sitting in the TV room with 5 other residents with no mask on. All residents were closer than 6 feet apart. When interviewed on 9/28/21, at 11:00 a.m. the director of therapy stated the therapy staff should treat any resident on precautions in the room if able. Further, the director of therapy stated the therapists would know who is on precautions by a sign on the residents door. When interviewed on 9/28/21, at 11:10 a.m. registered nurse infection preventionist (RN)-B stated any resident admitted who was not fully vaccinated or unvaccinated, was to be placed on observation precautions and full personal protective equipment (PPE) was to be worn since the residents may have COVID-19, such as gown, gloves, mask, and eyewear. Secondly, RN-B stated, all observation and isolation rooms should have an isolation cart at the doorway with a TBP sign inside the drawer to indicate what PPE is to be used for the resident and what TBP the resident is on. Further, RN-B stated therapy should know who is on precautions and what PPE to use according to their treatment plan, There was no other communication to other departments except for the signs by the doors. R236 did not have a sign or cart by her bedroom door. RN-B confirmed R263 had not been vaccinated against COVID-19 and should have been placed on the 14 day quarantine, which should have been enforced by staff. During observation on 9/28/21, at 1:35 p.m. R263 was sitting in the TV room with no mask on with 5 other residents. All residents were within 6 feet of each other. When interviewed on 9/28/21, at 1:36 p.m. nursing assistant (NA)-A stated they were not aware R263 was still on quarantine precautions. NA-A stated R263 was cooperative and would wear a mask if asked. When interviewed on 9/28/21, at 1:38 p.m. RN-C stated they did not know why R263 had not been quarantined or encouraged to wear a mask while out of the room today. RN-C verified R263 should be quarantined to room and if needed to come out of room should be encouraged to wear a mask. When interviewed on 9/28/21, at 1:50 p.m. licensed practical nurse (LPN)-B stated they had not made any attempt to quarantine R263 in her room because, this is a dementia unit. The facility Screening and Surveillance of resident infection prevention policy dated 8/30/21, indicated the purpose of the surveillance of COVID-19 is to guide appropriate interventions and to prevent the spread of COVID-19. Further, indicated a resident that doesn't have a history of testing positive for COVID-19, or is not fully vaccinated, would be placed in a private room and be quarantined for 14 days. The PPE Requirements for Health Care Workers Infection Control Policy dated 6/28/21, indicated eye protection, masks, gowns, and gloves would be worn for residents with suspected or confirmed cases of COVID-19 by healthcare personnel. The IJ which began on 9/27/21, was removed on 9/29/21, after the facility implemented a removal plan which included the following actions: all residents on the affected unit were tested for COVID-19, the facility updated their observation policy, all residents on quarantine/isolation had signage placed on door, a yellow wrist band placed, staff were educated and notified of need for education prior to working next shift. Verification of implementation of the removal plan was completed by observation, interview and document review. During an observation on 9/28/21, at 8:45 a.m. nursing assistant NA-K was observed delivering meals wearing mask under nose his nose and was not wearing eye protection. When interviewed NA-K stated he had forgotten to put on his eye protection and knew his mask should be over his nose. During an observation nursing on 9/28/21 at 8:52 a.m. NA-J entered a resident's room with no eye protection. During an observation on 9/28/21, at 8:53 a.m. NA-E was observed without eye protection and entering residents room delivering meals. When interviewed NA-E stated she forgot to wear her goggles and was aware she needed them. During observation on 9/28/21, at 8:58 a.m. RN-L had goggles on down on the tip of her nose not covering her eyes. RN-L stated she had a hard time wearing the goggles closer to her face because the goggles would fall when she would look downward. RN-L stated she was educated on wearing the goggles to protect her eyes. R61's quarterly MDS dated [DATE], indicated R61 had a BIMS of 14 with intact cognition. The MDS also indicated R61 required extensive assistance for toileting and personal hygiene. During observation on 9/27/21, at 1:09 p.m. NA-L entered R61's room, donned gloves, removed R61's soiled incontinent brief, performed pericare, and applied barrier cream to the perineum. NA-L then without removing gloves or performing hand hygiene applied a clean incontinent brief, pulled the covers over R61, placed the television remote control on the resident, and pulled the bedside table to R61. Then NA-L removed her gloves and performed hand hygiene. When interviewed NA-L stated she should have removed her gloves and washed her hands between the dirty and clean tasks. During an interview on 9/30/21, at 1:54 p.m. the director of nursing (DON) stated staff should perform hand hygiene when going from dirty to clean during resident cares; this included after applying cream to a resident's bottom and groin. The DON stated staff should remove their gloves, wash their hands or use hand sanitizer, then put on new gloves before continuing with cares. The facility Hand Hygiene policy dated 6/1/19, indicated staff should perform hand hygiene after touching body substances and any potentially contaminated objects, such as dressings, bedpans, basins, clothing, or linen and so forth.

