Every finding on record at Little Falls Care Center

Based on interview and document review, the facility failed to implement a system to ensure medications were consistently acquired, received, and administered as ordered for 3 of 3 residents (R20, R4, R22) reviewed. As a result, R20 did not receive hydromorphone (synthetic opioid/narcotic) for seven days and pregabalin (anticonvulsant to treat nerve pain) for four days. This resulted in actual harm when R20 experienced severe withdrawal symptoms.Findings include: R20 R20's annual Minimum Data Set (MDS), dated [DATE], indicated R20 was cognitively intact. Diagnoses included chronic obstructive pulmonary disease (COPD), type 2 diabetes with diabetic neuropathy (nerve damage in legs and feet), anxiety, and moderate protein-calorie malnutrition, and R20 received scheduled pain medication regimen. R20's care plan revised 9/10/25, indicated R20 had acute/chronic pain and interventions included administration of pain medications per order. During an interview on 7/29/26 at 2:35 p.m., R20 stated he went without his hydromorphone and pregabalin for days and went into withdrawal. R20 stated he was shaking, short of breath (SOB), sweating, nauseous, heart racing, and was in horrible pain. R20 stated he didn't eat for two days, wanted to crawl out of my own skin and it was a miserable four days. R20's Order Summary Report dated 6/3/26, indicated R20 had been taking the following long-term:hydromorphone HCL 4 milligrams (mg) by mouth two times a day (BID) related to other chronic pain was ordered 10/27/24pregablin 100mg by mouth three times a day (TID) for chronic pain was ordered 6/25/25 R20's July 2026 Medication Administration Record (MAR) indicated R20 was not administered medications as follows: hydromorphone 4mg7/21 bedtime (HS) dose7/22 morning (AM) and HS doses7/23 AM and HS doses7/24 AM and HS doses7/25 AM and HS doses7/26 AM and HS doses7/27 AM dosesTotal of 12 missed doses of hydromorphone 4mg. R20's progress notes dated 7/21/26 through 7/27/26, indicated staff noted no supply for each of the 12 missed doses of hydromorphone 4mg as indicted above. pregabalin 100mg7/24 12:00 p.m. and 8:00 p.m. doses7/25 8:00 a.m. 12:00 p.m. and 8:00 p.m. doses7/26 8:00 a.m. 12:00 p.m. and 8:00 p.m. doses7/25 8:00 a.m. 12:00 p.m. dosesTotal of 10 missed doses of pregabalin 100mg. R20's progress notes dated 7/24/26 through 7/25/26, indicated staff noted no supply for each of the 10 missed doses of pregabalin 100mg as indicted above. R20's July 2026 MAR indicated R20's pain level was recorded BID on a scale of 1 (no pain) to 10 (worst pain possible). R20's MAR indicated he consistently rated his pain between 6 to 8 during the dates/times R20 received hydromorphone 4mg. However, the facility failed to obtain R20's pain level on the dates/times the facility failed to provide R20's hydromorphone 4mg. Email dated 7/9/26 at 2:26 p.m., from licensed practical nurse (LPN)-C to the provider, indicated the facility requested the provider fax refill orders to the pharmacy for R20's hydromorphone HCl 4mg BID. Email dated 7/22/26 at 10:53 a.m., from licensed practical nurse (LPN)-C to the provider, indicated the facility needed a prescription sent to the pharmacy for hydromorphone 4mg BID, He is now out of the medication. However, the facility failed to provide evidence that they followed up with the provider for a refill order between 7/9/26 and 7/22/26. Pharmacy reorder form dated 7/24/26, indicated the facility requested a refill of R20's pregabalin 100mg, with special notes listed as no supply. The pharmacy returned the form via fax on 7/24/26, indicated Need new script from new provider. R20's progress note dated 7/26/26 at 11:28 a.m., indicated R20 was not feeling well and lost appetite. R20 had not taken scheduled pregabalin and hydromorphone due to being out of stock/supply and R20 might be going through some withdrawals. R20's progress note dated 7/26/26 at 8:51 p.m., indicated R20 currently out of pregabalin and hydromorphone, and R20 complained of not feeling well, SOB, and skin crawling. The nurse contacted the on-call nurse practitioner to report R20's complaints and need for medication orders. Pharmacy reorder form dated 7/26/26, indicated the facility requested a refill of R20's pregabalin 100mg with special notes listed as out, and hydromorphone 4mg with special notes listed as out. R20's progress note dated 7/27/26 at 2:10 a.m., indicated R20 was administered diphenhydramine (antihistamine) solution 25mg intramuscularly (IM) one time only for Anaphylactic reaction and to contact the MD/NP if repeat dosing needed. R20 observed to exhibit signs and symptoms of withdrawal, including complaints of difficulty sleeping, skin crawling. Pharmacy reorder form dated 7/27/26, indicated the facility requested a refill of R20's pregabalin 100mg with special notes listed as out since 7/24, and hydromorphone 4mg with special notes listed as out since 7/21. R20's progress note, dated 7/28/26 at 5:53 p.m., indicated licensed practical nurse (LPN)-A and the primary care provider (PCP) met with R20, and R20 stated that 'I don't feel good' and resident stated that he thinks he went through some withdrawal. LPN told PCP that R20 had been out of hydromorphone. PCP asked why we stopped his hydromorphone. Writer stated that we did not stop it and that the script [prescription] had not been sent to the pharmacy. R4 R4's quarterly MDS dated [DATE], indicated was cognitively intact, diagnoses included vascular parkinsonism (movement disorder from blocked blood vessels or small strokes), heart failure, and chronic obstructive pulmonary disease (COPD - a long-term lung disease that blocks airflow and makes breathing difficult). R4's care plan revised 4/16/26, indicated R4 was at risk for COPD complications. R4's order summary reviewed 7/30/26, indicated R4 had an order for Ipratropium-Albuterol inhalation solution (Duoneb - used to open lung airways) 0.5-2.5 (3) mg/3mL vial via nebulizer TID related to COPD, with a start date of 6/8/26. R4's July MAR indicated R4 was not administered medications as follows: Ipratropium-Albuterol inhalation solution (Duoneb):7/9 AM and mid-day (MID) doses7/10 AM, MID, and HS doses7/11 AM, MID, and HS doses7/12 AM, MID, and HS doses7/13 AM, MID, and HS doses7/14 AM, MID, and HS doses7/15 AM, MID, and HS doses7/16 AM, MID, and HS doses7/17 AM, MID, and HS doses7/18 AM, MID, and HS doses7/19 AM, MID, and HS doses7/20 AM, MID dosesTotal of 34 missed Duoneb treatments R4's pharmacy refill authorization form, faxed from the pharmacy to the facility, dated 7/8/26, indicated Please send updated signed med list for R4's Duoneb. Pharmacy reorder form dated 7/8/26, indicated the facility requested a refill of R4s Duoneb with special notes listed as no supply. The pharmacy returned the form via fax on 7/9/26 at 10:38 a.m., indicated Need new signed order. R4's progress notes, dated 7/9/26 through 7/20/26, indicated staff noted no supply for each of the 34 missed Duoneb treatments as indicted above. R4's progress note dated 7/16/26 at 9:10 a.m., indicated R4 requested a PRN (as needed)nebulizer treatment for shortness of breath (SOB). R22 R22's significant change MDS dated [DATE], indicated R22 had moderate cognitive impairment, diagnoses included COPD, spondylosis (causes pain in the spine area that worsens with movement), and chronic pain syndrome, and R22 received scheduled pain medication regimen. R22's care plan revised 7/16/26, indicated R22 preferred comfort-focused treatment. R22's order summary reviewed 7/30/26, indicated R22 had an order for oxycodone HCL (opioid/narcotic used to treat moderate to severe pain) 5mg by mouth BID related to chronic pain syndrome, with a start date of 6/8/26. R22's July MAR indicated R4 was not administered medications as follows: Oxycodone 5mg:7/18 AM and HS doses7/19 AM and HS doses7/20 AM and HS doses7/21 AM and HS doses7/22 AM doseTotal of 9 missed doses of oxycodone 5mg R22's progress notes dated 7/18/26 through 7/22/26, indicated staff noted no supply for each of the 9 missed doses of oxycodone 5mg. R22's pharmacy refill authorization form, faxed from the pharmacy to the facility, dated 7/8/26, indicated Need new script for R22's oxycodone 5mg by mouth twice a day. R22's pharmacy refill authorization dated 7/15/26, indicated Need New Script for R22's oxycodone 5mg by mouth twice a day. Email dated 7/22/26 at 10:59 a.m., from licensed practical nurse (LPN)-C to the provider, indicated the facility needed a prescription sent to the pharmacy for R22 for oxycodone 5mg BID. During an interview on 7/30/26 at 9:54 a.m., the on-call NP stated when the facility contacted her on 7/26/26, they requested just a refill order. NP stated the nurse failed to notify her R20 had missed several doses of hydromorphone and pregabalin. NP stated the nurse failed to notify her R20 was suffering from any symptoms. NP stated if the nurse had notified her of the missed medications and/or symptoms, NP would have directed the facility to send R20 to emergency room for withdrawal symptoms that possibly could not have been managed at the facility. NP further stated R20 could have suffered additional negative outcomes, such as seizures. During an interview on 7/30/26 at 11:43 a.m., pharmacy consultant (PharmD) stated because R20 had had been on a narcotic consistently and went cold turkey (stopped suddenly), it sounded like R20 suffered withdrawal symptoms due to the medications not being given. PharmD stated R20 had gone a long time without the medication, a provider should have been contacted to provide a prescription, and this was not the goal of care. During an interview on 7/30/26 at 2:20 p.m., director of nursing (DON) confirmed R20 had not received 12 doses of hydromorphone 4mg, and 10 doses of pregabalin 100mg, as per provider orders, and stated, were aware he was out of the medication. DON stated staff should have followed up with the provider between 7/9 and 7/22. DON stated R20 experienced withdrawal symptoms due to the missed medication doses. Additionally, DON stated staff were expected to notify the provider of suspected withdrawal symptoms. DON confirmed R4 had not received 34 Duoneb treatments, and R22 had not received 9 doses of oxycodone 5mg, as per provider orders, due to the facility failure to maintain a supply of the medications. A policy regarding the facility's medication ordering/acquisition process was requested but not provided.

Based on observation, interview, and document review, the facility failed to consistently include the facility census on the daily nurse staff posting. This had the potential to affect all 60 current residents, their families and visitorsThe facility's Staffing Data Submission Payroll Based Journal (PBJ), noted the facility was triggered for survey review of Low Weekend Staffing and Licensed Nurses for 24 hours per day during the 1st quarter of 2026 for the following dates:Saturday 10/26/25Saturday 11/29/25Saturday 12/13/25Sunday 12/14/25Sunday 12/28/25 In addition, the facility's Staffing Data Submission Payroll Based Journal (PBJ), noted the facility was triggered for survey review of Licensed Nurses for 24 hours per day during the 2nd quarter of 2026 for the following dates:Saturday 1/3/26Saturday 1/17/26Sunday 1/18/26Saturday 1/24/26Sunday 1/25/26 In review of the facility's staff postings and the actual working schedules for Quarter 1 and Quarter 2 indicated the facility had licensed nursing staff, 24 hours per day, 7 days per week, the review did not identify weekends that were excessively low for staffing. When interviewed on 7/29/26 at 1:30 p.m. staffing coordinator (SC) stated they were only responsible for putting in the information for agency staff. SC stated they were not sure why they would have triggered for anything on the PBJ. When interviewed on 7/29/26 at 1:37 p.m. administrator stated corporate submitted the PBJ. Administrator stated they were not sure that contract/agency staff had been entered for the PBJ. Administrator stated submission of the PBJ was an area for improvement, the triggering on the PBJ was a product of it not being submitted appropriately. Administrator stated there was a high probability that nurse manager hours were not coded correctly when they worked the floor as floor nurses. A facility policy regarding reporting PBJ was requested, however none was provided.

Based on observation, interview, and document review, the facility failed to implement proper infection control procedures when handling soiled linens. This had the potential to affect all residents who used facility laundered linens. Findings include: During observation and interview on 7/29/26 at 1:14 p.m. laundry aide (LA)-F stated the process for laundry services. LA-F stated soiled laundry was sorted by towel, blankets, etc and by unit. LA-F stated they only wear gloves for sorting soiled linens. The gowns hanging in the room were only for COVID. During interview on 7/29/26 at 1:29 p.m. Environmental services director (ES)-G stated his expectation was staff wore gloves and gowns when sorting soiled linens. Facility policy titled: Linen Handling last updated 3/10/26 indicated staff must wear appropriate personal protective equipment based on anticipated exposure and in accordance with standard precautions. Handle all soiled linens a potentially infectious.