Based on interview and document review, the facility failed to ensure medications were administered per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure resulted in an immediate jeopardy (IJ) for R3 when she received another resident's (R4's) medications and had developed [CONDITION(S)] (low blood pressure) and [CONDITION(S)] (slow heart rate), and required treatment in the ambulance, emergency department and hospital to stabilize. The facility had implemented immediate corrective action, therefore the deficient practice is being issued at past noncompliance. The immediate jeopardy began on 3/19/21, when R3 received her medications along with R4's medications, required emergency medications and hospitalization , and was identified on 3/25/21. The facility administrator and assistant director of nursing were notified of the IJ on 3/25/21, at 11:22 a.m. The facility had implemented corrective action on 3/22/21, the deficient practice was corrected on 3/24/21, prior to the start of the survey, and was therefore Past Noncompliance. Findings include: R3's admission Minimum Data Set (MDS) dated [DATE], included severe cognitive impairment with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R3 required extensive assistance with most activities of daily living (ADL's). R3's care plan dated 2/11/21, included, a focus on CHF, staff were directed to give cardiac medications as ordered. R4's admission MDS indicated R4 was cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Medication Discrepancy Report dated 3/19/21, signed by assistant director of nursing (ADON)-B, indicated R3 was additionally administered R4's medications on 3/19/21, for the 8:00 a.m. medication pass, which included [MEDICATION(S)] 5 mg (a blood thinning medication), [MEDICATION(S)] triturate (short acting [MEDICATION(S)]) 100 mg and [MEDICATION(S)] (diuretic/water pill) 40 mg. The report included, LPN asked this writer [RN-D] to medicate [R3]. LPN then left for break. Upon return, she handed this writer 2 tote packages from her pocket. I incorrectly gave both packages of meds she handed to me thinking they were both for resident. She asked me to medicate one person. According to the American Heart Association, a normal blood pressure reading for an adult is a systolic (top number) reading that is below 120 and a diastolic (bottom number) reading that is below 80. A blood pressure would be considered low if under 90/60. A normal pulse is between 60-100. R3's Blood Pressure Summary dated 3/25/21, showed a 3/17/21, 9:03 a.m. morning blood pressure of 112/69 mmHg (millimeters mercury). Following the [MEDICATION(S)] overdose and [MEDICATION(S)] medication error, R3's blood pressure on 3/19/21, at 11:30 a.m. was 62/42 mmHg. R3's Weights and Vitals Summary dated 3/25/21, indicated on 3/18/21 at 10:33 p.m. R3's heart rate was 77 beats per minute (bpm). Following the [MEDICATION(S)] overdose R3's heart rate on 3/19/21, at 12:00 p.m. was 64 bpm. R3's progress note dated 3/19/21, at 12:16 p.m. indicated orders were received to send R3 to HCMC (Hennepin County Medical Center). R3's progress note dated 3/19/21, at 12:27 p.m. included, Patient received medication of [MEDICATION(S)] [blood thinner] 5 mg [milligrams], [MEDICATION(S)] triturate 100 mg, [MEDICATION(S)] [[MEDICATION(S)]] 40 mg at 1000 [10:00 a.m.] in error. She receives [MEDICATION(S)] 5 mg and [MEDICATION(S)] [extended release] 24 hour 25 mg QD [daily], Aspirin 81 mg as scheduled. Staff updated NP [nurse practitioner] and have orders to push fluids, monitor BP [blood pressure] & HR [heart rate] q [every] 15 [minutes], then q 30. Her BP was dropping and new orders have been received to send to HCMC. R3's progress note dated 3/19/21, at 1:01 p.m. indicated R3, was sent to HCMC by non-emergent 911, by stretcher. R3's HCMC ED (emergency department) to Hospital admitted d 3/19/21, indicated R3's heart rate was 40-60 on admission with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's HCMC Medicine Discharge Summary dated 3/20/21, indicated R3 required admission to the hospital with the following diagnoses; administration of incorrect medications, acute [CONDITION(S)] [low heart rate], [CONDITION(S)] [low blood pressure] and acute kidney injury. The summary under Hospital Course indicated, Acute [CONDITION(S)], resolved; [CONDITION(S)] to the 30's - 40's [bpm] several hours after receiving resident's [R4] [MEDICATION(S)] triturate 100 mg on top of her own [MEDICATION(S)] 25 mg. Improved with 0.5 mg [MEDICATION(S)] [advanced cardiac life support medication given for reversal of symptomatic [CONDITION(S)]] by EMS [emergency medical services/ambulance]. Since admission has had intermittent 3 second pauses [heart beat stopping] and short drops to the 30's [bpm], otherwise maintaining HR [heart rate] in the 50's to 60's. Per ED [emergency department] discussion with poison control, patient given 3 mg calcium gluc [[MEDICATION(S)]] x 2 [medication given to reverse beta-blocker toxicity]. R3's Nursing Home Visit Progress Note, dated 3/22/21, indicated R3 was seen by nurse practitioner (NP)-A in the facility for a post-hospitalization follow-up visit. R3's Assessment and Plan section of the note indicated 1. Medication administered in error, accidental or unintentional, subsequent encounter. A: Patient was administered another patient's medications by error on 3/19, resulting in ED visit for treatment and monitoring. She was discharged in stable condition. 2. AKI [acute kidney injury]. A: AKI likely secondary to erroneous administration of 40 mg [MEDICATION(S)]. Repeat BMP [basic metabolic panel blood lab] as above. P: BMP 3/31. 3. [CONDITION(S)] secondary to erroneous administration of 100 mg [MEDICATION(S)] triturate. Now resolved. HR [heart rate] has returned to baseline 60's-80's. P: continue usual dose of [MEDICATION(S)] 25 mg twice daily, hold for heart rate less than 55. When interviewed on 3/24/21, at 12:30 p.m. registered nurse (RN)-C stated, on 3/19/21, there were three nurses assigned to pass medications. The nurses obtain their resident's medications from a PassPort machine that dispenses medications in small envelopes containing each resident's medications, which are labeled with the resident name and the medications included on the envelope. Each nurse gets their own assigned resident's medications. However, due to room changes, sometimes they will get another nurses resident's medications and these need to be exchanged. RN-C indicated the facility did not have policy/procedure for this exchange. RN-C had received medications for R3 and R4 the morning of 3/19/21, however, these residents were assigned to licensed practical nurse (LPN)-B. RN-C handed the medication envelopes for R3 and R4 to LPN-B. When interviewed on 3/24/21, at 4:32 p.m. LPN-B stated on the morning of 3/19/21, she received R3 and R4's medication envelopes from RN-C and placed them in her pocket. LPN-B was training RN-D. LPN-B stated, she requested RN-D give R3 her medications and went on a break. Then when she returned from break, RN-D stated she could not find R3's medications. LPN-B realized she had them in her pocket and handed R3 and R4's medications to RN-C. LPN-B was not aware of any policy on how to manage medications if they were not dispensed to the correct nurse. LPN-B was aware she should not have placed them in her pocket. When interviewed on 3/24/21, at 1:27 p.m. RN-D stated on 3/19/21, she was training with LPN-B on the transition care unit (TCU). LPN-B had requested she provide R3 her medications and LPN-B went on break. RN-D went to the medication cart and was unable to find the medications for R3. LPN-B returned from break and when asked about R3's medications, LPN-B removed 2 envelopes of medications from her pocket and handed them to her. R3's envelope was on top. RN-C stated she compared R3's medication envelope with the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-D then noted R4's name on the second envelope and notified the assistant director of nursing (ADON) of her medication error. RN-D was not aware of any medication reconciliation policy/procedure for when a nurse is dispensed medications belonging to another resident. RN-D was aware she should have checked each medication against the MAR prior to administering them. During observation on 3/24/21, at 8:43 a.m. RN-C removed the medication tote from the PassPort machine for her medication cart and placed the tote in her medication cart and reconciled the medications and removed the envelopes for residents assigned to RN-E. RN-C then gave the envelops to to RN-E to place in the tote in her medication cart for storage until administration. When interviewed on 3/24/21, at 8:51 a.m. ADON-B stated, the expectation was, prior to administering medication the nurse should verify the 5 Rights which are right resident, right drug, right dose, right route and right time. ADON-B stated when obtaining medications from the PassPort machine, the nurse should look to see if any medications belong on a different cart/assigned to a different nurse, and place those directly into the correct tote, not in the nurses pocket. When interviewed on 3/24/21, at 12:23 p.m. the ADON-A stated, prior to administering medication the nurse should verify the, 5 Rights which are; right resident, right drug, right dose, right route and right time. ADON-A also stated the expectation of nursing staff in removing medications from PassPort is the nurse should take medications not belonging in the medication cart tote and give them to the correct nurse who then places them in the correct medication cart and tote and the medications should not be stored in a nurse's pocket. ADON-A stated the practice of LPN-B storing the medications in her pocket and giving them to RN-D for R3's medication administration was part of the medication error. She indicated training of nurses had been started to include the 5 rights for medication administration. When interviewed on 3/24/21, at 12:20 a.m. NP-A stated the facility immediately reported the medication error to her and after assessing R3's condition the decision was made to transfer R3 to the hospital. NP-A indicated the decision was based on R3's blood pressure and heart rate dropping to levels of concern, along with R3 having had inadvertently received [MEDICATION(S)] in the setting of her existing kidney condition. NP-A stated, Because of the error she [R3] needed a ride in the ambulance. NP-A stated, With a beta-blocker overdose a person could become so [CONDITION(S)] it could lead to potentially death, cardiac arrest, shock or organ damage. A call was placed to medical doctor (MD)-C on 3/24/21, at 4:02 p.m. MD-C returned call on 4/2/21, at 11:34 a.m. MD-C stated he was the attending facility physician for medical resident MD-B who was caring for R3 while hospitalized on [DATE]-[DATE], and stated he recalled working with R3 and treating her [CONDITION(S)] after R3 was in the ED. MD-C stated the a dose of [MEDICATION(S)] 40 mg in the setting of a patient who was [MEDICATION(S)] naive (not accustomed to receiving [MEDICATION(S)]) would have an expected outcome of a large diuresis (loss of fluid volume) which would potentiate [CONDITION(S)]. MD-C stated without aggressive treatment a patient with a beta-blocker overdose of what R3 was administered, could result in the possible outcomes of death, stroke, heart ischemia (damage to the heart caused by inadequate blood perfusion). When interviewed on 3/24/21, at 4:29 p.m. consulting pharmacist (CP)-A indicated he had been made aware of, and was familiar with the medication error involving R3. CP-A stated the [MEDICATION(S)] medication error would of, potentiated (made worse) the effects of the beta-blocker blocker by lowering R3's blood pressure due to the [MEDICATION(S)] causing a decrease in body fluid volume. The facility's Medication Administration: General Guidelines policy dated 12/7/16, included: 14. Medications supplied for one resident must not be administered to another resident. 17. Prior to administration, the medication and dosage schedule on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . If the label and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . If the medication is discontinued, outdated or unusable, remove the medication for proper disposal. The facilities Training Attendance Record, Standards of Practice in Administering Medications, showed the facility had begun training staff on the 5 rights of medication administration. Between 3/22/21, and 3/24/21, the facility had retrained 40 nurses on proper medication administration and had a plan in place to train the remaining nurses prior to start of their next shift. During interview on 3/24/21, at 1:27 p.m. RN-D stated she had received education from the facility on medication administration and the 5 rights of medication administration during the last week. During interview on 3/24/21, at 2:31 p.m. RN-F stated he had received education from the facility on medication administration and the 5 rights of medication administration during the last week. During interview on 3/24/21, at 2:39 p.m. RN-G stated he had received education from the facility on medication administration and the 5 rights of medication administration during the last week. The past noncompliance immediate jeopardy began on 3/19/21. The immediate jeopardy was removed and the deficient practice corrected by 3/24/21, after the facility implemented a systemic plan which included: training of all staff responsible for medication administration on the 5 rights of medication administration. A plan was made for medication competency checks and audits to ensure compliance. This was verified through interview and document review.