Based on interview and document review, the facility failed to notify the provider of missed medications for 3 of 3 residents (R4, R20, R22) reviewed for medication errors. Additionally, the facility failed to notify the provider of a change in condition for 1 of 1 resident (R20) who exhibited severe withdrawal symptoms.Findings include: R4's quarterly MDS, dated [DATE], indicated was cognitively intact, diagnoses included vascular parkinsonism (movement disorder from blocked blood vessels or small strokes), heart failure, and chronic obstructive pulmonary disease (COPD - a long-term lung disease that blocks airflow and makes breathing difficult). R4's care plan, revised 4/16/26, indicated R4 was at risk for COPD complications. R4's order summary, reviewed 7/30/26, indicated R4 had an order for Ipratropium-Albuterol inhalation solution (Duoneb - used to open lung airways) 0.5-2.5 (3) mg/3mL vial via nebulizer TID related to COPD, with a start date of 6/8/26. R4's July MAR indicated R4 was not administered medications as follows: Ipratropium-Albuterol inhalation solution (Duoneb):7/9 AM and mid-day (MID) doses7/10 AM, MID, and HS doses7/11 AM, MID, and HS doses7/12 AM, MID, and HS doses7/13 AM, MID, and HS doses7/14 AM, MID, and HS doses7/15 AM, MID, and HS doses7/16 AM, MID, and HS doses7/17 AM, MID, and HS doses7/18 AM, MID, and HS doses7/19 AM, MID, and HS doses7/20 AM, MID dosesTotal of 34 missed Duoneb treatments R4's progress notes, dated 7/9/26 through 7/20/26, indicated staff noted no supply for each of the 34 missed Duoneb treatments as indicted above. R4's progress note, dated 7/16/26 at 9:10 a.m., indicated R4 requested a PRN (as needed) nebulizer treatment for shortness of breath (SOB). However, R4's medical record lacked evidence R4's provider was notified of the 34 missed Duoneb treatments. R20's annual Minimum Data Set (MDS), dated [DATE], indicated R20 was cognitively intact, diagnoses included chronic obstructive pulmonary disease (COPD), type 2 diabetes with diabetic neuropathy (nerve damage in legs and feet), anxiety, and moderate protein-calorie malnutrition, and R20 received scheduled pain medication regimen. R20's care plan, revised 9/10/25, indicated R20 had acute/chronic pain, and interventions included administration of pain medications per order. R20's Order Summary Report, dated 6/3/26, indicated R20 had been taking the following orders long-term:hydromorphone HCL 4 milligrams (mg) by mouth two times a day (BID) related to other chronic pain was ordered 10/27/24pregablin 100mg by mouth three times a day (TID) for chronic pain was ordered 6/25/25 R20's July 2026 Medication Administration Record (MAR) indicated R20 was not administered medications as follows: hydromorphone 4mg7/21 bedtime (HS) dose7/22 morning (AM) and HS doses7/23 AM and HS doses7/24 AM and HS doses7/25 AM and HS doses7/26 AM and HS doses7/27 AM dosesTotal of 12 missed doses of hydromorphone 4mg R20's progress notes, dated 7/21/26 through 7/27/26, indicated staff noted no supply for each of the 12 missed doses of hydromorphone 4mg as indicted above. pregabalin 100mg7/24 12:00 p.m. and 8:00 p.m. doses7/25 8:00 a.m. 12:00 p.m. and 8:00 p.m. doses7/26 8:00 a.m. 12:00 p.m. and 8:00 p.m. doses7/25 8:00 a.m. 12:00 p.m. dosesTotal of 10 missed doses of pregabalin 100mg R20's progress notes, dated 7/24/26 through 7/25/26, indicated staff noted no supply for each of the 10 missed doses of pregabalin 100mg as indicted above. However, R20's medical record lacked evidence R20's provider was notified of the 12 missed doses of hydromorphone 4mg and/or the 10 missed doses of pregabalin 100mg. R20's progress note, dated 7/26/26 at 11:28 a.m., indicated R20 was not feeling well and lost appetite. R20 had not taken scheduled pregabalin and hydromorphone, due to being out of stock/supply and R20 might be going through some withdrawals. R20's progress note, dated 7/26/26 at 8:51 p.m., indicated R20 currently out of pregabalin and hydromorphone, and R20 complained of not feeling well, SOB, and skin crawling. The nurse contacted the on-call nurse practitioner to report R20's complaints and need for medication orders. R20's progress note, dated 7/27/26 at 2:10 a.m., indicated R20 was administered diphenhydramine (antihistamine) solution 25mg intramuscularly (IM) one time only for Anaphylactic reaction and to contact the MD/NP if repeat dosing needed. R20 observed to exhibit signs and symptoms of withdrawal, including complaints of difficulty sleeping, skin crawling. However, R20's medical record lacked evidence R20's provider was notified of R20's change in condition. R20's progress note, dated 7/28/26 at 5:53 p.m., indicated licensed practical nurse (LPN)-A and the primary care provider (PCP) met with R20, and R20 stated that 'I don't feel good' and resident stated that he thinks he went through some withdrawal. LPN told PCP that R20 had been out of hydromorphone. PCP asked why we stopped his hydromorphone. Writer stated that we did not stop it and that the script [prescription] had not been sent to the pharmacy. During an interview on 7/29/26 at 2:35 p.m., R20 stated he went without his hydromorphone and pregabalin for days and went into withdrawal. R20 stated he was shaking, short of breath (SOB), sweating, nauseous, heart racing, and was in horrible pain. R20 stated he didn't eat for two days, wanted to crawl out of my own skin and it was a miserable four days. R22's significant change MDS, dated [DATE], indicated R22 had moderate cognitive impairment, diagnoses included COPD, spondylosis (causes pain in the spine area that worsens with movement), and chronic pain syndrome, and R22 received scheduled pain medication regimen. R22's care plan, revised 7/16/26, indicated R22 preferred comfort-focused treatment. R22's order summary, reviewed 7/30/26, indicated R22 had an order for oxycodone HCL (opioid/narcotic used to treat moderate to severe pain) 5mg by mouth BID related to chronic pain syndrome, with a start date of 6/8/26. R22's July MAR indicated R4 was not administered medications as follows: Oxycodone 5mg:7/18 AM and HS doses7/19 AM and HS doses7/20 AM and HS doses7/21 AM and HS doses7/22 AM doseTotal of 9 missed doses of oxycodone 5mg R22's progress notes, dated 7/18/26 through 7/22/26, indicated staff noted no supply for each of the 9 missed doses of oxycodone 5mg. However, R22's medical record lacked evidence R22's provider was notified of the 9 missed doses of oxycodone 5mg. During an interview on 7/30/26 at 9:54 a.m., the on-call NP stated when the facility contacted her on 7/26/26, they requested just a refill order for R20's medications. NP stated the nurse failed to notify her R20 had missed several doses of hydromorphone and pregabalin, and that R20 suffered from any symptoms. NP stated had the nurse notified her of the missed medications and/or symptoms, NP would have directed the nurse to send R20 to emergency room for withdrawal symptoms that possibly could not have been managed at the facility. NP further stated the nurse needed to provide a thorough SBAR (situation-background-assessment-recommendation) about the current situation and background. During an interview on 7/30/26 at 2:20 p.m., director of nursing (DON) stated it was important to keep the provider updated, and the nurses were expected to notify the provider in SBAR form for any missed medications and/or change in condition. The facility's Change in Condition policy, revised 7/29/25, indicated the facility would inform the resident, consult with the physician, and notify the resident representative when a change occurred, to ensure timely identification, assessment, and intervention for significant changes in resident's condition.

Based on observation, interview, and document review, the facility failed to ensure meal trays were served in a timely manner for 6 of 6 resident trays sampled to preserve desired temperatures and palatability. This had the potential to affect all residents who chose to eat on the unit or in their rooms. Findings include:During survey entrance on 7/26/26 at 8:30 a.m., facility mealtimes were requested and provided by facility Administrator (Admin) via email. The provided times were as follows:Breakfast - 8 AMLunch - NoonSupper - 5 PMEvening - snacks are offered and always availableDuring observation and interview on 7/27/26 at 5:28 p.m., the following temperatures were recorded by the Dietary Manager (DM) on a resident meal tray: Chicken - 105 degreesPotato - 108 degreesSliced Carrots - 94Jello - 53 degreesCranberry juice - 60 degreesIce water - 52 degreesDM stated meals served on the pod are dished in the dining room before residents are allowed into the dining room. DM stated staff on each pod is alerted via walkie talkies when trays are being delivered to the pods and then staff in the pod deliver the trays to the residents. DM stated dietary staff was responsible to deliver trays to the [NAME] pod and floor staff on Maple was responsible for delivering those trays. During observation of noon meal tray delivery on 7/28/26 at 12:11 p.m., certified nursing assistant (CNA-A) checked meals trays delivered to Maple pod with a digital food thermometer. The following was observed: Room tray for room [ROOM NUMBER] - both cold and hot food was under a plastic cover and served on the same plateShredded beef - 121.6 degreesTater Tots - 98.4 degreesSalad - 67.5 degreesStrawberries with whipped topping - 64.2 degreesApple juice - 54.7 degrees Room tray for room [ROOM NUMBER]Shredded beef on bun - 118.2 degreesGreen beans - 104.5 degreesStrawberries with whipped topping - 64.6 degreesApple juice 52.9 degrees CNA-A was unable to state what the safe and desirable temperature of each food should be. CNA-A stated she had not ever thought about the temp and 'just delivered trays' to the residents. During interview on 7/28/26 at 1:17 p.m. DM stated food served outside of the safe zone increases the risk of food born illnesses. When reviewing the temps taken on 7/26/26, DM stated she would not want to eat cold chicken or drink warm milk. DM stated she expected staff to deliver meal trays to residents as soon as they were delivered to the pod and to warm up trays of cold food or offer the resident a fresh tray. DM was unable to state how long meal trays sat on each pod before staff delivered them.On 7/29/26 at 9:41 a.m., a large, uncovered cart was observed sitting in the pod of residents' rooms waiting to be delivered. Plates were covered and sitting on trays, they were not enclosed in a cart, or on warmer plates.ON 7/29/26 at 9:41 a.m., a nursing assistant (NA)-B working on the unit confirmed the trays were waiting to be delivered and had been dropped off about 20 mins prior. While speaking to NA-B they took a tray from the cart and went and warmed it up in the microwave on the unit. NA-B stated although she reheated the plate, she did not temp the food nor was aware she should. On 7/29/26 at approximately 9:50 a.m., dietary manager (DM) was asked to come to the floor with a thermometer and the following temperatures on two trays of resident food were observed:Tray #1 labeled room [ROOM NUMBER]:Eggs-87 degrees Fahrenheit ( F)Toast-82 FBacon-78 FCoffee-114 FMilk-58 F Tray #2 labeled room [ROOM NUMBER]:Pancakes-92 FSausage-93 FBacon-86 FStrawberries-70 FThe DM stated these temperatures did not meet their expectations, and they expected staff to warm and recheck the temperatures of food prior to serving it to the residents. The DM removed the trays and had the residents provided with a new meal.On 7/29/26 at 10:00 a.m. the administrator and the DM stated they were unsure if the floor staff have been trained on when or to what temperature the food should be at prior to being served. The administrator and DM confirmed the food should have been warmed prior to being given to the residents and the above listed temperatures were outside of their expectations.A policy related to food temperatures was requested and none were provided.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and/or maintained to ensure proper goals and interventions were in place to maintain adequate nutritional status for 1 of 1 resident (R4) reviewed for care plans. Findings include: R4's quarterly Minimum Data Set (MDS) indicated R4's most recent admission to the facility was 4/10/26, cognitively intact, and had the following diagnoses: Heart failure, Chronic Obstructive Pulmonary Disease and Dysphagia (trouble swallowing involving both the mouth and throat parts of swallowing food/fluids). During initial record review on 8/26/26 at 11:33 a.m., indicated R4's most current weight as 168.6 lbs. The record further indicated R4 had a 14.33% weight loss over 6 months. Nutritional risk assessment completed 6/8/26 indicated R4's weight on 6/2/26 was 173lbs. The assessment further indicated R4's goal weight was 172-185, his oral intake was 51-75% of meals served and listed soft and bite sized with mildly thickened liquids as current ordered diet. Dietary assessment completed 6/8/26, indicated R4 did not have a swallowing disorder and was not on a prescribed weight-loss regimen. R4's care plan reviewed 8/28/26, indicated a focus of potential for altered nutrition, listed a goal of maintaining weight to within 5% of admission weight, and listed the goal weight range as 200-220lbs. During interview on 7/29/26 at 2:02 p.m., Licensed Practical Nurse manager (LPN-A) for the Maple unit stated he was familiar with R4 and his care plan. LPN-A stated he was aware of R4's diagnosis of dysphagia and stated he was on an altered diet of soft and bite sized pieces. LPN-A stated care plans were collaborative and included input from nursing and dietary staff. During interview on 7/29/26 at 4:24 p.m., Director of Nursing (DON) stated she was aware of R4 and his current health issues. DON stated care plans were completed primarily by the unit managers but were discussed with all team members to provide a whole picture of the residents. DON confirmed R4's care plan lacked accurate current information and had not been updated to reflect his current nutritional status and weight goals. DON stated she expected care plans to be reviewed routinely for accuracy and update accordingly. DON stated it was important for the care plans to be current and updated with accurate information to address their individual health needs. Facility policy titled Person Centered Care Planning indicated St [NAME] Health Services will develop and implement a person-centered care plan with identified medical, nursing, mental and psychosocial needs. The policy out lined the care plan will include measurable goals and interventions, identifying services to maintain or improve highest practicable well-being. It also indicated the care plan will be reviewed and revised quarterly, upon significant change of condition, or as otherwise necessary to reflect the residents' current needs, goals and preferences.

Based on observation, interview, and document review, the facility failed to monitor weights and modify/develop specific interventions for 1 of 1 resident reviewed for significant, unintentional weight loss. Findings include: R4's quarterly minimum data set (MDS) dated [DATE], indicted R4 admitted to the facility on [DATE], was cognitively intact and had the following diagnoses: Chronic Obstructive Pulmonary Disease, Heart failure, Dysphagia and Parkinsonism. R4's Nutritional Risk assessment dated [DATE] indicated R4's current weight as 173 lbs., indicated a 4% weight loss over 30 days, 10.3% weight loss over 180 days and indicated R4's goal weight as 172-185lbs. The assessment lacked recognizing R4's diagnosis of dysphagia and failed to identify R4's estimated nutritional needs. R4's Dietary assessment dated [DATE], indicated R4 was not on a prescribed weight-loss regimen and received a mechanically altered diet. R4's orders reviewed on 7/28/26 indicated R4 was to be weighed weekly and received a soft and bite size texture diet with nectar thick liquids. The orders lacked any order for dietary supplements to reduce weight loss. A progress note dated 6/8/26 indicated R4 had no decrease in food intake over previous 3 months, had weight loss greater than 3kg(6.6lbs) in previous 3 months, and had a mini nutrition score of 11 indicating at risk for malnutrition. Progress/dietary note dated 6/8/26 indicated weights: 173 (current); 180 (30d: 4% loss); 193 (180d: 10.3% loss) and indicated R4 required assistance with meals due to occasional swallowing difficulty. R4's care plan indicated a focus of potential for alteration in nutrition due to leaving 25% or more food uneaten at meals indicated goals of maintaining weight to within 5% of admitted weight and having adequate nutritional intake. Interventions included encouragement to feed self (initiated 11/4/24), fortified foods (initiated 5/6/26), monitor weights weekly (initiated 11/4/24) and offer substitutes for dislikes when not eating (initiated11/4/24). The care plan lacked any evidence of including a dietary supplement to R4's diet to maintain weight. Review of R4's weights from 2/17/26 through 7/28/26 revealed the following documented weights indicating a 14.33% weight loss over the previous 6 months: 7/28/2026 165.0 7/25/2026 168.6 7/21/2026 167.6 7/14/2026 169.5 7/7/2026 170.6 6/30/2026 169.4 6/23/2026 172.0 6/13/2026 176.0 6/9/2026 176.8 6/2/2026 173.0 5/30/2026 177.0 5/26/2026 177.0 5/23/2026 175.0 5/19/2026 179.2 5/12/2026 180.3 5/5/2026 179.8 4/28/2026 179.8 3/31/2026 182.6 3/24/2026 185.03/17/2026 184.2 3/17/2026 186.0 3/10/2026 183.6 3/3/2026 192.2 2/24/2026 187.8 2/17/2026 192.6 During interview on 7/29/26 at 2:02 p.m., Licensed Practical Nurse (LPN-A) stated R4 fluctuated between partial to full assistance with meals, did not refuse meals and had dysphagia. LPN-A confirmed R4 had steadily lost weight since his recorded weight on 2/17/26. LPN-A stated the facility registered dietician was aware but could not confirm if R4's primary care physician was aware of the weight loss. During interview on 7/29/26, at 4:24 p.m., Director of Nursing (DON) stated R4 could feed himself, took his meals in the dining room and did not refuse meals. DON stated R4 had a swallowing disorder and Parkinsonism which would 'complicate' swallowing. DON confirmed that R4 had lost greater than 14% over the previous 6 months and agreed that was a significant weight loss. DON stated her expectation for monitoring weights is any weight loss of 5% in one month and/or 10% in 6 months the primary physician should be updated. DON stated it was important to monitor weights and update the provider of continued unplanned weight loss and failure to identify or stabilize an unplanned weight loss could negatively affect a resident by muscle loss, weakness and general deconditioning. During phone interview on 7/29/26, at 5:15 p.m., Registered Dietician (RD) stated she was familiar with R4 and was aware there was some weight discrepancies. RD stated R4 had a fortified diet put in place on 7/13/26 but continued to lose weight. RD stated R4 should lso been receiving a dietary supplement such as Ensure or Boost, however, could not identify why she had not made that recommendation to the care team. Facility policy title Weight Monitoring Program with a last review date of 1/18/21 indicated the facility will monitor weights of individuals receiving services to prevent unintended weight loss and medically significant weight gain. The policy indicated a significant weight loss of 5% or more in 30 days or 10% or more within 180 days. The policy identified dysphagia as difficulty swallowing and can result from a lack of saliva, weak chewing muscles, lack of tongue control, absent or delayed reflexes, muscle paralysis, and/or a lack of proper coordination with breathing. The policy further indicated the following actions and interventions: IRS will be weighed weekly, as needed, or as ordered by physician/attending practitioner; Interdisciplinary team (IDT) will discuss the IRS with at risk weight loss, significant weight loss, or medically significant weight gain weekly. Documentation will include determined interventions; Dietary Risk and Nutritional Risk Assessments will be completed upon admission, annually, quarterly or with a significant change in condition; care plan will be initiated/updated based upon assessments; Assess and identify nutritional problems, eating and drinking habits, activity level, and patterns; Fortify foods and beverages to increase calories and offer high calorie foods/beverages during meals and snacks; Offer high calorie foods and beverages throughout the day and have readily available in room (if allowed and no choking risks); Supplements such as a high calorie shake, Ensure, Boost, etc. may be added as needed; these are best given between breakfast and lunch, between lunch and supper, or between supper and bedtime; supplements should not be given at mealtime unless preferred by resident or family designee or if ordered by physician; Medication review with pharmacist/pharmacy consultant will occur to identify any appetite suppressers; Consultation with physician/attending practitioner to determine if IRS could benefit from an appetite stimulant; Ensure documentation of all interventions tried to improve calorie and nutritional intake to prevent unintended. Refusals of meals, snacks, and alternate choices offered along with IRS' response should be documented; Assess and adjust care plans to meet the IRS' medical, physical, mental, and psychosocial needs in a way that supports overall nutrition; Audit and review nutrition progress notes and documentation regularly; any concerns or trends identified will be discussed at IDT; Quality Assurance Performance Improvement (QAPI) team will review at risk weight loss, significant weight loss, and medically significant weight gain data at meetings.