Based on observation, document, and interviews, the facility failed to maintain infection control measures related to the cohorting of coronavirus-19 (COVID) positive and negative residents for 2 residents (R2, R3) who were moved to the COVID unit without positive tests. This resulted in an Immediate Jeopardy (IJ) for R2, and R3 whom were placed at significant risk for harm or death as a result of the facility actions. The Immediate Jeopardy began on 12/1/2020, when R1 was placed on the COVID unit without positive test results, and R3, whom on 12/3/20 was placed on the COVID unit without positive results. On 12/3/20, at 4:17 p.m., the administrator and director of nursing were informed of the IJ, that began on 12/1/20 when R1 was moved to the COVID unit. The immediacy was removed on 12/7/20, at 2:40 p.m. when corrective action plan was implemented. However, noncomplinace remained at the lower scope and severity, isolated, with no actual harm with potential for more than minimal harm that was not IJ (Level D). Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1 was cognitively intact. R1's face sheet, printed 12/7/20, indicated R1 had [DIAGNOSES REDACTED]. R1's comorbidities place R1 ar risk for COVID-19. R1's progress notes dated 11/29/20 stated, Staff instructed to swab for COVID-19 to prevent having to send him out to HCMC tomorrow to have this done. Results will be faxed to HCMC as required before attending Tuesday's appointment. R1's progress notes dated 12/1/20 identified, residents family member was updated about the positive result and updated about resident's move to COVID-19 monitoring wing. R2's admission MDS dated [DATE], indicated R2 was cognitively intact. R2's face sheet, printed 12/7/20, indicated R2 had [DIAGNOSES REDACTED]. R2's comorbidities place R2 ar risk for COVID-19. R2's progress notes dated 12/1/20 identified that while swabbing resident, per facility wide testing, resident reports having lost his sense of taste and smell as of yesterday and has had multiple loose stools in the past few days. Writer informed him that he will need to be swabbed again later today d/t (due to) having s/sx (signs and symptoms) of COVID-19, and that specimen will be sent to a different lab. Resident swabbed for COVID-19, sample awaiting lab pick up. R2's progress notes dated 12/1/20 indicated that the writer informed family member (FM)-A that resident was moved to COVID-19 isolation wing for isolation precautions related to exposure from his roommate, R1. FM-A was upset and was informed that the facility was following CDC guidelines and facility protocol. The note identified that FM-A would like administrator to call her in the morning. R2's progress notes, dated 12/1/20, identified that the writer called FM-A to discuss questions. FM-A asked if resident is in own room in covid area. Writer stated no he is in shared room. Family requested since resident test is not back as positive could he be moved to private room to try to not become positive if not positive currently. Writer will notify bed management to look if open private room. Family asked for central contact for medical questions which at this time would be the 4G nurse manager. Writer will follow up with other depts. and family with contact information. When interviewed on 12/03/20, 11:30 a.m., R2's family member (FM)-A verbalized concern about communication with the facility and stated, I don't know what is going on, and you can't reach anyone there with concerns. FM-A verbalized they had been informed the ADON would be the only contact with the facility to find out any information about R2. FM-A stated, now he is in COVID-19 unit in isolation, he did not test positive for [MEDICAL CONDITION] he is only in there because his roommate tested positive. FM-A expressed great concern for R2 being on the COVID-19 unit and quarantined with R1, and verified they had requested R2 be moved off the unit while awaiting results and stated, Until yesterday the facility staff has refused to talk to me. Record review, 12/3/20, identified that R1 was admitted to the facility on [DATE], was quarantined in a private room on the transitional care unit (TCU), and tested negative for COVID on 11/24/20. On 11/25/20 R1 was moved into the shared room with R2 on the long term care (LTC) unit. Review of R2's medical record identified that R2 admitted to the facility on [DATE], was quarnantined in a private room, and on 11/13/20, transferred to the LTC unit. During facility wide testing, on 11/24/20, R2 tested negative for COVID-19. When interviewed on 12/3/20, at 2:21 p.m. Assistant Director of Nursing (ADON)-A verbalized residents should be placed in a private room while in quarantine. ADON-A verified R1 roomed with R2 when R1 became positive, R2 remained in the same room. ADON-A verified both R1 and R2 were moved to the COVID-19 unit and that R2 had not yet tested positive for COVID-19, but was symptomatic and pending swab results when transferred to the COVID-19 unit on 12/1/20. ADON-A verbalized if a resident is pending and has a roommate and has symptoms they are both put in isolation. ADON-A stated, If they are existing roommates and one is pending and the other is positive, they can be in isolation together, we don't transfer to COVID-19 unit unless they have a pending test result and roommate is positive. ADON-A further stated, Even without symptoms R2 would have transferred due to exposure. ADON-A verified R2's family had requested that R2 be moved off of the COVID-19 unit while awaiting test results. On 12/3/20, at the request of R2's family, and upon facility review of cohorting regulations, R2 was moved back to his old room on the non-covid unit and placed on precautions while awaiting test results. On 12/4/20, R2's COVID-19 test results collected on 12/1/20 identified that R2 was negative for COVID-19. On 12/3/20, review of R4's progress note dated 11/27/20, at 6:54 a.m., indicated, at around 4:00 a.m., this morning the Hennepin County Hospital called and talked to the writer, stated, R4, is admitted , has tested positive for COVID-19 and is currently intubated. The writer updated the complex supervisor and the POA-Care. Review of R3's progress note dated 11/27/20, indicated, R3 was transferred to the COVID-19 unit around 11:55 a.m., following R4 testing positive for COVID-19 while at the hospital. The Resident list report dated 12/3/20, indicated that R3 was in a private room on the COVID-19 unit, with COVID test results pending. Interview with the ADON-A acknowledged, on 12/3/20, at 2:21 p.m., that the facility identified R3 had been moved to the COVID unit without having a positive COVID test. ADON-A explained that R4, who was R3's roommate, had tested positive for COVID-19 on 11/27/20 while at the hospital, and that R3 was then moved to the COVID-19 unit on 11/27/20, after the facility was informed that R4 had tested positive. ADON stated, if there are existing roommates and one resident has a COVID-19 test pending and the roommate is positive for COVID-19, they can isolate together. Roommates would not be moved to the COVID-19 unit, unless one roommate is positive and the other roommate has pending test results. Review of the cohorting document provided by the facility, discharge of an inpatient or resident to congregate living setting that provides patient care, dated 4/13/20; revision date 8/3/20, did not address facility specific guidelines for cohorting residents. Facility policy titled Emerging Infectious Diseases (EID) Emergency Operations, dated 1/1/20 directed activate quarantine interventions for residents and staff suspected exposure as directed by local and state public health authorities, and in keeping with guidance from the CDC (centers for disease control and prevention). CDC document titled Responding to Coronavirus (COVID-19) in Nursing Homes Considerations for the Public Health Response to COVID-19 in Nursing Homes, updated 4/30/20, directed, Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. The IJ that began on 12/1/20, was removed on 12/7/20, at 2:40 p.m. when observations, interviews and record reviews identified that the facility had conducted facility wide audits, assured that all positive COVID-19 residents resided in private rooms in a designated cohorted area, and that all positive and negative COVID residents were separated. Education was provided to pertinent staff regarding key principles for quarantine, room transfers for COVID positive residents, and prevention of cohorting COVID negative and positive residents. A plan was identified for ongoing education regarding the key principles, and in addition, measures were put in place and implemented to assure for compliance monitoring.