Based on observation, interview, and record review, the facility failed to ensure residents were promptly informed of changes to the Nursing Home Resident [NAME] of Rights (RBOR) and failed to ensure the current RBOR was available and displayed for residents, staff, and visitors to review. This deficient practice had the potential to affect 60 residents, as well as staff and visitors who relied on the outdated information.Findings include:On 7/30/26 at 2:25 p.m., an outdated RBOR was observed posted in the facility.On 7/30/26 at 2:25 p.m., social services director (SSD) confirmed the posted RBOR information was outdated. SSD stated it was their responsibility to hang and keep the information updated, and it had not been completed.A policy regarding posting the RBOR was requested and none was provided.

Based on interview and document review, the facility failed to comprehensively assess a change in bowel status and, if needed, implement interventions to prevent complication (i.e., obstruction, discomfort) for 1 of 3 residents (R3) reviewed. R3 developed consistent loose stools on 6/20/26 which were not evaluated or assessed, and R3 then admitted to the hospital on [DATE] with a potential bowel obstruction. In addition, the facility failed to update or communicate the results of completed medical testing (i.e., lab results, urinalysis) with the primary hospice team for 1 of 3 residents (R1) reviewed. R1 had multiple laboratory tests ordered on 6/5/26; however, the rationale for testing and subsequent test results were never shared with hospice to ensure appropriate coordination of care. Findings include: BOWELS NOT ASSESSED:R3's last completed and signed Bowel and Bladder Comprehensive, dated 4/29/25, identified R3 has being occasionally incontinent of bowel and needing extensive assistance with most activities of daily living (ADLs). The assessment left several sections blank with no recorded data present and outlined at the bottom that no changes to the care plan were made.R3's most recent Bowel and Bladder Comprehensive, dated 3/26/26, identified the evaluation remained, In Progress, and was not signed as completed. The evaluation identified multiple sections to record various data points including catheter use, restorative potential, bladder observation and bowel function. However, the sections for bowel function, labeled as Bowel Observations and Bowel Program Selection, were both left blank, and no recorded data was present.R3's annual Minimum Data Set (MDS), dated [DATE], identified R3 had short and long-term memory impairment but was always continent of bowel. The MDS recorded R3 as not being on a toileting program for bowels and having no constipation present. R3's corresponding Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) identified urinary incontinence as an actual problem which would be addressed in care planning. However, the completed CAA lacked any recorded data or review of R3's bowel status or bowel incontinence.R3's care plan, printed 6/30/26, identified R3's potential and actual problems along with interventions to address them. This outlined R3 had an activity of daily living (ADL) self-care deficit due to dementia and required assistance of two (A2) with a PAL lift for toileting and wore XL green briefs. Further, R3 had bowel incontinence and staff were to ensure he was placed on the toilet when being changed for the day, staff allowed him to sit and empty his bowels on the toilet, and staff toileted R3 every 4 hours and as needed (PRN). The section of the care plan which identified R3 as being incontinent of bowel was last updated 4/2026.R3's POC (Point of Care) Response History, dated 6/1/26 to 6/29/26, identified R3's recorded bowel movements in the EMR charting. The data recorded the size of movement along with its consistency. From 6/10/26 to 6/19/26, R3 had 15 recorded bowel movements with only four (4) recorded as loose/diarrhea. From 6/20/26 to 6/25/26, R3 had 10 bowel movements. However, now seven (7) of the ten were recorded as loose/diarrhea.R3's Medication Administration History (MAR), dated 6/2026, identified R3's provided medications for the month period. R3 was recorded as having PRN laxative medications available, such as Miralax, but there were no recorded administrations of these medications recorded for the month. R3's progress note, dated 6/25/26, identified R3's family member notified staff R3 was having a medical emergency and the nurse responded. R3 was found with a large amount of emesis on his chest and his abdomen very distended. R3 was transferred to the hospital via EMS. The note concluded, [Family] called with update . had a small bowel obstruction . Plan is to see surgeon in the morning.R3's corresponding hospital admission H&P, dated 6/26/26, identified R3 was admitted to the hospital from the emergency department (ED) for vomiting and abdominal distention. R3 had a PEG tube (Percutaneous Endoscopic Gastrostomy; a flexible feeding tube surgically placed through the abdominal wall directly into the stomach) in place for several years prior and a CT scan of the abdomen recorded, . distended with air and fluid, concerns for enteritis or partial obstruction.R3's medical record lacked evidence of any fully completed and signed bowel assessments since 4/2025 (over a year prior). Further, the record lacked evidence that R3's developed consistent loose stools (starting 6/20) were acted upon and assessed to determine what, if any, interventions were needed to reduce them or if more evaluation (i.e., notification to the provider) was needed.When interviewed on 6/30/26 at 9:03 a.m., nursing assistant (NA)-E stated bowel movements were tracked on a paper form and then entered to the computer charting. The NA who helped a resident when they had a bowel movement was responsible for charting it. The nurses would then assess the person and report to the NA how often they would be toileted. NA-E recalled working with R3 and stated he did not speak and would be incontinent of bowel every now and then only. NA-E stated they had noticed prior to R3 being hospitalized that his stools were loose and watery but were unsure if this was a change for him as they only worked casual shifts. In the past though, NA-E stated R3's stools were more on the soft, formed side. NA-E stated they were unsure if R3 used any laxative medications or not, and R3 had used tube feeding for several years prior to this hospitalization. Further, NA-E stated if they recognized a change in a resident then they'd report it to the nurse.When interviewed on 6/30/26 at 9:15 a.m., registered nurse (RN)-B explained they worked for a pool agency but had worked multiple shifts at the care center. RN-B stated they had worked with R3, and he was currently hospitalized . R3 had a tube feeding which was not brand new to him. RN-B stated they were not very sure of R3's bowel status as they only worked casually. However, if there was a change in bowel status the NA(s) had noticed, then they should report it, and the nurse would assess. RN-B stated a change in bowel movement consistency warranted an evaluation including bowel sounds and medication review as staff needed to determine where the change was coming from. RN-B stated they thought this process would be recorded in the progress notes or on a new Bowel and Bladder Comprehensive.On 6/30/26 at 10:05 a.m., a group interview was held with the director of nursing (DON), licensed practical nurse manager (LPN)-A, registered nurse case manager (RN)-C, and the RN/MDS coordinator (RN)-E. R3's medical record was reviewed and RN-E explained they complete a bowel evaluation using a look back report which captures the NA recorded data on bowel movements and continence. That information was then pulled to the MDS and completed on the Bowel and Bladder Comprehensive in the EMR. The RN was responsible for doing that evaluation, but an LPN could contribute. RN-E stated the facility had just recently changed to doing the comprehensive evaluations every quarter as prior they were only done annually. RN-E verified R3's last completed Comprehensive had the data for the bowel sections left blank adding they didn't finish it. They didn't complete it as they did not get along with R3's family member who was often present in his room. RN-E stated the missed data collection was a reason they had asked to adjust these evaluations to quarterly and not just annually. RN-E added it was to improve our cares. RN-E then reviewed R3's POC charting and stated the data showed a change in bowel consistency on 6/21/26 and wondered if anyone had reported it or evaluated it. LPN-A and RN-C both stated none of the aides had reported anything to them about R3 having loose stools. RN-E verified the medical record lacked evidence that the change of bowel status had been evaluated or assessed and explained any change like that should be acted upon to determine if the physician needs to be involved or not. DON stated they felt R3's hospitalization was likely unavoidable given the wife would want treatment options for a potential obstruction which the care center could not perform.A facility policy on bowel assessment or evaluation was requested; however, none was received. A provided Assessment Matrix, dated 6/26/26, identified each assessment of the facility they completed and when to complete them. This identified nursing would complete the Bowel and Bladder Comprehensive on, Annual/Sig [sig change]. HOSPICE COORDINATION:R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment but no infections. A subsequent Discharge Return Anticipated MDS, dated [DATE], identified that R1 was admitted to the short-term general hospital.R1's Fax Cover Page, dated 6/5/26, identified the physician office faxed a series of orders to the care center from the medical doctor (MD). These included orders to draw multiple laboratory tests including a Complete Blood Count (CBC), metabolic panel (CMP), magnesium, phosphorus, and complete urinalysis (UA). The order listed a diagnosis for these as, Acute Confusion.R1's Health Laboratory (Results), dated 6/8/26, identified the tests were collected on 6/8/26 and showed the results. R1 was recorded with an elevated Creatinine, Blood Urea Nitrogen (BUN), and a decreased (low) red blood cell (RBC) count and hemoglobin. The UA showed, <10,000 colonies . Probable contaminant(s).R1's Hospice Visit Communication (record), dated 1/29/26 to 6/23/26, identified the registered nurse (RN) entries recorded on a paper format. R1 admitted to hospice on 1/29/26. This identified a total of nine (9) visits for June 2026 with the last entry on 6/23/26, Vitals low (BP, O2) Pulse [elevated] sent to ER per family. The notes lacked evidence that R1's completed labs on 6/8/26 were discussed or provided to hospice.R1's entire medical record, including progress notes, lacked evidence the laboratory testing was reported to the hospice agency for R1 to ensure hospice was involved in the decision making for R1 and to promote continuity of care.When interviewed on 6/29/26 at 11:57 a.m., hospice nursing assistant (NA)-B stated they had worked with R1 at the care center. R1 had several wounds on her legs and bottom and had become more tired as June 2026 progressed. NA-B stated R1's primary hospice nurse was RN-G who mostly helped with orders and treatments. NA-B stated there had been some issues with hospice care coordination at the care center over the past months but felt it was getting better lately as the hospice management had visited with the facility leadership prior about some issues. When interviewed on 6/29/26 at 12:23 p.m., hospice registered nurse (RN)-G stated they were R1's primary hospice nurse while R1 resided at the care center before her passing. R1's medical record was reviewed with RN-G who stated they were unaware R1 had lab testing completed on 6/8/26. RN-G added, We were not made aware of that. RN-G stated they would have liked to have been updated those tests were done and with the results and reiterated, I didn't know that happened. RN-G stated they did not have EMR access at the care center to see them without staff notification, but the care center was working on getting them access. The center and hospice relied on a lot of verbal communication to ensure continuity of care between them and RN-G stated there were times when some care things, like falls and this lab testing example, which didn't always get reported timely to hospice. RN-G stated a meeting was scheduled upcoming between hospice and the care center to discuss R1 (related to a missed antibiotic) and added they felt they were getting all the information on their other patients in the center adding further, I hope so.When interviewed on 6/29/26 at 1:02 p.m., RN-K stated the nurse manager or case manager would be the one responsible to update hospice with new orders or lab testing results. RN-K stated they had never been told or asked to do that prior as a floor nurse and reiterated the unit managers would handle it.On 6/29/26 at 2:02 p.m., a group interview was held with several members of the care center leadership present including the director of nursing (DON), administrator, licensed practical nurse manager (LPN)-A, and registered nurse case manager (RN)-C. It was explained that R1 was admitted to hospice in January 2026 for end-stage pulmonary hypertension and either of the nurse managers could update hospice with new orders, lab testing results, or other care-related items. R1's medical record was reviewed, and they explained that R1's family had called her MD on 6/4/26 with concerns for acute confusion which is what prompted the lab orders to come to the care center. LPN-A stated they could not recall if they visited with hospice about the lab orders and results or not, but RN-C then stated any communication with hospice should have a progress note completed in the record to show such happened. They verified hospice should have been updated with the orders and results for the lab testing completed on 6/8/26 as hospice would make the decision to treat or not treat any abnormal results.A facility Hospice Services policy, dated 3/2022, identified the care center as responsible to designate a nurse to coordinate and supervise the services and be available to consult with hospice staff about the care plan. This included, Collaborate with Hospice staff regarding resident changes in condition or Physician orders. The policy added, Coordination of Care - Hospice and care center staff will communicate with one another regularly and as needed for each hospice patient.

Based on observation, interview and document review the facility failed to ensure bruising and non-pressure wounds were adequately assessed and monitored for 2 of 3 resident (R2 and R3) reviewed for injuries of unknown origin.Findings include:R2R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment, no skin impairment or dressing changes. R1 had diagnoses of peripheral vascular disease and hypertension.R2's medical record lacked documentation of R2's skin tear on his right outer wrist.During an interview on 5/20/26 at 11:16 a.m., R2 stated he got the skin tear on his right wrist from running into the door frame of his room but was not sure what it occurred. R2 stated a nurse had come in and put the dressing on a few weeks ago but he was not sure who the nurse was.During an observation on 5/20/26 at 11:17 a.m., R2 was seen with a bandage on his right wrist. Bandage was approximately 1 inch by 1 inch piece of gauze with a clear undated dressing over the top. During an observation on 5/20/26 at 2:35 p.m., registered nurse (RN)-A removed the bandage on R2's right wrist. R2 had a skin tear that measured 1 centimeter (cm) by 0.5 cm, with a scant amount of serosanguinous (pink to light red fluid) drainage, and no signs of infection.During an interview on 5/20/26 at 2:49 p.m., RN-A stated on 5/12/26, she placed a new wander guard on R2's right wrist and there was no injury at that time. RN-A stated someone had to have known about the skin tear on R2 because it had a dressing on it. RN-A stated she was not aware of the skin tear on R2 until 5/20/26, when state agency told RN-A. RN-A was not sure who put the dressing on R2's right wrist or when it was placed. R3R3's annual MDS dated [DATE], indicated R3 has severe cognitive impairment, R3 had diagnoses of hemiplegia (paralysis on side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke), vascular dementia, and epilepsy.R3's Skin Issue form dated 4/16/26, indicated R3 had a bruise on his lower back with no other details.R3's medical record lacked any further documentation or monitoring of R3's bruise on his lower back.During an interview on 5/20/26 at 10:37 a.m., R3 stated he was not aware he had a bruise on his back.During an interview on 5/21/26 at 9:13 a.m., RN-B stated if a new injury is found on a resident staff would be expected to assess the injury, document the findings in the resident's medical record, update the provider, and add monitoring of the area to the resident's orders. RN-B stated he found the bruising on R3's back and noted it had come from his lift sheet being bunched in a ball under his back. RN-B stated it slipped his mind to put monitoring in place for the bruise. RN-B forgot to put the full assessment of the bruise in R3's medical record.During an interview on 5/21/26 at 10:29 a.m., RN-A stated if staff find a new skin issue or bruise on a resident the staff would be expected to get measurements, gather information, and place the information in a risk management note as well as write a progress note in the resident's medical record. The staff would then be expected to put orders in the medical record for monitoring as well as any treatment needed and update the provider. RN-A stated she was not aware of R2's skin tear on his right wrist or R3's bruise on his back. RN-A stated they were unable to find which staff placed a dressing on R2's skin tear on his right wrist. RN-A stated she was not sure why the steps were not followed when a new skin issue or bruise was found.During an interview on 5/21/26 at 10:47 a.m., the director of nursing (DON) stated staff would be expected to fill out the skin form and follow the skin policy. If there was a new skin tear or bruising, there should have been orders to monitor those areas weekly and get orders from the provider as needed for treatments. The DON was not sure why the policy was not followed for R2's right wrist skin tear or R3's bruising on his back.During an interview on 5/21/26 at 11:02 a.m., the administrator stated the staff would be expected to fill out a risk management form, monitor the area, and contact the provider for any new skin tears or bruise found. The administrator stated the nurses at the facility are newer and would need some retraining on the skin policy.The facility New Skin Condition Policy revised 3/2024, indicated if any new skin issue was noted staff would document the area in the electronic medical record for continued monitoring, report open area to nurse manager, and obtain a physician's order for any new treatment initiated.