Based on observation, interview and document review, the facility failed to implement the care plan for 2 of 2 residents (R1, R2) related to the use of mechanical lifts, which resulted in a fractured femur when R1 fell out of the mechanical lift. This resulted in an immediate jeopardy (IJ) situation for R1. This deficient practice had the potential to affect all 62 residents in the facility who required the use of a mechanical lift for transfers. The immediate jeopardy began on 6/23/20, at 2:11 p.m. when it was identified that staff continued to work with residents in the facility without training on implementation of care plans, use of appropriate transfer equipment according to the residents care plans. The administrator, and the director of nursing (DON) were notified of the IJ on 6/23/20, at 2:11 p.m. The IJ was removed on 6/24/20, at 5:12 p.m. but noncompliance remained at the lower scope and severity level G-isolated, scope and severity, which indicate actual harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 has severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R1 required extensive assistance of two staff for bed mobility and toileting, total assistance with two staff for transfers, and extensive assistance with one staff for locomotion, personal hygiene and dressing. MDS further indicated R1 had a fall prior to admission and one fall since admission. R1's care plan, revised 6/20/20, identified R1 was high risk for falls related to history of falls, cognitive impairment with poor short term memory, impaired safety awareness, wheel chair bound, dependence on others for transfers, had dementia, weakness, impaired balance, and chronic pain. R1's care plan listed various interventions including: one command/idea at a time, yes/no questions, use a mechanical lift with assistance of two staff for transfers using a large or a med sling, and re-educate staff on reading care plans prior to caring for residents. Review of R1's lift mobility assessments dated 2/11/20, and 6/21/20, indicated R1 required a mechanical lift with large sling, R1 could tolerated a semi-reclined position and was under 600 pounds. Review of R1's physical therapy notes dated 4/2/20, indicated R1 required significant time between each task due to redirection and reassurance with each transfer attempt, and recommendation was to continue with mechanical lift for safety. Review of an untitled document dated 6/14/20, listing activities of daily living (ADL's), indicated on page 2 of the document, under the title of transferring, R1 required assist of two staff using the mechanical lift with a large sling Review of R1's Pain Interview form dated 5/19/20, indicated R1 denied any pain in the last five days before the interview. Review of R1's Incident Report Summary dated 6/15/20, indicated nursing assistant (NA)-A reported a controlled landing during a transfer on 6/14/20, with R1. R1 had complaints of pain to left knee, x-rays were ordered and showed a fracture to left femur. Review of R1's Witnessed Fall Report, 6/14/20, indicated R1 was transferred with one assist using an EZ stand when R1 let go of the bars and was lowered onto the floor. Range of motion (ROM) of upper arms was done with complaints of discomfort in right shoulder. ROM was done to both lower extremities with complaints of pain in left knee. R1 was unable to report the degree of pain. R1 had been lifted off the floor using a mechanical lift and assistance of 4 staff. Review of R1's Investigation/Analysis dated 6/15/20, indicated R1 was being transferred with the stand lift on 6/14/20, by NA-A when R1's knees gave out and she began to slide to the floor. NA-A discovered after the fall that she had misread the residents Kardex for transfers and should have used the mechanical lift with assistance of two staff. NA-A was removed from the floor and educated on reading the Kardex and transfers before returning to the floor. R1 experienced left hip pain and was found to have a left femur fracture and was sent to the hospital on [DATE]. The report indicated R1 and other residents who utilized a lift were reviewed and housewide education of staff unsafe transfers initiated. Review of R1's Progress Notes from 6/14/20, to 6/15/20, revealed the following: -6/14/20, at 5:35 p.m. indicated R1 was sitting on the floor in her room with head on the edge of the bed. ROM completed with R1 complaining of discomfort in right shoulder and left knee. - 6/14/20, at 6:27 p.m. RN-C indicated X-rays were completed and staff were not to move R1 until the results of the X-rays were known. R1 was having some facial grimacing with repositioning and elevation of left extremity. - 6/15/20, at 1:23 p.m. staff spoke with orthopedics and they recommended R1 have surgical repair of the fracture to the left femur. A later note at 2:15 p.m. indicated R1 was transferred to hospital. Review of R1's X-ray dated 6/14/20, identified an acute mildly displaced supracondylar fracture of distal femur, no joint effusion, and moderate osteopenia/[MEDICAL CONDITION] and moderate [MEDICAL CONDITION]. Review of R1's hospital discharge summary dated 6/18/20, indicated R1 had sustained mechanical lift fall at the facility on 6/14/20, complained of right shoulder pain and x-ray negative for fracture. R1 complained of left thigh and ankle pain. A computed tomography (CT) scan of left lower extremity identified an acute comminuted moderately displaced [MEDICAL CONDITION] femoral shaft with intra-condo articular extension (a traumatic break from a direct blow or impact in the large thigh bone in more than two pieces, near the knee, involving the knee joint). R1 required open reduction and internal fixation of femoral fracture surgery. On 6/18/20, at 5:10 p.m. R1 was awake, lying in bed in her room. R1 indicated she had discomfort in her foot but was unable to remember recent events of surgery, hospitalization or fall. On 6/19/20, at 8:40 a.m. NA-C stated he was working on the morning of R1's fall, but had not received any training on care plans. NA-C stated the last training he received was on hand washing weeks prior. On 6/19/20, at 8:53 a.m. NA-A indicated she was working with R1 on the day shift on 6/14/20. During a transfer with the stand lift R1 moved her arms inside the sling, and her knees buckled. NA-A loosened the strap across the chest of R1 allowing R1 to be lowered to the floor. R1's head was on the bed and buttocks were on the floor. NA-A indicated R1 had been transferred back to bed with a full mechanical lift. NA-A stated when she arrived at work she reviewed R1's care card and most of her cares were assist of one staff, so NA-A wrote assist of one on her sheet and thought that was also for the transfers. On 6/19/20, at 10:14 a.m. NA-D indicated she had not received any recent training on reading care plans, usually training would be on the computer. On 6/19/20, at 10:18 NA-E confirmed she had not received any recent training on care plans. On 6/19/20, at 10:55 a.m. RN-A confirmed he was the supervisor on duty on 6/14/20, and responded to the fall for R1. RN-A indicated he completed the training on reading care plans and transfers with NA-A and reported to the DON the fall and the order from the NP to obtain x-rays all relating to the transfer with incorrect lift. RN-A confirmed NA-A reported she used the incorrect lift, getting the information from only looking at the first page of the care plan, seeing assist of one, and not reading the second page of the care plan where it reads the transfer is assist of two staff with the full mechanical lift. On 6/19/20, at 11:16 a.m. LPN-A stated she was the day shift nurse on 6/14/20, and was called to R1's room by NA-A at 2:15 p.m. R1 was sitting on the floor and NA-A stated R1 let go of the stand lift. LPN-A stated she had seen the stand lift in the hallway outside the room when she responded to the fall and told NA-A that R1 was a mechanical lift that requires assistance of two staff. NA-A indicated to LPN-A she wrote down assist of one from the care plan. LPN-A stated R1 had complained of pain with ROM at right shoulder and left knee. LPN-A confirmed she called the NP asking for x-rays due to the pain with movement. On 6/19/20, at 2:00 p.m. DON confirmed she was the on-call supervisor for 6/14/20, and was notified by RN-A about the fall from the stand lift for R1 and the orders to complete the X-rays. DON indicated she ensured teaching was completed with NA-A and instructed to be called if the x-rays showed a fracture. DON stated her expectations would be for the nursing assistants to read the care plans before caring for the residents to ensure they are following the care plan. DON stated after the fall the facility had started training the staff on care plans and transfers and had been able to reach about 45% of the staff up at that time with a goal to reach 100% of the staff. R2 R2's quarterly MDS dated [DATE], indicated R2 was severely cognitively impaired with [DIAGNOSES REDACTED]. The MDS further indicated R2 required extensive assistance of one staff for bed mobility, locomotion, dressing and personal hygiene and extensive assistance of two staff with transfers and toileting. Review of R2's care plan revised on 6/15/20, indicated R2 had a self care deficit related to weakness, [MEDICAL CONDITIONS], and had limited mobility. The care plan further indicated R2 had impaired thought processes due to [DIAGNOSES REDACTED]. Review of R2's untitled document provided by the facility and identified as the Kardex dated 6/23/20, indicated R2 required assistance of one staff using the EZ stand with the medium/beige sling. Review of R2's Lift Mobility assessment dated [DATE], indicated R2 required the mechanical EZ stand lift with the medium beige sling for transfers. On 6/18/20, at 4:45 p.m. NA-B grabbed the stand lift in the hall and brought it into R2's room. NA-B indicated she needed a different sling size and left the room briefly to obtain a different sling. NA-B returned with a green colored sling and transferred R2 with the stand lift to the bathroom, then to the wheel chair. After R1 was transferred to the wheelchair, observation of the label on the green sling listed large size. On 6/22/20, at 2:15 p.m. RN-F stated she received training on 6/19/20, on transfers and how to respond, residents who need assistance of two staff during transfers, and what slings to use. On 6/22/20, at 2:55 p.m. NA-B confirmed R2's care plan directed to use a medium sling and confirmed she had used a large size sling for the transfer. She indicated she did not know what was wrong with her that day. NA-B stated she had received training on reading the care plan the previous day, over the weekend. On 6/22/20, at 3:28 p.m. DON provided the following training materials and indicated the various training tools addressed different areas of resident care and had been initiated since R1's fall: -Audit/competency check list for how to use the smart EZ stand and the full lift. 11 out of 215 staff completed the stand lift and 12 out of 215 had completed the full lift competency. -Face to face competency on vulnerable adult (VA) reporting covered how to report an incident for the nurses and the nursing assistants, when to call the supervisor, falls/incident reports, injuries, infection control, use of goggles, cleaning equipment, wearing of face masks and gloves, and hand hygiene. Completed by 125 staff out of 215. -Kardex competency, asking the staff to go to the care plan or the Kardex and show the trainer what kind of transfer a particular resident requires and the equipment needed. Completed by 59 staff out of 215. - Blast email sent on 6/19/20, about 3:45 p.m. and included the VA, infection control, when to report to the supervisor, falls/incidents and transfer training's. A follow up call was made to ensure the email was received and allow for any questions. 