Based on interview and document review the facility failed to complete comprehensively assess level of supervision and failed to complete root cause analysis (RCA) following falls for 1 of 3 residents (R1) reviewed for falls.Findings include R1's psychiatric mental health evaluation summary note dated 2/25/26, indicated R1's diagnoses included major neurocognitive disorder due to vascular disease, with behavioral disturbance, severe, abnormalities of gait and mobility, repeated falls, cerebral vascular disease (CVA) with left hemiparesis, acute encephalopathy, and chronic pain.R1's comprehensive quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and required substantial/maximal assistance for toileting, transfers, lying to sitting on bed side, and put on/take off footwear.R1's activities of daily living (ADLs) care plan dated 2/19/25 revised on 3/1/26, indicated R1 required assistance of two with stand assist utilize full mechanical lift as needed for weakness or fatigue for transfers. R1's ADLs care plan dated 2/19/25 revised 8/28/25, directed staff to turn and reposition R1 in bed every 2-3 hours and as necessary. R1's ADLs care plan dated 8/22/25, directed staff to analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document these findings. Additionally, R1's ADLs care plan dated 8/22/25 directed staff to assess and anticipate R1's toileting needs, comfort level, body positioning, pain etc. Despite these directives, the care plan did not include enhanced supervision or incorporate the psychiatric evaluation's recommendation for 24-hour supervision, completed on 2/25/26.R1's psychiatric mental health evaluation dated 2/25/26, recommended R1 required 24-hour supervision to ensure safety. The evaluation further indicated simple ADLs needed to be initiated by caregiver and continual supervision may be needed to correct R1's behaviors.R1's medical record review from February and March 2026 showed no adequate documented analysis of root causes, no evidence that the interdisciplinary team revised the care plan, and no documentation that R1's supervision needs were reassessed according to the psychiatric evaluation.R1's progress note dated 2/18/26 at 8:25 p.m., indicated R1 had an unwitnessed fall in the lounge area next to brick wall when her wheelchair (WC) had stuck in a curve of the wall. The note further indicated R1 slipped out of WC landing on pedals with her knees bent under her. Staff assisted R1 straighten legs out and then used a full mechanical lift to transfer R1 back into her WC. The root cause analysis was not identified but the corresponding interventions identified as staff were to ensure R1 had been toileted every two hours, change and reposition, bed in lower position, and call light within reach.R1's progress note dated 2/25/26 at 9:14 p.m., indicated R1 experienced an unwitnessed fall in the hallway. Staff reported R1 had been pushing herself around the pod in an attempt to leave the building and was found sitting on the pedals of her WC. No injuries were noted. The root cause analysis identified R1 had slipped out of her WC due to the right foot pedal being in the down position. R1 used only one foot pedal because she propelled herself with her other foot, which increased the likelihood of sliding forward when the unused pedal remained attached. The corresponding intervention was to remove the right foot pedal, label it, and store it in the closet for use only during medical appointments.R1's progress note dated 3/4/26 at 10:59 p.m., indicated R1 had unwitnessed fall in her room with no injuries. The note lacked evidence of the root cause analysis for the fall. The note lacked the root cause analysis for the fall.R1's progress note dated 3/16/26 at 6:40 a.m., indicated R1 had unwitnessed fall in her room where she was found laying partially on the floor and partially on the fall mat next to her bed. The note further indicated R1 was found on the floor by another resident. Upon assessment, R1 did not sustain any injuries but staff were unable to rule out head strike and staff used mechanical lift to transfer R1 from the floor back to bed. However, the progress note did not include evidence of a root cause analysis (RCA) for the fall.R1's progress note dated 3/17/26 at 00: 30 a.m., indicated R1 had unwitnessed fall on 3/16/26 at 8:30 p.m. Staff found R1 lying on her floor mat with her bedding wrapped around her lower extremities. No injuries were noted. The note lacked evidence of the root cause analysis for the fall. Staff documented they have requested the provider to reconcile R1's medications to promote improved sleep patterns; however, this intervention alone did not substitute for a comprehensive RCA to determine why the fall occurred or how to prevent recurrence.R1's progress note dated 3/18/26 at 00:17 a.m., indicated R1 experienced unwitnessed fall on 3/17/26 at 10:10 p.m. Staff found R1 lying next to her bed, partially on the fall mat and partially on the floor, positioned on her left side. Her brief on the bed, and she was incontinent of urine. R1 did not sustain any visible injuries and transferred back to bed using a full mechanical lift. The note lacked evidence of the RCA.R1's treatment administration record dated March 2026, indicated R1 had a fall on 3/29/26 at 1:00 p.m. with no injury. R1's record did not include a comprehensive root cause analysis. =R1 experienced seven unwitnessed falls between 2/25/26 and 3/17/26. During this period, R1's psychiatric mental health evaluation identified a need for continuous supervision, yet across these events, the facility's documentation showed inconsistent completion of root cause analyses and limited evidence of comprehensive evaluation of contributing factors as directed by R1's care plan. Despite these recommendations, the facility did not consistently assess or address the factors contributing to R1's repeated falls, the care plan was not updated to reflect the psychiatric recommendation for enhanced supervision.During an interview on 4/20/26 at 5:23 p.m., a family member (FM)-A stated she was not always informed about R1's fall incidents. FM-A reported R1 should be toileting every two hours while awake but this was not happening, especially when agency staff were working. FM-A explained staff did not pay attention to R1's needs, which my increase her behavior resulting in falls. FM-A stated she came to visit R1 on 4/18/26 and she was incontinent with urine, her WC was wet and smelling. R1 was sitting alone in the pod, and she had to call an NA to help R1. FM-A stated she did not report the incident to the nurse manager because they would not do anything to address the issue as always.During an interview on 4/20/26 at 1:03 p.m., a nursing assistant (NA)- A stated R1 tries to get up without help a lot and we don't always have someone right there to watch her. NA-A explained she had been walking in the hallway past R1's room when she observed R1 lying on the floor next to her bed, partially on the fall mat, on 3/17/26. NA-A stated R1's brief was on the bed, and R1 was incontinent of urine at the time. NA-A stated she immediately notified the nurse, who came to assess R1 before R1 was transferred back to bed using a mechanical lift. NA-A stated she was not aware of any new interventions added after R1's repeated falls.During an interview on 4/20/26 at 1:48 p.m., NA-B stated R1 had experienced multiple falls in her room and R1 needed to be checked every two hours to prevent further falls. NA-B reported R1 might be highly sensible to environmental factors such as noise, loud music, or light which could contribute to her repeated fall incidents. NA-B stated she did not recall any team discussions on the unit regarding R1's multiple falls or strategies to prevent recurrence. NA-B explained they were not aware of any new interventions added following R1's repeated falls.During an interview on 4/20/26 at 2:49 p.m., a licensed practical nurse (LPN)-A who served as R1's case manager stated R1 was one of the frequent fallers and she was aware of her multiple fall incidents. LPN-A reported she did not provide any education to the staff regarding R1's repeated falls or the corresponding interventions needed to ensure R1's safety. LPN-A stated she was not sure who updated R1's care plan following the falls. LPN-A reported she was unaware of R1's psychiatric mental health evaluation dated 2/25/26, which recommended 24-hour supervision to ensure R1's safety. LPN-A confirmed that supervision levels were not increased despite R1's ongoing fall pattern.During an interview on 4/20/26 at 3:46 p.m., a registered nurse RN-A stated R1 had been falling a lot lately, but the care plan hadn't really changed. RN-A reported she completed the post fall evaluation on 2/26/26 for R1's unwitnessed fall on 2/18/26, during which R1's WC became stuck in a curve of the wall and R1 slipped out of WC, landing on pedals. RN-A stated she did not know what was decided during the interdisciplinary meeting regarding R1's falls. RN-A also reported she was unable to locate documentation in R1's medical record indicating whether a comprehensive assessment had been completed to guide an effective plan to prevent further falls. RN-A reported she was unaware of R1's psychiatric mental health evaluation dated 2/25/26, which recommended 24-hour supervision to ensure R1's safety. RA-A confirmed that supervision levels were not increased despite R1's ongoing fall pattern.During an interview on 4/20/26 at 4:16 p.m., the director of nursing (DON) stated R1 was a frequent faller, and the facility had been trying to work with FM-A to determine what interventions might work better for R1. The DON stated she did not know whether each fall had been reviewed to identify the root cause analysis with corresponding interventions to prevent recurrence. The DON stated she expected staff to complete a comprehensive assessment after multiple falls to determine to the root cause; however, she was unable to locate any comprehensive assessment in R1's medical record despite multiple falls. The DON reported she was unaware of R1's psychiatric mental health evaluation dated 2/25/26, which recommended 24-hour supervision to ensure R1's safety. The DON confirmed that supervision levels were not increased despite R1's ongoing fall pattern. The DON explained since R1's psychiatric mental health evaluation on 2/25/26, R1 had experienced seven fall incidents with no injuries. The DON confirmed staff did not update R1's care plan to reflect the psychiatric recommendations. The DON stated R1 should have had additional interventions added and that the facility did not follow through.Fall Prevention and Management Policy dated 6/5/23 indicated the care center will assess each resident for risk of falls and identify interventions to assist in preventing falls and/or injuries. The policy also directed staff to complete a falls analysis when a resident has two or more falls, to review fall trends, identify individual and systemic causes of falls, evaluate current interventions for effectiveness and if needed to determine additional interventions. Additionally, the policy indicated the facility will educate staff, residents, and families to promote a culture of safety, to keep residents safe and reduce falls risks.

Based on interview, and document review, the facility failed to follow the care plan to ensure safe transfers to eliminate/reduce the risk of an accident during a transfer for 1 of 3 residents (R1). This resulted in actual harm when R1 fell, sustained a significant head injury (brain bleed) that required hospitalization. The facility had implemented actions to prevent reoccurrence prior to the survey; therefore, the citation was issued at past non-compliance (PNC).Findings include:Findings include:R1's order summary report 9/2/25, indicated R1's diagnoses included primary hypertension, persistent atrial fibrillation, prediabetes, generalized weakness, chronic respiratory failure, abnormalities of gait and mobility.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment and required substantial/maximal assistance for toileting, transfer, as well as mobility/ambulating.R1's activities of daily living (ADLs) care plan dated 1/1/25, indicated R1 required assistance of one with walker with ambulation as well as mobility and transfers. R1's ADLs care plan dated 1/1/25, directed staff to ensure R1 had footwear for ambulation and mobility. A historic intervention initiated 1/1/25 and cancelled on 12/23/25, informed R1 was substantial/maximal assistance- Helper does more than half the effort. Helper lifts or holds trunk or limbs.R1's progress note dated 12/17/25 at 3:00 p.m., indicated R1 had a fall in the bathroom hitting her head on the wall while she was stepping off the weight's scale. The note further indicated the provider and the family were notified, and neuro check initiated.R1's progress note dated 12/17/25 at 3:04 p.m., indicated R1 had a witness fall hitting her head against the wall while she was stepping off the scale in the bathroom without footwear. Staff did not assist R1 to step off the scale and gait belt was not used either during the transfer. The root cause analysis for the fall identified R1 became weak/lost balance while standing on scale for weight check with the corresponding intervention identified as staff were to ensure R1 had footwear with gait belt and one assist during mobility/transfer.R1's progress note dated 12/20/25 at 11:20 a.m., indicated R1 was confused and drowsy at breakfast time. Staff transferred R1 with two assists with non-mechanical lift to the toilet to get a urine sample due to an increased confusion and a decreased of level of conscience (LOC). Per the family request, R1 was transported to the hospital.R1's emergency department (ED) provider notes dated 12/20/25 identified R1 was transferred to the ED for an evaluation of a known head bleed. The note further indicated R1's family reported that R1 fell 3 days ago at the nursing home when she was having worsening confusion, altered level of consciousness and decreased appetite, and fatigue. R1's head computed tomography (CT) scan showed bleeding in her brain. R1 was found to have an intraparenchymal hemorrhage of the right temporal occipital junction with subdural blood products along the right tentorium.R1's computed tomography (CT) head scan without intravenous (IV) contrast note dated 12/20/25 at 2:18 p.m., identified R1 had intraparenchymal hemorrhage in the region of the right temporal occipital junction with subdural blood product extending along the right tentorial reflection.R1's magnetic resonance imaging (MRI) head scan without and with contrast note dated 12/21/25 at 11:31 a.m., indicated minor subdural hematoma along the right convexity and intra-axial hemorrhage grossly noted.During an interview on 12/30/25 at 12:30 p.m., a family member (FM)-A stated staff informed her R1 fell on the scale and hit her head against the wall in the bathroom on 12/17/25. FM-A stated the fall occurred when staff did not follow proper protocol during weight check for heart failure management, leaving R1 standing and unsupported. FM-A stated since the fall, R1 has been less interactive, with increased confusion and decreased oral intake. FM-A stated on 12/20/25, R1 was found to be very sleepy, confused, and not acting like herself. FM-A stated she requested R1 to be sent to the hospital for further evaluation.During an interview on 12/30/25 at 3:07 p.m., a registered nurse (RN)-A, a case manager stated she was informed on 12/17/25 that R1 hit back of her head against the wall in the bathroom during a transfer in which the care plan was not followed. RN-A stated it was unsafe to stand R1 alone on the scale unsupported. RN-A stated it was on 12/20/25 she noted R1 had increased confusion and not acting like herself. Per FM-A request, she sent R1 to the hospital. RN-A stated she did not provide an education to the staff that was involved in the fall accident right away and the staff continued to care for other residents until 12/20/25 when R1 was sent to the hospital.During interview on 12/31/25 10:30 a.m., a licensed practical nurse (LPN)-A stated when head was involved in the fall accident, staff should initiated neuro check, do the vital signs, monitoring the resident, and provided an update to the provider and the family. LPN-A stated depending on the resident condition, she will request imaging from the provider to rule out brain injury.During an interview on 12/31/25 at 10:41 a.m., NA-B stated she checked the care plan to be familiar with the resident's needs before providing care to them. NA-B stated she used to work with R1, and she was one assist with gait belt and walker for transfer and mobility. Staff to ensure R1 had appropriate footwear prior to transfer from the bed the bathroom.During an interview on 12/31/25 at 12:18 p.m., a nursing assistant (NA)-A indicated she worked on 12/17/25 when R1 fell in the bathroom hitting her head against the wall. NA-A explained R1 required substantial/maximal assistance for toileting, transfers, as well as mobility/ambulating and she was responsible for providing care to R1 that morning. NA-A stated she got R1 out of bed on barefoot, no gait belt during a transfer from bed to the toilet for weight recording. NA-A stated R1 was stepping off the scale lost her balance and fell backward hitting back of her head against the wall. NA-A stated she bent down to move the scale after R1 took the last step back off the scale, leaving R1 standing unsupported with no footwear and gait belt. NA-A stated it just slipped my brain but acknowledged that the care plan indicated to provide footwear to R1 and used a gait belt during a transfer.During an interview on 12/31/25 at 12:38 p.m., RN-B stated when she came to R1's bathroom after the fall on 12/17/25, R1 was in a sitting position on the floor with her head against the wall. R1 told RN-B she hit her head against the wall during the fall. RN-B stated she initiated neuro check immediately and R1 was within her normal limit with no visible injury which was reported to the provider and the family. RN-B confirmed R1 was on blood thinners medications.During an interview on 12/31/25 at 3:57 p.m., the director of nursing (DON) stated the incident was considered isolated and staff received follow-up education on preventing falls. The DON indicted NA-A was responsible to transfer R1 from bed to the bathroom to record her weight according to the care plan. The DON acknowledged NA-A did not follow the care plan when she decided to transfer R1 barefoot without gait belt and putting her on scale on a standing position unsupported causing R1 to fall hitting her head against the wall. The DON stated she got report from RN-A R1 was sent to the hospital and was found having a brain bleed. The DON stated when she realized RN-B and NA-A lied about the incident, she suspended them pending total investigation and started full house education. The DON stated I can not have people like that in the facility. R1's care plan was also updated. Fall Prevention and Management Policy dated 6/5/23 indicated the care center will assess each resident for risk of falls and identify interventions to assist in preventing falls and/or injuries. The policy indicated the facility will educate staff, residents, and families to promote a culture of safety, to keep residents safe and reduce falls risks.Record reviewed indicated by 12/22/25, staff were interviewed to gather details regarding the circumstances surrounding the incident. No further incidents were reported to the staff. -NA-A and RN-B were terminated in the alleged misconduct in violation of employer rules or policies on 12/23/25.-On 12/22/25 the facility had developed and started education for all of their staff on transfer/ mobility and gait belt procedures for dependents residents. -On 12/30/25 through 12/31/25 staff were interviewed and were able to articulate appropriate transfer/ mobility and gait belt procedures. This deficient practice is being cited at past Non-compliance.