65 staff out of the 215 were reached and had no questions. Review of training material titled Resident Transfer dated 6/16/20, provided by the facility, listed a detailed step by step process for completion of resident transfers. The various steps included to check the individual resident care plan for transfer status and if staff question the transfer status, check with the nurse so the nurse can assess the resident and make changes applicable. Also, ensure correct sling size according to the residents weight. Review of face to face attendance record included 75 staff completed the training between 6/16/20 and 6/19/20 out of the total of 215. On 6/23/20, at 9:25 a.m. DON further indicated she felt the improper transfer with R1 should have never happened. She indicated her goal was to have 100% of the staff trained by the end of that week on Kardex and transfers as she felt this was the area that failed in the fall of R1. DON confirmed the Kardex and transfer training was a competency training where the staff demonstrate to the trainer how to go to the residents care plan or Kardex and look at how the individual resident transferred and the equipment needed. DON reviewed the various training components since R1's fall and confirmed the audits on transfers and Kardex's, emails with infection control, VA, fall, transfer and when to report to the supervisor training, phone calls to follow up on the Emails blast that went out late on 6/19/20, had all started at various times over the past week. she confirmed various staff had completed individual components but not all staff had completed all of the training. DON re-confirmed her goal was to ensure the competency training with the transfers and the Kardex had been completed with nursing staff. DON indicated her expectation were for staff to follow the policies, ensure residents were safe and their care plans were followed. On 6/23/20, at 11:05 a.m. DON confirmed there were currently 6 of the 84 staff scheduled to work had not received the re-education on proper implementation of care plans and transfers. DON also confirmed on 6/22/20, 36 out of 107 staff who provided direct care to residents in the facility had not received the re-education of implementation of care plans and transfers. On 6/24/20, at 10:15 a.m., medical director (MD) stated R1 had been admitted to the facility following a fall and had a [DIAGNOSES REDACTED]. The MD confirmed R1 had experienced pain after the fall on 6/14/20. The IJ that began on 2/23/20, was removed on 6/24/20, when the facility removed all staff from the schedule who had not received appropriate training on care plans, made a plan to ensure all staff were trained prior to providing direct care and assessments were completed for R1 and R2 for current plan of care accuracy, but the noncompliance remained at the lower scope and severity level of G-actual harm.

Based on interview and record review, the facility failed to ensure staff provided emergency care for one of one resident (R1) reviewed who requested cardio [MEDICAL CONDITION] resuscitation (CPR) and did not receive CPR when R1's heart stopped and respirations ceased. R1 died . The failure for the facility to identify the need for CPR placed 56 residents who requested CPR at risk for immediate jeopardy (IJ). The IJ began on [DATE], when R1 had a change in condition and required CPR. The CPR and emergency services was not initiated. The administrator, associate administrator, director of nursing, assistant director of nursing, chief clinical officer, RN educator, and transitional care unit (TCU) director were notified of the IJ on [DATE], at 5:30 p.m. The IJ was removed on [DATE] at 4:40 p.m. However, noncompliance remained at the lower scope and severity level of isolated actual harm that is not immediate jeopardy. Findings include: R1's medical record was reviewed. R1 was admitted on [DATE], with a [DIAGNOSES REDACTED]. The admission flow record dated [DATE] indicated full code (CPR). The intake form dated [DATE] indicated full code (CPR). The facility investigation document Verification of Investigation dated [DATE], at 11:45 a.m. completed by RN-D indicated LPN-A interpreted R1's POLST to provide comfort cares. LPN-A did not initiate CPR or call a nurse stat (facility CPR alert). The investigation further indicated the supervisor, RN-D, noted R1 to be cool to the touch and without a pulse, confirmed by RN-F. R1's progress note dated [DATE], at 2:47 p.m. by LPN-A indicated assessment completed while R1 was in bed, but noticed no blood pressure and no pulse at 11:30 a.m. An interview was conducted on [DATE], at 2:27 p.m. with LPN-A who stated she witnessed R1 sit on the floor on [DATE] around 11:20 a.m. in the dining room. LPN-A and another staff assisted R1 back into the wheelchair, to his/her room and into bed. LPN-A stated it was considered a witnessed fall, so returned with a machine for taking vital signs. S/he was not able to get a blood pressure reading and thought something was wrong with the machine. LPN-A turned the machine off and back on three times, and continued to attempt a blood pressure each time. LPN-A stated s/he did not touch R1 to check for an apical or radial pulse and thought something was not right with the machine. LPN-A stated s/he left the resident for a minute, walked to the nurses station, and checked the POLST which s/he interpreted to read comfort cares. LPN-A could not identify why s/he checked the POLST. LPN-A stated s/he did not start CPR, but now got assistance from RN-D who went to R1's room and assessed R1 to be deceased due to lack of pulse or breathing, at approximately 11:30 a.m. An interview was conducted on [DATE] at 10:33 a.m. with RN-D who stated s/he was asked by LPN-A to come to R1's room to check the vitals machine. RN-D stated s/he assessed R1 visually upon entering the room and noted that R1 was blue and did not appear to be breathing. RN-D used a stethoscope to check for an apical pulse and stated that R1 was cold and had no pulse. RN-D left the resident, walked to the nurses station, and checked the POLST with another nurse (RN-F.) They both visually verified the POLST indicated full code (attempt CPR if not breathing and no pulse.) RN-D stated neither s/he or RN-F started CPR. An interview was conducted on [DATE], at 2:12 p.m. with the director of nursing (DON)-E who stated policy indicated that staff perform CPR on a resident who is not breathing, has no pulse, and has an order to do CPR. DON-E stated LPN-B was trained in nurse stat an emergency response system for resident care, but it was not documented. An interview was attempted on [DATE], at 1:10 p.m. with RN-F who declined to be interviewed. Record review revealed LPN-B completed training on assessment and emergency resuscitation guidelines on [DATE]. Review of the facility emergency response guideline policy dated [DATE], indicated staff will call a nurse stat and begin CPR if a resident is found without blood pressure, pulse, or respirations and has a POLST indicating CPR. The facility policy and procedure for nurse stat was requested and none was provided. The facility policy and procedure for emergency resuscitation guidelines was requested and none was provided. The immediate jeopardy that began on [DATE] was removed and administrative staff were notified on [DATE] at 4:40 p.m., after verification of the removal plan through document review and staff interview. The facility created a policy titled emergency response guidelines that included what to do if finding a resident without a blood pressure, pulse, or respirations and educated all nurses on the policy, educated the nurses involved in the incident to read a POLST, policy for POLST, and how to call an emergency response (nurse stat), educated the nurse managers and unit supervisors on the policy and procedure for emergency response (nurse stat), to read a POLST verifying CPR or Do not resuscitate (DNR), what to do in the absence of a POLST, and the POLST policy, then then the nurse managers and unit supervisors educated all of the nurses. In addition, audits were completed of all resident charts by each nurse manager to ensure up to date POLST orders and mock emergency response (nurse stat) drills were completed on all shifts. The quality assurance and process improvement committee met to review the incident and outlined a new process for physicians or nurse practitioners to establish advanced care planning with for both short and long stay residents where the resident's code status and POLST will be reviewed quarterly at each care conference. Noncompliance remained at the lower scope and severity level of isolated actual harm that is not immediate jeopardy.

Based on observation, interview and document review, the facility failed to ensure elopement risk factors were evaluated and interventions implemented for adequate supervision for one of three (R1) residents with a history of elopement. Harm occurred when R1 wandered from the facility and had a fall with injuries that included a laceration and hematoma to the upper coner of the left eye, abrasions to bilateral arms and a swollen right knee. The findings include: R1's medical record was reviewed. Nursing home admission notes identified that R1 was admitted to the facility's short term rehab memory care unit located on the third floor on August 18, 2015, following a hospital admission for acute confusion when found by EMS wandering and dropping winter coats on the street. The hospital discharge summary dated August 18, 2015, identified the resident's family had noticed cognitive impairments over the past year, and long term memory care placement was being considered. The resident's admission Safety Risk Assessment completed on August 21, 2015, indicated No for history of wandering and/or elopement, even though the resident was admitted for confusion and wandering in the community. The resident's Care Plan printed for review on November 12, 2015, identified the resident was a vulnerable adult due to cognitive impairments with a goal that the resident will be safe in his/her environment. The only intervention directed staff to assist in emergencies. Nursing notes dated September 21, 2015, revealed R1 exited the secured short term rehab memory care unit on September 21, 2015, by the stairway. The nursing notes indicated the resident initially insisted that s/he wanted to go to the post office and that the resident was difficult to redirect back to the unit. On September 22, 2015, the nursing notes identified the resident had a Wanderguard (bracelet type device that triggers an alarm on all exit doors located on the first floor of the facility) due to seeking to exit from the unit and refusing to return to the unit. On October 1, 2015, the nursing notes identified the resident cut off the Wanderguard, and that staff pinned the Wanderguard to the back of the resident's sweater, and that 30 minute checks were completed. The resident's record lacked evidence of documentation that a reassessment of the Safety Risk Assessment was done. The record also lacked documentation that further interventions were implemented to ensure the resident's safety other than the placement of a Wanderguard, in which the resident had the ability to remove. On October 21, 2015, the resident transferred from the secured short term memory care rehab unit to the fourth floor long term care unsecured unit. The resident's record revealed that on November 10, 2015, at approximately 10:15 a.m., R1 left the facility, and traveled to Northeast Minneapolis. The nursing notes dated November 10, 2015, identified the resident was returned to the facility by a passerby six hours after s/he left the facility. The resident presented with a laceration and hematoma to the upper corner of the left eye, abrasions to bilateral arms, and a swollen right knee. The resident was sent and admitted to the hospital for evaluation of the injuries. The resident was readmitted to the facility on [DATE].Registered nurse (RN)-A was interviewed on November 12, 2015, at 9:30 a.m. RN-A voiced awareness of the resident's attempt to elope prior to being transferred to the fourth floor. RN-A stated the facility had a bed management team that discussed admissions and placement of residents. RN-A stated R1 was fearful of elevators and would not go on one, therefore it was suspected the resident had the ability to watch staff exit to the stairwell by pressing the button to release the door. RN-A stated the resident was not due for his/her quarterly assessment when asked if a reassessment for safety risk factors was completed. The DON, interviewed on November 12, 2015, at 12:25 p.m., verified R1 had a history of [REDACTED]. The DON stated an evaluation was completed by the interdisciplinary team (IDT) prior to the resident being transferred to the unsecured long term care unit and that the IDT deemed this was an appropriate placement for the resident. The DON stated there was no documentation of the evaluation, or what factors were considered when this decision was made. Observation of the resident's room on the fourth floor, revealed the room was located on the back side and out of view from the nursing station and in the same hallway as the stairwell door. The elevator doors were located directly across from the nursing station. On November 12, 2015, the resident was readmitted to the secured long term memory care unit on the second floor of the facility. Observation completed at 2:45 p.m., revealed R1 as well-groomed and dressed with an abrasion of approximately three centimeters (cm) above the left eyebrow with light gray/blue bruising noted on the eyelid and slightly below the left eye. R1 stated s/he had a fall at Walgreens and knew s/he had left the facility, but unsure why.