Based on observation, interview and document review, the facility failed to monitor, review, and analyze underlying causes of resident's anxiety and agitation for 1 of 1 resident (R1) who was reviewed for behaviors.Findings include:R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included traumatic subdural hemorrhage, cerebral infarction, anxiety disorder, and R1 had severely impaired cognition and R1 did not exhibit any behaviors.R1's medication administration record (MAR) and treatment administration record (TAR) for the month of August 2025, revealed R1 was prescribed Trazodone 100 mg at bedtime for insomnia. TAR lacked evidence of target behaviors being monitored.R1's Psychoactive Medication Informed Consent Form dated 3/19/25, revealed R1 was prescribed Trazodone, but the document lacked reason for use (target behaviors) of this psychoactive medication, non-pharmacological interventions, or benefits to be obtained in using this medication.R1's care plan as of 8/20/25, indicated R1 had impaired cognitive function and impaired thought processes related to disease process and recent stroke. R1 was also noted to have a communication problem related to expressive aphasia and receptive aphasia. R1 was at risk for falls related to confusion, gait/balance problems, psychoactive drug use, unaware of safety needs and directed staff to check for urinary tract infection with increased restlessness and confusion, and when restless at night offer a snack and something to drink. Further, R1's care plan identified R1 had difficulty with sleep and directed staff to administer any medications per provider order, monitor for side effects and effectiveness, offer a snack of pudding/toast for nighttime restlessness, discourage a pattern of daytime naps, and encourage R1 to follow a consistent routine retiring and arising. R1's Progress Notes revealed the following:-On 8/19/25, moved the trash bin she was running into and tried to move her to a more open area however continued to run into things.-On 8/19/25, minimal sleep this shift from 0100-0300. Restlessness and wandering remain evident throughout the pod, attempted to enter other resident's rooms as well as other rooms on the floor (shower room, clean utility room and dirt utility room).-On 8/18/25, resident has been wheeling self-backwards at an extensive rate of speed. Due to impairments of ability to see when wheeling backwards, resident then runs into items aggressively (walls, lifts, other residents, etc.) Resident was witnessed to have run into another resident his shift while this resident was sitting out on the pod. Resident had run into the back of the wheelchair and no injuries were sustained but when redirected, the behaviors did not change.-On 8/18/25, resident wandered into another resident's room who was sleeping, entered the room and began to attempt to rove their walker, thus resulting in this resident becoming entangled in the walker, nearly causing them to fall. Resident was redirected back to the center of the pod but wandering remains present as well as discussions toward other confused residents, stating you stay over there and stay away from me or else.-On 8/18/25, resident completely unconsolable this shift regardless of attempts from staff or other residents. Yelling out help, get him away from me. Resident crying uncontrollably to the extent that she was unable to catch her breathe. Behaviors only subside when resident was on a one to one with another staff member. There are no PRN (as needed medication) available to assist with increased anxiety and restlessness.-On 8/15/25, resident was wheeling herself backwards and yelling help repeatedly and trying to go into other people's rooms. Staff tried to offer a snack, which she did not want. Tried offering resident to watch a show on the tablet, which was not effective. When asking resident what her need was, she would say I don't need anything. No pharmacological interventions available currently.-On 8/11/25, R1 was yelling at staff to get out of here, you need to die and I'm going to kill you. R1 had been exhibiting behaviors since 2:00 p.m. Distraction, food, drink and toileting were not effective. There were no pharmacological intervention to give her. Daughter came in at about 6:30 p.m. took her outside and when daughter brought her back in the yelling started all over again. -On 8/9/25, resident was heard yelling at another resident on the pod. Staff tried to redirect resident away and continued to yell inappropriate words at another resident. Resident was then [NAME] down to other wing to completely change surroundings and resident continued to yell out obscenities and inappropriate comments to nurse and staff on that side. Non-pharmacological interventions attempted included one to one staff involvement, took for ride in wheelchair around inside of the building, offered snack and drink which were not effective.-On 7/24/25, resident was weeping and crying and stated, I might as well be dead. One to one distraction did not seem to be effective, and resident would continue to have weeping episodes.-On 7/19/25, resident was yelling out for help, thinks resident was trying to kill us thinking she had to clean something up. Distraction, toileting and one to one with the nurse was attempted but was not effective.-On 7/17/25, resident was wheeling into other rooms yelling at others saying, I'm going to kill you, I have the power. Staff separated then resident was calling multiple staff killers and that she had all the power.-On 7/16/25, Resident awoke at 0300 yelling out from her room. Resident yelling get her out of here or I will, then began making threats to nursing assistant of [NAME] staff if she wasn't removed. Resident was unconsolable at that time. Distraction was unsuccessful with the use of TV show, food/beverage, etc.-On 7/11/25, resident was roaming the pod aimlessly searching for random items such as the sewer stating, I'm going to blow it up. I have a finger that will do it. Behavior was unable to be redirected. Resident continued to push herself backwards in her wheelchair throughout the hallway and pods, talking nonsensical statements to self and others as they walked by.On 8/20/25 at 3:52 p.m., registered nurse (RN)-A stated R1 exhibited behaviors of yelling and ramming around in here, and R1 would often resist cares such as toileting especially at night. RN-A stated staff would attempt to offer distraction of coloring, drink, food, bathroom, one to one staffing but there were only so much non-pharmacological interventions that are effective.On 8/21/25 at 12:00 p.m., nursing assistant (NA)-A stated R1 exhibited behaviors such as yelling, swatting at staff, crying, and will self-propel around the unit with no sense of direction and would run into things.On 8/21/25 at 1:46 p.m., R1 was observed to be tearful and stating her daughter did not care about her, and NA-B would offer reassurance and offered toileting. Interventions were only effective a short while, and NA-B was observed to be tearful again.On 8/21/25 at 2:25 p.m., NA-B stated R1's cognition was impaired and R1 had some forgetfulness and confusion. NA-B stated later afternoon/evenings R1 would often get anxious and agitated and would cuss out staff or have some delusions about a shooter and interventions of distraction was often not effective. Further, NA-B stated these behaviors were R1's baseline and the behaviors appeared to be constant.On 8/21/25 at 2:59 p.m., NA-C stated R1 exhibited behaviors through out the night such as hollering, attempting to go into other resident's rooms and staff would offer snack, warm towels, sit with R1, read her a magazine to attempt to calm R1 and these behaviors have been R1's baseline since NA-C started working at the facility.On 8/21/25 at 3:15 p.m., RN-C stated R1 exhibited behaviors of hollering, verbal combativeness with staff and threatening to kill you. RN-C stated these behaviors have been R1's baseline and typically occur in the evenings, but at times do increase in frequency with an infection. RN-C stated staff are expected to chart resident behaviors in the resident treatment record and resident care plan would be expected to reflect target behaviors to monitor as well as person-centered interventions to implement. RN-C confirmed there were no target behaviors listed in R1's care plan and there was no treatment order for staff to monitor or document R1's behaviors to review for psychotropic medication effectiveness, which R1 was prescribed Trazodone.On 8/22/25 at 8:56 a.m., director of nursing (DON) stated R1 had exhibited behaviors since admitting to the facility, but the behaviors appeared to increase when there was an infection. DON stated staff were expected to monitor effectiveness of psychotropic medications and track behaviors. Each resident would be expected to have target behaviors in their treatment record for staff to document as well as in the resident care plan with interventions for staff to implement if a resident was exhibiting behaviors.A copy of the facility's behavior and psychotropic medication policy was requested but facility failed to provide.

Based on observation, interview, and document review, the facility failed to ensure care plan interventions for transfers were implemented for 1 of 3 residents (R1) reviewed.Findings include:R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included traumatic subdural hemorrhage, cerebral infarction, anxiety disorder, and R1 had severely impaired cognition.R1's care plan revised on 8/9/25, identified R1 had an activities of daily living (ADL) self- care deficit related to confusion due to recent stroke and staff were direct to ambulate R1 to meals as able with a single quad cane, gait belt, and contact guard assist, recommend another staff to follow with wheelchair and the nurse would document all attempts that fail. R1's care plan also directed staff to ambulate R1 to and from the bathroom with assist of one and a single quad cane, gait belt, and contact guard assist, recommend another staff to follow with wheelchair and nurse to document all attempts that fail.R1's Progress Note dated 8/20/25, revealed no change in condition noted this shift. R1 required extensive assist of one with the non-mechanical sit to stand lift and R1 did not exhibit any behaviors. R1's record lacked evidence of any failed attempts related to transfers or ambulation.On 8/20/25 at 12:16 p.m., anonymous reporter (AR) stated R1 received outpatient therapy and R1 was provided with orders for facility staff to assist R1 with ambulating to and from the bathroom with a cane, as well as to and from meals as tolerated. AR stated the facility were not following R1's care plan and had been transferring R1 using a non-mechanical stand lift. On 8/20/25 at 3:52 p.m., registered nurse (RN)-A stated R1 required assistance by staff for all activities of daily living (ADL), and R1's care plan at this time identified R1 required assistance by one staff member for stand and pivot transfers and utilizing a cane for ambulation. Further, RN-A stated at times R1 would be weaker and require more staff assistance with transfers and the use of a non-mechanical stand lift. On 8/21/25 at 9:25 a.m. licensed practical nurse (LPN)-A stated R1 required assistance with all ADLs and required a non-mechanical sit to stand lift for transfers and depending on the day was able to stand and pivot but was unable to ambulate. On 8/21/25 at 10:08 a.m., RN-B stated R1 was not resistive to cares and was usually easy to talk through tasks and allow staff to assist with tasks. RN-A stated R1 required a non-mechanical sit to stand lift for transfers assistance by one staff, and RN-A stated she had not witnessed R1 ambulate at the facility but R1 was able to ambulate in therapy. On 8/22/25 at 12:00 p.m., nursing assistant (NA) stated R1 recently received new therapy orders directing staff to assist with ambulating to and from the restroom with a cane and gait belt. NA-A stated R1 often chooses which staff she prefers to ambulate for and if R1 was not compliant staff would often use the non-mechanical sit to stand lift to transfer. On 8/21/25 at 12:15 p.m., NA-A was observed assisting R1 in her wheelchair to R1's room. NA-A asked R1 if she was able to walk to the bathroom and R1 stated yes, so NA-A placed a gait belt around R1's waist and R1 stated she wanted to use her walker instead of the cane. R1 placed hands on the walker and stood from her wheelchair and walked into the bathroom with NA-A holding onto the gait belt. R1 walked back out of the bathroom with the walker and appeared to be steady with NA-A holding the gait belt, R1 pivoted and sat back down in her wheelchair. On 8/21/25 at 1:46 p.m., NA-B was observed to assist R1 in her wheelchair back to her room. R1 appeared to be tearful and upset related to her family leaving her, but NA-B offered reassurance. NA-B exited R1's room and returned with the non-mechanical sit to stand lift. NA-B moved R1's wheelchair pedals off to the sit and positioned the lift in front of R1. R1 placed her feet on the platform, NA-B locks wheelchair brakes as well as the lift brakes and directs R1 to grab onto the bars and stand up. R1 follows all ques and stands up, and NA-B places the two paddles behind R1's bottom, unlocks lift brakes and brings R1 into the bathroom. NA-B then maneuvered R1 out of the bathroom in the lift and opens the lift legs over R1's wheelchair, locks the lift brakes and directs R1 to stand, paddles are removed and R1 sits down in her wheelchair. On 8/21/25 at 2:06 p.m., R1 was sitting in her wheelchair in her room and stated she was able to walk just fine to and from the bathroom with a cane, but R1 was unsure why the staff were using a lift instead. R1 stated I am afraid to ask they would tell me something I don't want to hear. On 8/21/25 at 2:25 p.m. NA-B stated all NA's have access to each resident's care plan which would identify what each resident's transfer status and ADL assistance was. If there were changes to a resident's care plan the changes were communicated through verbal report at change of shift. Further, NA-B stated R1 required a non-mechanical sit to stand lift always and R1 was able to ambulate with a walker and a gait belt. On 8/21/25 at 2:59 p.m., NA-C stated R1 required staff assistance with all ADLs and transferred with a non-mechanical sit to stand lift. NA-C stated R1 was not able to ambulate that she was aware of. On 8/21/25 at 3:15 p.m., RN-C staff were expected to review the communication board in the facility's electronic medical record (EMR) system for changes and updates to a resident's care plan, however RN-C stated she was made aware recently some staff were not aware of how to do it so RN-C changed the process as of 8/21/25, and will now have a binder to communicate updates. Further, RN-C stated R1 was able to stand and pivot with assist of one staff to transfer using a gait belt and was able to ambulate with a cane. RN-C was not aware staff were utilizing a non-mechanical sit to stand lift to transfer R1 and no staff had reported any concerns or changes with R1's transfers. RN-C stated R1's transfer status was revised on 8/9/25. In addition, RN-C stated staff would be expected to report any changes or concerns and if a resident refuses staff should be documenting. On 8/22/25 at 8:56 a.m., director of nursing (DON) stated R1's care plan was recently revised to ambulate R1 to and from the bathroom with assist of one staff and R1 was a stand and pivot transfer. DON stated staff were expected to report changes or concerns with a resident's transfer status to the case managers on the unit so the team was aware and could revise the care plan. Further, DON stated all staff would be expected to carry the electronic tablets and reference each resident's plan of care they are assisting. A copy of the facility's care plan policy was requested but facility failed to provide.

Based on interview and document review, the facility failed to notify physician and resident representative timely of a new injury for 1 of 3 residents (R1) reviewed.Findings include:R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included traumatic subdural hemorrhage, cerebral infarction, anxiety disorder, and had severely impaired cognition.R1's skin incident report dated 8/10/25, revealed registered nurse (RN)-D was called into R1's room to assess a skin tear to left front of lower shin. Staff had explained that they were getting R1 up and ready for the day and she pulled her pants down to change them. Upon lowering her pants, staff noticed that there was blood on the sheet and when she looked where it was coming from, staff observed a skin tear. RN-D completed wound care by cleaning and covering with bandage. R1 denied any pain in the area, but upon completing wound care R1 was seen wincing in pain. Both RN-D and staff assisted by applying Tubi grips to both lower extremities and proceeded to continue cares. Injuries observed at the time of the incident was a skin tear to left lower leg, RN-D cleansed wound with wound cleanser, skin flap was approximated with Q-Tip and covered with non-adherent pad, leg was then wrapped with rolled gauze and secured with tape, Tubi-grip placed over leg to hold dressing in place. Further incident report revealed R1's physician was notified on 8/12/25 at 2:05 p.m., and there was no evidence of resident representative being notified.R1's progress note dated 8/10/25 at 9:23 p.m., R1's left leg skin tear dressing was removed by a nursing assistant because R1's daughter wanted to look at the wound. R1's record lacked evidence of R1's representative being notified prior and notification to resident's physician.On 8/20/25 at 12:16 p.m., R1's resident representative (RR) stated she was at the facility on 8/09/25, and when she came to the facility on 8/10/25, RR stated she inquired to staff about a bruise on her arm and that was when the staff notified her of the skin tear on R1's leg. RR stated typically she would receive a phone call from the staff on incidents, but she was not notified of the skin tear until later in the day.On 8/20/25 at 3:52 p.m., RN-A stated staff were expected to notify provider and family as soon as staff were aware of any new skin impairments.On 8/20/25 at 9:25 a.m., licensed practical nurse (LPN)-A stated new injuries or skin impairments were expected to be reported to the charge nurse and they would complete an incident report and inform the unit case managers and director of nursing (DON), and the DON would notify the physician and family as soon as the DON was made aware.On 8/21/25 at 10:08 a.m., RN-B stated new skin impairments were expected to be reported to the physician and family immediately or within your shift depending on severity. The floor nurse would be expected to complete an incident report and part of the incident report would be notifications to appropriate parties such as physician, family and DON.On 8/21/25 at 3:15 p.m., RN-C stated for new skin impairments, the floor nurse was expected to complete a risk management (incident report), provide aid and treatment to the injury, notify DON and nurse on call. Further, RN-C stated the physician, and resident representative would be expected to be notified immediately as well.On 8/21/25 at 4:40 p.m., attempted interview with R1's provider was unsuccessful.On 8/22/25 at 8:56 a.m., DON stated staff were expected to complete an incident report upon discovering a new skin impairment, and part of the document required staff to notify the physician and resident representative. DON stated RN-D discovered the skin tear in the early morning of 8/10/25 and passed on in report to the next shift because RN-D was unable to complete all tasks due to having a busy night. DON stated RR was upset she was not notified.On 8/22/25 at 9:59 a.m., RN-D stated at approximately 5:30 a.m. on 8/10/25, RN-D was paged to go to R1's room and RN-D observed the skin tear. RN-D stated she assessed the wound and passed through report to the next shift of the update. RN-D stated she was not completed with her charting at 6:30 a.m. when her shift was over, so RN-D returned to the facility later that afternoon to complete the incident report. RN-D stated she was aware she did not notify R1's resident representative and I am sure [RR] was not happy, and RN-D confirmed she did not notify R1's physician because, it all happened so fast. Further, RN-D stated notifying the physician and resident representative was part of completing the incident report, and staff were expected to call nurse triage and leave a message for the resident's physician and notify the resident's representative.On 8/26/25 at 11:30 a.m., return call from RN-E, nurse at R1's physician's office, RN-E confirmed the provider was not notified of R1's skin tear until a note was received from the facility a couple days later about a wound dressing.A copy of the facility's notification policy was requested but facility failed to provide.

Based on interview and document review the facility failed to implement policies and procedures for an allegation of abuse for 1 of 1 resident (R1) who alleged abuse and the facility failed to have record of the investigation.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. He used a wheelchair for mobility. R1's care plan dated 1/31/25, identified at risk for falls related to confusion, gait/balance problems, alert and oriented with short term memory loss, and instructed staff to assist as needed with mobility and transfers, monitor him for any cognitive changes and update physician assistant (PA), nurse practitioner (NP) and medical doctor (MD) as needed. He was at risk for elopement/wandering with a wander guard placed underneath wheelchair. Staff were directed to identify if there were triggers for wandering/elopement money, stay being covered, selling house, and provide reorientation to surroundings and environment. R1's progress note dated 10/6/24 at 4:01 p.m., written by RN-A identified he was seen heading toward front doors in wheelchair pushing walker stacked with items from room. Staff approached to have him come back in from the front entry, but he continued to refuse, three different staff attempted redirection without success. Writer approached him and after a lengthy conversation was able to convince him to stay in the facility. He stated reason for wanting to leave was due to insurance reasons. He remained very upset with the first three staff members when they attempted to redirect him. He displayed paranoia and delusional thoughts the rest of the shift. He would not eat supper stating food was poisoned and felt like people at facility were trying to keep him locked up, and out to get him. Redirection for the thought process was unsuccessful. During an interview with director of nursing (DON) on 8/7/25 at 12:49 p.m., stated R1 had refused dressing changes and medication in the past, seemed well put together on the surface but was not cognitively intact. She indicated his son had informed her if R1 had known he had to pay out of pocket; he would have tried to walk home. DON also stated on 10/6/24, nursing assistant (NA)-A reported R1 stated he was thrown around, but that was not documented, and she was unsure if she had heard it from R1 as he told stories and used grandiose statements frequently. She had talked to him after this report, and he indicated he was trying to leave. This was not investigated or documented. R1 informed NA-A and registered nurse (RN)-A he was leaving the facility, and they brought him back into the building. He had told staff he was tackled to the ground. Both staff denied that had happened. The administrator at that time (currently retired) had many conversations with him but there was no documentation. During an interview on 8/7/25 at 4:11 p.m., NA-A stated R1 was forgetful, confused, and wandered. Over the weekend, October 2024, he noticed R1 was located by the front door of the facility in the wheelchair with a walker full of belongings and possibly tried to leave. He attempted to convince R1 to come back into the facility but refused. NA-A removed himself from the situation and RN-A redirected him back into the building. Staff (unsure of which ones) informed him R1 had made comments he was thrown out of his wheelchair, and he reported this information to the nurse (no idea which one) and the oncoming shift. The DON was aware of R1''s comments, she had talked to him about it. He stated on that day in October, R1 was not thrown out of his wheelchair onto the floor or hurt by staff. During an interview on 8/7/25 at 5:45 p.m., administrator stated there were a few incidents where R1 tried to leave the facility, talked to his sons about it, and claimed he was tackled to the ground by the NA. He interviewed staff and was informed they stood in his way to help prevent him from leaving. He had visited with one of his son's and indicated his father feasted up and said, they really did not take him to the ground but prevented him from leaving and was angry. A vulnerable adult report was not filed or investigated, on this incident. Surveyor was unable to reach RN-A for an interview. Facility policy Maltreatment Reporting Guidelines dated 11/26/24, identified care center will report any allegations of maltreatment of a vulnerable adult (VA) residing in their care center to appropriate authorities, as required by abuse reporting for the Federal Regulations and maltreatment reporting for the Minnesota State Statues. If alleged maltreatment occurs staff shall immediately report to their supervisor any suspected maltreatment. The supervisor shall first ensure the resident is safe and complete an initial assessment to determine if there was potential abuse, neglect or other type of maltreatment and notify the administrator. The staff person(s) should have been immediately suspended in the alleged maltreatment pending the outcome of the investigation. Begin an investigation of the alleged treatment, which may include resident and staff interviews, observations, and medical record review. The investigation shall be completed as much as able within five working days at which time the investigation findings will be updated in the Minnesota Department of Health (MDH)/Office of Health Facility Complaints (OHFC) website. Within five working days prepare a written report of investigation results. Based on the investigational findings, may any internal systemic operational changes needed to minimize any opportunity for reoccurrence.

Based on interview and document review, the facility failed to report an allegation of abuse immediately (within two hours) to the State Agency (SA) for 1 of 3 (R1) residents reviewed for allegations of abuse. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact with diagnoses of heart failure and bipolar disorder. The MDS also indicated she used a wheelchair for mobility, and was independent with personal hygiene. R1's care plan dated 12/7/24, indicated R1 required the assistance of one staff to use the toilet and required set up assistance with personal hygiene. R1's care plan also indicated she was vulnerable due to her physical condition. On 1/25/25 a written statement by registered nurse (RN)-A indicated R1 reported nursing assistant (NA)-A made her feel uncomfortable when he was washing her up. R1 stated she could see and feel NA-A's erection. R1 stated she asked NA-A to stop, but he continued washing her. On 1/25/25 at 11:27 p.m., an email from RN-B to the director of nursing (DON) and licensed practical nurse (LPN)-A indicated R1 reported NA-A was washing her up and she asked him to stop. R1 reported she could tell NA-A was getting excited and she was afraid of him. On 1/26/25 at 9:30 p.m., a progress note indicated R1 told RN-C about a situation where a NA assisted her with her toileting and perineal care (peri care). This information was relayed to the DON. On 1/27/25 at 5:44 p.m. (nearly two days later) a report to the SA was filed and indicated R1 felt violated while NA-A was washing her up, causing her to feel anxious, fearful, and sick to her stomach. R1 stated she felt NA-A's erection brush against her. On 2/4/25 at 10:56 a.m., the DON stated she was informed of R1's alleged abuse on 1/25/25 around 9:00 p.m. She was unaware of the details of the incident until she reviewed the written statements provided by RN-A and RN-B on 1/27/25. The incident should have been reported to the SA on 1/25/25. On 2/4/25 at 5:35 p.m., the administrator stated an immediate report to the SA is expected when abuse is reported. The facility Maltreatment Reporting Guidelines dated 11/26/24, directed Care center will report any allegations of maltreatment of a vulnerable adult (VA) residing in our care center to the appropriate authorities, as required by abuse reporting for the Federal Regulations and maltreatment reporting for the Minnesota State Statutes. Care center must report to the State Agency (MDH) any suspected maltreatment (all alleged violations involving abuse, neglect, financial exploitation or maltreatment, including injuries of unknown source and misappropriation of resident property) immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and document review the facility failed to ensure the provider and resident representative were notified of a fall for 1 of 3 residents (R2) reviewed. Findings include: R2's admission Minimal Data Set (MDS), undated as it was still in progress, indicated R2 had diagnoses which included type 2 diabetes and hypertension. R2's progress note dated 8/16/24, indicated R2 had rolled out of bed at 11:30 p.m. on 8/15/24, trying to get to the fridge, rolled onto the floor looking for kids. Staff implemented a low bed and fall mat was in place as well as safety checks every 1-2 hours. However, R2's record lacked evidence the provider or resident representative was notified of the fall. On 8/23/24 at 11:26 a.m., registered nurse (RN)-A stated staff would be expected to notify the resident's provider and representative right away following a fall. On 8/23/24 at 11:51 a.m., director of nursing (DON) stated staff were expected to notify the resident's representative and the provider as soon as possible, following a fall. DON stated follow up with staff regarding R2's fall that occurred on 8/15/24, revealed the floor nurse's night was chaotic and she forgot to complete an incident report for the fall and notify the provider and resident representative. Review of facility policy titled Accident/Incident dated 1/18/18, indicated notification of a family member or responsible party when a resident suffers an injury due to an accident/incident, family or the responsible party would be notified immediately. If there was no injury as a result of the accident/incident family or responsible party would be notified within a reasonable time frame. Family or responsible party would be advised of a fall. In addition, the physician would be notified immediately whenever an injury occurs and for all other events within a reasonable timeframe.

Based on observation, interview, and document review, the facility failed to follow physician orders for pressure ulcer care, and failed to follow infection control practices during a dressing change for 1 of 3 residents (R1) reviewed for pressure ulcers. Findings include: Definitions of pressure ulcer types according to National Pressure Ulcer Advisory Panel (NPUAP): Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough (non-viable usually moist tissue that can be soft and stringy in texture) and/or eschar (dead or devitalized tissue that is usually black and may appear scab-like) may be visible but does not obscure the depth of the tissue loss. Undermining and tunneling may occur. Fascia (connective tissues), muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound, it is an unstageable pressure ulcer. Stage 4 Pressure Ulcer: Sores that extend below the subcutaneous fat in deep tissues including muscle, tendons, ligaments, cartilage, or bone. This stage presents a high risk of infection. Unstageable Pressure Ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. R1's Face Sheet dated 7/25/24 indicated R1 had diagnoses of peripheral vascular disease, quadriplegia, and spinal stenosis. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and fully dependent on staff for activities of daily living (ADLs). R1's quarterly MDS dated [DATE] indicated R1 had one Stage 4 pressure ulcer. R1's Integrated Wound Care document dated 7/23/24, indicated a Stage 4 sacral pressure ulcer measuring 6.5 centimeters (cm) by 12.5cm and 1.8cm in depth, undermining (destruction of tissue extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface.) from 11 to 3 o'clock was 4.1cm in depth. The Stage 4 sacral pressure ulcer had heavy purulent drainage (product of inflammation that contains pus), mild odor, bone exposed, had 90% granulated (connective tissue) and 10% slough (non-viable yellow, tan, gray, green or brown tissue) on wound base. The document indicated an unstageable left buttock pressure ulcer measuring 9cm by 8cm and 3cm in depth, undermining from 12 to 3 o'clock was 5cm in depth. The unstageable left buttock pressure ulcer had heavy serosanguinous (a mixture of clear serous fluid and blood), tendon and bone exposed, had 10% necrotic (dead tissue) and 50% slough on wound base. The document indicated a Stage 3 right buttock pressure ulcer measuring 6.3cm by 4.5cm and 1.2cm in depth, undermining from 10 to 4 o'clock was 4.5cm in depth. The stage 3 right buttock ulcer had heavy serosanguinous drainage, 50% slough, 10% granulation, and 40% necrotic tissue on wound bed. The document had a note section that indicated a discussion was had with R1 about the continuous wound deterioration, and the likely outcome of continued wound deterioration. R1's Wound Care Order as ordered by the nurse practitioner (NP)-A on 7/23/24 directed for sacral and left buttock pressure ulcer: cleanse wound, apply skin prep to peri wound, cover bone with Adaptic (non-adhering wound dressing), then apply Santyl (ointment that removes dead tissue from wound) to wound bed, then calcium alginate (non-woven, absorbent dressing made from seaweed). May fluff kerlix to fill depth of wound, into fissure, and undermining areas if needed. Cover with abdominal pad dressing (ABD) and tape, change daily and as needed (PRN). Right buttock pressure ulcer: cleanse wound, apply skin prep to peri wound, apply Santyl to wound bed and calcium alginate, cover with silicone boarder dressing, change daily and PRN. R1's electronic health record (EHR) indicated both orders started on 7/25/24. On 7/25/24 at 10:24 a.m., registered nurse (RN)-A was observed providing wound care to R1. RN-A donned proper personal protective equipment (PPE). RN-A cleansed all three pressure ulcer beds with wound cleanser, then removed her soiled gloves. Without performing hand hygiene, RN-A donned clean gloves. RN-A placed Adaptic on the base of the left buttock and sacral pressure area where bone was exposed. RN-A placed calcium alginate on all three wound beds with a cotton swab. RN-A took the cotton swab and packed R1's left buttock ulcer with kerlix. RN-A grabbed new kerlix and packed R1's sacral ulcer. RN-A applied ABD dressings to all three pressure ulcers and secured bandages with tape. RN-A removed her soiled gloves, and without performing hand hygiene, donned clean gloves. RN-A placed another piece of tape on R1's left buttock dressing. RN-A removed her spoiled gloves, and without performing hand hygiene, removed R1's oxygen tubing from his nose. RN-A doffed her PPE and preformed hand hygiene before exiting the room. RN-A did not put Santyl on the wound beds as ordered. On 7/25/24 at 10:51 a.m., RN-A stated it slipped her mind to perform hand hygiene between glove changes, but the expectation was to sanitize hands after removing soiled gloves. On 7/25/24 at 1:13 p.m., RN-A stated she did not follow the physician's orders for R1's dressing changes because she was nervous. On 7/25/24 at 2:57 p.m., nurse practitioner (NP)-A stated R1's ulcers were going to happen due to R1 comorbidities and refusals to offload. If the facility was not following the physician's orders for pressure ulcer care, the integrity of the pressure ulcer is going to be compromised. She would expect the facility to follow orders. Hand hygiene and protecting the wound from unwanted bacteria was also important to healing when completing a dressing change. On 7/26/24 at 11:34 a.m., the administrator stated staff should follow care plans, orders, and to follow the hand hygiene policy. The facility policy Hand Hygiene revised 5/8/17, indicated hand hygiene is to be completed before and after direct contact with a resident, if moving from a contaminated body site to a clean body site during resident care, and between glove changes. A policy on pressure ulcers was requested but not provided.

Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 1), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: During review, Payroll Based Journal (PBJ) [NAME] Report 1705D identified excessively low weekend staffing was triggered. During review, staffing schedules and daily postings for the weekends during this quarter did not indicate staffing was excessively low therefore the data submitted in the PBJ to CMS was inaccurate. During interview on 4/18/24 at 3:25 p.m., scheduler (S)-E stated she does not submit this information and was not sure who does. S-E was able to provide additional documentation confirming staffing level was not excessively low. During interview on 4/18/24 at 4:02 p.m., Administrator stated the information is submitted by the corporate office for all 15 of their facilities. Administrator submits facility data to corporate office prior to submission. Administrator stated he was informed of a sister facility who was recently surveyed and cited for this issue as well. The corporate office determined that a data entry error was made at the time of submission, and this affected all facilities, and has been corrected prior to submission of the data for the next quarter. Administrator was advised that a correction had been submitted after the discovery of the error. There was no policy related to PBJ entries available by the end of the survey.

Based on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1), who was identified as an elopement risk, and was found outside the facility in a snowbank during inclement weather, from elopement. This resulted in an immediate jeopardy (IJ) situation. The IJ began on 2/6/22, when it was identified R1 had eloped from the facility and was found outside in a snowbank during inclement weather. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 2/15/22 at 2:00 p.m. The immediate jeopardy removal was verified by the surveyor on 2/16/22 with an effective date for removal as 2/15/22, but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 had a diagnosis of dementia and had severe cognitive impairment. Further, R1's MDS indicated R1 exhibited wandering behaviors daily and required supervision from staff while ambulating. R1's care plan dated 10/29/19, indicated R1 was at risk for safety due to wandering. Further, R1's care plan directed staff to encourage activities during highest wandering times, observe wandering, redirect, perform hourly rounds during times of increased wandering, and place soft touch call light under bed sheets on open side of the bed. In addition, care plan indicated R1 had a WanderGuard on her walker and ankle, which required staff to monitor daily. R1's physician's orders dated 5/27/21, indicated to check placement of WanderGuard on R1's ankle and walker twice daily, as well as check WanderGuard for proper functioning once weekly with machine. On 2/14/22, at 9:40 a.m. a new order was initiated to ensure proper functioning of R1's WanderGuard using machine daily during the night. Review of facility report number 8 to the State Agency dated 2/6/22, indicated R1 was found outside sitting in the snow outside of the facility. Review of facility's five-day investigation to the SA dated 2/11/22, indicated licensed practical nurse (LPN)-A stated R1 was found sitting in a snowbank wearing pants, sweater, and socks but was not cold to touch. LPN-A escorted R1 back into the facility at 1:05 p.m. when the WanderGuard alarm sounded, and LPN-A canceled the alarm at 1:06 p.m. LPN-A assessed R1 for injury and assisted with changing into dry clothing. Facility indicated the following were initiated to prevent reoccurrence to R1 which included WanderGuard on ankle was replaced immediately following the incident and WanderGuard functioning check was changed to daily rather than weekly. To protect other resident who require the use of a WanderGuard the facility implemented the following interventions which included tested all doors for proper functioning, list of residents at risk were placed at the nursing dietary and activities stations, facility made contact with WanderGuard vendor to assure system is properly functioning, and education was completed with dietary staff concerning the procedure of responding to the WanderGuard alarm. Review of WanderGuard alarm report dated 2/10/22, indicated on 2/6/22 R1's WanderGuard alarmed at 12:56 p.m. and was canceled at 12:57 p.m. R1's WanderGuard alarmed again at 1:05 p.m. and was canceled at 1:06 p.m. when R1 escorted back into the facility. Based on the weather history for Little Falls, MN on accuweather.com indicated the temperature range on 2/6/22 (day of R1's elopement) was a low of negative seven degrees to a high of 18 degrees Fahrenheit. On 2/14/22, at 1:18 p.m. R1 was observed sitting at a table in the commons area on the Maple pod. R1 did not exhibit any wandering behavior at this time and a WanderGuard bracelet was attached to R1's walker and on her ankle. On 2/14/22, at 12:28 p.m. LPN-A indicated she was R1's nurse on 2/6/22, when the incident occurred. LPN-A indicated R1 was very busy that day walking from pod to pod. Further, LPN-A indicated R1 exited the facility through the employee door by the garbage and R1 had been observed trying to go down that hallway in the past. LPN-A confirmed she did not hear the alarm system sound before R1 was found outside but it did alarm on the way back into the facility. In addition, LPN indicated there had been no further education provided since the incident. On 2/14/22, at 12:45 p.m. dietary cook (DC)-A indicated she saw R1 on the ground outside and then alerted staff for assistance. DC-A confirmed she did not hear the WanderGuard alarm sounding. On 2/14/22, at 12:57 p.m. dietary aide (DA)-A indicated as he returned to the dining room on 2/6/22, he saw R1's walker outside the window and saw her in the snow. DA-A confirmed he did not hear the alarm system at that time but indicated he has observed other dietary staff deactivate the alarm in the past. On 2/14/22, at 1:34 p.m. registered nurse (RN)-A indicated she was aware of R1's incident that occurred but confirmed since the incident she has not received any additional education regarding the facility's elopement procedure or other interventions to prevent reoccurrence. On 2/14/22, at 3:17 p.m. Administrator indicated he was made aware of the incident on 2/6/22, by the Director of Nursing (DON) at approximately 1:11 p.m. Administrator indicated during the internal investigation he interviewed all dietary staff who were working on 2/6/22, to ensure none of the staff shut off the alarm prior to someone responding and ensured there was no resident elopement. All dietary staff denied shutting off the alarm and through further investigation and interviews staff reported no alarm was heard at this time. Administrator confirmed he did not interview all the nursing staff on the day of the incident and there was no additional education provided other than to the dietary department. Administrator indicated after the investigation was completed the root cause was determined to be the alarm system did sound however someone did turn it off according to the log. When asked about following the facility's policy on Elopement and monitoring the functioning daily, Administrator confirmed the facility policy indicated resident WanderGuards would be tested daily and the facility (previous to R1's elopement) was not following the policy as they were monitoring the WanderGuard functioning weekly. Review of R1's treatment record indicate WanderGuard Protocol to ensure proper functioning of the WanderGuard of one time per day was initiated on 2/14/22 (after survey entrance), which was identified on the facility's five day investigation submitted to the SA as being initiated on 2/11/22. On 2/15/22, at 8:48 a.m. when asked why the order to ensure proper WanderGuard functioning daily was implemented on 2/14/22, at 9:40 a.m. rather than on 2/11/22, as indicated in facility's investigation to the SA, DON indicated she verbally informed the health unit coordinator (HUC) to add in the order on 2/11/22. Further, DON indicated she was informed on 2/14/22, that order had not been initiated yet. In addition, DON indicated she expected staff to put the new order in immediately. On 2/15/22, at 9:56 a.m. HUC indicated she was informed by the DON on 2/11/22, at approximately 12:00 p.m. to change the treatment order for the Wander Guard, however HUC stated, I ran out of time to do everything I needed to on Friday before I left. Further, HUC indicated it is important to get the new orders changed as soon as possible to be in compliance with the policy and to ensure the safety of the residents. Review of facility policy titled Elopement revised 10/23/17, defined elopement as when a resident who is cognitively and physically impaired leaves a care center unsupervised. Further, the policy indicated nursing staff will test the WanderGuard daily for proper signaling and damage to bracelet. In addition, policy indicated designated staff will test the door units daily by passing a WanderGuard through the door sensors and opening the door. However, the policy lacks the procedure to respond to a resident who's WanderGuard is setting off the alarm system and when to deactivate the alarm. The immediate jeopardy that began on 2/6/22 was removed on 2/15/22, and verified at 10:35 a.m. on 2/16/22 when it was verified the facility trained all staff on the following: the night shift nursing staff will test all WanderGuard devices daily to ensure they are functioning properly and the Elopement Policy which included the process for when the WanderGuard system is alarming, conducting searches to ensure all residents are accounted for, process if resident is not found in the building and notification of Administrator/DON/Family Representative/Doctor/law enforcement, and alarms will not be turned off until all resident with WanderGuard devices are located but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on document review and interviews, the facility failed to ensure [MEDICATION NAME] was not used in excess when the facility failed to adequately monitor the [MEDICATION NAME] and the International Ratio (INR) lab value for anticoagulant drug therapy for one of three residents (R1) reviewed for unnecessary medication. This failure resulted in actual harm for R1 who was hospitalized with a [MEDICAL CONDITION] and [MEDICAL CONDITION]. Findings are as follows: R1's medical record was reviewed, R1 was admitted to the facility on [DATE] following surgery to repair a fractured left hip. [DIAGNOSES REDACTED]. Hospital discharge documents dated 9/3/2013 were reviewed and revealed physician orders [REDACTED]. Draw R1's blood two times each week to check INR, send results to the primary care physician. Health Unit Coordinator (HUC)-G was interviewed on 10/2/2013 at 2:05 p.m. and said that she took the physician orders [REDACTED]. The error was not caught by the two staff that performed checks of the orders. R1's primary physician signed the orders the following day. A review of the FAXED communication from the facility to the primary physician dated 9/3/2013 lists all medications, dosages and times shown on hospital discharge documents and "PT/INR- One time Only for [MEDICAL CONDITION] Fibrillation. End date: 9/16/2013." Licensed practical nurse (LPN)-J and LPN-K signed the document on 9/3/2013. The physician signed the document/orders on 9/4/2013. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R1 should have had blood drawn for PT/INR three times during the 12 day stay at the facility. No lab results for PT/INR were present in R1's facility medical chart. Nursing progress notes dated 9/15/2013 at 4:35 p.m., 12 days after R1 was admitted to the facility, showed that R1 experienced black, tarry stool along with pale, yellowish coloring and decreased blood pressure, 100/30 and 100/39. R1 was sent to the hospital for medical evaluation. R1 was admitted to the hospital on [DATE]. LPN-E was interviewed on 10/2/2013 and said that a family member had voiced a concern on 9/14/2013 that R1 had increased confusion, R1 followed LPN-E's commands and had been given a medication for anxiety, LPN-E did not investigate further on that day. On 9/15/2013 at about 6:30 p.m. when R1 had black stool, the aide informed LPN-E. LPN-E observed the stool and checked R1's vital signs. R1's vital signs were abnormal with a very low blood pressure and poor color. When LPN-E was preparing paperwork for the emergency room and to report to the on-call doctor, she discovered that there were no PT/INR labs in R1's medical chart. R1's hospital record was reviewed. The emergency department record dated 9/15/2013, indicated that R1 presented to the emergency room anxious and scared, R1's vital signs were abnormal on arrival-blood pressure was 98/32 and her oxygen was 72% on room air. The hemoglobin in the emergency room was 4 (normal range 12.0-16.0) and INR was greater than 9.5 (normal value: 0.9-1.1). The documentation indicates the resident was on [MEDICATION NAME] due to [MEDICAL CONDITION]. Her [DIAGNOSES REDACTED]. The discharge document dated 9/23/2013 indicates the resident required blood transfusion of four units, IV Vitamin K, and three units of fresh frozen plasma. The resident was transferred to the ICU with acute blood loss [MEDICAL CONDITION] due to the supra therapeutic INR. The resident at discharged determined the risks of anticoagulation ([MEDICATION NAME]) therapy outweighed the benefits and told the physician that she would not be treated with [MEDICATION NAME] in the future. The resident discharged in stable condition to another nursing facility. Family member (FM)-I was interviewed on 10/4/2013 at 2:09 p.m. and said R1 spent six days in the intensive care unit, required seven units of blood, was diagnosed with [REDACTED]. When interviewed on 10/10/2013 the DON said the facility has no current policy regarding the monitoring of anticoagulant therapy but she is working to develop one.

Based on observation, interview and document review, the facility failed to provide safe mechanical lift transfers resulting in actual harm to 1 of 10 residents (R1). On 1/16/12, it was determined that there was an immediate and serious threat to resident health and safety. The immediate jeopardy began on 1/22/12 when R1 fell from a mechanical lift sling due to an incorrect transfer. As a result, R1 sustained a left hip fracture. The immediate jeopardy continued when observations noted R2 was unsafely transferred on 02/15/12 at 3:35 p.m. and R3 was unsafely transferred on 02/15/12 at 4:00 p.m., via mechanical lift, by staff. This failure had the potential to affect 10 of 47 residents, who required transfers by mechanical lift. The Administrator was notified of the immediate jeopardy, at the scope of a pattern, at 1:00 p.m. on 2/16/12. The immediate jeopardy that began on (1/22/12), was removed on 2/17/12 at 12:00 p.m., when the facility took steps to retrain all nursing staff and nursing assistants in the correct use of the mechanical lift. Return demonstration was monitored by the Director of Nursing or another RN prior to allowing staff to perform mechanical lift transfers. The facility also changed it's policy to include all sling types being used and the directions for the use of each. Residents using mechanical lifts were assessed as to what size sling was needed for safe transfer and the information was included on each care plan as well as the nursing assistant group sheets. The noncompliance remained at F323 the lower scope and severity level of actual harm that is not immediate jeopardy because the facility had failed to have RN oversight of skill competency resulting in R1 falling from a mechanical lift and suffering a hip fracture. Findings Include: R1's medical record was reviewed. R1 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 was nonverbal, severely cognitively impaired, unable to walk, totally dependent on staff and required two plus person physical assist for all transfers with a mechanical lift related to severe contractures of lower extremities. The fall report dated 1/22/12, identified R1 slipped out of the mechanical lift sling while being transferred by nursing assistants (NA)-U and NA-V. R1 was assessed at the time of the fall by RN-F and found to have no apparent injuries. The progress notes dated 1/25/12, indicated R1 was "more grabby" on the night shift and the left leg was less contracted than usual. The next progress note dated 1/26/12, indicated R1's left lower extremity (LLE) was limp and R1 made verbal noises and her eyes would widen when the LLE was touched or moved. The physician was notified and R1 was sent to the hospital for further evaluation. The hospital documentation by physician -W dated 1/26/12, indicated R1 had an angulated subtrochanteric/Intertrochanteric hip fracture as a result from an apparent fall from a mechanical lift two to three days prior. No orthopedic intervention was advised and R1 was transferred back to the facility with orders for pain medication and a hospice consult. The Resident Abuse Report Form dated 1/26/12, indicated the facility began investigating the circumstances regarding the fall R1 suffered on 1/22/12. R1 had slipped out of the mechanical lift sling on 1/22/12, while being transferred. The follow up investigation revealed nursing assistant NA-U and NA-V had not correctly secured R1 in the sling. NA-U and NA-V failed to cross the straps of the sling at R1's thighs and attach them to the lift, prior to moving R1. RN-F was interviewed on 2/15/12 at 2:45 p.m., and stated she was called to R1's room on 1/22/12 at approximately 9:00 p.m., after R1 slipped from the sling. RN-F stated three of the four sling straps were still connected and the left leg strap was hanging from the mechanical lift when she entered the room. R1 was sitting on the floor leaning up against the knees of NA-U. RN-F went on to say she thought an error occurred when the NA's did not hook up the sling correctly and R1 fell as a result. The two NA's acknowledged to RN-F they failed to cross the straps of the sling at the knees and R1 slipped out of the sling as they raised her from the wheelchair (W/C) to the bed. The incident was reportable to the state agencey (SA) at the point RN-F believed an error occurred when the sling was not connected correctly and R1 fell from the sling. NA-U was interviewed on 2/23/12 at 9:40 a.m. and stated that on 1/22/12 she was assigned to R1's care. NA-U prepared R1 for transfer from the wheelchair to the bed. She stated she assumed the straps of the sling were crossed at R1's thighs because the sling is normally left that way when R1 is in the wheel chair. She stated she hooked the sling straps to the mechanical lift. NA-V came in the room to assist NA-U with the transfer. NA-V operated the mechanical lift and NA-U stated she was turned away, opening the bed linens when NA-V started to lift R1 out of the chair. NA-U stated she heard a "snap" and when she turned around R1 was slipping forward feet first out of the sling. She stated she attempted to catch R1 but her buttocks hit the floor. NA-U stayed with R1. NA-V went to get the nurse. NA-U stated all three staff including herself, NA-V and RN-F manually lifted R1 from the floor and placed her on the bed without using the mechanical lift, which was inconsistent with R1's plan of care and the video training provided by the facility. NA-U verified she worked at the facility approximately six months. She explained her orientation for mechanical lift transfers consisted of watching a video and answering some questions (a written post test). She was mentored on the floor by another nursing assistant for four days and four hours each day. The only oversight of her competency for use of a mechanical lift was completed by another nursing assistant. On 2/23/12 at 9:00 a.m. NA-V stated on the evening of 1/22/12, she entered R1's room to assist NA-U with transferring R1 from the wheel chair to the bed. NA-V stated that NA-U had already hooked the sling straps to the mechanical lift. NA-V verified she was operating the lift. As she raised R1 from the wheel chair, the sling came out from underneath R1 and R1 started slipping forward. NA-U attempted to catch R1 as she fell out of the sling. NA-V stated when R1 came out of the sling, the sling was left hanging from the lift except the left leg strap was not attached. NA-V explained her orientation for mechanical lift transfers consisted of watching a video and answering some questions (a written post test). She was mentored on the floor by another nursing assistant. NA-V stated the only RN participation of her orientation was receiving her tuberculin skin test (TST). On 2/15/12 at 3:35 p.m., NA-K and NA-J were observed using a mechanical lift to transfer R2 out of bed and into the W/C. The sling was placed under R2 by the NA's rolling him from side to side in bed. NA-K positioned the lift over R2 while he was lying flat in the bed and both NA's connected the sling straps to the upper and lower bars of the lift. NA-K then raised the lift, moved the lift out and away from the bed, turned the lift, opened the base of the lift, positioned R2 over the wheelchair and then lowered R2 into the chair. NA-J was guiding R2 in the sling while being moved. NA-K failed to open and lock the base of the lift to establish a wide base of support, prior to moving R2. On 2/15/12 at 4:00 p.m., NA-N, NA-L and NA-O were observed using a mechanical lift to transfer R3 out of bed and into the W/C. The sling was placed under R3 by NA-N and NA-L by rolling her from side to side in bed. NA-N positioned the lift over R2 while she was lying flat in the bed. NA-N and NA-L connected the sling straps to the upper and lower bars of the lift. NA-N then raised the lift, moved the lift out and away from the bed, turned the lift, opened the base of the lift, positioned R3 over the wheelchair and then lowered R3 into the chair. NA-N failed to open and lock the base of the lift to establish a wide base of support, prior to moving R3. NA-L and NA-O guided R3 in the sling while being moved. NA-N, NA-L and NA-O all verified they had received mechanical lift training by way of a video and written post test during orientation. All three NA's verified they had not been required to complete a demonstration of using the lift nor had any of them been audited or re-trained by nursing staff following the incident with R1. At 8:10 p.m. on 2/15/12, NA-L stated there were two types of slings used at the facility one that is crossed at the thighs and one that is not, contradicting what RN-E/Manager stated about slings. NA-L went on to say R3 was transferred using the sling that is not required to be crossed and indicated the smallest sling was used for R3. NA-L indicated the NA's determine the size of the sling used for each resident by estimating their size from shoulder to mid thigh. At 8:20 p.m. on 2/15/12, NA-O stated two types of slings are used in the facility and the one used to transfer R3 was one that is not required to be crossed. NA-O stated the size of sling to be used for each resident was on the care plan however, a review of R3's care plan indicated the size of the sling was not specified. RN-E/Manager was interviewed on 2/15/12 at 6:45 p.m. and stated there was only one type of sling used for transferring residents with the mechanical lift. She stated the sling should be crossed with all transfers. RN-E/Manager went on to say the nursing assistants get their mechanical lift training during orientation and their competency is verified by another nursing assistant, not a nurse. RN-E/Manager verified she was not involved in any further education with nursing assistants for use of the mechanical lift. RN-E/Manager did not know how the nursing assistants chose the size of the sling used for each resident's mechanical lift transfer and verified she did not assess the resident for sling size. During an interview on 2/15/12 at 5:46 p.m. RN-D/Staff Educator stated her role was the re-education of staff however, the re-education of mechanical lift transfers was delegated to the nurse managers. Her primary role was the initial education of new nursing assistants during the orientation process. RN-D acknowledged that she "has nothing to do with the initial education of mechanical lift transfers" and the human resource person (who is not a nurse) is responsible to show a video about mechanical transfers and administer a post test to the new staff. RN-D verified she does not sign any skill competencies for nursing assistants. RN-D went on to say the 1/22/12 incident involving R1 was not delegated to her for follow up and she was unaware what re-education or audits were done with any of the staff. She stated the size of each resident's sling is identified on each care plan. The mechanical lift training video utilized by human resources was viewed on 2/17/12 at 9:00 a.m. Three types of slings were demonstrated in the video but only two of the slings are in use by the facility. One of the slings needs to be crossed at the thighs to effectuate a safe transfer and one of the slings is not required to be crossed. The video emphasized the importance of spreading the base of the lift to it's widest position to maximize stability and provide safe resident transfers. A review of NA-U's personnel file was done. Her date of hire was 6/20/11. NA-U had watched the mechanical lift training video and took the post test. The post test document was reviewed. NA-U failed the test. There was no evidence of any follow up to the test to ensure her competency of using the mechanical lift. Review of NA-V's personnel file revealed the date of hire was 7/5/11. NA-V's score on the post test was 66%. The General Orientation Checklist for New Employees indicated NA-U (who had failed the post test) had signed the skill competency for mechanical lift transfers, indicating NA-V had met the facility's competency measure for mechanical lifts. There was no evidence of licensed nurse follow up to ensure skill competency regarding the use of the mechanical lifts for either nursing assistant. The facility Resident Mechanical Lift Policy dated 5/04 identified one type of sling, "the U sling, which wraps around the thighs and crosses between the legs," and directed staff to cross the sling at the resident's thighs before attaching it to the bars of the sling. The sling identified in the policy (which was the type of sling used by R1) was one of the slings observed to be used by the nursing assistants. The policy also directed staff to spread and lock the base of the lift to it's widest position prior to moving the resident to maximize stability of the lift. The facility's corrective action plan, dated 02/01/12, included re-education of the two NA's involved in the incident as well as audits of other staff conducting mechanical lift transfers. Documentation indicated that NA-U was re-trained on the use of the mechanical lift on 2/8/12. There was no evidence NA-V had been re-trained. The staffing schedules indicated NA-V continued to perform resident cares, from 01/22/12 - 02/15/12, without being audited in the use of the mechanical lift. The nursing assistant care guides in use at the facility indicate 10 of 47 residents in the facility require transfer by mechanical lift. After the incident with R1 falling from the lift and sustaining a hip fracture, facility staff conducted only one audit of mechanical lift transfers, dated 01/27/12.

Based on observation, interview and record review, the facility failed to provide the necessary treatment/services to prevent the development of an avoidable decline in range of motion for 1 of 1 residents (R55) in the sample who have had a recent decline in range of motion (ROM) which resulted in actual harm. Findings include: Resident 55 (R55) had a decline in range of motion to her neck, arms, shoulders and wrists related to the facility's failure to implement a rehabilitation program. The decline in ROM, caused a change in functional mobility (dressing), which resulted in actual harm. Resident 55 (R55) had [DIAGNOSES REDACTED].) R55's Annual Minimum Data Set ((MDS) dated [DATE] indicated she was oriented, had no memory deficits, required extensive assistance with transfers, eating, toileting and hygiene as well as total staff assistance with bed mobility, locomotion and dressing. Further the MDS identified R55 as having functional limitations of range of motion of upper and lower extremities on both sides of her body. A quarterly MDS dated [DATE] indicated R55 required extensive staff assistance for bed mobility, transfers, locomotion, dressing, eating, toileting and personal hygiene. R55 did not have any functional limitations of range of motion in her upper extremities at that time. R55's care plan dated 1/21/11 included a problem, "Requires assistance for all mobility" with the goal to "maintain mobility function/strength/flexibility (ROM)." The interventions included "restorative upper extremity drills to maintain upper body strength; see restorative program." An occupational therapy (OT) plan of care dated 7/27/10 indicated "restorative exercise program set up with added neck range of motion exercises." The OT notes from 7/6/10 to 7/27/10 did not reveal any limits in range of motion to R55's neck, arms, shoulders and wrists. The 7/27/10 OT note indicated, "will D/C (discharge) today will instruct res (restorative) nrsg (nursing) to take off head rest to perform ex (exercises) to increase ability to extend neck back." The restorative nursing program documentation from July 27, 2010 through May 25, 2011 indicated the following exercises were to be implemented: "Neck range of motion with a 5-10 second hold to right and left and up and down 5-10 times; whatever she can tolerate." The July 27, 2010 through May 25, 2011 restorative nursing sheets identified this program should have been offered 275 times. The neck ROM was offered 120 times which R55 refused this exercise 76 times, participating only 44 times. R55 did not participate at all in this exercise from November 1, 2010 to May 25, 2011. "Hand exercises with 1 blue band 10-20 repetitions daily." The July 1, 2010 through May 25, 2011 restorative nursing sheets identified this program should have been offered 328 times. R55 was offered this program 190 times, refused this 3 times and was not offered the program 138 times. "Rows using red thera bands 10-20 repetitions with each hand daily, or weights." The July 1, 2010 through May 25, 2011 restorative nursing sheets identified this program should have been offered 328 times. R55 was only offered the program 203 times; out of which she refused twice and was not offered the program 125 times. "Stand daily along railing with assist of 1-3 times per week." The July 1, 2010 through May 25, 2011 restorative nursing sheets identified this program was never implemented during this time. "Pulleys 10 minutes 5 times per week." The July 1, 2010 through May 25, 2011 restorative nursing sheets identified this program was offered 185 times; 5 of which she refused. R55 was not offered the exercises 47 times. R55 was observed on 5/25/11 at 7:15 a.m. during her restorative nursing program. Nursing Assistant (NA)-I was helping her exercise with a theraband. R55 was able to pull the band but only by bending her left elbow slightly. She had the same response when using her right arm and was never able to pull the theraband away from her body when doing these exercises. R55 then used a hand gripper with a blue band with her left hand; she was able to squeeze it but when she switched to her right hand she was only able to squeeze it minimally. NA-I stated they had already worked with the arm pulleys that morning. At 7:30 a.m. NA-I went to take R55 to breakfast, the surveyor asked if she had already done her neck range of motion (ROM). NA-I stopped and brought R55 back in the room to finish the exercises. NA-I instructed R55 to look down. R55 looked down with her eyes and moved her chin down very slightly (approximately less than 1 centimeter). She repeated this several times her head tilted slightly to left the whole time. NA-I then instructed R55 to turn her head to the side. Even though R55 attempted to do this several time she was unable to move her head. R55 stated, "I can't do it" and was unsure if she had any discomfort. R55 stated, "I don't know." NA-I finished the exercises and brought R55 to the dining room for breakfast. At that time, NA-I stated the rehab aide often gets pulled to work on the floor to help out the nurse aides or there isn't a rehab aide scheduled. She continued to state that on Mondays they get pulled to help with lab work. A handwritten sheet was noted in the restorative nursing book. NA-I stated sometimes they write down when they get pulled form working the restorative program so they can identify why some of the residents did not get their exercise program. Review of the March to May 2011 Restorative Nurse Aides sheet, identified that 12 times a notation was written. The notations identified they were, "pulled to floor, short staffed; " " aid; " "did group 4 then blood work," "work floor (call in)," "no restorative scheduled," "pulled for podiatry," and "short staffed." On 5/26/11 at 7:10 a.m. Restorative Aide (NA)-B stated she has noticed a decline with R55's range of motion for several months and had charted it. She also reported this change to NA-P who was in charge of the program, but did not recall when she did this. The Occupational Therapist (OT)-A was interviewed 5/26/11 at 7:30 am.; she stated she was told of R55's decline just that day and interviewed R55 who refused to participate in a formal physical therapy evaluation. She stated the rehab nurse aides report to her or physical therapy if there are any changes to the residents and was unaware of R55's changes in range of motion. The Registered Nurse (RN)-A was interviewed on 5/26/11 at 7:45 a.m.; she stated she was unaware of R55's decline in ability and range of motion. She added the nurses do not evaluate the restorative nursing program, and therapy would make any changes to the program if needed. She continued to state if residents are unable or refuse to participate in the restorative program the nurse aides would report that to therapy. She was aware that at times rehab aides would get pulled to work on the floor and were unable to complete the exercise program with the residents. She stated even though R55's care plan directed staff to hand R55 her shirt; she hadn't been able to do that for over 6 months. She was also unaware the restorative program indicated that R55 was to stand at the railing for her restorative program. She stated she hadn't been able to stand for about a year. NA-O was interviewed on 5/26/11 at 8:45 a.m. she stated R55 has become more difficult to dress as her range of motion is decreased and was stiff which has occurred over the last 4-6 months. R55 was able to assist with dressing her shirt; but no longer can assist with this at all. A review of R55's progress notes identified on 12/15/10 a dietician noted, "Patient needs more assistance and has recently moved to assist dining room." There were multiple nursing assistant entries that identified the following: 12/26/10 "unable to stand. Refuses neck exercise." 2/5/11 "Will not do neck exercises saying that it makes her feel ill. Resident cannot stand." 2/13/11 "Continues to refuse to do neck exercises, and is unable to stand." 2/20/11 " ...refuses neck ROM and is unable to stand." 3/5/11 " ...refuses cervical and is unable to stand " 3/20/11 "Still refusing neck exercises and is unable to stand." 3/29/11 "Resident continues to be unable to stand, and refusing to do neck exercises." 4/2/11 "Is unable to stand and refuses to do any neck exercises." 4/17/11 "Resident showing a decline in amount of exercise she can do. Having difficulty doing hand exercises. States that she has no strength in her hands." 5/1/11 "Resident showing decline in amount of exercise she can do. Shows interest in being involved in exercise and enjoys being in the physical therapy room with other residents and staff." Although the NA had multiple entries indicating a change in condition, there was no indication if the nursing or therapy staff were aware of these changes. The facility Director of Nursing (DON) provided a range of motion assessment for R55 dated 5/26/11 at 2:30 p.m. which OT-A completed. The assessment revealed R55 had limitations of range of motion of her neck, shoulders, right elbow and wrist. The DON stated the RN unit manager in charge of the restorative program was unaware of the changes in R55's range of motion status. During a phone interview on 5/27/11 at 11:35 a.m. OT-A stated R55 she was unsure of what R55 baseline status had been but R55 currently had contractures in her neck, arms, shoulders, wrists and always holds her head tilted to the left. R55 did not have any functional limitations of range of motion in her upper extremities during the quarterly MDS dated [DATE]. The quarterly MDS on 4/11/11 identified functional limitations of range of motion to her bilateral upper and lower extremities which resulted in contractures even though R55 was on a exercise program. The exercise program was not consistently implemented for R55, her range of motion was not reassessed nor were her refusals assessed to determine an alternative method. The decline in ROM, caused a change in functional mobility (dressing) for R55, which resulted in actual harm. A restorative nursing policy/procedure was requested; but not provided by the facility.